Comparative safety and efficacy of SMAS rhytidectomy techniques: a network meta-analysis protocol

Superficial musculoaponeurotic system (SMAS) rhytidectomy techniques are widely used in facelift surgery to achieve long-lasting facial rejuvenation. Nonetheless, variations in technique lead to differences in complication rates, aesthetic outcomes, and longevity of results. Current literature lacks a comprehensive network meta-analysis (NMA) that ranks these techniques based on both safety and efficacy. Thus, the aim of this study is to perform a NMA to determine their rankings based on complication and aesthetic outcomes.

A network meta-analysis comparing different facelift techniques following PRISMA-NMA guidelines will be conducted. MEDLINE (PubMed), Scopus, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinicaltrials.org will be searched from inception to search date. Screening, data extraction, and risk-of-bias assessments will be performed independently by two reviewers and discrepancies resolved by a third independent reviewer. Eligible studies will include randomized controlled trials (RCTs) and observational studies of adult patients undergoing a facelift procedure (SMAS plication, SMASectomy/imbrication, SMAS flap, high lateral SMAS, deep plane facelift, and composite rhytidectomy) and reporting at least one complication outcome (e.g., facial nerve injury, hematoma, seroma, skin necrosis, infection) and/or aesthetic outcome (e.g., patient satisfaction, longevity of results). R 4.4.2 Software (netmeta package) will be used to generate forest plots, treatment rankings, evaluate consistency between direct and indirect evidence, and assess heterogeneity. The ROBINS tool will be used to assess the risk of bias in nonrandomized studies and the RoB 2 tool will be used for RCTs. We will conduct a frequentist fixed- and/or random-effects NMA using the graph theory approach for each outcome. For dichotomous outcomes, odds ratios (ORs) with their corresponding 95% confidence intervals (CIs) will be calculated for all possible pairwise comparisons between the SMAS techniques. For continuous outcomes, standardized mean differences (SMDs) with 95% CIs will be calculated. Sensitivity analyses will be performed in cases of significant heterogeneity. Subgroup analyses by patient characteristics will be performed if sufficient data is available in the included studies.