Deep Plane Facelift versus SMAS Facelift Demystified

What is a SMAS Facelift?

The high-SMAS facelift is a modified version of the traditional facelift procedure that addresses the lower ⅔ of a patient’s face by targeting the supportive tissues of a patient’s face, the “ SMAS” or superficial muscular aponeurotic system. The superficial muscular aponeurotic system is a fibrous tissue network dividing the deeper facial muscle layers from the superficial skin layers. With aging, the SMAS integrity weakens, creating caudal migration (sagging) of the mid-face and lower face.   This leads to classic stigmata or signs of facial aging which include tear trough deformities, deep naso-labial folds, jowls, and marionette lines.  One of the fundamental tenets of the SMAS facelift surgery is to reposition the SMAS to a more youthful state, thus addressing and correcting all of the aforementioned areas.

Definitively, the goal of the SMAS facelift is to reverse the appearance of sagging, tightening underlying facial musculature, removing excess fat ( most typically jowls and sub-mentum or under chin), adding fat as appropriate ( tear troughs and pyriform fossa), and re-draping the skin in natural and quiet way which creates an enhanced, anatomically correct appearance.

How is a SMAS Facelift Performed?

The SMAS facelift is generally performed under general anesthesia, although it is possible to perform the procedure under local anesthesia with sedation.  The SMAS Facelift procedure generally lasts 4-6 hours, depending on what ancillary procedures, such as micronized fat transfer or blepharoplasty, are performed. Incisions are made in the hairline above and behind the ear. The skin is then gently elevated before the SMAS is elevated and repositioned to a more youthful state – doing so addresses and corrects such age-associated findings including jowls, loss of cheek projection, deep naso-labial folds, and tear trough deformities. The skin is then carefully and strategically re-draped, with the excess skin being removed.

The recovery from a SMAS facelift takes about 2-3 weeks, with the patient wearing a compression garment day and night for the first seven days, and during the evenings for the next seven days. During this time period, the patient may experience mild bruising and swelling.  Pain and discomfort are rare findings with SMAS facelift surgery.  Additionally, because the incisions are designed to hide within the natural folds and curvatures of the skin, visible scarring is minimized and naturally concealed as the patient recovers. Results typically last about 6 to 8 years depending largely on the age of the patient, and other factors such as a history of smoking. 

Why undergo a SMAS Facelift?

The principal advantage of a SMAS facelift over a deep plane facelift is customized tissue repositioning.  Due to the more extensive skin and SMAS elevation with the SMAS facelift, the procedure allows for greater and more customized tissue repositioning.  This is generally more valuable in the older patient population which we expect to have greater skin excess or soft-tissue laxity, requiring a multi-dimensional approach to allow for ideal results.  This is simply not possible to the same degree with a deep plane facelift, hence, in our experience, the SMAS facelift is considered superior in patients over the age of 50.

What is a Deep Plane Facelift?

A deep plane facelift is considered a more invasive facelift procedure whereby the tissue plane created extends deeper to the superficial tissues of the face to address deeper structural components. The procedure primarily focuses on the repositioning of muscle and fat layers below the SMAS layer, rather than SMAS re-positioning with associated skin pulling and removal. This deeper technique allows for the treatment of a wider array of aging signs such as marionette lines and naso-labial folds. The goal of the deep plane facelift is to tighten the skin and muscles of the face, jaw, and neck as a single unit to create a rejuvenated, youthful but natural look. 

The deep plane facelift is performed under general anesthesia and typically takes about 4 to 6 hours from beginning to end.  Just as in the SMAS facelift, incisions are made behind the ear and along the hairline for concealed scarring. Unique to the deep plane facelift, the patient’s sagging skin and muscles are lifted together in one layer, releasing the ligaments between the skin and bone to allow access to underlying fat pads. This enables the surgeon to dissect underneath to lift underlying fat pads and tissues. The deep plane facelift results are a lifted look in the mid-face, creating the appearance of added volume to the cheeks and face.

Another value of the deep plane facelift lies in the fact that because most work is done on deeper tissues away from the dermis, patients experience favorable recovery and healing periods rather than the extended downtime that would be expected from a more invasive procedure. Many argue that this also enables long-lasting results, comparable to that of a SMAS Facelift.  The recovery process of the deep plane facelift is comparable to that of the SMAS facelift, with compression bandages being worn for the first two weeks following surgery, with typical mild-to-modest bruising, pain, and swelling being expected.  The recovery period generally lasts about two to three weeks.

How do SMAS vs Deep Plane Facelift differ?

The goal of a facelift is to reverse signs of aging to promote a more youthful and refreshed appearance to the face. Both the deep plane and SMAS facelifts create optimal results in patients over the age of 40, notably in those suffering from signs of aging such as excessive skin, hollow cheeks, loss of cheekbone projection, jowling, pronounced naso-labial folds, marionette lines, loose under chin skin, loss of jawline contour, and generalized neck laxity. However, where they differ most lies in the depth of tissue planes and techniques of soft-tissue repositioning which can create very different results.

The fundamental differentiation between the two procedures is found at the level of the major ligaments core to the connective tissues and muscles that allow for facial movements. The deep plane facelift re-positions these ligaments that anchor down the muscle and connective tissues of the lower face to allow for true resuspension at a constructional level. This allows for the potential of more anatomically correct soft-tissue repositioning. If performed improperly, however, the ligamentous repositioning can create an “ operated on “ appearance which can be disconcerting to both the patient and surgeon. Comparatively, in the SMAS facelift, the ligaments remain tethered to the tissues and muscles. The SMAS facelift procedure tightens and shifts the soft tissue rather than reconstructing the facial structures. Specifically, the SMAS facelift targets the skin and underlying SMAS layer, allowing for independent shifting and repositioning of skin and SMAS followed by excess skin removal and tightening. While this procedure is much less invasive, prioritizing work near the surface of the skin, it also allows for a true bi-planer tissue repositioning, unlike the deep plane facelift. The deep plane facelift goes much deeper into the facial structure to target muscles, fat layers, and ligaments. This procedure prioritizes the movement of these structures rather than tightening, pulling, and removing the skin. The result avoids tightness in the face by focusing instead on its structural composition. 

Is a Deep Plane Facelift better than the SMAS Facelift ?

The superficiality and separation of the SMAS facelift enables more directionality and customization of “ pull “ in the desired result of individual facial aesthetic. Because the skin and the muscles of the SMAS layer are lifted separately, the surgeon is able to customize results to suit the patient’s face via the directions of lifting and tightening. However, because the work of the SMAS lift is not reconstruction but rather of re-positioning and tightening, in the wrong hands, results can theoretically have an undesirable tight appearance, looking less natural than that of the deep plane. When the skin is re-draped after lifting the SMAS, disruption or contour irregularities in the skin can cause unnatural effects, although this, again, is rare in experienced hands. However, in patients with extensive soft-tissue laxity or loose skin as classically seen in the older patient population, because of its bi-planer approach, the SMAS facelift is often better suited to address the multi-dimensional deficits found in the aging face.

In direct comparison, the SMAS facelift is considered a more superficial procedure to that of the deep plane facelift which means that deeper structural components of the face that fall as a consequence of aging and shifting are not primarily addressed, although when combined with a sub-periosteal mid-face suspension, the same objectives as the deep plane facelift are met, and, notably, with considerably less risk. In contrast, with the deep plane facelift, the skin and muscles are elevated as a singular unit, allowing the surgeon to access deeper tissues and muscles to create a more naturally elevated facial appearance. The deep plane facelift goes beyond the SMAS, and by suspending the ligaments that anchor down aged muscle structures, is able to create more realistic comprehensive results throughout the face and neck. Thus, this procedure is not only considered to be more natural looking but more effective and long-lasting in terms of results than a conventional SMAS Facelift. Patients can appear younger without a dramatic difference, without substantial added risk or pain.

What is the ideal age for a Deep Plane Facelift?

In general, best results with the deep plane facelift are found in a younger patient demographic, usually in patients under the age of 50. This patient population typically have much less soft-tissue laxity or skin sagging or skin excess, thus the deep tissue re-positioning is able to create an enhanced and rejuvenated look, without the need for extensive skin resection, often found necessary in the older patient population.

Does a Deep Plane Facelift last longer ?

Deep plane facelifts may last longer, and indeed, by virtue of the fact that the ideal patient for this procedure is younger than that of a SMAS facelift, the younger tissue is likely tied to the extended result. Results for a deep plane facelift can be expected to last 6-8 years, but again, keep in mind that deep plane facelifts are frequently not ideal in older patient populations.

Why have a Deep Plane Facelift?

Deep plane facelift surgery should be considered for the younger patient with mild-to-modest soft-tissue laxity of the mid and lower face, and in patients not suffering from profound skin excess. In this patient population, the deep plane facelift is capable of producing a natural, enhanced appearance with a lower likelihood of creating a “ pulled “ or “ windblown “ appearance, occasionally seen in SMAS facelift surgeries.

What is a Deep Plane lower face lift?

The deep plane lower facelift is a modification of the conventional deep plane facelift, addressing not only the mid-face, but also focusing on the lower facial features of aging, including the jawline contour, jowls, and sub-mental or under chin laxity. This procedure is generally performed in the subset of patients who aren’t lacking projection of the cheek region and mid-face, but rather require enhancements to the lower face, hence this modification of the deep plane facelift is more rarely performed, as it addresses a smaller subset of the aging face spectrum.

To find out if the deep plane facelift or high SMAS facelift are appropriate procedures for you, call the offices of Dr. Vallecillos at 310-273-3007 to schedule your consultation today.