Deep plane vs. SMAS facelifts


These are excellent questions that have been studied by facelift surgeons from the 1990′s to the present. I will try to explain the deep plane technique versus the SMAS technique as well as the controversy as best I can using layman’s terms.
Deep plane facial dissection
Based on surgical principles of mobilization, advancement and healing

The deeper you lift up the tissues, the easier it is to pull or advance that tissue over to the new position, where it will heal.

Analogy: Imagine yourself trying to move a large area rug over a few inches.

It is very difficult to do!! There is too much area of the rug creating friction which prevents you from moving the area rug more than a few inches at best. If you lift up 20-30% of the rug and try to move it, it is a little bit easier to move it a further distance. If you lift up half or more of the rug, it is the easiest method to move the rug as much or as little as you need.

Diagrams of the Facelifting techniques

SMAS Facelift Image Credit:
Extended SMAS Image Credit:

Deep plane Facelift Image Credit:
Dr. Kamer’s Personal perspective
Revision rates significantly higher with previous rhytidectomy techniques
o 21.7% SMAS plication tuck rate (short skin flap)
o 11.4% Extended SMAS rhytidectomy tuck rate (long skin flap)
o 3.3% deep plane tuck rate

Kamer FM, Frankel AS. SMAS rhytidectomy versus deep plane rhytidectomy: an objective comparison.Plast Reconstr Surg. 1998 Sep;102(3):878-81.

Why is there a significant discrepancy in the touch-up (tuck-up) rates?

So we can compare the techniques directly. If one technique is not working as well, we can eliminate surgeon ability or skill out of the equation. Why did the SMAS plication method have such a high tuck-up rate. Well, lets look at the technique itself and see how much mobilization and advancement we can get with this SMAS plication technique. If we look at the SMAS plication or SMAS imbrication method (see above photo), you can see that the SMAS may only move about 1/2-3/4″ tighter. If the SMAS layer stretches a little bit, it may end up being not be tight enough which leads to a tuck-up. Let’s now compare this to the extended SMAS and Deep plane technique.

Duct tape analogy:

The Controversy
Another way to look at it is, if the SMAS facelift works 80% of the time, then are we doing the deep plane facelift unnecessarily 80% of the time and it is only really necessary 20% of the time? If it is difficult for a surgeon to distinguish when to use which procedure, then they will perform the deep plane facelift on everyone, so that they can minimize the need for tuck-ups. Is the risk to the facial nerve higher with the deep plane facelift than the SMAS facelift? Yes. The SMAS facelift surgeons will look at it a different way, they never ever want to have a facial nerve injury for any of their patients, so they can justify a higher tuck-up rate, because at least they are keeping the patient safer. Daniel Baker wrote an article titled: Baker DC: Deep dissection rhytidectomy: a plea for caution. Plast Reconstr Surg 1994 Jun; 93(7): 1498-9. The deep-plane surgeons will say that their rate of facial nerve injury is negligible in their hands so they can have the best of both worlds.

Which looks more natural? Some say that the deep plane facelift lifts the cheek fat pad better than the SMAS technique, but some SMAS techniques can also get this type of improvement. Dr. Aston performed an interesting study in the 90′s comparing the two methods.

Ivy EJ, Lorenc ZP, Aston SJ Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg. 1996 Dec;98(7):1135-43; discussion 1144-7.
Presented is a prospective study comparing limited SMAS (lateral SMASectomy), conventional SMAS, extended SMAS, and composite rhytidectomies. Randomized patients received either a limited SMAS or conventional SMAS face lift on one side and an extended SMAS or composite rhytidectomy on the other. … The study comprises 21 patients, … No discernible differences in facial halves were noted again. Differences between facial sides on the 6- and 12-month postoperative photographs were not detectable. We conclude that for routine facial plasty, comparable clinical outcomes are obtained at 6 months and 1 year with limited (lateral SMASectomy) and conventional SMAS face lifts compared with extended SMAS and composite rhytidectomies. All procedures are lacking in their improvement of midface ptosis and the nasolabial folds. The increased surgical risks, morbidity, and convalescence associated with those more extensive procedures do not seem to be warranted in the average patient.

It hasn’t been proven that one technique lasts significantly longer than the other. If a patient was able to get an equivalent improvement (both 10 year improvements) at one year with either technique, I think that both will last equally long. However, if the patient could get significantly tighter result with the deep plane technique along with a longer chronologic improverment relative to the SMAS technique, then from this standpoint the deep plane would take longer to return to the original age (15 year improvement versus 10 year improvement.)

See my explanation on how long a facelift should last. … hp?t=61255

So after this lengthy explanation, what’s the conclusion?

  1. Both techniques are valid.
  2. The results from these techniques look approximately the same even when performed on different halves of the face.
  3. The deep plane technique has a lower tuck-up rate relative to SMAS technique.
  4. The risk for facial nerve injury is higher with deep plane facelifts than SMAS techniques. If the surgeons can’t agree on one type of facelift technique, then the potential patients should be better informed regarding which risk they prefer, the rarer risk of facial nerve injury or the higher risk of getting a tuck-up.

If there are any more specific questions, please don’t be shy, I’m happy to answer them as best as I can.


Dr. Yang