In Defense of the SMAS Facelift

The deep plane facelift dominates on social media, but offline, plastic surgeons are quietly performing SMAS lifts in record numbers.

What’s in a name? Just ask your friendly, neighborhood plastic surgeon. They’re apt to regale you with tales of their bespoke extended, vertical vector, composite flap, scarless, mystery, reset lift. (Love you all, but whew, our heads are spinning!)

Much of the hype on social revolves around the deep plane facelift, but IRL, the majority of American plastic surgeons are performing some version of a SMAS lift. There are several iterations and each addresses the muscle layer of the face—the SMAS or superficial musculoaponeurotic system—in its own way.

Generalizing SMAS lifts is tricky, I’m learning, because they exist on a broad spectrum. But as Pierce Janssen, MD, an aesthetic plastic surgery fellow at the Cleveland Clinic, explained to me via DM, we can divide SMAS facelifts into two main categories: Extended SMAS techniques—which, like deep plane lifts, dissect under the muscle (“sub-SMAS”) and fully release the ligaments that tether soft tissue to bone—and more limited SMAS procedures (think: plication and lateral SMASectomy), which do not go under the muscle or touch the ligaments. All methods can yield good results, he notes, when performed by well-trained, experienced surgeons.

Since SMAS facelifts get short shrift online, I asked board-certified plastic surgeon Dino Elyassnia, MD, who performs a high SMAS facelift, to further educate us on these procedures. For those unfamiliar, Dr. Elyassnia practices alongside his mentor, the renowned Dr. Timothy J. Marten, at The Marten Clinic in San Francisco, where he specializes in preservation rhinoplasty, facial rejuvenation surgery, and deep neck sculpting.

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Technique names are “really the last thing people should worry about,” Dr. Elyassnia insists. Despite the Instagram rhetoric, the terms “don’t mean much to a patient, because they are so technical and because anybody can say anything, so it's a hard thing to rely on when choosing a doctor,” he says. The way he sees it, “requesting a deep plane has become a simple way for people to say, Okay, I'm going to get a good facelift—but that's not the right way to evaluate these things.” Instead, focus on results, he says, and “finding something you think, artistically, is beautiful.”

Dr. Elyassnia also makes the point that, historically, the facelift technique a surgeon favors is largely determined by their educational pathway. Plastic surgeons, who train in general surgery and plastic and reconstructive surgery, classically learn SMAS techniques (just as their mentors did) while facial plastic surgeons, with their otolaryngology/ENT background, traditionally learn the ways of the deep plane. So, really, SMAS vs. deep plane represents “not so much a split of anatomy or technique,” he tells me, “but more a split of ENTs and plastic surgeons.”

Compounding our confusion, “a lot of plastic surgeons have adopted the deep-plane wording, not wanting to lose out on patients who are looking for that,” Dr. Elyassnia says. This further undermines the integrity of these concepts. “Some who do a slightly different variation of the surgery may think, Well, I can call it a deep plane, because what I'm doing is almost identical, and the patient doesn’t know any better. So now, everybody’s using the term ‘deep plane,’ but it doesn't mean anything anymore.”

Our conversation only got more interesting from there. Ahead, Dr. Elyassnia shares the sometimes-subtle differences between reigning facelift techniques, what he learned from observing a deep-plane pioneer perform the surgery live, and the one surgical maneuver he believes just isn’t worth the risk.