Dr Scott J Turner | Specialist Plastic Surgeon (FRACS) | Sydney
The SMAS, the Superficial Musculoaponeurotic System, is the anatomical structure that sits beneath the skin of the face and forms the foundation of nearly every contemporary facelift technique. Whether you’re researching mini facelift, lower facelift, deep plane, or Vertical Restore facelift, the SMAS is the layer being addressed in some way. Understanding what the SMAS is, why it became central to facelift surgery, and how the various SMAS techniques differ helps you make sense of the surgical options described on procedure pages and consultation discussions.
I’m Dr Scott J Turner, a Specialist Plastic Surgeon (FRACS) at our Bondi Junction and Manly clinics in Sydney. This article is an educational overview: what the SMAS is anatomically, how facelift surgery evolved from skin-only techniques to SMAS modification, the four major SMAS facelift variations, and how surgeons think about choosing between them. For full procedure detail including candidacy, recovery, cost, and consultation requirements, see SMAS Facelift surgery in Sydney.
What is the SMAS?
The Superficial Musculoaponeurotic System, almost always abbreviated to SMAS, is a continuous layer of fibromuscular tissue that sits beneath the skin and the subcutaneous fat across the face. It was first formally described in surgical anatomy literature in 1976 by Mitz and Peyronie, and that description fundamentally changed how facelift surgery is performed.
Anatomically, the SMAS connects several important structures. In the cheek and lower face it functions as a fibromuscular sheet that supports the soft tissues of the face. As it extends downward into the neck, the SMAS becomes continuous with the platysma muscle. As it extends upward toward the temple and forehead, it connects with the temporal fascia and the frontalis muscle. The result is a single continuous tissue layer that runs from the forehead through the face into the neck.
The SMAS is also the layer that small muscles of facial expression sit within. When you smile, frown, or move the corners of your mouth, you’re moving muscles that are embedded in the SMAS layer. This is why operations on the SMAS need to respect the fine branches of the facial nerve that supply these muscles.
Beneath the SMAS sits a deeper plane containing the retaining ligaments (the fibrous bands that anchor the soft tissues to the underlying facial skeleton), the buccal fat pad, the deep facial fat compartments, and the major branches of the facial nerve. Surgery that operates beneath the SMAS, such as deep plane technique, works in this deeper anatomical plane.
For most facelift purposes, the practical importance of the SMAS is this: the SMAS is the structural layer that holds facial position. As the SMAS weakens and stretches with age, the soft tissues it was supporting descend. Facelift surgery that addresses the SMAS is addressing the actual structural cause of facial descent rather than working only with the skin on top.
How Facelift Surgery Evolved: From Skin to SMAS
Facelift surgery has been performed for more than a century, but the operation looked very different in its early decades.
Skin-only facelifts (early 20th century to 1970s)
The first facelift operations were skin-only procedures. The surgeon would make incisions in front of and behind the ear, undermine the skin to free it from the underlying tissues, pull the skin upward and backward, and trim and close. The structural layer beneath was not addressed.
The problem with skin-only facelifts was that the structural cause of facial descent was the SMAS layer, not the skin. By tightening only the skin, the operation produced an immediately noticeable change but the result was short-lived. Within months to a year or two, the skin would re-stretch (skin has elastic properties; pulling it tight does not change its underlying nature) and the descent would return. The well-known “wind-tunnel” appearance of older facelifts was partly the result of skin tension being used as the primary lifting force.
Skin-only facelifts also created a particular problem with scar quality. When skin is closed under tension, the resulting scar tends to widen and become more visible over time. Many older facelifts have visible scars in front of the ear because of this tension-based closure.
SMAS plication and the Mitz-Peyronie revolution (1976)
The 1976 anatomical description of the SMAS by Mitz and Peyronie identified the layer that would change facelift surgery. Once the SMAS was understood as a continuous structural sheet, surgeons began modifying their technique to address it directly.
The first SMAS technique was plication: rather than cutting or removing SMAS tissue, the surgeon would fold the SMAS upon itself with sutures, pulling the deeper layer in the desired direction and securing it. The skin was then redraped over the repositioned SMAS without tension, allowing for cleaner closure and less prominent scars.
SMAS plication became the foundation technique that all subsequent SMAS-based variations built upon.
SMASectomy (1990s)
A refinement called SMASectomy was developed in the 1990s. Rather than folding the SMAS, the surgeon would remove a strip of SMAS tissue (usually a few millimetres wide, oriented along a specific vector) and then suture the cut edges together. The effect was similar to plication but produced more predictable repositioning and avoided the bulk that plication could sometimes create at the fold.
SMASectomy is still widely used today, particularly in patients with thicker SMAS tissue or where a more focused vector of pull is desired.
High SMAS technique
The high SMAS facelift was developed to extend SMAS modification into the midface. In conventional SMAS technique, the SMAS incision is made below the cheekbone, which limits the operation’s effect on the upper midface. The high SMAS technique places the SMAS incision above the zygomatic arch (the cheekbone), giving the surgeon access to the midface fat pads and allowing more effective repositioning of the upper cheek.
The high SMAS approach is more demanding technically because the dissection passes closer to the temporal branch of the facial nerve, but it offers improved correction of midface descent compared to standard SMAS techniques.
Extended SMAS
The extended SMAS facelift extends the SMAS dissection laterally and inferiorly, with limited release of the cheek retaining ligaments. This is essentially a partial transition toward deep plane technique, and represents the technical evolution that ultimately led to the modern deep plane facelift.
Deep plane facelift (1990s onward)
Building on the SMAS understanding, the deep plane facelift took the dissection beneath the SMAS rather than at its level. By releasing the retaining ligaments that anchor the deeper soft tissues to the skeleton, the deep plane technique allows the entire composite of skin, fat, and SMAS to be repositioned as a single unit. For more on this, see our Deep Plane vs SMAS Facelift comparison guide.
Modern integration
Contemporary facelift practice draws from all of the above. A surgeon may use plication on one zone, SMASectomy on another, high SMAS access for the midface, or deep plane dissection beneath the SMAS depending on what each patient’s anatomy needs. The various techniques are not competitors so much as tools, each suited to particular patient situations.
The Four Main SMAS Facelift Variations Today
Four SMAS-based variations are commonly performed in contemporary facelift practice. Each addresses the SMAS at a different depth or with a different mechanism.
SMAS Plication
Plication is the simplest SMAS technique. The SMAS is identified beneath the subcutaneous fat, and a series of sutures are placed to fold and secure the SMAS in the desired vector. No SMAS tissue is removed.
When SMAS plication may suit: Mild to moderate facial ageing, patients who are good candidates for a relatively limited operation, patients who prefer the shortest available recovery time among SMAS techniques.
Limitations: The amount of structural change that can be achieved is more limited than with deeper techniques. Suitable for early to moderate descent rather than significant structural change.
SMASectomy
SMASectomy removes a strip of SMAS tissue (typically 1 to 2 centimetres wide) along a specific vector, then sutures the cut edges together. The result is a more direct repositioning of the SMAS than plication can achieve, with less bulk at the closure.
When SMASectomy may suit: Patients with thicker SMAS tissue where plication would create bulk, patients needing more direct vector control of the SMAS lift, moderate facial ageing where structural change is needed but full deep plane dissection is not warranted.
High SMAS
The high SMAS technique extends SMAS access into the upper midface by placing the incision above the cheekbone. The mid-cheek soft tissues are then accessible for repositioning along with the lower face.
When high SMAS may suit: Patients with significant midface descent (deepening nasolabial folds, hollowing of the upper cheek), patients who would otherwise need a more extensive procedure to address the midface, situations where comprehensive midface and lower face correction is desired without going as deep as full deep plane technique.
Extended SMAS
The extended SMAS technique extends the dissection laterally and includes partial release of the retaining ligaments at the cheek. The technique sits between standard SMAS plication and full deep plane facelift in its anatomical extent.
When extended SMAS may suit: Patients whose anatomy or surgical history makes full deep plane dissection technically risky (for example, certain revision cases), patients needing more structural change than plication or SMASectomy can provide but where deep plane is not the preferred approach.
How the Choice Between SMAS Techniques Is Made
The selection of which SMAS variation suits a particular patient is made during consultation based on several factors.
Pattern of facial descent. If descent is concentrated in the lower face and jawline, plication or SMASectomy may be appropriate. If descent extends into the midface, a high SMAS or deep plane approach may be more appropriate.
Skin and tissue quality. Thicker SMAS tissue may favour SMASectomy over plication because plication can create visible bulk in thicker tissue. Thinner SMAS tissue may favour plication because the tissue is less suited to cutting and re-suturing.
Recovery priorities. Plication generally allows the shortest recovery among SMAS techniques. Patients prioritising fastest return to normal activities may favour the simpler operation, accepting that the structural change is more limited.
Revision considerations. In revision facelift cases (where the patient has had previous facelift surgery), the SMAS anatomy may have been altered by the previous operation. SMAS-based techniques are often Dr Turner’s preferred approach in revision cases because the dissection is more controllable in altered anatomy than full deep plane technique.
Combined procedures. If a patient is having other procedures at the same time (eyelid surgery, lip lift, fat grafting, neck lift), the SMAS technique selection takes into account the total surgical plan rather than the SMAS work in isolation.
The decision is not made from a photo or an online consultation. It requires hands-on examination of the SMAS thickness, the skin elasticity, the pattern of descent, and the broader surgical context. For a candidacy assessment, recovery information, and consultation requirements specific to your situation, see SMAS Facelift Sydney.
SMAS Technique and Longevity of Results
A common patient question is how long facelift results last. The answer varies by technique, and the SMAS work is one of the major factors.
Published clinical experience suggests that SMAS-based techniques may produce structural improvements lasting approximately eight to twelve years, depending on the specific variation, the patient’s anatomy, and lifestyle factors after surgery. Deep plane techniques may last longer (approximately twelve to fifteen years in some published series) because the structural change is more extensive.
The factors that influence longevity are the same regardless of technique: stable weight maintenance, sun protection, non-smoking status, good general health, and avoidance of significant medical illness. The face continues to age after any facelift; surgery does not stop the ageing process but resets the starting point.
For a more detailed comparison of SMAS and deep plane longevity, see our Deep Plane vs SMAS Facelift comparison guide.
Where SMAS Surgery Sits in the Modern Cluster of Facelift Options
It’s worth understanding where SMAS-based facelift sits relative to the other techniques available in modern practice.
Mini facelift typically uses SMAS plication or limited SMASectomy, with abbreviated incisions. It’s a SMAS technique with reduced surgical scope. Lower facelift addresses the lower third of the face and upper neck, again typically using SMAS plication or SMASectomy plus platysmaplasty. It’s a SMAS technique with focused anatomical scope. Deep plane facelift works beneath the SMAS in a deeper plane, releasing retaining ligaments rather than working at the SMAS level. Vertical Restore Facelift uses deep plane dissection with a vertical vector and full-face scope.
So the question “is a SMAS facelift right for me” is really part of a broader question about which surgical approach matches your individual anatomy and goals. The SMAS is not a single procedure; it’s the underlying tissue layer that nearly every facelift technique addresses, with variations in how that layer is modified.
For an overview of all facelift techniques performed at our Sydney practice, see the main Facelift page.
Risks and Realistic Expectations
All facelift surgery, including SMAS-based techniques, carries risk. Outcomes vary considerably between individuals based on anatomy, skin quality, the specific technique used, and health factors, and no technique guarantees a specific result. For a full discussion of possible complications, candidacy considerations, and realistic outcome expectations, see the SMAS Facelift surgery page and our risks and complications after facelift surgery guide.
Frequently Asked Questions
What is a SMAS facelift?
A SMAS facelift is a category of facelift surgery that modifies the Superficial Musculoaponeurotic System (the SMAS), the fibromuscular layer beneath the skin that provides structural support to the face. Rather than tightening only the skin (as in older skin-only facelift techniques), SMAS facelift addresses the structural layer that has descended with age. There are several SMAS variations including plication, SMASectomy, high SMAS, and extended SMAS. Each suits a different pattern of facial ageing and surgical goal. The specific technique selection is made during consultation after assessment of your individual anatomy.
What is the difference between high SMAS facelift and standard SMAS facelift?
Standard SMAS techniques work below the cheekbone, which limits the operation’s reach into the upper midface. The high SMAS facelift places the SMAS incision above the zygomatic arch, giving access to the midface fat pads and allowing more effective repositioning of the upper cheek. High SMAS suits patients with significant midface descent (deepening nasolabial folds, hollowing of the upper cheek). It is more technically demanding because the dissection passes closer to the temporal branch of the facial nerve, but offers improved midface correction compared with standard SMAS techniques.
What is plicated SMAS facelift?
Plication is the simplest SMAS technique. The surgeon identifies the SMAS layer beneath the skin and subcutaneous fat, then folds the SMAS upon itself using sutures, securing it in the desired vector. No SMAS tissue is removed. Plication suits mild to moderate facial ageing and patients prioritising the shortest available recovery among SMAS techniques. Its main limitation is that the structural change achievable is more modest than with techniques that remove SMAS tissue or work in deeper planes.
Is a SMAS facelift worth it?
This question depends entirely on your individual situation. SMAS-based facelift produces structural change that can last approximately eight to twelve years in published clinical experience, with longevity influenced by your anatomy, lifestyle, and the specific technique used. Whether the operation is worthwhile for you depends on your specific pattern of facial ageing, your goals for surgery, your tolerance for the recovery period, and your overall situation. The honest answer requires individual clinical assessment. Some patients are better suited to a SMAS technique; others may be better suited to deep plane, mini facelift, or non-surgical alternatives, or to delaying surgery entirely. The consultation is where this assessment happens.
What is SMAS anatomy and why does it matter for facelift?
The SMAS (Superficial Musculoaponeurotic System) is a continuous fibromuscular tissue layer beneath the skin and subcutaneous fat. It connects with the platysma muscle in the neck, the temporal fascia in the temple, and the frontalis muscle in the forehead, forming a single integrated structural sheet across the face. The small muscles of facial expression sit within this layer. As the SMAS weakens and stretches with age, the soft tissues it supports descend, producing the structural changes characteristic of facial ageing (jowling, midface descent, nasolabial fold deepening). SMAS facelift technique addresses the structural cause of these changes rather than working only with the skin on top, which is why modern facelift outcomes are more durable than the skin-only operations of earlier decades.
Next Steps
If you’ve found this useful and want to understand whether SMAS facelift, deep plane, or another approach matches your individual anatomy, the SMAS Facelift procedure page covers candidacy, recovery, cost, and consultation requirements in full. Cosmetic surgery in Australia requires a GP referral, two preoperative consultations, psychological screening, and a cooling-off period in line with AHPRA guidelines.
Contact our clinic for general enquiries on 1300 437 758 or email [email protected].
General information only, not medical advice. All surgery carries risk. Outcomes vary considerably between patients based on anatomy, skin quality, health factors, and individual response to surgery. Any decision about facelift surgery requires individual clinical assessment by a qualified health practitioner.
