Understanding SMAS Facelifts: Modern Surgical Approaches to Facial Rejuvenation

By Dr. Scott J Turner, Specialist Plastic Surgeon | Published: 12/06/2025

Facelift surgery has evolved dramatically over the past century, transforming from crude skin-tightening procedures to sophisticated surgical techniques that address the underlying anatomical structures responsible for facial ageing. The development of SMAS (Superficial Musculoaponeurotic System) facelift techniques represents one of the most significant advances in cosmetic facial surgery, with the potential to offer patients natural-looking, long-lasting results that preserve facial expression and character.

Dr Scott J Turner, a Specialist Plastic Surgeon, provides comprehensive facial rejuvenation procedures including various SMAS facelift techniques and deep plane facelifts at his clinics in Sydney, Australia. Understanding the different SMAS approaches available can help patients make informed decisions about their facial rejuvenation options.

The evolution of facelift surgery

Early facelifts dating back to 1901 focused only on skin tightening, often producing artificial-looking results that lasted just a few years. The major breakthrough came in 1976 when Mitz and Peyronie identified the SMAS layer – a specialised tissue network beneath the skin that plays a crucial role in facial ageing.This discovery revolutionised facelift surgery by providing surgeons with a deeper understanding of facial anatomy and the underlying causes of ageing. Modern SMAS-based techniques address these structural changes rather than simply tightening the skin surface, resulting in more natural and longer-lasting outcomes.

Understanding the SMAS: anatomy and function

The Superficial Musculoaponeurotic System is a specialised layer of fibromuscular tissue that extends from the neck (platysma muscle) to the forehead (temporoparietal fascia). This network consists of muscles, fibrous connective tissue, collagen, and subcutaneous fat that work together to:

• Connect facial muscles to the overlying skin
• Enable coordinated facial expressions
• Provide structural support for facial tissues
• Maintain facial volume and contours

As we age, the SMAS layer undergoes predictable changes including tissue descent, muscle laxity, and loss of structural support. These changes contribute to the formation of jowls, deepening of nasolabial folds, and neck laxity that characterise facial ageing.Modern SMAS facelift techniques target these underlying structural changes rather than simply tightening the skin surface, resulting in more natural, longer-lasting outcomes.

How SMAS techniques modernised facelift surgery

The transition from “skin-only” facelifts to SMAS-based procedures represents a fundamental paradigm shift in facial rejuvenation surgery. Traditional skin-only techniques, used from 1901 to the 1970s, had significant limitations:

• Results typically lasted only 2-5 years
• Created an artificial, “windswept” appearance
• Failed to address the underlying causes of facial ageing
• Often produced the characteristic “pulled” or overly tight look

SMAS-based techniques revolutionised facelift surgery by addressing the underlying causes of facial ageing rather than simply tightening the skin surface. This fundamental shift enabled surgeons to achieve more natural, longer-lasting results while preserving facial expressions and character.

Benefits, safety and effectiveness of SMAS facelifts

Recent clinical evidence demonstrates the significant advantages of SMAS facelift techniques. A comprehensive systematic review of 183 studies found patient satisfaction rates exceeding 85% across different SMAS approaches, with consistently high success rates in achieving significant improvement in facial aesthetics.

Key benefits include:

• Longevity: SMAS techniques may provide results lasting 10-15 years, with some patients experiencing benefits for even longer periods, though individual results vary significantly. This potential durability is achieved by addressing the structural foundations of facial ageing rather than surface symptoms.
• Natural appearance: By working with the body’s natural tissue layers, SMAS facelifts may restore facial contours while preserving individual facial character and expressions. Patients may avoid the artificial “pulled” appearance associated with older techniques, though individual results vary.
• Comprehensive rejuvenation: Modern SMAS approaches can simultaneously address multiple areas of facial ageing, including jowls, nasolabial folds, marionette lines, and neck laxity.
• Improved healing: SMAS techniques allow for closure without excessive skin tension, promoting better healing and less noticeable scarring.

Safety profile

Current evidence demonstrates that SMAS facelift techniques have favourable safety profiles when performed by qualified practitioners. A 2023 systematic review of 27 studies involving 6,086 patients found:

• Temporary facial nerve injury: 0.85% overall
• Skin necrosis: 0.41%
• Permanent facial nerve injury: Only 1 case reported across all studies
• Patient satisfaction: Greater than 85% across all techniques

Contrary to earlier concerns, recent meta-analyses show that more advanced techniques like deep plane facelifts do not carry higher nerve injury risks than traditional SMAS approaches. The key to optimal outcomes lies in proper patient selection, surgical technique, and practitioner experience.

Types of SMAS facelifts: techniques and applications

Modern facelift surgery encompasses several distinct approaches, each with specific indications, advantages, and limitations. Understanding these differences helps patients and surgeons select the most appropriate technique for individual needs.

SMAS plication

Technique: SMAS plication involves folding the SMAS layer over itself and securing it with sutures, without removing any tissue. This creates lift and tightening through tissue repositioning and maintains SMAS integrity by avoiding tissue removal.

Ideal candidates: Patients with mild to moderate facial ageing, good skin elasticity, and thinner facial structures.

Advantages:

• Shortest operative time among SMAS techniques
• Lower risk profile with minimal tissue manipulation
• Less invasive approach suitable for various patient types

Limitations:

• More limited lifting effect compared to other techniques
• May not be suitable for patients with significant tissue laxity
• Less effective for addressing advanced facial ageing

SMASectomy (SMAS imbrication)

Technique: SMASectomy involves surgical removal of predetermined SMAS tissue segments, followed by overlapping and suturing of the remaining edges. This technique allows for customised tissue removal based on individual anatomy, particularly focusing on redundant SMAS tissue overlying the anterior parotid gland area.

Ideal candidates: Patients with moderate facial ageing, heavier facial tissues requiring volume reduction, and those seeking more significant improvement than plication alone can provide.

Advantages:

• Powerful lifting effect comparable to more extensive techniques
• Allows for customised tissue removal and contouring
• Effective for patients with excess facial tissue

Limitations:

• Tissue removal is irreversible
• Requires precise surgical technique for optimal results
• Slightly higher risk of complications compared to plication

High SMAS (Extended SMAS)

Technique: High SMAS techniques involve extended dissection of the SMAS layer above the zygomatic arch level, allowing for comprehensive treatment of both the lower face and midface regions. This advanced technique requires elevation of the SMAS flap extending into the midface region, often with strategic release of retaining ligaments to enhance tissue mobility. This approach shares similarities with vertical facelift techniques in addressing midface concerns.

Ideal candidates: Patients with moderate to severe facial ageing, midface ptosis, and those seeking comprehensive facial rejuvenation. This approach is suitable for individuals willing to accept longer recovery periods for more extensive results.

Advantages:

• Comprehensive treatment of lower face and midface ageing
• Addresses multiple ageing components simultaneously
• Significant improvement in jawline definition and neck contours

Limitations:

• More complex surgical technique requiring advanced expertise
• Higher cost due to surgical complexity
• Requires careful patient selection

A recent study of 325 patients undergoing High SMAS techniques (2018-2022) demonstrated significant improvement in jawline and cervical angle definition with no major complications, supporting the effectiveness and safety of this approach.

When does Dr Turner choose a SMAS facelift over deep plane facelift?

The choice between SMAS and deep plane facelift techniques depends on individual patient factors, degree of facial ageing, and aesthetic goals. Successful outcomes depend heavily on appropriate patient selection and realistic expectations. Dr Scott J Turner evaluates multiple factors during consultation including facial anatomy assessment, ageing patterns, patient goals, health status, and risk tolerance to determine the most suitable approach.Dr Turner typically recommends SMAS facelift techniques in the following situations:

SMAS facelift is preferred for:

• Shorter recovery preference: SMAS techniques offer a significant advantage for patients who need to return to work or social activities more quickly. The less invasive nature typically results in reduced swelling and bruising, allowing most patients to resume normal activities within 2-3 weeks. This makes SMAS facelifts particularly suitable for professionals or individuals with busy lifestyles.
• Lower risk tolerance: Patients who prioritise safety benefit from SMAS techniques’ excellent safety profile. With temporary facial nerve injury rates of less than 1% and virtually no permanent nerve damage reported in large studies, SMAS procedures offer peace of mind for risk-averse patients. The superficial dissection plane avoids deeper anatomical structures where nerve complications are more likely.
• Revision facelift cases: SMAS techniques are Dr Turner’s preferred approach for patients requiring revision surgery due to altered facial anatomy from previous procedures. Prior surgery creates scar tissue and changes normal tissue planes beneath the SMAS layer, significantly increasing nerve injury risk with deeper dissection. The superficial SMAS approach allows effective rejuvenation while maintaining safety margins.
• Older patients with thinner SMAS: Advanced age often results in thinning of the SMAS tissue layer, making deep plane dissection technically more difficult and potentially less effective. SMAS plication or SMASectomy techniques can achieve excellent results while working within age-related tissue limitations. The superficial approach respects anatomical constraints while providing meaningful facial rejuvenation with enhanced safety.

Deep plane facelift may be recommended for:

• Comprehensive midface rejuvenation: When addressing volume loss, marionette lines, and cheek descent is essential for optimal results, deep plane techniques excel by targeting the deeper facial structures. This approach allows for restoration of youthful cheek position and volume while effectively softening deep nasolabial folds and marionette lines that cannot be adequately addressed with superficial SMAS techniques alone.
• Maximum longevity: Patients seeking the longest-lasting results may benefit from deep plane surgery’s potential durability, with studies suggesting 12-15 years of improvement compared to 8-12 years with SMAS techniques, though individual results vary significantly. The comprehensive repositioning of deeper facial structures may provide more stable, long-term support that resists the effects of continued ageing better than superficial approaches.
• Willingness for extensive surgery: Deep plane facelifts are suited for patients prepared for a more extensive procedure with longer recovery periods and slightly higher risk profiles. These patients understand that achieving maximum results requires accepting 3-4 weeks of recovery time and the minimal additional risks associated with deeper dissection in exchange for superior outcomes.
• Primary facelift in younger patients: Deep plane is Dr Turner’s preferred technique for first-time facelift patients in their 40s to early 60s who have good tissue quality and healing capacity. These younger patients benefit most from the comprehensive correction and maximum longevity that deep plane techniques provide, making it an excellent investment in long-term facial rejuvenation.

The decision ultimately depends on thorough facial analysis, patient goals, and individual anatomy. During consultation, Dr Turner evaluates skin quality, tissue elasticity, facial bone structure, and the specific pattern of ageing to recommend the most appropriate technique for optimal, natural-looking results.

Conclusion

SMAS facelift techniques represent the current standard of care in facial rejuvenation surgery, with the potential to offer patients natural-looking, long-lasting results through anatomically-based approaches. Understanding the differences between SMAS plication, SMASectomy, and High SMAS techniques enables informed decision-making about facial rejuvenation options.

The favourable safety profiles and high patient satisfaction rates associated with modern SMAS techniques make them attractive options for patients seeking facial rejuvenation. Success depends on proper patient selection, surgical expertise, and realistic expectations.

For patients considering SMAS facelift surgery in Sydney, Dr Scott J Turner provides comprehensive consultations at his Manly and Double Bay clinics, offering individualised treatment planning based on current evidence-based practices.

For more information about SMAS facelift options and to schedule a consultation, contact Dr Scott J Turner’s practice.

Disclaimer: Dr Scott J Turner is a specialist plastic surgeon registered with AHPRA. All surgical procedures carry risks including but not limited to infection, scarring, asymmetry, and nerve injury. Individual results vary and depend on multiple factors including healing capacity, skin quality, and adherence to post-operative care instructions. Recovery times vary between individuals, with pain tolerance and healing rates differing between patients. This information is for educational purposes only and does not constitute medical advice. A GP referral is required, and two consultations with a 7-day cooling-off period are mandatory before cosmetic surgery. A second opinion from another qualified medical practitioner is recommended.