Deep Plane Facelift vs SMAS Facelift: Differences, Suitability and Risks
In a deep plane facelift, the surgeon works beneath the SMAS layer, releases the face's retaining ligaments and repositions the skin and SMAS together as a single unit. In a SMAS facelift, the skin is separated from the SMAS, the SMAS is usually tightened with folding stitches (plication) or by removing a strip of it, and the ligaments are generally not released. Which technique suits you depends on where and how much the face has descended, your skin quality and your expectations, and is decided at consultation.
Why does the face sag? It is not only the skin, but the deeper support tissues
Facial sagging is caused not only by loosening skin but by the weakening and descent of the support layers beneath it. You can think of the face as a layered structure: bone at the base, then muscles, fat pads and a fibrous support network holding them together, and skin on top. With age, it is not just the outer skin that changes; these deeper structures also lose volume and shift position.
What is the SMAS layer?
The SMAS (superficial musculoaponeurotic system) is a fibrous support layer lying just under the skin that connects the facial muscles, fat and skin. When we are young, this firm layer holds the cheek fat, the jawline and the neck muscle in place. Over time, with gravity and collagen loss, the SMAS loosens as a whole, and because the skin is attached to it, the two descend together. This is a major reason for jowls along the jawline, deepening lines running from the nose to the mouth (nasolabial folds) and laxity in the neck.
What do the retaining ligaments do?
Retaining ligaments are strong fibres that anchor the SMAS and fat pads to the underlying bone and muscle coverings. The ligaments around the cheekbone (zygomatic) and the chewing muscle (masseteric) in particular determine the position of the midface and jawline. The key difference between facelift techniques is how the surgeon approaches these ligaments.
How is a SMAS facelift performed?
In a SMAS facelift, the surgeon first separates the skin from the SMAS, then tightens the SMAS as a separate layer and redrapes the skin independently. "SMAS facelift" is not a single operation but a family of techniques:
- Plication: the SMAS is folded and tightened with stitches without being cut.
- Imbrication: the SMAS is incised and lifted, advanced upwards, then trimmed or overlapped and stitched in its new position.
- SMASectomy: a strip of SMAS is removed and the edges are stitched together in a new position.
- Extended and high SMAS: the surgeon works more widely beneath the SMAS, and some ligaments may also be released, so these techniques sit between SMAS and deep plane approaches on a spectrum.
In methods such as plication and SMASectomy, the SMAS generally stays attached to the retaining ligaments and the tissue is tightened by pulling it back and up against them. Shorter operating time and working in a plane further from the facial nerve branches are advantages of these techniques. Their limitation is that movement may be more restricted in areas held by ligaments, such as the midface and deep nasolabial folds.
How is a deep plane facelift performed?
In a deep plane facelift, the surgeon does not separate the skin from the SMAS. Instead, the skin and SMAS are lifted together as a single composite flap, working in the natural gliding space beneath the SMAS. In this plane, the zygomatic and masseteric retaining ligaments are released in a controlled way.
Once the ligaments are released, the descended cheek and jawline tissues can be moved up and back, closer to their youthful position, and secured without being forced against the ligaments. The core idea is repositioning rather than pulling: the lifting load is carried by the deeper tissue rather than the skin, and the skin is closed with as little tension as possible.
Working in this plane requires detailed anatomical knowledge and experience, because branches of the facial nerve run nearby. For this reason, it is important that the technique is planned by a plastic surgeon who knows facial anatomy well and is used to working in this plane, based on a detailed facial assessment before surgery.
What is the difference between a deep plane and a SMAS facelift?
The main difference is the tissue layer the surgeon works in and whether the retaining ligaments are released. The table below summarises general tendencies; in every patient the technique is adapted to the surgeon's assessment.
| Feature | Deep plane facelift | SMAS facelift (plication / SMASectomy) |
|---|---|---|
| Tissue layer | Beneath the SMAS; skin and SMAS lifted together | Above the SMAS; skin and SMAS handled as separate layers |
| Retaining ligaments | Zygomatic and masseteric ligaments are released | Usually not released; tissue is pulled against the ligaments |
| Where the lifting load sits | Deep tissue (SMAS); aim is tension-free skin closure | SMAS stitches; skin needs separate, balanced tightening |
| Effect on midface and nasolabial area | More movement possible because ligaments are free | Effect may be more limited |
| Jawline and neck | The neck muscle (platysma) continues from the SMAS, so it can be lifted together | Effective on the jawline; extra neck work may be needed more often |
| Technical difficulty | Closer to facial nerve branches; requires experience | Works in a plane further from nerve branches |
| Operating time | Usually longer | Usually shorter |
| Recovery | Most patients return to social life in 2–3 weeks | Most patients return to social life in 2–3 weeks |
| Often considered for | Moderate to advanced sagging, marked midface and jawline descent | Mild to moderate sagging, patients wanting a more limited procedure |
Studies in the medical literature comparing deep plane and SMAS techniques for longevity or patient satisfaction do not show that one technique is clearly superior in every patient. What matters most is choosing the technique that fits the patient's anatomy and the surgeon's experience with it.
Natural results and the "pulled" look
A "pulled" or "wind-swept" appearance can occur with any technique when the lifting load is placed on the skin or the tissue is pulled too horizontally. The deep plane approach aims to reduce this risk by moving the load to the deeper tissue, but a natural result also depends on the direction of lift, how volume loss is addressed and tension-free skin closure. We cover this in more detail in our article on the natural-looking facelift.
Jawline and neck
The neck muscle (platysma) is the continuation of the SMAS in the neck. In a deep plane facelift, the outer part of the platysma can be lifted up and back while the cheek and jawline are repositioned, which helps improve the jawline-to-neck transition. However, if there are prominent vertical neck bands or fat under the chin, an additional procedure for the front of the neck may be needed whichever technique is chosen. For more on this, see can a facelift and neck lift be done together?
How long do the results last?
No facelift technique stops ageing: surgery turns the clock back, but the clock keeps running. Releasing the ligaments and securing the tissue without tension is thought to help results last longer, but longevity also depends on personal factors such as skin quality, weight changes, smoking, sun exposure and genetics. The effect is generally felt for many years in most patients, but it would not be right to give an exact figure for any individual, because the face continues to age from its new position.
Recovery, anaesthesia and hospital stay
The word "deep" can sound like a harder recovery, but in practice recovery times are similar for both techniques. Because the skin keeps its blood supply together with the SMAS in the deep plane approach, some surgeons report less swelling and bruising; this varies from person to person. The operation is performed in a hospital; general anaesthesia is usually preferred, and in suitable patients it can also be performed under local anaesthesia. The length of surgery depends on whether the neck and additional procedures are included, and the hospital stay is usually two nights.
Which technique may suit whom?
The technique is chosen according to where and how much the face has descended, skin quality and the patient's expectations; no single technique is right for everyone.
Situations in which a deep plane approach is often considered:
- Marked jowling with loss of jawline definition
- Deep nasolabial folds caused by descent of the midface
- Flattening over the cheekbones and a hollow feel in the cheeks
- Patients whose face and neck laxity need to be treated together
- Patients who have had a previous facelift and have sagged again (revision), where the plan is assessed separately because of scarring and tissue changes from the earlier surgery
Situations in which SMAS techniques are often considered:
- Mild to moderate sagging, mostly limited to the lower face and jawline
- Patients who prefer a shorter operation or for whom a more limited procedure is planned because of their general health
- Cases where a short-scar, limited procedure may be enough
If there is no significant sagging and the concern is mainly volume loss or expression lines, non-surgical options such as botox, fillers or facial fat injection may be discussed instead. In recent years, the trend has been towards using the deep plane technique more often than SMAS techniques. As a general framework, deep plane tends to be considered for patients with marked midface and jawline sagging, and SMAS techniques for more limited sagging concentrated in the lower face; however, the right method is decided at consultation, through facial analysis and a discussion of the patient's expectations.
What are the risks of deep plane and SMAS facelifts?
Both techniques are surgical procedures usually performed under general anaesthesia and carry similar risks, which should be discussed in detail at consultation.
- Haematoma (a collection of blood under the skin): the most common early complication of a facelift; high blood pressure can increase the risk, and it sometimes requires a return to theatre.
- Facial nerve involvement: weakness of the facial muscles is rare and usually temporary; permanent injury is even rarer. Because the deep plane approach works closer to nerve branches, anatomical experience is important.
- Numbness: numbness around the cheeks and ears is common and usually improves over months. Injury to the great auricular nerve, which supplies sensation to the ear, is a rare but possible risk.
- Scars and earlobe changes: in most patients the scars are hidden around the ear and along the hairline; scar quality varies from person to person. If the skin is closed under tension, the scar may widen or the earlobe may be pulled down.
- Skin circulation problems, infection, asymmetry and hair loss along the incision: skin circulation problems are markedly more common in smokers.
Results vary from person to person; which technique is used, and to what extent, is decided at consultation.
Planning a deep plane facelift in Istanbul from abroad
A deep plane facelift should be performed by a specialist in plastic, reconstructive and aesthetic surgery, in a hospital with an operating theatre and an anaesthesia team. Many plastic surgeons in Istanbul perform this technique; rather than focusing on a name, check whether you receive clear answers to these questions:
- Does the surgeon perform both deep plane and SMAS techniques, and can they explain why they recommend one for you?
- Is the source of your sagging (skin, fat, SMAS, ligaments, bone support) assessed separately at consultation?
- Is the need for additional procedures for the neck, eyelids or volume loss discussed?
- Are the risks, the recovery process and the follow-up plan explained clearly?
If you are travelling for surgery, plan your stay around recovery rather than around the operation date alone. The hospital stay is usually two nights. Self-dissolving stitches are usually used; if removable stitches are used, they are usually taken out around day 10, and your first check-ups take place in Istanbul. The NHS advises that you should not fly for 7 to 10 days after facial cosmetic procedures, because air travel after major surgery increases the risk of blood clots. Ask in advance how follow-up will be arranged once you are home, and who you should contact if you have a concern.
Assoc. Prof. Dr. Yalçın Bayram is a specialist in plastic, reconstructive and aesthetic surgery in Şişli, Istanbul, and performs surgical facelift techniques, including the deep plane facelift. For an overview of the techniques, see our facelift page; for his background, see about us. You can use the contact page to arrange a consultation.
What is assessed at consultation?
At consultation, the source and distribution of sagging, skin quality, volume loss and overall facial balance are assessed together to decide on the technique. Whether the sagging is concentrated in the midface, jawline or neck, skin elasticity, volume loss over the cheekbones and temples, bone support, facial symmetry and facial expressions are examined separately. General health, medications, smoking history and any previous aesthetic procedures are also reviewed. This information is considered together with the patient's expectations to discuss whether a deep plane, a SMAS technique or a more limited procedure is appropriate.
For the stages of the operation and a recovery timeline, see how a facelift is performed; for an objective checklist when comparing surgeons, see how to choose a facelift surgeon.
Frequently asked questions
Does a deep plane facelift last longer than a SMAS facelift?
Releasing the ligaments and securing the tissue without tension is thought to help results last longer, but comparative studies do not show a clear difference in every patient. Longevity also depends on personal factors such as skin quality, weight changes, smoking and genetics. No technique stops ageing.
Is a deep plane facelift riskier?
Because the deep plane approach works closer to branches of the facial nerve, it requires detailed anatomical knowledge and experience. In experienced hands, complication rates are reported to be similar to SMAS techniques. Nerve involvement is rare and usually temporary; the most common early complication with both techniques is haematoma.
Will my face look tight after a deep plane facelift?
The deep plane approach aims to avoid a tight look by placing the lifting load on the deeper tissue rather than the skin. A natural result also depends on the direction of lift, how volume loss is addressed and how the skin is closed. Swelling in the first weeks can cause a temporary feeling of tightness.
Is recovery different after deep plane and SMAS facelifts?
With both techniques, most patients return to social life within 2–3 weeks, and the final result usually settles within 3–6 months. Some surgeons report less swelling after a deep plane facelift, but the speed of recovery varies from person to person.
How long should I stay in Istanbul after a facelift?
The hospital stay is usually two nights. Self-dissolving stitches are usually used; removable stitches, if used, are usually taken out around day 10. The NHS advises not flying for 7 to 10 days after facial cosmetic procedures, so your length of stay should be planned with your surgeon at consultation.
Medical review: This article has been medically reviewed by Assoc. Prof. Dr. Yalçın Bayram, specialist in plastic, reconstructive and aesthetic surgery (Şişli, Istanbul). For his background and academic publications, see about us. This article is for general information; the right approach for you is decided at consultation.
