SMAS facelift techniques

What the SMAS is

The SMAS (superficial musculoaponeurotic system) is a continuous sheet that links the facial muscles to the skin and carries the cheek fat. Vladimir Mitz and Martine Peyronie described it from dissections in 1976 and noted that working under it was safe over the parotid gland in front of the ear and became dangerous further forward, where the facial nerve branches run (PMID 935283).

Lifting the SMAS moves the cheek and jowl tissue itself. In cadavers, lifts that tightened the SMAS raised the face vertically, and a skin-only lift tightened only horizontally (PMID 36332084).

Where it came from

• 1976: Mitz and Peyronie named the layer and showed it could be used in facelifts (PMID 935283).
• 1977: John Owsley lifted the SMAS and the neck platysma together as one flap (PMID 928549), and reported his longer experience with it in 1983 (PMID 6828592).
• 1977: Thomas Rees and Sherrell Aston did a sub-SMAS lift on one side of the face and a skin lift on the other, and observers saw no difference at late review; the study did not test the longer flaps that came later (PMID 928550).
• 1992: Fritz Barton released the deep attachments of the SMAS over the cheek muscles and improved the fold beside the mouth, an effect that seemed to last up to 4 years (PMID 1409995). His high SMAS flap, cut along the cheekbone arch, carried the lift into the midface (PMID 19332004, PMID 14663239).
• 1997: Daniel Baker described the lateral SMASectomy, a faster operation with flap-like pull (PMID 9252623); Thomas Baker and James Stuzin published their extended SMAS technique (PMID 9252622).
• 2009 and 2014: Rod Rohrich matched the SMAS method to each side of the face and added fat grafting into the cheek fat compartments, the lift-and-fill approach (PMID 19319074, PMID 24569422).
• Today plication is the most common method among board-certified plastic surgeons, followed by SMAS flaps, and fat grafting at the same operation is rising (PMID 38302713). Most surveyed facial plastic surgeons now perform the deep plane lift, a close relative (PMID 41251721).

How it is done

All SMAS lifts start with incisions around the ear and a skin flap. They differ in what is done to the SMAS underneath (PMID 38302713).

• Plication: the surgeon folds the SMAS on itself with stitches and does not lift it off the deeper layer, which keeps the dissection away from the facial nerve (PMID 36332084).
• Imbrication (SMAS stacking): the SMAS is cut, overlapped and sewn, which can add fullness over the cheekbone (PMID 19319074).
• Lateral SMASectomy: a strip of SMAS over the front edge of the parotid gland is removed and the mobile SMAS in front is sewn to the fixed SMAS behind; it combines the pull of a flap with the speed and safety of plication (PMID 18922307).
• SMAS-platysma flap: the SMAS and the neck muscle are lifted as one flap and advanced (PMID 928549).
• High SMAS: the flap is cut along the cheekbone arch so it lifts the midface, cheek and jawline as one unit (PMID 36563671).
• Extended SMAS: the dissection under the SMAS continues forward past the retaining ligaments that tether the cheek (PMID 41100833).

Recent variants move the plication closer to the mobile cheek fat (the Delta facelift) (PMID 37619977), use two SMAS slings to the temple and behind the ear (PMID 42192009), or perform plication and neck tightening under local anesthesia as an outpatient (PMID 42380310).

Who it suits

• Adults with jowls, a softened jawline and loose skin of the lower face and neck; the SMAS is lifted in almost every facelift done for these changes (PMID 38302713).
• The method is matched to the face. Every face is asymmetric, and Rohrich chose SMASectomy or stacking for each side according to how flat the cheek had become (PMID 19319074).
• Lateral SMASectomy is a quick, reproducible operation for carefully selected patients (PMID 18922307). In the high SMAS approach, a deeper fold beside the mouth led to a longer dissection (PMID 14663239).
• People who have lost cheek volume usually need fat grafting with the lift, whatever the SMAS method (PMID 36729730).

Results and how long they last

Head-to-head studies find little difference between methods. In a 1996 study, patients had a limited SMAS lift on one side and an extended SMAS or composite lift on the other: the more extensive side looked better on the operating table, and by 6 to 12 months reviewers saw no difference (PMID 8942899). A 2026 cohort comparing deep plane and SMAS plication found the same satisfaction, recovery time and complication rates (PMID 42384060). In cadavers, extended dissection added only a little lift over plication except in the lower face (PMID 36332084).

• Satisfaction was above 85% across SMAS techniques in a systematic review (PMID 38283861).
• Reviews have not shown that dissecting further forward improves the midface or makes the result last longer (PMID 41100833, PMID 36729730).
• How long it lasts: among patients who came back to the same surgeon for a second SMAS flap facelift, the average time between the two operations was about 12 years (PMID 20224461).
• In that group, about 1 in 5 came back within 5 years, most often because of loss of skin elasticity (PMID 20224461).
• After lift-and-fill, the fold beside the mouth improved by at least one grade in most patients (PMID 24569422).

Risks and how surgeons lower them

• Facial nerve: temporary weakness of a facial muscle followed about 2 in 100 high lateral SMAS and composite lifts, more than after plication; permanent injury did not differ between techniques (PMID 30768122). Across SMAS techniques, temporary nerve injury was under 1 in 100 and permanent injury was rare (PMID 38283861).
• Surgeons lower nerve risk by staying in the right layer: over the cheekbone arch the forehead branch lies under a separate deeper fascia, so the high SMAS cut along the arch is safe (PMID 20335873).
• Hematoma: major bleeding under the skin was most frequent after imbrication, at about 2 in 100 (PMID 30768122). Stitches that close the space under the neck skin are one added step to lower it (PMID 40719487).
• Skin necrosis, loss of an area of skin, was most frequent after the SMAS flap, at about 1.6 in 100 (PMID 30768122).
• Cross-cheek depression (the "joker line"), a groove from the mouth corner toward the ear, makes a face look pulled. Most patients who develop it show a version before surgery, so it can be spotted at the consultation; it is treated by filling the groove with volume (PMID 18971739).

Recovery

• Recovery took about 4 weeks after both SMAS plication and deep plane in a prospective comparison (PMID 42384060).
• On the operating table the more extensive lift looks better; swelling then hides the shape, and the result is judged at 6 to 12 months (PMID 8942899).
• SMAS plication with neck tightening can be done under tumescent local anesthesia with light sedation as needed, with patients going home the same day (PMID 42380310).

Questions to ask a surgeon

• Ask which SMAS method is planned for each side of the face, and why (PMID 19319074).
• Ask how long results last in the surgeon's own patients and when they come back for a second lift (PMID 20224461).
• Ask how often the surgeon sees temporary facial weakness with the chosen method (PMID 30768122).
• Ask whether fat grafting is planned for lost cheek volume (PMID 24569422).
• Ask the surgeon to check for a cross-cheek groove before surgery (PMID 18971739).

Open questions

• Extent of dissection against result: cadaver gains from extended work are small (PMID 36332084), and clinical comparisons show similar results at 3 months (PMID 42384060) and 1 year (PMID 8942899).
• Durability: no randomized long-term comparison of SMAS methods exists (PMID 41100833).
• Nerve risk rises with deeper and more forward dissection (PMID 30768122).
• Treating the SMAS with light to make it hold sutures better has been tested only in the laboratory (PMID 41322035).

Terms

• SMAS: superficial musculoaponeurotic system, the fibrous and muscle layer under the facial fat (PMID 935283).
• Plication: folding the SMAS on itself with stitches, without lifting it (PMID 36332084).
• Imbrication (SMAS stacking): cutting the SMAS and overlapping the edges (PMID 19319074).
• Lateral SMASectomy: removing a strip of SMAS over the front edge of the parotid gland (PMID 18922307).
• High SMAS: a SMAS flap cut along the cheekbone arch to include the midface (PMID 36563671).
• Extended SMAS: a SMAS flap dissected forward past the retaining ligaments (PMID 41100833).
• Skin-only lift: a skin flap with no SMAS work, now a small share of facelifts (PMID 38302713).
• Joker line: a cross-cheek groove from the mouth corner toward the ear (PMID 18971739).

Papers