Ari Wes, M.D., M.S., is a plastic surgeon and the founder of Wes Plastic Surgery, a facial aesthetics practice in San Francisco. He earned his M.D. and M.S. at the University of Pennsylvania and completed his plastic surgery residency and chief residency at the Hospital of the University of Pennsylvania. He has authored more than 50 peer-reviewed publications and focuses on facial aesthetic surgery, including facelift, rhinoplasty, and eyelid surgery.
Deep Plane vs. SMAS Facelift: Which Is Right for You?
Most patients who sit down in my office at Wes Plastic Surgery have already read something about deep plane facelifts. They’ve seen the term online and they know it’s supposed to be “better,” but they aren’t sure why, or whether it matters for their face specifically. I’m glad patients are researching technique, because it’s the single most important variable in your result. But the internet tends to present this as a binary, deep plane good, SMAS bad, and the reality is more nuanced than that.
I perform the deep plane technique for the majority of my facelift patients. I have clear reasons for that preference, and I’ll explain them. But I also want to be honest about what SMAS techniques do well, because dismissing them entirely would be intellectually dishonest.
The Anatomy You Need to Understand
The SMAS is the layer that matters in facelift surgery. It stands for superficial musculoaponeurotic system, which is a fibrous sheet of tissue and muscle that sits beneath the skin and subcutaneous fat. It connects to the platysma in the neck and the muscles of facial expression. When your face ages, it’s largely the SMAS and the fat compartments sitting on it that have descended.
Every facelift technique worth discussing addresses the SMAS. The question I focus on with patients is how.
What SMAS Plication and Imbrication Do
In plication, the surgeon folds the SMAS over on itself and sutures it in its new position. In imbrication, a strip of SMAS is removed and the remaining edges are sutured together. Both approaches tighten the SMAS from above without lifting it off the deeper structures.
I trained in these techniques and I’ve seen good results from them, particularly in patients with milder laxity. The operative time is shorter, the dissection is less involved, and for a patient with early jowling and a relatively preserved midface, the result can be quite nice.
Where I see these techniques fall short is in the patients who make up the majority of my practice: people with meaningful midface descent, deeper nasolabial folds, and established jowling. Plication and imbrication tighten the SMAS where it currently sits. They don’t move it back to where it was. For a face that has descended significantly, tightening tissue in a displaced position doesn’t address the root of the problem. It makes things tighter, but not necessarily more youthful. And that’s the distinction that matters.
Why I Prefer the Deep Plane Approach
When I perform a deep plane facelift, I go beneath the SMAS. I release the retaining ligaments, the zygomatic and masseteric ligaments specifically, that anchor the SMAS to the underlying bone. Once those are released, I can reposition the entire SMAS-platysma complex as a single, composite unit.
The reasons I find this approach superior come from what I observe in the operating room and in long-term follow-up, not just from the literature.
Because the skin stays attached to the SMAS throughout the dissection, I’m not elevating them as separate layers. The blood supply to the skin runs through the SMAS, and keeping them connected preserves it. This is counterintuitive, because a deeper dissection sounds riskier, but the opposite tends to be true. I see very low rates of skin healing complications with this technique, and I think the preserved vascularity is a significant part of why.
The repositioning of volume is what I find most clinically meaningful. The malar fat pad sits on the SMAS in the cheek region. When I elevate the SMAS flap, that fat pad comes with it and moves back to a higher, more youthful location. This restores midface fullness in a way that SMAS tightening alone cannot replicate. When I examine a patient whose previous facelift looks tight but flat, this is almost always the explanation. The tissue was tightened but the volume was never returned to where it belonged.
The skin closure is the part patients feel most directly. Because the structural correction is happening at the SMAS level, the skin simply drapes over a repositioned foundation. I’m not pulling it tight. I’m laying it down over tissue that has already been moved. That’s why deep plane results avoid the “pulled” quality that people associate with facelifts. The skin isn’t under tension because it doesn’t need to be.
What I See Over Time
The difference between these techniques becomes most apparent at three, five, and ten years. I follow my patients long-term, and what I notice is that deep plane results maintain their correction in a way that SMAS plication results often don’t.
The reason is structural. A plicated SMAS is being held in position by sutures. Over time, those sutures can loosen, the tissue can stretch, and gravity continues to pull. A repositioned SMAS-platysma flap heals into its new position. The correction is maintained by tissue integration, not just suture strength.
The published research confirms this. Studies comparing long-term outcomes show better maintained correction with deep plane techniques at five-plus years. But I don’t need to cite the literature on this one. I see it in my own patients. When a deep plane patient comes back at year five, they still look like their one-year photo with some softening. When I’ve examined patients who had plication elsewhere and come to me for revision at year four or five, the correction has often significantly relaxed.
When SMAS Techniques Make Sense
I don’t want to give the impression that I think SMAS plication is a bad operation. For the right patient, it’s a reasonable choice. Someone in their late forties with early jawline softening, good midface volume, and minimal neck laxity might get a result from plication that’s indistinguishable from what a deep plane approach would achieve, with a shorter surgery and a slightly easier first two weeks of recovery.
The problem is when plication is applied to faces that have descended beyond what it can meaningfully correct. And in my experience, most patients who’ve reached the point of seriously considering a facelift have more going on than early softening. They’ve lost midface volume. They have real jowls. The neck has changed. For those patients, and that’s the majority of people sitting in my consultation room, the deep plane technique produces a qualitatively different result.
What Even a Deep Plane Facelift Can’t Do
A deep plane facelift is the most comprehensive facelift technique I know of, but its scope is still defined. It addresses the midface, lower face, and neck. It doesn’t touch the eyelids, the brow, or the skin texture. Patients with significant periorbital aging often benefit from combining a facelift with blepharoplasty, and I discuss this during consultation when it applies. Skin quality is also a real limit. In patients with very thin, heavily sun-damaged skin, even excellent structural repositioning can be constrained by the skin’s ability to drape smoothly. The SMAS work can be flawless and the skin still limits the final result. This is something I’m honest about before surgery, not after.
How I Make This Recommendation for You
I don’t have a one-size-fits-all answer. I examine your face, I assess the degree and location of descent, I look at your skin quality and your midface volume, and I make a recommendation based on what I think will give you the most natural, longest-lasting result. Sometimes that’s a deep plane facelift. Occasionally it’s something more conservative. And I explain my reasoning either way, because I think you should understand why I’m recommending what I’m recommending.
If you’re trying to decide between approaches and want to hear a specific recommendation for your anatomy, that’s the conversation I have every day at Wes Plastic Surgery, and I’m happy to have it with you. Contact us today to learn more.