By Charles H. Thorne, MD
The right facelift technique depends on your anatomy. The choice between a deep plane lift, a SMAS flap or a SMAS plication is driven by anatomic factors such as skin type, facial shape (full vs. thin), the amount of skin laxity you have and previous facelift procedures. It is also driven by your individual aging pattern and your age. A patient at the younger end of the facelift spectrum who does not have abundant loose skin is often better served by the deep plane lift. A patient with more skin laxity may do better with a dual plane (SMAS flap) procedure. Finally, very thin patients who have had previous facelifts may be best suited for SMAS plication. The consultation is where you and I examine your face together and match the technique to your anatomy.
A consultation can be arranged at (212) 794-0044, 812 Park Avenue, New York, NY 10021, in person at 812 Park Avenue or by virtual consultation.
Key Takeaways
- The choice of facelift technique is ideally based on your anatomy; there is no one operation for everyone.
- Deep plane facelifts suit patients at the younger end of the spectrum with less skin laxity or patients whose skin type is thicker and facial aging pattern less advanced.
- Dual plane procedures like SMAS flap and SMAS plication techniques address faces with more skin laxity.
- A surgeon who performs all three techniques can explain which one fits your face and why.
- Every patient is unique, and the technique that works for one person may not be ideal for another.
What Are the Main Facelift Techniques?
The American Society of Plastic Surgeons defines a facelift, or rhytidectomy, as a surgical procedure to improve visible signs of aging in the face and neck. The difference between various facelift techniques is how much dissection and lifting is done in each plane. The three main approaches to the cheek are the deep plane facelift, the SMAS flap and the SMAS plication.
In a deep plane facelift, the skin and the SMAS (the layer of tissue beneath the skin) are lifted together as one unit. In a SMAS flap procedure, the skin is separated from the SMAS, the SMAS is lifted and repositioned, and then the skin is redraped. In a SMAS plication, the skin is separated from the SMAS and then the SMAS is folded and sutured in place without being separated from the deeper structures, and the skin is redraped over it.
Each technique addresses a different anatomic situation.
How Does Anatomy Determine the Right Technique?
A published classified approach to endoscopic deep plane facelift planning categorizes patients into groups based on facial aging patterns and anatomical needs.
The key factors are skin laxity and how far the deeper tissue has descended. Patients who are at the younger end of the facelift spectrum, age 35 to 50, who do not have abundant loose skin may be better served by the deep plane lift. A published critical review of 78 surgical facial rejuvenation procedures with deep plane technique found that deep plane rhytidectomy has proven to be an effective facelift technique only in cases of faces with less skin and less SMAS laxity.
When there is more skin laxity, a technique with more skin undermining such as a SMAS flap or SMAS plication technique allows the skin to be redraped independently of the deeper tissue. This addresses the excess skin and the deeper descent separately, which is often the right match for an older face or one with more sun damage. Since aging skin sags more than the underlying tissue, it stands to reason that tightening the skin more than the deeper tissue is appropriate and that can only be done if the skin is separated from that deeper tissue.
What Does a Deep Plane Facelift Address?
One surgeon quoted by the American Society of Plastic Surgeons describes that the deep plane facelift is ideal for patients with heavy nasolabial folds, marionette lines, jowls and platysmal bands. In my practice I have found that lifting the face as one unit can reduce tension on the skin, which can lead to a more natural result and avoids the overly pulled look. In my practice I have found that this can lead to faster healing, less bruising and fewer subcutaneous irregularities.
The more limited skin separation from the underlying tissues leaves less of a space for blood to collect and decreases the risk of such a collection, known as hematoma, the most common complication of a two-layer facelift. In addition, it is faster to perform. In my practice I have found that the risk of hematoma may be less in deep plane lifting. The thing to remember in the deep plane vs SMAS decision refers only to the cheek. The neck part of the procedure may be exactly the same in the two procedures so the incidence of hematoma in the neck would not be different.
The deep plane procedure does have some advantages, so it has enjoyed a renaissance since its original description almost 40 years ago. Every patient is unique, and a deep plane facelift is fantastic for many patients.
What Does a SMAS Flap Address?
The SMAS flap procedure is a two-plane operation meaning that it separates the skin from the SMAS and lifts both layers separately. This approach addresses both the deeper tissue descent and the skin laxity independently. It suits patients with more skin laxity.
The SMAS flap allows the surgeon to tailor the lift in two layers, which can be an advantage when the skin and the deeper tissue have aged at different rates. The differential lifting of the two tissue layers makes it especially versatile.
What Does a SMAS Plication Address?
In a SMAS plication procedure, the skin is separated from the underlying SMAS and then the SMAS is folded on itself without dissecting in the deep plane. The skin is then redraped over it. This technique involves less dissection than a SMAS flap. In my practice I tend to use it in patients who have very thin tissues and have had previous facelifts.
It addresses the same areas as the other techniques but with less dissection and there is no proof that it is inferior in any way.
When Is a Neck Lift the Right Choice?
Except in young patients having a mini lift, most patients who have a facelift have a neck lift at the same time. The reverse is also true, most patients whose primary complaints are in the neck have a cheek lift at the same time. Some young patients who have a heavy neck undergo an isolated neck lift but most patients in the facelift age group have a cheek lift at the same time. Of course, patients differ in their aging patterns and the amount of intervention in the cheek vs the neck differs in every patient.
The consultation is where you and I examine your face and neck together and decide on an appropriate plan.
Who Is a Good Candidate for Facelift Surgery?
The American Society of Plastic Surgeons describes that in general, good candidates for a facelift include healthy individuals who do not have medical conditions that impair healing, nonsmokers and individuals with a positive outlook and realistic expectations. A published report describes that patients with severe systemic diseases, such as heart failure, renal failure and poorly controlled diabetes are not candidates for facelift surgery. Additionally, patients with skin disorders, such as Ehlers-Danlos Syndrome, progeria and elastoderma can experience severe wound healing issues and are not candidates for rhytidectomy according to that source.
Given reasonable overall health, two critical parts of the medical history are presence or absence of high blood pressure and medications that affect blood clotting.
What Happens During Recovery?
Recovery milestones are similar across facelift techniques. A bandage is placed around your face to minimize swelling and bruising. Small tubes may be present to draw off any excess blood or fluid.
Many surgeons, including me, have patients spend the first night after a facelift under the care of medical professionals, either in a hospital, surgical facility or a hotel with a private duty nurse. Patients generally report some discomfort for 3 to 5 days post-operatively. The dressing is somewhat uncomfortable and our nurses remove it upon arrival to the hotel after surgery. The nurses remove any drains on the first post-operative morning before I arrive to check on the patient. If the patient has a hemostatic net in place, that is removed on the second post-operative day.
I remove two thirds of the sutures/staples after 5 days and the final third between post op day 10 to 14.
The Cleveland Clinic reports that after your facelift surgery, you will experience bruising and swelling that will last for about two to three weeks. We tell patients that they can return to unrestricted activity and exercise after 3 weeks. Occasionally there is still a lingering bruise somewhere at that time but in most cases the bruising has disappeared by then.
The NHS reports that it takes about 2 to 4 weeks to fully recover from a facelift. Bruising is visible for at least 2 weeks.
Some swelling is present for several more weeks. In fact, the patients often like it because it temporarily hides some of the fine wrinkles which will reappear over the first 6 weeks as the swelling disappears.
Results vary. The timeline above is a general guide, and your own recovery depends on your health, your age, the extent of the operation and how you heal.
Risks and Complications
Risks are discussed at consultation and depend on your individual health, your anatomy and the extent of the operation. The most common complication is a hematoma, a collection of blood, which occurs in approximately 1 percent of patients in my practice and is managed by returning to the operating room to remove some sutures, drain the blood and re-suture the area. Risk factors for hematoma are high blood pressure and medications that affect blood clotting, explaining why your doctor will pay particular attention to those issues.
The most dreaded complication is nerve injury, which results in asymmetrical facial movement, and occurs in approximately 0.1 percent of cases, with most nerve injuries being temporary. Permanent nerve injury creating facial asymmetry is slightly more common in the deep plane facelift but in experienced hands it is rare.
Delayed healing behind the ears occurs in 4 percent. While patients always ask about scar location, facelift scars are usually a non-issue. Well-placed incisions on the face that are closed without tension almost disappear over time.
When to Call
The nurses will call me immediately if there is any change in facial swelling suggesting a hematoma. Once you are no longer under the care of a nurse, you will have my cell phone number and should call me with any concerns. Hematomas have been reported up to 10 days post-operatively although the vast majority occur within the first 24 hours.
How Do I Choose a Surgeon?
Make sure your plastic surgeon is board-certified by the American Board of Plastic Surgery, or an equivalent certifying board, and has extensive experience specifically with facelift surgery. Seek a surgeon who can perform all of the major facelift techniques and can explain which one best fits your face.
Some surgeons use the same technique in every patient and show excellent results, so there is some truth to the statement that the surgeon is more important than the technique. That said, I try to vary the technique to fit the patient rather than fit every patient into one technique. You may have heard the expression, “If you have a hammer, the whole world looks like a nail.” A consultation with a knowledgeable plastic surgeon will help you determine whether the deep plane approach, a SMAS flap or a SMAS plication, and what type of neck lift, is the best match for you.
Frequently Asked Questions
Which facelift technique lasts the longest?
The longevity of a facelift depends more on your anatomy, your skin quality and how you age than on the technique. All three techniques can produce long-lasting results when matched to the right patient. The consultation is where you and I discuss your goals and your anatomy and decide which approach is likely to give you the result you want. We studied 100 consecutive facelift patients in our practice and, on average, the patients thought they looked 10 years younger after the procedure.
Is the deep plane facelift safer than other techniques?
In my practice I have found that the risk of cheek hematoma is less in deep plane lifting. But hematomas more frequently occur in the neck and that is unrelated to what was done in the cheek (Deep plane vs other techniques). A published meta-analysis of 183 facelift studies, however, found an increase in major hematoma for the deep plane technique (1.22 percent). Permanent nerve injury creating facial asymmetry is slightly more common in the deep plane facelift but in experienced hands, it is very rare. Safety depends on the surgeon’s experience and on matching the technique to your anatomy.
Can I have a facelift if I am under 50?
Patients who are at the younger end of the facelift spectrum, age 35 to 50, who do not have abundant loose skin may be better served by the deep plane lift. Age is not the only factor. The decision depends on your anatomy, your skin quality, how far the tissue has descended and your goals. The consultation is where you and I examine your face and decide whether a facelift, a neck lift or a smaller procedure is the right match.
What if I only want my neck lifted?
Some patients need more work on the neck than on the face. When the primary concern is neck bands, loose skin under the chin or a heavy neck, a neck lift may be the right operation. A cheek lift is almost always performed at the same time and helps redistribute the excess neck skin better than if the neck was done alone.
How long before I can return to work?
Cleveland Clinic reports that most people who have more invasive facelifts can return to work in two to three weeks. The NHS reports that it takes about 2 to 4 weeks to fully recover from a facelift. Your own timeline depends on your health, your age, the extent of the operation and how you heal.
Will my scars be visible?
The incisions are placed in the natural creases around the ear and in the hairline. After several weeks, bruises, scars and changes to your skin color should have faded according to the NHS. Most scars fade over time and are well hidden by the hair and the natural contours of the ear.
Next Steps
The consultation is where you and I examine your face together, discuss your goals and decide which technique is the best match for your anatomy. Everyone wants a youthful yet natural look, and understanding facelift techniques can help you see how the right approach contributes to that goal.
To arrange a consultation, call (212) 794-0044 or visit the office at 812 Park Avenue, New York, NY 10021. Virtual consultations are also available. Office hours are Monday to Friday, 9 AM to 5 PM. Our staff will respond within 24 hours during normal business days.
Sources
- Critical Review of a Series of 78 Surgical Facial Rejuvenation Procedures With Deep-plane Technique (National Center for Biotechnology Information (NCBI) / PMC)
- Deep Plane Facelift – StatPearls (NCBI Bookshelf)
- Facelift (Rhytidectomy): What Is It, Recovery & What to Expect (Cleveland Clinic)
- Facelift Surgery (American Society of Plastic Surgeons)
- Facelift Recovery (American Society of Plastic Surgeons)
- Facelift Candidates (American Society of Plastic Surgeons)
- Facelift roulette: Which option has the best odds of meeting your desired look postop? (American Society of Plastic Surgeons)
- Facelift (rhytidectomy) (NHS (UK National Health Service))
- A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques (Aesthetic Surgery Journal)
- Endoscopic Deep Plane Facelift: A Classified Approach. (PubMed)
