What Is the Difference Between a Deep Plane and a SMAS Facelift?

Good morning. I'm Dr. Shervin Naderi, a double board certified facial plastic surgeon who's been in practice for almost 25 years. When I started my career, we did facelifts differently, we did rhinoplasty differently, we did brow lifts differently.

Over the last 25 years or so, we have pioneered multiple changes to these techniques. What I do today with a facelift is very different than what I did 20-25 years ago. What I do with a rhinoplasty is very different. What I do with a brow lift is very different.

Eyelid surgery hasn't changed much. Believe it or not, even lasers haven't changed that much. But that's a whole different topic. I want to today focus on facelift because over the last quarter century, what I've noticed is people coming asking for an actual procedure instead of actually going to the expert and saying, what do I need?

So it's our job to examine the patient and come up with solutions. Today, patients come in asking for an exact procedure or exact device. They're going, I want this. I want a deep plane facelift.

Even the deep plane surgery has changed compared to what it was many years ago. So let's talk about that. One of the biggest misconceptions is what is a deep plane facelift versus what's a SMAS facelift? So I'm not going to even talk about a skin-only lift because that was before my time, before I was a resident.

Surgeons used to just basically lift the skin and pull it back and it had a very weird look. If you look at very, very old people from who had facelifts 30, 40 years ago, basically layer one of their face was pulled up, pulled back and it kind of had that look to it. It was a terrible procedure. So we're going to use the layers of the face.

Layer one is skin and over here's ear, over here's mouth because the incision is made by the ears and the dissection is carried towards the mouth and that's what I have here, skin versus mouth. So what I want to show you is the different layers and how different surgeries are done. Layer one and layer two. Layer two is basically the subcutaneous fat, the little layer of fat that's stuck underneath the skin.

Those two for all practical purposes are connected to each other. They shouldn't be separated. When it comes down in the neck many years ago, we used to do liposuction to that layer two. I almost never do that anymore.

The dissection in the neck is deeper. It's going below that subcutaneous fat area. But many, many years ago, if somebody came in with fullness there, liposuction was a thing. Still today many surgeons do it.

It's not the right approach for most people. But in the face, which we're talking about, layers one and two are basically connected. So in a skin only lift that was elevated, pulled back and you had this weird look. Now, what's a SMAS lift?

Layer three is your SMAS. So layer three is where the term SMAS is thrown out there. And in a SMAS lift where I trained many years ago, where a lot of surgeons still to this day do that surgery and to perfectly fine surgery, it was powerful for correcting jowls. It did much less in the neck.

It did much less to almost nothing in the mid-face and cheeks. So that was a whole different procedure. But for jowls, it was great. And again, there's a lot of surgeons that still do a SMAS lift.

But what is it? So in a SMAS lift, layers one and two, the skin and subcutaneous fat are elevated in a large flap. Large flap, almost all the way to here. From the ears, almost all the way to here, all that skin is elevated down the neck as well.

That's elevated. And then a little bit of the SMAS layer is lifted. So a little bit of SMAS layer is lifted. A lot of skin and subcutaneous fat is lifted.

But that little layer of SMAS that's lifted, now you're putting tension on it, pulling it back. And the skin and subcutaneous fat is going to go with it because the tension is now on the SMAS layer. But again, you're only dissecting the SMAS a little bit. You're dissecting the skin a lot.

You're dissecting the SMAS a little bit. And you're pulling it. A lot of pull, a lot of tightness. You're really putting strong stitches to kind of basically correct the jowls.

And that's what I did 20 years ago, 15 years ago, 10 years ago. That was the procedure that we did. What's a deep plane? A deep plane is the exact same planes.

It's just a different extent of the dissection. It is not deeper. The word deep is a misnomer. It's wrong.

We're not going deeper. We're going farther. So in a deep plane, two things are happening. The dissection underneath the SMAS is much more.

In the SMAS lift the dissection is this much. In a deep plane, the dissection is a lot. It's almost all the way to the mouth. Almost all the way to the mouth.

The modiolus. That's what's happening. However, the beauty of a new composite deep plane, the new way of doing deep planes, composite deep planes is that the skin is not lifted that much. Layers one and two is lifted just a little bit.

And then immediately we dive under layer three, which is actually inside layer four. Layer four is that glide plane where things glide. So we're underneath the SMAS and then we keep going and going and going and going. Why do we keep going?

Because there are ligaments attaching and tethering things. And without releasing those ligaments, you just don't get the proper release. That's it. That's the reason you want to keep going until you get to these release points and release those ligaments.

So that's why you get a better result, a better surgery with a deep plane. It's more risky. We are dissecting all the way out to where the little fine branches of facial nerve are coming to muscles. That's why it's incredibly important to have somebody who understands the anatomy.

It is a more meticulous surgery. It is a higher risk surgery. It is a more costly surgery because of these reasons, but it results in better outcome because you're not separating the skin from the underlying structure. You're keeping the skin attached.

The skin is healthier and you're moving everything as a composite unit this way. And you're moving it more. You're getting much more movement because you've released all those ligaments and the skin is going with it in a very nice, healthy fashion. So that is a deep plane.

Now, just to clarify, you may have heard the term SMAS lift, SMAS imbrication, SMAS plication. In a SMAS imbrication, the SMAS is lifted a little bit. In a SMAS plication, it's not even lifted. It's just puckered up and stitched.

And as you stitch it, it kind of pulls the SMAS a little bit. But the big difference is how much skin is elevated, how much SMAS is elevated. That's it. That's the difference and the ligaments that are released.

So in a SMAS lift, big skin flap, little SMAS flap. In a deep plane, little skin flap, big SMAS flap. All together as one unit, composite unit. The dissection is in layer four.

Layer five is deeper structures, deeper muscles, periosteum, deeper fascia. Totally separate issue. So I want you to understand the difference between these terminologies and procedures. Now you can go to five surgeons.

All of them say I do a SMAS lift. All of them say I do a deep plane facelift. They will all do it differently. We don't use the same sutures.

We don't use the same methods for elevation. We don't use the same extent of the dissection. All of us are different. So you have to just pick and choose which surgeons work you like best, which surgeon you think is more experienced, which one has more gray hair, et cetera.

That's how you're choosing your surgeon. If you just go by terminology, deep plane, it's different. It's not like a Toyota Camry. Five Toyota Camrys are exactly the same thing.

But when you say deep plane, you're just getting a car. Which car you're getting depends on the skills of the surgeon. Anyway, I hope this helps.