Deep Plane vs. SMAS Facelift: Which Is Better?

Key points

Both techniques lift the deeper support layer of the face (the SMAS), not just the skin. They differ in how that layer is handled.
In head-to-head studies, including a randomized split-face trial and a study in identical twins, neither technique was clearly better for every patient.
Deep plane lifts needed fewer touch-up procedures in one large series and had slightly higher patient satisfaction in pooled data.
Permanent facial nerve injury is rare with both: about 0.05% in pooled data from more than 15,000 patients.
The right technique depends on your anatomy and on your surgeon's training and experience with it.

What is the SMAS?

Under the skin and fat of the cheeks lies a firm sheet of connective tissue that continues into the platysma muscle of the neck. Surgeons call it the SMAS, short for superficial musculoaponeurotic system. With age, this layer and the fat it carries slide downward. That descent is what you see as jowls, deeper folds beside the mouth and a softer jawline.

The first facelifts tightened only the skin. Skin stretches, so a skin-only lift tends to look tight and relax early. Modern facelifts reposition the SMAS and let the skin redrape over it without tension. Both techniques in this article do exactly that.

How a SMAS facelift works

In a SMAS facelift, the skin is lifted off the SMAS first, and the two layers are handled separately. The surgeon then tightens the SMAS in one of three ways:

Plication: the SMAS is folded on itself and stitched, without cutting it.
SMASectomy (imbrication): a strip of SMAS is removed and the edges are sewn together.
SMAS flap: the SMAS is lifted as its own layer and anchored higher.

The skin is then laid back down and the excess is trimmed.

How a deep plane facelift works

The deep plane facelift was described by Dr. Sam Hamra in 1990¹. Instead of separating skin from SMAS across the cheek, the surgeon works underneath the SMAS and releases the attachments that tether it to the deeper face. Skin, cheek fat and the SMAS-platysma layer then move together as one thick flap.

Hamra designed the operation to improve the folds between the nose and the mouth, which earlier facelifts changed very little¹. In a cadaver study, a deep plane release also let the neck muscle move several times farther than SMAS plication did².

Do the results differ? What the studies show

Several studies have compared the techniques directly, and most found less difference than you might expect:

A randomized split-face study of 21 patients performed a limited or conventional SMAS lift on one side of the face and an extended SMAS or composite lift (a deep plane variant) on the other. Three independent surgeons could not detect a difference between the two sides in photographs taken 6 and 12 months later³.
A masked comparison of 40 patients found that deep plane lifts did not score better than SMAS plication in patients younger than 70. In patients aged 70 to 80, deep plane scored slightly higher⁴.
A study of eight pairs of identical twins, operated on with four different techniques, found that no single technique produced a superior result when it was matched to the right patient⁵.
A 2026 randomized trial assigned 30 women to deep plane, high SMAS or plication facelifts. All three made patients look younger to 200 independent raters, with no statistical difference between the techniques⁶.

Other data favor the deep plane. In one surgeon's series of 634 facelifts, a later “tuck-up” procedure was needed after 11.4% of SMAS lifts and only 3.3% of deep plane lifts⁷. A 2025 meta-analysis of 21 studies and 2,896 patients found patient satisfaction of 94.4% after deep plane and 87.8% after SMAS facelifts⁸. Both numbers are high.

A systematic review in Plastic and Reconstructive Surgery concluded that high-quality comparative data were lacking and called for better trials⁹. More than a decade later, recent reviews still ask for longer follow-up.

Is one safer than the other?

The main concern with a deeper dissection is the facial nerve, which runs beneath the SMAS and moves the muscles of expression. The published data are reassuring for both approaches:

A meta-analysis of 183 studies found that the risk of permanent nerve injury did not differ among facelift techniques. Temporary weakness was most frequent with high lateral SMAS (1.85%) and composite lifts (1.52%). Major hematoma, which is bleeding under the skin, was more frequent with deep plane (1.22%) and SMAS imbrication (1.92%) than with plication¹⁰.
Pooled data from 15,404 facelift patients put motor nerve injury at 0.66% overall and permanent motor nerve injury at about 0.05%¹¹.
A 2026 meta-analysis limited to deep plane facelifts (45 studies, 10,784 patients) reported temporary facial nerve injury in 1.2%, hematoma in 1.8% and no permanent facial nerve injuries¹².
In an academic-center review of 229 facelifts, complication rates were not statistically different between lifts performed under the SMAS and skin-level lifts with or without plication¹³.

One 2025 meta-analysis did report a higher overall complication rate after deep plane (17.2%) than after SMAS facelifts (10.3%)⁸. Studies define “complication” differently, which makes these totals hard to compare.

No operation is free of risk. At your consultation we go over the risks that apply to you, including bleeding, infection, scarring, nerve injury and anesthesia.

Deep plane vs. SMAS at a glance

	SMAS facelift	Deep plane facelift
How it lifts	Skin and SMAS are separated. The SMAS is tightened on its own.	Skin, fat and SMAS are released and lifted together as one unit.
What studies suggest	Scored as well or better in patients under 70 in one masked comparison⁴.	Designed for the folds beside the mouth¹. Fewer touch-ups in one large series⁷.
Patient satisfaction (pooled)	87.8%⁸	94.4%⁸
Temporary nerve weakness	Under 2% in pooled data¹⁰	About 1.2% in pooled data¹²
Permanent nerve injury	Rare: about 0.05% across techniques¹¹	Rare: about 0.05% across techniques¹¹

Which facelift is right for you?

The name of the technique matters less than whether it fits your face. These are the things I look at in a consultation:

Where aging shows most: the jowls and jawline, the folds beside the mouth, the cheeks or the neck.
The thickness and quality of your skin and the tissue under it.
Whether this is your first facelift or a revision.
Your health, your medications and the recovery time you can plan for.

The research supports fitting the operation to the patient. As the twin study concluded, there is no facelift technique suitable for every patient⁵. A surgeon's training and experience with the technique they recommend counts for more than its label.

Questions worth asking any surgeon you consult:

Which technique do you recommend for my face, and why?
How often do you perform it, and may I see before and after photos of patients like me?
What are the risks for me specifically?
Where is the surgery performed, and who provides the anesthesia?

Facelift consultations in Lincoln, Nebraska

I'm a board-certified plastic surgeon in Lincoln, and I see patients from Lincoln, Omaha and across Nebraska for facelift, neck lift and facial fat grafting. A consultation is the place to find out which approach suits your face. You can read more about my approach to facial rejuvenation, book a consultation or call (402) 489-4700.

Frequently asked questions

Is a deep plane facelift better than a SMAS facelift?

Not for everyone. Randomized and comparative studies, including one in identical twins, have not shown one technique to be clearly better across all patients. Deep plane lifts showed slightly higher patient satisfaction and fewer touch-up procedures in some studies. The best choice depends on your anatomy and your surgeon's experience.

Does a deep plane facelift last longer?

It may, but this has not been proven. One large series found fewer touch-up procedures after deep plane lifts (3.3% versus 11.4%). A randomized split-face study saw no difference at one year, and recent reviews still call for long-term comparisons.

Is a deep plane facelift more dangerous for the facial nerve?

Permanent facial nerve injury is rare with every modern technique: about 0.05% in pooled data from more than 15,000 patients, and a large meta-analysis found no difference between techniques. Temporary weakness, which recovers, occurs in roughly 1 to 2 percent.

How do I know which facelift technique I need?

You don't have to decide that yourself. At your consultation I examine your face and neck, listen to what bothers you, and recommend the approach that fits your anatomy and goals. I'll explain why, and what the alternatives are.

Where can I have a facelift consultation in Lincoln, NE?

At my office at 4130 Pioneer Woods Drive, Suite 1, in Lincoln, Nebraska. Call (402) 489-4700 or request an appointment online.

References

Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86(1):53-61. PubMed 2359803
Jacono AA, Parikh SS, Kennedy WA. Anatomical comparison of platysmal tightening using superficial musculoaponeurotic system plication vs deep-plane rhytidectomy techniques. Arch Facial Plast Surg. 2011;13(6):395-397. PubMed 22106184
Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg. 1996;98(7):1135-1143. PubMed 8942899
Becker FF, Bassichis BA. Deep-plane face-lift vs superficial musculoaponeurotic system plication face-lift: a comparative study. Arch Facial Plast Surg. 2004;6(1):8-13. PubMed 14732637
Antell DE, Orseck MJ. A comparison of face lift techniques in eight consecutive sets of identical twins. Plast Reconstr Surg. 2007;120(6):1667-1673. PubMed 18040204
Baptista VS, Mussalem MGVB, Ferreira LM, Carvalho Junior JDC. Perceived age reduction after rhytidoplasty: a randomized clinical trial comparing three surgical techniques using human and AI assessment. Facial Plast Surg. 2026;42(2):247-260. PubMed 41061760
Kamer FM, Frankel AS. SMAS rhytidectomy versus deep plane rhytidectomy: an objective comparison. Plast Reconstr Surg. 1998;102(3):878-881. PubMed 9727459
Khoury S, Almubarak Z, Khan H, et al. The deep plane versus SMAS facelift: a systematic review and meta-analysis. Aesthetic Plast Surg. 2025;49(21):5895-5903. PubMed 40801931
Chang S, Pusic A, Rohrich RJ. A systematic review of comparison of efficacy and complication rates among face-lift techniques. Plast Reconstr Surg. 2011;127(1):423-433. PubMed 21200240
Jacono AA, Alemi AS, Russell JL. A meta-analysis of complication rates among different SMAS facelift techniques. Aesthet Surg J. 2019;39(9):927-942. PubMed 30768122
Gandra G, Silva BS, Horta R. Facelift surgery and nerve injury: a systematic review and meta-analysis. Aesthetic Plast Surg. 2025;49(20):5696-5711. PubMed 40456989
Koroma P, Reji N, Burridge I, et al. Deep plane facelifts: a systematic review and meta-analysis of outcomes. Aesthetic Plast Surg. 2026;50(17):6874-6896. PubMed 42576065
Rammos CK, Mohan AT, Maricevich MA, et al. Is the SMAS flap facelift safe? A comparison of complications between the sub-SMAS approach versus the subcutaneous approach with or without SMAS plication in aesthetic rhytidectomy at an academic institution. Aesthetic Plast Surg. 2015;39(6):870-876. PubMed 26311561

This article is educational and does not replace a consultation. Every patient is different, and individual results vary. Medically reviewed by Gustavo R. Machado, MD.

Deep plane vs. SMAS facelift: what is the difference, and which is better?