What You Need To Know About The Latest SMAS Facelift Techniques

The technical term for a facelift is “rhytidectomy,” which is derived from the Ancient Greek words for "wrinkle" (rhytis) and "excision" (ektome). And, while there remains some debate over what constituted the world's first-ever rhytidectomy, it occurred at least a century ago in Europe at the request of a female patient. All this is to say, women (and, later, men) have been interested in the surgical removal of wrinkles for at least 100 years. Fortunately, face-lifting techniques have come a long way in that time.

“Traditional facelifts originally only addressed sagging skin,” says board certified plastic surgeon Jason Roostaeian, MD. “But the skin isn’t where the issue is. It’s the descent of the tissue deep into the skin, along with facial devolumization, that we’re mostly trying to remedy.”

OG facelifts relied entirely on pulling skin backward, limiting the amount of correction and resulting in the telltale taut effect. As Dr. Jason explains, the reason tightening the facial skin alone leads to lackluster results is threefold:

1. The tightened skin starts to stretch again over time.
2. Too much tension in the skin creates more visible scarring.
3. Simply pulling the skin taut “doesn’t restore the volume and convexity” patients lose with age.

In an effort to address these shortcomings, facial plastic surgeons in the 1970s coined the term “superficial musculoaponeurotic system” (SMAS) to describe the layer of fat and connective tissue that lies between the skin and the facial muscles and began experimenting with techniques that could lift and firm the face in a more natural way. Today, the evolution of SMAS-based surgeries has become the gold standard of modern facelifts.

SMAS Plication Facelift

In a face-lifting technique known as plication, plastic surgeons suture the SMAS in a stair-step pattern that is pulled tight and secured to more stable deep tissue for a lifted effect. But there are complicating factors. When the skin is draped back over the sutured SMAS, the bunching of the underlying tissue can sometimes cause visible irregularities in the patient’s lower cheeks. “The whole essence of youth is smoothness," Dr. Jason says. "Anytime you have a little contour problem, it ruins that. It’s aging.”

SMASectomy Facelift

To eliminate the risk of contour inconsistencies, today’s cosmetic surgeons generally rely on variations of a facelift technique known as SMASectomy, which utilizes both the mobile and immobile portions of the SMAS.

“Over the lateral portion of your face, closer to the ear, the SMAS tends to be stiffer, and, as you move forward toward the center of your face, it gets more mobile,” Dr. Jason says. “To avoid the pincushion effect that spanning sutures often produce, we instead remove a piece of the tissue at the junction of the mobile and immobile SMAS, pull up the mobile portion, and anchor it to the immobile portion near the ear.”

As a result, the sagging tissue and lax skin of the lower face and jowl area is lifted. Surgeons remove any excess skin and are able to hide the sutures in the natural crevices and folds around the ear.

High SMAS Facelift

A deep plane facelift takes the SMASectomy method one step further. Plastic surgeons dissect the underside of the SMAS, separating it from the deeper muscle tissue to mobilize the entire SMAS layer prior to the SMASectomy. Dr. Jason prefers a slightly modified version of this technique known as a High SMAS Facelift.

While other SMAS techniques focus only on the lower face, Dr. Jason likes that this approach “frees up the entire SMAS as one unit — all the way up above the level of the zygomatic arch (cheekbone) — so you can have an effect on the cheek as well as the jawline.”

“If you only work below the cheek, then you’re not going to get an effect on the cheek,” he says, adding that the results are often longer-lasting and more stable because the SMAS is thicker near the ear, allowing for a more secure suture.

The Procedure

Dr. Jason tailors each surgical procedure to the unique needs of his patients and says there is no "right age" for a facelift. "How do you know you're a good candidate? When you first note the signs of aging that are best solved with a facelift," he explains. "A facelift is the most elegant solution for sagging, loose skin of the lower face." Generally speaking, facelift conversations begin with patients over 50.

It's quite common for plastic surgeons to combine a High SMAS Facelift with a neck lift (to alleviate excess neck skin) and procedures like buccal fat pad removal and/or fat grafting (to address the volume distribution issues associated with facial aging). A brow lift, meanwhile, can refresh the upper portion of the face to balance out the lower facelift.

The result? Total facial rejuvenation.

The Recovery

An advantage of a deep plane facelift is that it’s less traumatic to the superficial layers of the skin because the majority of the surgical manipulation occurs deeper. This usually leads to less bruising and better healing.

Dr. Jason’s facelift patients are typically out and about two weeks post-op (though patients who have had fat grafting to restore some of the lost volume in conjunction with their facelift procedure may experience longer recovery times due to the bruising that often accompanies the liposuction). He generally tells patients to allow six weeks before any major events and to expect something very close to a final result at three months. Scars, meanwhile, will grow nearly imperceptible over the course of a year.

It should be noted that, in addition to the risks associated with general anesthesia, facelifts carry a small risk of nerve damage that can create a slight unevenness when a patient smiles. This is due to manipulation of the platysma muscle, which can disrupt the facial nerve, but is rarely permanent.

Of greater concern for facelift patients is the chance of developing a hematoma (i.e. a collection of blood beneath the skin). While a hematoma has no impact on a patient’s long term result when managed properly, it can have a dramatic effect on the recovery process if left untreated.

“The face is very vascular. Whenever you lift up tissue and release all those attachments, you open up a big space into which you can bleed excessively,” says Dr. Jason. “Anesthesia and epinephrine in the operating room lower your blood pressure and constrict your vessels, so when that wears off and the blood vessels open up, we have to be diligent about monitoring your blood pressure.” For this reason, he requires an overnight hospital stay for his facelift patients so they can be monitored and cared for by professionals.

Patient Perspective

So what is it really like to get a facelift? The AEDITION spoke to two of Dr. Jason’s patients to gain more insight into the experience — from pre-op through recovery.

Rosemary, 55

When Rosemary booked a consultation with Dr. Jason to discuss an osteoma (a bony outgrowth) on her forehead, she jokingly asked if it would be possible to “just pull everything up” during the procedure. “He laughed and explained to me that the incisions for facelift surgery were very different,” she recalls. “But we talked about how the lower half of my face — my jawline and neck — was showing signs of aging more than the upper part.”

Dr. Jason pointed out that the Botox® and fillers that Rosemary’s dermatologist was injecting couldn’t really address the issues of the lower face, but she was nervous about having a medically necessary surgery — let alone cosmetic one — so she initially held off.

After several months of research, however, Rosemary made a second appointment and decided to go through with the facelift. She combined it with her osteoma removal, which meant a slightly longer recovery. In addition to her overnight stay at the UCLA Surgery Center, she opted to spend three days at a recovery facility, which she says is “well worth it, if you can afford it.” Rosemary credits her minimal swelling and bruising to the diligent icing by her after-care nurses.

Though she admits to feeling “a little shocked” by her swollen and bruised appearance immediately post-op, Rosemary was able to attend a party at her husband’s office about a month after the surgery. She says she’s gotten very positive feedback about her procedure from friends and family, but no one can guess what she’s had done.

Three years later, she’s still thrilled with her results. “It took off 10 years, and now if I don’t get enough sleep, my face doesn’t show it like it used to,” she says. “It’s been a really good thing.”

Diana

A facelift wasn’t necessarily on Diana’s radar, but she was concerned about looking older. When her close friend and her sister both began looking into facelift surgery, Diana realized she wanted to take the plunge. “I wanted to look better,” she says, “just for myself.”

Her friend referred her to Dr. Jason, who helped her formulate a plan that included a brow, neck, and facelift. She remembers the first week or so following her surgery was emotionally challenging. “After the surgery, it was exciting because I looked really good,” she shares. “And then like a week later, my face started looking really bad — like squared off, a weird shape and kind of yellow. It was depressing.”

But having her sister and friend going through similar experiences was very helpful, as was the reassurance she received from Dr. Jason. The changes she was experiencing were all part of the normal healing process. Two years post-op, Diana couldn’t be happier. “I had a really good experience, and I think I look great,” she says. “I love it.”