Deep Plane vs SMAS Facelift: What Is the Difference?

Deep plane and SMAS facelifts both treat more than the skin: they work on the deeper support layer of the face, called the SMAS. The real difference is the plane in which the surgeon works and whether the ligaments that hold the face in place are released. In SMAS techniques the layer is folded, stitched or partly removed and tightened separately from the skin. In a deep plane facelift the surgeon works beneath the SMAS, releases the retaining ligaments and repositions skin and SMAS together as one unit.²

A pooled analysis of published studies found the complication rates of the two approaches to be broadly similar, and its authors concluded that the technique should be chosen for the individual patient.¹ This guide explains what the difference means in practice, when each approach tends to be discussed, and why the name of a technique is not, on its own, a reason to choose it.

What is the SMAS and why does it matter?

From the surface inward, the face is made of skin, fat beneath the skin, a layer of muscle and fibrous tissue called the SMAS, deeper fat compartments and bone. The SMAS is a supporting sheet connected to the muscles of expression, and it carries the soft tissues of the face. The branches of the facial nerve run beneath it at depths that change from one area to another, which is why any technique that works under the SMAS depends on detailed anatomical knowledge.⁶

Ageing does not only loosen the skin. The cheek tissues descend, jowls form along the jawline, the fold between nose and mouth deepens and the neck loses definition.⁵ Trying to correct these deeper changes by pulling the skin alone tends to produce a face that looks tight without solving the underlying problem. That is why most modern facelift techniques address the SMAS.

What happens in SMAS techniques?

“SMAS facelift” is not a single operation but a family of techniques. In plication the SMAS is folded and stitched without being cut. In imbrication it is partly cut and overlapped. In SMASectomy a strip is removed and the edges are sutured together. More limited approaches, such as the MACS lift, use a shorter incision and suspension sutures.^2,3

What these approaches have in common is that skin and SMAS are largely handled separately, and the ligaments that anchor the face to bone are mostly left in place. Preserving the ligaments means a less extensive operation; the trade-off is that in marked laxity the tissues may not move as far as needed.²

What changes in a deep plane facelift?

In a deep plane facelift the surgeon moves into the plane beneath the SMAS beyond a defined point. The retaining ligaments around the cheekbone and the chewing muscle are released. The tissues of the cheek, jawline and neck can then be moved upward and backward without separating skin from SMAS.²

The aim is to place the tension on the deeper support layer rather than on the skin. Because the ligaments are released, the midface and neck tissues can be repositioned more fully.² The other side of this is that the dissection takes place close to the facial nerve, which is why the technique requires precise anatomy and careful planning.⁶

What does the research show?

A systematic review and meta-analysis published in 2025 examined 47 studies including 10,766 patients. Haematoma occurred in about 3% of deep plane patients and about 2% of SMAS patients. Nerve injury rates were similar, most injuries were temporary and permanent damage was rare. The authors described the safety profiles as comparable and recommended an individualised choice of technique.¹

Only one study in that analysis compared the two techniques directly, and it reported greater midface improvement with the deep plane approach.¹ A finding based on a single study should be read with caution. A separate review comparing the MACS lift with deep SMAS techniques also found similar complication rates, with shorter operating times for MACS, but it was based on four retrospective studies and 286 patients.³

In short, the research does not say that one technique is always better. It says that ligament-releasing techniques can move tissues further, while more limited techniques are less invasive but may give more limited correction in severe laxity.²

Which face, which approach?

The deciding question is which tissue is responsible for the change, and to what degree. When marked midface descent, a deep nasolabial fold, clear jowling and neck laxity occur together, a technique that releases the ligaments may make more sense.² When the change is more limited or mostly confined to the lower face, a smaller intervention may be enough.^2,3

Sometimes the right answer is not a facelift at all. If the main concern is skin quality, fine lines or pigmentation, a facelift will not correct it.⁴ If volume loss is prominent, additional options such as fat transfer may be discussed.⁵ In people who have had a facelift before, the previous technique and the state of the tissues change the plan again.

When surgery may not be appropriate

A planned facelift may need to be postponed, or may not be suitable, for someone who cannot stop smoking, whose blood pressure or diabetes is not controlled, who has a bleeding disorder or whose weight is still changing significantly. Blood pressure matters particularly because it is linked to haematoma, so these points are discussed openly before surgery.⁴

Dr. Atmış’s approach

Op. Dr. Esin Özlem Atmış uses the deep plane technique for facelift and neck lift surgery. The technique is not a package, however. At consultation she first assesses which part of the face has changed and whether the concern comes from the skin, the SMAS, volume change or the neck. That assessment determines the extent of surgery and whether anything else should be combined with it.

The aim is to bring the structures that have actually changed back toward their earlier position while keeping the person’s expression and facial character. Not pulling tissues tighter than necessary, and treating face and neck in proportion, is what a “natural” result means in practice. A one-night hospital stay is usual, and patients travelling from abroad plan about seven days in Istanbul. Reviews are planned at 1, 3, 6 and 12 months; if you live abroad, they can be held online where appropriate, and an in-person examination is requested if needed.

What a facelift does not change

A facelift does not correct fine wrinkles, sun damage, lines around the nose and upper lip or uneven skin colour. Nor does it stop ageing: the result can remain noticeable for many years, but the face continues to age.⁴ Knowing these limits in advance keeps expectations realistic, whichever technique is used.

Recovery also depends more on the individual’s tissues and the extent of surgery than on the name of the technique. For a detailed timeline, see our guide to facelift recovery week by week.

Frequently asked questions