Rudimentary facelift surgery was being performed in the early part of the 20th-century extending well into the 1970s with pure undermining of the skin, pulling the skin back, suturing it into place and excising the excess amount left. These skin-based procedures did not have outcome longevity. Our improved anatomical understanding of the facial anatomy helped usher in a new year in facial rejuvenation and facelift surgery. The most fundamental change was the recognition that the Superficial Musculo-Aponeurotic System (SMAS) layer network of fine muscles of facial expression and related fascia were fundamental to the ultimate appearance of the face. Furthermore, the relationship of the facial nerve, which provides motor innovation to these muscles and their overlying SMAS was increasingly defined. It became evident that manipulation of the SMAS, would yield a longer lasting facial rejuvenation results. All the variations of SMAS -based surgeries are effectively variations of what is called deep plane facelift surgery. The exceptions being SMAS plication and excision surgery techniques which strictly speaking do not enter the deep plane where facial nerve injury is more likely.


SMAS Plication is the simplest SMAS based surgery and involves widespread skin undermining from in front of the ear, to close to the lips and across the cheek. Skin undermining often extends into the neck as the procedures often need to be combined for a good, harmonious outcome. At this point the redundancy in the SMAS is marked out and using permanent or absorbable sutures, it is placated. This lifts the lower face and neck but is unable to address the mid-cheek region. The advantage is that it is very safe in regards to any possible threats to facial nerve.

Lateral SMAS-ectomy is a technique which involves excision of the redundant lateral SMAS. The principles of the surgery remain the same. After initial skin incision widespread undermining towards the nose and lips, often extending into the neck is performed prior to assessing the redundancy in the SMAS. With excision of this redundancy in the SMAS or on some rare occasions it’s transpositions to other parts of the various tightening of the SMAS is achieved. Excision often allows for a more nuanced and sculpted facelift surgery outcome in comparison to SMAS plication. The risk of facial nerve damage is slightly higher than plication owing to the incision made in the SMAS. The surgery effectively has the same cost benefit profile as SMAS plication surgery. The mid cheek region remains out of the scope of this technique. The widespread skin undermining contributes to longer post-operative swelling as well as increased risk of skin flap loss.

Extended SMAS is an extended technique. The incision starts in the temporal hairline or just in front of the ear and the sideburn extending behind the ear and depending on the type of incision (short scar or long scar), extending into the hairline. After widespread undermining of the skin towards and very close to the nose and the corner of the mouth, the SMAS is accessed on the zygomatic or the cheekbone skeleton, and is undermined all the way towards the apple of the cheek. Resuspension of the undermined SMAS against the skeleton or underlying stable tissues then achieves the lift. Finally, the skin is closed over the lifted SMAS. The advantage of this technique is that it is a powerful tool in addressing ageing and the descent of the mid cheek. Combined with neck rejuvenation and eyelid lift techniques, it consistently provides reproducible, natural long lasting results. The learning curve is rather steep and the facial nerve is under threat during surgery. The widespread facelift surgery skin flaps are ultimately re-suspended with the excess being excised. Relatively prolonged post-operative swelling and risk of partial skin flap loss are amongst the drawbacks of the surgery.

High SMAS is another extended technique that similarly yields powerful mid cheek results, whilst addressing the rest of the face and when combined with neck lift and eyelid procedures, produces excellent long lasting natural outcomes. In this technique after widespread undermining of the skin towards the nose, corners of the mouth and extending into the neck, the SMAS is accessed above the zygomatic or cheekbone in the temporal region. After undermining towards the apple of the cheek, the SMAS is re-suspended against the deep temporal fascia achieving a lift. The facelift skin flaps are then closed after excision of the excess skin. Similar to the extended SMAS technique, the widespread undermining of the facelift skin flaps does mean a prolonged post-operative swelling and there is risk to the facial nerve branches even in the most experienced of hands.

Dr Ross Farhadieh

Dr Farhadieh is an internationally renowned Australian qualified and trained Plastic Surgery. He holds fellowship qualifications in Plastic Surgery from Royal Australian College of Surgeons, Royal College of Surgeons (England) as well the European Board of Plastic Reconstructive Aesthetic Surgery. He has multiple clinical subspecialty fellowships in Cosmetic, Pediatrics as well as Microsurgery from World Leading institutes in London.


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