Deep Plane Facelift vs SMAS Face Lift. Understand the difference and make the right decision.

Welcome to my page. I'm Dr. Shervin Naderi, a double board-certified facial plastic surgeon who's been practicing in the Washington, D.C. area for almost a quarter century. I want to focus on facelift techniques today. Everything evolves, everything improves, everything changes over time. The way I do a facelift today is very different than the way I did it 10, 15, 20, or 25 years ago. Same with rhinoplasty, same with endoscopic brow lifts. Almost everything evolves. Believe it or not, eyelid surgery and lasers have remained the same, and I'll talk about that in a different video. But when it comes to deep plane versus SMAS facelift, there's a lot of misconception, a lot of terms thrown out there, a lot of marketing hype. Everybody says my technique, my technique, my technique, but let's talk about what that means. I have created 5 sheets of paper and I've labeled them The way Dr. Ben Talei has divided the face into 5 layers. Facial anatomy is extremely complicated. It's— this area has the most complex anatomy of the entire body. When you look at a medical student, the amount of time that it's spent studying this versus the rest of the body tells you how complicated this anatomy is. Lots of nerves, lots of blood vessels, lots of traffic going on in that region. But if you break down the face into five general layers in different depths, makes things simpler. Layer one, think of layer one as the skin. In the old technique, which was even before my time, a skin-only facelift elevated the skin and pulled the skin. You have seen celebrities, maybe some older family members, who look like they had a facelift like that. Their mouth went wide. There's different striations of the face. They walk into the room and you can tell they had a facelift. They couldn't hide it. It was not natural. That was a skin lift. Layer 1 was lifted and pulled. Now, I have it labeled ear and mouth because the dissection incision is made close to the ear, either in front of it or behind it. There's different variations and technique for that and depends on male versus female, etc. But the incision is made by the ear, the skin was elevated and pulled back. Again, not a good technique. We don't do that. I have never done that technique in my entire career. 20 to 25 years ago, the standard of care around the entire world was what's called a SMAS lift. The SMAS, S-M-A-S, was layer 3. Layer 3 was either lifted or just kind of tucked up and sutured upon itself. SMAS imbrication versus SMAS plication. But that layer 3 SMAS, you must be wondering, well, what happened to layer 2? Layer 1 is the skin. Layer 2 is the subcutaneous fat underneath the skin. There's a thin layer of fat that's basically underneath the skin. That's layer 2. For all practical purposes, in this region of the face, these 2 layers are kept together during the section of a facelift. Whether it's a deep plane or a SMAS lift, the skin and the subcutaneous fat are kept together, lifting it, exposing layer 3, which is the SMAS. S-M-A-S. The superficial musculoaponeurotic system. Now, here is the difference in techniques. In the traditional SMAS lift, there's a large flap that's composed of layers 1 and 2. Essentially skin, a lot of skin dissection and a little bit of SMAS dissection. The pull is on the SMAS, the tension's on the SMAS, and the skin goes with it. So again, two decades ago, the way I would do my facelift, I would make the incision, lift a lot of skin, freeing up the skin everywhere, exposing the SMAS layer three, lifting a little bit of layer three that SMAS. Pulling the tension, putting all the sutures in that layer, SMAS, and then the skin would drape with it. It was a fantastic procedure for addressing jowls. It didn't do a great job in the neck. It almost did nothing for the cheeks, augmenting the cheeks and volumizing and making the midface look more youthful. So it didn't do any of that. Now, how is that different from a deep plane? A deep plane is not a deeper plane. We're not going below In a deeper plane, we're going further out and the dissection changes. In a SMAS lift, remember, a large long skin flap all the way out here, skin is elevated exposing it to potential hematoma and more bleeding. In a deep plane, the skin is lifted just a little bit, especially in today's deep plane. The deep plane that was still around 20 years ago was very different than today's deep plane. The modified composite, you may have heard that term, composite deep plane, keeps the skin dissection very minimal and immediately dives under layer 3, under the SMAS, the same layer as a SMAS lift, same layer, it's not deeper, it's the same exact layer, but the dissection goes on and on and on and on much further towards the mouth. Within a layer called layer 4. So a little bit of skin dissection, a lot of SMAS dissection. Why do we do that? Why do we need to go all the way out there? Because it releases ligaments that are holding things, tethering things. Without that release, you just can't get that kind of lift. In a SMAS lift, we never approach those ligaments. None of those ligaments were released. So yeah, it was a safer surgery. You didn't expose the facial nerve branches, But larger skin flap, more hematoma risk, the skin quality changed, it had this waxy appearance to it, was not very healthy. In a deep plane lift, especially a composite deep plane lift, the skin is healthier, it's kept thicker, it's kept attached. The dissection's further out, yes, more risk to the facial nerve branches, more meticulous dissection, more cost to the surgery because of these additional factors that you have to Consider, the surgeon has to have much more anatomic knowledge, much more skill, and be willing to accept the extra risk to the facial nerve. Both the patient and the surgeon have to accept that risk. But then the release of these ligaments creates a beautiful mobilization of the face. Better work on the neck is done today. Augmentation of the midface, even without fat injections, the midface fills up beautifully and hollows go away. Even without fat injection. Now again, a lot of times we have to augment and use some fat, but there are situations where you don't need extra fat because this SMAS layer is freed up, elevated in a proper way, and the midface is supported beautifully. So that is a deep plane. It is not a deeper, it is a further dissection. In fact, it should be called a further plane facelift, not a deep plane facelift. Layer 4 is that glide plane, which allows things to glide. There is your MOBA SMAS, and there's your tethered SMAS, fixed SMAS. There's a lot of anatomy to the face, but I just want you to walk away with this knowing that a deep plane facelift is not a deeper dissection, it's a farther dissection, a more complete release of ligaments, a better mobilization of the tissue, and a better result. Does it last longer than a SMAS lift? Not necessarily, but the results are better. Let's briefly talk about the neck. In the neck, when you come down again, layers one and two in the old days were dissected. Layer one was dissected free by itself. Layer two, that subcutaneous fat, was liposuctioned. Today, we hardly ever do that. We keep layers one and two connected because that subcutaneous fat is important to create a beautiful softness to the neck and not make it look like it's been kind of aged. So layers one and two kept together. Much more limited dissection, pretty much here. That's where the dissection is instead of all this being dissected. Layer 3 in the neck corresponds to SMAS up here, but it's called the platysma muscle. Platysma muscle is the same layer 3 down the neck. Layer 3 here is called SMAS. Layer 3 here is called the platysma muscle. So we go underneath it just like we went underneath the SMAS. We go underneath the platysma muscle and expose deeper structures. What are the deeper structures? Digastric muscle, submandibular gland, deep neck flat. Those are things that we never approached before. 20 years ago, I would never touch any of that. Today, it's a routine part of my surgery. By reducing the bulk there, by sculpting those, we create more room for a more beautiful, sharper neckline and a cervicomental angle. So I hope this helps. I hope this helps with your decision-making. Again, not Nothing wrong with this moss lift. I did it many times decades ago, but today my preferred choice is a composite extended deep plane. The section's different. It's a more beautiful, complete release and much more natural looking results without that tension, without the tight pull on it. Hope this helps. Look for the other videos. Subscribe to the videos and learn more.