Difference Between Multilevel Facelift and an Extended SMAS?

I am due for facial surgery at month's end. Dr. will be doing and extended SMAS along with an incision in the 'sideburn' area. Also, why are staples used behind ears in facelift and on top of head for endoscopic browlift?

Doctor Answers 13

SMAS facelift

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Multilevel face lift is not a commonly used term, but most likely refers to a facelift in which a skin flap is elevated as well as a SMAS flap.  The SMAS is the tissue under the skin and fat which gives the facelift its structural support.  This should result in a longlasting effect for you. 


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The SMAS facelift is a general term for the lifting of the face with two separate planes of lift. The first plane is the deep tissues of the face which includes fat, muscle and fascia. The second plane is the superficial fat and overlying skin. This is the basic description for the best of all facelift techniques.

The first techniques attempted utilized pulling of only the skin. Early on it became apparent that pulling of the skin alone led to early recurrence and excess scarring - not an ideal outcome. Other techniques have been attempted with a modicum of success. The most prominent of these other procedures is the deep plane technique whereby the entire sandwich of tissue (Skin, fat, muscle and fascia) is lifted together. This technique leads to a large amount of swelling but an early recurrence of the signs of aging. But most importantly, this technique does not allow us to lift the tissues vertically.

The process of aging is caused by gravity, facial animation, stresses on the skin (weight gain, smoking, drinking, sun damage and age). The combination of gravity and facial animation pulls the tissues of the face in a downward and inward direction. Smiling reverses the sag - so look in the mirror and smile to see where your facial tissues use to be and where you hope that surgery would replace them. It is for this reason that the SMAS lift should move all tissues in a vertical direction - put the tissues back to where they once were.

So with that said, what are the risks and benefits of the Vertical SMAS Facelift.
  1. More natural lifting of the fascial tissue avoids the windblown or pulled look of many other techniques.
  2. Vertical lift adds to the volume of the cheek, removes the jowl and marionette lines to yield a more oval face.
  3. Vertical lift often eliminates the malar depression or tear trough.
  4. The SMAS facelift has a lower risk of facial nerve injury than the deep plane facelift and recovery from swelling is significantly shorter.
  5. Perhaps the only really increased risk relative to other techniques is the risk of bleeding or hematoma. The creation of two flaps of tissue can result in an increase risk of bleeding. But these small blood clots under the skin are still infrequent and ultimately resolve.
  6. All facelift procedures have risks to the sensory and motor nerves of your face. This technique does not have the same risks as a deep plane for motor nerve injury.
  7. A SMAS facelift does not address the forehead (Brow lift) or the lower lid bags (Blepharoplasty) but they are often performed together.
In the end, the SMAS facelift is an ideal procedure when performed in a vertical fashion. Find a board certified plastic surgeon with experience in performing this technique.

If you would like more information on facelifts, please read my book " A More Beautiful You - Reverse Aging Through Skincare, Plastic Surgery and Lifestyle Solutions".

Robert M. Freund, MD
New York Plastic Surgeon
4.8 out of 5 stars 34 reviews

Facelift terminology - an enigma for the consumer

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Its questions like this one that tell me that we have not done our job as plastic surgeons in making the public aware of the variations in technique, extent of lift, duration of the result, and cost related to different facelifts.  These terms are technical and relevant to the patient who has working knowledge of the anatomy and the operations that affect the anatomy.  The best thing you can do is find a surgeon who generates beautiful results consistently and can get you back to your life in 10 days to 2 weeks looking great! 

Jay Calvert, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 52 reviews

Facelift Levels

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All SMAS Facelifts are "multilevel." The term "extended" SMAS generally means that more work is being done in the mid face. Sometimes some physicians use the term to mean any procedure that is more extensive than the average. 

Staples are used in the scalp as they close the hair bearing areas exceptionally well without injuring the hair follicles like sutures frequently do.

Robert T. Buchanan, MD
Highlands Plastic Surgeon

the difference between multilevel facelift and extended SMAS

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As a consumer  It is best not to get hung up on the different terms being used by different facelift surgeons around the country. Its best look for somebody is board certified, has excellent results,  photo gallery, ratings, reviews, and  you have good rapport with. The type of facelift we perform is an extended SMAS and occurs in multiple levels including the sub-platysmal, supra-platysmal, above and below the SMAS  in our practice. Please see the link below to our facelift  photo gallery.  

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

Multilevel Facelift versus Extended SMAS Facelift : differences explained

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Over the last several years as facelift procedures have become more and more popular, the terms and names describing them have grown exponentially. This is due in part to marketing efforts by surgeons, the advent of different degrees of surgery being done and demand from patients to learn more about the various techniques available to them.

Let's answer your question by comparing the differences between a Multilevel Facelift and an Extended SMAS Facelift by first reviewing what all facelifts have in common:

1. Incisions are made to gain access to deeper tissues and to remove extra sagging skin

2. The SMAS (layer of tissue and muscle below the skin which causes jowls) is elevated via a number of various techniques

Now lets compare the two procedures being discussed:

1. Multilevel Facelift : while all facelifts have at least 2 levels of lifting (the skin and SMAS), a multilevel procedure indicates that a third level of lifting occurs below the SMAS. This is a subtle but important distinction. This is more commonly referred to as a Deep Plane Facelift.

2. Extended SMAS Facelift : this in general implies 2 levels of lifting (skin and SMAS) but uses longer incisions and more lifting of the skin to get further out onto the face than a standard facelift does (helps better address crow's feet, nasolabial folds or marionette lines). 

Both are highly effective techniques and it is your anatomy, desired goals and surgeon's experience that will dictate what will work well for you.

All the best,

Dr. J


Kamran Jafri, MD
New York Facial Plastic Surgeon

Type of facelift

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These are merely the choices of surgeons and the results will vary from one to the next.there are many "types" of facelift but in the end it depends oin what YOU need and the ability of your surgeon to deliver.Doing your homework will pay dividends.Soem surgeons will use staples in the scalp or behind the ear.This is a surgeons choice,

Robert Brueck, MD
Fort Myers Plastic Surgeon
4.9 out of 5 stars 69 reviews

Difference Between Multilevel Facelift and an Extended SMAS?

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           My advice would be to dismiss all of these terms bandied about and focus on the results that the surgeon you have selected produces.  Find a plastic surgeon with ELITE credentials who performs hundreds of facelifts and facial procedures each year.  Then look at the plastic surgeon's website before and after photo galleries to get a sense of who can deliver the results.  Kenneth Hughes, MD Los Angeles, CA

Difference Between Multilevel Facelift and an Extended SMAS?

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 I have performed Facelifts for 25 years and the most important factor in selecting a type of facelift is not how deep or extensive the tissues are dissected or even how much the tissues are pulled.  The most important factor is the shape of the face that results.  Find a facelift surgeon that understands and follows the proper aesthetics of facial beauty for the creation of a naturally, more attractive face. 

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 28 reviews

Different facelift techniques

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There are many different techniques for performing a facelift. They mostly differ on the method of fixating the deeper tissue or smas. However, most studies have shown the results to be similar long term. That being said skin staples are also commonly used in hair bearing regions due to the lack of reactivity in the hairline regions.

Scott Trimas, MD
Jacksonville Facial Plastic Surgeon
5.0 out of 5 stars 20 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.