What is the best (and longest-lasting) facelift technique to lift heavy jowls?

I am confused by different techniques & vectors etc. It seems conclusive that the SMAS is the key, but is an extended/high SMAS lift different to a standard SMAS lift? What's the difference between plication, imbrication, SMASectomy, etc? What about a MACS lift - is this an imbrication technique? What is a purse-string? Where should the lift be sutured to achieve long-lasting & effective jowl lifting? A lot of people on this website seem to have recurrent jowls after full SMAS facelifts - why?

Doctor Answers 29

What is the best (and longest-lasting) facelift technique to lift heavy jowls?

The most important thing is to find an experienced expert facelift surgeon and rely on his/her expertise to give you a good result. In my experience a full face and neck lift (platysmaplasty) using the SMAS technique is best to correct jowls.

Best Facelift Technique

Hello.  Thank you for your question.  This is a very complex question.  It would require a textbook chapter to describe the differences in all of the various facelift techniques, and I am certain that you will get varying opinions on which technique is the best or provides the longest lasting results.  The reality is that there are no randomized clinical studies or evidence to support one technique over another.  However, every surgeon likely has their own opinion on which technique works best in their hands.  Experienced facelift surgeons may very well incorporate all of the techniques that you described, in addition to others, depending on the anatomy and goals of the individual patient.  The bottom line is that all properly performed facelifts involve the same basic principles, including elevation of the skin, lifting and suspending the SMAS and platysma to recontour the jawline and neck, followed by redraping and trimming of the redundant skin.  The various facelift techniques primarily differ in how the SMAS is managed (plication, imbrication, SMAS flap, deep plane, MACS).  All of these techniques can provide good, long-lasting results when properly performed by an experienced facelift surgeon.  The longevity of any facelift result likely depends more on patient factors, such as skin and soft tissue elasticity, genetics, body weight, body habitus, underlying skeletal anatomy, sun exposure, smoke exposure, etc., than it does on the specific technique used.  The exact same procedure can be performed on 10 different people, and the longevity of the result will vary in each one.  A facelift simply turns back the hands of time for the patient, and they will continue to age in their own unique way from that point on.  I would recommend that you schedule a consultation with a board-certified Facial Plastic Surgeon with extensive facelift experience and allow them to assess your individual anatomy, concerns, and goals in order to determine the best treatment plan for you.  I hope this information is helpful.  Best of luck.

Michael Boggess, MD
Nashville Facial Plastic Surgeon
4.8 out of 5 stars 33 reviews

Lifting the SMAS happens with different facelift techniques, but the best technique depends on what is best for the individual

Thank you for your question. I understand you’d like to know the best and longest lasting method of treating heavy jowls, and you’re also questioning a number of different techniques including SMAS lift, SMASectomy, MACS lift, deep plane lift, etc. You’re also asking why people often have recurrent jowls even after full SMAS facelifts.
You’ve certainly asked an interesting question, one that has been asked by people in this field for decades. The truth of the matter is the “best technique” does not exist, because there is so much variability to the human body. Before I explain this further, let me give you a little information about my background. I am a Board-certified cosmetic surgeon and a Fellowship-trained oculofacial plastic and reconstructive surgeon, practicing in Manhattan and Long Island for over 20 years. One of the areas I specialize in is facial aging, and I treat many patients, many of whom come from all over the world, for various facial aging concerns.
I think the way face lifting surgery is marketed often confuses people, particularly because there are doctors who claim to do more complicated procedures that other doctors can’t - this is simply not the case. Every surgeon who performs face lifting surgery, and is properly trained and experienced, can perform all the procedures you mentioned in your question. In many cases, the procedures are customized even further because these doctors use their knowledge and experience to get the best out of the procedure and give the patient the best results possible.
With regard to your question about why some people get recurrent jowls, this simply has to do with the limitations of face lifting and the factors related to facial aging. Facial aging is essentially volume loss and sagging. Volume loss refers to loss of bone, muscle, fat, and soft tissue; while sagging refers to the descent and weakening of the soft tissue of the face. This means that when you’re performing face lifting surgery, you’re lifting against a structure that has less volume and you’re lifting tissue that is less firm and more elastic.
A colleague once likened the skin to taffy — it is extremely stretchable. Whether you go very deep or more superficial, you are essentially still lifting the foundation of the face called the SMAS. The challenge here is tissue quality, and there is an invariable amount of regression which the skin in the neck can stretch. When you turn your head up and down or side to side, the skin will stretch a little. The face will also stretch because of the normal movement from the expressions we make.
What I always try to explain to my patients is if they are a candidate for a facelift, my first task is to reposition everything to where it should be. This doesn’t always mean that volume correction is not appropriate; volume correction can be done with the help of cheek or chin implants, or with the help of hyaluronic acid fillers and structural volumizing at the deeper levels of the face. In my practice, I will also sometimes perform a limited facelift combined with injectable fillers to simultaneously restore volume.
It is important to keep in mind that face lifting is an art requiring a lot of finesse. There are so many variabilities, and each doctor will approach each case with their own personal style, so there really isn’t just one way to perform the best job possible. If that was the case, all doctors would be doing the exact same procedure.
Ultimately, I think what you are dealing with is just the elasticity of the human body and the various ways that the face and neck area can be lifted. I recommend you meet with different doctors and specialists, and learn more about these different options, as well as the different anesthesia scenarios. Many surgeons who perform these procedures do have the appropriate experience and training needed to achieve great results, it is really just a matter of finding the right doctor whose style suits you best in terms of their approach to the procedure, the anesthesia method, and the mutual understanding of your cosmetic goals.
I hope that was helpful and I wish you the best of luck!

Amiya Prasad, MD
New York Oculoplastic Surgeon
4.3 out of 5 stars 59 reviews

Surgeons Differ on Technique, but SMAS Is the Key

You ask a very difficult and complex question. As the various options imply, there is no firm consensus on what the best facelift technique is, and the skill of the surgeon in performing the technique is ultimately more important than the actual technique used. That being said, in my own firm opinion, techniques that actually release and move tissue will last longer and have a more natural result than techniques that rely on stitches (e.g., MACS lift, imbrication, plication). There is universal consensus that the deeper tissues (i.e., SMAS) contribute in a major way to the aging process, and that jowls are caused more by relaxation of the SMAS and overlying subcutaneous fat than by skin relaxation. An extended high SMAS technique and the variation of the deep plane facelift that I perform share the objective of elevating the midface in addition to the jowls and lower face. A standard SMAS lift does not raise the deeper tissues over the cheek. In terms of duration of the result, my patients return for a second procedure after about 12 years, on average, and that includes about 200 patients on whom I have done 2 facelifts. However, due to the inherent loss of elasticity with age, which is highly variable among patients, there is always some relaxation in the first 6 months, and a 70-year-old patient having a facelift for the first time will not get the same duration or as complete an elimination of jowls as a 50-year-old patient.

Best facelift for jowls

Most surgeons agree that the SMAS is important in facelifting.  Every doctor has their routine so making this question of "the best technique" difficult if not impossible to answer.  The amount of skin advancement, undermining an vector of pull is important too.

Depending on one's anatomy there may be persistence of jowls.  The goal is generally improvement and not perfection.   

I recommend that you consult with a Specialist in your area and discuss your jowl concerns.  Generally, gently distracting your face back using your fingers gives you an idea of what to expect after surgery.

Ernest Robinson, MD
Aliso Viejo Facial Plastic Surgeon
5.0 out of 5 stars 10 reviews

Need to Address the SMAS Layer for Long-Lasting Results

There is no “best” technique for a facelift. Generally, most surgeons agree that the SMAS layer is a major key to the longevity of the lift. Remember that the skin and underlying tissues left behind are in the same condition as those that were removed. In other words, if your skin and underlying tissues are in good shape, then your result will last longer. The younger the patient, the longer it lasts, but the results aren’t as dramatic as they would be if there was a greater amount of sagging/excess skin, as happens with older patients. Many articles address the different techniques, but no one single technique has been proven as “the best.” Jowls will recur in everyone, because the aging process continues after the procedure. If your tissues are in poor condition, it will occur sooner.

Facelift technique for heavy jowls

Thank you for a very insightful question!  Entire books have been devoted to this topic, along with countless scientific articles and book chapters.  You are correct that addressing the SMAS is a must for achieving a good correction of the jowls.  There are several techniques for this, and many good board certified plastic surgeons who achieve similar results with these different techniques.  My best advice is to seek out board certified plastic surgeons with expertise in facelifts and have a consultation where you can ask these exact questions.  Look at their pre/post-op photos.  Jowling can be improved and even eradicated, but will always come back to a certain extent given time and gravity.  Best wishes for a beautiful and durable result!

Concept Facelift

Thank you for your question.  Firstly most of our patients will have their main concern as the lower facelift, jowl and neck area. I have pioneered a revolutionary local anaesthetic facelift known as the ‘Concept™ Facelift’. This innovative procedure combines the latest surgical techniques with the use of local anaesthetic to dramatically reduce the risks associated with traditional facelifts, while significantly reducing the bruising and downtime of your recovery, from months to a matter of days.  The main benefits of the Concept Facelift would be: minimally invasive as it is a short scar facelift, significantly less risk under local than general anaesthetic, full recovery in matter of days rather than months and fresh, youthful and long lasting results.

I advise all our patients to have a one to one consultation with a Surgeon to discuss and address your concerns and can provide you with information about which surgery is best suited to the look that you want to achieve.

Good Luck with your procedure! 

What is the best (and longest-lasting) facelift technique to lift heavy jowls?

You have asked very technical questions that would take a great deal of time to answer in detail. The general theme in all of the different techniques is in tightening the SMAS layer. All experienced facial plastic surgeons have preferences as to the best technique. However, we modify the technique used depending on the patient's skin type, degree of looseness, etc. You might consider getting several consults with experienced facelift surgeons before you make a final decision. Good luck.

Warren J. Katz, MD
Dallas Facial Plastic Surgeon
4.6 out of 5 stars 11 reviews

Longest Lasting Facelift Technique


The goal of the lift is to give you a natural result that gives you a foundation on which to continue aging gracefully. In my opinion, addressing the SMAS layer is a must to achieve a powerful, but natural result with longevity. Lifting the SMAS not only helps contour key areas of the face, it takes the tension off the overlying skin allowing it to drape naturally and avoiding the "windswept" look.  As you have seen with your research, there are several techniques to address the SMAS.  While there is a lot of technical detail to each, the simple answer is that the difference with all of these techniques is in the extent the SMAS is manipulated. The SMAS is a strong tissue layer that is continuous with tissue in the scalp above, in the neck below and envelopes some muscles in the face. In the mid face, it also lies directly over nerves that control movement of your face. For these reasons, working with the SMAS layer must be done with precision to create lift/suspension in all the targeted areas while avoiding potential harm to adjacent vital structures. 

Again, there are a lot of technical variations but in a nutshell: The standard and high SMAS techniques will elevate a significant portion of the SMAS layer affecting a larger area of the midface and often the neck as well.  A plication, imbrication and SMASectomy are techniques that address a limited portion of the SMAS in a vector tailored to the needs/goals for your midface. These techniques are often accompanied by different interventions to laterally tighten the neck (if needed). MACS and purse string are targeted SMAS suspension techniques with little or no elevation of the layer itself.

The appearance of jowls is the result of several factors including skin elasticity, underlying fat, and to some extent even the bony framework of the jaw. Specifically addressing the reasons for the appearance of jowls is the best way to assure longevity of the results. This likely includes mobilizing and removing excess skin, supporting the surrounding deeper tissue with some sort of SMAS manipulation and addressing excess fat. If the jawline needs further support or contour this can be achieved with various filler material either at the time of surgery or after full healing has occurred.

Daniel Beck, MD
Dallas Plastic Surgeon
4.9 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.