SMAS or Endoscopic Procedure for Cheeks?

I am a 36 year old man who desires a more youthful appearance. I've gone from 400-200-280 pounds in 20 years time. After researching all of the procedures, the only one I trust is the smas lift. Am I being closed-minded towards the endoscopic procedure? From my photo, would fillers work?

Doctor Answers 16

Surgery or Fillers

Hi eddro -

Hopefully your research on achieving a younger appearance has included surgical consultation. This will be the best way to determine what is best for your particular situation. It's the diagnosis of the condition to be treated that then dictates the appropriate treatment. Fillers may well be a better initial option in your case.


Tom Kaniff

Sacramento Facial Plastic Surgeon
4.7 out of 5 stars 25 reviews

SMAS facelift v. Endcoscopic procedures

I think for patients who have lost massive weight, nothing is better than a SMAS facelift.  However, this sometimes needs to be coupled with malar implants or fat grafting, and endoscopic mid face lift is not out of the question.  Best to evaluate the surgeon and their plan.

Jay Calvert, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 50 reviews

Weight Loss and SMAS Facelift

It is important that you be evaluated by a surgeon.  If you have some significant laxity of your skin and soft tissues then you may be a candidate for a SMAS facelift even though you are relatively young.  Endoscopic procedures have some value in younger patients but often need to be supplemented with lower face procedures to achieve acceptable results.  Fillers may be of value in your case to give you a little more softness over your cheekbones and tear trough area.

Michael Sundine, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 18 reviews

Fillers are great for facial volume

It appears as though you're an excellent candidate for fillers or fat grafting to your face.  It may be too early for a facelift.

Jeffrey E. Schreiber, MD, FACS
Baltimore Plastic Surgeon
5.0 out of 5 stars 202 reviews

SMAS or endoscopic procedure for face after massive weight loss?

Eddro, congratulations on your weight loss! Keep up with this hard work, as these major weight fluctuations have contributed to your premature facial aging. Normally, 36 is a bit young for consideration of a facelift (of any kind, but we'll talk about that in a moment), but with as much weight as you have lost, you may indeed be a candidate for facial cosmetic surgery that involves incisions, deep tissue (SMAS) tightening, and elevation and repositioning of the jowls, loose neck skin, and facial skin. Consultation with one or more qualified, experienced, American Board of Plastic Surgery-certified plastic surgeons will allow a direct physical examination and evaluation that will give you recommendations and options to consider.

SMAS stands for Superficial MusculoAponeurotic System, which basically is the fascia-like layer of tougher tissues just beneath the facial fat and above the facial muscles and motor nerves. This layer is continuous with the platysma in the neck, the parotid fascia in the cheek, and the temporal fascia over the cheekbone and zygomatic area. Endoscopic lifts utilize an endoscope to access even deeper layers (below the periosteum, which is the tough tight layer just above the bone, and below the motor nerves that control facial movement). This periosteal layer NEVER sags or gets loose, so tightening this layer has never made "sense" to me, and the increased swelling, pain, and longer recovery without better results make me reject this choice personally, though well-trained surgeons do use this technique with good results. I simply feel that similar or even better results can be obtained with the SMAS lift, but without the prolonged swelling and slightly higher risk of facial nerve damage, as compared to the endoscopic midface lift procedures.

Your photo does not show your neck, and your beard growth, angle of photo, and shirt neckline obscure your jowl area, so it is difficult to advise if I feel a facelift is appropriate. If it is, I recommend the SMAS procedure with special incision considerations for your sideburn and posterior hairline areas. Your brows are at the lower limits of normal position, but a bicoronal forehead lift or endoscopic lift scars would be visible without hair to hide the scars, so I would hold off on that until necessary. In the meantime, I would recommend Botox to treat your deep frown lines, perhaps with filler if needed to smooth any residual depression when the muscles here are paralyzed.

However, use of larger amounts of facial filler are needed only if there is loss of facial volume in the cheeks, giving a sunken or hollow look. The last thing you need, IMHO, is a fuller, rounder face that recalls how you looked when you weighed more! Realize that this is not the usual answer I would give a 36 year-old patient, but your issue seems to be loss of skin tone and position related to weight loss, not premature facial aging. Anatomy is the deciding factor here, not chronological age!

A smile and great attitude make as much of an impression on others as a rejuvenated face. Do both and you have a winning combination! Good luck!

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
4.9 out of 5 stars 255 reviews

How to achieve more youthful cheek appearance

If your concern is your cheek area, I suspect that a volume enhancing procedure such as fat grafting or filler injection would be best for you. A SMAS facelift would not address this area. A more in depth examination would allow for a better assessment, though,

Fat loss in these areas is quite common and begins in our 20s/30s. The weight loss you'd mentioned is another common factor as well.

Fillers such as restylane/ juvderm/radiesse or your own fat can be placed to improve the cheek contour.

Thomas A. Lamperti, MD
Seattle Facial Plastic Surgeon
4.9 out of 5 stars 21 reviews

SMAS lift vs. endoscopic midface vs other options?

Although it's hard to tell from this photo, it looks like the main issue is one of volume loss in the cheek area.  Secondly, the tear trough area looks a little prominent.  

These two areas would not be improved all that much with a SMAS facelift.  Similarly, the endo mid-face procedure is a "long haul for a short slide".

I would, instead, try to restore some volume to the cheek and tear trough areas.  There are a number of options for this....sculptra, micro fat transfer, radiesse (for the cheeks) and other fillers for the tear trough.  Those options would be much less invasive,  allow more flexibility in shaping the area, and have less downtime for you.


All the best,

Thomas Fiala, MD
Orlando Plastic Surgeon
4.9 out of 5 stars 79 reviews

Midface lift

Based on your young age, I would err towards a less invasive procedure.  If you don't have much excess skin, then you would be a candidate for a cheek lift/midface lift/endoscopic midface lift

Samer W. Cabbabe, MD, FACS
Saint Louis Plastic Surgeon
4.9 out of 5 stars 57 reviews

SMAS Facelift versus Endoscopic Facelift


It is difficult to make a determination of your needs for only one picture. Given your young age, I would say that you are on the younger end of the spectrum of requiring a SMAS facelift.  If your cheeks are a concern, an endoscopic midface lift would provide better results, and they are long-lasting. Having said that, you may want to consider a non-surgical approach with the use of injectable fillers, which produce excellent results in terms of midfacial volumization, without the need for a more invasive and costly procedure.

Best of Luck,

Glenn Vallecillos, MD, FACS

Diplomate, American Board of Plastic Surgery

Glenn Vallecillos, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 31 reviews

Weigh Loss, Fillers, and Smaller procedures recommended for Younger Patients

Given your weight history and fluctuation, I would recommend that you lose weight or have stable weight before having anything done.  You don't list your height, but your weight has fluctuated from 400 to 200 to 280.  Assuming you're normal in height, you may want to consider having a weight of around 200 or less before considering any facial surgery.

Due to your age, I would recommend simpler things like skin care, facial resurfacing, Botox/ Dysport, and facial fillers before a facelift.  If you decide to have a facelift, then you will probably be a candidate for a smaller incision facelift. 

You didn't mention any other things in your medical history, but not smoking, controlling diabetes, and other issues related to medical illnesses may help with your overall health and quicker recovery after any potential surgery.

I wish you the best of luck in your search!

Roy Kim, MD
San Francisco Plastic Surgeon
4.2 out of 5 stars 6 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.