Difference in Results/longevity Between SMAS Lift Done Under Oral Sedation and Deep Plane Performed Under IV Sedation?

Assume the same patient consults with two highly qualified, board certified, face-only surgeons. One does 100+ procedures per/yr using a short scar, SMAS face/neck lift under oral sedation and local anesthetic at an in-office suite. The other PS does an equal # of lifts using a deep plane technique with IV sedation in an outpatient setting. .What difference in near term and long term results would you predict depending on which surgeon was chosen?

Doctor Answers 9

SMAS Facelift vs. Deep Plane Facelift : Results will be the same IF the SMAS is handled properly

Hi Grace,

Certainly sounds like you have been doing your research so in order to answer your question I will get right into it:

It does not matter what anesthesia is used or which well established facelift technique is chosen. What does matter and the only way to get effective facelift results, is to have the right combination of surgeon, patient's anatomy and appropriately chosen facelift technique for that specific anatomy.

Let's also clarify the 2 facelift techniques being discussed:

1. SMAS facelift: in general, this refers to a technique where the SMAS (the layer of muscle and tissue under the skin that slowly droop down and cause jowls) is lifted and elevated using a variety of techniques - the heavier the jowls and skin of the patient the more invasive the SMAS lifting technique needs to be. For example, in a thin patient with mild jowls a SMAS plication can be done (this is where the SMAS is folded onto itself and sewn into a higher position). In a patient with more advanced signs of aging this approach probably will not work as well and a sub-SMAS technique should be used (this is where the SMAS is cut and the surgeon will dissect under it in order to really lift it up into a higher position).

2. Deep Plane Facelift: in this facelift technique the dissection of the SMAS goes even deeper and we will actually get down to the level of the facial bones before lifting the SMAS up. This technique was wildly popular in the 1990's however as time has gone on and patient demands for quicker recovery and more natural results have grown it is not used as often. This is a not a reflection of the quality of the the procedure but simply the "new age" of facelift patients and the increasing effectiveness of other techniques.

Anesthesia choice is always important for ensuring patient safety and the ability for the surgeon to accomplish everything they need to do during a facelift. Certainly the best way to do a Deep Plane Facelift is with IV sedation or General Anesthesia (although I do know colleagues who will do it under local anesthesia and have excellent results).

Facelifts with local anesthesia and oral sedation have taken some criticism due to the backlash against corporate outfits that heavily advertise these facelifts (and often times don't do them all that effectively either). This is rather unfair as when taken by itself as an increasingly utilized form of anesthesia and not in connection with the greedy corporations promoting this technique, it is a highly effective and efficient way to get excellent facelift results. I do the exact same facelift techniques (SMAS and sub-SMAS) with local anesthesia, IV sedation or general anesthesia - we will use whatever is in the patients' best interests and safety. 90% of my patients choose local anesthesia because of it's high safety profile and their concern for "going under". They do great and sleep right through the procedure just like they would with IV sedation.

Lastly, I cannot stress enough how important it is that the "right" facelift is chosen for your specific anatomy and goals - keep talking with your surgeon, seek other opinions and make an informed decision and all will be well.

All the best,

Dr. Jafri

New York Facial Plastic Surgeon
5.0 out of 5 stars 11 reviews

SMAS Vs. Deep Plane

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 33 reviews

Differences in Results and Longevity

Generally speaking, differences in results and longevity between techniques and Surgeons depend on several things.  I am assuming that the Surgeons you are seeing are board certified by the American Board of Facial Plastic and Reconstructive Surgery or the American Board of Plastic Surgery.  A lot depends on what the Surgeon actually does during the procedure and the aging indications of the patient. In my opinion, IV sedation is in the healthy patient's best interests because it offers amnesia (no memory), analgesia (pain control), and anxiolysis (takes away anxiety).  Unless you have a keen interest in being aware of the details of the surgery, I would encourage any healthy patient to seek this option.  My general feeling about short scar techniques, beyond their perceived marketing value, is that they limit the capability of the Facelift procedure. A patient in his/ her late 40's, early 50's without significant skin laxity can be well suited for this procedure.  A patient in his/ her mid 60's to 70's with significant aging changes and skin laxity  is likely to have a compromised result, in order to suit the confines of the incision length.  A well designed, well executed Facelift, with appropriate vectors placed on the SMAS, and adequate yet judicious skin removal will yield a beautiful result, despite the length of the scar.  In my hands and based on the population I see, I feel I obtain the best results with a modified deep plane technique.  The incision length chosen depends on the needs of the patient.

Stephen Prendiville, MD
Fort Myers Facial Plastic Surgeon
4.8 out of 5 stars 93 reviews

Difference in facelift technique/anesthesia

Very interesting question we discuss among ourselves all the time.

The end result is what counts ("The road to there is not so important....") for you! Most of the face lifts done show a "good" (early) result. Few an "excellent" result.

I personally think face lift is THE cosmetic operation where experience and artistic skills are important. The best recommendation for you should come from other happy face lift patients or Nurses who see the Plastic Surgeon's work and operating skills.

How long a face lift "lasts" is in the eye of the beholder (" How long you like the result...). Weight loss/-gain, life style, skin care, exposure to the elements and smoking can shorten the face lift dramatically.

You have thought about this already quite a bit. Probably you have already made a closer selection of Surgeons. My thoughts may sway you to one or the other.

Good luck! I am sure you will look "fabolous" !

Guido P. Gutter, MD
Evansville Plastic Surgeon
4.9 out of 5 stars 18 reviews

Facelift under oral or iv sedation

I think there are several variables that dictate the success and longevity of your result.  I list them in order of importance:

1.  The experience of your surgeon

2.  Patient anatomy: degree of loose skin/fatty tissue/muscle laxity

3.  Surgical technique chosen

4.  Anesthesia choice


In regards to surgical technique, I would need to see your pictures to make best recommendation.

In regards to anesthesia, I am much happier with the degree of muscle tightening and restoration of the neck/jawline that i can get under a general anesthetic or deep iv sedation.     

I wish you a fantastic result and safe recovery.

Paul S. Gill, MD
Houston Plastic Surgeon
4.8 out of 5 stars 86 reviews

Difference between SMAS facelift and deep plane facelift

 There are too many variables in the patient's  anatomy of the skin, muscles, and fat, and the differential aging process to  give a qualified answer. It is probably best to look at the surgeon's before and after photo gallery and choose which surgeon gives the most natural results without looking and pulled, tightened, or wind tunneled.The anesthesia has got nothing to do with the outcome of the results, it is just a matter of patient's safety and comfort

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 143 reviews

Assume the same patient consults with two highly qualified, board certified, face-only surgeons. One does 100+ procedures per/yr

Very interesting question.  A question that can be the subject of a study that would appear in one of our plastic surgery journals.  You either have done a lot of home-work or have seen many plastic surgeons in consultation.  However, plastic surgery is not an exact science, especially when it comes to facial rejuvenation, and there are many personal preferences.  Therefore, so long as these surgeons are certified by the American Board of Plastic Surgery, adequately experienced, and reputable, both their opinions and recommendations are respectable.  It all depends on what the surgeon is comfortable with.

Ruben B. Abrams, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 19 reviews


Surgeon needs to be Board Certified by the American Board of Plastic Surgery. The only approved board by The American Board Of Medical Specialties. The rest are self designated boards.If both surgeons are, and competent  then either one will have a great results

Samir Shureih, MD
Baltimore Plastic Surgeon
4.2 out of 5 stars 7 reviews

Facelift Techniques

The long term results do not differ in my opinion between the two techniques.  The deep plane is a more aggressive approach to achieve the same end.  That should give you food for thought.

Dr. ES

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.