The surgeon you have consulted with has misrepresented the SMAS facelift – and the skin lift facelift as well. In experienced hands, SMAS surgery does not result in more bruising and swelling than a skin-only facelift, and is not associated with longer recovery times. ‘SMAS’ is an acronym used to describe the sturdy, collagen-rich connective tissue layer of the face that resides between the skin and deeper structures such as the parotid gland and the muscles of facial expression. One must have a keen understanding of facial anatomy in order to be comfortable with performing surgery on the SMAS, but if one knows the anatomy well and has experience with SMAS elevation then the surgery can be performed quite safely, and with a recovery that is no more significant than a skin facelift. Most surgeons tend to do what they’re comfortable with, and I think many surgeons who don’t operate on the SMAS leave it alone because they aren’t comfortable or experienced with dissection of the deeper soft tissue layers of the face. And that probably is a good thing, as the facial nerve and its branches are just below the SMAS so you absolutely must be confident about what you are doing. In discussing facelift techniques with colleagues, I have not yet run across a surgeon experienced in SMAS surgery who has gone back to performing skin-only facelifts. It is worth pointing out that some younger patients with mild jawline and neck skin laxity are reasonable candidates for limited, skin-only facelifts (primarily to treat the jawline and neck), and that may apply to you. But if you have more significant aging changes and want to achieve a lift of the midface, correct deepening nasolabial folds, lift the corners of the mouth and improve marionette lines, then a SMAS facelift is the best approach. The advantages of SMAS elevation and tightening are numerous: SMAS is made primarily of collagen, which has extremely strong tensile strength. In other words, it doesn’t stretch out – like skin does. Skin-only facelifts tend to produce shorter-lasting results, as the skin always stretches out over time. If it’s the skin that is holding the facelift, the face will tend to look unnaturally postop, and the lift is not going to last as long. Putting the tension on the SMAS layer allows the surgeon to do a tension-free skin closure around the ears. This results in much more favorable scars, and a much more natural appearance, than when the tension is placed on the skin. The SMAS layer is continuous with the platysma layer in the neck, so tightening the SMAS in the face has the effect of tightening the platysma and enhancing neck definition simultaneously. No facelift lasts forever, and a high-SMAS flap can be mobilized and elevated again in the future without distorting facial appearance. Repeated skin-only facelifts will widen the mouth, produce a ‘windswept’ appearance, and ultimately make a patient look like a plastic surgery casualty from the cover of Us magazine. Surgeons use a wide variety of approaches to surgery on the SMAS, so it’s important to know that there is not just one ‘SMAS facelift’. I prefer to elevate a high-SMAS flap which is anchored to deep temporal fascia (lateral to the eye area) to lift the midface and correct nasolabial folds and marionette lines. The high-SMAS facelift requires an extended elevation of the SMAS, so the surgeon must be well-trained and experienced with the procedure. Other surgeons prefer to excise (remove) SMAS laterally to tighten the SMAS layer, and others suture the SMAS on itself (referred to as ‘imbrication’) to tighten the SMAS. Regarding facelift recovery, SMAS surgery is not the most relevant issue. A state-of-the-art facelift surgery involves restoration of facial volume by means of structural fat grafting, and in my experience it is fat grafting that contributes more to postop to mid-facial swelling than surgery on the SMAS layer. However, even with diffuse facial fat grafting most SMAS facelift patients have recovered to the point of being prepared for social interaction by 10 to 14 days postop. It is the ancillary procedures with greater recovery issues that tend to prolong the total facelift recovery – procedures such as a major subciliary lower blepharoplasty, skin resurfacing, dermabrasion, etc. May a skin-only facelift look as good as a SMAS facelift in some cases? Maybe in a few, but the improvement won’t last as long, and the patient will not look natural if another skin-only facelift (or two) is done later in the patient’s life.