Can a skin only facelift ever be equal to a SMAS lift?

I just had a plastic surgeon consult and he told me he would only do a skin only lift. He believes the SMAS lift is too rough on the patient causing much more swelling and bruising and longer recovery time. Also more of a chance of something going wrong. He truly believes a skin only can look as good as the SMAS. I really pushed him on this and he didn't bend.

Doctor Answers 33

SMAS Facelift vs Skin Only Facelift

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:
  1. 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.
  2. 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.
  3. 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.
  4. 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. 


Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 110 reviews

SMAS lift vs Skin Only Facelift

SMAS (superficial musculoaponeurotic system) is the structural layer of the face beneath the skin and enveloping the facial muscles. Most but not all top plastic surgeons utilize the SMAS in one way or another during their face and neck lift procedures. If done properly the risks can be limited and complication rates not much different than that of skin lifts. It does take more time and expertise to perform a SMAS facelift. Most studies have shown that the longevity and duration of outcome is better when SMAS is incorporated. Hope this helps.

Babak Azizzadeh, MD
Beverly Hills Facial Plastic Surgeon
4.0 out of 5 stars 7 reviews

Can a skin only facelift ever be equal to a SMAS lift?

In short, NO.  Skin only lifts depend on the skin to support it.  No matter how snugly the skin is drawn, in time it will loosen over a fairly short period of time.  This is because the skin is highly elastic and stretches very easily.  Traditional face lifting utilizes sutures placed into the strong sheeting around the facial muscles (SMAS) to achieve a long-lasting result.  The strength of the facelift, therefore, relies on the support of the SMAS, which results in little tension being placed on the skin itself.  There are many variations on SMAS lifts: deep plane, partial deep plane, plication, imbrication, etc...  It's best to meet with a facial plastic surgeon or plastic surgeon that specializes in one of these SMAS techniques and evaluate their pre and post operative portfolio to assess the results and longevity. The money and time invested in skin only facelifts is not well-spent.

Parker A. Velargo, MD
New Orleans Facial Plastic Surgeon
5.0 out of 5 stars 42 reviews

SMAS vs. skin-only facelift

Your question highlights the too-often incorrect nature of judging procedural techniques which I discuss in my book. Studies comparing skin-only vs. SMAS-tightening techniques have shown inconclusive results where some SMAS techniques lasting longer but some skin-only techniques being equal in effect. In fact, there are many variations of the SMAS-tightening procedure. The procedures and techniques should serve the goals of your procedure and are dependent on the specific anatomy of individual patients. In the end, you are trusting the surgeon you choose, not the procedure he or she does. Discuss your specific goals and your tolerance to risks and unwanted side effects and let the surgeon determine how to produce the results your desire.

Robin T.W. Yuan, M.D.

Robin T.W. Yuan, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 10 reviews

SKin only lift

Hello smokes, 
Thank you for your question.

Unfortuantely I have to disagree with your consultant.  It actually has been proven time and time again that a skin only facelift, while technically easier and faster, fails to give long lasting results.  The results may only last as few as 3-6 months dependent on your skin type! :(

I would recommend consultation with a facial plastic surgeon in your area who can evaluate you and discuss the benefits of the various approaches and surgical options. 

The AAFPRS website has a surgeon locator.

Good luck, 

Dr. S

Scott Shadfar, MD
Edmond Facial Plastic Surgeon
5.0 out of 5 stars 4 reviews

Why Skin Only Facelifts Do Not Work

Aging faces sag because of 
  1. Loss of elasticity in the skin
  2. Sagging of the deep tissues of the face including fat, muscle and fascia (SMAS)
  3. Loss of soft tissue volume
  4. Loss of bony support and volume.
The loss of skin elasticity means that the  deep sagging cannot be held in place by youthful skin. If you tighten the sagging skin, the deep tissues will stretch out the skin in a very short period of time. In essence, the procedure will be a waste. Also important, the stress on the incision will lead to a stretched out scar.

Ideal procedures address the deep tissues ( I prefer a vertical lift to the SMAS structures and volume enhancements when necessary with fat grafting). When the deep tissues are tightened as the primary therapy, the results will be more natural (less pulling) and more durable. The incision in the skin will be under less stress and the scars will heal better and become much more difficult to see.

If you want more information about facelifts, please read my book "A More Beautiful You - Reverse Aging through skin care, plastic surgery and lifestyle solutions".

Robert M. Freund, MD
New York Plastic Surgeon
4.8 out of 5 stars 30 reviews

Skin only facelift

A skin only facelift may be ok in some patients who only have some loose skin. If the soft tissues below have descended and deflated then you need a lift of this tissues and perhaps even fat grafting.   A SMAS lift will help improve the deeper structures.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Facelift

WOW, whoever told you a skin only facelift !!!, have no clue about cosmetic surgery.....................

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

Skin only facelift

Time has shown that skin only facelifts do not work. There needs to be a lifting of the underlying tissues, not just the skin, for the procedure to be effective. Please seek a consultation with a board certified facial plastic surgeon with expertise in facelifts.

Suzanne Kim Doud Galli, MD, PhD, FACS
Washington Facial Plastic Surgeon
5.0 out of 5 stars 6 reviews

Skin only facelift or smas facelift?

Thank you for your question.

Facelift surgery continues to evolve.  The earliest facelifts were simply tightening of the skin.  Unfortunately these did not hold up long-term because the skin is smarter than your Physician and relaxes.  Next Physicians turn towards the deep muscle layer under the face the smas, This is a much stronger and more powerful layer.  Unfortunately deep elevation of this layer does increase the risk of nerve injury.  Even deeper facelifts involving the layer above the bones are performed as well and these can have longer recovery and other issues.  Today, augmenting the face with fat in conjunction with skin and smas facelifts has become very popular.

In my opinion the key is to find a happy medium that both you and your surgeon are comfortable with.  The smas can be manipulated by tightening it, without necessarily elevating it.  In the neck, the put his mama or lower border of the smas can easily be tightened with very little risk.

Discuss your concerns with your plastic surgeon.  In your situation he may be correct.  Each patient's facial rejuvenation is slightly different.  If you don't like what you're hearing a second opinion may be in order.  When more than one surgeon comes up with the same plan and it makes intuitive sense to you that is often a way to go.

I hope this has been helpful

Adam Tattelbaum, MD
Washington DC Plastic Surgeon
5.0 out of 5 stars 90 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.