The face has layers. Going from superficial to deeper, you have
Most facelift techniques get into those middle layers to lift and reposition the tissue. Skin only facelifts do exist, but they tend to relax quickly, as the skin stretches. To address facial aging you need to hoist up those deeper tissues.
I would also argue that you need to address the components separately. How is your skin quality? How can you make your skin sheet better? (Ex: facial products, microneedling with exosomes, stem cell effect of fat transfer) As for volume, you lose facial volume as you age. A facelift tightens the skin and repositions the deeper tissue. It doesn’t add volume unless you do fat grafting, which I think is critical, particularly in the temple, the tear trough, and around the mouth. (fat grafting info)
FYI- There are discussions now at my national meetings about the SMAS- is it really a layer? does it exist?- despite the fact that for 30 years doing SMAS removal, SMAS flaps, and SMAS plication were the basis of most facelifts.
You can’t go anywhere now without people talking about a deep plane facelift. In this facelift, the dissection is carried deeper and more medially toward the midface. This carries out dissection anterior to the masseter muscle and zygomatic arch, carrying it to the nasolabial fold.
The SMAS was the basis of the modern facelift. It repositions facial fat and helps with cheek deflation. It focuses on the immobile region laterally, where it is stuck to the parotid gland, chasing it toward where it thins in the medial cheek. Deep ligaments originate deeply and travel through the SMAS to insert into the skin to support the face’s soft tissue from falling with gravity.
The deep plane is not focused on this lateral immobile region. It focuses more on the medial tissue and resuspending this tissue out more laterally.
This was a study in the Plastic and Reconstructive Surgery Journal April 2026, “Demystifying Deep Layer Facelift Techniques: A Systematic Review of Superficial Musculoaponeurotic system Techniques.” They reviewed publications from 1975-2020. After screening, the articles were narrowed down.
What did they find?
They conclude that this was a hard study to do, as the terminology and what surgeons do varies. They state the reason to go medial and deep for the deep plane facelift is to help with the nasolabial fold issue, but the studies do not show sustained benefits in this area. “It is not supported in the literature, nor are they supported in the photos included in the articles.” (ouch)
They conclude, “In our review more articles using medially based techniques reported poor longevity or disappointing improvement in the cheek or nasolabial folds than those using laterally based techniques.” “From our perspective, seemingly very different techniques are more similar than different.”
I remember a talk I went to 20 years ago with the greats of plastic surgery facelifts, who all had their different style of facelift- deep, SMAS ectomy, SMAS plication- showed 1 year and 10 year results. The results were all fabulous. They all lasted well. And they were all different techniques.
So this study doesn’t surprise me.
I think the deep plane facelift has importance in mobilizing the thicker tissue of the midface to laterally. I think the SMAS facelifts has had great results for decades. For me, patients all have slightly different issues. What has dropped? Where is the volume? Where is it heavy? How thin is the tissue? Social media is great at promoting buzzwords, and then that is all people talk about and they want THAT procedure. But I don’t think the traditional “SMAS” facelift of old is dead.
The reality of facelifts is more nuanced. I think a good facelift addresses the deep medial plane, and the lateral face, and the volume loss, and the skin laxity. So it may be more of a hybrid of all.
This study concluded that the “seemingly very different techniques are more similar than different.” For you, the patient, this means that the many variations of the facelift are all good.
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