Technique families
| Technique | What is done to the SMAS | Key paper |
|---|---|---|
| Plication | Folded and sutured without undermining it (PMID 36332084) | ABPS data: 40% of facelifts (PMID 38302713) |
| Imbrication / SMAS-stacking | Incised, overlapped and sutured (PMID 19319074) | Stacking vector set by facial asymmetry (PMID 19319074) |
| Lateral SMASectomy | Strip over the anterior parotid edge excised, mobile SMAS sutured to fixed SMAS (PMID 18922307) | Baker 1997 (PMID 9252623) |
| SMAS-platysma flap | SMAS and platysma elevated and advanced (PMID 928549) | Owsley 1977, 1983 (PMID 928549, PMID 6828592) |
| High SMAS | Flap planned along the zygomatic arch, extended medially to include midface (PMID 36563671) | Barton 2002, 2003 (PMID 19332004, PMID 14663239) |
| Extended SMAS | Sub-SMAS dissection carried medially past the retaining ligaments (PMID 41100833) | Baker and Stuzin personal technique (PMID 9252622) |
Landmark papers
- Rees and Aston 1977: unilateral sub-SMAS dissection in 25 patients showed no difference from skin-only at late review (PMID 928550).
- Owsley 1977: platysma-fascial rhytidectomy described (PMID 928549).
- Owsley 1983: SMAS-platysma face lift, 6-year experience, low complications (PMID 6828592).
- Barton 1992: releasing deep SMAS attachments over facial muscles; marked nasolabial fold improvement in over 80% of 100 patients at 6-12 months (PMID 1409995).
- Baker 1997: lateral SMASectomy (PMID 9252623).
- Baker 2008: lateral SMASectomy fixes mobile anterior SMAS to fixed SMAS over the parotid; combines flap versatility with plication speed (PMID 18922307).
- Barton 2003: high-SMAS in 267 patients; 97% (183 of 189) with fold scores 2-3 improved (PMID 14663239).
- Frontal branch lies under a separate parotid-temporal fascia over the arch, so high-SMAS division above the arch is safe (PMID 20335873).
- Rohrich 2009: individualized component face lift, 822 lifts; SMASectomy against SMAS-stacking chosen by malar deflation (PMID 19319074).
- Connell: SMAS flap face lift lasts 12 years on average; 21.4% of 42 secondary patients returned within 5 years (PMID 20224461).
Comparisons
- Cadaver, 18 hemifaces: SMAS plication and extended SMAS both lifted vertically; skin-only did not; extended SMAS added only an incremental lift except in the lower face (PMID 36332084).
- Prospective cohort 2026, 166 patients: deep plane (45) vs SMAS plication (121), no difference in satisfaction, recovery or complications (21.6% vs 28.7%) at median 3 months (PMID 42384060).
- Meta-analysis, 183 studies: temporary nerve injury higher with high lateral SMAS (1.85%) and composite (1.52%) than plication; skin necrosis higher with SMAS flap (1.57%); major hematoma higher with imbrication (1.92%) (PMID 30768122).
- Systematic review 2023, 27 studies, 6,086 patients: satisfaction over 85%; temporary nerve injury 0.85%; skin necrosis 0.41% (PMID 38283861).
- Systematic review 2026, 17 articles: medially based deep-plane techniques not shown to improve the midface or longevity over laterally based SMAS techniques (PMID 41100833).
- Systematic plus case-based review, 65 articles: satisfaction equivocal across techniques; fat grafting used with all (PMID 36729730).
- Split-face study 1996: lateral SMASectomy and standard SMAS matched extended SMAS and composite at 6 and 12 months (PMID 8942899).
Current variants (2021-2026)
- Delta facelift: superior-vector plication close to the mobile medial fat, 283 patients; 11 neuropraxias, 6 minor hematomas; repeat lift at mean 9.3 years in 9 (PMID 37619977).
- Double-sling composite facelift, 72 patients, SMAS slings to temple and mastoid (PMID 42192009).
- SMAS plication plus platysmaplasty under tumescent local anesthesia, 80 patients: complications 10%, hematoma 2.5%, no conversion to general anesthesia (PMID 42380310).
- Photochemical tissue passivation of SMAS: suture pull-through resistance +229% (P = .21) in human SMAS; rat plication laxity 54% lower at 12 weeks (PMID 41322035).
- Selective neck sutures to close dead space in face lifts (PMID 40719487).
- Lift-and-fill: individualized SMAS treatment plus compartment fat grafting, 100 patients; nasolabial fold improved one grade or more in 81% (PMID 24569422).
Practice shares
- ABPS tracer data, 3,400 facelifts 2006-2021: plication 40%, flaps 35%, SMASectomy 22%, MACS 6%; lateral SMAS flap use rose 14% to 18%; extended SMAS fell 21% to 18% (PMID 38302713).
- AAFPRS survey 2026: SMAS plication and imbrication most used among surgeons who do not perform deep plane (PMID 41251721).
Sequelae specific to SMAS work
- Cross-cheek depression ("joker line"): most patients who develop it show a version preoperatively; treated with volume (PMID 18971739).
Glossary
- Plication: folding SMAS on itself with sutures, no SMAS undermining (PMID 36332084).
- Imbrication / SMAS-stacking: SMAS incised and overlapped (PMID 19319074).
- Lateral SMASectomy: excision of a SMAS strip over the anterior parotid edge (PMID 18922307).
- High SMAS: SMAS flap incised along the zygomatic arch to include the midface (PMID 36563671).
- Extended SMAS: SMAS flap dissected medial to the retaining ligaments (PMID 41100833).
- Skin-only lift: skin flap without SMAS work; 8% of ABPS tracer facelifts (PMID 38302713).
- Joker line: cross-cheek depression from the commissure toward the ear (PMID 18971739).
Papers
| PMID | First author | Year | Journal | Title | Finding |
|---|---|---|---|---|---|
| 38302713 | Stein MJ | 2024 | Aesthetic Plast Surg | Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery. | ABPS 3,400 facelifts: plication 40%, flap 35%, SMASectomy 22% |
| 36729730 | Avashia YJ | 2023 | Plast Reconstr Surg | An Evidence-Based and Case-Based Comparison of Modern Face Lift Techniques. | Evidence and case review of modern lifts: satisfaction equivocal |
| 41100833 | Schultz KP | 2026 | Plast Reconstr Surg | Demystifying Deep Layer Face-Lift Techniques: A Systematic Review of Superficial Musculoaponeurotic System Techniques. | Systematic review: deep plane not shown superior to lateral SMAS |
| 36332084 | Rao V | 2023 | Plast Reconstr Surg | Quantifying the Effective Lift of Skin-Only, SMAS Plication, and Extended SMAS Face-Lift Techniques in a Cadaveric Study. | Cadaver: plication vs extended SMAS lift differ little |
| 19319074 | Rohrich RJ | 2009 | Plast Reconstr Surg | The individualized component face lift: developing a systematic approach to facial rejuvenation. | Individualized component face lift, 822 lifts (landmark) |
| 18922307 | Baker DC | 2008 | Clin Plast Surg | Lateral SMASectomy, plication and short scar facelifts: indications and techniques. | Lateral SMASectomy, plication and short scar indications (landmark) |
| 9252623 | Baker DC | 1997 | Plast Reconstr Surg | Lateral SMASectomy. | Lateral SMASectomy described (landmark) |
| 928549 | Owsley JQ Jr | 1977 | Plast Reconstr Surg | Platysma-fascial rhytidectomy: a preliminary report. | Platysma-fascial rhytidectomy (landmark) |
| 6828592 | Owsley JQ Jr | 1983 | Plast Reconstr Surg | SMAS-platysma face lift. | SMAS-platysma face lift, 6-year experience (landmark) |
| 36563671 | Marten T | 2022 | Facial Plast Surg | High SMAS Facelift: Combined Single Flap Lifting of the Midface, Cheek, and Jawline. | High SMAS single-flap midface, cheek and jawline |
| 19332004 | Barton FE Jr | 2002 | Aesthet Surg J | The "high SMAS" face lift technique. | High SMAS technique steps (landmark) |
| 14663239 | Barton FE Jr | 2003 | Plast Reconstr Surg | The high-superficial musculoaponeurotic system technique in facial rejuvenation: an update. | High SMAS in 267 patients, 97% fold improvement (landmark) |
| 9252622 | Baker TJ | 1997 | Plast Reconstr Surg | Personal technique of face lifting. | Baker and Stuzin personal technique (landmark) |
| 928550 | Rees TD | 1977 | Plast Reconstr Surg | A clinical evaluation of the results of submusculo-aponeurotic dissection and fixation in face lifts. | 1977 split-face: sub-SMAS no better than skin-only (landmark) |
| 1409995 | Barton FE Jr | 1992 | Plast Reconstr Surg | Rhytidectomy and the nasolabial fold. | Barton: SMAS release and nasolabial fold, 100 patients (landmark) |
| 20335873 | Trussler AP | 2010 | Plast Reconstr Surg | The frontal branch of the facial nerve across the zygomatic arch: anatomical relevance of the high-SMAS technique. | Frontal branch protected over the arch (landmark) |
| 20224461 | Sundine MJ | 2010 | Plast Reconstr Surg | Longevity of SMAS facial rejuvenation and support. | SMAS flap facelift lasts 12 years on average (landmark) |
| 42384060 | Neel OF | 2026 | Aesthetic Plast Surg | Deep Plane Versus SMAS Plication Facelift: A Prospective Cohort Study of Clinical Outcomes and Complication Rates. | Deep plane vs plication cohort, no difference at 3 months |
| 30768122 | Jacono AA | 2019 | Aesthet Surg J | A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques. | Complications by SMAS technique, 183 studies |
| 38283861 | Mortada H | 2024 | JPRAS Open | Evolution of Superficial Muscular Aponeurotic System Facelift Techniques: A Comprehensive Systematic Review of Complications and Outcomes. | SMAS techniques review, 6,086 patients |
| 8942899 | Ivy EJ | 1996 | Plast Reconstr Surg | Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. | Split-face: limited SMAS equals extended at 1 year (landmark) |
| 37619977 | Grotting JC | 2024 | Aesthet Surg J | Superior Vector Plication of the Mobile Anterior Midface: The Delta Facelift. | Delta facelift, 283 patients |
| 42192009 | Öreroğlu AR | 2026 | Aesthetic Plast Surg | Double-Sling Composite Facelift. | Double-sling composite facelift, 72 patients |
| 42380310 | De Riso S | 2026 | Aesthetic Plast Surg | SMAS Plication Facelift and Platysmaplasty Under Tumescent Local Anesthesia: A 10-Year Retrospective Evaluation of Safety, Efficacy, and Patient Satisfaction in an Outpatient Setting. | SMAS plication under tumescent local, 80 patients |
| 41322035 | Tereshenko V | 2025 | Aesthet Surg J Open Forum | Increasing Superficial Musculoaponeurotic System Durability and Retention in Facelift Surgery. | Photochemical passivation strengthens SMAS |
| 40719487 | Ganesh Kumar N | 2025 | Plast Reconstr Surg | Role of Selective Neck Sutures in Face Lifts. | Selective neck sutures |
| 24569422 | Rohrich RJ | 2014 | Plast Reconstr Surg | Lift-and-fill face lift: integrating the fat compartments. | Lift-and-fill face lift, 100 patients |
| 41251721 | Pak KY | 2026 | J Craniofac Surg | Evaluating Facelift Outcomes and Technique Trends in the United States. | AAFPRS survey technique use |
| 18971739 | Lambros V | 2008 | Plast Reconstr Surg | The cross-cheek depression: surgical cause and effect in the development of the "joker line" and its treatment. | Cross-cheek depression after face lift (landmark) |
Open questions / controversies
- Extent of SMAS dissection against result: cadaver lift gains are incremental (PMID 36332084); clinical comparisons show equivalence at 1 year (PMID 8942899) and 3 months (PMID 42384060).
- Durability: 12-year mean for SMAS flap (PMID 20224461); no randomized long-term comparison exists (PMID 41100833).
- Nerve risk rises with medial dissection (PMID 30768122).
- Tissue engineering of the SMAS is preclinical (PMID 41322035).