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The SMAS is a layer of tissue that acts as a structural support system connecting the skin and soft tissue of the face. The SMAS is located underneath the dermis of the skin, right next to subcutaneous fat. My goal in facelift surgery is to put tension on the SMAS, not the skin. Skin is designed to stretch and be elastic, so when it is pulled together too tightly, the results appear unnatural and mal-positioned. In addition, when the skin is tightened, tension occurs on the incision, causing it to widen and resulting in poor scar formation and hairline displacement. Finally, since skin will eventually stretch and relax over time, the results of a “skin only” facelift will gradually dissipate.

There are some well-regarded surgeons who have advocated lifting the face at a deeper level to the SMAS, specifically in the sub-periosteal plane (the periosteum is a very thin and almost transparent layer of tissue directly in contact with the bones of the face). While it’s true that lifting the facial tissues by lifting the periosteum can address some of the drawbacks of a skin-only facelift, this approach has several theoretical and practical problems.

From a theoretical standpoint, I feel that lifting in the very deep sub-periosteal plane does not make sense because this layer does not descend to any meaningful degree during the aging process. Moreover, the periosteum is not intimately connected to the critical structures that descend with age (the skin, dermis, and SMAS).

There are practical problems as well with trying to lift the face in the sub-periosteal plan. This type of lift very often results in prolonged swelling of the face and delays the patient’s return to normal social activities. If tolerating this longer recovery resulted in a superior long-term result, I would at least consider this approach, but I do not believe this is the case.

Importance of SMAS Facelift

The important point to understand is that the last 25 years have brought surgeons to the understanding that supporting the SMAS is fundamental to achieving natural-appearing and long-lasting results. Many surgeons have contributed to our improved understanding of the important role of the SMAS in supporting a facelift result ,including Drs. Connell, Barton, Hamra, Owsley, and many others. However, that is only the beginning of the story. Another important consideration is exactly how the surgeon should elevate or suspend the SMAS. I feel this issue is critically important to achieving improved results, and is the primary distinguishing feature amongst many facelifts today. Please see the following sections for further details.

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