What is the deep-plane facelift? One of the main differences from the conventional SMAS method
Do you ever feel, about the facial sagging that bothers you every time you look in the mirror, "If only this sagging were gone, I could have more confidence in myself..."?
While researching sagging treatment, many people probably see information on the convenientthread liftor the "cuttingfacelift" and feel questions about the effect, durability, and naturalness.
A generalfaceliftor thread lift can sometimes weaken in effect within a few years or result in an unnatural expression. This is, in part, due to not appropriately processing specific anatomical structures in the deep layer of the face.
In this article, we explain one of the treatment methods currently attracting attention in the world's cosmetic surgery societies, the "deep-planefacelift." The main difference from the conventional SMAS method, and the treatment options you should consider, will become clear.
The limits of the "cutting facelift" and the history of its evolution
The history of the facelift is also the history of surgeons' quest for a more natural and longer-lasting result.Wan et al.(2015), according to whose paper the early facelifts from the early to mid-1900s were a "subcutaneous lift," which simply dissected and pulled the skin and cut off the excess skin.
But the skin is an elastic tissue. If you try to support the heavy internal fat and muscle with the force of the skin alone, it quickly stretches and the sagging recurs. Also, it had the fatal drawback that forcibly pulling places excessive tension on the skin, resulting in a so-called "face shoved into a wind tunnel" unnatural pulled look, or in the scars widening.
And so what appeared in the 1970s was the "SMAS (superficial fascia) method." Deep in the facial subcutaneous fat there is a fascial layer called the SMAS (superficial fascia) that works in concert with the muscles of expression. The aim was to further enhance the lifting effect by lifting and fixing this fascial layer, not just the skin. The cutting facelift performed at many clinics today is, in most cases, a variation of this "SMAS method" (such as the simple method of merely folding and suturing the SMAS).
So did the SMAS method solve all the problems of sagging treatment?
The anatomical limits of the conventional SMAS method
In fact, the conventional SMAS method had anatomical limits.
Beneath the fascial layer there are multiple strong fibrous tissues called "retaining ligaments" that firmly tie the facial skin, fat, and fascia to the bone. These retaining ligaments around the cheekbones and along the jawline strongly fix the tissue that has drooped with aging in that low position.
In the conventional SMAS method, these retaining ligaments are not completely severed. Just behind the retaining ligaments runs the "facial nerve," which is extremely important for moving the facial expressions. This is because safely dissecting the deep layer requires extremely advanced anatomical knowledge, skilled technique, and sufficient surgery time.
Even if you pull the fascia without releasing these retaining ligaments, the sagging around the mouth (the marionette lines) and the base of the nasolabial folds that you really want to lift may not be sufficiently lifted. If you pull forcibly, unnatural tension is applied, which becomes a cause of the effect not lasting.
An innovative approach that releases these retaining ligaments at the root and moves the facial tissue as a "block" to a youthful position. That is precisely the "deep plane" explained next.
The deep-plane facelift: a treatment option from which fundamental improvement can be expected
The deep-plane facelift was proposed by Hamra in 1990 and has since been refined over decades by the world's top surgeons; it is an effective lifting technique. The biggest difference from the conventional SMAS method lies in the "depth" of the approach and the "processing of the retaining ligaments."
Entry just above the facial nerve, into the deep layer (deep plane)
In the deep-plane facelift, you enter the space (the deep plane) deeper than the fascial layer, just above where the muscles of expression and the facial nerve exist. And, under direct vision, you safely and completely sever the retaining ligaments that fix the tissue in its drooped position.
This makes the skin, subcutaneous fat, and fascial layer completely free as a single thick block (a composite flap). The tissue whose retaining ligaments have been released can be moved, as if sliding, to its original youthful, high position without applying unreasonable force.
The effectiveness for the Asian bone structure and tissue
There is also the question of whether a surgical method developed in the West can be applied to the Asian bone structure, but there is an interesting research result.
Wong, Hsieh, Mendelson(2024)'s paper "Deep Plane Face Lift in Asian Patients" reports that the deep-plane facelift also brings a good effect to the Asian face.
The Asian face has wider cheekbones, a flatter face, and thicker, heavier skin and subcutaneous tissue compared with Westerners — these are its characteristics. Forcibly pulling this heavy tissue diagonally upward or sideways with the conventional SMAS method carried the risk of making the face look even flatter and wider.
On the other hand, the deep-plane facelift makes it possible to lift the tissue as a "block" with a natural vector.Wong et al.'s study reports that from 2021 to 2023, a deep-plane facelift was performed on 61 Asian patients (average age 52), and many patients obtained satisfactory results.
However, complications were also reported (epidermal abrasion behind the ear 3%, hypertrophic scarring 1.6%, transient facial nerve palsy 1.6%, etc.), and you need to fully understand that there are individual differences and that thorough discussion of the risks with a physician in advance is necessary.
By fundamentally releasing the heavy tissue and returning it to its original position without strain, improvement of the heavy sagging, deep nasolabial folds, and marionette lines peculiar to Asians can sometimes be expected.
The clinical results shown by large-scale data
Furthermore,Kao and Duscher(2024)'s paper "The Ponytail Lift: 22 Years of Experience in 600 Cases of Endoscopic Deep Plane Facial Rejuvenation" analyzes the data of 600 cases of the deep-plane approach using an endoscope over 22 years. The average age of patients in this study was 50.9, and as many as 80.8% were troubled by sagging around the marionette lines (jowls), 57% by neck sagging, and 47.4% by the depth of the nasolabial folds.
Even in this long-term, large-scale data, the result was reported that not a single case of flap (skin flap) necrosis occurred, and permanent nerve injury was also zero. However, these are research reports, and the result may differ depending on the individual case. Because surgery always involves risk, thorough discussion with a physician is important.
Also, because the deep plane does not forcibly pull the skin by the skin layer alone, it is reported that the blood flow of the skin is preserved, postoperative recovery is fast, and unnatural scars are prevented. Avoiding excessive tension on the skin is also extremely important for preventing the hypertrophic scarring (the phenomenon of scars turning red and raised) that is common in Asians.
The technical features of the deep-plane facelift
We believe you now understand how reasonable a treatment option the deep-plane facelift is. We explain the features of this treatment method in more detail.
The reason it is positioned as an advanced specialized technique
The deep-plane facelift is positioned as "an extremely high-difficulty surgery that is difficult to standardize and perform in a manualized way."
This surgery requires detailed analysis of each patient's facial bone structure, the way the fat is attached, and the way the muscles are attached. And the technique of dissecting, in millimeter units, the layer right at the edge of the facial nerve is required.
The deep-plane facelift can be safely performed only by a limited number of surgeons who are well versed in the deep anatomical structure of the face and have accumulated many years of training. To release the retaining ligaments and reposition the tissue while reliably avoiding the risk of nerve injury, the surgeon's advanced technique and a sincere attitude of devoting sufficient time to each patient are indispensable.
To those seeking fundamental improvement
For women in their 40s and 50s, facial sagging is not merely a change in appearance but a problem deeply related to the inner self, such as confidence and vitality. That is precisely why you must not compromise with superficial, stopgap treatment.
The deep-plane facelift, which appropriately processes the anatomical structures the conventional SMAS method could not reach, releases the retaining ligaments, and reconstructs the entire face from the deep layer to a youthful position.As the study by Wong et al.(2024) shows, a good effect has also been reported for the Asian bone structure and thick tissue, and it is a treatment option from which a certain result can be expected. Also, as the study byKao and Duscher(2024) shows, an appropriate deep-plane approach preserves blood flow and can be expected to bring a natural, long-lasting result.
If you truly want it to be effective and to maintain a beautiful, natural expression 5 and 10 years from now, we recommend consulting a specialist who has mastered the technique of the deep-plane facelift.
At Zetith Beauty Clinic, based on the world's most cutting-edge knowledge of anatomy and cosmetic surgery, we provide made-to-order sagging treatment that discerns in detail the state of each patient's bone structure and tissue. We value quality over efficiency, and with advanced techniques such as the deep-plane facelift, we support the fundamental improvement of your face. To regain a smooth contour without unnatural pulling, and a radiant confidence. First, please experience a full consultation by a specialist at Zetith Beauty Clinic.
References
- Wong C, Hsieh M, Mendelson B. Deep Plane Face Lift in Asian Patients. Plastic & Reconstructive Surgery. 2025 (DOI)
- Kao C, Duscher D. The Ponytail Lift: 22 Years of Experience in 600 Cases of Endoscopic Deep Plane Facial Rejuvenation. Aesthetic Surgery Journal. 2024 (DOI)
- Wan D, Small K, Barton F. Face Lift. Plastic and Reconstructive Surgery. 2015 (DOI)
- Wan D, Small K, Barton F. Face Lift. Plastic and Reconstructive Surgery. 2015 (DOI)
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Author of this article
Hiromitsu Nakamura Physician
Zetith Beauty Clinic Ginza, Osaka, Fukuoka
He has a track record of research presentations at domestic and international academic conferences, and is also engaged in technical guidance and education for Zetith Beauty Clinic as a whole. He specializes in precise rhinoplasty based on anatomical grounds, pursuing natural results tailored to each person's bone structure and tissue.