Facelift with incision: How does SMAS treatment change outcomes? Choosing the right surgical approach

A Facelift with incision affects outcomes, durability, and patient burden depending not only on skin handling but also on how the underlying fascia (SMAS = superficial musculoaponeurotic system) is managed. There are methods of folding and suturing the SMAS, partially excising it, or lifting it by dissecting deeper layers—the choice is tailored to the degree of Sagging (skin laxity)[1]. The deeper the dissection, the greater the lift effect tends to be; however, the surgical design must also account for nerve protection[2]. The extent of dissection is what defines the choice of surgical approach.

What is SMAS and why is the method of treatment important?

SMAS (superficial musculoaponeurotic system) is the layer of fascia and muscle beneath the facial skin and serves as the foundation for lifting Sagging (skin laxity)[3]Pulling skin alone tends not to provide long-lasting results because the deeper foundation is not addressed. In fact, research comparing lifting force across three approaches—skin only, SMAS plication, and broad SMAS undermining—has shown a trend toward greater effectiveness as SMAS involvement increases.[4]Which layer is addressed affects both the final result and longevity.

What are the differences among plication, excision, and deep undermining?

There are three major SMAS approaches: plication (folding and suturing to reduce), SMASectomy (excising and suturing portions), and deep plane (undermining to deeper layers and releasing ligaments).[1]Deep plane is considered suitable for improving nasolabial fold areas by adequately releasing the ligaments that anchor the face.[5]By contrast, plication is relatively less invasive and may be appropriate for those with mild to moderate Sagging (skin laxity).

Which approach provides longer-lasting results?

Techniques that address deeper layers tend to produce more pronounced lifting effects.[4]However, research findings are not entirely consistent regarding whether the duration of results and satisfaction levels differ markedly depending on the technique.[6]The magnitude of effect and the burden of complications or recovery exist in a trade-off relationship. Rather than choosing based solely on stronger effects, it is more realistic to consider the balance between the degree of sagging (skin laxity) and the burden you can tolerate.

Does complication risk vary depending on the surgical technique?

With facelift procedures, concerns typically center on damage to nerves that control facial movement and blood accumulation (hematoma). A meta-analysis comparing complications across different SMAS techniques demonstrates that the likelihood of complications varies by technique.[1]Systematic reviews of nerve injury have been conducted, with most cases considered temporary; however, for techniques addressing deeper layers, a thorough understanding of anatomy becomes increasingly important.[2]What matters is not the newness of instruments, but rather whether that surgeon can safely handle each layer.

How do I choose a technique suited to me?

The selection criteria are: the degree of sagging (skin laxity), whether you want to address nasolabial folds and neck sagging, and how much recovery burden you can tolerate.[4]For mild to moderate sagging (skin laxity), folding methods are an option; if you want significant lifting and improvement of nasolabial folds, techniques that address deeper layers become candidates.[5]There is no single correct approach to SMAS handling; rather, the technique should be tailored to each individual, using folding, cutting, or elevation selectively.[1]First, determine your priorities, and it becomes easier to narrow down your options.

What to confirm during your consultation before deciding

What you want to clarify is which layer your sagging (skin laxity) originates from and how much lifting you desire. During your consultation, confirm which layer the recommended technique addresses, the expected results and duration, and the risk of nerve damage or hematoma as well as how they will be managed. Since effect strength and recovery burden are a trade-off, a surgeon who presents both equally is easier to trust. Base your decision on the thoroughness of risk explanation rather than promises of strong results.