Types and differences of facelifts: which lifting procedure is best for you?
The differences in lift amount by procedure, revealed by cadaver studies.
What you'll learn in this article:
- The fundamental mechanism of the SMAS technique (fascia lifting) and how it differs from surgery that lifts only the skin
- The characteristics of various procedures such as SMASplication, SMASectomy, and the Deep Plane technique, and a data-based comparison
- How to choose the optimal procedure to match your age, the state of your sagging, and your tolerance for downtime
"facelift—but there are so many types you don't know what the differences are," "if I'm going to pay a lot, I absolutely don't want to fail." Do you have such worries? Even looking at clinic websites, they're full of jargon, leaving you unsure which one suits you. In this article, based on facial anatomy and the latest medical research data, we explain the differences between each procedure in an easy-to-understand way.
1. What is the SMAS technique—why it lifts not just the skin but the whole structure
faceliftlifting procedure, the keyword you absolutely must know is the "SMAS (superficial musculoaponeurotic system)." Medically defined by Mitz and Peyronie in 1976, this tissue is a thin, tough membrane that envelops the facial expression muscles and divides the subcutaneous fat into layers. Facial aging is caused not merely by the skin stretching, but by a phenomenon in which the entire facial tissue descends (a cascade of descent) as this SMAS and the "retaining ligaments" connecting bone and skin loosen with age.
In the past,faceliftthe mainstream was the "subcutaneous lift," which simply detached and pulled the skin and cut away the excess. However, pulling only the skin not only quickly relapses, but also has the fatal drawbacks of strong tension on the scar making it conspicuous, and an unnatural result in which the face looks pulled sideways (lateral sweep).
What then became the modern mainstream is the "SMAS technique," which lifts the "SMAS" beneath the skin along with it. By firmly lifting and fixing the foundational structure that is the SMAS, you avoid applying excessive pulling force to the skin itself. As a result, scars heal cleanly and a natural, long-lasting lift effect is obtained. Most of what is now called a "facelift" refers to procedures that handle this SMAS in some form.
2. SMASplication and SMASectomy—what's the difference? The data shown by cadaver studies
Although we lump them together as the SMAS technique, they further divide into types depending on "how the SMAS is handled." The representative approaches are "SMASplication (folding plication)" and "SMASectomy (excision)."
SMASplicationis a technique repopularized by Robbins et al. in 1995, in which the SMAS is folded and sutured rather than cut to achieve a lift effect. It suits patients whose SMAS is thin and would tear if you tried to detach it. On the other hand,SMASectomyis a technique proposed by Baker in 1997, in which a band of the SMAS in front of the ear is cut out and the cut edges are sutured together. Because it eliminates the excess overlap of the SMAS, it has the characteristic of being able to tidy things up even when sagging is severe.
What's of interest here is the point, "Is there really a difference in lift effect between procedures?" Medical research using cadavers (anatomical donors) enables rigorous comparison of effects that is difficult in living bodies. Mohammadi et al. conducted a landmark study using nine fresh cadavers (average age 53.1) (Mohammadi et al. 2015), performing "SMASplication" and the "MACS technique (described later)" on the left and right sides of the face and comparing the lift amounts. As a result, it was demonstrated that for lifting the marionette lines and the corners of the mouth, SMASplication showed a significantly greater lift effect than the MACS technique (a vertical lift of more than 2 cm (Mohammadi et al. 2015)). The cadaver-study data corroborates how superior procedures that firmly dissect and lift the SMAS (such as plication) are in terms of physical lift amount.
3. The High-SMAS technique and the Deep Plane technique—deep procedures that reach the midface
When sagging progresses and nasolabial folds and under-eye sagging (midface sagging) become conspicuous, the ordinary SMAS technique has the problem that the lifting force struggles to reach the central area. Developed to solve this are the "High-SMAS technique" and the "Deep Plane technique," which dissect more deeply and over a wider area.
The High-SMAS techniqueis a procedure developed by Barton et al., which lifts the SMAS from an even higher position (above the zygomatic arch) than the ordinary SMAS technique, powerfully lifting the tissue located high on the cheek in the vertical direction.
The Deep Plane techniqueis a procedure published by Hamra in 1990, which enters an even deeper layer beneath the SMAS (above the expression muscles) and, by directly releasing the strong retaining ligaments, lifts the entire face at once as a single block.
What is the Deep Plane technique optimized for Asian patients?
Facelift techniques developed mainly in the West, but the bone structure and skin thickness of Caucasians and Asians are fundamentally different. According to a study by Wong et al. (2025), the Asian face is characterized by a greater width (the breadth of the cheekbone protrusion) and thicker, heavier skin and subcutaneous tissue. For this reason, with conventional procedures that only pull from the "outside," such as around the ear, the width of the cheekbones becomes a physical barrier, and the force does not reach the sagging at the center of the face, such as the nasolabial folds.
Thus, what was optimized to fundamentally solve Asian sagging is the extended Deep Plane technique. Wong et al. made modifications to release the thick Asian tissue along with the ligaments and to lift and fix it directly at a position closer to the center of the face (the anterior face). In a follow-up of 61 Asian patients who underwent surgery with this technique (Wong et al. 2025), a remarkable 98% answered "satisfied" or "very satisfied" (Wong et al. 2025), showing how overwhelmingly effective the Deep Plane technique is for the heavy tissue and deep nasolabial folds characteristic of Asians.
4. The MACS technique—a minimally invasive procedure aiming for early recovery
The MACS technique has fewer scars. But there's a reason to choose Deep Plane
Developed to meet the need of "I want the effect, but I want the incision area as small as possible" is theMACS (Minimal Access Cranial Suspension) technique, published by Tonnard et al. in 2002. This procedure approaches through only a short incision (short scar) in front of the ear, looping special sutures (purse-string sutures) around the SMAS and lifting it in the vertical direction. Because the tissue is not widely dissected, the greatest advantages are a low risk of nerve damage and very short downtime (early recovery can be expected).
However, it's not all advantages. According to Kao et al.'s analysis of 600 cases over 22 years (Kao et al. 2024), it is pointed out that techniques like the MACS that incise in front of the ear and lift with looped sutures have limits. Traction by suture loops can create unnatural tightening in the tissue, and pulling the skin in front of the ear can cause the sideburn position to recede or the shape in front of the ear canal (the tragus) to flatten, posing a risk of producing the "surgical stigma" characteristic of facelifts.
Furthermore, as the aforementioned Wong et al. data shows, for the heavy tissue and nasolabial folds of Asians, the force does not reach with traction from the outside alone, as in the MACS technique. The appeal of the MACS technique's short downtime is great, but when you want to improve severe sagging or pursue fundamental rejuvenation suited to the Asian bone structure, this is exactly the clear reason the Deep Plane technique—which firmly handles the ligaments and lifts the whole facial structure—is chosen over the temporary benefit of fewer scars.
5. How to choose a procedure—determined by the degree of sagging, age, and downtime
We've looked at various procedures so far, but the most important thing is to "choose a procedure that suits your condition and lifestyle." The optimal option changes with the degree of sagging, age, the downtime (recovery period) you can tolerate, and the surgeon's skill.
[20s–30s: mild sagging / preventive purpose]
If the sagging is not yet severe and you seek mild change or future prevention, the short-downtime MACS technique or an endoscopic mini lift are suitable. Early return is possible, and a natural result can be expected.
[Late 30s to 40s: moderate sagging]
When the breakdown of the facial line or the marionette lines around the mouth begin to bother you, standard SMAS techniques such as SMASplication or SMASectomy are a well-balanced option. As Mohammadi et al.'s data shows, a solid physical lift effect is obtained.
[40s and beyond: severe sagging / nasolabial folds]
If you are troubled by deep nasolabial folds, volume loss in the midface (the front of the cheek), or descent of heavy tissue, the High-SMAS technique or the Deep Plane technique is suitable. Especially for Asians, as Wong et al. demonstrated, there are many cases where a sufficient effect cannot be obtained without the Deep Plane technique, which releases the ligaments. Since the technical difficulty is extremely high, it is essential to choose a skilled specialist well-versed in anatomy.
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6. Summary of this article
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References
- Mohammadi S, Ahmadi A, Salem M, et al. A Comparison Between Two Methods of Face-Lift Surgery in Nine Cadavers: SMAS (Superficial Musculo-Aponeurotic System) Versus MACS (Minimal Access Cranial Suspension). Aesthetic Plastic Surgery. 2015 DOI
- 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
About the author
Hiromitsu Nakamura Physician
Zetith Beauty Clinic Ginza, Osaka, Fukuoka
He has a track record of presenting research at academic conferences both in Japan and internationally, and is also involved in technical guidance and education across all Zetith Beauty Clinic locations. He specializes in precise cosmetic medicine grounded in anatomical evidence, pursuing natural results tailored to each individual's bone structure and tissue.