High SMAS facelift: what is it and how does it differ from the Deep Plane?

The SMAS performs two functions at once: suspending the facial tissues (it keeps the volumes in place thanks to its anchoring to deep bony structures) and transmitting the contraction of the mimetic muscles from their deep origin to the skin. It is the facial equivalent of a structural mesh.

With aging, the SMAS undergoes three changes:

• Loss of tone and elasticity due to degradation of its collagen component.
• Atrophy of the fat compartments anchored to its deep surface.
• Elongation and descent due to the effect of gravity and repeated muscle contractions.

The clinical result is what you recognize as facial aging:

• Sagging cheeks, with loss of volume in the upper part of the face and accumulation in the lower part.
• Deepening of the nasolabial fold (from the nose to the corner of the mouth).
• Appearance of marionette lines (from the corner of the mouth toward the chin).
• Loss of the facial oval, with sagging of the lower third ("jowls" or double chin).
• Associated neck laxity due to descent of the platysma.

• It is not a single muscle: it is a continuous fibromuscular sheet that in its upper portion relates to the temporoparietal fascia and in its lower portion to the cervical platysma.
• It is not a "tight" layer that can be cinched like a corset without consequences. Pulling on the SMAS without correctly releasing its ligaments causes distortion of the facial nerve and a "pulled" look.
• It cannot be reached with non-surgical treatments. Thread lifts remain in the subcutaneous plane. Focused ultrasound can produce pinpoint coagulation in the SMAS, but it does not reposition it.

The High SMAS facelift is a major surgical procedure performed under general anesthesia or deep sedation with local anesthesia, with a hospital stay of approximately 24 hours. It takes 2 to 4 hours on average, depending on associated procedures.

1. Preoperative consultation and planning

Before surgery:

• Full preoperative blood tests.
• Electrocardiogram (ECG).
• Consultation with the anesthesia team.
• Facial photographic study in different positions (front, oblique, profile, expressions).
• Dynamic analysis of facial animation (expression, full smile, frown).
• Stopping smoking at least 3 weeks beforehand, and antiplatelet medication as instructed.
• Signing the informed consent form specific to facelift surgery.

The photographic study is not a formality: it makes it possible to identify pre-existing asymmetries, plan vectors and compare the postoperative result objectively.

2. Marking and incision design (in a seated position)

On the day of surgery, the patient is marked in a seated position, not lying down. Marking the patient lying down is one of the classic mistakes: the way the tissues fall changes and asymmetries are created.

The incisions are designed to remain hidden:

• Temples: within the hairline.
• Preauricular: following the natural contour of the tragus.
• Earlobe: going around the earlobe without amputating it (this avoids the "pixie" ear).
• Retroauricular: in the crease, extended into the hair at the back.

3. Subcutaneous dissection and exposure of the SMAS

After the skin incision, a dissection is performed in the subcutaneous plane, preserving the fat that remains attached to the skin flap, until the SMAS layer is exposed. The extent of the dissection depends on the specific technique: in a classic High SMAS, it reaches the lateral nasolabial fold.

4. Elevation of the SMAS in its upper portion

This is where the "High" technique differs. Whereas in the classic SMAS the elevation was performed below the zygomatic arch, in the High SMAS the dissection begins above the arch and the layer is lifted as a single unit from its highest portion.

This achieves two key effects:

• It restores the volume of the middle third (cheeks) to its youthful position, without the need to add filler.
• It allows a strictly vertical vector of pull (upward), not a horizontal one (backward). It is the difference between rejuvenating the face and "pulling" it.

5. Deep fixation with non-absorbable sutures

Once elevated, the SMAS is fixed with non-absorbable sutures to stable structures:

• Deep temporal fascia (upper anchor).
• Mastoid periosteum (posterior anchor).

The tension is borne by these two points. The skin is then redraped without tension. This is the fundamental principle of the High SMAS: the skin does not hold the result.

6. Skin resection, closure and dressing

Once the SMAS has been fixed, the redundant excess skin is resected using a conservative technique: it is always preferable to resect less and leave the skin redraped without tension. The incisions are closed in layers with fine sutures (5-0 or 6-0 depending on the area). Fine drains are placed for 24-48 hours and a compressive facial dressing is applied.

• Middle third with moderate laxity and flat/sagging cheeks: High SMAS is usually sufficient and offers excellent naturalness with a shorter recovery.
• Severely sagging middle third, marked zygomatic ptosis, deep nasolabial folds due to descent of the malar compartment: Deep Plane is indicated because it releases the ligaments that the High SMAS does not address.
• Young patient with early laxity: first consider non-surgical alternatives (Ultherapy, radiofrequency, thread lifts) or less extensive techniques (MACS-lift).
• Very elderly patient with very thin skin: the extensive dissection of the deep plane can compromise the blood supply to the skin; a conservative High SMAS is usually preferred.

The decision is individual and is made in consultation. There is no "best" technique in the abstract: there is the technique indicated for each anatomy.