Deep plane or SMAS: what really changes in a facelift

“Deep plane” has become the word that separates the good surgeons from the rest on half the internet. Anyone looking for a facelift arrives at the consultation asking about it, and arrives convinced it is a superior technique.

The honest answer is duller and more useful: they are two ways of treating the same layer, neither is superior in general, and the evidence cited to claim otherwise does not exist with that force.

This page explains what each one does, what the studies comparing them actually say, and which questions really do help in choosing a surgeon.

What the SMAS is and why everything turns on it

Under the skin of the face and above the muscle there is a continuous layer of fibrous and muscular tissue: the superficial musculoaponeurotic system, or SMAS. It is what holds the cheek in place. Over the years it slackens and descends, and the fat and skin it carries come down with it.

From that comes the idea that defines modern surgery: if what has fallen is the SMAS, stretching only the skin fixes nothing — it just tightens what sits on top of a framework that is still hanging, and produces that pulled look everyone recognises and nobody wants.

Every technique used today, whatever it is called, tries to reposition that layer. The argument is about how.

The two families, in plain language

SMAS techniques

The skin is lifted, exposing the SMAS, and it is worked on from above. Within this family there are variants with names of their own:

• Plication: the SMAS is folded over on itself with sutures, without cutting it.
• Imbrication: one edge is overlapped on another.
• SMASectomy: a strip of SMAS is resected and the edges are closed, leaving them under tension.

The skin and the SMAS move separately, each in its own vector.

Deep plane techniques

The dissection goes beneath the SMAS, into the space between that layer and the facial muscles. There the retaining ligaments are released — the anchors that hold the tissue to the bone and prevent it from being repositioned.

The practical consequence is that skin and SMAS travel together, as a single composite unit. Its advocates argue that this gives a more genuine movement of the midface and skin that closes with no tension at all, because the skin is not holding anything up.

⚠️ It is a plane closer to the branches of the facial nerve. That does not make it dangerous — the safety data are comparable — but it explains why it demands very fine anatomical knowledge.

What the studies say (and what they do not)

Here is the reason for this page.

In 2025 a systematic review with meta-analysis was published that searched MEDLINE, Embase, Cochrane, CINAHL and LILACS for everything published on these techniques up to May 2024. It included 47 studies and 10,766 patients.

What it found on safety:

On the nerves it adds the qualification that matters: most of the injuries reported were temporary and resolved over time, and permanent injury was rare. That applies to both families.

What it found on aesthetic result: both techniques improve significantly. And then comes the sentence almost nobody quotes:

🔑 Only one of the 47 studies compared the two techniques directly. That study found better rejuvenation of the midface with the deep plane.

The authors conclude, in their own words, that the comparative data are limited and the outcome measures heterogeneous, which prevents definitive conclusions about relative efficacy, and that the choice of technique should be individualised.

⚠️ Translated: the sales line “we do deep plane, which is better” runs ahead of the evidence. It is not false that the deep plane may give a better midface; it is that stating it as an established fact, on this basis, does not stand up.

Why comparing two surgical techniques is so difficult

It is not bad faith on the researchers’ part. It is that the study design you would need is almost impossible to carry out:

• Each series is signed by a different surgeon, with their own learning curve and judgement. If a surgeon who has spent twenty years doing deep plane gets better results than one starting out with SMAS, what has been measured is the surgeon, not the technique.
• Patients are not interchangeable. The technique is chosen according to anatomy, so the two series start from different faces in the first place.
• There is no standard measure of a “good result”. Each paper uses its own scale, which is why the meta-analysis talks about heterogeneity.
• And you cannot randomise properly: nobody is going to draw lots over which technique is used on their face.

This does not mean it makes no difference what is done. It means that the question “which is better?” is badly framed, and that anyone answering it with absolute certainty is selling, not informing.

What is documented to change the result

If the name of the technique is not the decisive variable, what is? A paper covering 25 years and 1,089 patients of facial surgery answers fairly clearly, and its conclusions are almost the opposite of what the marketing promises:

• 🔑 “Patient selection is as important as technical advances.” It is the first conclusion, and it is the one least quoted.
• The best long-term results were in younger patients with fuller faces. Volume helps; a very depleted face gives less margin.
• ⚠️ Fuller necks relapsed more. The neck is the weak point of this surgery, and it is so regardless of the facial technique.
• Opening and treating the platysmal bands in the midline reduced the recurrence of neck deformities.
• Surface treatment of the skin — laser, topical retinoids — improved long-term results.
• And a figure that breaks another expectation: men and women had similar results and similar revision rates.

That same paper states that plication and SMAS resection techniques, applied with an individualised analysis of each component of the face, achieved consistent and reliable results. It comes from an author with an enormous body of work on facial rejuvenation. It is not a nostalgic defence of the old: it is the observation that a well-indicated technique works.

So how is the choice made?

Not from a menu. It is chosen by anatomy, and it is the surgeon who chooses, after examining you.

What you can do is change the questions you take to the consultation. Instead of “do you do deep plane?”, which has only one good answer and tells you nothing, these work better:

• Where exactly is my laxity and what does each area call for? If the answer is generic, there has been no examination.
• What are you going to do with my neck? It is the area that relapses most and the one that weighs most on how the result is perceived.
• What is this surgery NOT going to improve? A facelift does not treat the eyelids, or skin quality, or lost volume.
• How many times a year do you do this operation? It is worth more than the name of the technique. And it is a question that has to be answerable: this clinic’s answer is that two of the surgeons on the team specialise in this procedure — Dr Abel Llinás Porte and Dr Alessandro Thione, and they are the ones who perform it.
• What happens if a complication arises? There should be a concrete answer, not a reassuring one.

And one check that comes before everything else: who is allowed to operate on you. It is explained on the page about the 2026 regulations.

What this page is not saying

It is not saying the deep plane is marketing. It is a real technique, with a sound anatomical basis, which in the only comparative study available came out better in the midface. Many excellent surgeons use it as their standard and have reasons for doing so.

It is saying something else: that universal superiority has not been demonstrated, that the safety difference between the two is one percentage point in haematoma, and that a patient should not choose a surgeon on the strength of a word they learnt on social media.

And here, what do we do?

Both, and everything in between. At ICPM we use the deep plane, SMAS techniques — flap, plication and resection — and combinations of the two. There is no house technique: there is a decision per face.

What decides it is not a school preference but the clinical assessment of four things:

• The type of face and where the descent is concentrated.
• The laxity of the tissues, which determines how much can be mobilised and how much will hold.
• The weight of the tissues, which is what will pull on the result over the following years.
• What else has to be corrected in the same procedure — the neck, above all.

🔑 That is why this page does not defend any technique. A team that has mastered only one has to indicate it every time, and will find reasons. One that has mastered several can choose, and then the useful conversation in clinic stops being what the dissection plane is called and becomes why that one was chosen for your face.

And who operates is part of the answer. Two of the surgeons on the team specialise in this procedure: Dr Abel Llinás Porte and Dr Alessandro Thione.

Frequently asked questions

Is the deep plane better than SMAS?

It has not been shown to be so in general. The largest systematic review available pooled 47 studies and 10,766 patients, and only one compared the two techniques directly: that one found better rejuvenation of the midface with the deep plane. The authors themselves conclude that the comparative data are insufficient for a definitive conclusion and that the choice should be individualised.

Which is safer?

They are comparable. In that same review, haematoma was 3% with deep plane techniques and 2% with SMAS techniques, infection was low in both and nerve injury rates were similar, mostly temporary.

Does the deep plane last longer?

There is no comparative evidence showing that it does. What is documented as a factor in durability is patient selection, treatment of the platysmal bands in the midline and skin care.

Does the deep plane touch the facial nerve?

It works in a plane closer to its branches, yes. Even so, the nerve injury rates reported are similar to those of SMAS techniques and most cases are temporary.

If my surgeon uses SMAS, am I getting an old technique?

No. SMAS plication and resection, applied with an individualised analysis, have produced consistent and reliable results in series of more than a thousand patients followed for twenty-five years. What is old — and abandoned — is the facelift that only stretched the skin.

Which technique do you use at ICPM?

Both families and their combinations: deep plane, SMAS flap, plication and resection. What decides in each case is the clinical assessment — type of face, laxity of the tissues, weight of the tissues and what else has to be treated — not a fixed preference. The operation is performed by the two surgeons on the team who specialise in it, Dr Abel Llinás Porte and Dr Alessandro Thione.

What should I ask in the consultation, then?

Where your laxity is, what will be done with your neck, what the surgery will not improve, how often the surgeon operates and what route there is if a complication arises. All of them tell you more than the name of the dissection plane.

Sources

• Vayalapra S, et al. Comparing the Safety and Efficacy of Superficial Musculoaponeurotic System and Deep Plane Facelift Techniques: A Systematic Review and Meta-analysis. Annals of Plastic Surgery, 2025. PMID 40600822. — Search in MEDLINE, Embase, Cochrane, CINAHL and LILACS up to May 2024; 47 studies and 10,766 patients; haematoma 3% in deep plane and 2% in SMAS; low infection rates in both; similar nerve injury, mostly temporary and with permanent injury rare; a single direct comparative study, with better midface rejuvenation in the deep plane group; the authors conclude that limited comparative data and heterogeneous measures prevent definitive conclusions.
• Rohrich RJ, Narasimhan K. Long-Term Results in Face Lifting: Observational Results and Evolution of Technique. Plastic and Reconstructive Surgery, 2016. PMID 27348643. — Twenty-five years of experience and 1,089 patients: patient selection is as important as technical advances; better results in younger patients with fuller faces; a higher relapse rate in fuller necks; opening and treating the platysmal bands in the midline reduces relapse; SMAS plication and resection with individualised analysis give consistent results; similar results and revision rates in men and women.
• Cervicofacial Rhytidectomy. StatPearls, NCBI Bookshelf. NBK564338. — Anatomical description of the SMAS, of the dissection planes and of the branches of the facial nerve most exposed in cervicofacial surgery.

Book your consultation

If you have read this far with a technique in mind, the consultation is where that question turns into a better one: what your face has, what can be repositioned and how far it can go. At our clinic in Valencia we examine you, explain what is proposed and why, and also say what will not improve.

Clinical confirmation by the surgeon

Dr Alessandro Thione

Specialist in Plastic, Aesthetic and Reconstructive Surgery
Registration no. 46/4621959

Dr Abel Llinás Porte

Specialist in Plastic, Aesthetic and Reconstructive Surgery
Registration no. 46/4623604

Last reviewed: 6 September 2026. This content is for information only and does not replace an individual assessment by a healthcare professional.