What is Facelift? Understanding the Rejuvenation Mechanism of SMAS Treatment and Its Indications

Facelift (SMAS lift) is a surgical procedure that lifts facial Sagging (skin laxity) by manipulating not only the skin but also the SMAS (superficial muscular aponeurotic system) fascial layer beneath it. The characteristic feature is that it aims for a rejuvenation effect with greater longevity compared to non-incisional methods such as Thread lift. Zetis Beauty Clinic offers such Treatments.

Mechanism — Surgical Techniques Vary Based on SMAS Layer Handling

Facelift is not a single fixed surgical procedure but rather divides into several technique groups depending on how the SMAS layer is manipulated. SMAS plication is a relatively conservative approach that reduces the SMAS layer by suturing without excision, and is considered a widely practiced technique due to its low complication rate and long-term durability[1]. Lateral SMASectomy is a method that excises the lateral portion of the SMAS and repositions the remaining tissue to improve the jawline and neck contrast[2]. High-SMAS/extended SMAS with more extensive SMAS dissection, and deep plane/composite rhytidectomy that dissects into deeper supporting ligaments, are expected to achieve more dramatic and sustained midface lifting; however, they are associated with higher invasiveness and nerve injury risk[3].

Indications — Skin Sagging (skin laxity) and SMAS Laxity Are Key Decision Factors

Generally, indications include moderate to advanced signs of facial aging accompanied by skin Sagging (skin laxity), SMAS laxity, and cheek fat descent. In young patients with only submental fat excess and minimal skin redundancy, liposuction alone may be sufficient; however, in patients with skin redundancy, liposuction alone is insufficient, and Facelift surgery including SMAS treatment is necessary[4]. It has also been noted that loosening of supporting ligaments (retaining ligaments) with age is a primary cause of jowling and volume descent, and it is argued that anatomical understanding of supporting ligaments is important for achieving natural and sustained results in midface and cervical lifts[5].

Complications — Nerve Injury Risk Varies by Technique and Dissection Extent

Several meta-analyses comparing complication rates among SMAS techniques exist, quantitatively demonstrating differences in safety profiles between techniques[6][7]In particular, nerve injury is a major concern, and systematic reviews and meta-analyses focusing on nerve injury in Facelift surgery have examined its frequency and related factors[8]It is reported that the risk of facial nerve injury increases with deeper and more extensive dissection (deep plane/composite)[3]In high-SMAS techniques where dissection extends beyond the zygomatic arch, the anatomical proximity to the frontal branch of the facial nerve crossing the zygomatic arch is reported as the basis for this risk[9]Complications such as skin roughness, hematoma, hair loss, skin necrosis, and hyperpigmentation have also been reported, and since high-SMAS and similar techniques were primarily developed for Caucasian patients, caution is advised in evaluating their use in other ethnicities[10]There is also a note that early relapse is often underestimated as a complication, and caution is necessary when evaluating long-term outcomes[1].

Differences from other lift techniques — Comparison with Thread lift and endoscopic lift

Thread lift (thread lift), a non-incisional option, is less invasive compared to incisional SMAS lift, but the durability of results and the range of applicable patients differ, and it is considered a separate positioning[11]Regarding endoscopic techniques that aim for sustained effects while minimizing incisions, there are reports based on long-term experience, and it is positioned as one alternative approach[12].

Limitations of evidence level — superiority among techniques has not yet been established

This is a point we should communicate honestly. Network meta-analyses directly comparing various SMAS techniques are currently underway, and high-level evidence regarding definitive superiority among techniques remains limited[3]Existing meta-analyses are primarily integrations of retrospective and observational studies, and well-established recommendations based on randomized controlled trials are currently sparse[6][7]Technique selection is determined individually by the physicians at Zéties Beauty Clinic, taking into account the surgeon's experience, anatomical features such as SMAS thickness and the degree of ligament laxity, and the balance between acceptable risk and recovery period