Where should you have an incisional Facelift? Distinguish by the depth of SMAS and nerve explanation

Choosing where to have an incisional Facelift starts with selecting a facility that can explain with reasoning how deep and in what way the SMAS (the fascial layer beneath the skin) will be manipulated. There are different levels in how SMAS is handled, ranging from folding and suturing to releasing ligaments and lifting deeper layers together.[1]. While deeper approaches are thought to have longer-lasting results, they are also considered to carry higher risk to the facial nerve[1][2]. However, there is limited data from high-quality research comparing different techniques, so it is not yet determined which is best[1].

What levels of SMAS handling are there?

First, it's important to know that even though incisional Facelift is spoken of as one thing, SMAS manipulation is divided into 6 different levels. A meta-analysis synthesizing 183 studies organizes them in order of least to most invasive as: SMAS plication (folding and suturing), SMASectomy/imbrication (partial excision and suturing), SMAS flap elevation, high SMAS lift, deep plane, and composite[1]. The logic behind this hierarchy is that moving deeper layers more extensively produces longer-lasting results[1].

Even with different names, the content can be similar. In textbooks, names like extended SMAS, high SMAS, and composite are all understood as alternative terms for deep plane techniques that dissect deeper than SMAS[3]. There is also a two-layer approach called "lift-and-fill" where the skin is lifted, SMAS is overlapped or partially excised, and fat grafting restores the lost volume[3][4]. During consultation, asking "which layer is dissected to what extent and what is released?" rather than the technique name will give you a better understanding of what is actually being done.

Do deeper techniques really last longer?

Theoretically yes, but it has not been proven. The introduction of the same meta-analysis mentions that while some studies report shorter-lasting effects from plication, other studies show little difference in results even with deeper procedures, and cites a 2011 systematic review concluding that "high-quality data comparing effects between techniques is lacking"[1].

A research protocol registered in 2025 also states that there is still no analysis ranking complications, satisfaction, and duration of results by technique[2]. So a physician who discusses which layer is moved in what way and acknowledges the limits of the evidence is more trustworthy than one who flatly claims "our method lasts the longest."

How should they explain the risk to the facial nerve?

The most important thing to ask about when choosing a facility is how the facial nerve will be avoided. Deep plane and composite techniques, which involve releasing ligaments and moving larger tissue masses, are expected to produce more dramatic and longer-lasting midface lifting, but are considered to carry higher risk of facial nerve injury[2]. Surgery deeper than SMAS is considered to have more complications, and some surgeons avoid deep dissection for this reason[1].

The facial nerve has 5 branches: temporal, zygomatic, buccal, marginal mandibular, and cervical; injury to any of them can lead to facial asymmetry, difficulty closing the eyes, speech difficulty, or difficulty closing the mouth[5]. The review states that the pillars of prevention are anatomical understanding, identification of landmarks, and meticulous preoperative planning[5]. Textbooks also note that partial SMAS excision and suturing may reduce the danger of nerve injury compared to plication alone[6].

The question is simple: "At what depth do the nerve branches run, and how does your technique avoid them?" If the physician can answer using layer names and diagrams, you can choose the facility based on understanding their approach.

How much will nasolabial folds and the neck improve?

The range of improvement differs depending on whether ligaments are released. Deep plane is characterized by short skin dissection and complete release of the ligaments connecting SMAS to deeper structures, and textbooks note it is superior to SMAS lift for nasolabial fold improvement[6]. Techniques that release ligaments move tissue more extensively and can more easily correct the midface and neck, while ligament-preserving methods like MACS and PRESTO are safer with less invasiveness but offer limited correction for severe sagging, according to reviews[7].

The neck requires separate treatment. The neck contour is determined by how the platysma (thin muscle on the front of the neck) is handled, and the explanation describes combining external SMAS lift with midline platysma plication[8]. Extended SMAS technique has been reported to be useful for ptosis of the submandibular gland, which causes fullness beneath the jaw[9]. If you want "the neck corrected too," asking how the platysma and submandibular gland will be handled will make the plan more concrete.

How much bleeding and swelling after surgery?

Numbers are limited. In a retrospective study of 160 patients undergoing deep plane lift simultaneously with permanent filler removal, complications occurred in 22%, with temporary swelling and bruising in 15%, mild infection in 4%, and hematoma in 3%[10]. Mean follow-up was 16 months, with average hospitalization of 32 hours[10]. However, this is a special case involving filler removal and tissue reconstruction, so it cannot be directly applied to routine lift procedures[10].

What you should ask the facility is the frequency of hematoma at their facility and how they manage it, and the proportion of nerve paralysis that is temporary versus permanent. The meta-analysis defines temporary nerve injury as "movement that returns without intervention during postoperative recovery"[1]. Knowing this definition allows you to verify what is meant by the explanation "paralysis usually resolves."

5 things to confirm during consultation

First, at which of the 6 SMAS levels the procedure will address it and why[1]. Second, whether ligaments will be released or preserved for your degree of sagging[7]. Third, how the facial nerve branches will be avoided[5]. Fourth, how far nasolabial folds and neck will be included[6][8]. Fifth, the frequency and management of hematoma and nerve paralysis at their facility[10].

The design varies depending on skin thickness, degree of sagging, amount of fat, and neck condition. Therefore, you cannot decide which technique suits you based on an article alone. During examination, confirm whether sagging involves only skin or deeper layers, the degree of ligament laxity, and neck muscle condition, then work together to clarify which layers will be moved and to what extent.