The “High SMAS” Facelift

February 13, 2018

When I first came to Nashville, I assumed that my focus would be rhinoplasty. Although I’ve become a busy rhinoplasty surgeon, perhaps what I’m most sought after by patients is for a facelift or for nonsurgical facial rejuvenation. I’ve now done hundreds of faces since coming to town, and I’m starting to see a lot of word of mouth patients coming in, as well as difficult facelift problems sent to me by my colleagues. What an honor!

I’m often asked by colleagues what my facelift technique is. If it’s a patient’s first facelift, I almost always employ what is called the “High SMAS” facelift. This is a technique where you “lift” not just the facial skin, but the underlying fascia and facial musculature. Many authors have called it many different things, like the “Extended SMAS” or the “Deep Plane Facelift”. Because I learned this technique in Dallas from Dr. Fritz Barton and in Houston from Dr. Steve Hamilton, I call it the “High SMAS” facelift, as they do.

The technique was innovated by Dr. Bruce Connell in southern California in the 1970’s. He was a facelift pioneer, and his results still stand the test of time. Dr. Barton had begun mastering the technique from afar in New York under the direction of Dr. Tom Rees, and then in Dallas. Dr. Hamilton studied directly under Dr. Connell, but they both have the same technique, which I now employ. Our version of it takes the dissection a bit higher onto the cheekbone. This allows us to redrape the lower eyelid soft tissues and support them. In younger facelift patients (those in their early 40s to early 50s), typically the lower eyelids aren’t terribly aged, and so it’s beneficial to support the lower eyelid by redraping the SMAS, rather than having to take apart the lid and its’ structural support (something I reserve for more aged lower eyelids). As well, I truly feel like there is no way to restore the youthful tension of the face that is better than this redraping of the SMAS and facial musculature.

Why doesn’t everyone employ this technique if it is so good? That’s a question that many ask and a hotly contested debate at meetings, but there are a couple of reasons. The first is that the High SMAS technique is extremely intricate from an anatomical perspective, so it takes a long time and a lot of facelifts to master it. As well, many surgeons are afraid of injuring the branches of the facial nerve, so they are timid when it comes to releasing the appropriate ligaments and septal structures. I am a very experienced facial anatomist, having done multiple game-changing anatomical dissection studies. This experience combined with an exhaustive number of facelifts gives me total confidence in doing this without any danger to the facial nerves. I have come to the point where I have done so many that I am becoming extremely facile and efficient, so that the extra time in the OR can be spent artistically redraping and testing which vectors work.

Although I typically don’t post before and afters, I am posting some before and afters from a patient who has a nice result from this operation. This patient was very diligent in her skin care and postoperative regimens, and so she has maintained her result over a long period of time.

SMAS facelift Nashville
SMAS facelift Nashville

Avoiding the Unfavorable Facelift Result

February 28, 2017

Happy 2017 Readers!  Last month, we explored the phenomena of overfilled facial features.  I discovered that it stimulated conversation about a new problem that we’re seeing with the rise in facial fillers being injected.  However, we didn’t discuss something important and closely related:  The Unfavorable Facelift Result.

Every facelift patient I see voices the same concerns.  They say that so-and-so’s facelift looks “weird” or “unnatural”.  This often leads to the belief that they don’t want anyone to tell that they’ve had anything done.  While hiding surgical scars and achieving harmony are high on the list of operative goals, you do want something done, and you want that something to make you look younger!

So what is it that makes patients look bizarre after a facelift?  There are 4 major culprits:  1. Excessive skin tension.  2. An unartistic vector of pull.  3. Tethering of the muscles of facial expression.  4. Corrective disharmony between facial features.




When the patient is laying on the table, it is very tempting to take out a lot of skin.  Many a great surgeon has redraped the skin and taken out a lot of it, and on the table the patient looked like they were in their 30s.  The surgeon patted himself on the back and thought that he’d “hit a home run”.  However, as the patient healed, the earlobe pulled down, the scars widened, and wrinkles that formerly looked natural were now “windswept”.  Avoiding undue tension on the skin is an important part of obtaining a nice result.  Don’t ask me how I know!




As the face ages, the soft tissues descend with gravity.  Therefore, it would seem intuitive and natural the restoring the face’s youthful shape would be pulling those tissues upward.  However, it is technically more straightforward and easy to pull the soft tissues lateral, towards the ear.  The problem with this is that it leads to flattening of the facial features and sometimes the creation of a cross cheek depression.  Pulling the facial fascia in an upward direction more accurately restores the patient’s youthful appearance.




All of our anatomical study up until 2009 was on the anatomy of the face in cadavers or during live dissection in the operating room.  In 2009, it occurred to me that we were missing the point – the face is a dynamic, fluid structure.  Facial expression is an overlooked part of youth and facial beauty.  I realized that we should focus not just on this static anatomy, but on dynamic anatomy.  Using ultrasound, we demonstrated that the fascial fascia and the muscles that control facial expression move around a great deal in ways we never previously recognized.  Tethering these muscles with poorly-placed sutures creates some of the weird smiles we see after facelift surgery.




On an almost daily basis, patients tell me that they just want their neck done or just want their face done.  It’s understandable – they don’t want all of that expense, pain, recovery time, and with all of the bad results, it’s natural to assume doing less would lead to a better outcome. However, many strange outcomes you see are actually not bad facelifts.  Often, the patient has had a good facelift result, but their neck and upper face remain in an aged position, or their eyes are undercorrected.  This leads to disharmony, which your brain interprets as “strange”.  It’s sometimes best to do it all and turn back the clock on your entire face.  The caveat to this is the male patient.  I frequently find that male patients just need conservative upper eyelid surgery and a good necklift.


I hope that this editorial spurs your intellectual curiosity.  If you’re considering facial rejuvenation, keep some of these points in mind to further a good conversation with your plastic surgeon.  We love informed patients!