The “High SMAS” Facelift

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.