Comparisons of superficial musculoaponeurotic system (SMAS) and deep plane facelifts often credit results to the dissection plane, even though surgeon, patient, and adjunct procedures also shape the outcome.
Dr. Basel Sharaf is professor of plastic surgery, director of aesthetic surgery, and director of FaceAcademy360 at Mayo Clinic in Rochester, Minnesota. He spoke in the panel ‘Does facelift plane actually matter?’ at Plastic Surgery The Meeting 2026, organized and hosted by the American Society of Plastic Surgeons (ASPS). The meeting was held October 15 to 18, 2026, in Houston, Texas. He compared the anatomic rationale for deep plane dissection with what outcome studies can show.
Dr. Sharaf began with the 5 facial soft-tissue layers. ‘This talk is really about layer three,’ he said, meaning whether surgeons go under the SMAS, manipulate it, or stay above it. The deep plane rationale centers on retaining ligaments that anchor soft tissue to bone. Releasing them lets cheek and midface tissue move with the SMAS-platysma unit, and lifting skin and SMAS as one flap reduces skin tension. Still, he cautioned, sound anatomic logic alone does not prove better results.
Facelift Outcome Studies Rarely Isolate the Dissection Plane
In his view, the SMAS plane is a spectrum. Studies pool very different operations under one label, blurring real differences between SMAS and deep plane techniques. ‘When we are measuring outcomes, what are we measuring?’ he asked. He framed the observed result as the sum of technique, surgeon, patient, and adjuncts. ‘Most studies credit the plane without isolating it from the rest,’ he said.
Which Patients May Benefit From a Deep Plane Facelift?
Tissue quality varies across the face. Dr. Sharaf described the lateral SMAS as strongest, with bursting strength decreasing toward the midface and the nasolabial fold, and warned that a suture placed in thin, weak medial tissue may tear through. Tissue also varies with age. ‘Does the age of the patient matter? Absolutely,’ he said while presenting patient cases. Tissue in a 70-year-old may differ from tissue in a 45-year-old, yet age alone did not dictate technique; anatomy, filler history, patient goals, and how the tissue holds up also guided him.
In his opinion, deep plane dissection may help most with marked jowling and midface descent; deep nasolabial folds, where ligament release may soften the fold; and revision cases, where previously operated planes may call for deeper mobilization. The trade-off is more extensive dissection and a steeper learning curve.
‘So does the plane really matter? I think perhaps we're asking the wrong question in 2026,’ Dr. Sharaf said. ‘We should be asking which plane for which patient and whose hands?’ He concluded that both approaches are safe and effective in experienced hands, and that indication, anatomy, filler history, and surgeon experience likely matter more than the label.
Abbreviation: SMAS, superficial musculoaponeurotic system.