SMAS / Dual Plane Facelift

The SMAS or Dual Plane Facelift achieves natural facial rejuvenation by releasing the skin from the deeper tissue (the SMAS – superficial musculoaponeurotic system) and lifting the skin and the SMAS separately from one another, each along anatomically appropriate vectors.

With increasing age the skin loses elasticity, volume often diminishes or shifts, and soft tissue sinks down from its original position under the pull of gravity. The consequences are hollowed cheeks, deep nasolabial folds, a softer jawline with jowls, and a loss of contour at the neck–chin junction, sometimes extending to a double chin. Patients frequently feel that their external appearance no longer reflects their inner sense of self. Remarks about a ‘tired’ appearance can also add to the problem. With an SMAS / dual plane facelift, cheek volume, the nasolabial folds, the jawline and also the neck contour can be improved, and a fresh, more youthful appearance can be achieved without a mask-like effect, in keeping with the patient’s self-perception.

SMAS (Dual Plane) Facelift Technique in Bern

In a dual plane facelift, the skin and the SMAS are mobilised separately from one another and lifted and fixed in different directions. To achieve this, two separate tissue units (so-called flaps) are formed: a superficial skin flap and a deeper SMAS flap, which consists of muscle, fat and connective tissue. The advantages of this method are that the directions (vectors) for treating the skin and the deep tissue can be chosen independently of one another, and that moving the skin and the subcutaneous tissue along different vectors achieves a better anatomical reversal of the ageing process.

Typically, the deep tissue (SMAS) is lifted more vertically, while the skin is lifted obliquely. A further advantage is the ability to reposition deep facial tissue with the SMAS flap without relying on skin tension. This avoids the disadvantages of excessive skin tension. There are numerous variants of the dual plane concept, developed by different authors and known as the ‘extended SMAS’, ‘high SMAS’ or ‘FAME lift’.

In contrast to mini-lifts or ‘skin-only’ lifts, which primarily tighten the skin, the SMAS or dual plane facelift performs volume and shape correction in the deep supporting layers, with the separate tightening of the skin matched to it. This produces a long-lasting result with youthful proportions, improved volumes and clearer contours. Where there is marked volume loss, an additional fat transfer (lipofilling) or another volumising procedure may be appropriate. Excess fatty tissue, by contrast – particularly at the chin and neck – can be excised or removed minimally invasively in order to improve the contour in a lasting way.

We would be happy to consult with you at our AARE KLINIK in Bern if you are interested in an SMAS or dual-plane facelift. Simply give us a call or use our online appointment scheduling system.

SMAS / Dual Plane or Deep Plane Facelift?

Both techniques aim at natural, long-lasting results. The SMAS or dual plane facelift has the advantage where the skin and the deep structure need to be repositioned in different directions (for example, a predominantly vertical repositioning of the deep tissues with obliquely directed excess skin). Here the separate mobilisation allows very precise adjustment of both planes. A deep plane facelift, by contrast, may be appropriate where the deep tissue and the overlying tissue are to be lifted as a unit along one dominant vector. At the AARE KLINIK, every treatment is planned individually and the appropriate technique – dual plane or deep plane facelift – is selected according to findings and goals.

Considerations

When to consider a SMAS / Dual Plane Facelift:

• You suffer from the aging effects to your face or neck.
• Face and/or neck have lost their youthful contours and their volume.
• Your formerly oval face has become increasingly rectangular.
• You are affected by one or more of the following: sunken cheeks, deep nasolabial creases, jowls, a double chin, an undefined chin–neck contour (jawline), loose and wrinkled skin on the cheeks and/or neck.
• Your appearance does not coincide with your actual age (discrepant self-perception).
• Your appearance does not coincide with how others perceive you (discrepant external perception).

Consultation

A prerequisite to a successful operation is careful planning. This starts with a personal consultation at the AARE KLINIK. Clear communication of your wishes and expectations ascertain what you would like to improve. A comprehensive consultation, along with an explanation of the options and the scope of the procedure, will enable you to make an informed decision.

During the consultation, the medical history is taken, a physical examination is performed and digital photos are taken. Bone structure and soft tissue are assessed, and the thickness, texture and elasticity of the skin are tested. Based on this an individual treatment plan is drawn up and the goals of the operation are discussed and defined. A dual plane facelift is an extremely versatile operation that can be tailored to the specific needs of each patient. It often makes sense to combine several treatment methods to achieve the best possible result (platysmaplasty/neck tightening, liposuction of the chin and neck, fat transfer (lipofilling), and where indicated a temporal or brow lift with eyelid surgery or a skin resurfacing treatment (dermabrasion/peeling)). 

The pros and cons of the different surgical procedures, together with possible risks – and how to avoid them – are discussed. The personal and financial cost of having a facelift has to be carefully considered before the definitive treatment plan is agreed upon and documented.

To plan the operation and to make a risk assessment we require a full medical history (pre-existing conditions and previous surgery), information about current diseases (high blood pressure, diabetes, thyroid dysfunction), allergies or aversion to medications, and any important medical reports. Please bring any important medical information along to the consultation. Portrait photographs that show you in your youth are also relevant for the assessment of age-related and constitutional changes.

Procedure

A dual plane facelift needs to be tailored to the individual characteristics and needs of the patient. Thus every procedure differs. Common to the dual plane approach is the limited release of the skin and the separate dissection of the skin and the SMAS. The skin incisions are typically made in front and behind the ears, and where needed can be extended along the hairline. An inconspicuous scar is promoted by precise placement within the natural contours and hair margins.

The deeper structures are repositioned and fixed along anatomical vectors, and the skin is tightened separately in its optimal direction and without excessive tension. The chin line and the neck are often treated additionally with a platysmaplasty, that is, tightening of the superficial neck muscle. In this context, excess fat, muscle or salivary gland tissue can also be removed. Where needed, missing volume can be replaced with the patient’s own fat, shaping the facial contours more softly and femininely. 

In suitable cases, a temporal or brow lift can lift and shape sunken eyebrows, and an upper and lower eyelid plasty can treat hooded lids and bags under the eyes. The skin is closed with fine sutures. At the AARE KLINIK we do not use drains; instead, we use special sutures (the Auersvald net) to prevent haematomas and seromas in the first 2–3 days.

A natural appearance and long-lasting result are mainly dependent on the correction of the deep-layered structural tissues. As skin only has a covering and not a structural function, a permanent effect cannot be achieved by the tightening of skin alone. In a dual plane facelift, youthfulness is therefore returned through the specific treatment of the deep tissues, while the skin envelope is adapted and only excess skin is removed – without creating an artificial, ‘lifted’ appearance.

Risks

Serious complications after a dual plane facelift are rare, but comprehensive discussion of the risks is nevertheless an integral part of preparation. Common changes, usually temporary, are swelling, bruising, a feeling of tightness and numbness of limited areas. Less commonly, haematomas, infections, healing problems or conspicuous scars occur. 

A temporary thinning of hair at the incision margins is possible. Very rarely, a temporary weakness of the facial muscles can occur. The risk of circulatory disorders of facial skin is increased in smokers, which is why a strict stop to smoking is strongly recommended for 2–4 weeks before and after the procedure.

After peels or laser treatments, redness may persist for weeks or months, and pigment changes of the skin (lightening or darkening) are possible during the healing process.

General risks from facelift surgery include:

• Haematoma (bruising), bleeding and swelling
• Seroma (accumulation of wound fluid)
• Healing problems or infection
• Wound breakdown/dehiscence (separation of wound edges)
• Injury of nerves or vessels
• Numbness in area of operation (temporary or permanent)
• Circulatory problem of the skin
• Scars
• Pigmentation changes (hypo- or hyperpigmentation)
• Hair loss (temporary, rarely permanent)
• Slight asymmetry
• Unsatisfactory aesthetic result
• Secondary surgery
• Thrombosis or embolism

Overall a dual plane facelift is a safe procedure when undertaken by an experienced plastic surgeon and patients are mostly satisfied with the results. You can help to minimise the risks by following the advice of your surgeon

Preparation

Our aim is to make the time before and after your surgery as comfortable as possible. By following a few recommendations you can support our care:

To aid the healing process, avoid smoking for two weeks before and after the operation. Avoid medication that increases the risk of bleeding, like aspirin, non-steroidal anti-inflammatory drugs, as well as vitamins and homeopathic remedies for two weeks prior to the operation. Prior to additional dermabrasion, laser treatment or a chemical peel, you may have to perform a pre-treatment with special ointments, and possibly antivirals. 

If you have short hair, it may be advantageous to let it grow before surgery, to facilitate the concealment of fresh scars. All chemical hair treatments (dyeing, bleaching) should be performed before surgery, as you should refrain from having any such treatments for at least 4 weeks after surgery. Dual plane facelift surgery is mostly performed as a short-stay procedure under general anaesthesia. Make sure that you can be collected and cared for by someone for 24 hours after the procedure.

Day of Surgery

In most cases a dual plane facelift is performed as a short-stay procedure with an over-night stay at the AARE KLINIK. In individual cases, when necessary, the procedure can be undertaken as part of a short inpatient stay in an affiliated private hospital.

During surgery you will receive various medications for your wellbeing. Depending on individual cases and the length of operation, you will have a general anaesthesia, in selected cases a local anaesthesia with sedation (twilight anaesthesia). For your safety, your heart rate, blood pressure, oxygen supply etc. are monitored during the operation. After surgery the fresh sutures will be cleaned, covered with ointments and a light cotton or gauze dressing. You will be taken to the recovery room, where you will have continued monitoring until you awaken and are able to get up. 

After a few hours you will be allowed to return home; after a short inpatient stay you will remain overnight at the AARE KLINIK. Already on the day of the surgery you should get up regularly for a few minutes in order to minimise the risk of thrombosis. You can use mild pain relief that reduces swelling and can be continued for the first few days after surgery. You should have someone to care for you continuously for 24 hours post operation. We also offer the possibility for a short inpatient stay at the AARE KLINIK in a single room with a nurse if required.

After Surgery

It is important to realise that recovery from an operation varies for every individual. During the first days after surgery you should keep your head and upper body in a raised position to prevent swelling. The eye area can be cooled carefully with moist gauze. However, cooling of the cheeks and neck with ice should be avoided, in order not to compromise skin circulation. You should not perform any strenuous activities or physical exercises (sports) for several days after the surgery. 

Only take prescribed pain medication and do not take medication like aspirin. After dermabrasion, laser treatment or chemical peeling you might be required to use ointments or to take antiviral medication. During the first 2–5 days after the procedure, you might experience significant swelling of the facial skin, which will usually subside after 2–3 weeks; slight bruising is possible. You might experience a slight loss of hair in the area of the surgery. It might take a few months before the hair grows again. 

Typically you will be back on your feet a couple of days after surgery and be able to resume your daily activities. Bandages and, if used, drains will be removed in the first days after surgery, after which you can take showers again. Full baths and excessive heat, however, should be avoided for several weeks until swelling has subsided. 

Most sutures are removed within a week. Due to the fact that the swelling of facial skin lasts longer, the important appointments should be scheduled at the earliest 6 weeks after surgery. After removal of the sutures we recommend the start of an intensive skin and scar care with rehydrating creams and light massage. The fresh scars should be protected from UV radiation for at least 6 months, in order to prevent increased pigmentation. Raised scars may require treatment with special silicone gel and cortisone injections in some individual cases. 

After surgery you will be examined at the AARE KLINIK at regular intervals, so that the healing process can be assessed until the final surgical result is achieved.

Outcome

The healing process is gradual and it will take several months before the surgical result can be fully determined; the final result can usually be assessed after 3–6 months. Facial scars usually heal quickly and unobtrusively, but you may be flushed for a few weeks or have slightly darkened pigmentation. This usually fades with time until it is barely visible. Swelling may persist for several weeks, as well as redness after abrasion, laser resurfacing or chemical peels. In some cases hair regrowth may take a few months. 

A dual plane facelift gives the face a fresher expression, defines the cheeks, jawline and neck, and harmonises the proportions. As a result of this, the feeling of well-being is increased and your external appearance brought back in line with your personal feeling. The result is usually long-lasting and natural, depending on the individual anatomy and the surgical technique used. The aging process continues and can be accelerated by sun exposure and other factors such as smoking. Both the individual aging process, as well as lifestyle have an impact on the long-term outcome and possibly whether another treatment is required at a later date.

Costs

A dual plane facelift is undertaken in order to improve appearance, making it an aesthetic procedure, in which case the costs have to be carried by the patient. Rare exceptions are medically indicated cases, such as after facial nerve paralysis (Bell’s palsy), in which case a unilateral facelift may be justified. In these cases the costs may be carried by medical insurance, but the decision lies with the individual insurance company, which is why a cost estimation should always be given before an operation. Costs start from CHF 20,000.

The cost of a dual plane facelift is highly variable and depends mainly on the extent of surgery and on where the procedure is performed (AARE KLINIK or hospital). A more accurate cost estimate can therefore only be made after a personal consultation.

The overall costs are made up of:

• Surgical fee (including consultation and post-operative care)
• Anaesthesia fee
• Technical infrastructure costs (AARE KLINIK/hospital)
• Inpatient hospital costs
• Medication
• Diagnostics (laboratory, ECG, scans, etc.)

How do I make an appointment at the AARE KLINIK?

To schedule an appointment for a Dual Plane/SMAS facelift, please use our contact form (click here) or call the AARE KLINIK directly at 031 333 01 07.

Meet PD Dr. med. Oliver Scheufler

PD Dr. med. Oliver Scheufler, a specialist in plastic, reconstructive, and aesthetic surgery and the author of this website, would be happy to meet with you for a personal consultation. In addition to his work at the AARE KLINIK, PD Dr. Scheufler is also active in research and completed his habilitation at the University Hospital of Basel. As a result, the University of Basel awarded him the title of Privatdozent. He has also served as a visiting professor at Duke University (USA).