Demystifying Deep Layer Face-Lift Techniques: A Systematic Review of Superficial Musculoaponeurotic System Techniques

Facial aging is a multifactorial process that results from deflation and descent of facial soft tissue. Modern deep layer face-lift techniques aim to restore a youthful facial shape by using the superficial musculoaponeurotic system (SMAS) to reposition descended facial fat into areas of deflation within the lateral cheek and malar eminence. Although there are many advocates of various SMAS techniques and numerous descriptions of methods to manipulate and fixate repositioned facial fat, there is no consensus in the literature as to a "best" SMAS technique. The authors' investigation aimed to determine whether there should be a consensus on the preferred method of SMAS manipulation in terms of improving contour in the aging face.

A systematic review was performed to investigate the current body of literature on SMAS face-lift techniques. Careful review of operative technique was performed, and techniques were classified as medially or laterally based, depending on the extent of sub-SMAS dissection. Analysis of aesthetic outcomes and complications was performed to determine the superiority of one technique over another in achieving a youthful facial contour.

A total of 17 articles were selected for review that clearly described operative technique and reported aesthetic outcomes. Patient satisfaction and improvement in overall facial contour was noted across studies.

Various SMAS techniques can provide excellent aesthetic outcomes; however, medially based "deep plane" techniques, which carry dissection medial to the stout retaining ligaments, have not been shown to provide significant improvement in the appearance of the midface or improved longevity of results.