The Low–High SMAS Ad-Integrum Facelift: A Lateralized Deep-Plane Technique in 384 Consecutive Patients

Abstract Background Deep-plane facial rejuvenation techniques reliably address midface and cervicomandibular aging, yet facial nerve safety and postoperative hematoma remain major concerns. Objectives To describe the Low–High SMAS ad-integrum facelift, a lateralized deep-plane technique that uses the parotid fascia as a consistent visual deep reference within a space-based dissection strategy, and to evaluate its clinical safety profile in a consecutive series of patients. Methods A retrospective observational study included 384 consecutive patients undergoing deep-plane rhytidectomy between April 2023 and October 2025. The technique combined a high lateral SMAS access with sequential dissection through the prezygomatic and premasseteric spaces, using the parotid fascia as a consistent deep reference. A multimodal hemostasis protocol included tumescent infiltration with epinephrine and tranexamic acid, conservative subcutaneous undermining, and mechanical dead-space coaptation using polyurethane foam compression boards secured with transcutaneous sutures. Outcomes included complications, operative time, and clinical stability; mean follow-up was 18 months. Results The mean age was 54 years, and 365 patients were women and 19 were men. No clinically evident facial nerve motor deficits were documented during routine postoperative follow-up. Major hematoma requiring operative evacuation occurred in 1.0% of patients; seroma occurred in 1.6% and was managed with outpatient aspiration. No surgical site infections were recorded. Superficial epidermolysis occurred in 2.1% of patients and was confined to active smokers, resolving with conservative wound care. Conclusions In this retrospective single-surgeon series, the Low–High SMAS ad-integrum facelift approach, guided by the parotid fascia and sequential anatomical spaces, was associated with a favorable clinical safety profile, including a low rate of major hematoma requiring operative evacuation and no clinically evident facial nerve motor deficits documented during routine postoperative assessment. Further prospective and multi-surgeon studies are required to confirm reproducibility, generalizability, and comparative safety.