Facelift Twin Studies: What Identical Twins Reveal About Deep-Plane, SMAS, and Long-Term Facelift Results
A comprehensive review of the landmark identical-twin facelift studies, what the evidence reveals about surgical technique and longevity, and how these findings inform The Ramly Method of personalized facial rejuvenation.
By Elie Ramly, MD
Plastic and Reconstructive Surgeon | Beverly Hills, California
What do identical-twin studies tell us about facelift surgery?
Does a deep-plane facelift last longer than a SMAS facelift? Can one surgical technique produce more natural or durable results than another? And what happens when identical twins undergo different facelift operations?
These questions have fascinated plastic surgeons for decades.
Identical-twin studies offer an unusual opportunity to investigate them. Because identical twins share nearly identical genetic backgrounds, comparisons between them can reduce some of the anatomical and biological differences that complicate conventional surgical research.
The findings are both illuminating and more nuanced than many descriptions suggest.
The central lesson is not that all facelift techniques produce equivalent results, nor that one operation is universally superior. It is that surgical technique matters—and that its value depends on the patient's anatomy, the correction being sought, and how the result evolves over time.
Some twin studies found no consistently superior approach among the techniques examined. Another demonstrated a significant difference in long-term neck outcomes between two incision strategies.
Research beyond the twin literature provides further evidence that the extent and method of structural tissue mobilization can influence the degree of correction achieved.
Together, these findings support an approach to facial rejuvenation that prioritizes anatomical precision, individualized surgical planning, and long-term outcomes over loyalty to a single technique.
This philosophy is central to The Ramly Method, my individualized approach to facelift surgery, which draws upon established techniques and specific anatomical maneuvers to create a surgical plan tailored to each patient's face.
The goal is to optimize aesthetics, safety, and longevity while preserving facial identity—helping patients look younger, healthier, and more refreshed, while remaining unmistakably themselves.
In this article, I examine the landmark published twin studies, their actual findings and limitations, and what they mean for contemporary deep-plane, high-SMAS, extended-SMAS, and other structural facelift techniques.
The Key Findings: What the Facelift Twin Studies Actually Show
Four important publications help explain what identical twins can teach us about facelift surgery and facial aging.
Antell and Orseck, 2007 — Eight pairs of identical twins
This study compared several established facelift techniques, including skin-only lifting, conventional SMAS flaps, SMASectomy, and SMAS plication. The investigators did not identify one technique that consistently produced superior results when appropriately selected for the patient.
Alpert and colleagues, 2009 — Two pairs of identical twins followed for ten years
Four patients underwent four different facial rejuvenation approaches, with photographic follow-up at one, six, and ten years. The study offers an unusual opportunity to examine long-term results, although its small sample does not establish a universally superior operation.
Antell and colleagues, 2016 — Four twin pairs and one set of identical triplets
This study compared full-length and short-scar facelift incisions. At approximately five years, full incisions produced significantly better neck-region scores, even though earlier results were comparable.
Guyuron and colleagues, 2009 — 186 pairs of identical twins
This separate study investigated how smoking, sun exposure, body composition, and other factors influence facial aging. Although it did not compare facelift techniques, it provides important context for interpreting long-term surgical outcomes.
These studies investigated different questions and should not be treated as interchangeable evidence.
Their collective value lies in helping us understand how anatomical differences, surgical decisions, and continued aging interact over time.
Why Identical Twins Are Valuable in Facelift Research
Facial aging is influenced by multiple interacting factors.
These include genetics, facial skeletal structure, soft-tissue distribution, skin characteristics, sun exposure, smoking, weight changes, and individual patterns of tissue descent.
When surgeons compare facelift results between unrelated patients, differences in these variables can make it difficult to determine whether one technique is responsible for a better outcome.
Identical twins offer a partial solution.
Their shared genetic background reduces some variation in baseline anatomy and intrinsic aging characteristics, potentially making comparisons between surgical approaches more informative.
However, identical twins are not identical in every clinically relevant respect.
They may differ in sun exposure, smoking history, weight, facial volume, degree of aging, medical history, and postoperative behavior. Their facial anatomy and aging patterns can also diverge over time.
Furthermore, the landmark facelift twin studies were small, and most comparisons were not randomized trials.
A twin study can provide an unusually informative comparison, but genetic matching alone does not establish that every difference in surgical outcomes was caused by the technique.
This distinction is fundamental to interpreting the literature responsibly.
It is also one reason the findings are so relevant to personalized facial rejuvenation: even individuals with nearly identical genetic backgrounds can develop different anatomical needs.
1. Antell and Orseck (2007): Do Different SMAS Facelift Techniques Produce Different Results?
Study: A Comparison of Face Lift Techniques in Eight Consecutive Sets of Identical Twins
Journal: Plastic and Reconstructive Surgery, 2007
Read the original study on PubMed
Study Design
Between November 1997 and April 1999, eight sets of identical twins underwent facelift surgery performed by the senior author, Darrick E. Antell.
The investigators retrospectively reviewed the charts and photographs of all 16 patients.
Four surgical approaches were represented:
Skin-only facelift
Conventional SMAS-flap facelift
SMASectomy
SMAS plication
These operations differ in how they address the superficial musculoaponeurotic system, or SMAS, a fibromuscular layer involved in contemporary facelift surgery.
A skin-only facelift primarily repositions the skin envelope.
SMAS plication reinforces or repositions the SMAS using sutures without necessarily elevating it as a separate flap.
SMASectomy involves excision of a portion of the SMAS followed by closure or advancement to reposition and support facial tissues.
A conventional SMAS-flap procedure involves mobilization of the SMAS layer, allowing tissue repositioning through a different surgical approach.
Importantly, this was not a direct comparison of contemporary extended deep-plane surgery against high-SMAS surgery.
What Did the Researchers Find?
The authors concluded that no single technique consistently produced superior results when selected appropriately for the individual patient.
Their findings emphasized an important principle: different patients, including genetically identical twins, may benefit from different operations.
Identical twins can develop different patterns and degrees of facial aging. Consequently, the most appropriate technique for one twin may not be the most appropriate technique for the other.
Does This Mean All SMAS Techniques Are Equally Effective?
No.
The absence of a consistently superior technique in a small observational study does not establish that all procedures are equivalent.
Nor does it establish that more extensive structural mobilization is unnecessary or that every technique can achieve the same correction.
The study instead highlights the importance of selecting an operation according to the patient's anatomy.
What Are the Study's Limitations?
The study included only 16 patients and was retrospective.
Technique selection was not randomized. Different procedures were selected for different patients, making it difficult to separate the effects of surgical technique from patient selection.
The study also predates several refinements in contemporary extended deep-plane and high-SMAS surgery.
The important conclusion: The 2007 twin study supports individualized technique selection. It does not demonstrate that technique is inconsequential or that all facelift operations are interchangeable.
2. Alpert and Colleagues (2009): What Happens Ten Years After Different Facelift Techniques?
Study: Identical Twin Face Lifts with Differing Techniques: A 10-Year Follow-up
Journal: Plastic and Reconstructive Surgery, 2009
Read the original study on PubMed
Study Design
This study provides one of the most interesting long-term photographic comparisons in facelift literature.
Two sets of identical twins—four patients in total—underwent facial rejuvenation procedures performed by four different surgeons.
The approaches included:
Lateral SMASectomy with extensive skin undermining
Composite rhytidectomy
SMAS-platysma flap with bidirectional lift
Endoscopic midface lift combined with open anterior platysmaplasty
The patients were photographed by an independent surgeon at one, six, and ten years postoperatively.
Their results were presented and discussed in a professional panel format, allowing the participating surgeons to evaluate the outcomes and reflect on their approaches.
Why Is This Study Important?
Many facelift outcome studies have substantially shorter follow-up periods.
The Alpert study offers an uncommon opportunity to observe how different surgical approaches appear over an entire decade.
It also illustrates a fundamental reality of facial rejuvenation: surgery can reposition and reshape aging tissues, but it cannot stop the biological aging process.
Over time, patients continue to experience changes in skin quality, facial volume, tissue support, and skeletal relationships.
A facelift changes facial appearance at the time of surgery and may preserve aspects of that correction over time. It does not permanently freeze the face at a particular age.
Did the Study Prove That Deep-Plane Surgery Is Superior?
No.
The study compared four specific approaches in only four patients, with different surgeons performing the operations.
The published abstract does not identify one technique as universally superior.
The long-term photographs are valuable for examining differences in appearance, but such a small sample cannot establish a reliable hierarchy among contemporary facelift techniques.
Additionally, surgical technique and surgeon were linked. That makes it impossible to confidently attribute every observed difference to the operation rather than its execution.
What Can Patients Reasonably Conclude?
Long-term photographic evaluation is important.
An excellent early postoperative result does not, by itself, establish how that result will appear five or ten years later.
The study also highlights why evaluating facelift surgery requires more than comparing technique names. The anatomical territory addressed, degree of mobilization, method of fixation, surgeon's experience, and original pattern of facial aging all matter.
The important conclusion: The Alpert study demonstrates the value of evaluating surgical outcomes over time. It does not establish that technique is irrelevant, but its design prevents definitive conclusions about the superiority of any one approach.
3. Antell and Colleagues (2016): Can Different Facelift Techniques Produce Different Long-Term Results?
Study: A Comparison of the Full and Short-Scar Face-Lift Incision Techniques in Multiple Sets of Identical Twins
Journal: Plastic and Reconstructive Surgery, 2016
Read the original study on PubMed
Study Design
This later study investigated a different surgical question.
Rather than comparing SMAS manipulation techniques, the investigators compared full-length and short-scar facelift incisions.
The study included four sets of identical twins and one set of identical triplets.
The patients underwent facelift surgery performed by the senior author, with incision assignment determined through the study protocol.
Photographs obtained at approximately one and five years were evaluated by eight board-certified plastic surgeons.
What Did the Researchers Find?
At the shorter follow-up interval, the investigators did not identify a meaningful difference between the incision approaches.
At approximately five years, however, the full-incision technique received significantly better scores in the neck region.
The reported long-term difference was specific to the neck.
The findings did not establish that a full incision was superior in every facial region or for every patient.
Why Is This Finding Important?
This study provides an important example of how surgical decisions can influence long-term results.
Two approaches may produce comparable early outcomes while differing in their ability to maintain correction in a particular anatomical region.
Patients frequently focus on incision length when comparing facelift options.
A shorter incision can sound inherently preferable because it may involve a smaller visible scar.
However, incision design also affects surgical access and the ability to address particular anatomical regions.
For some patients, especially those requiring more extensive neck rejuvenation, a longer incision may allow a more comprehensive correction.
Does This Prove That More Extensive Surgery Is Always Better?
No.
The study evaluated incision design and its relationship to long-term neck outcomes. It did not establish universal superiority of a particular SMAS or deep-plane technique.
Nevertheless, it provides meaningful evidence that a surgical choice can influence long-term correction.
The important conclusion: Surgical decisions that appear comparable in the short term may produce different outcomes over time. The appropriate extent of an operation should be determined by the anatomical correction required, not simply by the desire to minimize incision length.
4. Guyuron and Colleagues (2009): Why Identical Twins Can Age Differently
Study: Factors Contributing to the Facial Aging of Identical Twins
Journal: Plastic and Reconstructive Surgery, 2009
Read the original study on PubMed
Study Design
Guyuron and colleagues studied 186 pairs of identical twins recruited at the Twins Days Festival in Twinsburg, Ohio.
Participants completed questionnaires addressing environmental exposures and lifestyle characteristics, and facial photographs were independently evaluated for differences in apparent age and facial features.
Unlike the preceding studies, this investigation did not compare facelift operations.
Its purpose was to understand why genetically identical individuals can develop different appearances as they age.
What Did the Researchers Find?
The investigators identified associations between facial aging and several factors, including:
Smoking duration
Sun exposure and sunscreen use
Body mass index and age-related differences in facial fullness
Hormone replacement therapy
Certain additional medical and lifestyle variables
Importantly, the relationship between body composition and perceived age varied according to the age of the participants.
This illustrates why facial aging cannot be explained by a single mechanism.
Why Is This Relevant to Facelift Surgery?
Genetic matching does not eliminate environmental differences.
One twin may experience greater sun exposure, smoke for many years, or undergo substantial weight changes while the other does not.
Over a decade, these differences may meaningfully affect facial appearance.
Consequently, a long-term comparison between twins who underwent different facelift operations cannot automatically attribute every visible difference to surgical technique.
The Guyuron study reinforces the importance of accounting for these potential confounders.
It also illustrates an important principle in facial rejuvenation: even individuals with nearly identical genetics can develop different anatomical changes and aesthetic needs.
The important conclusion: Facial aging is highly individualized. Understanding each patient's anatomy and aging pattern is essential to selecting the most appropriate rejuvenation strategy.
What the Twin Studies Really Tell Us About Facelift Surgery
The most important lesson from identical-twin facelift research is not that every surgical technique produces the same result.
It is that the details of the operation matter, and their effects must be understood in the context of individual anatomy and long-term outcomes.
The landmark studies investigated different questions and produced different findings.
Antell and Orseck's 2007 study did not identify a consistently superior technique among the skin-only and SMAS approaches examined.
Alpert and colleagues' 2009 study provided an unusual opportunity to evaluate four different facelift approaches over ten years, without establishing a definitive winner.
However, Antell and colleagues' subsequent 2016 study demonstrated a meaningful long-term difference: full-length facelift incisions produced significantly better neck-region scores than short-scar approaches at approximately five years, despite comparable earlier outcomes.
That distinction is important.
Different surgical approaches can produce similar early results yet differ in their long-term performance.
Beyond the twin literature, anatomical and comparative research has demonstrated that the extent and method of structural tissue mobilization can influence the degree of correction achieved.
These findings provide a rationale for advanced techniques such as deep-plane, high-SMAS, and extended-SMAS surgery, particularly when facial descent requires more comprehensive anatomical repositioning.
The evidence does not support a single operation for every patient.
But neither does it suggest that the choice of technique is inconsequential.
It supports a more sophisticated conclusion: the surgeon must understand the capabilities and limitations of different techniques, identify the anatomical changes that require correction, and select the surgical maneuvers most appropriate for that individual.
The operation matters. The anatomy matters. And the goal is not simply to lift the face, but to restore a more youthful, healthy, and refreshed appearance while preserving the patient's natural facial identity.
What Do the Twin Studies Tell Us About Deep-Plane, High-SMAS, and Extended-SMAS Facelifts Today?
This is one of the most important questions for patients considering contemporary facial rejuvenation.
The historical twin studies were performed using specific operations from their respective eras. They should not be interpreted as direct comparative trials of every technique practiced today.
Nevertheless, they provide a useful framework for understanding how modern surgical approaches should be evaluated.
Deep-Plane Facelift
Deep-plane surgery involves mobilization of facial tissues beneath the SMAS in selected anatomical regions, allowing repositioning of deeper soft tissues while maintaining important relationships between the skin and underlying facial structures.
Depending on the specific operation, retaining ligaments may be released to permit mobilization and repositioning.
The anatomical rationale is to achieve correction through structural tissue movement rather than relying primarily on skin tension.
High-SMAS Facelift
A high-SMAS facelift uses an elevated SMAS flap and a superiorly oriented approach to tissue mobilization and repositioning.
Depending on the precise dissection and fixation strategy, it can provide meaningful correction of the cheek, jawline, and other areas of facial descent.
High-SMAS techniques are not synonymous with simple SMAS plication.
They involve a different degree and method of SMAS mobilization.
Extended-SMAS Facelift
Extended-SMAS approaches involve more extensive mobilization of the SMAS layer, allowing repositioning of facial soft tissues through a separately dissected structural flap.
The extent of dissection, release, and fixation varies among surgeons and specific technique modifications.
SMAS Plication and SMASectomy
SMAS plication repositions or reinforces the SMAS using sutures.
SMASectomy involves excision and closure or advancement of a portion of the SMAS.
Both are structural SMAS techniques, and neither should be confused with a purely skin-only facelift.
They may provide effective rejuvenation when appropriately selected and executed.
Is One of These Approaches Proven to Last Longer?
The twin studies alone do not provide a definitive answer.
They do not establish that contemporary extended deep-plane surgery universally outperforms high-SMAS or extended-SMAS surgery.
Nor do they establish that all structural SMAS techniques produce equivalent results.
To understand those questions, we must also examine direct comparative studies, anatomical investigations, longer-term clinical series, and patient-reported outcomes.
The central distinction is between anatomical rationale and demonstrated comparative effectiveness. A technique may offer compelling structural advantages without those advantages having been definitively established across every clinical outcome.
What Does Research Beyond Identical Twins Tell Us?
Twin studies are only one component of the facelift evidence base.
Several other types of investigation help clarify the relationship between surgical technique and outcome.
Direct Comparisons of Deep-Plane Surgery and SMAS Plication
Adamson, Dahiya, and Litner published a comparative study in 2007 examining deep-plane and SMAS-plication facelifts.
The study included 50 patients, with 25 undergoing each approach.
Three independent blinded observers evaluated preoperative and postoperative photographs.
The investigators reported significantly greater improvement in two assessed anatomical regions in the deep-plane group, supporting the potential for greater correction with that technique in the studied patients.
These findings are clinically relevant, but the study was not a randomized long-term twin comparison. Its results should not be generalized into a guarantee of superior durability for every deep-plane operation.
Intraoperative Comparisons of Tissue Repositioning
Another study examined 32 patients undergoing sequentially more extensive facelift maneuvers, including SMAS plication, imbrication, and deep-plane lifting.
The investigators measured skin redundancy and soft-tissue repositioning during surgery.
They found greater intraoperative tissue mobilization with the deep-plane technique.
This supports the anatomical rationale for more extensive structural mobilization when greater correction is needed.
However, an intraoperative measurement is not the same as a ten-year clinical outcome.
Research on Composite Flaps and Midface Elevation
Additional comparative work has examined how preserving certain skin-SMAS relationships may influence midface elevation.
A 2016 study comparing bilamellar and total composite-flap approaches reported greater measured midface elevation in the composite-flap group at an average follow-up of approximately 18 months.
These findings suggest that the details of dissection and preservation of tissue attachments may meaningfully influence surgical outcomes.
They do not establish that one entire category of facelift is superior in every patient.
What the Broader Evidence Suggests
Taken together, these studies provide a stronger anatomical and clinical rationale for advanced structural mobilization than the twin literature alone.
They suggest that the extent and method of tissue mobilization can influence the degree of correction achieved.
But greater immediate repositioning, better photographic improvement in a particular region, lower complication rates, greater patient satisfaction, and longer-lasting results are distinct outcomes.
Evidence supporting one should not automatically be presented as proof of another.
The Ramly Method: An Individualized Approach to Facelift Surgery
The conclusions of the twin studies reflect a principle that is central to my philosophy of facial rejuvenation: the operation should be designed around the patient, rather than the patient being fitted into a predetermined operation.
I refer to this individualized approach as The Ramly Method.
Facial aging is highly personal.
Two individuals of the same age, even identical twins, may develop different patterns of facial descent, volume loss, skin changes, and neck aging. Their facial proportions, structural support, tissue characteristics, and aesthetic priorities may also differ.
It follows that the operation most appropriate for one patient may not be the operation most appropriate for another.
My approach begins with a detailed understanding of each patient's anatomy, the changes that have occurred over time, and the features that make their face uniquely recognizable.
From there, I develop a surgical plan that may incorporate techniques and specific components of techniques drawn from deep-plane, high-SMAS, extended-SMAS, SMAS-flap, and other established approaches to facial rejuvenation.
Rather than approaching these techniques as mutually exclusive categories, I consider the anatomical principles and surgical maneuvers that each offers.
Depending on the patient, this may involve different degrees of tissue mobilization, selective release of retaining structures, adjustments in the vectors of repositioning, tailored treatment of the neck, and restoration of facial volume where appropriate.
Each decision serves a specific anatomical and aesthetic purpose.
The goal is not to perform the deepest dissection, the greatest amount of lifting, or the most extensive operation possible.
It is to perform the appropriate correction, in the appropriate anatomical planes, to the appropriate degree, while carefully balancing aesthetic improvement, surgical safety, recovery, and long-term durability.
Preserving Facial Identity Is the Central Objective
One of the most important aspects of facial rejuvenation is recognizing what should not change.
A person's face carries their identity: the proportions, contours, expressions, and subtle anatomical relationships that make them immediately recognizable.
Successful facial rejuvenation should respect those characteristics.
My goal is not to create a different face or impose a standardized aesthetic. It is to address the changes that have accumulated with age while preserving the qualities that make each patient look like themselves.
Ideally, the result is a face that appears younger, healthier, more rested, and naturally refreshed—without appearing fundamentally altered.
This requires more than lifting tissues.
It requires understanding facial balance, the relationship between volume and structural support, the interaction between the face and neck, and how surgical changes will harmonize with the patient's existing features.
Aesthetics, Safety, and Longevity Must Be Considered Together
Durability is important, but it is not the only measure of success.
A technically durable result that looks unnatural is not a successful aesthetic outcome.
Likewise, an operation that achieves substantial correction but introduces unnecessary surgical risk may not represent the best choice for a particular patient.
I therefore consider three objectives together.
Aesthetic harmony: Achieving meaningful rejuvenation that respects facial proportions, expression, and individual identity.
Surgical safety: Selecting anatomical planes, maneuvers, and the extent of dissection according to the patient's needs, medical considerations, and risk profile.
Long-term durability: Providing appropriate structural support and repositioning while accounting for the natural aging process that continues after surgery.
These objectives are interconnected.
The ideal surgical plan seeks the best overall balance rather than maximizing any one variable in isolation.
Why This Philosophy Is Consistent With the Twin Studies
The twin studies do not validate any individual surgeon's proprietary method, including my own.
Their findings are nevertheless consistent with the broader principles underlying an individualized approach.
The 2007 study illustrates why different techniques may be appropriate for different patients.
The 2009 study highlights the importance of understanding how surgical outcomes evolve over time.
The 2016 study demonstrates that particular surgical choices can influence long-term correction in specific anatomical regions.
Taken together with the broader anatomical and comparative literature, these findings support thoughtful surgical planning that accounts for both the immediate correction and its anticipated evolution over time.
The Ramly Method is my application of these principles: an anatomy-driven, individualized approach designed to optimize aesthetics, safety, and longevity while preserving the patient's natural facial identity.
Does a Deep-Plane Facelift Last Ten to Fifteen Years?
Patients frequently encounter claims that one facelift lasts five years, another lasts ten, and a deep-plane facelift lasts fifteen years or longer.
These figures should be interpreted cautiously.
There is no universally accepted definition of when a facelift has stopped lasting.
Possible endpoints include:
Persistence of improvement relative to the preoperative appearance
Degree of recurrent tissue descent
Patient satisfaction over time
Photographic changes in specific facial regions
The patient's decision to undergo revision surgery
These endpoints are not interchangeable.
A patient may continue to look substantially better than before surgery while also experiencing new age-related changes.
Similarly, a patient may remain satisfied for many years without maintaining precisely the same degree of anatomical correction.
The Alpert study provides photographic follow-up at ten years, but it does not establish a guaranteed ten-year duration for every technique.
A more useful question than “How many years does a facelift last?” is “How well does this operation address my anatomy, and what changes should I realistically expect over time?”
Long-term outcomes depend on the operation, the patient, the quality of surgical execution, and the aging process that follows.
What the Twin Studies Do Not Establish
For patients evaluating competing surgical claims, understanding the limitations of the evidence is as important as understanding its findings.
The studies do not establish that:
Deep-plane surgery is universally superior to all SMAS techniques.
SMAS plication and deep-plane surgery have equivalent outcomes in every patient.
High-SMAS and extended deep-plane surgery have been definitively compared in genetically matched patients.
Greater surgical dissection necessarily produces a more natural result.
A specific facelift technique guarantees ten or fifteen years of correction.
Identical twins experience identical facial aging after surgery.
One study can determine which operation is best for every anatomical pattern.
These are important distinctions because facelift terminology is frequently used in marketing as though technique names alone determine outcomes.
In reality, anatomical diagnosis and surgical execution remain central.
Frequently Asked Questions About Facelift Twin Studies
Have identical twins actually undergone different facelift techniques?
Yes. Published studies have compared different facelift approaches in identical twins, including SMAS techniques, composite procedures, and different incision designs. These studies are valuable because genetic matching reduces some sources of variation between patients.
How many important facelift twin studies have been published?
Three notable peer-reviewed studies directly investigate aspects of facelift surgery in identical twins: Antell and Orseck (2007), Alpert and colleagues (2009), and Antell and colleagues (2016). The first two examine different surgical approaches, while the third focuses on incision design. Guyuron and colleagues (2009) studied facial aging in twins rather than facelift techniques.
Did the 2007 Antell twin study prove that deep-plane facelifts last longer?
No. The study compared skin-only, conventional SMAS-flap, SMASectomy, and SMAS-plication approaches. Its authors concluded that no technique was consistently superior when appropriately selected for the patient.
Did the ten-year Alpert twin study establish the best facelift technique?
No. The study documented long-term results in two pairs of identical twins who underwent four different surgical approaches. Its small sample and the use of different surgeons prevent a definitive ranking of techniques.
Did any twin study find a long-term advantage for a more extensive operation?
Yes, in a specific context. The 2016 Antell study found significantly better long-term neck-region scores with full-length facelift incisions compared with short-scar incisions. This finding concerns incision design and neck correction, not universal superiority of a particular SMAS or deep-plane technique.
Is Deep-Plane Surgery Better Than SMAS Plication?
Some direct comparative research outside the twin literature has reported greater photographic improvement or intraoperative tissue repositioning with deep-plane approaches.
However, those findings do not establish that deep-plane surgery is the correct operation for every patient or that every long-term outcome is superior.
The answer depends on the anatomical problem being treated, the specific techniques compared, and the outcome being measured.
Is High-SMAS the Same as SMAS Plication?
No. High-SMAS surgery involves mobilization and repositioning of an elevated SMAS flap. SMAS plication generally involves suture-based repositioning or reinforcement without the same flap elevation.
Both engage the SMAS, but they are anatomically and technically distinct operations.
Has High-SMAS Been Directly Compared With Deep-Plane Surgery in Identical Twins?
The landmark twin studies do not establish a definitive contemporary comparison between modern high-SMAS and extended deep-plane techniques.
These operations must be evaluated using additional anatomical, clinical, and comparative evidence.
Do Facelift Twin Studies Prove That a Facelift Lasts Ten Years?
No. Ten-year follow-up demonstrates that outcomes can be observed over that interval. It does not establish a guaranteed duration of correction for every patient or technique.
Can a Facelift Look Natural After Ten Years?
Yes, natural-appearing long-term results are achievable, but the twin studies do not establish that any technique guarantees an undetectable appearance.
Naturalness depends on patient anatomy, surgical planning, execution, healing, and continued aging.
Why Don't Surgeons Perform More Twin Studies?
Identical twins who both desire facelift surgery, agree to participate in research, and are suitable for different procedures are uncommon.
Long-term follow-up is also difficult and expensive.
Consequently, larger comparative cohorts, standardized photographic analysis, and validated patient-reported outcomes are important complementary sources of evidence.
What Should Patients Ask a Surgeon About Facelift Technique?
Patients should ask not only which facelift technique a surgeon performs, but why that particular approach is appropriate for their anatomy.
A thoughtful consultation should explain which areas of facial aging require correction, which anatomical structures will be addressed, how the surgical plan may be individualized, what alternatives exist, and how aesthetic goals, safety, and long-term durability are balanced.
The most important question is not simply, “Do you perform a deep-plane facelift?”
It is, “How will you design my facelift to address my anatomy while preserving what makes me look like myself?”
Final Perspective: What Identical Twins Teach Us About the Art and Science of Facelift Surgery
The landmark identical-twin studies offer a remarkable perspective on facial rejuvenation.
They demonstrate that facelift surgery cannot be reduced to a simple contest between technique names.
Different operations address different anatomical problems, and the results of those decisions must be evaluated not only immediately after surgery, but over time.
The 2007 Antell study emphasizes the importance of individualized procedure selection.
The 2009 Alpert study illustrates the value of long-term follow-up.
The 2016 Antell study demonstrates that specific surgical decisions can produce measurable differences in long-term outcomes.
The broader comparative literature adds another important dimension: the extent and method of structural tissue mobilization can influence the correction achieved, providing a meaningful anatomical rationale for advanced deep-plane and SMAS-based techniques.
The conclusion is neither that every facelift is equivalent nor that one operation should be performed on everyone.
The conclusion is that surgical technique matters precisely because patients are different.
This is the philosophy behind The Ramly Method.
I believe the most thoughtful approach to facelift surgery is one in which the surgeon draws upon the full range of established techniques, selecting and combining the anatomical maneuvers that best serve the individual patient.
Sometimes that requires extensive structural mobilization. Sometimes a more selective approach is appropriate.
The surgical plan should follow the anatomy, not the other way around.
And throughout that process, the central purpose must remain clear.
A facelift is not intended to give someone a new identity. It is intended to help them look like a younger, healthier, more refreshed version of themselves.
To me, the beauty of facial rejuvenation lies in achieving a result that appears entirely natural and effortless—even when the anatomical planning and surgical execution behind it are extraordinarily sophisticated.
That is the goal of The Ramly Method: personalized facial rejuvenation that preserves identity, respects anatomy, and brings together artistry, precision, safety, and long-term thinking.
About the Author
Elie Ramly, MD is a Harvard-trained plastic and reconstructive surgeon practicing in Beverly Hills, California.
His clinical focus includes facelift and neck-lift surgery, revision facial rejuvenation, and advanced rhinoplasty. His approach emphasizes detailed anatomical assessment, thoughtful surgical planning, and natural, identity-preserving results.
Dr. Ramly maintains surgical privileges at Cedars-Sinai Medical Center.
His practice is built around the belief that successful facial rejuvenation should preserve what makes each person recognizable while addressing the anatomical changes that accompany aging.
Schedule a private consultation to discuss individualized facial rejuvenation options.
References and Further Reading
Primary Facelift Twin Studies
Antell DE, Orseck MJ. A comparison of face lift techniques in eight consecutive sets of identical twins. Plastic and Reconstructive Surgery. 2007;120(6):1667–1673. PubMed
Alpert BS, Baker DC, Hamra ST, Owsley JQ, Ramirez OM. Identical twin face lifts with differing techniques: a 10-year follow-up. Plastic and Reconstructive Surgery. 2009;123(3):1025–1033. PubMed
Antell DE, May JM, Bonnano MJ, Lee NY. A comparison of the full and short-scar face-lift incision techniques in multiple sets of identical twins. Plastic and Reconstructive Surgery. 2016;137(6):1707–1714. PubMed
Identical-Twin Research on Facial Aging
Guyuron B, Rowe DJ, Weinfeld AB, Eshraghi Y, Fathi A, Iamphongsai S. Factors contributing to the facial aging of identical twins. Plastic and Reconstructive Surgery. 2009;123(4):1321–1331. PubMed
Additional Comparative Facelift Research
Adamson PA, Dahiya R, Litner J. Midface effects of the deep-plane vs the superficial musculoaponeurotic system plication face-lift. Archives of Facial Plastic Surgery. 2007;9(1):9–11. PubMed
Limited vs extended face-lift techniques: objective analysis of intraoperative results. PubMed
Total composite flap facelift and the deep-plane transition zone: a critical consideration in SMAS-release midface lifting. PubMed
Related Reading
What a Facelift Actually Does (And What It Cannot Do)
The Modern Facelift: A History of How the Operation Became What It Is
Inside a Facelift: A Layer-by-Layer Anatomical Guide
Deep Plane Facelift vs. SMAS Facelift: A Surgeon's Comparison
Facial Nerve Safety in Deep-Plane Facelift Surgery
How to Choose a Facelift Surgeon
Medical disclaimer: This article is intended for general medical education and does not constitute individualized medical advice. The studies discussed have important methodological limitations, and published findings should not be interpreted as guarantees of surgical outcomes. The appropriate treatment depends on each patient's anatomy, health, goals, and a thorough consultation with a qualified plastic surgeon.