Objective To investigate the effect of biplanar malar fat pad suspension combined with low SMAS plication in the correction of moderate to severe midface sagging. Methods The clinical data of 65 patients with moderate to severe midface sagging who received correction treatment in Xiamen Siming Meiying YAHANN Medical Beauty Clinic from January 2024 to January 2026 were retrospectively analyzed. According to different surgical methods, they were divided into the control group (n =32) and the combined group (n =33). The control group received simple low SMAS plication, and the combined group received biplanar malar fat pad suspension combined with low SMAS plication. The operation-related indicators, facial structural parameters, nasolabial fold depth, midface soft tissue laxity, overall facial aesthetic effect and complication rate were compared between the two groups. Results The operation time of the combined group was longer than that of the control group, and the intraoperative blood loss was more than that of the control group (P <0.05). There was no statistically significant difference in postoperative hospitalization time between the two groups (P >0.05). At 6 months after operation, the left zygomatic prominence distance, right zygomatic prominence distance and nasolabial fold angle in the two groups were lower than those before operation, and those in the combined group were lower than those in the control group (P <0.05). At 6 months after operation, the scores of WSRS and midface soft tissue laxity in the two groups were lower than those before operation, and those in the combined group were lower than those in the control group (P <0.05). The GAIS score of the combined group was lower than that of the control group (P <0.05). There was no significant difference in the incidence of complications between the two groups (P >0.05). Conclusion Biplanar malar fat pad suspension combined with low SMAS plication for the correction of moderate to severe midface sagging, although with slightly longer operation time and more intraoperative blood loss than simple low SMAS plication, can more effectively improve the laxity of midface soft tissue and facial structure, reduce nasolabial fold depth, and enhance overall facial aesthetic effect, without increasing the incidence of postoperative complications. It has good clinical safety.