How is the deep plane facelift different from other face lift techniques?
What is a Deep Plane Facelift?
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Doctor Answers 21
Face lifting techniques vary. Results often don't
The traditional face lift technique, called a SMAS technique, is one in which predominantly the plane of dissection is directly under the skin. The SMAS, which is the muscular and soft tissue layer just below the skin is then tightened and suspended. Following excess skin excision, the incisions are closed. There is a limit to how far you can lift the skin of the face before you start to increase risk of poor wound healing.
Deep plane face lifting was an attempt to move the dissection more centrally towards the nose and upper lip. As opposed to a traditional face lift, where tissues are raised above the SMAS, deep plane techniques work below the SMAS. Deep plane facelifting is specifically designed to gain access to the midface (the triangular area below the eye, to the side of the nose and above the mouth). Volume loss and descent of the fat pads in the midface is a significant part of facial aging that is not well treated by traditional face lifting techniques. By using a deeper plan of dissection, access to these midfacial or malar fat pads is accomplished. Theoretically, increased midface rejuvination is possible via the deep plane.
Unfortunately, a significant increase in risk to facial nerves exists when dissecting below the SMAS. Many surgeons felt that the risk did not justify the results, which may or may not be superior in the short term. Long term studies have yet to show one technique to be better than the other.
In addition, the advent of subperiosteal midface lifting all but eliminated the need for deep plan facelifting. This procedure gives a superior vertical vector of volume displacement which provides a more natural midfacial rejuvination effect anyway.
Finally, other forms of face lifts (s-lift, lifestyle lift, lunch time lift, j-lift, etc.) are just smaller versions of the traditional SMAS facelift. Results, as you might expect, are typically smaller.
What is a deep plane facelift? Is a deep plane facelift better?
Some surgeons will do a very limited deep plane dissection (between the Platysma-SMAS complex) and others will carry it all the way in order to get more movement. These technicalities are difficult for most patients to understand however, so just trust in the before and after photos. You should go with whichever surgeon has the best aesthetic. As a good rule of the thumb, the before and afters showing the most change in the cheeks, folds and under eyes (without the use of fat grafting) will have the more durable results. We all love what we do, so surgeons who do deep plane believe its better while the ones doing SMAS techniques will say those are better. In the end, evidence of which is better is irrelevant. Just find the photos that best suit you. Just make sure you are looking at the right things when evaluating those photos. The lighting should be the same in the before and after. No hair covering the ear or incision lines to cover potential scars. Look at the cheek, folds around the mouth & nose, and the under eyes to see if the hollowing is less. Look at the sideburns and hairline for a natural appearance. Look a at the angle of the jaw to see if the definition increased or not. And look to see if the patient looks awkward for any reason. Hope this helps.
Deep plane Facelifts lift the deeper cheek muscles
Deep Plane face lifts lift not only the jowls and neck areas, but also release the cheek ligaments and elevate the cheek fat pads and muscles. This is called the malar fat mound, and when lifted reduces the nasolabial folds and gives the face a youthful heart shape.
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Facelift Options and Choices - Listen to Recommendations from your PS and view LOTS of Photos
No matter what the specific type of facelift, the goal should be a look that is natural appearing. My goal is to make scars so inconspuicuous that even your hairdresser can't tell. Other signs to look for as you review before and after images are the position of the ears and hairline following a facelift. These can be dead giveaways that one has had a facelift, in addition to maiing a person look odd and unnatural. Hollowed areas above and below the eyelids can also be aging and make a person look unnatural. Likewise, a face that is Over-filled with fat or another filler can also take on an unnatural appearance.
Before and after photos should not be a before of a patient the morning of surgery with hair pulled back, no makeup and a smile, with the after being a fully made up person with a smile. Look for accurate and consistent photos. Dozens of them.
In doing your research to find a plastic surgeon to make a permanent change in your face, and trusting with your health, look at many many before and after photos. Photos (many of them) are evidence that your plastic surgeron is able to accomplish a facelift that is beautiful, natural looking and long lasting.
Take your time checking your plastic surgeons record of safety.
- Where did they received surgical training and how many years of formal surgical training they received after medical school?
- Were they trained at a top tier university medical center?
- Do they have hospital privileges - ideally at multiple local hospitals- to perform the procedure(s) of interest to you?
- Is their surgical facility accreddited by the Joint Commission, AAAASF, or both?
- What is the post-operative experience like?
- Who is in the room with you during surgery? Does your PS have a team of extraordinary medical professionals?
- Is anesthesia administered by a board-certified MD anesthesiologist?
Deep Plane Facelift
A deep plane face lift is similar to a sub-SMAS face lift with dissection beneath the muscle-fascia layer, however, only limited dissection is performed above the muscle-fascia layer. Proponents claim that the minimal dissection between the skin, fat, and muscle-fascia layer gives the skin an even smoother appearance and faster recovery time while still providing dramatic, longer lasting results than with a standard skin-only face lift.
Deep plane facelift involves a deeper and riskier dissection
The deep plane facelift involves disscting in the tissue layer (the SMAS) that contains the muscles and some of the inelastic tissue of the face. The SMAS is then pulled "up and back," helping restore a more youthful appearance to the face. Although its use has decreased in popularity over the last few years due to the risks of nerve damage and the fact that some of the benefits of the lift can be achieved through other techniques (such as fat grafting), it remains a valuable tool for facelift surgeons.
Deep Plane Facelift
There are many different types of facelifts, each one having a different take by different surgeons. I use a variant of a deep plane facelift and find it provides the most robust changes while still keeping the face looking natural. Some things to consider when discussing deep plane facelifts:
- Anatomy- This facelift is not for every surgeon. It requires much more knowledge of facial anatomy. However, an experienced facelift surgeon can perform this lift with little risk to the facial nerves. A surgeon's knowledge of anatomy is more critical to avoiding damage to nerves than technique.
- Results- A deep plane facelift is a results driven procedure. Patients wanting the best results will want to have the more robust changes to the face while still looking natural.
- Downtime- The deep plane facelift has a reported longer period of recovery. However, I have found the opposite to be the case. I vary my technique to minimize postoperative edema so that patient's have the benefits of a more robust lift without the downtime. Dissection below the platysma muscle (see article, yes it is in the face) is a natural embryologic glide plane which is bloodless and can expedite recovery.
- Incisions and Longevity of Lift- Several biomechanical studies have looked at the strength of tissues being held. Deeper plane tissues is a stronger flap and has less chance of sliding back to original position
Overall, deep plane facelifts (which is a large category of lifts) can provide excellent rejuvenation in the right hands. Their are risks with any facelift, so pick a rejuvenation procedure by surgeon not by technique. Not all deep plane facelifts are the same.
Definition of a "deep plane" or "composite" facelift
I use a particular technique, called the "composite rhytidectomy" for face-lifting. "Rhytidectomy" is the clinical term for facelift. "Composite" refers to a specific technique which will now be discussed. The evolution of the technique began in the mid-1980's and is now a well defined operation with predictable results.
Conventional techniques for face-lifting begin by lifting the skin off the cheek and neck. The deeper layers are accessed by this dissection and are available for manipulation. However, much of the blood supply to the skin is supplied by networks of blood vessels within these deeper layers that nourish the skin by small perforating vessels. Lifting the skin requires division of these "perforators" thus compromising the blood supply.
The "composite" technique lifts both the skin and the deeper layers (which will be discussed later) as a unit, preserving both the network of blood vessels in the deeper tissue as well as the perforators. The resulting flap of tissue is maneuvered to reposition sagging areas of fat, muscle, and skin to their more natural youthful position. The skin remains well nourished by attention to the blood supply anatomy.
Many conventional techniques rely on pulling the skin to effect changes in the neck, jowl, and cheek. Remember that the pulling is directed behind and above the ear, a significant distance from the center of the neck and the medial cheek. To sharpen the neck angle and flatten the jowl, a significant amount of tension needs to be generated at the level of support around the ear. This commonly will leave the patient with the appearance of being "pulled too tight." The patients have an "operated upon" look.
The composite rhytidectomy bases all support for the facelift on a deeper inelastic layer. As stated, the skin remains attached to the deeper connective tissue and muscular layers during dissection. As the flaps of tissue are redraped, the sutures of support are placed through the deeper inelastic layers of connective tissue. The attached skin accompanies these deeper layers in redraping and are not required to support the lift. The skin is closed almost tension free with the most delicate of sutures. As a result, the patients look more natural, the incisions heal better, there is little risk for hair loss, and the lift probably lasts longer.Management of the Deeper Plane
Deep plane facelift is an excellent procedure
The more important question to ask is, "is the deep plane Facelift the best procedure for me"? The reality is that most surgeons who say that they are doing the deep plane Facelift are not doing it the way Sam Hamra initially described. I also do what I call a hybrid Deep Plane Facelift on people who complain mostly about the neck and jawline and not so much about the jowls.
The 2 main ideas of the deep plane Facelift are that the tension and lift is comes from tightening the SMAS (deep layer) and that the cheek or malar fat pad is left attached to the skin and then elevated with the skin flap. The reason to do this is to get a significant improvement to the cheeks or midface as well as tightening of the neck and jawline all while minimizing the healing and minimizing the risks of skin divots and irregularities.
There are risks of nerve injury for the unskilled or untrained surgeon but I can tell you that the rate of nerve injury should be zero when done correctly. I find myself doing a hybrid deep plane Facelift on younger patients and more of the vertical Facelift technique on older patients.
Deep Plane Facelift
The original deep plane facelift reported by Dr. Hamra describes elevating only a short area of skin flap around the ear before focus is directed to dissecting and elevating the SMAS flap over the zygomaticus muscle and to a point near the nasolabial folds.
We believe, in order to get the best result, the SMAS flap should be repositioned. However, in our experience and opinion, the small amount of skin flap elevation limits the refinement achievable. The extended SMAS-plasty technique consists of elevating a formal facial skin flap followed by elevation of a SMAS flap similar to that described by Dr. Hamra. The SMAS elevation is also extended inferiorly to the platysma.
After all the flaps are elevated, excellent redraping can be performed to achieve a natural and long lasting refreshed look. There is a slight increase risk of injury to the facial nerve due to the extent of dissection, but in experienced hands, the risk is very low and not higher than that reported in less involved facelifts.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.