The Deep Plane Facelift

History

The signature operation of facial rejuvenation is the rhytidectomy. Of all the procedures designed to remedy the effects of aging, the rhytidectomy has the most profound ability to improve the patient's appearance. The first recorded efforts to surgically rejuvenate the face appeared early in the 20th century . The first 50 years of the 20th century saw little advance; burdened by the risks of anesthesia and the lack of medications, such as antibiotics, surgeons were forced to move forward with great trepidation. As technologic advances erupted in the latter half of the 20th century, surgical advances soon followed. In the last 30 years of the century, these technologic advances enabled surgeons to provide excellent surgical results to their patients and the popularity of facial rejuvenation has since exploded. Facial rejuvenation surgery has never been more popular, as adjunctive modalities such as dermal fillers and Botox have brought interest in cosmetic improvements to an all-time high. Today, an attractive outward appearance is a sign of strength and health instead of vanity .

The original techniques employed short skin flaps and minimal, if any, manipulation of the underlying soft tissues for fear of damaging the facial nerve. With greater anatomic understanding, the techniques progressed deeper into the ptotic tissues of the aging face. The skin flaps gradually became longer and the manipulations of the underlying soft tissue, the superficial musculoaponeurotic system (SMAS), became more aggressive. With these advances, new frontiers were crossed and new complications arose. In addition, physicians working in this field have now gained a much greater knowledge and appreciation for other factors that historically had been neglected, especially in regard to lifestyle choices, such as smoking and alcohol intake, and in medications, such as antiplatelet agents.

The field has undergone a fascinating 40-year evolution since the groundbreaking work of Dr. Skoog in the 1970s . Skoog was the first to perform what can be called the deep plane technique. Hamra advanced the concept to include the soft tissues of the midface with his deep plane and composite techniques . Today, there is great controversy as to the appropriate technique and plane of dissection for optimal rejuvenation . With the advent of the deep plane facelift technique, rhytidectomy took a quantum leap forward. For decades, rhytidectomy provided the patient with a benefit that often pleased the patient but left the surgeon wanting more. This exciting technique enabled the surgeon to provide a more lasting, natural result. We propose our techniques described herein not as an answer to these dilemmas but as a proven method to safe, excellent, reproducible results in facial rejuvenation.

Personal Philosophy

The evolution of our technique is based on several criteria. First, the result with the deep plane technique was superior to that of the SMAS lift plication and imbrication techniques. With a more thorough undermining of the ptotic soft tissues of the face, a better postoperative result soon followed, as would be expected. Although the SMAS procedure is excellent for short-term gains in reducing skin laxity and mild improvement of soft tissue ptosis, the majority of the ptotic soft tissue remains fallen. We agree with the previously published viewpoint that “minilifts” or subcutaneous facelift procedures have only dealt with laxity of the skin and do not completely address the ptotic soft tissues of the face .

Second, once experience was gained with this technique, the long-term results became evident. In addition, the occurrence of the “pulled” or “operated look” decreased rapidly with the increased use of this technique. We also believe that with the shorter skin flap and superior blood supply of the deep plane technique, the catastrophic issues of skin loss and poor scar appearance are greatly diminished. With its strict adherence to physiologically sound principles, the effect of the deep plane technique is maintained for a longer period than that of the skin flap techniques. This is due to the composite flap maintaining the viscoelastic properties of the SMAS . Though others have not agreed with these opinions, we maintain our results have improved greatly since the transformation of techniques .

Much excitement has been generated over the “weekend” or “mini-facelifts.” With the promise of smaller incisions and less downtime, these procedures have received significant attention over the last several years as the popularity of plastic surgery has flourished. These techniques are similar to standard SMAS facelifts and thus are an option for certain patients.

Generally speaking, patients for whom these procedures are devised suffer from lax skin, especially in the lower face. When a patient considers facial cosmetic surgery, we feel the first operation should be the definitive procedure. If the patient has had a “less invasive” procedure in the past, the tissue planes are forever altered, thus making further surgery, when the aging process has come to fruition, much more difficult. This is obviously a matter of personal preference, and some patients will persist in having certain procedures performed regardless of the surgeon's preferences. This is a matter for each individual practice. For ours, all primary facelifts are done via the deep plane techniques.

A variety of midfacial approaches have been proposed over the last 20 years. The point of origin for most of these procedures is from the work of Tessier . Several variations of this approach have been proposed . We favor the deep plane technique over the subperiosteal midface approach for several reasons. The first is the direct nature in which the deep plane technique addresses the fallen tissue. The focus of midfacial rejuvenation is the suspension of the soft tissues of the midface that have fallen with time. In the deep plane technique, the surgeon may directly manipulate this tissue to the desired location. To state the issue directly, deep plane surgery “works at the level at which mobility and aging laxity are occurring” . The tissue to be repositioned in the midface is the cheek fat that rests on the zygomaticus musculature. With elevating the soft tissues off the zygomatic musculature, the surgeon may now address the nasolabial fold and the descent of the soft tissues in a manner not possible before. A SMAS correction is inherently more effective than a subperiosteal approach in the midcheek because it is closer to the tissue to be repositioned .

In addition, the nerves that innervate the facial musculature enter from below. Thus, it stands to reason that dissection techniques that leave the nervous structures between the plane of dissection and the target tissue leave the nerves at risk from either direct trauma through inadvertent movements of the dissector or, more commonly, through traction neuropraxia. The subperiosteal technique has been reported to have a high rate of facial nerve injuries, implying a steep learning curve .

Edema from periosteal manipulations is significant, and for it to persist for weeks, if not months, is not uncommon . To patients who are expecting a “minimally invasive” procedure, this may prove to be a difficult issue. In the subperiosteal approach, the zygomaticus musculature is repositioned to a place it never was before, the intermalar distance is necessarily increased, and frequently manipulation of the lateral canthus is required . Not only is the lateral canthus often altered, but the resetting of the zygomaticus musculature may also lead to an unwanted alteration of the patient's appearance . One must be concerned about the potential for distortion of the palpebral fissure with many of these procedures . When an open lower lid blepharoplasty approach is incorporated into the subperiosteal midfacial techniques, the lower lid malposition rate has been reported to be as high as 50% .

An argument can be made for addressing the midfacial region via volume rather than surgical manipulation. Whether it be autologous fat injection or dermal fillers, volume replenishment is almost always employed as an adjunct to surgical elevation to create the optimized outcome. The surgeon, to attain the desired result, must be fully versed in not just surgical handling of ptotic tissues but also in the key role that volume plays in facial rejuvenation .

Our approach to facelifting, as with our overall practice approach, is the attainment of a natural, lasting result via conservative means. We seek to provide the patient with rejuvenation where the observer cannot detect that an operation has occurred. The deep plane technique may not be considered conservative in some quarters, but with the technique performed as described herein, we feel it to be exceedingly safe and well tolerated by the patient.