Deep Plane Facelift

A deep plane facelift is a plastic surgery procedure that lifts and tightens tissues in the face and neck that have become weak over time. The deep plane technique offers the ability to correct even the most severe forms of facial aging, eradicating the deepest lines and wrinkles while lifting sagging skin. Typically the surgery includes platysmaplasty and neck liposuction, if needed.

Anatomy of the Face and Neck

In order to understand the deep plane technique and how it differs from other facelift techniques, we must first understand the muscular and fatty layers that are treated with surgery.

As we age, the main tissue layers that provide structural support in the face and neck are the SMAS and platysma. The SMAS (Subcutaneous Musculo-Aponeurotic System) is a fibromuscular layer deep to the skin that begins at the jawline and continues up to insert on the zygomatic arch and cheek bone. There are dense ligaments that run from the bone through the SMAS to the skin at various points in the face. If these ligaments are not released, the face cannot be lifted.

The platysma is the muscular continuation of the SMAS layer into the neck. It runs from the jawline all the way to the clavicles (collar bone). It inserts laterally to the lining of the sternocleidomastoid muscles on both sides, and one side inserts onto the other at the midline beneath the chin.  It tends to sag and form bands as we get older. Jowls form as a result of sagging of either the SMAS, the platysma, or both.

There are three important groups of fat in the face and neck. The fat that is between the skin and the muscles (SMAS and platysma) is the layer that thickens and thins with weight gain and loss. This layer can be contoured surgically with liposuction, or non-surgically with freezing (CoolSculpting) or dissolving (Kybella).

In the neck, beneath the platysma, is another fat pocket that does not change with weight gain or loss. This subplatysmal fat, if excessive, can only be reduced with surgical excision and muscle tightening (platysmaplasty).

In the face, the superficial fat also includes the nasolabial fat pad. Deep fat below the SMAS is also sensitive to weight gain and loss, but less so than superficial fat. Buccal fat, also deep to the SMAS, is similar to subplatysmal fat: it does not change with weight gain or loss. Often buccal fat will prolapse downward as we age, adding to the heaviness of the jowls.

How is a deep plane facelift performed?

A deep plane facelift begins similarly to a traditional facelift technique. An incision is made in the hairline in front of the ear, continues around the earlobe, behind the ear, then into the hair behind the ear. The incision is designed so hair will grow right through the scar so it is invisible once healed. Then, the skin is raised off the SMAS in front of the ear until the angle of the jaw.

At this point, the SMAS is incised and the dissection is carried deep to the SMAS all the way forward past the jowl & marionette lines. The dissection is carried superiorly deep to the malar fat pad (the fat that makes up the nasolabial fold), releasing the entire midface. The wide release includes separating the deep fibrous attachments between the bone and the SMAS. It is this wide release and ligament separation that allows for a lift that is tension-free, so it never looks pulled or strange. However, the release also must include the upper platysma to be effective. Therefore, the dissection is carried below the jawline underneath the platysma.

In the neck, liposuction can be performed if needed. The skin is then elevated completely off the platysma. Procedures vary as to how the muscle is tightened next, depending upon what the goals are for each patient. If there is subplatysmal fat, the platysma is separated in the midline and fat directly removed. If the muscle needs to be tightened in the midline, then a platysmaplasty is performed where the muscle is sewn together. Often a myotomy, or muscular cut, is made horizontally to improve how the muscle drapes beneath the jawline.

The deep plane neck lift technique involves an additional dissection and release below the platysma to the above steps. An extensive release below the platysma, frees the platysma posteriorly from its insertion at the sternocleidomastoid, then tightens the platysma by sewing it behind the ear. This creates a much more elegant jawline contour and restores volume at the angle of the mandible, where many patients lose contour and volume as they age.

The deep plane lift is performed by lifting the dissected skin, fat, SMAS and platysma vertically. This vertical elevation elevates the midface up, increasing volume in the upper cheeks while reducing volume in the lower face. Jowls and nasolabial folds are improved. When buccal fat is excessive or prolapsing, it can be removed directly via the deep plane approach since the level of dissection allows direct access to the buccal fat pad. The necklift is also an obliquely vertical lift, beautifully tightening the platysma along the jawline.

Who is the ideal candidate for the deep plane facelift?

A deep plane facelift procedure is an ideal lift for anyone who has a combination of midface volume loss, jowls and neck laxity. Due to its extensive release, the deep plane lift can handle heavy-featured patients, overweight patients and patients like men with heavy tissues.

In patients with no midface concerns but only jawline and neck issues, the deep plane lift can be utilized by limiting the deep plane dissection to the lower face and neck. It still allows a superior neck contour with less surgery. However, many times our surgeons will recommend a full face and neck lift even in these patients if the amount of neck laxity is extensive, since the more the laxity, the more a larger lift can improve the outcome.

How does the deep plane facelift differ from other facelift approaches?

There are many different types of facelift procedures, and even many variations to the deep plane facelift technique. In general, other facelift techniques address subcutaneous skin while deep plane facelifts have the ability to address deeper tissue. The more invasive nature of the deep plane technique typically means that there is more swelling of the face after other facelifts since the skin is lifted a longer distance. Potentially this may also lead to a greater risk in delayed healing around the incisions.

The deep plane lift raises the skin, fat and SMAS/platysma as one unit, so the skin never looks pulled and the lift never looks overdone since the pull is deep. The ligaments that bind the skin and SMAS are more effectively released with the deep plane lift, resulting in a more natural lift. In fact, the most important advantage of the deep plane lift is the ability to release and mobilize facial tissues without having to pull very much. The tissues are simply re-draped to where they were 15 years before, resulting in a very natural rejuvenation.

Other techniques cannot access the buccal fat pad nor lift the midface, important for an overall restoration of a youthful profile. Many surgeons that do not perform the deep plane lift compensate for the lack of midface lift by performing fat transfer to the midface during surgery. This is not required with deep plane lifting. Indeed, many patients find that fillers for youthful midface volume are no longer required after deep plane lifting.

This distinction is also similar for the neck. The skin is still raised off the muscle and the muscle is often treated centrally, especially when there is excess deep fat. However, with the deep plane release below the platysma, especially when the platysma is cut to release it as some of our surgeons do, platysmaplasty is often unnecessary. The neck and jawline look great in most patients without it.

The below chart summarizes the differences:

Deep Plane Facelift	Other SMAS Facelift Techniques
Release of entire midface; No need for fat transfer	No midface release; Additional fat transfer often needed to simulate midface lift
Shorter skin elevation = less risk to blood flow to skin	Longer skin elevation = greater risk to blood flow to skin
Buccal fat pad is accessed directly	Buccal fat pad is not accessible
Lateral platysmaplasty reduces recurrence of bands & gives sharper jawline	Central platysmaplasty allows neck band recurrence & treats jawline less effectively
Lift is deep, so skin never looks pulled	Lift is superficial, so skin may look pulled
Lasts 10 – 15 years	Lasts 5 – 10 years
Surgery takes 5-6 hours	Surgery takes 3-4 hours
Higher cost	Lower cost

Deep Plane Facelift Results

1. Improved midface volume. This is not fat transfer or fillers, but elevation of the patient’s own deep fat that has descended over the years. Other facelift surgeons try to get the same result by transferring fat into the midface since they cannot lift it with directly, as Dr. Constantinides did with the deep plane release and elevation.
2. Improved jawline, but also improved mid-cheek creases while smiling. No other facelift technique achieves this since release of the deep plane is required to release the pull of the muscles on the skin of the mid-cheek. This always looks natural and makes patients look more youthful in a subtle but powerful way.
3. Improvement of the saggy neck by tightening the platysma. Most facelift can do this to some degree. The difference is that the deep plane lift releases the platysma from beneath, from where it is stuck. Without this release, in cannot tuck up under the mandible to restore a long, elegant jawline.
4. Elevation of the platysma under the chin, creating a more dramatic jaw-neck contour. The deep anterior necklift removes fat and deeper tissues that then allow the platysma to tuck beneath the chin, improving neck contour even further.
5. Improvement of the contour of the sternocleidomastoid (SCM) muscle. This is the long muscle that runs from beneath the back part of the mandible to the clavicle.

What to expect after my procedure?

Post procedure, most patients will wear a bulky compressive dressing around their whole head and neck, with the central face exposed. The next day, this dressing is typically removed by the surgeon along with any drains used for the procedure. Patients will then receive a compressive facial garment which must be work consistently to aid the healing process. A cold compress can be used over this dressing over the first week to minimize brushing and swelling.

Pain is managed with a combination of non-steroidal medication, ice, compression, head elevation to limit swelling and, when needed, narcotic pain medication. Strategies to limit the need for narcotics will be thoroughly discussed before and after surgery. Pain usually peaks on day 2 or 3 after surgery and is well-managed with this combination of therapies.

One week after surgery patients will return to the office for suture removal. Following suture removal, many patients will be able to begin reducing the time they must wear their compression garments. Each patient will receive instructions specific to their case regarding exercise and other physical activity. However, many patients may begin to take more vigorous walks after one week. Aerobic exercise may resume at lower levels two weeks after surgery. Lymphatic massage is recommended to speed up the healing process once sutures are out.

By two weeks, most patients are back at work or begin to be social once more, with most of the bruising and early swelling resolving. Good skin care is essential during this early healing period. It’s vital to follow post-procedure recommendations to ensure a fast and complete recovery.

Patients should expect to be numb around the ears and in the central neck for several months. These are the areas that only the skin is raised, before the dissection is carried into the deep plane. In areas where the deep plane dissection occurs there should be no numbness.

What are the risks of deep plane facelift surgery?

The risks of deep plane facelifts are similar to any other facelift surgery. Complications are rare, and may include seroma (collection of fluid under the skin), hematoma (collection of blood under the skin), compromised blood flow to the skin (especially in smokers, diabetics and overweight patients), poor scars, hair loss around the incisions, skin irregularities, permanent numbness around the ears or neck, or nerve injury causing weakness around the mouth.

The most common risk is formation of a small seroma, seen in about 10% of patients. This is removed with a small needle and may delay healing in the area by several days. The overall risk that healing leaves an irregularity or scar that requires a touch-up surgery after one year is about 5%.

Where is the surgery performed?

We currently offer deep plane facelift surgery at our Lamar Central location with Dr. Minas Constantinides.