Trials, Tribulations, and Techniques for Transitioning to an Extended Deep Plane Facelift for All Patients: Insight from a Very Experienced Surgeon's Perspective

Abstract

The extended deep plane facelift is a powerful technique to correct aging of the midface and neck. After many years of superficial muscular aponeurotic system lift techniques, the senior author transitioned to an extended deep plane facelift for all patients. The primary catalyst for this shift in practice was the pursuit of superior rejuvenation of the midface. Consistent uniform elevation of the deep plane with complete ligament release and management of the soft tissue flap were the most significant challenges in the early adoption period. Navigating the transition was facilitated by consultation with experienced colleagues and frequent cadaver dissections. This manuscript details the authors' current technique. Complications and recovery from this technique are similar to those reported with historical techniques and are minimized with proper preparation, precision, and perioperative management. In our experience the results from this procedure are extremely reproducible, durable, and natural, and patients are overwhelmingly extremely satisfied.

Keywords

extended deep plane - facelift - facial aging - complications - technique

Since the early 1900s the facelift has been the gold standard for rejuvenation and cosmetic correction of aging to the midface and lower face. The earliest techniques were designed around elliptical skin incisions within natural skin creases.[1] In the 1970s more detailed anatomic descriptions of the deeper layers of the face allowed surgeons to achieve more powerful results and reduce unsightly scarring. The superficial muscular aponeurotic system (SMAS) was termed by Mitz and Peyronie in 1976 to describe a layer of fascia investing the facial mimetic musculature, continuous with the platysma in the neck, the temporoparietal fascia, and galea of the scalp.[1] Lifting the skin and superficial facial fat pads via imbrication or plication of this layer improved longevity and incision appearance versus earlier techniques with reduced tension on the skin.

Deep plane and composite lift techniques were the next major development in the 1990s after publication by Hamra.[2] Elevation of the deep plane beginning at the zygomaticus musculature allowed significantly improved mobilization of the midface and nasolabial fold compared with prior SMAS techniques. Recent innovations have tweaked and expanded on Hamra's technique. Extension of the deep plane into the neck to include release of the masseteric, cervical, and mandibular cutaneous ligaments as discussed by Frankel and Jacono has had the most significant impact on the senior author's practice.[3] Releasing of all major facial retaining ligaments permits the surgeon to truly reposition the facial tissues to their youthful height and avoid the telltale windswept appearance, pixie deformities, and midface undercorrection, which plagued previously described facelift techniques.

In this work, the authors will describe pearls and pitfalls of a very experienced surgeon transitioning from years of SMAS techniques to the extended deep plane facelift. Since the transition, we have found our results to be aesthetically superior without an increase in complications or recovery time. For these reasons the extended deep plane facelift is the only lift offered by the senior author for both primary and secondary facelifts. Our current technique, described in detail below, is extraordinarily reliable in our hands. Of course, these techniques have been and will continue to be constantly refined through collaboration with colleagues and careful evaluation of thousands of cases over a 30-year career.

Why Switch to the Extended Deep Plane Lift?

Good is the enemy of great. Many years of very good results with SMAS lifting preceded the senior author's switch to the extended deep plane facelift technique ([Fig. 1]). The decision to change was difficult and required more than 2 years of deliberation and cadaveric dissections. The main shortcoming of the SMAS lift in our hands that catalyzed the change was inadequate correction of the midfacial descent. Inadequate correction of the midface was a significant limitation even in “good” SMAS results ([Fig. 1]). Prior to adopting the extended deep plane lift, several techniques were employed to attempt to achieve an increase in upper midfacial volume and shortening of the lower eyelid—hallmarks of the youthful female face.[4] Combining the SMAS lift with fat grafting to the midface and lower lid complex produced a result that was often very good, but somewhat unpredictable and occasionally short lived. Fat grafting also increased edema, bruising, and downtime for patients seeking a streamlined experience. The subperiosteal midface lift via the temporal brow approach was a very familiar dissection due to years of trauma experience and offered very good results, but again the result would frequently begin to decline after 3 to 5 years.[4] Alternatively, some surgeons sought to suspend the midface directly through a transconjunctival or lower lid approach. The senior author never adopted this approach and has seen many referrals with significant lid malposition complications from these attempts elsewhere.

Fig. 1 Typical results after sub-SMAS lift without deep ligament release and fat grafting. Notice the ptosis of the midface in the preoperative picture (A). In the postoperative picture (B) the jowl and submental regions show definitive improvement. There is a mild improvement in the midface, but definitive signs of aging remain in the lower lid–upper midface complex.

Thus, after long discussions with Dr. Andrew Frankel and other colleagues and friends around 2012 we began to transition our approach to an extended deep plane technique. After adoption we came to appreciate even further the power of extended ligament release and repositioning for neck rejuvenation. In addition to dramatically improved results in the midface, we quickly realized a much more natural and defined jawline with improvements extending well below the cricoid in the neck with the more aggressive subplatysmal release ([Fig. 2]). Patients were thrilled about the lower neck results, which we were never able to achieve with earlier lifting techniques. The ability to directly address the buccal fat was an added bonus for patients where the lateral lobe contributed to undesired lower facial fullness. The power of the lift to very naturally rejuvenate from the lower lid to the jowl was a complete game changer for our practice ([Fig. 3]). While we expected recovery to be more arduous due to the more aggressive dissection, we found this not to be the case ([Fig. 4]). In fact, a complete release in the deep plane while maintaining a composite flap without skin delamination over the midface and much of the lateral neck reduced the potential space for subcutaneous fluid collection. Initially, we transitioned from suction drains to red rubber catheters with success. Then, over 2 years ago drains were removed completely from our protocol and patients are more comfortable and much happier with the simplified postoperative routine.

Fig. 2 Before (A,C) and after (B,D) deep plane facelift and upper blepharoplasty. The patient is a 57-year-old female shown only 6 weeks after surgery and her result will continue to improve. Notice the harmonious rejuvenation from the midface to the jawline and neck with wrinkle reduction extending low into the neck.

Fig. 3 Results after extended deep plane facelift. The patient is a 55-year-old female who is shown 6 months after surgery. Notice the restoration of midface volume on frontal view (A,B), and also three-quarter view (C,D). Also, note the jawline contour and well camouflaged incisions on lateral view (E,F).

Fig. 4 Photo recovery diary for the patient from [Fig. 2]. Note the early bruising at day 1, which resolved before day 8. There is moderate edema at day 8 and 9 with only mild residual edema extending into the third week recovery. This timeline is typical for our practice.

Early Challenges in Switching

The surgeon naturally focuses on safely elevating the flap during the early transition to the deep plane lift. The facial nerve midface branches within the fascia underlying the SMAS are often visible particularly during the extended dissection beyond the buccal fat pad to the nasolabial fold. Varying dissection techniques have been described including the scissor-spread technique and angled 10 blade techniques (the authors' preference—see raising the flap below). From years of elevating the midface through the endoscopic temporal approach, identifying the zygomatic major muscle takeoff from the malar eminence was familiar to the senior author. Clearly identifying this muscle is a critical step to ensure safe elevation in the proper plane. Once the surgeon consistently identifies this key landmark the extended elevation of the deep plane becomes far less daunting. Nevertheless, the senior author spent approximately 2 to 3 years performing dissections on fresh cadaver faces prior to making the change in his practice. There is no substitute for hands-on practice at elevating the tissues safely and identifying the key structures.

Overall, despite the focus on safely raising an extended deep plane flap, the true challenge with this procedure lies in the managing the massive tissue mobilization and flap suspension. Releasing the retaining ligaments and extended dissection results in significantly more tissue mobilization than classic SMAS techniques ([Fig. 5]). In the authors' hands this requires extending incisions and carefully resuspending to avoid visible bunching (see flap management below). Incision planning is also paramount. Significant tissue mobilization risks distortion of the temporal hair tuft when the temporal incision is positioned vertically and is best designed in a trichophytic location (see lateral skin flap elevation below).

Fig. 5 Flap management in the extended deep plane facelift. (A) Preoperative markings and (B) tissue mobilization after complete ligament release and deep plane resuspension. Notice bunching in the lateral canthal region (arrow) that must be corrected with wide subcutaneous dissection, a longer hairline incision, or a concomitant temporal brow lift.

Our Current Technique

The senior author has published free video of his extended deep plane facelift technique. It is currently available at: https://www.youtube.com/watch?v=xl9jFxHDVB4.

Marking and Tumescence

The lateral incisions are marked with a surgical marking pen beginning anteriorly with a trichophytic incision marked along the temporal tuft extending retrotragal ([Fig. 5]). The retrotragal approach is generally selected for both males and females, although males are given the option to choose a pretragal incision to avoid movement of facial hair. The authors have found that the trichophytic incision is better suited than incisions within the temporal hair tuft for the extended deep plane lift. Because of the significant degree of tissue movement and repositioning, distortions of the temporal tuft were common when the natural hairline is not preserved.

The incision is then marked around the crease of the lobule and postauricular limb over the posterior concha. To transition the postauricular segment to the occipital hairline, a notch is created across the skin of the mastoid at the level where the ear attaches to the skull. Creating this notch rather than extending the incision further superiorly facilitates closure and camouflage while maintaining a shorter subcutaneous dissection and decreasing the risk of distal skin necrosis. The remainder of the incision is then marked down the occipital hairline.

Next, important surgical landmarks are marked prior to infiltration with tumescence. The zygomatic arch and lateral malar eminence are marked to indicate the superior border of the deep plane entry point and insertion of the zygomaticus major (ZM) muscle, which is critical to dissection. The extended deep plane entry is then carried inferiorly across the angle of the mandible and down into the neck along the anterior sternocleidomastoid muscle (SCM). The extent of the subcutaneous dissection just beyond the deep plane entry point in the face and neck is also marked ([Fig. 5]). Note, the temporal branch of the facial is generally not marked, since it is not at risk during subcutaneous dissection.

A pressurized infusion bag and an 18-g spinal needle are then utilized to infiltrate all areas of subcutaneous dissection. The tumescent solution contains 500 mL lactate ringers, 25 mL 1% plain lidocaine, 25 mL 0.25% bupivacaine, 1 g of tranexamic acid (in 10 mL), and 1 mL 1:1,000 epinephrine. Care is taken to avoid infiltration medial to the deep plane entry point where the composite flap is elevated in both the face and the neck. Likewise, the neck is infiltrated only centrally to maintain the composite platysmal flap. The authors have found infiltration around the mandibular cutaneous ligaments, and in the region of the temple and lateral canthus particularly helpful to facilitate dissection and limit postoperative bruising. Both sides of the face are and neck are infiltrated at the same time with a total of 200 to 250 mL solution.

The Central Neck

The senior author prefers to begin with the central neck. In earlier years, we elected to forego opening the central neck for patients with Dedo class I or II cervical aging with limited pathology of the platysma. However, we discovered that although uncommon, there were isolated cases of central neck failures despite a strong lateral lift. Given the limited morbidity from the incision and approach, it is now routine for our practice to treat the central neck.

A 3- to 5-cm incision is positioned in the submental crease. Although some surgeons prefer a midneck incision for ease of access to the deeper neck structures, the author prefers to extend the incision length within the submental crease rather than introduce an incision in a more visible location that may become less favorable as the patient continues to age. Subcutaneous dissection is then performed with facelift scissors to delaminate the submental skin. This dissection is extended over the border of the mandible to release the mandibular cutaneous ligaments in the subcutaneous plane. The marginal mandibular nerve is safe below the plane of dissection. Liposuction of the subcutaneous fat is then performed in the central pocket to reveal the medial platysmal borders. The decision to perform deep neck work is based on the patient's anatomy and goals, but deep neck contouring techniques including submandibular gland resection are performed at this time when indicated. Subsequently, the platysmal borders are then plicated in all cases with interrupted 3–0 buried polyglactin suture. Care is taken to capture the hyoid periosteum in this closure. The submental incision is then irrigated and closed.

Lateral Skin Flap Elevation

Attention is then directed to the lateral incisions. The incisions in the hairlines are beveled slightly to allow for trichophytic closure. Hydrodissection over the tragus prior to incision helps to avoid disruption of the tragal perichondrium, which may cause chondritis ([Fig. 6]). The subcutaneous flap is then raised carefully with a number 10 blade. The senior author has found that raising the subcutaneous flap sharply with a number 10 blade combined with directed counter-tension and transillumination of the assistant allows for the most uniform flap without irregularities. The subcutaneous elevation is stopped 1 to 2 cm beyond the entry for the deep plane in both the face and neck. Limited subcutaneous dissection is important to improve the impact of the composite central lift and limit lateral dead space after redrape and therefore the need for drains. Limited delamination also reduces the risk of flap devascularization and hastens the recovery process for the patient. The author therefore does not connect the subcutaneous neck dissection to the central pocket except in heavier necks where it is necessary for flap redrape. Importantly, however, if the subcutaneous dissection is too limited, then bunching and uneven redraping of the flap will cause unsightly deformity in postoperative outcome.

Fig. 6 Hydrodissection with local anesthesia solution over the tragus prior to incision helps to avoid disruption of the tragal perichondrium, which may cause chondritis.

Raising the Extended Deep Plane Flap

After the subcutaneous elevation, the SMAS is incised sharply with a 10 blade from the lateral zygoma past the angle of the mandible and down the anterior border of the SCM. The deep plane dissection is performed in three separate pockets to isolate the zygomatic and masseteric cutaneous ligaments. The deep plane is first raised from the lateral border of the zygoma down the belly of the ZM muscle extending down to the modiolus. A 10 blade or needle point cautery is utilized to dissect to the attachment of the muscle to the zygoma and then a spreading technique with small tenotomy scissors allow for the SMAS flap to be quickly raised from the belly of the ZM muscle. Since the muscle is innervated from below this plane is always safe to raise quickly. Next, the deep plane under the platysma is raised from the anterior border of the SCM. Incision at this location is typically just above the great auricular nerve and the external jugular vein. The authors have found success with needle point cautery to begin the flap in this location followed by a blunt spreading or finger technique, and the senior author has found a significantly lower incidence of great auricular nerve injury with the extended deep plane entry in comparison to previous SMAS flap techniques. The third entry point to the deep plane is in the cleavage plane at the anterior border of the parotid over the mandible. The senior author has found that the relative thickness of the SMAS in this location allows for it to be elevated easily with sharp dissection, a finding corroborated by Mani and others.[5] Care must be taken to avoid entry too high at this location or the parotid duct may be inadvertently injured during the early dissection prior to development of a clean flap.

Once the deep plane flap is developed in these three locations, it is time to release the zygomatic and masseteric cutaneous ligaments and join the flap pockets for one completely released composite flap. In the authors' experience, this is best performed sharply with either a 10 blade or needle point cautery device. The number 10 blade provides tactical feedback to ligament release which, when released, have a “guitar string” feel resulting in a progressive untethering of the composite flap. The surgeon must have direct visualization of the ZM muscle along its entire belly to safely release the zygomatic retaining ligaments without injuring the facial nerve branches that arborize in varying patterns in the fascia immediately below ([Fig. 7]). Release of the masseteric cutaneous ligaments is best performed with the previously developed neck and face deep planes suspended with Andersen prong retractors to allow for clear visualization of the plane. Dissection too deep at the site of these ligaments will carry the surgeon into the masseter muscle and risks damage to the lower facial nerve branches. Thin patients are more likely to have a thin SMAS layer and at higher risk for this complication. The deep plane is elevated out to the capsule of the submandibular gland in the neck and low in the neck below the level of the cricoid. In the face, the deep plane dissection is carried beyond the buccal fat pad to the nasolabial fold.

Fig. 7 Raising the deep plane flap in the midface with complete release of the zygomatic retaining ligaments. Prior to release of the midfacial retaining ligaments it is critical to clearly define and dissect the zygomaticus major muscle from its origin on the malar eminence (arrow). The 10 blade indicates the sub-SMAS plane over the masseter. Countertraction with an assistant facilitates dissection. SMAS, superficial muscular aponeurotic system.

If the buccal fat pad is contributing to lower facial fullness or jowling, it can be easily removed from the deep plane approach. The fat pad is best delivered through a small score in the overlying buccopharyngeal fascia with a gentle two-handed technique to avoid separation of the fat or damage the facial nerve branches which lie immediately on top ([Fig. 8]).

Fig. 8 Removal of the buccal fat pad. After release of the zygomatic retaining ligaments, palpation clearly identifies the location of the buccal fat pad. A small score in the region between the zygomatic major muscle and the masseter will allow for two-hand dissection of the fat pad from its fascial attachments. Care is taken to avoid injury to the parotid duct or buccal branches of the facial nerve.

Flap Management and Suspension

After care is taken to ensure complete release, the SMAS flap is resuspended in the face and neck. The facial portion of the flap is resuspended in a superolateral vector at an angle roughly parallel to the ZM muscle, although each individual varies and the exact vector is altered at the surgeon's discretion. The cervical portion of the flap is resuspended at a more vertical vector with large bites to the mastoid fascia. The senior author has trialed a variety of suture types for suspension of the deep plane flap. The strongest and the least problematic have been polyglactin (Vicryl). Permanent sutures resulted in occasional extrusion or foreign body reaction, whereas monofilament dissolvable sutures offered less tensile strength and more breakage. Polyglactin generates only a mild inflammatory response and holds 50% of its tensile strength until 2 to 3 weeks providing support through the early proliferative phase of healing to generate some early fibrosis.[6] Although the wound will not reach near peak tensile strength until at least 6 weeks,[7] the senior author has not identified any polyglactin deep suture failures despite routinely allowing exercise and full activity at 3 to 4 weeks.

The surgeon must be meticulous in flap suspension to ensure there are no visible irregularities, which is one of the most common complications in the deep plane technique. There are few areas that are particularly susceptible. Wide subcutaneous undermining in the temporal region above the lateral canthus and extending onto the lower eyelid is important to prevent bunching of the SMAS flap at lateral orbit due to the significant movement of the midfacial fat pads and skin ([Fig. 9]). This was an area of early difficulty for the senior author during his transition to the deep plane technique. Another common area for irregularities is the thin preauricular skin over the parotid. With proper ligament release it is common to move the SMAS flap all the way up to the tragus and thus trimming and meticulous suturing in this area is necessary.

Fig. 9 Contour irregularities over the zygoma after release and resuspension of the deep plane flap. This may be treated with dermal filler or fat grafting.

Skin Removal and Closure

After suspension of the SMAS flap, the surgical site is irrigated copiously with cool saline and meticulous hemostasis is obtained. Since no drains are placed, this is critical to decreasing the risk of seroma. The skin is then redraped without tension and skin excision begins with the temporal tuft portion of the incision. A single hook placed at the anterior limit of the incision allows for the surgeon to mark and excise in a beveled trichophytic fashion to the posterior corner of the temporal tuft incision. A 5–0 nylon placed in this location holds the flap in place for the remainder of the skin removal. Without any tension on the skin the preauricular skin is excised from the temporal tuft incision to the lobule and another 5–0 nylon is placed at the inferior lobule. Next, attention is directed to the occipital incision. A single hook at the inferior edge of the incision allows the surgeon to create an even distribution of the neck flap, which is redistributed in a more vertical fashion. The skin is excised in a beveled fashion and two 5–0 nylon sutures are placed leaving the remaining postauricular skin to be excised last. After a few 5–0 polydioxanone sutures are placed in the temporal and occipital incisions to ensure zero tension closure, a combination of running-locking and interrupted 6–0 polypropylene and 5–0 nylon sutures are utilized for closure. The submental incision is closed in a similar fashion, the hair is washed, and a standard facelift dressing is applied.

Complications and Pearls

Complications of the extended deep plane lift may be characterized into three main categories: incisional and soft tissue, nerve injury, and hematomas and infections.

Incisional and Soft Tissue

While proper release and repositioning of the deep plane results in decreased skin tension, there is still the possibility for keloids, hypertrophic scarring, and alopecia. A thicker composite flap also improves flap perfusion and the author has seen a significant decrease in the rates of flap necrosis since switching to the extended deep plane facelift. To achieve the most favorable scarring, the authors have found the most reliable results with beveling of the occipital and temporal incisions. Deep sutures in these locations help to reduce tension but overuse of buried suture risks an effluvium alopecia. Pixie ear is uncommon if the skin is redistributed carefully without tension. Extreme care when performing a skin–muscle flap blepharoplasty along with the extended deep plane dissection due to the risk of lid malposition and prolonged edema. The author has found that the above technique alone results in rejuvenation of the lower lid–midface complex and a skin–muscle blepharoplasty is never a necessary adjunct.

The most common soft tissue complication in the early transition is flap irregularities ([Fig. 9]). Wide undermining in the temporal region along with suspension of the deep plane flap at or below the level of the zygomatic arch has decreased this complication in our practice. Combining the extended deep plane facelift with a temporal brow lift also aids in reducing bunching and irregularity. Despite minor bunching and irregularities, the need for touch-up procedures after the extended deep plane facelift is far less than rates seen with previous SMAS techniques. Kamer and Frankel found the rate of “tuck” procedures was more than 3.5 times less after a deep plane technique versus an SMAS lift.[8] Proper release of the facial retaining ligaments and wide flap mobilization results in a longer lasting and more reliable result with fewer complications when the soft tissue flap is managed with care.

Nerve Injury

Raising the deep plane flap with the above strategies and careful technique is extremely safe. In their series of 153 patients Jacono and Parikh found a 0% rate of permeant nerve injuries, 1.3% rate of temporary motor nerve injury consistent with rates reported for SMAS lift techniques.[9] Temporary nerve injuries may be secondary to thermal damage or crush injury. Aberrant recovery with synkinesis is a feared complication and, although rare, may be debilitating to the patient. The utmost care with cautery in the temporal region and spreading techniques in the sub-SMAS plane is imperative.

Sensory nerve injury may also be debilitating for patients. The posterior branch of the great auricular nerve crosses at the subplatysmal entry point at the anterior SCM. It is identified and preserved nearly all cases. In the senior author's experience, it is actually injured less frequently than imbrication or plication techniques that suture blindly in this area.

Hematoma and Infection

By raising a large composite flap with less subcutaneous dissection, the surgeon decreases potential space for collection of blood and serous fluid. The rate of hematoma in the composite deep plane lift was recently estimated at less than 2% in a meta-analysis by Jacono et al.[10] We have found our rates to be consistent with these numbers. Although bleeding complications are rare, early recognition and management are key to avoiding long-term sequela. It is our experience to aggressive needle aspirate early hematoma or serous collections in a serial manner along with continuous pressure dressings to prevent reaccumulating. In very rare cases of large organized or expanding hematomas, opening the incisions and suction-aided drainage and cautery are required.

Infection rates are typically very low for facelift surgery due to excellent perfusion to the facial soft tissues. The extended deep plane lift is no different. However, in cases of blood or fluid collection, perfusion is limited and bacteria and biofilms may form. These complications may be severely debilitating and must be treated promptly and aggressively. Even in cases of small fluid collections, it is important to ensure the patient is treated with antibiotics. A culture is obtained whenever an infection is clinically suspected so that culture-guided therapy may be initiated.

Conclusion

The extended deep plane facelift is a powerful technique to correct aging of the midface and neck. In our experience the results from this procedure are extremely reproducible and natural, and patients are overwhelmingly extremely satisfied. Surgeons transitioning to this technique should seek opportunities for cadaver dissection of the deep plane, but the most difficult adjustment is managing the widely mobilized composite flap. Complications from this technique are similar to those reported with historical techniques and are minimized with proper preparation, technique, and perioperative management.

Conflict of Interest

None declared.

Update in Facial Rejuvenation 2024–The Experts Perspective

• References

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Publication History

Article published online:
15 February 2024