The deep plane facelift utilizes a plane of dissection below the superficial muscular aponeurotic system (SMAS) of the midface, allowing for direct lysis of key facial retaining ligaments and maximum mobilization of the superficial soft tissue. By placing tension only at the level of the fascia, the deep plane technique creates a tension-free skin closure and ensures long-term results. Additionally, the deep plane technique can also address pseudo-herniated buccal fat contributing to jowling. With that said, the debate continues as to which facelift technique is superior. Nevertheless, a properly executed deep plane facelift can produce dramatic and sustainable rejuvenation to the lower face and the midface.
Increased risk of hematoma:
Active smokers: Skin flap necrosis is 12 times more common in smokers who undergo any type of facelift. Note: this common dictum may not hold true for the deep plane technique.
Body Dysmorphic Disorder (BDD): a psychiatric condition classified as an obsessive-compulsive–related disorder, where patients exhibit an obsessive preoccupation with perceived defects in their appearance that are either minute or absent. Moreover, patients with BDD tend to have poor satisfaction following surgery and show a higher rate of aggression and litigation toward surgeons. The prevalence of BDD may be as high as 13% in patients who present for a facial plastic surgery consultation.
Medical clearance: risk stratification and medical optimization for general anesthesia are necessary.
Neurologic examination: trigeminal and facial nerve function requires documentation.
Pre-operative photography: static and dynamic images in a frontal, three-quarter, and lateral views should adequately document ear position/shape, facial asymmetries, hairlines, and patterns of muscle action. The "chin-down" position is very useful to assess the effectiveness of any facelift on the cervico-mental angle and the neck in general.
The surgeon should mark the incisions in the temporal hairline (to ensure maximal preservation of hairline) and post-tragal (pre-auricular in men to avoid transplanting hair-bearing skin onto the tragus). A retro-auricular incision and occipital hairline incision may be needed depending on the amount of planed dissection and skin redundancy.
Important landmarks are identified including the trajectory of the temporal branch of the facial nerve (ear lobe to lateral orbital rim) and the deep plane entry point (a diagonal line from angle of the mandible to lateral canthus).
Anesthesia: although the deep plane facelift may be performed entirely under local anesthesia, nevertheless general anesthesia or intravenous techniques (i.e., propofol) are advisable to ensure patient comfort. Muscle relaxants are avoided to allow monitoring of the facial nerve.
Administration of a single dose of intravenous antibiotics covering skin flora should take place pre-operatively.
A single dose of an intravenous steroid injection (i.e., 8 mg of dexamethasone) may help with swelling.
Local anesthesia is infiltrated along the proposed incision lines and beneath the area of planned subcutaneous dissection.
Since the original description of the deep plane rhytidectomy by Sam Hamra in 1990, several modifications have been made by various authors to further improve rejuvenation of the midface, jawline, and neck.. Herein, this activity will outline the basic surgical principles involved in performing a safe and reproducible midface lift using the contemporary deep plane (sub-SMAS) technique.
Incisions are as outlined above.
A subcutaneous flap is elevated uniformly slightly anterior to the marked deep plane entry point using a combination of sharp dissection (facelift scissors or scalpel), a multi-prong retractor, direct counter-tension, and backlighting of the flap. The postauricular skin is then dissected in a similar subcutaneous fashion and connected to the anterior facial dissection with care not to injury the great auricular nerve overlying the sternocleidomastoid muscle.
The deep plane is then entered by incising the SMAS sharply from just above the angle of the mandible to the lateral orbital rim.
The composite skin/SMAS flap is then carefully elevated off the parotid–masseteric fascia. There is a natural glide plane between the SMAS and the parotid-masseteric fascia. The masseteric ligaments, located at the anterior border of the masseter are released, and dissection is carried anteriorly towards the oral commissure until the surgeon identifies the facial artery.
The elevation of the deep plane is then focused superiorly by developing a pocket superficial to the lateral orbicularis oculi. This dissection is carried medially into the premaxillary space and nasofacial crease, where the composite flap transitions from skin/SMAS to skin/malar fat pad. The superior aspect of the zygomatic major muscle is clearly identified during this step.
Sharp release of the zygomatic ligaments (now isolated between the superior and inferior deep plane pockets) is performed with care to stay superficial to the zygomatic muscle to protect the facial nerve branches innervating the muscle from below.
Dissection continues inferiorly along the zygomatic muscles to the nasolabial fold where the surgeon performs the release of the maxillary ligament, completing the midface release.
If excessive jowling exists due to buccal fat pseudo-herniation, this may be addressed at this time. With an assistant applying pressure to the buccal fat pad transorally, a small incision is made sharply in the overlying fascia. A conservative amount of buccal fat is then teased out and excised using bipolar cauterization with care to avoid injury to the buccal branches of the facial nerve which run around this buccal fat pad.
The SMAS flap is then suspended, working inferiorly to superiorly, with several half-mattress sutures (4-0 nylon or 3-0 polypropylene) placed along the cuff of SMAS at the deep plane entry point and anchored to the parotid and deep temporal fascia in a vertically oblique vector of about 60 degrees.
After resuspension of the SMAS, the redundant skin is meticulously excised and suspended in a similar vector as the deep-plane flap to allow a tension-free skin closure. A combination of deep (4-0 Vicryl) and superficial (5-0 nylon) suture are options for closure with attention to preserving the hairline, everting the skin edges, excising bunched skin, recreating a natural pre-auricular area hollow and tragus, and avoiding a pixie ear deformity.
Before final skin closure, a small drain is inserted through a stab incision posterior to the occipital hairline and placed under bulb suction.
Antibiotic ointment applied to the incision line, and placement of a compressive facelift dressing, complete the process.
The well-vascularized flap created by the deep-plane dissection provides increased protection against the potential problems associated with rhytidectomy; however, the following complications may occur:
A deep plane facelift is a powerful tool that can restore a more youthful and rested appearance to the aging midface. When performing a deep plane facelift, proper patient evaluation, and execution of a thorough, anatomic-based treatment plan can produce safe, reliable, and satisfactory outcomes.
It remains imperative to identify the risk factors and perform a thorough assessment of the patient before performing a deep plane facelift. An interprofessional team approach is an ideal way to limit the complications of this procedure. Prior to surgery, the patient should have the following done:
An interprofessional team of an experienced surgeon, anesthesiologist, and surgical assistants and operative nurses should be involved during the deep plane facelift to maximize outcomes. Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of the deep plane facelift, should monitor the patient for possible complications including a hematoma or facial nerve deficits. It is also crucial to educate the patient on adequately maintaining the surgical wounds, and avoiding strenuous activity, heavy lifting, or bending over during the first several days post-operatively to help prevent complications. [Level 5]
Pharmacist involvement will include verifying dosing and agent selection for antibiotic prophylaxis, as well as pain medications and corticosteroids following the procedure, and performing medication reconciliation, reporting any concerns to the healthcare team. Nursing will assist in patient preparation for surgery, during the procedure, and in monitoring post-surgically, noting any concerns and letting the surgical team know. They are also front-line for verifying medication compliance and any potential adverse effects.
As can be seen from the above, deep plane facelifts require an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level 5]
Adequate pain medication is necessary, as patients often report mild peri-incisional pain for three to four days postoperatively. To minimize edema and ecchymosis, the patient should wear the facelift dressing continuously for the first 24 hours, sleep with the head elevated for one week, and avoid rigorous activity for two weeks. The patient may be given a low-dose corticosteroid taper, Arnica montana, or Bromelain to help lessen bruising and swelling as well, though definitive data on the efficacy of these measures is lacking. Patients are asked to return at one day postoperatively for drain and dressing removal, and again at four days and seven days for further wound assessment and suture removal. Photographic documentation should occur at around nine to 12 months postoperatively.
Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of the deep plane facelift, should monitor the patient for possible complications including hematoma formation and facial nerve deficits.
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