Deep Plane Facelift


Article Author:
Blake Raggio


Article Editor:
Bhupendra Patel


Editors In Chief:
Brian Downs
Ziad Katrib


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
9/10/2019 2:10:33 PM

Introduction

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.[1] 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 pseudoherniated 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 lower face and the midface.[2]

Anatomy

The primary factors contributing to the aging of the midface[3][4]:

  • Gravity: posited to be the central factor in facial aging secondary to its downward pull on the poorly anchored superficial soft tissue envelope.
  • Volume loss: includes fat, muscle, and bone loss

Relevant Anatomy[5][6]:

  • Superficial cervical fascia: encompasses the majority of superficial facial fat and is continuous with the platysma muscle in the neck, superficial muscular aponeurotic system (SMAS) in the midface, and galea in the upper face.
  • Deep cervical fascia: covers the deeper structures of the face, including the masseter, facial nerve, and buccal fat pad.
  • Deep plane: this is the embryologic cleavage plane that separates the superficial soft tissue envelope (covered by the superficial cervical fascia) from the deeper structural aspects of the face (encompassed by the deep cervical fascia).
  • Key retaining ligaments of the face and neck: zygomatic (strongest of all the facial retaining ligaments), maxillary, masseteric, mandibular, and cervical.[7]
  • Facial nerve: at risk for injury during facelift dissection, particularly at the temporoparietal, pre-parotid, and mandibular angle regions.
  • Great auricular nerve: sensory nerve coursing over the body of the sternocleidomastoid muscle, located approximately 6.5 cm below the external auditory canal.[8]

Indications

Areas of the midface able to be addressed by the deep-plane facelift technique[5][6]:

  • Malar fat pad descent        
  • Nasolabial folds
  • Jowling: a result of pseudo-herniated buccal fat and descent of the mobile, medial SMAS
  • Festoons (malar mounds): hammocks of lax skin and orbicularis muscle that form large bags typically resting below the orbital rim
  • Facial dimples: caused by fascial bands from the zygomatic major muscle (minor dimple) or a bifid zygomatic major muscle (major dimple)

Contraindications

Increased risk of hematoma[6]:

  • Patients taking anticoagulants, antiplatelet agents, and nonsteroidal anti-inflammatory drugs
  • Patients taking herbal medications and supplements such as chondroitin, ephedra, echinacea, glucosamine, ginkgo biloba, goldenseal, milk thistle, ginseng, kava, and garlic
  • Men (relative contraindication): twice as likely to experience hematoma (up to 8%)
  • Poorly controlled hypertension, both pre-operatively and intra-operatively.

Active smokers: Skin flap necrosis is 12 times more common in smokers who undergo any type of facelift. Note: may not hold true for the deep plane technique.[9]

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.[10][11]

Equipment

Preoperatively

  • Local anesthesia, such as 1 to 1 mix of 1% lidocaine with 1 to 100000 epinephrine, with 0.5% bupivacaine with 1 to 200000 epinephrine. Note: tumescent anesthesia may be an option in the areas of proposed skin flap elevation.
  • Topical antiseptic, such as povidone-iodine paint

Intraoperatively             

  • Bipolar cautery
  • Scalpel
  • Tissue scissors
  • Multi-prong retractors
  • Facelift scissors
  • Lighted retractor
  • Closed suction drain with bulb
  • Suture for SMAS suspension (3-0 or 4-0) and skin closure (4-0 and 5-0 nylon, 4-0 vicryl)
  • Stapler (may be used for hairline closure)

Postoperatively

  • Antibiotic ointment
  • Compressive dressing material

Personnel

  • Anesthesiologist
  • Surgical scrub technician
  • Operative nurse (circulator)
  • A surgical assistant is useful to help retract, manage intraoperative bleeding, and cut suture.

Preparation

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.

Technique

Since the original description of the deep plane rhytidectomy by Sam Hamra in 1990,[1] several modifications have been made by various authors to further improve rejuvenation of the midface, jawline, and neck.[3][12][13][14]. 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.

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 pseudoherniation, 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.[15]

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.

Complications

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[16]:

  • Hematoma formation: occurs in less than 2% of cases; must be addressed promptly to prevent flap necrosis.
  • Infections: occurs in less than 1% of cases
  • Skin slough: occurs in less than 3% of cases; most commonly in the post-auricular location.
  • Facial nerve injury: occurs in less than 1% of cases (similar for standard facelifts)
  • Great auricular nervy injury: occurs in up to 7% of cases (most commonly injured nerve); causes lobule numbness
  • Pixie-ear deformity: caused by excessive tension on the lobule during skin inset
  • Alopecia: may be prevented with beveled hairline incisions and avoidance of cautery near the hairline

Clinical Significance

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.

Enhancing Healthcare Team 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:

  • Evaluation by a surgeon experienced in selecting the appropriate patient for the deep plane facelift surgery
  • Assessment by a primary care physician and/or anesthesiologist to ensure that the patient is fit for anesthesia

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 V]

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 V]

Nursing Actions and Interventions

Adequate pain medication is necessary, as patients often report mild peri-incisional pain for 3 to 4 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 1 week, and avoid rigorous activity for 2 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.[6] Patients are asked to return at 1 day for drain and dressing removal, and again at 4 days and 7 days for further wound assessment and suture removal.  Photographic documentation should occur at around 9 to 12 months postoperatively.

Nursing Monitoring

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.


  • Image 11306 Not availableImage 11306 Not available
    Contributed by Prof. Bhupendra C. K. Patel MD, FRCS
Attributed To: Contributed by Prof. Bhupendra C. K. Patel MD, FRCS

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Deep Plane Facelift - Questions

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A 62-year-old female patient presents for a facial rejuvenation consultation. In addition to having severe malar fat pad drooping, she also has deep nasolabial folds, severe jowling, thick platysmal bands, and excessive neck laxity. She is concerned mainly about her jowls, but also expresses fear about complications afterwards, in particular, facial nerve weakness. You explain to her that she is a good candidate for a deep plane facelift, which is overall a safe and effective procedure. What advantage does the deep plane facelift offer compared to other facelift techniques?



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A 40-year-old female patient presents as a consult for midface rejuvenation. She has no significant medical or surgical history, takes no medications, and reports being in overall “great health.” Examination shows mild malar fat pad descent, slight depth of the nasolabial folds, and some minimal jowling. It is recommended that she defers any surgical procedures until her signs of aging are more noticeable. The patient reiterates she “needs” the surgery, as she is overly bothered by her facial appearance. What is the next best step in the management of this patient?



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A 64-year-old male presents to the office asking about midface rejuvenation. He has a history of anxiety and is an active smoker. It is conveyed to the patient that a deep plane facelift would address his prominent nasolabial folds and severe jowling. Which of the following poses the highest risk for a hematoma in this patient?



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During a pre-operative consultation for a midface lift, the patient inquires about the type of facelift technique that will be performed. The patient is educated about the method which is a midface lifting technique which involves dissection in a plane between the superficial and deep cervical fascia to release the major retaining ligaments of the face, which allows maximum mobilization of the midface. Which of the following facelift approaches is best described by the technique being used?



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A 50-year-old female patient returns 1 week after her deep plane facelift and complains of right-sided ear lobule numbness. The patient is reassured that this deficit will likely be unnoticeable after several weeks. An injury of which of the following structures most likely contributed to this complication?



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Deep Plane Facelift - References

References

Hamra ST, The deep-plane rhytidectomy. Plastic and reconstructive surgery. 1990 Jul;     [PubMed]
Wulu JA,Spiegel JH, Is deep plane rhytidectomy superior to superficial musculoaponeurotic system plication facelift? The Laryngoscope. 2018 Aug;     [PubMed]
Gordon NA,Adam SI 3rd, Deep plane face lifting for midface rejuvenation. Clinics in plastic surgery. 2015 Jan;     [PubMed]
Fitzgerald R,Graivier MH,Kane M,Lorenc ZP,Vleggaar D,Werschler WP,Kenkel JM, Update on facial aging. Aesthetic surgery journal. 2010 Jul-Aug;     [PubMed]
Jacono A,Bryant LM, Extended Deep Plane Facelift: Incorporating Facial Retaining Ligament Release and Composite Flap Shifts to Maximize Midface, Jawline and Neck Rejuvenation. Clinics in plastic surgery. 2018 Oct;     [PubMed]
Derby BM,Codner MA, Evidence-Based Medicine: Face Lift. Plastic and reconstructive surgery. 2017 Jan;     [PubMed]
Rossell-Perry P,Paredes-Leandro P, Anatomic study of the retaining ligaments of the face and applications for facial rejuvenation. Aesthetic plastic surgery. 2013 Jun;     [PubMed]
Lefkowitz T,Hazani R,Chowdhry S,Elston J,Yaremchuk MJ,Wilhelmi BJ, Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy. Aesthetic surgery journal. 2013 Jan;     [PubMed]
Parikh SS,Jacono AA, Deep-plane face-lift as an alternative in the smoking patient. Archives of facial plastic surgery. 2011 Jul-Aug;     [PubMed]
Joseph AW,Ishii L,Joseph SS,Smith JI,Su P,Bater K,Byrne P,Boahene K,Papel I,Kontis T,Douglas R,Nelson CC,Ishii M, Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics. JAMA facial plastic surgery. 2017 Jul 1;     [PubMed]
Dey JK,Ishii M,Phillis M,Byrne PJ,Boahene KD,Ishii LE, Body dysmorphic disorder in a facial plastic and reconstructive surgery clinic: measuring prevalence, assessing comorbidities, and validating a feasible screening instrument. JAMA facial plastic surgery. 2015 Mar-Apr;     [PubMed]
Sykes JM,Liang J,Kim JE, Contemporary deep plane rhytidectomy. Facial plastic surgery : FPS. 2011 Feb;     [PubMed]
Baker SR, Deep plane rhytidectomy and variations. Facial plastic surgery clinics of North America. 2009 Nov;     [PubMed]
Choucair RJ,Hamra ST, Extended superficial musculaponeurotic system dissection and composite rhytidectomy. Clinics in plastic surgery. 2008 Oct;     [PubMed]
Jacono AA,Ransom ER, Patient-specific rhytidectomy: finding the angle of maximal rejuvenation. Aesthetic surgery journal. 2012 Sep;     [PubMed]
Jacono AA,Sean Alemi A,Russell JL, A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques. Aesthetic surgery journal. 2019 Feb 15;     [PubMed]

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