September 22nd, 2021 | Categories: Uncategorized

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Yes. But is it really the best option? The earliest facelifts were skin-only (subcutaneous) lifts that looked good initially but did not last long due to the weak mechanics of skin (the weakest organ). Scar widening was caused because tension was placed along the incision, not deeper tissues. Torg and Skoog revolutionized facelift surgery in the 70s by exploiting the “SMAS”. This is a dense connective tissue layer in the cheek lying between the subcutaneous fat above and the muscles that control facial expression below. By raising the “hood” (skin and fat) and exposing the SMAS, tightening and rotating of these deeper tissues not only softened the nasolabial and melolabial folds (marionette lines), but load-shared with the skin closure, making incisions fainter and results more long-lasting.

The deep plane facelift was also described in the late 1970s but did not gain widespread acceptance until the 1990s. At that time Dr. Hamra, a Dallas plastic surgeon, celebrated the deep plane lift for its ability to maximize blood supply to the skin and minimize the nasolabial fold. This procedure raises the skin and the SMAS together as a single composite unit and dissection undermines the nasolabial fold. His results were good, probably because he was good, but the operation was quickly challenged for the greater risk of injury to the facial nerve branches just deep to it. Most traditionally trained plastic surgeons, like myself, do not rely on the deep plane lift as a first choice because there has been no aesthetic advantage demonstrated in results.

Sometimes I am a control freak. So, philosophically, I prefer to adjust separate layers in different ways. For example, pulling skin more vertically and deeper structures more posteriorly. This is where a traditional SMAS lift shines. A SMAS lift raises the skin and SMAS layers separately. This allows better control and customization to individuals’ anatomies and goals. The deep plane method tends to be limited to one direction of tightening which is fine in many, but not all cases. Additionally, the SMAS can be tightened, trimmed, removed, and repaired in different ways to address different goals and choices. The deep plane technique is more regimented and less customizable. A SMAS lift is safer and allows for deep fat injection to the sub-SMAS space to volumize the malar and nasolabial region more dependably.

I also get the sense, based on patient feedback, that there is controversy as to which technique is superior. There actually is no controversy. I imagine there are less surgeons who routinely perform deep plane facelifts, and this is an opportunity to market a “premium” product in a competitive market. The best facelifts I’ve ever seen (T. Marten, San Francisco) are “classical” facelifts. More recently, the most famous facelift patients (i.e., Marc Jacobs, Paul Nassif) and celebrity facelift surgeons tout the deep plane technique. That’s not to say the results are superlative, or even superior, to results of more traditional methods. But social and mainstream media are effective marketing tools.

When you combine these phenomena with higher costs, there is certainly some perception of superiority. In my practice, the two methods cost the same, the results look the same, but the deep plane facelift is theoretically riskier for nerve injury.

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