Deep Plane Facelift

Before a facelift, it helps to understand the superficial musculoaponeurotic system, or SMAS, and how it changes with age. It's a middle layer beneath the fat under your skin, surrounding the face, neck, and scalp. In the scalp it's called the galea, and in the neck, the platysma muscle (the muscle that causes neck bands).

On the sides of the face, this layer is relatively fixed. In the middle of the face, it's much more mobile. A facelift moves the mobile part and secures it to the side. There are also a few areas of dense fibers near the eye and around the mouth. As soft tissue descends with age, it collects up to and around these ligaments, creating the visible break points many people notice.

“Deep plane” is an umbrella term for any facelift that works beneath the SMAS, releasing those attachments so the tissue can be lifted effectively and naturally. It also recruits much more of this layer in the middle of the face than less invasive lifts, which only grab the SMAS at the side.

Modern “preservation” deep plane facelifts separate the skin from the SMAS only minimally, unlike traditional techniques. Because only the SMAS is lifted, the skin rises in a natural direction with it. Keeping skin and SMAS together also lowers the risk of skin texture changes, irregularities, and hematoma (a collection of blood).

It can improve the position of the cheeks, the lower face and jowls, the jawline, and the neck. It helps the nasolabial folds (the lines from nose to mouth) somewhat, but not completely: working too close to the center of the face carries a much greater risk of facial nerve injury, so most surgeons avoid it.

When the middle of the face needs a more dramatic change and the cheeks need more lift, a subperiosteal midface lift can be added through a small incision hidden in the hair. In the neck, combined with a neck lift, it sharpens the angle under the jaw and chin by setting the skin and deeper tissues back and higher. Any excess skin left after repositioning is removed.

When you look up and see vertical bands, the platysma muscle has loosened. Suturing it together in the middle, combined with a pull toward the side incision, creates a tight neck contour. If the bands are hard and bothersome when the muscle is active, small partial cuts below the sutured area can soften them. This is called a platysmaplasty.

Below that muscle, in the deep plane, additional work may include targeted fat removal, submandibular gland reduction, or digastric muscle reduction, depending on your anatomy. Deep neck fat is often undertreated in aesthetic medicine because it's hard to reach. Liposuction and injections like Kybella only treat the fat just under the skin, and overdoing that layer can leave the neck hollow, with muscle fibers showing. That layer also shrinks more with age than the deep fat, so it's preserved when possible. It's liquid gold later in life.

Yes. If you only want a better neck contour, without changing the jowls, cheeks, or lower face, an isolated neck lift can work well. It usually uses an incision behind the ear (not in front) and a second one under the chin.

Both use the same incisions: along the hair at the temple, over the small cartilage in front of the ear, around the ear, and behind it. Both can be combined with a neck lift through a small incision in a natural crease under the chin. They differ in depth, the areas treated, how much correction they give, and recovery.

• Deep plane facelift: works under the SMAS into the cheek and center of the face, and under the platysma in the neck. It treats more of the face and lasts longer, but it is a more demanding operation, so bruising and swelling are typically greater.
• S-lift: tightens the SMAS with sutures, securing it further to the side. It is more superficial, with a lighter recovery.

A facelift alone can cause slight bunching beside the eyes and brows, as the SMAS is reset, and can leave the upper face looking out of harmony with a refreshed midface, jowls, and neck. That's why brow lifts have become one of the most common additions. They create a balanced rejuvenation and reduce bunching at the temples.

Both address a descended brow and hooding at the outer brow, can use an endoscope, and share incisions. The endoscopic brow lift traditionally uses two or three incisions in the hair near the top of the head plus one in each temple; the temporal lift uses only the temple incisions. Both give a mild to moderate lift. The temporal lift focuses on the outer brow, while the endoscopic lift is more comprehensive and can lift the middle of the brow higher.

Upper and lower eyelid surgery are common additions because they rejuvenate the eyes at the same time, so you don't end up with a youthful face and tired eyes. This may include upper blepharoplasty (removing excess upper eyelid skin), lower blepharoplasty (removing puffy fat or excess skin under the eyes), and ptosis repair (raising a drooping eyelid).

More about eyelid surgery

One of the most common additions to a facelift worldwide, because it addresses one of the three layers of aging. Moving your own fat to your face restores lost volume and also transfers stem cells and growth factors that help rejuvenate the skin and tissues. It can be processed to rejuvenate without adding volume (for example, making lips pinker and less creased) or for higher volume in the areas most affected, like the temples and cheeks.

Even after an excellent facelift, skin can be what makes someone look their age. Adding a laser treats texture, fine lines, sun damage, and pigment changes that lifting doesn't touch.

With age, the distance between the nose and upper lip lengthens and the lips thin. A lip lift, done at the same time as a facelift, shortens that distance and turns the lip slightly outward.

The traditional subnasal lip lift gives a durable, measurable shortening of the upper lip while increasing upper tooth show and lip eversion. A scarless V-Y advancement is an option when the lips have thinned, you don't want to shorten the upper lip, don't want a scar under the nose, and mainly want fuller, more everted lips. The scarless lip lift uses a suture to raise the lip from inside the nose; most patients see a shorter lip, and some see more visible red lip.

A chin implant sharpens the jawline, restores bone lost with age around the jaw, and improves the balance of the lower face with the rest of the face.

A genioplasty changes the projection or height of the chin by making a cut through the bone. It's a powerful procedure and, unlike a chin implant, not reversible. A small titanium plate holds the chin in its new position.

During a facelift, the buccal fat pad can be reached through the facelift incision instead of through the mouth. It's mainly added for a round face with excess fullness below the cheeks.

Your plan comes from a comprehensive consultation at The Stern Center for Aesthetics. You start with a 3-D skin analysis, then meet Dr. Kinkhabwala for a formal evaluation of your anatomy and goals. Afterward, you can meet with one of the practice's aestheticians to plan skin care, facials, microneedling, and lasers. The final plan is based on your goals, your anatomy, and the surgical evaluation.

Anesthesia: General anesthesia is used for your comfort and to protect your airway during surgery.

Where the scars are: along the hair at the temple, over the small cartilage in front of the ear, around the ear, and slightly into the hair behind it. A separate incision is often made in a natural crease under the chin for the deep neck and neck bands.

Dressings: Incisions are covered with gauze and a head wrap, which the surgeon removes the next day.

How long it takes: It varies with complexity and any added procedures, but a deep plane facelift alone typically takes around 5 hours.

• Hematoma: making sure there's no bleeding before closing, compression wraps after surgery, and fibrin sealants. Drains are used case by case.
• Temporary nerve weakness: rare, and caused mainly by nerves stretching during the lift or heat from nearby cautery.
• Scarring: meticulous closure and a good skin care routine afterward. Staying out of the sun is critical, because UV light discolors incisions. For people prone to thick scars, injections of fluorouracil or Kenalog can reduce the risk.
• Hair loss near incisions: Dr. Kinkhabwala avoids cautery along the hairline to prevent heat damage to the hair follicles.