Traditional approaches to rhytidectomy, while addressing aging changes to the lower face, are limited by the ability to adequately address aging changes in the midface. The deep-plane and composite facelift techniques are modifications of traditional rhytidectomy techniques that also address ptosis of the midface and aging in the melolabial area and lower face. [1, 2]
History of the Procedure
Rhytidectomy dates to the turn of the 20th century. In its nascent form, rhytidectomy consisted of very limited skin excision and elevation, as first performed by Lexer in 1916. Advances in the technique consisted of more extensive undermining in the subcutaneous plane. The next major advance did not occur until 1968, when Skoog developed a subplatysmal dissection in the neck, elevating the skin and platysma as a single unit to effect a more permanent change. Subsequent definition of the superficial musculoaponeurotic system (SMAS) by Mitz and Peyronie in 1976 led to the development of SMAS rhytidectomy techniques, which remain the standard in rhytidectomy procedures. 
In the last quarter century, additional rhytidectomy techniques, including deep-plane, composite, and subperiosteal dissections, have been developed. The goal of these more extensive dissections is to address aging of the midface structures and the lower face and neck. The deep-plane rhytidectomy was designed to reposition the malar fat pad, thereby addressing the midface and nasolabial or melolabial folds. This technique was introduced by Hamra in 1990 and modified further in 1992 to incorporate the orbicularis oculi muscle into the flap, termed the composite rhytidectomy. [4, 5] Modifications of the deep-plane/composite rhytidectomy techniques have since been used and reported by numerous authors. [6, 7, 8, 9, 10, 11, 12, 13, 2]
While achieving excellent results in aging changes of the lower face and neck, traditional rhytidectomy techniques are less effective in addressing aging changes of the midface and melolabial folds. Various techniques designed to address this problem area have evolved in the last decade. While SMAS techniques are effective in repositioning the platysma, they have little effect on the nasolabial area. Lateral tension placed on the SMAS does not efface the nasolabial fold and can potentially deepen this structure. Additionally, cheek fat cannot be repositioned adequately by traditional SMAS techniques because it remains tethered by the zygomaticus muscles, which have bony origins.
The deep-plane and composite rhytidectomy techniques were designed to address this limitation of SMAS rhytidectomy. A deep subcutaneous plane is developed, separating the malar fat pad from its attachments to the zygomaticus muscles, which is joined with sub-SMAS dissection in the lower face. The result is a composite flap that includes the malar fat pad, which now is mobilized and can be repositioned to restore youthful contour to the malar eminence and soften the melolabial fold. The malar crescent created by ptosis of the orbicularis oculi can also be addressed by composite rhytidectomy techniques. This allows uniform harmonious rejuvenation, particularly when combined with rejuvenation of the upper face, creating a natural appearance as youthful contours are restored to every area of the face.
Aging is a natural phenomenon affecting both the deep and superficial structures of the face.
Aging affects both deep and superficial structures, including skin, subcutaneous fat, muscle, and bone. In the face, ptosis of deep anatomic structures contributes to the telltale signs of aging, such as midface ptosis, jowling, and deepened nasolabial folds. While SMAS rhytidectomy techniques address the neck and jawline with excellent results, these techniques are less effective on the midface. Descent of the malar fat pad results in hollowing in the area of the orbit, loss of malar prominence, and deepening of the nasolabial fold.
The deep anatomic structures primarily responsible for aging changes of the midface and lower face are the orbicularis oculi muscle, the cheek fat of the midface, and the platysma muscle of the lower face. Ptosis of these structures results in descent of the malar crescent, deepening of the nasolabial fold, and jowling, respectively. By addressing each of these areas, a natural harmonious rejuvenation can be achieved.
The preoperative consultation is the foundation of choosing a surgical approach and obtaining a successful result in terms of both technical success and patient satisfaction. Standard preoperative photographs are taken prior to the consultation. A photograph can be used during the consultation as a communication tool between the surgeon and patient. If using digital imaging systems, care must be taken to show realistically achievable results. A combination of examining the patient in front of a mirror and viewing photographic images allows the patient to highlight areas of concern and allows the surgeon to convey what can be realistically achieved with surgery. The patient must understand the goals of surgery and, as importantly, the limitations of surgery and what surgery cannot accomplish. This is a critical step in ensuring that the patient's concerns are addressed adequately by the surgical procedures chosen and that the patient's expectations are realistic.
The entire face must be evaluated carefully. If the patient has significant aging changes in the upper face and lower face, these should be discussed. Rejuvenation focused on only the lower face can result in an unnatural and operated appearance. If appropriate, this should be explained to the patient, and additional rejuvenation procedures that may enhance the overall result should be discussed.
The limitations of rhytidectomy should also be addressed. Concerns over fine lines, skin changes, or hyperfunctional facial lines may require procedures such as skin resurfacing, injectable fillers, or BOTOX® treatment. Importantly, the patient must understand that rhytidectomy does not address all of these issues and that other procedures may be more appropriate or used as an adjunct to enhance the results. This interaction between patient and surgeon allows the formulation of a surgical approach focused on addressing the patient's primary concerns in the setting of realistic expectations to achieve a natural, harmonious appearance.
A detailed medical history is taken to determine the patient's suitability as a surgical candidate. Any previous history of surgical procedures in the head and neck is documented. Any history of hypertrophic scarring or keloids is elicited. A history of bleeding disorders in the patient or family is important and may warrant a more extensive laboratory workup. Additionally, the medications the patient takes should be documented carefully, and any anticoagulant medications should be discontinued prior to surgery if medically appropriate. Patients should also be questioned about any herbs, vitamins, or supplements they may take because many of these also have anticoagulant effects. Many patients do not volunteer these as medications unless specifically asked.
A routine physical examination is performed. If the patient has any significant medical problems or the history elicits any areas of concern, referral is made for preoperative medical assessment and clearance.
Lower facial rejuvenation can be accomplished by various surgical techniques. Candidates for deep-plane or composite rhytidectomy have aging changes in the midface and lower face. These include ptosis of the malar fat pad, deepening of the melolabial folds, and development of a malar crescent that may not be addressed adequately by other techniques.
Superficial musculoaponeurotic system
The SMAS is a fibromuscular layer overlying the parotideomasseteric fascia and investing the mimetic muscles of the face and the platysma. The temporoparietal fascia is analogous to this layer above the level of the zygoma. The superficial layer of the deep fascia splits to envelop the parotid gland. The superficial layer overlying the parotid gland is known as the parotid fascia. The facial nerve branches lie deep to this layer, which continues overlying the masseter muscle as the parotideomasseteric fascia.
However, some controversy is present in the literature regarding the relationship of the SMAS to the parotid fascia. As described by Mitz and Peyronie, the SMAS is part of the fascia superficialis and is a layer distinct from the underlying parotid fascia.  Other anatomic studies have suggested a more intimate relationship between the SMAS and the parotid fascia. From their dissections, Jost and Levet suggest that the parotid fascia actually represents the SMAS rather than constituting a separate layer.  Other authors, such as Stuzin et al and Yousif et al, have described a true parotid fascia underlying but intimately related to the overlying SMAS. [15, 16]
The mimetic muscles of the mid and upper face differ in their embryologic development from the muscles of the lower face. The muscles of the lower face, including the platysma, risorius, depressor anguli oris, and posterior auricular muscles, derive from the primitive platysma. The muscles of the mid and upper face derive from the embryonic sphincter colli profundus and, in contrast to muscles of the lower face, have direct bony insertions. Thus, the zygomaticus minor muscle arises from the region of the zygomaticomaxillary suture and passes downward and medial into the orbicularis oris muscle. The zygomaticus major arises further lateral on the zygomatic bone and runs to the angle of the mouth, blending with the orbicularis oris in the region of the modiolus.
Freilinger et al described 4 layers of the facial musculature.  The superficial layer is composed of the depressor anguli oris, zygomaticus minor, and orbicularis oculi. The depressor labii inferioris, risorius, platysma, zygomaticus major, and levator labii superioris alaeque nasi constitute the second layer. The third layer is composed of the orbicularis oris and levator labii superioris. The mentalis, levator anguli oris, and buccinator constitute the fourth or deep layer. The first 3 layers are superficial to the plane of the facial nerve and therefore receive motor innervation from their deep surfaces. The fourth layer lies deep to the plane of the facial nerve, and these muscles receive their innervation from their superficial surface.
Dissection in the deep plane overlying the zygomaticus major muscle can be performed safely because this muscle receives motor innervation from the facial nerve on the deep surface of the muscle. The facial nerve branches innervate most of their respective facial muscles on the deep surface of the muscles. The 3 exceptions are the facial muscles lying deep to the plane of the facial nerve, which receive innervation along their superficial surface: the mentalis, the levator anguli oris, and the buccinator. Although the facial nerve branches are, for the most part, deep to the SMAS-facial muscle layer, the nerve fibers become more superficial medially to innervate the facial muscles. Thus, a deep-plane dissection begins in the sub-SMAS layer and becomes more superficial, overlying the zygomaticus major muscle in a deep subcutaneous plane. This transition allows the dissection to be carried medially to the nasolabial fold without injury to the facial nerve branches.
The retaining ligaments of the face anchor the skin to the underlying bone, supporting the midface and maintaining its relative position to the underlying bony structures. Furnas described 4 retaining ligaments supporting the soft tissues of the face.  The platysma-auricular ligament and the platysma-cutaneous ligaments are aponeurotic condensations attaching platysma to dermis. Of greater significance are the osseocutaneous ligaments, which serve to support the skin and facial structures against gravitational forces and resultant ptosis. For this reason, the ligaments must be released surgically to allow full mobilization of the facelift flap.
The osseocutaneous ligaments are the zygomatic ligament and mandibular ligament. The zygomatic ligaments originate from the zygomatic arch near the body of the zygoma. The malar fat pad overlies the orbicularis oculi, zygomatic, and levator muscles in a plane superficial to the SMAS. The zygomatic retaining ligaments extend through the malar fat pad (McGregor patch), inserting into the overlying dermis and anchoring this structure to the zygomatic eminence. Therefore, this is the key ligament in deep-plane and composite dissections because its release allows complete mobilization of the midface. The mandibular ligaments originate above the inferior border of the mandibular body, directly below the corner of the mouth. These ligaments serve to tether the parasymphyseal dermis to the underlying mandible, defining the anterior extent of the jowls.
Nasolabial or melolabial folds
The cutaneous insertion of the zygomatic muscles, levator labii superioris, and levator labii anguli oris defines the nasolabial crease. Lateral to the crease, these muscles have no direct dermal attachments, and a generous layer of subcutaneous fat is present. In contrast, medial to the crease, the skin adheres tightly to the orbicularis oris muscle, with very little subcutaneous fat evident. Thus, the nasolabial fold represents a transition between the skin territories of the cheek and the upper lip. The skin of the upper lip is supported by its attachment to the mimetic musculature against gravitational forces. The skin lateral to the nasolabial fold has no direct attachments to the underlying musculature for similar support. This discrepancy leads to pronounced ptosis of the skin and subcutaneous tissues of the midface compared to the upper lip, resulting in deepening of the nasolabial fold with age as the cheek mass selectively descends.
The anatomic relationship of the SMAS to the nasolabial fold is a subject of some controversy in the literature. In their classic description, Mitz and Peyronie described the SMAS continuing anteriorly into the upper lip, investing the muscular layer.  Other authors have debated the continuity of the SMAS in the cheek with the fascia of the upper lip. Barton noted a thin layer of fascia investing the zygomatic muscles extending into the upper lip but no identifiable subcutaneous extension of the SMAS.  Pensler et al described identifying a SMAS layer medial to the nasolabial fold.  Yousif et al have suggested this actually represents the "fascial-fatty" layer, which these authors describe as superficial to the SMAS in the cheek and the upper lip.  Yousif et al describe anatomic continuity of the SMAS with the superficial layer of the orbicularis oris, suggesting the superficial layer of this muscle represents the SMAS in the upper lip, separate from theoverlyingfasciallayer. 
Despite these inconsistencies between studies, the SMAS clearly becomes attenuated in the medial aspect of the cheek but appears to continue in the upper lip as investing fascia of the musculature. Lateral traction on the SMAS has been shown to have little effect on the nasolabial fold. Yousif et al have described deepening of the nasolabial fold with lateral traction on the SMAS because this translates to pull on the orbicularis oris medial to the fold.  Barton suggests that the anchoring effect of the musculature of the upper lip prevents significant effect on the medial cheek skin by lateral traction on the SMAS.  Also, tethering of the SMAS to the bony origins of the mimetic muscles, particularly the zygomaticus major, prevents any significant effect on the nasolabial fold, and these attachments must be released to effectively address this area.
Greater auricular nerve
The greater auricular nerve is found in the deep cervical fascia of the sternocleidomastoid muscle, posterior to the angle of the mandible.  The nerve branches at the anterior border of the muscle. It crosses the sternocleidomastoid muscle 6.5 cm below the caudal edge of the bony external auditory canal and is found just posterior to the external jugular vein. The vein and nerve are deep to the SMAS-platysma layer except where the terminal branches of the nerve pass superficially to innervate the earlobe. This is the most commonly injured nerve in rhytidectomy procedures, and care should be taken in elevation over the sternocleidomastoid muscle.
The vascular supply of the composite flap is based on the facial, angular, and inferior orbital arteries. The facial artery supplies the platysma and continues as the angular artery. This communicates with branches of the supratrochlear and infraorbital arteries. As the skin, subcutaneous tissue, and, in the lower face, the SMAS layer, are elevated in continuity in the deep-plane and composite rhytidectomies, the arterial perforators to the overlying skin are preserved.  This creates a maximally vascularized flap, which can be repositioned under extraordinary tension without vascular compromise. Complications such as skin slough and necrosis are also less likely to occur.
Because rhytidectomy is an elective procedure, relative contraindications include significant medical problems that can potentially increase the surgical risk. Any history of significant bleeding problems or a family history of bleeding problems warrants more extensive preoperative evaluation. Any patient on anticoagulants must be able to stop these medications during the preoperative and postoperative period.
Smoking is a relative contraindication for deep-plane or composite rhytidectomy. With deep-plane dissection techniques, a well-vascularized composite flap is developed and skin necrosis or flap loss is a rarity. This technique can be performed successfully in persons who smoke, but the additional risk of postoperative wound complications must be understood and accepted by the patient. Ideally, if the patient is committed to an optimum aesthetic outcome, he or she is compliant with smoking cessation.
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