eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Rhytidectomy, Deep Plane Facelift

Author: Jefferson K Kilpatrick, MD, Consulting Staff, Department of Facial Plastic-Head and Neck Surgery, Pinehurst Surgical Clinic
Coauthor(s): Keith A LaFerriere, MD, Clinical Professor, Fellowship Director, Department of Surgery, Division of Otolaryngology, University of Missouri at Columbia
Contributor Information and Disclosures

Updated: Nov 10, 2008

Introduction

Rhytidectomy (facelift) is one of the most commonly performed plastic surgery procedures in the head and neck. Traditional approaches to rhytidectomy (facelift), such as superficial musculoaponeurotic system (SMAS) imbrication or plication procedures, can significantly improve changes in the lower face and in the neck caused by aging. These procedures are discussed in the eMedicine article Rhytidectomy, SMAS Facelift.

The deep plane facelift was developed as a modification of standard facelift techniques to correct facial changes caused by aging that are due to ptosis of midface structures (malar fat pad). The deep plane facelift also attempts to correct deep nasolabial folds. Other techniques (excluding specific midface procedures) do not adequately address these problems.

In carefully selected patients, deep plane rhytidectomy (facelift) can be safely performed with a high level of patient satisfaction. The surgeons' goal is to obtain a pleasing aesthetic result that appears natural and provides no evidence of an operation. This article discusses the preoperative evaluation and surgical techniques that help surgeons select patients who may benefit from a deep plane rhytidectomy procedure.

Problem

Traditional facelift techniques, such as SMAS imbrication or plication rhytidectomy, may adequately treat changes in the lower face caused by aging, such as jowling of the lower face or platysmal banding in the neck; however, these techniques do not adequately address aging changes due to ptosis of midfacial structures and a deep melolabial fold. The deep plane rhytidectomy evolved as a technique designed specifically to address aging changes in these areas.

Frequency

Not every patient with aging changes in the lower face has ptosis of the mid face or a deep melolabial fold. Patients without may be candidates for other procedures that usually have a shorter healing period and involve less risk to the facial nerve, such as an SMAS flap, plication, or imbrication facelift.

Etiology

Aging occurs as a natural phenomenon.

Pathophysiology

The deep plane facelift allows direct lifting of the malar fat pad with the overlying skin. This area can be repositioned with sutures to improve aging changes in the mid face.

Presentation

Obtain a general medical history. The patient should be in good enough health to undergo a 3- to 4-hour elective surgical procedure. Note any history of bleeding tendencies or the use of medications that may cause bleeding abnormalities. Patients should discontinue any anticoagulating medications for an appropriate period to prevent intraoperative bleeding problems.

Evaluate the patient's goals and expectations. This information is typically obtained during the initial consultation and should be reviewed prior to surgery to prevent any miscommunication. Confirm that the patient's goals are realistic and that these goals cannot be met with a less extensive rhytidectomy procedure or other cosmetic procedures.

The patient should clearly understand the risks and different options available to treat facial changes caused by aging before giving informed consent. In general, deep plane rhytidectomy has a higher risk of injury to branches of the facial nerve and takes slightly longer to heal than other facelift techniques.

Indications

Candidates for a deep plane rhytidectomy should have significant facial changes caused by aging in the region of the mid face and melolabial fold.

Relevant Anatomy

The SMAS is a layer of muscle and connective tissue that overlies the parotidomasseteric fascia and envelops the mimetic muscles of the face and the platysma in the neck. Branches of the facial nerve leave the parotid gland and pass medially towards the midfacial musculature beneath the parotidomasseteric fascia.

If dissection in the lower face remains below the SMAS and above the parotidomasseteric fascia, injury to branches of the facial nerve is avoided. This sub-SMAS dissection can safely proceed medially as far as the facial artery and vein. Anterior to this point, the nerves innervate the perioral musculature, and the possibility of nerve injury increases. Dissection in the lower part of the face up to a level just below the origin of the zygomaticus major and minor muscles is performed in the sub-SMAS plane. By necessity, dissection in the mid face to separate the malar fat pad and skin complex from the deeper structures is performed above the SMAS. As a result, the nerves innervating the zygomaticus major and minor muscle complex, which enter these muscles from their deep surface, are not injured. To accomplish this goal, the sub-SMAS dissection is stopped in the lower part of the face at a level approximately 1 cm below the zygomatic arch.

Identification of the orbicularis oris muscle and the origin of the zygomaticus major and minor muscles is a key part of the operation. Dissection is facilitated into the mid face in a safe plane just above the orbicularis oris and zygomaticus major and minor muscles to the melolabial fold and into the upper lip, if needed. A thick subcutaneous flap is created that contains the malar fat pad attached to the skin and allows for repositioning of the malar fat pad–skin complex in a more youthful posterior-superior direction.

Anatomic details relevant to this technique are further discussed in Intraoperative details.

Contraindications

Relative contraindications include poor medical health, patients who require blood-thinning medications on a regular basis, patients with unrealistic expectations, and patients who smoke. It should also be used with caution in secondary facelifts unless the original procedure did not involve a sub-SMAS technique, as scarring from the original procedure may obscure the tissue planes and place the facial nerve at undue risk.

Although some authors advocate a deep plane facelift for patients who smoke because it provides a thicker flap and may preserve arterial perforators to the skin, any facelift in a patient who smokes has increased risk of postoperative wound complications.

More on Rhytidectomy, Deep Plane Facelift

Overview: Rhytidectomy, Deep Plane Facelift
Workup: Rhytidectomy, Deep Plane Facelift
Treatment: Rhytidectomy, Deep Plane Facelift
Follow-up: Rhytidectomy, Deep Plane Facelift
References
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References

  1. Kamer FM, Nguyen DB. Experience with fibrin glue in rhytidectomy. Plast Reconstr Surg. Sep 15 2007;120(4):1045-51; discussion 1052. [Medline].

  2. Baker DC. Deep dissection rhytidectomy: a plea for caution. Plast Reconstr Surg. Jun 1994;93(7):1498-9. [Medline].

  3. Gassner HG, Rafii A, Young A, et al. Surgical anatomy of the face: implications for modern face-lift techniques. Arch Facial Plast Surg. Jan-Feb 2008;10(1):9-19. [Medline].

  4. Godin MS, Johnson CM Jr. Deep-plane/composite rhytidectomy. Facial Plast Surg. Jul 1996;12(3):231-9. [Medline].

  5. Hamra ST. A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure. Plast Reconstr Surg. Sep 1 2002;110(3):940-51; discussion 952-9. [Medline].

  6. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. Jul 1992;90(1):1-13. [Medline].

  7. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. Jul 1990;86(1):53-61; discussion 62-3. [Medline].

  8. Kamer FM. One hundred consecutive deep plane face-lifts. Arch Otolaryngol Head Neck Surg. Jan 1996;122(1):17-22. [Medline].

  9. Kamer FM, Mingrone MD. Deep plane rhytidectomy: a personal evolution. Facial Plast Surg Clin North Am. Feb 2005;13(1):115-26. [Medline].

  10. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. Jul 1976;58(1):80-8. [Medline].

  11. Pastorek N, Bustillo A. Deep plane face-lift. Facial Plast Surg Clin North Am. Aug 2005;13(3):433-49. [Medline].

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Further Reading

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Keywords

deep plane facelift, rhytidectomy, facelift, face lift, facelifts, face lift surgery, facelift surgery, ptosis of midface structures, superficial musculoaponeurotic system imbrication, SMAS imbrication, plication rhytidectomy, lifting face, deep nasolabial folds

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Contributor Information and Disclosures

Author

Jefferson K Kilpatrick, MD, Consulting Staff, Department of Facial Plastic-Head and Neck Surgery, Pinehurst Surgical Clinic
Jefferson K Kilpatrick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Keith A LaFerriere, MD, Clinical Professor, Fellowship Director, Department of Surgery, Division of Otolaryngology, University of Missouri at Columbia
Keith A LaFerriere, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Anthony P Sclafani, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons
Disclosure: Medicis None Speaking and teaching; Contura None Board membership; Contura Grant/research funds Independent contractor; Cascade Medical Grant/research funds Independent contractor; Cascade Medical None Board membership

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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