Deep Plane Rhytidectomy

Rhytidectomy (facelift) is one of the most commonly performed plastic surgery procedures in the head and neck. Traditional approaches to 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.[1] These procedures are discussed in the Medscape Drugs & Diseases article SMAS Facelift Rhytidectomy.

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.[2, 3, 4] Other techniques (excluding specific midface procedures) do not adequately address these problems.

In carefully selected patients, deep plane rhytidectomy 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.

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 midface 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.

Aging occurs as a natural phenomenon.

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 midface.

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.

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

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 midface 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 midface 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.

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.

The only laboratory studies needed are those that would be required for anesthesia. This decision is determined individually based on a patient's past medical history and the type of anesthesia being used.

The procedure may be performed under general anesthesia or IV sedation with local anesthesia. General anesthesia is often preferred because of the length of the procedure and the delicate dissection required to prevent injury to branches of the facial nerve.

Postoperative instructions are provided to the patient prior to the procedure so that any questions can be discussed prior to surgery.

Preoperative photographs are taken for documentation and to review with the patient. The photographs are used for reference and guidance throughout the procedure.

While in the holding area, the incisions are marked on the patient in an upright position. Marking the patient in the upright position is especially important when planning the submental incision, which may be visible if it extends too far laterally. After marking the incisions, the hair is taped to keep it out of the wounds during the procedure.

A standard facelift incision is used; many variations exist. The authors use an incision that begins in the temporal hairline and is in vertical alignment with the preauricular crease. The incision then extends behind the tragus (in women) or in the preauricular crease (in men) and passes around the lobule at its junction with the face. It then extends just lateral to the postauricular sulcus and onto the conchal bowl for a few millimeters. The incision then curves in a horizontal fashion into the hair at a level that is covered by the pinna to hide the scar. Great care is taken to plan incisions so that the postauricular and temple hairline is not altered. Patients should be able to wear hairstyles of any length after a facelift.

If extensive excess skin is present in the neck, the posterior incision may be altered to parallel the postauricular hairline, beveling the incision across the hairs so that hair growth grows through the incision. This allows for more skin excision and improves the result in these very difficult necks.

A 2-cm incision is made in the submental crease, and the submental dissection proceeds in a subcutaneous plane directly above the platysma in the midportion of the neck. This dissection extends laterally 5-6 cm and eventually communicates with the dissection from the periauricular incisions. A standard corset platysmaplasty may be performed if significant platysma banding exists or if added neck definition is necessary. A corset platysmaplasty involves removal of the redundant medial platysma from the mentum to the level of the hyoid bone. Removal of midline submental fat is often included with the muscle resection. The fresh edges of the platysma are then reapproximated in the midline using buried nonabsorbable sutures to tighten the platysma sling in the neck in a fashion similar to the tightening of the laces on a corset.

(A cadaveric study by Jacono and Malone indicated that when midline corset platysmaplasty is performed concomitantly with deep-plane rhytidectomy, the ability to lift the neck, jawline, and midface becomes significantly limited. The investigators found that when, concomitant with the platysmaplasty procedure, deep-plane rhytidectomy was performed preauricularly in the vertical dimension, the amount of lift was reduced by 40.5%; when the procedure was performed postauricularly, lift was reduced by 23.9%.[5] )

The periauricular incisions are made, and the skin is elevated in a subcutaneous plane. Great care is taken to avoid injury to the great auricular nerve in the neck. A small amount of subcutaneous fat is left on the skin flap to avoid excessive thinning of the flap. The dissection proceeds above the platysma to connect with the previous submental dissection in the neck. The subcutaneous dissection in the face proceeds about 2 cm past a line drawn from the angle of the mandible to the level of the origin of the zygomaticus major and minor muscles. An incision is made in the SMAS layer that parallels this line. The SMAS is elevated gently, and the dissection proceeds from inferior to superior and lateral to medial. See the image below.

The proper plane of dissection is between the SMAS and the parotidomasseteric fascia. The parotidomasseteric fascia must remain intact to prevent injury to the branches of the facial nerve, which can be observed as they pass from the parotid gland beneath the parotidomasseteric fascia that overlies the masseter muscle. This loose plane is between the fascia on the undersurface of the platysma muscle (SMAS) and the parotidomasseteric fascia overlying the masseter muscle. The anterior extent of this dissection is the facial artery and vein. Much of this dissection can be performed bluntly with a Kitner dissector or a fingertip. The assistant always monitors the face for any evidence of facial nerve stimulation. Perform any spreading with blunt instruments in the direction of the nerve. Hemostasis is essential for adequate visualization. Do not violate the parotidomasseteric fascia during the procedure. See the images below.

The dissection is continued in this plane superiorly to a level approximately 1 cm below the zygomatic arch. In the superior aspect of the dissection, the subcutaneous dissection continues from the preauricular incision until the lateral portion of the orbicularis oculi muscle is encountered. Dissection proceeds on top of the orbicularis muscle medially and inferiorly until the origins of the zygomaticus major and minor muscles are identified (see the image below). By definition, the dissection at this point is above the SMAS. By continuing this dissection inferiorly, a connection can be safely made with the sub-SMAS dissection in the lower part of the face.

From the origin of the zygomaticus major and minor muscles, the dissection proceeds medially and stays directly on top of the fascia overlying these muscles, elevating the malar fat pad–skin complex from these deeper structures. If indicated, this dissection can extend to the melolabial fold and into the upper lip in patients with deep melolabial folds. The resulting facial flap that is elevated consists of a myocutaneous flap (platysma/skin) in the lower part of the face and a very thick subcutaneous flap with malar fat pad attached to the skin in the midface. These 2 flaps can be elevated as a unit in a superior-lateral direction to achieve improvement that appears natural in the aging changes of the lower and midface.

After absolute hemostasis is obtained, the malar fat pad is then repositioned in a posterior-superior direction perpendicular to the melolabial fold. The fat pad is sutured to the fascia overlying the malar eminence. Owsley described absorbable sutures, such as 3-0 Vicryl, as appropriate for suturing the malar fat pad to the fascia.

The edges of the SMAS flap are subsequently imbricated in a posterior-superior vector and sutured to the preauricular parotid fascia with a permanent 2-0 braided suture. In patients with a large amount of fat overlying the parotid fascia, open liposuction or direct defatting to the level of the parotid fascia is performed to avoid excess bulk in the preauricular area. The first imbrication suture is placed from the angle of the mandible to the inferior preauricular area. The SMAS flap is then imbricated superiorly in a similar direction until the flap is entirely repositioned under considerable tension. The posterior edge of the platysma in the neck is then plicated to the fascia overlying the sternocleidomastoid muscle.

Absorbable sutures are then placed between the permanent stitches to help reinforce and smooth the suture line. Absolute hemostasis is obtained. Drains may be placed, or platelet gel may be used without drains. The skin is then redraped gently and closed as in a standard facelift. Great care is taken to avoid excessive skin removal, which would create tension on the wounds and may lead to wide or unsightly scarring.

A retrospective cohort study by Schroeder et al of patients who underwent deep plane rhytidectomy with platysmaplasty found that the local employment of tranexamic acid (TXA) can lead to a significant decrease in intraoperative blood loss, postoperative drain output, and time to drain removal. In the report, 1 cc of TXA was added to every 10 cc of local anesthetic and tumescent solution. While 25% of control patients had an estimated intraoperative blood loss of less than 50 cc, blood loss below 50 cc was seen in 75% of the TXA patients.[6]

The use of drains is up to the surgeon's discretion. If used, the drains are usually removed on postoperative day 1.

Patients are dressed with a standard light-pressure facelift dressing that consists of ointment over the wounds, a nonadherent dressing, and fluffed gauze or cotton secured with a light wrap. If platelet gel is used, gauze dressings are loosely applied to the preauricular and postauricular areas and held in place with an expandable net dressing. Prior to discharge, the flaps are checked for any signs of postoperative hematoma.

The aforementioned study by Schroeder et al of deep plane rhytidectomy/platysmaplasty patients in whom TXA was used reported that on the first postoperative day, controls had a drain output of 50.4 cc, while that of the TXA patients was 14.8 cc. Moreover, 34.4% of drains were removed from the control group on postoperative day 1, versus 77.3% in the TXA group. On average, drains were removed at postoperative days 1.8 and 1.2 in the controls and TXA patients, respectively.[6]

Patients are routinely examined postoperatively on days 1, 7, 14, and 28. Patients are then examined at 6 months postoperatively and then yearly. Patients are encouraged to call if they have any problems or concerns and should be examined for any unusual problems in the healing period.

Postoperative photographs are used to document postsurgical changes.

As with any rhytidectomy (facelift) technique, postoperative hematoma may occur and should be evacuated immediately to prevent slough of the flaps and wound healing problems. Patients with hematoma usually report severe unilateral pain. Any unusual pain in the postoperative period should be investigated.

Injury to branches of the facial nerve may occur; however, this occurrence is extremely rare if the above-described anatomical planes are maintained throughout the dissection.

The incidence of wound healing problems is as much as 12 times higher in patients who smoke than in patients who do not smoke. Monitor sloughing of skin flaps closely. Usually, sloughing is treated conservatively. After healing by secondary intention has occurred, scar revision may be necessary.

With careful patient selection and proper surgical technique, patients should expect a good cosmetic result from deep plane rhytidectomy (facelift).

Long-term studies have not clearly demonstrated a significant advantage of the deep plane technique over other, more conservative rhytidectomy (facelift) techniques. However, a prospective study by Jacono et al indicated that vertical vector deep plane rhytidectomy results in long-term midface volume augmentation. Using a three-dimensional (3-D) analysis at minimum 1-year follow-up, the study, which involved 43 patients who underwent the procedure, found that each hemi-midface had gained an average of 3.2 mL in volume.[7]

The surgeon must carefully select those patients with significant malar sagging and deep melolabial folds who would most benefit from deep plane facelift. Moreover, the surgeon must be comfortable with the anatomy and somewhat longer healing times associated with the deep plane rhytidoplasty.

A study by Sand et al found that in deep plane facelifts, use of a high SMAS entry point permitted vertical tissue movement to be increased by 77.3%, and horizontal movement by 61.4%, compared with vertical and horizontal movement achieved using a standard SMAS entry point.[8]

The benefit of a deep plane rhytidectomy (facelift) is still debated and has strong advocates and detractors. Other procedures are available, such as the subperiosteal midfacelift, to address aging face changes in the midface and melolabial fold area. Surgical techniques will continue to evolve in order to find safer approaches to correct aging face changes in the midface.

The use of adjuvant therapies such as platelet gel or fibrin glue to promote hemostasis and wound healing is still debated.[9]