Deep-plane facelift

What it is

Surgeons call the tissue a facelift lifts beneath the skin the SMAS. Cadaver studies find a distinct SMAS layer only over the parotid gland in front of the ear and where the flat facial muscles lie; between those muscles it is thin or absent, so the "SMAS" a surgeon raises is a flap of fat, facial muscle and a thin layer of fascia (PMID 37039509, PMID 12560687).

The space beneath that flap, floored by a thin deep fascia, is the "deep plane" (PMID 36261112).

Small ligaments run through these layers and hold the face against gravity while letting it move. A lift that leaves them in place drags them upward and puts the weight of the face on the stitches; releasing them allows the surgeon to reattach the tissue higher while the support structure keeps its natural orientation, which anatomists argue should help the lift last (PMID 37747400).

A deep-plane lift works in that space: the surgeon releases the cheek (zygomatic-cutaneous) ligaments and moves skin, fat and SMAS as one composite flap (PMID 22065880, PMID 38354840). Hamra's reasoning was that skin, cheek fat and muscle sag together, so they should be lifted together (PMID 1615067).

Where it came from

• Facelifts had long done little for the fold between nose and mouth. In 1990 Hamra carried the dissection under the SMAS over the cheek muscles and past that fold, and named it the deep-plane rhytidectomy (PMID 2359803). It built on a deeper lift Skoog described in the 1970s (PMID 36261112, PMID 8554742).
• In 1992 Hamra added the muscle around the eye to the flap (composite rhytidectomy), so the neck muscle, cheek fat and lower eyelid muscle moved together with the skin (PMID 1615067). He later changed the eye-area step to stop the prolonged swelling it sometimes caused (PMID 9774027).
• Hamra then re-examined his own 1990 patients years later: the jawline lift had held, and the early improvement in the nasolabial fold had faded (PMID 12172164).
• Kamer, a facial plastic surgeon, found in his own practice that fewer deep-plane patients than SMAS patients asked for a later touch-up (a tuck): about 1 in 30 against about 1 in 9. It was a chart review, not a randomized comparison (PMID 9727459).
• In 2011 Jacono began carrying the release into the jawline and neck, the "extended deep plane", with variants for the jaw angle and the platysma muscle of the neck (PMID 22065880, PMID 30418482, PMID 35446382).
• Today most surgeons who answered a survey of the American Academy of Facial Plastic and Reconstructive Surgery perform it, and surgeons with fewer years in practice were more likely to (PMID 41251721). Among plastic surgeons tracked by their certifying board, SMAS plication and SMAS flaps remained the most common approaches (PMID 38302713).

Who it suits

• People with jowls, a blurred jawline and a deep fold beside the mouth; the extended version adds the jaw angle and the neck (PMID 2359803, PMID 30418482).
• People with neck bands and loose neck skin, when the platysma is lifted and suspended as part of the operation (PMID 35446382, PMID 39212629).
• First and second facelifts alike: the direction of lift is set for each face after the release, in primary and secondary cases (PMID 38657095).
• Asian patients: a deep-plane series reported high satisfaction and no hematoma (PMID 40183553).
• Deep plane is one of several SMAS techniques that give good results. Reviews have not shown that it gives a better midface or a longer-lasting result, and in a randomized trial deep-plane, high SMAS and plication facelifts made patients look younger by a similar amount (PMID 41100833, PMID 41061760).

How it is done

• Through incisions in front of and behind the ear, the surgeon raises a limited skin flap, enters beneath the SMAS and releases the cheek ligaments (PMID 22065880, PMID 39072376).
• The dissection stays just above the deep fascia, the layer in which the facial nerve branches run; staying in that level protects them (PMID 37036327, PMID 36261112).
• Once released, the flap is lifted in the direction the face fell. That direction differs between people and between the two sides of one face, and is more vertical in women than in men (PMID 38657095).
• In the neck, the platysma is released and fixed behind the ear (the "mastoid crevasse"), which deepens the angle under the jaw, often with tightening of the muscle under the chin (PMID 37767973, PMID 39212629).
• Variants: composite (adds the eye muscle) (PMID 1615067); a shorter-scar vertical version (PMID 22065880); limited delamination, which separates less skin from the flap (PMID 39072376).

Results and how long they last

• Patient satisfaction is high after both deep-plane and SMAS facelifts in pooled studies (PMID 40801931).
• On the operating table, extended SMAS and composite sides looked better than standard SMAS sides in a split-face study; once swelling set in the difference disappeared, and none was visible at 6 and 12 months (PMID 8942899).
• Identical twins, each operated on with a different technique including composite, were photographed for 10 years so the results could be compared side by side (PMID 19319071).
• The extended version added volume over the jaw angle and lengthened the visible jawline at about a year and a half (PMID 30418482). Neck bands, loose skin and visible glands stayed improved at 18 to 21 months with the platysma "hammock" flap (PMID 35446382).
• In a randomized trial, deep-plane, high SMAS and plication facelifts each lowered the age that lay viewers and face-age software guessed, with no difference between techniques (PMID 41061760). In a separate photo study, software read front-view photos as about 2.5 to 3 years younger after either deep-plane or SMAS lifts (PMID 42775335).
• How long it lasts: in Hamra's long-term follow-up the jawline lift held and the improvement in the fold beside the mouth faded (PMID 12172164). No named facelift technique has been shown to last longer than the others, and surveyed surgeons did not link longer-lasting results to deep plane (PMID 41100833, PMID 41251721).

Risks and how surgeons lower them

• Facial nerve: temporary weakness of a facial muscle is the main added risk of deeper work. In pooled data it followed about 1.5 in 100 composite lifts, and permanent injury did not differ between techniques (PMID 30768122).
• Surveyed surgeons reported temporary nerve weakness in 1 to 5 of every 100 cases, most often the muscle that lowers the lower lip, and more of it with deep-plane lifts and frequent gland reduction (PMID 41251721). Temporary palsy appears to rise as the dissection extends (PMID 38198817).
• How surgeons lower nerve risk: dissecting in the most superficial level of the deep fascia (PMID 37036327), finding the midface fascia and staying just above it (PMID 36261112), and taking particular care at the cheek ligaments, the inner midface and the platysma over the jaw angle (PMID 39212629).
• Bleeding under the skin (hematoma): major hematoma followed about 1 in 80 deep-plane lifts in pooled data, more than after SMAS plication (PMID 30768122). In a large multicenter series of the limited-delamination version, hematoma occurred in about 1 in 50 and a fluid collection needing a needle in about 1 in 50 (PMID 39072376).
• Any complication: about 1 in 6 deep-plane and 1 in 10 SMAS patients in pooled data; the figures come from separate studies and were not compared head to head (PMID 40801931).
• Revision: under 1 in 100 in the limited-delamination series (PMID 39072376); about 1 in 25 in the early vertical deep-plane series (PMID 22065880).

Recovery

• Swelling sets in within the first day and hides the shape of the result; the outcome is judged at 6 to 12 months (PMID 8942899).
• Early composite lifts sometimes caused prolonged swelling around the eyes; Hamra's later change to the eye-area dissection removed it (PMID 9774027).
• Shorter incisions and less skin lifting are used to shorten recovery (PMID 22065880).

Questions to ask a surgeon

• Which ligaments will you release, and how far forward? (PMID 22065880)
• What will you do in the neck: platysma, glands, fat? (PMID 39212629)
• How often do your patients have temporary facial weakness? (PMID 41251721)
• How often do your patients have a hematoma, and how do you prevent it? (PMID 30768122)
• How many of your patients ask for a touch-up? (PMID 9727459)
• May I see your results at one year and later? (PMID 8942899)

Open questions

• Longevity: no controlled study shows deep plane outlasts SMAS techniques (PMID 41100833, PMID 41251721); anatomy studies argue that full release should help it last (PMID 37747400).
• Nerve risk: pooled data link temporary injury to composite and high lateral SMAS lifts (PMID 30768122); survey data link it to deep plane (PMID 41251721).
• Evidence: most outcomes come from single-surgeon series and surgeon-rated photographs; prospective comparisons are still needed (PMID 39072376).

Terms

• Deep plane: the space under the SMAS whose floor is the deep fascia (PMID 36261112).
• SMAS: the tissue a facelift lifts under the skin: fat, facial muscle and thin fascia, a distinct layer only over the parotid gland and the flat facial muscles (PMID 37039509).
• Composite flap: skin, fat, SMAS, platysma and the eye muscle lifted as one unit (PMID 1615067).
• Extended deep plane: deep-plane release carried into the neck and jawline with platysma work (PMID 30418482).
• Zygomatic-cutaneous ligament: the cheek ligament released in the deep plane (PMID 22065880).
• Tuck: a small second tightening after a facelift (PMID 9727459).
• Mastoid crevasse: the fixation point behind the ear for the platysma in deep-plane neck lifting (PMID 37767973).
• Limited delamination: a deep-plane variant that separates less skin from the SMAS flap (PMID 39072376).

Papers