The ‘DEEP PLANE’ Facelift vs The ‘High SMAS’ Facelift
There is a lot of information circulating online about ‘deep plane’ versus ‘SMAS’ facelifts, and the truth is that arguments about which approach is better tend to miss the most important points that are relevant to consumers. Let’s take a look at how we got here.
FROM SUPERFICIAL TO THE DEEP PLANE
Twenty years ago, there was a surge in interest in ‘rapid-recovery’ facelifts and ‘short scar’ facelifts. Some procedures were even trademarked, and companies were formed to hire surgeons and promote the procedures – like the ‘Lifestyle Lift’ (a company which has since declared bankruptcy). This was an effort to encourage mass consumption of facelift services by leading consumers to believe that you can get a great result with a one- to two-hour facelift surgery, that you only have to pull on the skin to improve appearance, that it can be done under local anesthesia only with no anesthesia care required, and that recovery takes just a couple of days. Most of these surgeons, by the way, were not board-certified plastic surgeons.
In my earlier years in practice, I saw a large number patients who had undergone these procedures and most had extremely visible and unfavorable scars, deformity of the normal ear anatomy, and either no lasting change in facial contour or some degree of contour deformity that made them feel self-conscious. ‘Fast and cheap’ did not do them any favors. I treated all of these patients with face and neck lift surgery in a deep plane to correct the deformities, restore normal or at least near-normal anatomy and to truly rejuvenate their faces.
The failure of superficial dissection, short surgeries and ‘short scar’ approaches to create positive and youthful-appearing outcomes led to an understanding by the general public that there’s no shortcut to an aesthetically ideal face and neck lift result, and that deeper plane approaches to facial rejuvenation have the ability to create more aesthetically ideal and long-lasting enhancements of face and neck appearance.
A great face and neck lift result requires thoughtful preoperative evaluation and planning, several hours of surgery time under deep IV sedation or general anesthesia (ideally provided by a board-certified anesthesiologist), anatomic dissection and contour modification in planes deep to the skin, careful suspension of the deeper soft tissues which carry the overlying skin with them, and meticulous closure of incisions to achieve scars that do not distort normal ear anatomy and that are essentially invisible – even for patients who have short hair styles. There’s no shortcut to an aesthetically ideal and natural-appearing result.
The current ‘fast and cheap’ approach to face and neck contouring is a ‘threadlift’, where barbed sutures are introduced into the subcutaneous planes of the face in an attempt to pull on facial skin and ‘hitch it up higher’ so to speak. In my experience there are two categories of threadlift patients: those who saw no improvement or experienced a limited improvement that did not last, and those that have obvious and permanent contour deformity from this procedure.
Threadlift patients often have visible threads under the skin, contour deformity, unnatural changes in appearance and asymmetrical results. I have stopped seeing patients with unsatisfactory threadlift results as the contour deformities can be significant, they are often impossible to fully correct and require major surgical procedures that patients often cannot afford, and there usually are no detailed notes from the threadlift provider explaining exactly what was done and why. In some cases, these procedures are being performed by individuals who do not have a medical license at all (i.e. not an MD, NP, RN, etc.).
Don’t gamble on your facial appearance with a ‘fast and cheap’ approach. Once you have a distorted and unnatural appearance, whether from a surgical or a non-surgical procedure, it’s often impossible to reverse it. Find an experienced surgeon who describes the use of multiple approaches and who individualizes the surgical plan for each unique patient. Look for plastic surgery specialty training, ideally including a fellowship. You absolutely must review ‘before and after’ images taken from multiple perspectives with consistent lighting and photo composition. And be wary of surgeons who show preop images with their patients in no makeup and wearing a hospital gown on the morning of surgery, then postop photos with the patient in full makeup and even smiling.
WHY THE DEEP PLANE?
The phrase ‘deep plane’ is back in vogue in facelift surgery, and the increased use of this term is leading prospective patients to wonder if they are getting the best possible care, or their money’s worth, or both – if their plastic surgeon is not planning a ‘deep plane facelift’.
There are four important things to know about face and neck rejuvenation and ‘the deep plane’:
1. There is no single facelift procedure that this the best choice for every patient.
2. Most board-certified plastic surgeons who perform a large volume of face and neck lift surgery and who are focused on natural-appearing results are comfortable with multiple approaches to these surgeries, offer some version of a deep plane facelift, and customize their face and neck lift plan for each individual patient.
3. The ‘deep plane’ in the face is below the SMAS, and the ‘deep plane’ in the neck is below the platysma muscle. The SMAS and platysma fuse just above the jawline and are really one continuous structure. There are many procedures that involve dissection and contour adjustment below the SMAS and the platysma, and can therefore be considered ‘deep plane’ procedures.
4. The most significant factor that determines whether or not you end up with a natural-appearing, youthful, long-lasting face and neck lift result is not the specific procedure that is performed, but rather the skill and experience of the surgeon performing it. There are many potential paths to a beautiful facelift result, and when selecting a facelift surgeon for myself the most important consideration will be the surgeon, not the procedure, in which I have the most confidence.
The most basic approach to face and neck surgery is a skin-only lift. The problem with addressing the skin alone is that the skin is stretchy, and therefore unable to create dramatic and lasting positive changes to facial contour. Most experienced facial surgeons rarely perform a skin-only face and neck lift.
When you elevate the facial skin, the next layer down in the face is the SMAS, a connective tissue layer made of collagen and fat. Because collagen is structurally strong and does not stretch, the SMAS provides a very useful means of reshaping facial contour in a lasting way. The SMAS, however, is rigidly held in place to the facial bones in several locations by ‘SMAS retaining ligaments’, and these ligaments must be released in order to move the SMAS to create meaningful and aesthetically-pleasing improvements in facial contour.
Procedures that do not release the SMAS retaining ligaments, such as ‘SMAS plication’ and ‘SMAS imbrication’, where the SMAS is sutured but not dissected and mobilized (the retaining ligaments are not released), generally have very limited and sometimes no positive impact on facial shape and contour, and are not ‘deep plane’ approaches.
‘HIGH SMAS’ vs ‘DEEP PLANE’ FACELIFT SURGERY
Both of these procedures require dissection below the SMAS, and both procedures use traction on the mobilized SMAS layer to rejuvenate facial shape and appearance. During both procedures the surgeon may dissect below the platysma muscles of the neck from the lateral (ear area) facelift approach as well as medially (from an incision placed below the chin). Dramatic and lasting contour improvements can be accomplished with both procedures working in a deep plane, both above and below the jawline.
In the ‘High-SMAS’ approach, a more extensive skin dissection is performed in the cheek and a horizontal incision is made into the SMAS high on the cheek. A roughly vertical incision into the SMAS is made in front of the ear, and a triangular SMAS flap is elevated working medially towards the central face. The SMAS retaining ligaments are released so that primarily vertical traction on the SMAS lifts the nasolabial fold area, lifts the corners of the mouth and eliminates the jowls. I prefer this approach for patients with moderate midface aging who still have a relatively well-defined jawline.
In the ‘Deep Plane’ approach, a less extensive skin dissection is performed and the SMAS is entered through an oblique incision that runs along an imaginary line connecting the outer corner of the eye with the lateral angle of the jaw. Sub-SMAS dissection extends more medially both in the upper and lower cheek. I prefer this approach for patients with more advanced midface aging and who have poorly-defined jawline anatomy.
Again, during both procedures a lateral subplatysmal dissection can be performed to define and accentuate a youthful jawline laterally, and the central neck can be better defined via an incision placed below the chin which provides access to remove subplatysmal fat excess if present and to reduce the prominence of the submandibular salivary glands if necessary.
Again, the specific procedure that is performed should depend exclusively on each patient’s preoperative anatomy. There is no ‘one size fits all’ face and neck lift plan, so look for a board-certified, experienced surgeon with before and after images that give you confidence, who can provide you with a thoughtful and through preoperative evaluation and who can clearly explain to you their rational for your individualized surgical plan.