Master Techniques in Facial Rejuvenation 2

16  The Deep Plane Facelift
177
The soft tissue components of the face are the final
facet of the examination. Jowling, buccal fat, the sagging
midface and nasolabial fold, infraorbital hollowness, and
the aging neck are the focal points of the soft tissue
examination. In the majority of cases the lifting of the
surgical procedure is complemented by augmenting the
soft tissues via autologous fat or commercially prepared
fillers. The scope of this chapter is not to elaborate
on these modalities, as they are described elsewhere in
the book.
SURGICAL TECHNIQUE
Nearly all of our deep plane facelifts are performed
under intravenous sedation. Usually, these procedures
are combined with a series of other facial rejuvenation
procedures. After administration of the anesthetic, the
patient is prepped. The first step in our preparation is
a minor shaving of hair in the preauricular and post­
auricular areas. The preauricular area is shaved to enable
the “bird’s beak” incision, which extends horizontally
to the temporal hair tuft through the sideburn [73]. The
postauricular shaving is performed by noting the superior
aspect of the conchal bowl and drawing a straight line
in an inferoposterior vector from this point (Fig. 16.4).
A thorough injection of local anesthetic (an equal
mixture of 0.5% lidocaine with 1 : 200,000 epinephrine
and 0.5% bupivacaine with 1 : 200,000 epinephrine) is
then performed in the subdermal planes of dissection
bilaterally. The surgeon should note the character of the
skin and dermis during the injection, especially in revision
procedures. When performed in conjunction with other
auricular. This structure is located approximately 6.5 cm
inferior to the bony auditory canal [72].
PREOPERATIVE ASSESSMENT
Prior to the analysis of the patient’s cosmetic desires
and possibilities, a thorough history and physical exami­
nation must be performed. This is especially true for
aesthetic surgery. As an elective procedure, there can
be no excuse for an overlooked medical issue that can
compromise the outcome. General issues that should
be investigated include previous surgeries, medications,
smoking, and alcohol intake, and any coexisting medical
conditions. Specific issues to facial rejuvenation surgery
such as the use of aspirin and other nonsteroidal anti-
inflammatory medications, hypertension, and smoking
history should be thoroughly explored and explained to
the patient. In addition, there are several medical diseases
the facial plastic surgeon must respect. Obviously, any
blood dyscrasia must be evaluated with a hematologist.
Also, several connective tissue disorders, such as Ehlers-
Danlos syndrome, may compromise the result of an oth­
erwise good operation.
Perhaps of equal importance in the preoperative
assessment is the evaluation of the patient’s psyche by
the surgeon. We make a point to ascertain the patient’s
motivation for the proposed procedure(s). This is a highly
individualized approach that each surgeon must discover
for himself or herself. We cannot stress enough the impor­
tance of this evaluation and opportunity to educate the
patient on realistic expectations. No matter what the
technique nor how well it is executed, a psychologically
impaired patient will not be pleased.
The surgeon should then evaluate the nature of the
skin. Sun damage, smoking history, and Fitzpatrick type
are but a few of the skin features that must be assessed
during the preoperative consultation process. Fair skin
with a moderate amount of sun damage usually heals
best; darker skin types necessitate more caution on the
part of the surgeon. The patient should be questioned as
to his or her healing history and any preexisting medical
conditions or medications that might hinder the healing
process.
After the initial examination of the skin, we prefer to
examine the overall appearance of the face. The patient’s
ethnicity, body habitus, and age all play a role in this
initial assessment. The general proportions of the face
should be considered. The face is generally broken down
into fifths vertically, based on the width of an eye; and
thirds horizontally, as measured from the hairline to the
glabella, from the glabella to the subnasale, and from the
subnasale to the menton. Any facial asymmetries should
be noted at this time. All faces have some level of asym­
metry. This is normal and should be conveyed to the
patient, preoperatively.
The surgeon should then proceed to examine the
patient’s bony infrastructure. This is the scaffolding on
which the soft tissues of the face are suspended. The
malar prominence, mandible, and hyoid positions are all
examined and palpated. A strong bony structure to the
face is obviously the favorable situation.
Figure 16.4  The markings begin at the temporal hair tuft and through
the sideburn to the bird’s beak. The planned incision then traverses the
preauricular area, or retrotragal (not shown here), around the lobule,
and onto the posterior surface of the auricle. The incision terminates
in the postauricular hair-bearing area that has been bisected as shown.

178
MASTER TECHNIQUES IN FACIAL REJUVENATION
into the external auditory canal and behind the tragus.
Emerging from the inferior aspect of the tragus, the inci­
sion now emerges at a near 90-degree angle to the tragus
until a natural preauricular crease is encountered, where
the incision will make another 90-degree turn inferiorly
as it tracks along the preauricular crease. The incision
then gradually wraps around the lobular attachment and
slightly onto the posterior aspect of the conchal bowl as
it rises to reach the posterior take off near the superior
aspect of the conchal bowl (Fig. 16.6). Occasionally the
anterior aspect of the incision must be extended into
the temple region when the surgeon anticipates that a
significant amount of skin will be removed [80,81]. This
extension is commonly used in revision procedures and in
older patients who have extremely lax skin with multiple
fine rhytids.
The lengths of the anterior and posterior components
of the incisions are dictated by the anticipated amount
of skin mobilization and resection. The function of these
incisions is primarily to manage the dog-ears that occur
with the advancement of the flap. The lift is basically
a posterior and anterior rotation flap with a central
advancement component [82].
All incisions are made with a No. 10 blade, except
the retrotragal aspect. We prefer the use of these larger
blades because with their increased surface area the knife
stays sharper for longer periods, an important factor
when performing extensive incisions. The incision begins
at the anterior/superior aspect and traverses the retrotra­
gal portion, around the lobule, and onto the postauricu­
lar portion, where it terminates in the hairline. The initial
portion of the incision, through the sideburn, should be
procedures, the facelift is always performed last to ensure
that a compressive dressing may be placed at the termi­
nation of the case. The face and neck are then prepped
and draped in standard surgical fashion and the head is
wrapped with a sterile towel and clamped.
Our incision placement is dictated by the desire to
preserve hair and create the optimal vectors for lifting
the tissue in a natural manner. Thus, we choose to bring
the anterior and superior aspect of the incision forward,
through the sideburn hair with a gentle curve as it pro­
gresses anteriorly (Fig. 16.5). Care is taken to maintain
an adequate amount of sideburn hair that will grow over
and thus mask the scar. In order to maintain a normal hair
pattern, the preauricular tuft must not be advanced over
the level of the supraauricular sulcus [74]. By employing
a frontotemporal hairline incision, the surgeon may place
the vector of lift more superiorly than lateral. It is not a
pure vector but we feel it minimizes untoward sequelae
[33,75–77]. We agree with others that the classic incision
beginning at the superior attachment of the auricle and
tracing superior and posterior inherently shifts the hair
in an unnatural fashion and can be a stigma of facelift
surgery [74,78,79].
The postauricular incision is marked by bisecting the
superior aspect of the shaved hair, as noted from the
superior conchal bowl vector, to the inferior aspect of
the native hairline. The preauricular incision is marked
horizontally from the temporal hair tuft, through the
sideburn, now shaved, to the bird’s beak above the ear.
The incision then traverses inferiorly in a native preau­
ricular crease until the tragus is encountered. The selec­
tion of a pretragal or retrotragal incision is based on the
patient’s desire and anatomy. Either approach when care­
fully planned and executed results in an excellent result.
For the retrotragal incision, a sharp demarcation is made
Figure 16.5  The anterosuperior aspect of the incision is made. This
incision is beveled, consistent with hair-saving principles.
Figure 16.6  The postauricular incision is made slightly onto the pos­
terior aspect of the conchal bowl, out of the sulcus. This position is
due to the forward traction placed on the auricle. When released, the
incision will rest in the sulcus. The surgeon should not disrupt the
perichondrium.

16  The Deep Plane Facelift
179
performed with a beveled blade parallel to the follicles to
ensure masking hair growth during the recovery period.
The incision is beveled in accordance with accepted hair-
saving principles [83]. Further extension of this incision
superiorly, along the hairline in patients with excess skin,
should be performed without beveling as this will yield
a better postoperative scar. Once the incisions have been
performed, the skin is then elevated. The bird’s beak
area is grasped with an Adson forceps and, using sharp,
fine scissors, the skin elevation is begun. We prefer to
use a transillumination technique to ensure proper depth
of dissection. The plane of dissection is subdermal, just
inferior to the hair follicles. With the transillumination
technique, the assistant places the overhead lights onto
the skin while the operative field has no direct light (Fig.
16.7). This is in direct opposition to the commonly used
technique of bright illumination from behind the sur­
geon’s head and onto the field. Once adequate skin has
been raised, several different instruments can be used to
retract the skin. A thimble with a double prong, a variety
of rake retractors, and our preference, the Anderson bear
claw, are all acceptable retractors. The skin elevation, as
with almost all our dissection maneuvers, requires an
excellent assistant to provide countertraction. Other tech­
nical aspects worthy of mention include the dissection
over the sternocleidomastoid musculature. The fascia in
this area can be very adherent, leading to injury of the
great auricular nerve if care is not taken (Fig. 16.8) [84].
After discerning the plane, we change scissors from sharp
tipped to dull. Many surgeons will perform a blunt dis­
section of the subdermal plane, which is definitely accept­
able, but in this day and age of minimal downtimes and
the need for expedient recoveries, we have found our
technique to be less traumatic to the tissues and thus
our postoperative edema is considerably less than if we
employed the blunt dissection techniques.
The subdermal elevation is continued for approxi­
mately 4 to 5 cm from the incision points (Figs. 16.9
and 16.10). This dissection may be carried slightly more
Figure 16.7  The transillumination technique ensures proper depth of
dissection.
Figure 16.8  The postauricular skin is raised, displaying the thin flap
and adherent fascia overlying the sternocleidomastoid muscle.
Figure 16.9  The extent of skin dissection using the transillumination
technique.
anterior in the region of the malar eminence, where the
dissection turns deeper as the deep plane is raised.
In the inferior aspect of the dissection, the subdermal
plane is raised until the surgeon reaches the angle of the
mandible. At this point, a lighted retractor is used to
dissect the posterolateral portion of the platysma (Fig.
16.11). The overhead lights used for transillumination
are now removed from the field. The subdermal dissec­
tion should be relatively bloodless as long as adequate
local anesthetic has been injected and sufficient time has
transpired.
Once the edge of the platysma has been identified,
the plane can be rapidly developed with broad spreading
movements of the dissecting scissors. The preplatysma
dissection may require the use of extra-long scissors to
dissect to the midline. We try to lift all of the subdermal
fat off the muscle, leaving a clean plane of muscle at the
floor of the dissection.
We infrequently perform liposuction of the neck,
though it is a viable option in select cases. We prefer
direct excision of fat. We concur with other authors that
liposuction can lead to several postoperative issues that
are exceedingly difficult to remedy. As with many other

180
MASTER TECHNIQUES IN FACIAL REJUVENATION
arch and body. This incision, as with all others in the deep
plane technique, is performed with the No. 10 blade. The
incision into the deep plane is generally placed near the
anterior aspect of the parotid gland. By placing the inci­
sion this far forward with a curve at the superior aspect,
the frontal branch of the facial nerve is avoided in the
dissection because it is posterior and superior to the inci­
sion into the deep plane (Fig. 16.14).
The lighted retractor, preferably with nonlacerating
teeth, is used to gain a purchase of the SMAS and the sur­
geon’s wrist is turned to place the SMAS under extreme
issues in plastic surgery, it is best to underdo this portion
of the procedure than to try to attain the “perfect” result,
which can lead to drastic, difficult postoperative issues
[85,86].
After completely elevating the skin and subcutaneous
tissue from the platysma, the surgeon pays attention to
the deep plane. We prefer to enter this plane 2 to 3 cm
anterior and slightly superior to the angle of the mandible
inferiorly (Figs. 16.12 and 16.13). A line may be marked
for the incision into the deep plane from just above the
angle of the mandible to the junction of the zygomatic
Figure 16.10  The shaded area depicts the extent of the subcutaneous
dissection.
Figure 16.11  The lateral aspect of the platysma is dissected. The red
muscle is seen on the floor of this dissection.
Figure 16.12  The inferior portion of the deep plane is entered over the
masseter muscle approximately 2 to 3 cm anterior and slightly superior
to the angle of the mandible.
Figure 16.13  The deep plane is incised. The outlined portion illus­
trates the amount of tissue excised when the flap is suspended.

16  The Deep Plane Facelift
181
note the SMAS lifted up with the retractor at the roof
of the dissection while the masseteric fascia falls to the
floor, broadly displaying the deep plane (Figs. 16.16 and
16.17). Occasionally facial nerve branches can be seen
traversing this fascia (Fig. 16.18). The surgeon can take
great comfort in that as long as the masseteric fascia is
seen, the facial nerve branches are intact. Once opened,
the plane can be developed with either scissors in a
spreading fashion or with the No. 15 blade in a pushing
motion. We prefer to use the No. 10 blade to push down
the connective tissue attachments from the undersurface
of the flap (Fig. 16.19). The muscle fibers of the platysma
are usually seen on the undersurface of the flap and are
used as guide for the dissection. The blade should be
positioned so as to peel fibers from the undersurface as
opposed to using the knife from the floor of the dissec­
tion and pushing the fibers up to the undersurface of the
platysma. The surgeon must be mindful of the position
of the mandible as the dissection continues anteriorly
and inferiorly so as not to risk injury to the marginal
mandibular nerve.
tension. The assistant provides countertraction similar
to that provided when raising the skin flap. This can be
awkward for the surgeon and assistant until the move is
learned. Patience is encouraged in attaining the proper
balance of retraction between surgeon and assistant.
With the SMAS held taut by the lighted retractor and
the countertraction provided by the assistant, the plane
is incised with the No. 10 blade (Fig. 16.15). Almost
immediately after opening this plane, the surgeon will
Figure 16.14  The trajectory of the frontal branch of the facial nerve
is depicted. Note that the placement of the incision into the deep plane
is anterior to these rami and thus protects the nerve from injury.
Figure 16.15  The superior aspect of the incision is made and the flap
is raised. Note the near pure anterior vector of the incision over the
zygoma, as the incision is directly over the bone.
Figure 16.16  The deep plane has been exposed and tension, with
the lighted retractor, must be utilized to further dissect the plane. The
retractor is placed immediately superficial to the incision and elevated
away from the face. The assistant provides vital countertraction (note
the fingers of the assistant) and the plane is dissected.
Figure 16.17  With adequate traction, and countertraction, the plane
immediately shows itself.

182
MASTER TECHNIQUES IN FACIAL REJUVENATION
flap is dissected as described earlier until 1 to 2 cm below
the arch. Discerning the correct plane of dissection can be
difficult in this region and often the platysmal based flap
does not extend this far superiorly. Thus with the bulk
of the deep plane lifted by the more inferior approach
discussed earlier, this aspect of the flap is easily dissected
in the superficial plane.
Once free, the zygomaticus provides an excellent land­
mark as the surgeon continues freeing the soft tissues of
the midface anteriorly while safeguarding the facial nerve
branches deep to the muscle [47]. It is often necessary
to incise the tissue anterior to this muscle to completely
mobilize it. Superior dissection is generally avoided sec­
ondary to the persistent edema that results from surgical
manipulation in this region. This edema persists longer
than any other in the deep plane facelift and can be
most troublesome to patients. Thus we have diverged
from the composite technique as described by Hamra
[7,32,87,88]. We prefer to perform our periorbital dis­
section in the blepharoplasty component of our facial
rejuvenation. This is in contrast to others favoring the
Figure 16.18  The masseteric fascia ensures the underlying facial nerve
branches are intact.
Figure 16.19  The blade is angled superficially and the connective
tissue is pushed down from the undersurface of the flap.
Figure 16.20  Once incised, the upper portion of the deep plane is
dissected to the origin of the zygomaticus major medially.
Figure 16.21  The origin of the zygomaticus major is seen as the red
muscle in the distal aspect of the dissection.
After mobilization of the inferior aspect of the flap,
attention is then directed to the superior portion of the
dissection. With a finger, the surgeon palpates the zygo­
matic arch to ascertain the location of the notch on the
inferior aspect of this bone. With the No. 10 blade, he or
she makes an incision approximately 1 to 2 cm in front
of this landmark.
The zygomatic major muscle is the key structure to be
identified (Figs. 16.20–16.22). Often, a small, perforating
branch of the transverse facial artery will be encountered
before the zygomaticus is completely identified. This is
carefully addressed with bipolar cautery. Discerning the
zygomaticus from the lateral, inferior aspect of the orbi­
cularis is often difficult, and the surgeon should consider
the depth of the dissection to ensure proper identifica­
tion, the orbicularis being the more superficial of the
two muscles. Another option is to bypass this aspect
of the deep plane procedure and transition the flap at
this superior aspect to a superficial plane. This requires
a further release of the osseocutaneous ligaments in the
superficial versus deep plane. The inferior aspect of the

16  The Deep Plane Facelift
183
easily identifiable deep plane flap inferiorly and transition
to the superficial plane superiorly and release these liga­
ments in the safer, more superficial, plane.
As the plane elevation continues, the lighted retrac­
tor must be advanced with the advancing dissection to
maintain appropriate tension at the point of dissection.
The surgeon must retain focus on elevating the flap at the
appropriate depth. It is common to migrate superficially
as the flap is dissected anteriorly. This risks perforat­
ing the flap and limiting the tension that may be placed
upon it when suspending the fallen tissues. There is no
definitive anterior limit to the dissection. We generally
try to free the flap until the fibers of the platysma taper
medially [64].
Once raised, the surgeon may address the buccal fat
pad if necessary. We generally do not perform resection
of the buccal fat pad, but it is in the center of the field at
the end of this dissection if the surgeon chooses to alter
it. Care should be exercised here as this is deeper than
deep plane technique, where the periorbital rejuvena­
tion is incorporated into the facelift component of the
rejuvenation. Our preference to avoid dissection in the
periorbital area is shared by others [89]. Our rationale
is similar, to avoid excessive postoperative edema and
recovery periods, and the difficult issues that often arise
with periorbital manipulation. Grounded in the excellent
anatomic work of Pessa, we do not dissect superior to the
caudal margin of the orbicularis oculi so as not to disrupt
the malar septum [41,42].
When this dissection is complete, the surgeon will have
the flap raised in two sections with an intervening ridge
of adherent tissue between two well-developed planes
(Fig. 16.23). The ligamentous attachments in this area are
densely adherent. With the two well-developed portions
of the plane as a guide, the surgeon may confidently use
the No. 10 blade in a pushing fashion similar to that
done with the inferior and superior aspects of the flap
(Fig. 16.24). It is not recommended to dissect only the
superior or inferior portion of the flap and then free this
area. After dissecting the inferior plane, the surgeon may
be tempted to continue the dissection superiorly. The
surgeon should avoid this temptation because it is easy
to be led deep to the zygomaticus musculature and into
the facial nerve branches. It is by connecting the tunnels
that the surgeon may move forward with the dissection
in a safe manner. Alternatively, the surgeon can raise the
Figure 16.23  The intervening bridge of tissue separating the superior
and inferior portions of the deep plane is dissected using the push-down
technique.
Figure 16.24  The medial aspect of the deep plane is raised using sharp
dissection. Please note that the suspensory ligaments shown here must
be released for a maximum lift.
Figure 16.22  The key anatomic relationships of the deep plane dis­
section are depicted. The superior aspect of the dissection is at the
superior segment of the zygomaticus major. The zygomaticus serves as
a safe guide for the dissection as it progresses anteriorly. The inferior
aspect of the deep plane is anterior to the mandible, at the posterior
end of the platysma.

184
MASTER TECHNIQUES IN FACIAL REJUVENATION
midline binding of the muscle. The bound muscles act as
a sling to lift the submental region. If one is too aggres­
sive in binding these muscles together it can actually limit
the superior lift attained by the deep plane portion of
the lift [90].
After completing the platysmal portion of the proce­
dure, fat may then be directly excised from the under­
surface of the skin and subcutaneous flap with standard
facelift scissors or by meticulous liposuction under direct
visualization. The fat can also be removed directly off the
platysma itself. The surgeon should be aware that there
are several vessels that may be encountered when remov­
ing fat in this manner. We use both direct and submental
liposuction to remove excess fat in this area depending on
the severity of the amount of fat. We prefer, as do others,
direct lipectomy for removal of significant amounts of
fat. With the direct exposure, the surgeon may comfort­
ably remove adequate fat while maintaining the masking
properties of this fat layer [91].
The surgeon should display extreme caution in this
aspect of the case. This is not a fat-removal procedure.
Although there is a strong temptation to aggressively
utilize this technique, many patients may develop pro­
found anterior banding because the cushioning padding
of fat has been removed. At the far end of this spectrum
is the “cobra” deformity, which manifests as a deep sub­
mental concavity as a result of oversuctioned fat [85,91].
Once this deformity is created it is exceedingly difficult
to remedy.
the plane of dissection and the facial nerve branches are
at greater risk.
The submental region poses unique challenges. Some
patients may require no intervention in this region, others
need submental liposuction, and yet others benefit from
a submental incision with direct fat excision and platys­
maplasty or platysmaplasty without fat excision [80].
When performing liposuction without platysmaplasty we
create two small, 1-cm incisions within a native crease.
When combining platysmaplasty either with direct sub­
mental fat excision or liposuction, the approach is via a
2- to 3-cm incision in a natural submental crease. The
planned incision is injected with local anesthetic and the
incision is made. A small subcutaneous dissection is per­
formed until the medial aspects of the paired platysma
muscles are defined (Fig. 16.25). The medial edges of
these muscles, or bands, are completely freed and the
dissection is carried laterally to meet with the previously
undermined skin in the neck. This dissection is performed
with a headlight. There are a variety of rakes and retrac­
tors that can be utilized for this step of the procedure. We
prefer a small fine rake followed by a malleable retractor.
Again, the use of countertraction by the assistant greatly
facilitates this dissection.
After the medial aspects of the muscles are freed, the
flaccid medial components and bands are grasped with
an Allis clamp. A Kelly clamp is then placed parallel
to the excess musculature being retracted by the Allis.
This excess tissue is then sharply excised and the clamp
is released. Care should be exercised so as not to pull
on the tissues excessively with the Allis to make sure
that an excess of platysma is not removed. There is
little need for hemostasis as the clamp is released. After
the excess platysma is removed, the free ends are then
bound with buried 3-0 Prolene sutures (Fig. 16.26). This
closure should be tensionless so that when the tissue
is suspended in the superolateral vector the bound pla­
tysma muscles do not shred. The surgeon must be cau­
tious not to remove too much platysma, as the actual
mechanism of tightening the neck is from the supero­
lateral movement of the deep plane and skin, not the
Figure 16.25  The medial aspects of the paired platysma muscles are
dissected via a submental incision in a natural skin crease.
Figure 16.26  The medial edges of the trimmed platysma muscles are
bound with permanent suture.

16  The Deep Plane Facelift
185
rough and will be palpable through the overlying skin, we
will run a 4-0 or 5-0 caliber suture through these areas
to smooth them. When suspending the inferior aspects of
the flap, near the lateral edge of the platysma, the surgeon
should take care not to place excessive tension on one
side of the flap. This is to avoid difficulties in suspend­
ing the contralateral, lower region of the flap. Here the
surgeon is basically pulling against himself or herself.
When the flap suspension is complete, the surgeon will
more often note puckering at the interface of the skin flap
and deep plane. With sharp scissors, he or she should
free these regions with caution. It is possible to perforate
the deep plane flap when performing this tailoring if the
surgeon migrates deeply. This can be fixed with a 4-0
Prolene, but it is obviously best to avoid this problem
with a careful dissection technique.
The skin flap is then tailored and sutured into place.
The first step in this process is to grasp the flap and
redrape it along a superolateral vector and secure it to the
region immediately above the ear. With the tissue firmly
held with Adson forceps, a No. 11 blade is then used to
incise the skin at the point of approximation between
the flap and area superior to the auricular root. As with
draping of the deep plane flap, the primary vector should
be superior and limited by the amount of dog-ear forma­
tion anteriorly. The anterior aspect of our incision is a
more favorable vector for tissue suspension [77].
Once incised, a key suture is placed to reapproximate
the opposing edges (Fig. 16.29). At this point the surgeon
will have a dog-ear anteriorly between the suture and
the most anterior component of the incision, near the
anterior portion of the sideburn. This dog-ear is marked
and excised and the opposing skin edges are stapled or
sewn in layers with 5-0 monocryl and 6-0 Prolene (Figs.
16.30 and 16.31).
The next key suture is the postauricular tacking stitch.
The skin flap is grasped in the postauricular region and
draped in an almost direct superior vector. As opposed
to the preauricular tacking suture, a No. 11 blade is not
needed to incise the flap. In actuality, the surgeon is grasp­
ing tissue that previously lay at the level near the lobule
and advancing it to the turnoff point of the postauricular
incision as it turns posterior into the hairline. This will
Before closure, the surgeon should reassess the area
to make sure a smooth contour surface exists with no
irregularities. A suction drain is then placed in the prepla­
tysmal plane and suspension of the flaps is begun.
The drain serves two purposes. The first is to limit
postoperative hematoma formation. Although no drain
prevents or resolves a true hematoma, a drain can mini­
mize the extent of the complication. The other purpose
of the drain is to evacuate normal fluid that accumulates
under the flap and prolongs the healing process. While
these collections are generally physiologically benign, in
this era a premium is placed on a speedy recovery and
return to normal activity. With the drain, this recovery
is hastened.
At this point, the lateral aspect of the deep plane flap is
grasped and pulled in a superolateral vector and sutured
in the preauricular area (Fig. 16.27). The surgeon should
attempt to move the flap as superior as possible and
avoid a lateral pull, as that leads to the “operated look”
dreaded by surgeon and patient alike. When suspending
the deep plane, the surgeon should minimize tension. If
not, the SMAS will elongate over time and the improve­
ment will be gradually lost [92].
As desirable as a purely vertical vector is in facelifting,
when oblique traction is applied to the lateral face the
distortions that are produced with a purely vertical lift
are minimized, such as crowding of tissue at the lateral
orbital rim [27]. The superior vector is usually limited
with a dog-ear of the deep plane and skin flaps anteriorly.
The flap is then sutured in place with buried 3-0 Prolene
sutures. We choose Prolene less for its permanent effect
than for its excellent biocompatibility and inert nature.
We have rarely had any of our deep Prolene sutures split.
Infrequently, we need to incise the posterior aspect
of the deep plane flap to redrape it behind the ear to
the mastoid tip. The suture suspensions track from the
mastoid tip to the superoanterior aspect of the flap near
the zygomatic arch (Fig. 16.28). In the region of the
zygomatic arch we often use a smaller caliber suture, 4-0
or 5-0 Prolene, depending on the nature of the flap and
overlying skin. If the tissue lying between the sutures is
Figure 16.27  The deep plane flap is grasped near the angle of the
mandible and using a near vertical vector is suspended superiorly with
a buried 3-0 Prolene suture.
Figure 16.28  The last of several suspension sutures is placed.

186
MASTER TECHNIQUES IN FACIAL REJUVENATION
with Adson forceps in front of the ear, and using the
inferior conchal bowl as a guide the surgeon cuts the skin
with scissors to the area immediately inferior to the tragus.
The preauricular skin is then tailored, with this mark
as a guide (Fig. 16.33). When excising the excess skin
the surgeon should leave a 2- to 3-mm gap between the
opposing skin edges (Fig. 16.34) to compensate for the
inherent residual laxity that causes a sheared appear­
ance to the scar as it heals. Obviously, care must also be
taken to avoid leaving too large a gap and thus creating
a situation of extreme tension at the closure site, espe­
cially at the lobule where a satyr ear may result. The
Figure 16.29  The first skin suspension suture is placed. The skin flap
is suspended in a superolateral vector. The flap is incised with a No. 11
blade as it is held in the desired location with Adson forceps.
Figure 16.30  The anterior dog-ear is excised.
Figure 16.31  The anterior aspect of the incision is closed with staples.
Figure 16.32  The posterior dog-ear is excised. This area is closed in
a similar fashion to the anterior dog-ear.
Figure 16.33  The preauricular excess skin is removed. Note the
guiding cut at the inferior aspect of the tragus.
leave a dog-ear in the hair-bearing area. This is marked,
excised, and stapled in an identical fashion to the preau­
ricular dog-ear (Fig. 16.32).
At this juncture, the fashioning of the preauricular
incision is performed. The surgeon should grasp the skin

16  The Deep Plane Facelift
187
If a retrotragal incision was created, the tragal area is
secured first. This is performed by assessing the amount
of skin required to close the retrotragal incision under
no tension, as any tension will pull the tragus anteriorly
during the wound-maturation phase. Once the proper
amount of skin is known, a pretragal crease is recreated
by slightly thinning the area on the flap where the new
crease will lie. After very gentle thinning, a 5-0 monocryl
is used as a tacking suture to secure the skin flap to the
base of the tragal cartilage. The skin is then closed with
single 6-0 Prolene sutures around the tragus and with a
running locking 6-0 Prolene above and below the tragus.
If a submental approach was performed, this incision is
closed with interrupted vertical mattress sutures.
After closure is complete, the wounds are coated with
antibiotic ointment and a nonadherent Telfa dressing is
placed over the incisions. The wounds are then dressed
in a light compressive dressing of fluffed cotton and
Kerlix. Figs. 16.38 and 16.39 demonstrate preoperative
and postoperative photographs of individuals who have
undergone deep plane facelift procedures.
POSTOPERATIVE CARE
The patient undergoing facial rejuvenation is very con­
cerned about the night of his or her surgery. By keeping
the patient within our facility, with our personnel, the
patient is reassured of attendant care in a manner not
possible in a hospital. In addition, even though it is cer­
tainly acceptable to send the patient home, or to a hotel,
skin closure is performed with 5-0 Prolene sutures in
a running, locking fashion that is begun at the lobular
attachment with a vertical mattress suture (Fig. 16.35).
Another vertical mattress suture is placed adjacent to this
one and a running, locking suture is performed on the
posterior aspect of the closure (Figs. 16.36 and 16.37).
Figure 16.34  A 2- to 3-mm gap is ideal to compensate for postopera­
tive skin laxity.
Figure 16.35  The preauricular closure is begun with a vertical mat­
tress suture and completed in a running, locking fashion.
Figure 16.36  The complete closure. The postauricular incision is
closed in an identical manner to the preauricular portion, starting with
a vertical mattress and completed in a running, locking fashion.
Figure 16.37  The complete closure is shown with the deeper suspen­
sion sutures.

188
MASTER TECHNIQUES IN FACIAL REJUVENATION
After this period, depending on the patient’s healing, we
continue taping only at night for up to a month. We
advise patients that they can return to nonstrenuous work
within 1 week, though most patients choose to take 2
weeks off. The patient is also instructed that he or she
may comfortably go out in public within 10 to 14 days.
Strenuous activity may slowly commence 2 to 3 weeks
from the procedure.
COMPLICATIONS
The most common risk with this technique, as with all
facelifts, is hematoma formation. Hematomas predomi­
nantly occur within the first 6 to 12 hours after the
procedure, thus our preference for keeping our patients
on the night of the procedure with trained personnel, if a
problem arises it is optimal to have the facilities to deal
with such an issue immediately.
The following morning all drains are removed and a
lighter compression dressing is placed. This lighter dress­
ing is removed by the patient, at home, on the following
day. The patient is instructed to maintain meticulous
care of the incisions with 50% hydrogen peroxide and
antibiotic ointment. On postoperative day 3 or 4, the
preauricular and submental sutures are removed and the
incisions are immediately taped with flesh-tone tape after
the application of an adhesive. The postauricular sutures
and staples are removed 1 week after the surgery, fol­
lowed by the application of tape and adhesive. The tape
remains on the incisions 24 hours a day for 1 week.
A
B
C
D
Figure 16.38  Preoperative frontal (A) and lateral (C) views of a 67-year-old woman. Postoperative frontal (B) and lateral (D) views of a 67-year-old
woman after a tricophytic browlift, upper lid blepharoplasty, transconjunctival lower lid blepharoplasty with skin pinch, and deep plane facelift.

16  The Deep Plane Facelift
189
our technique. Infection is also very rare, secondary to the
excellent vascular supply to the face as a whole. Hyper­
trophic scarring in our practice is most commonly seen
in the postauricular region and is managed with monthly
Kenalog-10 injections and massage. These scars usually
resolve given the appropriate time.
The most feared complication of the deep plane tech­
nique is facial nerve paralysis. In the senior author’s prac­
tice of a decade with the technique described herein,
no permanent nerve injuries have occurred (unpublished
data). Kamer has recently reported no facial nerve inju­
ries in over 2600 cases with a similar deep plane tech­
nique [101]. Reports in the literature range from 0.4% to
2.6% for various techniques [47,96,102–107]. Although
it seems counterintuitive, we feel that dissecting in a
within our facility. The only factor proven to increase the
incidence of hematoma is preoperative hypertension [93].
The incidence of hematomas in facelift surgery has been
reported to be between 0.3% and 15% with a variety of
operative techniques [93–99]. For deep plane techniques,
the incidence has been reported at 2.2% for major hema­
tomas and 6.65% for minor hematomas. It should be
noted that none of the hematomas in this report were in
the deep plane, thus confirming the premise that this is
a relatively avascular plane [99]. Left untreated, a facial
hematoma can have catastrophic consequences [100].
The damage incurred with hematomas is greatly lessened
when the issue is promptly noted and treated.
Other, less common issues may also occur. Skin loss is
exceedingly rare with the enhanced vascularity seen with
A
B
C
D
Figure 16.39  Preoperative frontal (A) and lateral (C) views of a 48-year-old woman. Postoperative frontal (B) and lateral (D) views of the same
48-year-old woman after a coronal browlift, upper lid blepharoplasty, transconjunctival lower lid blepharoplasty with skin pinch, and deep plane
facelift.

190
MASTER TECHNIQUES IN FACIAL REJUVENATION
Subplatysmal dissection inferior to the mandible has
also sparked our interest and we are gradually imple­
menting them into our armamentarium [114]. Other
techniques employed for lower third enhancement can
be found in the excellent work done by Dr. Feldman
[115]. Our approach to facelifting, as with our overall
practice approach, is the attainment of a natural result via
conservative means. We seek to provide the patient with
a lasting, natural result where the observer cannot detect
that an operation has occurred. The deep plane technique
may not be considered conservative in some quarters but
with the technique performed as described herein, we feel
it to be exceedingly safe and well tolerated by the patient.
Various modalities have been recommended to address,
and complement, trouble areas of facial rejuvenation such
as the nasolabial folds. Fat grafting, soft tissue fillers, and
alloplastic implants are all adjunctive methods that may
be utilized by the surgeon to attain the optimal result. It
is beyond the scope of this chapter to discuss, in detail,
each of these methods.
We have followed with great interest the progress of the
invasive, minimally invasive, and endoscopic approaches
to midfacial rejuvenation [34,116–118]. We feel, as do
others, that an ideal midfacial rejuvenation procedure has
yet to be determined (see Figs. 16.38 and 16.39).
References available online at expertconsult.com.
R E F E R E N C E S
39. Jacono AA, Ransom ER. Anatomic predictors of unsatisfactory
outcomes in surgical rejuvenation of the midface. JAMA Facial
Plast Surg 2013;15(2):101–9.
64. Shah AR, Rosenberg D. Defining the facial extent of the platysma
muscle. Arch Facial Plast Surg 2009;11(6):405–8.
75. Hamra ST. A study of the long-term effect of malar fat reposition­
ing in face lift surgery: short-term success but long-term failure.
Plast Reconstr Surg 2002;110(3):940–51.
76. Hamra ST. Frequent face lift sequelae. Hollow eyes and the
lateral sweep: cause and repair. Plast Reconstr Surg 1998;102:
1658–66.
90. Jacono AA, Malone MH. The effect of midline corset platysma­
plasty on degree of face-lift falp elevation during concomitant
deep-plane face-lift. JAMA Facial Plast Surg 2016;18(3):183.
101. Kamer FM. Evolution of my facelift technique. American Academy
of Facial Plastic and Reconstructive Surgery Annual Fall Meeting.
New York 2004; NY.
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Observational results and evolution of technique. Plast Rencostr
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109. Hidalgo DA. Discussion: Updating the concepts on neck lift and
lower third of the face. Plast Reconstr Surg 2012;130:206.
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lateral approach to the neck: An Alternative to submental incision
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deeper plane is safer than other procedures. The surgical
planes are very well delineated using our technique. It is
not uncommon to notice a mild paresis within the first
6 hours after surgery. Calm should be maintained as this
is most likely secondary to the use of local anesthesia.
If the paresis exists beyond this time, patience must be
practiced by both the physician and the patient, as the
issue will likely resolve, albeit slowly.
The most common nerve injury is iatrogenic trauma to
the greater auricular nerve [107]. Of the motor branches
of the facial nerve, the frontal and marginal branches are
at the greatest risk for a functional deficit. This is due to
the lack of a significant anastomotic network [47]. For
the deep plane and subsequent composite techniques, the
reported rates of facial nerve injuries were 0.99% and
0%, respectively, with no permanent weakness [69].
FUTURE CONSIDERATIONS
Since the first edition of this text there have been several
excellent reviews on both the longevity and the tech­
niques of face lifting [108–110].
Long-standing improvement in the midface continues
to be an elusive goal for the facial cosmetic surgeon.
It has been found that after 12 years the improvement
in the jawline is superior to that found in midface, as
noted by improvement in the nasolabial fold. It should
be noted in this report that the sample size was small,
20 patients, and that all patients were pleased with their
results. Within this field of surgery patient satisfaction
must be recognized and honored [111,112].
We would suggest that the issues with the midface
should not be considered a technical fault, but merely
that the patient does continue to age and that different
components of the face age differently. An improvement
that lasts for years should not be dismissed in this realm
of surgery, especially with patients’ understanding that
they will continue to age and that we have an arsenal of
techniques to deal with aging after the original procedure.
We feel our techniques minimize the common sequelae of
the standard facelift [33,76].
Our general approach to the midface has evolved to
be more of volume than lifting. It is with this compre­
hensive approach to the various aspects of aging, ptosis
soft tissue, and bony resorption, that our results have
continued to improve. To minimize the “lateral sweep,”
we prefer a prehairline incision in the temple region to
make the vector more vertical [29,76].
We have discussed the subperiosteal and composite
techniques previously in this chapter. The benefits of
approaching the midface through the lower lid must be
weighed against the morbidity incurred [113].

16  The Deep Plane Facelift 190.e1
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92. Har-Shai Y, Bodner SR, Egozy-Golan D, et al. Mechanical prop­
erties and microstructure of the superficial musculoaponeurotic
system. Plast Reconstr Surg 1996;98:59–70.
93. Straith R, Raghava R, Hipps C. The study of hematomas in 500
consecutive face lifts. Plast Reconstr Surg 1977;59:694–8.
94. Larrabee WF Jr, Ridenour BD. Rhytidectomy: Technique and
complications. Am J Otolaryngol 1992;13:1–15.
95. Rees TD, Aston SJ. Complications of rhytidectomy. Clin Plast
Surg 1978;5:109–19.
96. Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast
Surg 1983;10:543–62.
97. Perkins SW, Williams JD, Macdonald K, Robinson EB. Prevention
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98. Adamson P, Moran M. Complications of cervicofacial rhytidec­
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99. Kamer FM, Song AU. Hematoma formation in deep plane rhyt­
idectomy. Arch Facial Plast Surg 2000;2:240–2.
100. Rees TD, Barone CM, Valauri FA, et al. Hematomas requiring
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101. Kamer FM. Evolution of my facelift technique. American Academy
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102. Baker TJ, Gordon HL. Complications of rhytidectomy. Plast
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103. Cohen SR, Webster RC. Primary rhytidectomy—complications of
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105. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year experi­
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191
INTRODUCTION
The gradual transformation of the aging face culminates
in predictable changes in the surface topography and
anatomical relationships of facial subunits. The morpho­
genesis affects individuals on a variable time course, as
each person has a unique underlying bone structure and
genetic predisposition. The progression of facial aging is
therefore best evaluated on an individual basis, irrespec­
tive of chronological age. There are innumerable findings
associated with facial aging; however, the consequences
of volume depletion and gravitational tissue descent are
the most germane to the rhytidectomy surgeon. Under­
standing and addressing these processes with a compre­
hensive treatment plan is essential to restore a natural
rejuvenated appearance with long-lasting results.
ANATOMY AND AGING PATHOPHYSIOLOGY
WITH SURGICAL IMPLICATIONS
Midfacial Aging
A volumized face is the hallmark of youth. The “baby
face” of infancy is characterized by full round cheeks
and is essentially devoid of any recognizable underly­
ing skeletal structure. During development into adult­
hood, the face progressively reveals a relative increasing
prominence of bony structures and decreasing of the
once omnipotent soft tissue structures. One noticeable
change during maturation is a decrease in the volume of
the inferior midface (centered around the nasal ala) that
characterizes the “chubby cheeks” of childhood. This
leads the way to the heart-shaped face of young adult­
hood [1]. Most noticeable at this stage is volumization
and fullness over the zygoma body tapering to a relative
concavity in the perioral region, often referred to as an
Ogee Curve.
With aging, the prominence over the malar region
flattens, and diminishing volume is most appreciable in
the upper and lateral midface. Midface volume defla­
tion decreases the malar prominence, hollows the sub­
zygomatic areas, and deepens the lower eyelid cheek
junction. Concomitant with these deflationary changes
is an increase in the volume of the inferior midface in
the perialar region, and a widening of the midfacial
tissues just lateral to the nasolabial folds is noticed (Fig.
17.1). The heart shape face of youth therefore becomes
inverted, taking on the shape of a square or an inverted
triangle. Cadaveric studies have shown that the face is
comprised of many discrete fat compartments [2]. With
age, increased tissue in the inferior midface has been dem­
onstrated in magnetic resonance imaging (MRI) studies
comparing faces in their thirties with those in their sixties.
These MRI studies of the medial cheek fat compartment
have suggested that both inferior redistribution of fat
and potential fat hypertrophy are plausible reasons for
widening of the inferior midface and deepening of the
nasolabial folds in older patients [3,4].
Photographic and surface anatomy studies have sup­
ported ptosis of the overhanging cheek mass as the
primary causative agent in widening of the lower midface
with aging [4]. The stigmata of midfacial aging were
compared between photographs of a patient in an upright
versus supine position, and provide a compelling visual
demonstration of the role that gravity plays in periorbital
and midfacial aging. This study demonstrated improve­
ment in characteristic manifestations of midfacial aging,
including tear trough, cheek volume, and nasolabial
folds, when comparing the upright photograph with the
supine photograph of the same patient [5]. Gravitational
pull results in descent of the facial soft tissue, thereby
creating a relative volume increase in the inferior aspect
of the soft tissue compartment. This further supports the
role of ptosis in the morphogenesis of midface aging.
In addition to soft tissue changes, degenerative changes
occur in the midfacial skeleton. Shaw et al. demonstrated
resorption of the zygomatico-maxillary complex when
comparing computed tomography scans of those in their
thirties with others in their fifties and sixties [6]. There
was a statistically significant derotation or inward rota­
tion on lateral projection of the maxilla of six degrees
that was statistically significant. Quantitatively, this small
bony change between these age groups accounts for a
minority of the midfacial volume change.
These anatomic studies strongly support reposition­
ing of ptotic midfacial tissues as a primary modality for
midface rejuvenation and revolumization. This can be
accomplished with the deep plane procedure and its mod­
ifications described later. Patients with more significant
facial atrophy or thin faces may require volume supple­
mentation with fat grafting or injectable fillers, as there
is insufficient volume reservoir to reposition. One excep­
tion is the lower eyelid cheek junction, where progressive
volume loss exposes the bony architecture of the inferior
orbital rim. This requires volumization in all cases, either
with a fat transposition lower blepharoplasty, autologous
C H A P T E R 17 
Deep Plane Rhytidectomy
Modifications
Andrew A. Jacono, MD, FACS and Melanie H. Malone, MD

192
MASTER TECHNIQUES IN FACIAL REJUVENATION
fat grafting, or injectable fillers. Treatment of the lid-
cheek junction is beyond the scope of this chapter.
The malar region is not one confluent soft tissue mass,
but is a conglomeration of individual fat compartments
separated by fascial septa. Rohrich and Pessa [7] have
defined the cheek fat into malar and nasolabial fat com­
partments. The malar fat pad has a medial, middle, and
lateral anatomic division. These fat pads are tethered
in place by the zygomatic cutaneous ligament, a strong
dense fascial attachment from the periosteum to the soft
tissues of the midface [8].
Biomechanical studies have shown that the zygomati­
cocutaneous ligament is the strongest of all of the facial
ligaments, elongating by a mere 9 mm [9]. Mobilization
and elevation of the malar fat pad therefore requires divi­
sion of this ligament. The nasolabial fat compartment,
which exists just lateral to the nasolabial fold, is the most
medial of the fat compartments, and is also tethered by
fascial attachments to the zygomaticus major muscle.
These attachments are released along the plane super­
ficial to the zygomaticus major and minor until reaching
the nasolabial fold medially overlying the maxilla. This
has been defined as the premaxillary space, and a dense
maxillary ligament that tethers the midface is bluntly dis­
sected to further release the midface [10].
The deep plane rhytidectomy rejuvenates the deflated
upper midface by releasing the ligamentous attachments
noted previously, and repositioning the ptotic fullness of
the inferior and medial midface to its former position on
the malar prominence. In this model, the malar region
is revolumized by vertically repositioning the midfacial
fat compartments while simultaneously decreasing the
presence of the excessive inferior midfacial tissue [11]
(Fig. 17.2). In traditional superficial musculoaponeurotic
system (SMAS) flap and SMAS plication procedures very
limited or no dissection is performed in the midface,
and the zygomaticocutaneous ligament remains unin­
terrupted. Gassner et al. [12] have shown in histologic
studies that the SMAS does not exist in the midface
medial to the lateral aspect of the zygomaticus muscula­
ture. For this reason, SMAS flap and superficial plication
rhytidectomy techniques are plagued by failure in the
midface because traction on the SMAS does not mobilize
the midface soft tissue structures [2].
In deep plane rhytidectomy, the vector of suspension of
the composite flap should be vertical oblique to maximize
revolumization of the midface. The individual’s anatomy
will dictate the exact angle. On average, this angle
approaches 60 degrees in most patients. When examining
the vectors of redraping in over 300 patients, this angle
varies from the upper 40s to 70 degrees. Still, the angle
Figure 17.1  With midface descent, notice the increase in the volume
of the inferior midface around the perialar region with widening of the
midfacial tissues just lateral to the nasolabial folds.
Release of
zygomatic
ligaments and
repositioning
of cheek fat
vertically
Inferior medial cheek fullness
created by ptotic medial, middle,
and lateral cheek fat compartments
Malar region revolumized
by repositioning cheek fat,
not by adding volume
Figure 17.2  The deep plane facelift revolumizes the midface by repositioning the midfacial cheek fat compartments after lysing the tethering
zygomatic ligaments that limit their motion, thus reducing the width of the inferior and medial midface.

17  Deep Plane Rhytidectomy Modifications
193
point to be on average 5 cm lateral to the symphysis in
our examination of 108 patients, which would restrict
skin redraping of the neck 5 cm posterior to the pogo­
nion [22].
THE DEEP PLANE RHYTIDECTOMY
The deep plane rhytidectomy was first described by Hamra
[23]. Unlike SMAS rhytidectomy, it does not delaminate
the skin from the SMAS in a biplanar fashion. Deep plane
surgery elevates the facial tissues in a sub-SMAS plane,
creating a composite flap of skin, subcutaneous fat, and
SMAS in the lower face, above the margin of the man­
dible but below the cheek. Because the SMAS is tenuous
in the midface, the flap in the upper cheek is developed by
lysing the zygomatic cutaneous ligaments and elevating
the facelift flap off the surface of the zygomaticus mus­
culature. This creates a flap that is a composite of skin
and the malar fat pad. The upper and lower composite
flaps are then connected. Hamra’s deep plane facelift does
not elevate the platysma below the angle of the mandible
into the neck. Neck rejuvenation is accomplished with a
midline platysmal plication through a submental incision,
along with a plication of the lateral platysma to the SCM
muscle and mastoid fascia, creating a corset in the neck.
Modifications of the Deep Plane Rhytidectomy
What follows is a description of the surgical technique
for our modification of the deep plane rhytidectomy. The
deep plane is entered after the skin is elevated in the
subcutaneous plane to a line drawn from the angle of the
mandible to the lateral canthus (Fig. 17.3). While we lyse
the zygomatic-cutaneous ligaments similar to Hamra, we
have incorporated more extensive release of the facial-
retaining ligaments to allow for greater face and neck
redraping (Fig. 17.4). These include the ligamentous
is always more vertical than an exact superolateral vector
of 45 degrees [13]. Volumetric analysis with a 23-month
follow-up has shown that patients gain 3.2 cc of volume
in each hemi midface following vertical vector deep plane
rhytidectomy as a result of adequate repositioning of the
ptotic cheek fat compartments [14]. There is no statistical
difference between the cheek volume gain from vertical
vector deep plane rhytidectomy and that achieved 16
months after 10 cc of autologous fat transfer per cheek
for midfacial rejuvenation [15].
Jawline and Neck
Just below the subcutaneous fat layer of the face exists
the SMAS, a dense fibrofatty layer originally described
by Mitz and Peyronie [16]. The SMAS is contiguous
with the platysma in the neck, and the junction between
the two exists high in the cheek, not along the margin
of the mandible. The platysma has been shown in sur­
gical dissection of over 70 patients during deep plane
rhytidectomy to exist 4 cm above the angle of the jaw
along a line drawn between the lateral canthus and the
mandibular angle, thereby occupying 57% of the face
[17]. The SMAS and platysma in the face are held to
the deeper facial structures with masseteric cutaneous
ligaments that extend from the masseter muscle, through
the SMAS/platysma, to the skin. With aging, gravitational
weakening of these ligaments allows the SMAS to slide
over the masseter and the SMAS becomes redundant, and
jowls form. To completely release these ligaments, dissec­
tion must continue in the sub-SMAS plane to the anterior
border of the masseter [18].
In the neck, vertical descent of the platysma that was
once positioned in the face creates redundant platysma in
the neck. This, along with degeneration of the platysma,
creates vertical cording or banding that is often described
as a “turkey gobbler deformity.” Similar to the retaining
ligaments in the midface, retaining ligaments also exist
in the neck, tethering the platysma to the deep investing
fascia [19]. These cervical-retaining ligaments restrict the
ability to mobilize and redrape the platysma, limiting
rejuvenation of the neck. The retaining ligaments of the
neck are reproducibly found along the posterior border of
the platysma at its junction with the sternocleidomastoid
(SCM) muscle, along the anterior inferior portion of the
parotid gland, and along the posterior body of the man­
dible [19,20]. Extending subplatysmal dissection below
the angle of the mandible with a lateral platysmal dissec­
tion to release the cervical retaining ligaments allows for
improved rejuvenation of the neck [11,21].
In patients with more significant neck skin redundancy,
the mandibular ligaments may tether the skin at the man­
dibular border, preventing anterior submental skin tight­
ening and necessitating release. The tethering effect of the
mandibular ligaments is variable and depends upon their
elasticity and position. In some patients, the mandibular
ligaments have greater flexibility or elasticity and their
tethering effect is less significant. They have the greatest
distensibility of all the facial-retaining ligaments in bio­
mechanical studies [9]. Additionally, the further posterior
the ligament is displaced from the symphysis, the greater
tethering effect it has in the neck. We have noted this
Anterior limit
of deep plane
dissection is
the facial
aorta
Sternocleidomastoid muscle
Incision
Entrance point
to deep plane
dissection
Extent of subcutaneous
undermining
Extent of deep plane
dissection
Figure 17.3  Diagrammatic representation of the planes of dissection
of the deep plane facelift, with deep plane entry point from the angle of
the mandible to the lateral canthus, and in our modification extended
for 5 cm below the angle of the mandible.

194
MASTER TECHNIQUES IN FACIAL REJUVENATION
attachments of the medial aspects of the zygomaticus
major, the anterior extensions of the masseteric cutane­
ous ligaments, and the mandibular cutaneous ligaments.
In addition, we have extended the deep plane dissection
below the angle of the mandible inferiorly. The platysma
is elevated from its fascial attachments to the SCM muscle
and inferior body of the mandible 5 cm inferiorly into
the neck. This releases the cervical-retaining ligaments
that limit platysma motion during surgery, allowing for
greater platysma redraping. This approach can limit the
need to open the neck during rhytidectomy in a major­
ity of cases. There are specific indications for opening
the neck, and treating the platysma and subplatysmal
contents. Another modification we discuss is the method
and vectors of suspension we employ once the deep plane
and tendinous structures are released.
Surgical Technique
Preoperative Marking
The patient is positioned upright preoperatively and
important landmarks are drawn with a marking pen (Fig.
17.5). The path of the temporal branch of the facial
nerve is marked beginning at the root of the ear lobule,
traversing at a point halfway between the lateral canthus
and tragus, and ending approximately 1.5 cm from the
lateral brow. Next the deep plane entry point is marked
as a line extending from the angle of the mandible to the
lateral canthus. A horizontal line is drawn across the neck
at the level of the cricoid to mark the minimal inferior
extent of neck skin elevation. The perimandibular skin
is mobilized to identify where the mandibular ligament
tethers the perijowl and submental neck skin, and this is
marked (Fig. 17.6). A submental incision is marked in the
submental crease. Incision lines are then drawn beginning
Zygomatic-
retaining
ligament
Cervical-retaining
ligaments
Masseteric
cutaneous ligament
Mandibular-
retaining
ligament
Zygomaticus muscle ligamentous
attachments to skin and
maxillary ligaments
Figure 17.4  Ligamentous attachments released in the extended deep
plane facelift include the zygomatic cutaneous ligaments, the maxillary
ligaments, the anterior extensions of the masseteric cutaneous liga­
ments, the cervical-retaining ligaments, and the mandibular cutaneous
ligaments.
Figure 17.5  Important landmarks drawn preoperatively include the
trajectory of the temporal branch of the facial nerve, the deep plane
entry point, incision lines, and inferior extent of neck skin elevation.
Figure 17.6  The mandibular ligament restricts motion of the perijowl
and submental neck skin, and is marked by grasping the skin and feeling
its tethered points.

17  Deep Plane Rhytidectomy Modifications
195
the helix appear unnaturally wide. It should be placed
at the natural highlight that reflects the apparent width
of the helical crus. It should then traverse along the
posterior edge of the tragus, but not on its inner surface
as this can create an unnatural folding of the cheek skin
that blunts the tragus and can be a tell-tale sign of a
facelift incision. A small step in the incision is placed
at the inferior tragus to preserve the natural depression
at the intertragic incisure (Fig. 17.8). Around the earlobe,
the incision should continue 2 mm inferior to the lobule
cheek junction to preserve the natural sulcus between
in the anterior temporal hairline, typically at the height
of the lateral brow. This incision follows around the
temporal tuft and into the hairless recess between the
sideburn and helical root, turning downward into the
preauricular crease, paralleling the curve of the helical
margin and approximately at the width of the crus of the
helix. This incision is similar to that described by other
authors with several minor modifications [24]. In the
majority of patients, the incision proceeds in a retrotragal
manner, just along the posterior margin of the tragus. We
council male patients about the potential for transposi­
tion of bearded skin into the ear canal with a retrotragal
incision and discuss a preauricular incision as an option.
Ultimately, we allow them to decide on the approach, and
we note that approximately 75% of men choose the ret­
rotragal approach for improved incision camouflage. The
incision then continues in a counter clockwise manner
down the lobule-facial crease and around the lobule onto
the posterior conchal cartilage skin to the level of the
triangular fossa. In patients with greater neck skin laxity,
the incision transitions down and follows the anterior
edge of the occipital hairline several centimeters depend­
ing on the anticipated amount of cervical skin resection.
Anesthesia
The senior author (AAJ) performs rhytidectomy under
local anesthesia, conscious sedation, or general anesthesia
solely based on patient preference. Roughly 20% of these
patients elect to receive only local anesthesia, typically
for financial reasons or fear of general anesthesia, while
the remaining patients choose to receive local anesthesia
with intravenous sedation with propopfol. A mixture of
five parts 0.5% lidocaine with 1 : 200,000 units of epi­
nephrine, five parts 0.25% bupivacaine with 1 : 200,000
epinephrine, and one part 0.9% bicarbonate is used. This
mixture provides a rapid-onset, long-duration, adequate
hemostasis, and greater comfort given the inclusion of
buffer. Tissue resistance is noted during injection as
it provides a preview of how easily the tissue planes
will dissect and the extent of ligamentous attachments
throughout the cervicofacial region.
Incision and Skin Flap Elevation
Skin incision is initiated at the anterior temporal hairline
at the level of the lateral brow with a No. 10 scalpel
cutting perpendicular to the skin. This can be extended
superiorly during the operation if needed to redrape
and remove the vertically elevated skin. In the past we
implemented a beveled trichophytic incision but noted
depression of the incision in a significant percentage of
cases. We believe this occurs because the skin of the
anterior temporal region is thin and the skived edge of
the beveled incision tends to become devitalized and heal
in a contracted fashion. This is different from the thicker
anterior forehead/scalp skin in the area of the frontal
hairline where trichophytic incisions were first described.
We have noted temporal scars that are barely perceptible
with this modification (Fig. 17.7). The incision is then
carried down the preauricular path described earlier. The
incision should not be placed at the anterior edge of the
helical crus cartilage because it can make the root of
Figure 17.7  Postsurgery preauricular facelift incision. Notice well-
healed and unnoticeable temporal scar and well camouflaged retrotragal
incision with preservation of intertragic notch hollow.
Figure 17.8  A small step in the incision is placed at the inferior tragus
to preserve the natural depression at the intertragic incisure.

196
MASTER TECHNIQUES IN FACIAL REJUVENATION
flap be shifted anteriorly and vertically in order to prevent
hairline margin step offs, which limits the amount of
redundant neck skin that can be removed (Fig. 17.11).
The length of the incision in the occipital region
depends on the amount of cervical skin to be excised in
the posterior flap. We prefer to be conservative with the
initial length of this incision to limit scarring, as it can
always be extended to remove a dog-ear deformity.
The initial portion of the subcutaneous flap is then
elevated using Brown-Adson forceps and a No. 10 scalpel
beginning with the superior preauricular point. The plane
should be elevated just deep to the reticular dermis,
leaving a very thin layer of fat attached to the flap. The
temporal region skin is elevated with a broad, parallel
stroke of the blade for 2 cm (Fig. 17.12). After elevating
the 2-cm skin pocket, the flap will be able to accom­
modate an Anderson multiple-prong retractor. This is
the lobe and the cheek (Fig. 17.9). Posteriorly, the inci­
sion should continue a few millimeters onto the posterior
conchal cartilage rather than directly in the postauricular
crease. This helps minimize later inferior descent of the
posterior auricular scar into a more visible location with
age. In patients with less neck laxity the incision ends
here. If the surgeon is uncertain of the amount of neck
skin that will need excision, the incision can always be
extended to remove redundancy. In cases of more sig­
nificant neck skin excess, the incision is transitioned at
the level of the triangular fossa down the anterior aspect
of the occipital hairline posteroinferiorly (Fig. 17.10).
Here we utilize a beveled trichophytic incision because
the scalp skin is thicker here and the attendant problems
discussed before have not been noted. In the past, we
utilized a high transverse incision that was hidden into
the occipital hair. This incision requires that the neck skin
Figure 17.9  The lobule cheek junction incision preserves the natural
sulcus between the lobe and the cheek.
Figure 17.10  The postauricular incision is transitioned at the level of
the triangular fossa down the anterior aspect of the occipital hairline
posteroinferiorly.
Limits anterior
neck redraping
Flap shift to
match hairline
Flap shift perpendicular to
incision redrapes neck
redundancy most effectively
Figure 17.11  Diagram demonstrating how a high transverse postau­
ricular incision requires that the neck skin flap be shifted anteriorly and
vertically in order to prevent hairline margin step offs, which limits the
amount of redundant neck skin that can be removed. This does not
occur with incisions along the occipital hairline.
Figure 17.12  The first 2 cm of the preauricular skin flap is performed
sharply with a No. 10 blade.

17  Deep Plane Rhytidectomy Modifications
197
of the mandible and connects to the anteriorly created
cheek subcutaneous flap. At this point inferior and medial
dissection in the neck in a subcutaneous/supraplatysmal
plane is accomplished with a lighted retractor to provide
tension while vertical blunt spreading with facelift scis­
sors. Dissecting inferiorly over the SCM in this manner
will preserve the great auricular nerve, which courses
from the posterior border of the SCM anterosuperiorly to
the region of the lobule. Dissecting on top of the supra­
platysma fascia during the medial neck skin elevation
preserves a blanket of fat on the skin flap that prevents
irregularities and adhesions between the deep dermis of
the skin and the platysma postoperatively. This dissection
is continued to the midline using a longer lighted retrac­
tor and long facelift scissors, and extending inferiorly just
below the level of the cricoid (Fig. 17.15). This pocket
will be connected to the opposite side when it is elevated.
Deep Plane Dissection: Release of the Zygomatic-Cutaneous
Ligament, Zygomaticus Major Muscle Fibrous Attachments,
and Masseteric Cutaneous Ligaments
An Anderson five-prong retractor is placed at the anterior
extent of the skin dissection parallel to the deep plane
entry point line. The flap is held under significant verti­
cal tension away from the body and a No. 10 scalpel
is used to make the incision into the deep plane (Fig.
17.16). The tension facilitates entry into the sub-SMAS/
subplatysma complex. The incision starts at the angle
of the mandible and ultimately extends up to the lateral
canthus. For 3 cm superior to the angle of the mandible
the platysma fibers can be visualized and are penetrated.
A lighted retractor is again used to create vertical tension
away from the body and vertical blunt dissection with
facelift scissors helps elevate the composite skin/SMAS/
platysma flap off of the parotid-masseteric fascia. As this
dissection proceeds anteriorly, the masseteric cutaneous
ligaments are released, allowing for more complete repo­
sitioning of the jowl (Fig. 17.17). To completely release
these ligaments, dissection must continue to the anterior
border of the masseter [18]. Another anatomic landmark
of the end of this dissection is the facial artery, which can
Figure 17.13  Elevation of the subcutaneous flap to the deep plane
entry point is performed with facelift scissors with the flap back lit with
an operating room light to visualize the subdermal plexus and maintain
uniform flap thickness.
Figure 17.14  The preauricular subcutaneous flap ends at the marked
line of the deep plane entry point.
Figure 17.15  Neck flap subcutaneous dissection is continued to the
midline using a longer lighted retractor and long facelift scissors.
used to place superior and lateral tension on the flap.
Direct counter-tension is placed by an assistant manually
retracting the skin in the opposite direction and the flap
is back lit with an operating room light to visualize the
subdermal plexus (Fig. 17.13). Flap elevation continues
with facelift scissors, tips pointed upward, making small,
forward snipping motions to create an even-thickness
flap. The intensity of the transilluminated light gives the
surgeon the ability to gauge the thickness of the flap and
create a uniform depth. Elevation in the cheek ends at the
marked line of the deep plane entry point (Fig. 17.14).
The postauricular skin is then grasped at its postau­
ricular peak with Brown-Adson forceps and sharp dis­
section with a No. 10 blade is carried inferiorly. The
skin in this region has a paucity of subcutaneous fat
and tightly adheres to the fascia overlying the SCM
muscle and mastoid so blade dissection is more expedi­
ent. This continues inferiorly to the level of the angle

198
MASTER TECHNIQUES IN FACIAL REJUVENATION
plane entry point, creating a plane superficial to the orbi­
cularis oculi muscle. This plane is contiguous with the
prezygomatic space that is superficial to the zygomaticus
musculature of the face. The prezygomatic space can
be easily dissected with blunt finger dissection medially
to free it to the nasal facial crease. This technique was
originally described as the finger-assisted malar elevation
(F.A.M.E.) by Aston [25,26] (Fig. 17.18).
A
B
Figure 17.16  (A) An Anderson five-prong retractor is placed at the
anterior extent of the skin dissection parallel to the deep plane entry
point line. (B) With vertical tension on the retractor, a No. 10 scalpel
is used to make the incision into the deep plane.
Figure 17.17  The sub-SMAS dissection continues anteriorly with ver­
tical spreading motion with facelift scissors until the masseteric cutane­
ous ligaments are released to the anterior border of the masseter.
C
A
B
Figure 17.18  Elevation of the superior aspect of the deep plane
pocket. (A) Blunt dissection at the superior extent of the deep plane
entry point, creating a plane superficial to the orbicularis oculi muscle.
(B, C) Blunt finger dissection medially to free it to the deep plane to
the nasal facial crease. Note the circular hashed marking that identifies
the location of the zygomatic ligaments.
be palpated and visualized in this plane. Elevation of this
flap continues superiorly until resistance is reached at the
zygomatic osteocutaneous ligament.
Isolation of the zygomatic cutaneous ligament begins
with blunt dissection at the superior extent of the deep

17  Deep Plane Rhytidectomy Modifications
199
for approximately 5 cm with tension of the flap with
a lighted retractor away from the body and continued
vertical scissor spreading blunt dissection. The tips of
the scissors are spread into the fascia underlying the
platysma, leaving the marginal mandibular and cervical
branches of the facial nerve down on the superficial cervi­
cal fascia that is contiguous with the parotid-masseteric
fascia. The dissection proceeds inferiorly and posteriorly
in a back-handed direction to free the platysma, except
at its posterior attachment to the SCM-investing fascia or
the cervical-retaining ligaments.
With the extended inferior platysma dissection com­
pleted, a marking pen is used to draw the lateral platys­
mal border at its connection to the SCM for 5 cm below
the angle of the mandible, extending the deep plane infe­
riorly. A No. 15 scalpel is used to make a broad and
gentle incision until a lip of tissue is obtained, the edge
grasped, and sharp dissection within the SCM fascia is
continued for approximately 1 cm. A lighted retractor is
then placed under the lip, retracting away from the body,
and facelift scissors are used to bluntly dissect through
the ligaments and the area of the subplatysma flap previ­
ously elevated is freed (Fig. 17.21).
Deep Plane Flap Suspension
A cuff or lip of platysma/SMAS is separated at the deep
plane entry point for placement of suspension sutures.
Facelift scissors are used with small snips along the entire
deep plane entry point. Irrigation is performed with a
bacitracin solution and hemostasis obtained with bipolar
electrocautery to minimize thermal injury to flaps and
nerves. At dissection’s end, the result from inferior to
superior should be a platysma-SMAS complex free on the
superior, inferior, and deep borders that can be mobilized
vertically without restriction. The SMAS and platysma
are conjoined to the skin as a composite flap from the
mandibular border until the orbital rim, and skin is freed
as cutaneous flaps in the temporal region as well as in the
neck below the angle of the mandible and postauricular
region.
The deep plane flap is typically sutured at four nearly
equidistant points along the cuff formed from angle to
lateral canthus (Fig. 17.22). The flap is suspended at an
The zygomatic osteocutaneous ligaments are now
intervening between the cheek dissected superiorly in the
prezygomatic space and inferiorly in the sub-SMAS plane.
These ligaments tether the SMAS/platysma complex to
the malar bone and prevent vertical elevation of the flap.
Sharp dissection of the ligaments is initiated with a No.
10 scalpel staying superficial to the zygomaticus muscula­
ture (Fig. 17.19). This protects any facial nerve branches
as they innervate the zygomaticus muscle from its deep
surface. Once through the dense ligaments, blunt dissec­
tion continues along the plane of the zygomaticus major
and minor until reaching the nasolabial fold medially
overlying the zygoma (Fig. 17.20). This has been defined
as the premaxillary space, and a dense maxillary ligament
that tethers the midface is bluntly dissected to further
release the midface [10].
Release of the Cervical-retaining Ligaments
With the deep plane now free, the only remaining point
that tethers the SMAS-platysma complex from moving
vertically is the cervical-retaining ligament. Through the
inferior aspect of the deep plane flap, the platysma is
elevated inferiorly below the margin of the mandible
Figure 17.19  Release of the deep plane flap with sharp dissection of
the zygomatic ligaments using a No. 10 scalpel cutting from superior to
inferior and staying superficial to the zygomaticus musculature.
A
B
Figure 17.20  (A, B) Deep plane flap is released through the zygomatic ligaments and elevated to the nasolabial fold.

200
MASTER TECHNIQUES IN FACIAL REJUVENATION
moment. The three remaining sutures are thrown simi­
larly, yet their vectors tend to become slightly less vertical
as they progress superiorly. The most superior suture is
suspended to the deep temporal fascia. Volumetric analy­
sis with 23-month follow-up has shown that patients gain
3.2 cc of volume in each hemi midface following vertical
vector deep plane rhytidectomy as a result of adequate
repositioning of the ptotic cheek fat compartments [14]
(Figs. 17.24–17.25).
Mandibular Ligament Release
Before tying the deep plane suspension sutures, redrap­
ing of the anterior submental skin is noted as the deep
plane flap is elevated vertically. In patients with more
significant neck skin redundancy, the mandibular liga­
ments may tether the skin at the mandibular border,
preventing anterior submental skin tightening. Identifica­
tion of the correct zone can be performed by distracting
the skin along the anterior aspect of the mandible away
from the face. The area of tethering should be drawn
with a marking pen. The approach is through a sub­
mental incision of approximately 1 cm. A Brown-Adson
forceps is used for skin retraction and a subcutaneous
dissection ensues using sharp iris scissors. Full release of
the ligaments requires dissection to the posterior edge
of the tethering point and inferiorly to the lower edge
of the mandible as it transitions to neck (Fig. 17.26).
The marginal branch of the facial nerve has been shown
to exist posterior to the ligament in studies by Langevin
et al. [27] so it is not at risk during this dissection.
Lateral Platymsa Suspension in the Neck
Once the decision has been made to release the mandibu­
lar ligament and the deep plane flap has been suspended
and tied, the platysma flap below the mandibular angle is
addressed. With vertical repositioning of the deep plane
flap, the redundant platysma overlies the auricle, and the
platysma must be split at the level of the ear lobule so
that redraping of the platysma can occur postauricularly.
A horizontal myotomy of the platysma parallel to the
inferior margin of the mandible allows for this to occur. A
angle that maximizes elevation of the cheek fat pads and
revolumizes the midface (Fig. 17.23). On average, this
angle approaches 60 degrees in many patients. The first
suture (3-0 Nylon, PS-2 needle) is placed in a horizontal
mattress fashion from the cuff created at the deep plane
entry point to the parotid masseteric fascia in the pre­
tragal (or preauricular) region, but is left untied for the
A
B
C
Figure 17.21  Release of the cervical-retaining ligaments. (A) Surgical
marking of the lateral platysmal border at its connection to the sterno­
cleidomastoid (SCM) extending 5 cm below the angle of the mandible.
(B) A No. 15 scalpel is used to make a broad and gentle incision until
a lip of tissue is obtained, the edge grasped, and sharp dissection within
the SCM fascia is continued for approximately 1 cm. (C) Subplatysmal
flap freed after blunt dissection through the ligaments 3 cm anterior to
the sharply elevated flap.
Figure 17.22  The deep plane flap is typically sutured at four nearly
equidistant points along the cuff formed at the deep plane entry point
to the preauricular and deep temporal fascia.

17  Deep Plane Rhytidectomy Modifications
201
is then placed from the hairline into the neck until the
next morning in order to decrease bruising and recovery
time.
Once the SMAS-platysma complex is suspended, the
skin is then redraped. In the cheek and face the same
plane that was used as a composite flap was elevated
along the majority of the facial rhytidectomy. The major­
ity of the skin is removed vertically in the temporal region
(Fig. 17.28). Since the skin has been delaminated from
the platysma in the neck, redraping of the neck skin
can be mobilized independently for the best contour.
Excess skin is then removed segmentally at all points
from anterior to posterior following suturing. Adequate
roughly 3 cm myotomy is made at the level of the angle of
the mandible. Following myotomy, the inferior platysmal
tab is anchored with a 3-0 Nylon suture vertically to the
mastoid tip (Fig. 17.27). This vector of pull is transmit­
ted along the submandibular region directly away from
the cervicomental angle. This maneuver creates definition
at the posterior mandibular border and angle. Plication
of the platysma in this region without flap elevation and
redraping often creates an unnatural fullness in the area
just below the angle of the mandible due to bunching.
Typically two more sutures are placed inferior to the
platysmal tab approximately 2 cm apart to redrape the
released platysma flap to the SCM. A Jackson-Pratt drain
A
B
Oblique at
approximately
60 degrees
Sutures in cuff at entrance to
deep dissection
(anchored to temporalis
fascia and parotid fascia)
Lateral platysmal
myotomy to reorient
neck vector
Suspension
suture anchored
to mastoid fascia
Figure 17.23  (A) The flap is vertically suspended at an angle that maximizes elevation of the cheek fat pads and revolumizes the midface. (B)
Diagrammatic representation of suture suspension along vertically oblique vector of 60 degrees.
A
B
Figure 17.24  (A) Preoperative and (B) 12-month postoperative views of a 51-year-old woman who underwent a vertical oblique vector-modified,
extended deep plane facelift without midline platysmaplasty. Notice the volumizing of the midface with repositioning of the cheek fat compartments.

202
MASTER TECHNIQUES IN FACIAL REJUVENATION
occipital hairline (Fig. 17.29). The submental incision is
then closed if present and a head wrap is placed until the
next morning only. The majority of anterior sutures are
removed at 4 days.
Midline Platysmaplasty Indications
It is our opinion that midline platysmaplasty can be
avoided in certain cases if adequate lateral distraction
of the platysma is achieved. We demonstrated in cadav­
eric studies that extended deep plane rhytidectomy with
release of the cervical-retaining ligaments results in 554%
greater lateral distraction of the platysma compared with
SMAS plication techniques [21]. It is our belief that limit­
ing the deep plane dissection only to the midface and not
extending it past the angle of mandible into the neck likely
restricts the transmitted degree of deep tissue mobiliza­
tion [21] and provokes a higher recurrence of platysmal
banding [28–30]. Failure to release the platysma from the
cervical-retaining ligaments in this manner may result in
failure in the neck with need for neck revision [31–34].
We believe that mild-to-moderate platysmal band correc­
tion can be achieved exclusively by lateral advancement
of the platysma (Figs. 17.30–17.31).
Additionally, the opposing force created by midline
platysmaplasty may compromise the aesthetic outcomes
of rhytidectomy. We have performed a cadaveric study
showing that midline platysmal fixation creates opposi­
tional vectors of tension that reduced neck flap redraping
by 23.9% [35] (Fig. 17.32). These findings are corrobo­
rated by data demonstrating similar effects in traditional
SMAS plication techniques [36]. This reduces the amount
of redundant neck skin that can be removed, which pre­
disposes to recurrent neck ptosis, the very thing that
platysmaplasty attempts to prevent.
Despite the significant limitation in rhytidectomy flap
mobility that has been demonstrated, there remain rela­
tive and absolute indications for midline platysmaplasty.
elevation of the temporal skin in the subcutaneous plane
avoids bunching. In those with more significantly laxity,
the temporal incision must be carried superior to the
lateral brow to correct a dog-ear. Deep everting 4-0 Vicryl
sutures are placed along the entire temporal incision to
prevent depression and spreading of the scar over time.
We encountered more obvious anterior temporal scars
when we first adopted the vertical technique using only
a superficial skin closure. Skin closure is with everting
5-0 Nylon vertical mattress sutures. The remainder of
the incision is closed with 5-0 Nylon sutures anteriorly,
5-0 Nylon sutures behind the ear, and 4-0 Nylon in the
A
B
Figure 17.25  (A) Preoperative and (B) 15-month postoperative views of a 57-year-old woman who underwent a vertical oblique vector-modified,
extended deep plane facelift without midline platysmaplasty. Notice the volumizing of the midface with repositioning of the cheek fat compartments.
Figure 17.26  Release of the mandibular ligaments requires dissection
to the posterior edge of the tethering point and inferiorly to the lower
edge of the mandible as it transitions to neck.

17  Deep Plane Rhytidectomy Modifications
203
A
B
Figure 17.27  Neck platysma redraping. (A) A horizontal 3-cm myotomy of the platysma parallel to the inferior margin of the mandible allows
for better redraping. (B) The platysma flap is sutured to the mastoid periosteum.
Figure 17.28  The majority of the skin redundancy is removed vertically in the temporal region.
A
B
Figure 17.29  (A) Preauricular and (B) postauricular skin closure.

204
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
C
D
B
Figure 17.30  (A, C) Preoperative and (B, D) 12-month postoperative views of a 59-year-old woman who underwent a modified, extended deep
plane facelift without midline platysmaplasty.
We advocate concomitant midline platysmaplasty for
patients with excessive redundancy of the platysma,
which is determined preoperatively. With the patient
standing in an upright position, the surgeon places three
fingers at the deep plane entry point on both sides of the
face and moves the skin vertically to assess whether the
submental and platysmal skin laxity is corrected with
this simulation of vertical suspension (Fig. 17.33). If
the submental area is corrected with this maneuver then
no platysmal surgery is indicated. If the patients still
has platysmal redundancy with this maneuver then a
midline platysmaplasty is planned accordingly. Gener­
ally, patients with platysmal banding that constitute less
than 1.5 cm in depth in the anteroposterior direction will
experience adequate redraping from lateral dissection
alone. Patients with more redundancy in their platysmal
banding will likely not achieve adequate treatment from
lateral dissection alone, and these patients are selected
preoperatively to undergo concomitant midline platysma­
plasty (Fig. 17.34). We prefer to make this determination
preoperatively and perform this medial work prior to the
lift because it is difficult to reapproximate the midline
platysmal edges after they have been lifted vertically with
the extended deep plane release and resuspension of the
platysma. With this in mind, the decision to perform the
midline corset can also be made intraoperatively when
midline platysma laxity is noted after elevation and
redraping of the lateral platysma flaps with the vertical
neck lift.
Despite the extended deep plane approach, we have
documented in a series of 323 patients a 13% rate of
required midline platysma plication to address platysmal
redundancy that could not be corrected laterally [37].
In further follow-up of 634 patients, the senior author
(AAJ) has noted the platysmaplasty rate to stay relatively
constant at 16%. The patients who required concomitant

17  Deep Plane Rhytidectomy Modifications
205
A
B
C
D
Figure 17.31  (A, C) Preoperative and (B, D) 10-month postoperative views of a 53-year-old woman who underwent a modified, extended deep
plane facelift without midline platysmaplasty.
Figure 17.32  Midline platysmal fixation during platysmaplasty creates oppositional vectors of tension that reduce lateral neck flap redraping.

206
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
B
Figure 17.33  (A)
Preoperative
neck
laxity. (B) Simulation of vertical suspension
of the neck with three fingers at the deep
plane entry point. If the neck is redraped
no midline platysma surgery is required.
A
B
C
D
Figure 17.34  (A, C) Preoperative and (B, D) 12-month
postoperative views of a 57-year-old woman with exces­
sive platysmal redundancy of anterior-posterior dimen­
sion greater than 1.5 cm. She required a concomitant
platysmaplasty with a modified, extended deep plane
facelift.

17  Deep Plane Rhytidectomy Modifications
207
significant supraplatysmal fat excess that can be grasped
and clearly identified prior to injection. A rough guide­
line for performing submental liposuction is when more
than 3 cm of thickness can be grasped in the submental
skin between the thumb and forefinger (Fig. 17.39). In
general we prefer to leave the natural blanket of fat
between the skin and platysma to avoid forming depres­
sions from adhesions and retraction. When performing
submental liposuction we employ modern techniques
that mitigate the chance of commonly noted irregulari­
ties [39–48]. Removal of fat at and above the jawline and
jowls is avoided as there is a greater chance of iatrogenic
irregularity here. We no longer use large spatulated can­
nulae in order to avoid skeletonization, retraction, and
fibrosis. Instead we use small microliposuction cannulae
to decrease the chance of lumps and bumps postopera­
tively. With the suction off the cannula, a preplatysmal
plane is dissected in the neck. The cannula is then placed
on suction and supraplatysmal fat is removed with the
opening pointed toward the platysma, taking great care
to leave approximately 1 cm of protective fat layer on the
dermis in order to avoid irregularities in this region. This
thickness can be determined by rolling the skin between
the thumb and index finger. We do not advocate the use of
ultrasonic cannulae as the risk of thermal injury is higher.
The type of platysmaplasty performed is similar to
the Corset Platysmaplasty described by Feldman [49],
with minor modifications. Feldman originally described
extensive defatting in nearly all zones of the neck, making
the incision in the submentum after the face had already
been dissected, and only excises the intraplatysmal fibers
when the platysma is decussated below the chin. We
perform a smaller submental incision (typically 1.5 cm),
elevating the neck skin in a supraplatysmal fascial plane
utilizing blunt vertical spreads with facelift scissors to a
level just below the cricoid cartilage. The intraplatysmal
fibers are separated and subplastymal flaps are elevated
laterally to the submandibular gland anterior border to
assist in mobilization and to decrease the chance of pal­
pable midline banding. At this point the subplatysmal
fat and digastric muscles are examined and the need for
reduction is determined. We prefer interrupted and buried
4-0 Vicryl sutures. Burying the knots helps minimize the
possibility of palpation of the sutures through the skin.
FUTURE CONSIDERATIONS
Efficacy
There is a paucity of data comparing efficacy of rhytid­
ectomy by technique. Short-term follow-up has shown
higher efficacy in techniques utilizing more aggressive
SMAS manipulation, boasting fewer secondary proce­
dures and happier patients [50]. The need for tuck up
varies widely amongst rhytidectomy techniques. SMAS
plication and imbrication techniques have been shown to
carry the highest tuck up rates, of up to 21% and up to
50% at 2 years [51,52]. More extensive skin flaps with
extended SMAS dissections have a lower tuck up rate
of 11% [53]. The deep plane rhytidectomy reproducibly
carries substantially lowered tuck up rates of 3% to 4%,
which is statistically significant [11,53].
midline corset platysmaplasty were most commonly in
their later sixth, seventh, or eighth decade of life.
There are some absolute indications for midline corset
platysmaplasty. Subplatysmal lipectomy is an absolute
indication to perform midline platysmaplasty (Fig. 17.35).
If the platysma is not plicated following subplatysmal
excision, then cobra neck deformity is a certain sequelae
(Figs. 17.36–17.37). Another absolute indication for pla­
tysmaplasty is dictated by the decussation pattern of the
platysma. The midline platysmal decussation pattern is
variable, and has been identified as three types: type I
(75% of patients) with the platysma separated from the
midline but intersecting for 2 cm from the chin, type II
(15% of patients) with the platysma fibers joining com­
pletely in the suprahyoid region, and type III (10% of
patients) where the fibers are separated at the midline
and do not intersect [38]. Those type III patients with a
naturally wide platysmal dehiscence (>2–3 cm) have ana­
tomically inadequate midline muscular decussation and
therefore should be identified as cases that are an absolute
indication for concomitant platysmaplasty (Fig. 17.38).
Adjunctive Submental Procedures and Platysmaplasty
If the need for an additional midline submental procedure
is confirmed preoperatively, we perform this first prior
to lifting the neck skin and platysma portion. One must
remain cognizant that increasing the number of proce­
dures performed in the submentum increases the chances
of irregularities, and each maneuver must be performed
precisely and in a metered fashion.
We perform subcutaneous liposuction in the neck in
less than 10% of our patients, and only when they have
Figure 17.35  Intraoperative view of fat pad removed from subpla­
tysmal lipectomy.

208
MASTER TECHNIQUES IN FACIAL REJUVENATION
viscosity, which heightens the risk of tissue ischemia
from microvascular thrombosis [58]. Active smoking is
considered to be a relative contraindication to surgery.
Historically, surgeons have addressed this by scaling back
their rhytidectomy, offering a surgery of only limited
skin undermining to prevent any potential postopera­
tive complications. The modern era of rhytidectomy is
defined by greater and longer lasting results achieved by
more extensive elevation of the skin and SMAS. Patients
are less willing to accept a subpar correction, or even
worse, an increased risk of postoperative complications
[57]. The traditional deep plane rhytidectomy, popular­
ized by Hamra [59], introduced the concept of raising
a compound flap, one consisting of skin, subcutaneous
tissue, and SMAS. This thicker flap is well vascularized
and heartier because the blood supply to the flap has
not been interrupted. The vascular supply to the facelift
flap elevated by various techniques is best preserved with
either a composite flap or subperiosteal face lift tech­
nique [60]. The composite flap is vascularized by arterial
Studies on medium-term efficacy of less invasive SMAS
approaches have a greater recurrence of neck laxity
than jowl reformation [50]. There are limited long-term
follow-up data available for review. Patients presented for
secondary facelifts after primary SMAS plication rhytid­
ectomy on average 9 years later [54]. Secondary facelifts
were sought after primary SMAS flap rhytidectomy on
average 11.9 years later, suggesting this is a slightly more
durable procedure; however, the data remain too limited
to draw conclusions and the significance of this informa­
tion is unclear [55].
Tobacco Use
It is well understood that smoking delays wound healing,
and in the case of rhytidectomy specifically, patients who
smoke are known to have an increased risk of flap necro­
sis and hematoma [56,57]. The viability of the facelift
flap is predicated on adequate oxygenation and vascular
circulation, both of which are compromised by tobacco
use. Nicotine increases platelet adhesiveness and blood
A
C
B
D
Figure 17.36  (A, C) Preoperative and (B, D) 9-month postoperative views of a 61-year-old woman with excessive subplatysmal fat requiring
concomitant subplatysmal lipectomy and midline platysmaplasty with a modified, extended deep plane facelift.

17  Deep Plane Rhytidectomy Modifications
209
is the same as less invasive SMAS plicating and suturing
techniques that can cause temporary traction injury [65].
Deep plane surgery bears an improved risk profile
in some aspects when compared with the traditional,
less extensive surgeries; namely, lower rates of skin flap
sloughing and need for tuck up procedures [11,53].
CONCLUSION
Deep plane rhytidectomy is a safe procedure with supe­
rior outcomes in facial rejuvenation. A comprehensive
understanding of the facial anatomy and pathophysiology
of aging is imperative to incorporate this procedure suc­
cessfully. Several surgical techniques have been expanded
upon since the inception of deep plane composite flap
rhytidectomy, enabling a more facile incorporation of this
technique to produce farther reaching and longer lasting
rejuvenating effects.
References available online at expertconsult.com.
perforators of the transverse facial artery that have a
relatively constant anatomic location at 3.1 cm lateral
and 3.7 cm inferior to the lateral canthus [61]. These
vessels are not interrupted in deep plane face lifts [62]. In
a retrospective study of 18 patients who actively smoked
during the preoperative and postoperative course, we
saw no skin necrosis after deep plane rhytidectomy [63].
COMPLICATIONS
It is important to clarify that more aggressive dissection
with deep plane techniques does not portend an increased
risk to the patient. The rate of facial nerve damage and
hematoma in deep plane rhytidectomy has been shown to
be equal to those of less invasive techniques [11,53]. Our
incidence of facial nerve injury with an extended deep
plane approach is 1.2% in a prior study reviewing 323
patients who underwent this technique with the primary
author [64], and has remained stable on follow-up review
of over 600 cases. This temporary facial nerve injury rate
A
C
D
B
Figure 17.37  (A, C) Preoperative and (B, D) 12-month postoperative views of a 67-year-old woman with excessive subplatysmal fat requiring
concomitant subplatysmal lipectomy and midline platysmaplasty with a modified, extended deep plane facelift.

210
MASTER TECHNIQUES IN FACIAL REJUVENATION
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35. Jacono AA, Malone MH. The effect of midline corset platysma­
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and clinical implications for cosmetic surgery. Plast Reconstr Surg
2007;119(7):2219–27, discussion 2228-31.
14. Jacono AA, Malone MH, Talei B. Three-dimensional analysis of
long-term midface volume change after vertical vector deep-plane
rhytidectomy. Aesthet Surg J 2015;35(5):491–503.
18. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superfi­
cial and deep facial fascias: relevance to rhytidectomy and aging.
Plast Reconstr Surg 1992;89(3):441–9, discussion 450-1.
19. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg 2014;
134(6):1173–83.
21. Jacono AA, Parikh SS, Kennedy WA. Anatomical comparison of
platysmal tightening using superficial musculoaponeurotic system
plication vs deep-plane rhytidectomy techniques. Arch Facial Plast
Surg 2011;13(6):395–7.
A
B
Figure 17.38  (A) Preoperative and (B) 12-month postoperative views of a 63-year-old woman with type 3 widely dehiscent medial platysmal edges
requiring concomitant midline platysmaplasty with a modified, extended deep plane facelift.
A
B
Figure 17.39  (A) Preoperative and (B) 12-month postoperative views of a 59-year-old woman with supraplatysmal fat excess requiring concomitant
subcutaneous neck liposuction with a modified, extended deep plane facelift.

17  Deep Plane Rhytidectomy Modifications 210.e1
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211
HISTORY
The senior author’s first experience with rhytidectomy
was during residency in the late 1970s. At that time, the
emphasis was on extensive defatting of the neck with
complete platysma muscle transection, plicating medial
borders and pulling laterally. However, several years
of patient complaints, complications, and overoperated
necks led to a modification of this technique. With the
advent of liposuction in the 1980s, the author found
that he could obtain excellent neck contouring in many
patients utilizing liposuction combined with strong lateral
platysmal suturing.
When superficial musculoaponeurotic system (SMAS)
dissection first became popularized in 1976, it became
fashionable to include a dissection of the lateral SMAS
directly overlying the parotid gland. The senior author
initially utilized this form of SMAS dissection beginning
in the late 1970s and continued using it into the mid-
1980s, but overall was disappointed with the effects of a
simple elevation and tightening of the lateral superficial
fascia. Specifically, he saw little difference in overall facial
contour whether he had performed a lateral SMAS dis­
section or had omitted it.
As he gained greater experience with SMAS dissec­
tion, it became obvious that for the superficial fascia to
produce any effective contour change in face lifting, it
was necessary to elevate the SMAS anterior to the parotid
gland. The problem of more extensive SMAS dissection
is that facial nerve branches are in greater jeopardy. He
also noted that the superficial fascia tends to thin out as
it is dissected more anteriorly, making the SMAS easy to
tear. A SMAS dissection that is not raised as a continuous
fascial sheet but rather is raised with several tears in it
is a poor substrate for holding the tension of contour­
ing the face. For these reasons, he felt that an extensive
SMAS dissection was not warranted in most patients as
it offered little long-term benefit when compared with
SMAS plication.
In 1992 Dr. Baker realized that an alternative to
formal elevation of the superficial fascia was a “lateral
SMASectomy,” removing a strip of the SMAS in the
region directly overlying the anterior edge of the parotid
gland, and extending to the lateral canthus. Excision of
the superficial fascia in this region secures the mobile
anterior SMAS to the fixed portion of the superficial
fascia overlying the parotid. The direction in which the
SMASectomy is performed is oriented so that the vectors
of elevation following SMAS closure lie perpendicular
to the nasolabial fold, thereby producing improvement
not only of the nasolabial fold but also of the jowl and
jawline. In 2001 this technique was further developed and
refined into the minimal incision rhytidectomy (short scar
facelift).
SENIOR AUTHOR’S PERSONAL PHILOSOPHY
For many years I have listened to panels and presentations
and have read articles about the “super-SMAS,” “deep
plane,” “subperiosteal,” and various other extended rhyt­
idectomy procedures. In their search for the penultimate
facelift, these pioneering surgeons demonstrate superb
anatomic studies, beautiful illustrations, and impeccable
photographs. Their presentations are well organized,
stimulating, and seductive.
I have always considered myself a bold and aggressive
surgeon, and the temptation to utilize these new, deeper
dissections is extremely appealing. However, I am reluc­
tant to employ them, and I keep asking myself why? The
explanation is partly that I am not convinced that the
results are superior to those obtained by the standard
SMAS-platysma techniques. More important, I do not yet
believe that the implied “benefits” outweigh the increased
morbidity and risks, especially to the facial nerve.
The presentations on deep dissection and subperiosteal
rhytidectomies recall the period between 1976 and 1980,
when virtually all panels and courses were advocating
complete platysma muscle transactions and a multitude
of platysma flaps. As a plastic surgeon just completing
residency, I was highly impressed; I became a believer
and a convert: the only way to get the “best result” in
rhytidectomy was with these techniques. However, many
years of patient complaints, complications, and overop­
erated necks occurred before most of these techniques
were abandoned. I can only speculate on whether the
deep plane rhytidectomy techniques will have a similar
evolution.
In the 21st century, the consumer’s preference has
been for minimally invasive and noninvasive techniques:
fillers, Botox, endoscopy, and limited incision aesthetic
surgery. The rationale for any minimal incision surgery
is evident: less invasiveness, less bleeding, presumably
less pain, faster healing, and less scarring. The primary
advantages of minimal incision rhytidectomy, however,
are that it preserves the posterior hairline and avoids
retroauricular scars, which are particularly important for
a woman with a pulled-up or swept-back hairstyle. It
is a ponytail-friendly facelift. The primary goal of any
surgeon performing rhytidectomy should be to utilize a
technique giving consistently good results with minimal
C H A P T E R 18 
Lateral SMASectomy Facelift
Daniel C. Baker, MD and Steven M. Levine, MD

212
MASTER TECHNIQUES IN FACIAL REJUVENATION
risk, complications, morbidity, and a speedy postopera­
tive recovery.
My intention is neither to discredit these deep dis­
section techniques nor to deplete the splendor of cre­
ative surgery. Their contribution is already evident: an
increased and clearer knowledge of facial anatomy,
muscle function, and human expression. I am certain that
some aspect of these techniques will be incorporated by
many plastic surgeons. The questions that remain to be
answered are: (1) what are the indications for these newer
techniques? (2) How great are the risks and complica­
tions? And, most important, (3) do the benefits signifi­
cantly outweigh the risks to justify using these techniques
routinely?
There are several advantages of lateral SMASectomy
in comparison with traditional SMAS elevation. First,
because the procedure does not require traditional SMAS
flap elevation, there is less concern about tearing of the
superficial fascia. Second, the potential for facial nerve
injury is lower because most of the deep dissection is over
the parotid gland. If the SMASectomy is performed ante­
rior to the parotid, the deep fascia will similarly provide
protection for the facial nerve branches as long as the
resection of the superficial fascia is done precisely and
the deep fascia is not violated. Third, because SMAS flaps
have not been elevated, they tend to hold suture fixation
more strongly, and the potential for postoperative dehis­
cence and relapse of contour is decreased.
There are certainly other rhytidectomy techniques that
produce excellent results. Each surgeon must adopt a
technique that serves his or her patients best. Ideally,
the technique should be safe, consistent, easily reproduc­
ible, and applicable to a variety of anatomic problems.
The surgeon also must have the versatility to adapt and
modify his or her technique to the needs and desires
of each patient. At present, the lateral SMASectomy
provides this for most of my patients. In the future, as
endoscopy and fixation techniques advance, I will seek
to modify and further improve my present rhytidectomy
operation.
It must be emphasized that I do not perform SMAS­
ectomy in every rhytidectomy. Patients with thin faces
and minimal subcutaneous fat undergo simple plication
or imbrication.
SURGICAL TECHNIQUE
Anesthesia
Virtually all of our facelifts are performed with the patient
under monitored intravenous propofol sedation. Patients
are given oral clonidine, 0.1 to 0.2 mg, 30 minutes before
surgery to control their blood pressure. The face and neck
are infiltrated with local anesthesia, 0.5% lidocaine with
1 : 200,000 epinephrine, through use of a 22-gauge spinal
needle. The face is injected before we scrub to provide the
requisite 10 minutes for vasoconstriction.
Incisions
When the temporal hairline shift is assessed as minimal,
the preferred incision is well within the temporal hair.
With this incision, it is often necessary to excise a triangle
of skin below the temporal sideburn at the level of the
superior root of the helix. Keep in mind, this incision will
move the natural hairline. This may be acceptable if the
shift is minimal or if the hairline is low.
However, when larger skin shift is anticipated (fre­
quently the lift is more vertical with minimal incision
rhytidectomy) or the distance between the lateral canthus
and temporal hairline is greater than 5 cm, we prefer
an incision a few millimeters within the temporal hair­
line (Figs. 18.1–18.3). Although this is a compromise,
the alternative of a receding temporal hairline is never
acceptable to a female patient. When the incisions are
properly executed, these scars heal well and are easy
to revise or camouflage. The only exception might be
in a patient with deeply pigmented skin in whom the
scar will contrast and appear as a white line. The tem­
poral hairline incision should be made parallel to the
hair follicle and no higher than the frontotemporal
hairline.
The temporal hairline incision allows for the more
vertical elevation of the facial flap that is usually required
in a short scar rhytidectomy. Other indications for this
incision are a receding hairline from previous facelifts and
a fine, fragile hairline.
Figure 18.1  Lateral SMASectomy dissection. The temporal hairline
incision allows for a more vertical elevation of the facial flap that is
usually required in a short scar rhytidectomy. Subcutaneous dissection
is performed extending across the zygoma to release the zygomatic
ligaments but stops several centimeters short of the nasolabial fold.
The SMAS resection is performed on a tangent from the lateral malar
eminence to the angle of the mandible in the region along the anterior
edge of the parotid gland. The width depends on the laxity of the tissues
and the desired elevation. Vectors are perpendicular to the nasolabial
fold. A platysma flap is elevated and secured to the mastoid periosteum.
SMAS, Superficial musculoaponeurotic system.

18  Lateral SMASectomy Facelift
213
Skin Flap Elevation
All skin flap undermining is carried out under direct
vision (with scissors dissection) to minimize trauma to
the subdermal plexus and preserve a significant layer of
subcutaneous fat on the undersurface of the flap (see Fig.
18.2). We usually perform some subcutaneous dissec­
tion in the temporal region to allow the skin to redrape
better. (We believe that hair loss results primarily from
tension rather than superficial undermining.) Subcutane­
ous dissection in the temporal region must be performed
carefully to avoid penetrating the superficial tempo­
ral fascia that protects the frontal branch of the facial
nerve. All dermal attachments between the orbicularis
oculi muscle and the skin are separated up to the lateral
canthus.
Dissection extends across the zygoma to release the
zygomatic ligaments but stops several centimeters short
of the nasolabial fold. In our opinion, further dissection
provides little benefit; on the contrary, the only result
is increased bleeding. In the cheek, dissection releases
the masseteric-cutaneous ligaments and, if necessary, the
mandibular ligaments.
Subcutaneous dissection continues over the angle of
the mandible and sternocleidomastoid for 5 to 6 cm into
the neck. This exposes the posterior half of the platysma
The choice of preauricular incision is up to the surgeon.
When executed properly, all these incisions heal well and
are imperceptible. We usually prefer a curved incision
anterior to the helix and continue inferiorly anterior to
the tragus in a natural skinfold. This preserves the thin,
pale, hairless tragal skin and its demarcation from the
usual coarser, thicker, darker cheek skin with its lanugo
hairs. We perform intratragal incisions in patients in
whom the cheek and tragal skin are similar and the
tragal cartilage is not sharp or prominent. All of these
incision choices can yield excellent results. It is important
to recognize that no one incision pattern will work best
for everyone and it is important to customize this deci­
sion based on the patient’s anatomy. As always, closure
must be without tension and the flap overlying the tragus
should be defatted to dermis.
In minimal incision rhytidectomy, efforts are made to
end the incision at the base of the ear lobe. This is usually
possible in young patients, but sometimes a short retro­
auricular incision is necessary to correct a dog-ear after
the facial flap rotation.
Figure 18.2  The incision and area of dissection in lateral SMASec­
tomy. The temporal hairline incision is utilized to allow a more vertical
elevation of the facial flap. A curved incision anterior to the helix is
utilized, continuing inferiorly anterior to the tragus in a natural skin
fold. Facial subcutaneous dissection is performed, extending across the
zygoma to release the zygomatic ligaments but stopping short of the
nasolabial fold. Subcutaneous dissection continues over the angle of
the mandible and sternocleidomastoid for 5 to 6 cm into the neck. This
exposes the posterior half of the platysma muscle. If a submental inci­
sion has been made, the facial and lateral neck dissections are connected
through and through to the submental dissection. SMAS, Superficial
musculoaponeurotic system.
Figure 18.3  Outline of the SMAS excision. The SMAS resection is
performed on a tangent from the lateral malar eminence to the angle
of the mandible in the region along the anterior edge of the parotid
gland. Continuous with the lateral SMASectomy is the resection of a
strip of posterior platysma muscle several centimeters long over the tail
of the parotid and anterior border of the sternocleidomastoid. SMAS,
Superficial musculoaponeurotic system.

214
MASTER TECHNIQUES IN FACIAL REJUVENATION
patients, this involves a line of resection extending from
the lateral aspect of the malar eminence toward the tail
of the parotid gland. Usually, a 2- to 3-cm segment of
superficial fascia is excised, depending on the degree of
SMAS-platysma laxity.
In SMAS resection, we like to pick up the superficial
fascia in the region of the tail of the parotid, extending
the resection from inferior to superior in a controlled
fashion. When SMAS resection is being performed, it is
important to keep the dissection superficial to the deep
fascia and avoid dissection into the parotid parenchyma.
Note that the size of the parotid gland varies from
patient to patient; consequently, the amount of protec­
tion for the underlying facial nerve branches will also
vary. Despite this, as long as one carries the dissection
superficial to the deep facial fascia, ensuring that only
the superficial fascia is resected, facial nerve injury as
well as parotid gland injury will be prevented. In essence,
this is a resection of the superficial fascia in the same
plane of dissection in which one would normally raise the
SMAS flap.
muscle. If a submental incision has been made, the facial
and lateral neck dissection is connected through and
through to the submental dissection.
Defatting the Neck and Jowls
Whenever possible, we prefer closed suction-assisted lipo­
plasty in the neck and jowls. We use a 2.4-mm Mercedes
tip cannula, keeping it under constant, steady motion
in the subcutaneous space. We attempt to leave a layer
of subcutaneous fat on the undersurface of the cervi­
cal skin. If we suction the jowls, this is always done
conservatively.
We rarely suction or remove subplatysmal fat because
(1) the facial nerves run just beneath the platysma and
(2) any patient with significant subplatysmal fat probably
has a fat, round face, so removing subplatysmal fat could
create an overoperated look.
We usually perform lipoplasty before elevating the skin
flaps. In doing so, we are careful not to oversuction the
portion of the SMAS-platysma that will be elevated over
the mandible with the lateral SMASectomy. It is better
to be conservative with liposuction at the beginning of
the case as you can always remove more fat at the end
of the case.
Open Submental Incision With Medial
Platysma Approximation
For many patients, excellent results can be achieved
with closed lipoplasty and a strong lateral platysma pull.
However, with a short scar rhytidectomy, there is limited
access to the platysma and the lateral vector has changed.
Therefore, in these patients as well as patients with sig­
nificant active platysma bands on animation, the medial
approximation provides another vector to enhance the
cervicomental recontouring (Fig. 18.4).
The submental incision is made either in the submental
crease or just anterior to it. The subcutaneous dissection
is performed with the neck hyperextended, and under­
mining is usually to the level of the thyroid cartilage
and angle of the mandible. Suction-assisted lipoplasty is
then performed with a large, single-hole cannula under
direct vision. Direct fat excision is carried out if neces­
sary, but to avoid depressions, subplatysma fat is rarely
removed.
The medial borders of the platysma muscle are identi­
fied and elevated for several centimeters. To break the
continuity of the bands, a wedge of muscle is removed
at the level of the hyoid. The medial borders of the
muscle are then sutured together with interrupted buried
4-0 polydioxanone (PDS; Ethicon, Inc., Somerville, NJ,
USA). The submental incision is left open to allow for
final hemostasis and recontouring after communication
with the facial dissection and completion of the lateral
SMASectomy.
Lateral SMASectomy Including Platysma Resection
The outline of SMASectomy is marked on a tangent
from the lateral malar eminence to the angle of the man­
dible, essentially in the region along the anterior edge
of the parotid gland (see Figs. 18.1 and 18.3). In most
Figure 18.4  Medial platysma approximation. Subcutaneous dissec­
tion through a submental incision is performed with the neck hyper­
extended. The dissection usually extends to the level of the thyroid
cartilage and angle of the mandible. Suction-assisted lipoplasty is then
performed. The medial borders of the platysma muscle are elevated for
several centimeters. To break the continuity of the bands, a wedge of
muscle is removed at the level of the hyoid. The medial borders of the
muscle are then sutured together.

18  Lateral SMASectomy Facelift
215
with scissors. Fat can also be trimmed at the sternoman­
dibular trough, final contouring being accomplished with
lipoplasty.
For the neck, a flap of the lateral platysma is developed
in the region inferior to the mandibular border. After this
lateral platysma flap is raised, the platysma is secured to
the mastoid periosteum with figure-of-eight 2-0 Maxon
sutures to help define the jawline and improve contouring
in the submandibular region. This is the basic rhytidec­
tomy operation that the senior author has performed
since July 1992.
Skin Closure, Temporal and Earlobe
Dog-Ears
After SMAS and platysma approximation, some tether­
ing of the skin might appear at the anterior extent of
the subcutaneous dissection because of the pull of the
underlying SMAS. This can also occur in the lower eyelid
with elevation of the malar fat pad. Further subcutaneous
undermining is necessary to free these tethers, allowing
the skin to redrape.
The first key skin suture rotates the facial flap ver­
tically and posteriorly to lift the midface, jowls, and
submandibular skin. Suture fixation is at the level of the
insertion of the superior helix. We like to use a buried
3-0 PDS through the temporal fascia with a generous bite
of dermis on the skin flap. Closure is under minimal to
moderate tension. Staples are used to close any incisions
in the hair. A wedge is usually removed at the level of the
sideburn to preserve the hairline. If an anterior hairline
incision has been made, we like to close it with buried
4-0 PDS sutures and 5-0 Nylon sutures on the skin. Extra
time and attention must be spent on this closure to elimi­
nate any dog-ears and obtain the finest scar. Excess skin
is then trimmed from the facial flap so that there is no
tension on the preauricular closure. Wound edges should
be “kissing” without sutures.
In short scar rhytidectomy, trimming at the earlobe
must be without tension, and the skin flap is tucked under
the lobe with 4-0 PDS sutures, taking a bite of earlobe
dermis, cheek flap dermis, and conchal perichondrium to
minimize any tension. A small dog-ear might be present
behind the earlobe; this is easily trimmed and tailored
into a short incision in the retroauricular sulcus. A closed
suction drain is usually brought out through a separate
stab in the retroauriculus sulcus. Figs. 18.6 and 18.7 are
representative preoperative and postoperative photos of
patients who have undergone lateral SMASectomy.
POSTOPERATIVE CARE
For the first 48 hours of the postoperative period, blood
pressure monitoring is continuous to avoid systolic spikes
and potential bleeding. Treatment of rising blood pres­
sure is essential to minimize hematoma formation.
We usually utilize suction drains and a soft head dress­
ing to cover the flaps and incisions. Although drains never
prevent expanding hematomas, we prefer to remove sero­
sanguineous fluid in this manner. Sutures are removed on
the 7th and 10th postoperative days.
Continuous with the lateral SMASectomy is the resec­
tion of a strip of posterior platysma muscle several cen­
timeters long over the tail of the parotid and the anterior
border of the sternocleidomastoid. The facial nerves are
protected here.
Vectors
The various vectors accomplish correction of the anterior
neck, the cervicomental angle, the jowls, and the naso­
labial fold. The first key suture grasps the platysma at
the angle of the mandible and advances it in a postero­
superior direction; it is secured with 2-0 Maxon (United
States Surgical Corp., Norwalk, CT, USA) to the fixed
lateral SMAS (see Figs. 18.3–18.5). This lifts the cervical
platysma and cervical skin.
Interrupted 3-0 PDS buried sutures are used to close
the SMASectomy, the fixed lateral SMAS being evenly
sutured to the more mobile anterior superficial fascia
(Fig. 18.5). Vectors are perpendicular to the nasolabial
fold. The last suture lifts the malar fat pad, securing it
to the malar fascia. It is important to obtain a secure
fixation to prevent postoperative dehiscence and relapse
of facial contour.
If firm monofilament sutures are used, such as PDS
or Maxon, the sutures should be buried and sharp ends
on the knot trimmed. Final contouring of any SMAS
or fat irregularities along the suture line is completed
Figure 18.5  Superficial musculoaponeurotic system (SMAS), pla­
tysma, and skin closure in lateral SMASectomy.

216
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
B
D
C
Figure 18.6  Preoperative (A, B) and 2-year postoperative views (C, D) after lateral SMASectomy, perioral dermabrasion, autologous fat transfer
(AFT) to face, and chin implant. SMAS, Superficial musculoaponeurotic system.
When large hematomas are recognized early, they are
usually successfully managed at the bedside with seda­
tion, blood pressure control, and irrigation.
The overall incidence of hematoma for women is
about 1.5%; for men it is 4%.
COMPLICATIONS
Table 18.1 summarizes the complications of this tech­
nique, which are consistent with other standard facelift
operations. Despite special attention to blood pres­
sure control in the postoperative period, the hema­
toma rate is still 1.5%. The most common problems
are minor revisions of earlobe and temporal hairline
scars. Secondary lifts are occasionally performed, but
we require all patients to allow healing for 1 year
before considering any revisions. Our goal is to keep
the occurrence of all revisions to less than 5%. When
revisions exceed this limit, it is time to reevaluate the
technique.

18  Lateral SMASectomy Facelift
217
A
C
D
B
Figure 18.7  Preoperative (A, B) and 1-year postoperative views (C, D) after lateral SMASectomy, AFT to face, and perioral dermabrasion. SMAS,
Superficial musculoaponeurotic system.

218
MASTER TECHNIQUES IN FACIAL REJUVENATION
S U G G E S T E D R E A D I N G
Baker DC. Anatomy and injuries of the facial nerve in cervicofacial
rhytidectomy. In: Kaye BL, Gradinger GP, editors. Symposium on
Problems and Complications in Aesthetic Plastic Surgery of the Face.
St. Louis: CV Mosby; 1984.
Baker DC. Deep dissection rhytidectomy: A plea for caution. Plast
Reconstr Surg 1994;93(7):1498–9.
Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997;100(2):
509–13.
Baker DC. Minimal incision rhytidectomy (short scar facelift) with
lateral SMASectomy: evolution and application. Aesthet Surg J
2001;21(1):68–79.
Baker DC. Rhytidectomy with lateral SMASectomy. Facial Plast Surg
2000;16(3):209–13.
Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy
hematomas. Plast Reconstr Surg 2005;115(7):2119–222.
Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy.
Anatomical variations and pitfalls. Plast Reconstr Surg 1979;64:
781–95.
Baker DC, Rees TD. Complications of cosmetic facial surgery. In: Lewis
JR. Aesthetic plastic surgery. Boston: Little, Brown; 1989.
Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hemato­
mas requiring surgical evacuation following male rhytidectomy: a
thirty year review of 985 cases. Plast Reconstr Surg 2005;116(7):
1973–85.
Baker DC, Aston SJ, Guy CL, Rees TD. The male rhytidectomy. Plast
Reconstr Surg 1977;60:514–22.
TABLE 18.1  Complications Associated With
3500 Lateral SMASectomy Facelifts
Complication
Incidence (%)
Hematoma (female/male)
1.5/4.0
Facial nerve weakness
0.1a
Earlobe scar revision
2.0
Skin slough
2.0
Retroauricular and temporal scar revisions
2.0
Infection
1.0
“Minilift” after 1 year
2.0
aAll resolved within 6 months.

219
HISTORY
The history of facial rejuvenation has mainly focused
on addressing cervicofacial laxity. In 1919 Bettman and
Bourget simultaneously presented their experience with
subcutaneous rhytidectomy [1,2]. In 1960 Aufricht was
the first to describe plication of the tissue deep to the
superficial fat plane [3]. Webster and other facelift sur­
geons used similar techniques of suturing the “deeper
layers” to improve their results [4,5]. During the same
period Skoog had started performing facelifts utilizing the
skin and platysma as a musculocutaneous advancement
flap [6]. In 1976 Mitz and Peyronie advanced the rhytid­
ectomy procedure into the modern era by describing the
anatomy of the superficial musculoaponeurotic system
(SMAS) [7]. They showed that a deeper fascial tissue layer
exists between the subcutaneous fat and the parotidomas­
seteric fascia. Their anatomic studies established that the
SMAS invests the muscles of facial expression and is con­
tiguous with the frontalis and platysma muscles. Follow­
ing Mitz and Peyronie’s description, the incorporation
of the SMAS layer in cervicofacial rhytidectomy gained
significant popularity [8–15]. In the 1990s, the deep plane
facelift and subperiosteal facelift also became increasingly
used, specifically to address nasolabial folds [16–24]. The
deep plane rhytidectomy eventually became touted as the
gold standard among all facelift techniques.
It was not until the latter half of the 20th century
when surgeons started considering that facial rejuvena­
tion requires three-dimensional considerations. In the
1970s Hinderer published studies on the use of alloplastic
implants for chin and cheek skeletal enhancement [25].
In the 1980s Binder introduced the concept of using
midface implants for three-dimensional volume restora­
tion and facial rejuvenation [26]. The introduction of
liposuction by Illouz in the 1980s gradually led to the
use of autologous fat grafting for soft tissue augmen­
tation, which was further advanced by Coleman and
Glasgold in the 1990s and 2000s [27–29]. In the 2000s
and 2010s, Pessa, and Mendelson elucidated through
elegant anatomic and radiographic studies that the aging
process is not just due to gravitational laxity, but perhaps
more importantly related to changes in the superficial and
deep facial fat compartments, as well as facial skeletal
remodeling [30,31].
PERSONAL PHILOSOPHY
Aging is a multifactorial process that affects the skin,
subcutaneous, and deep fat compartments, as well as the
craniofacial skeleton (Figs. 19.1–19.4) [29–32]. The ulti­
mate goal of facial rejuvenation is to improve the appear­
ance of patients in a natural, youthful, attractive, and
appropriate manner. Over the past decade, the author’s
view relating to rhytidectomy as the cornerstone of facial
rejuvenation has significantly changed due to a much
better understanding of the anatomic changes that occur
in the aging process [32]. The principles of “facial ana­
tomic subunits” that have long been the guiding principles
in facial and nasal reconstruction but rarely considered
in aesthetic procedures are now utilized by the author
to improve the facial shape and surface topography of
patients, as well as to create smooth transitions between
the temple, zygomatic arch, lateral cheeks, lower eyelids,
anterior midface, buccal space, mandibular jaw line, and
neck to obtain ideal results (Figs. 19.5–19.6) [33–37].
Henceforth, the rhytidectomy technique and comple­
mentary procedures should be modified to address a more
holistic approach to facial rejuvenation. Whereas in the
past, rhytidectomy was a standardized procedure per­
formed in a cookie-cutter fashion for all patients with
aging faces, it is now a customized procedure and just
one of many tools in our armamentarium for comprehen­
sive facial rejuvenation. Procedures such as autologous
fat grafting, chin augmentation, conservative periorbital
rejuvenation, and buccal space modification are often
utilized in conjunction with rhytidectomy to create facial
harmony and enhance youthful contours and shape [37].
Today, we modify the SMAS technique, undermining, and
suspension vectors to not only address jowls, cervico­
facial laxity, and platysmal banding, but also to restore
the triangle of youth that is more “heart shaped” and
aesthetic [38–50].
The key components of our rhytidectomy procedure
include limited skin undermining in the facial region,
tunneling the undissected facial and cervical tissue with
a cannula to create pockets of mechanical adhesions in
the healing process, customizing the extent of sub-SMAS
dissection depending on the desired outcome, performing
the SMAS suspension in a vector that provides appropri­
ate lifting and reshaping of the face, implementing hori­
zontal platysmal myotomy at the level of cervicomental
junction with corset platysmaplasty for individuals with
prominent banding, and using judicious cervical suction-
assisted lipectomy. By limiting facial skin flap dissection,
we maintain the anterior dermal-SMAS attachments,
which allow aggressive suspension of the face without
significant tension on the skin [49]. The SMAS serves as
the carrier of the facelift flap. The undissected areas could
safely undergo simultaneous cutaneous skin resurfacing
C H A P T E R 19 
Reshaping Rhytidectomy
Babak Azizzadeh, MD, FACS

220
MASTER TECHNIQUES IN FACIAL REJUVENATION
C
B
A
Figure 19.1  The progression of the aging face. The aging process is illustrated in this individual in her 20s (A), 40s (B), and 60s (C). The face
continuously and gradually changes, resulting in prominent nasolabial folds, jowl formation, marionette furrows, neck laxity, volume loss, facial
shape alteration, and rhytids in the perioral and periorbital region.

19  Reshaping Rhytidectomy
221
the subcutaneous dissection, the risk of facial hematoma
formation and facial nerve injury is also likely reduced.
Short skin flaps diminish the chance of flap necrosis in
patients who have compromised vascularity, such as
smokers, diabetics, and elderly patients [51,52]. We have
also seen less long-term skin atrophy and telangiectasias.
The general criticism of SMAS facelift in the 1980s
and 1990s was that it did not address the “midface,”
since it did not “flatten” the nasolabial fold. In that
era, effacement of the nasolabial fold was an important
goal of facelifts. In the past decade, our enthusiasm for
and autologous fat grafting to address photodamage, fine
or deep rhytids, volume restoration, as well as reshaping
a more youthful appearance.
The vector of SMAS suspension is typically more pos­
teriolateral in gaunt patients with major rhytids and verti­
cal in individuals with a round, square, and rectangular
facial shape. This approach addresses all aspects of the
aging process beyond just cervicofacial laxity.
We have found our rhytidectomy technique to produce
an extremely reasonable operative time, minimal compli­
cation rate, and postoperative recovery time. By limiting
B
A
Figure 19.2  Facial shape. The aging process reverses the triangle of youth (A) by widening the lower third of the face (B).
B
A
Figure 19.3  Skeletal remodeling. Underlying skeletal changes in the face (A) and the resultant effect on facial aging include widening and deepening
of the eye socket, resorption of the pyriform aperture, enlargement of nasal bones leading to nasal tip drooping, development of prejowl sulcus,
and mentum (B). (Adapted from Mendelson B, Wong CH: Changes in the facial skeleton with aging: implications and clinical applications in facial
rejuvenation. Aesthetic Plastic Surgery 2012;36(4):753.)