Deep Plane Facelift
3 December 2019 onur
Before reading this post, I suggest you take a look at my blog post titled “What is SMAS?”
The story begins like this: In the early stages of facial rejuvenation surgery, we thought that aging was caused by the skin and occurred in the skin. This was because the signs of aging appeared on the “surface” of the skin. The simplest solution that came to mind was to stretch the loose skin and seek a solution to these problems that we see on the surface. That’s exactly how we did it, lifting and stretching the loose skin of an old face, removing the excess and suturing it nicely to leave a gentle scar around the ear. It turned out well – the wrinkles decreased, and the form of the face improved.
Those first facelift surgeries were miraculous for that period. Believe it or not, even if you were the richest and most powerful woman in the world 100 years ago, it was not possible for you to interfere with the aging process. Those “classic” facelift surgeries that we don’t like today were a great privilege that only the jet set could have in the early 1900s.
Every son strives to be better than his father. If he can, he surpasses him. But it is impossible not to give the fathers their due. If classical facelift surgery is performed well, highly successful results can be obtained in the appropriate patient group. We can imagine the deep plane facelift as a businessperson who takes over their father’s legacy and turns the family business into a holding.
“Plane” means “level surface” in surgical terminology. In other words, the anatomical planes on which we separate the tissues from each other during surgery.
The surgical plane called “deep plane” in facial rejuvenation surgeries refers to what is below the SMAS layer. When we move under the SMAS layer and lift the face along the deep plane under this layer, we can mobilize not only the patient’s skin but also the entire soft tissue mass that loosens and sags due to aging and gravity.
Working in this layer requires detailed anatomical knowledge and technical competence. It is unforgiving. It slightly extends the time spent during the procedure. However, there are important advantages coming with it.
The deep plane facelift was popularized by Tord Skoog, a Swedish plastic surgeon, and was ultimately refined in the hands of American plastic surgeon Sam Hamra. On the other hand, many surgeons have adopted simpler alternatives than this technique due to the practical technical difficulties, and the deep plane facelift has not reached the popularity it deserves.
In Skoog’s time, all hospitals in Sweden were publicly owned and there were legal barriers to plastic surgery under anesthesia in public hospitals. Back then, classical facelift surgery was typically known as a hemorrhagic surgery, and stopping the bleeding was one of the surgical stages that took time and required anesthesia. Skoog discovered that bleeding was much less when he worked in the deep plane below the SMAS layer. He overcame legal obstacles and began to perform the surgery under local anesthesia.
The deep plane is a natural zone of separation between tissues and is relatively avascular. That is why deep plane facelift surgeries typically cause less bleeding, a smaller risk of postoperative collection of excess blood and less postoperative edema.
Since a thicker tissue is lifted in deep plane facelift surgery compared to classical facelift surgery, the disruptions in tissue circulation and the tissue loss in classical facelift surgery are less common. It is more advantageous to employ this technique in patients at risk for circulatory disorders such as smokers and diabetics.
Contrary to classical surgery, deep plane facelift surgery does not create excessive tension on the skin, and it is the SMAS layer that carries the load. Since the skin is not much stretched, the surgical signs (earlobe shift, hairline shift, excessively tense and flattened facial contour, enlarged scars, etc.) due to skin tension after classical facelift surgery are much rarer in this technique.
Another advantage is that the results of the surgery are more permanent compared to the classical technique. The skin is elastic. When exposed to tension for a certain period of time, it stretches and becomes looser, just like it does in pregnancy. Therefore, the effect of facial rejuvenation surgeries due to skin tension ends when the skin loosens and sags again. The SMAS layer in deep plane surgeries is not as flexible as the skin and can maintain the new position given in surgery for about 10 years.
The best candidates for deep plane facelift surgery are the patients whose face is full in terms of soft tissue and who have few superficial fine wrinkles but advanced sagging due to gravity.
Deep plane facelift surgery also has some disadvantages and limitations. Its effect is limited on thin faces where aging is more “superficial”, fine wrinkles on the skin are more common and soft tissue sagging is less. Another issue is that deep tissue movements and superficial tissue movements must be in different directions in some patients.
Multi-layered (lamellar) techniques in which the skin and SMAS layer are lifted in separate layers and moved in different directions have proven to be useful in overcoming some limitations of deep plane facelift surgery mentioned above. I will soon write about the multi-layered (lamellar) techniques, which are the most preferred option in my own practice.
Until then, take good care…
… of yourself and your beauty.