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Comparison of Conventional
and Deep Plane Facelift
Andrew J. Miller, MD; H. Devon
Graham III, MD
Revitalization of the aging
face is a complex process that must include several components all
working together in harmony to create a natural, youthful
appearance. As more details of the facial anatomy have been
described, the facelift operation has expanded tremendously to
include deeper layers of the face with a goal of achieving both a
longer lasting effect from surgery and a more complete
recontouring effect of the melolabial fold. A comprehensive
understanding of the anatomy of the face and the different
procedures available is necessary in order to perform
facelift surgery effectively and safely.
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The ability to recreate a
natural, youthful appearance has been a goal of plastic
surgeons for over a century. The facelift operation strives
to achieve a recontouring of facial soft tissues through
alteration of specific areas such as the nasolabial fold, an
irregular jawline, and the check and neck area. The term
rhytidectomy is a misnomer in that the facelift operation is
not an operation for rhytids (wrinkles). Instead, a
resurfacing procedure with the CO2 laser is needed to
address this problem. When performing any type of aesthetic
facial plastic surgery, the surgeon must evaluate not only
the area in question but also the relationship of that area
to the entire face. This rule applies especially to the
facelift operation because in order to obtain a natural
appearing face, the patient may need additional procedures
such as blepharoplasty,
brow1ift, or cervical recontouring.
This paper provides a comprehensive discussion of the
concepts necessary to master when performing a facelift.
First, the details of facial anatomy are reviewed because a
clear understanding of the anatomy is paramount in
performing the facelift operation effectively and safely.
Next, the physiology of aging is discussed to demonstrate
the specific areas to address during the operation. Then,
conventional and deep plane facelift operations are
explained in detail with a subsequent comparison of the two
methods. |
PHYSIOLOGY OF AGING
In order to achieve facial rejuvenation with any facelift
procedure, the surgeon must first understand the physiology of
aging. As a person ages, the skin loses elasticity and the
retaining ligaments begin to loose strength . The subcutaneous
fibrofatty layer begins to descend secondary to gravity, which is
manifest in several areas of the face. First, the bunching of the
lateral portion of the melolabial fold is a result of the descent
of the malar fat pad. The medial part of the fold remains flat
because of the lack of fibrofatty tissue in this area as well as
the strong attachment of the healthy orbicularis oris muscle to
the dermis. Also, the zygomaticus muscles remain in the same
location with aging as demonstrated by MRI studies. Therefore, the
major contributor to the melolabial fold is the malar fat pad,
composed of fibrofatty tissue, which descends over a relatively
immobile muscle layer. Also, the descent of the malar fat pad may
result in an infraorbital hollowing effect. In addition to the
deepening of the melolabial fold, the descent of the fibrofatty
layer of facial tissue also results in jowling, or an irregularity
of the jawline, manifested by a sagging of the facial tissue about
the mandibular retaining ligaments. The masseteric cutaneous
ligaments also weaken with age causing a mid-check ptosis. In the
neck, lipodystrophy and platysmal banding occur and may be
addressed at the same time as midface rejuvenation.
CONVENTIONAL FACELIFT
Facelift procedures can
wary extensively, so the surgeon should become familiar with the
different techniques available along with the benefits and
complications of each. In general, the facelift operation can be
divided into conventional and deep plane procedures. The
conventional procedures are performed primarily in the superficial
plane and do not pose as significant a risk to the facial nerve. A
conventional facelift may involve only a subcutaneous elevation
and redraping of the skin; this has been done for almost a
century. In 1974, Skoog first described a facelift in which the
deeper fascial layer as well as the skin and subcutaneous fat was
mobilized. These deeper tissues were dissected and redraped in an
attempt to provide a longer lasting effect. Since the formal
description of this fascial layer, or SMAS, in 1976, multiple
procedures involving the SMAS have been reported. Several types of
conventional SMAS techniques are employed that place the facial
nerve at minimal risk, including plication, imbrication, and SMAS
elevation to the anterior border of the parotid gland.
The techniques of conventional facelift will vary from surgeon to
surgeon, but in general, the methods are relatively simple and
effective. Pre- and post-auricula incisions are placed, making
sure to notch the incision postauricularly to avoid contracture.
Then a wide subcutaneous pre-SMAS/platysma flap is elevated,
taking care to dissect over the malar eminence and mandibular
areas to release the retaining ligaments. This subcutaneous plane
is above the SMAS, so dividing the retaining ligaments in this
area will not place the facial nerve at risk. The next step
involves making a determination regarding the mobility of the SMAS.
If the SMAS is mobile, it may be plicated or folded upon itself
and sutured to the fascia of the parotid gland, mastoid bone, and
sternocleidomastoid muscle. If the SMAS is not very mobile, a
limited SMAS flap can be developed. This flap is created by first
making an inverted "L" shaped incision in the SMAS 1 cm inferior
to the zygomatic arch in a horizontal direction, and then 1 cm
anterior to the preauricular incision in a vertical direction. The
SMAS is then elevated only as far as the anterior border of the
parotid gland so as to not endanger any facial nerve branches. The
SMAS flap is then resuspended in a more superior direction to
achieve the lifting effect, tightly suturing it to the same
fascial structures as with plication. Finally, the skin is
redraped in a more posterior and slightly superior direction
preserving the natural hairline, and the excess skin is removed.
The incisions are closed with minimal tension over a drain.
The conventional procedures are very effective in correcting
contour deformities of the jawline, lower cheek, and neck. These
methods are quite reliable and entail few complications. However,
the melolabial fold is not well treated with the conventional
facelift. Surgeons have discovered that pulling on the SMAS during
conventional facelift operations results in no change of the
melolabial fold because the retaining ligaments were still in
place between the SMAS and the deeper tissues. Therefore, as the
anatomical aspects of the facial planes became recognized, the
deep plane techniques were created and have evolved in order to
mobilize the melolabial fold and to lengthen the effect of the
facelift operation.
DEEP
PLANE FACELIFT
If the goal of a deep plane facelift is to smooth the
melolabial fold and to acquire a longer lasting effect with SMAS
repositioning, it is necessary to first recall the pertinent
anatomy. The surgeon should remember that the main contributor to
the melolabial fold is the ptosis of the malar fat pad, which
descends secondary to gravity and the increasing weakness of the
retaining ligaments. The fat pad descends while the underlying
musculature remains active and in a normal position. Also, when
considering SMAS redraping, it is important to realize that the
SMAS invests the zygomaticus muscles and inserts into the
superficial part of the orbicularis oris. Therefore, the goals of
deep plane facelift should be to mobilize and elevate the malar
fat pad and to completely free the SMAS of its muscular
attachments so that it may be repositioned effectively. Early deep
plane lifts extended the SMAS flap dissection, releasing the SMAS
anteriorly through the retaining ligaments, but not releasing the
SMAS from the zygomaticus muscles or the orbicularis oris.
Therefore, when the SMAS was redraped, the result was a bowstring
effect of the zygomaticus muscles that actually deepened the
melolabial fold and lifted the corner of the mouth.
In order to address the malar fat pad and the SMAS, attachments to
the underlying musculature, the extended deep plane facelift
procedures were designed. Mendelson, in 1992, proposed a technique
that begins with limited subcutaneous undermining. Then the SMAS
is incised as in the conventional facelift, and an SMAS
flap is elevated in a relatively avascular plane between the SMAS
and the thin underlying parotidomasseteric fascia, with the facial
nerve branches just deep to this plane. This elevation continues
anteriorly in an extremely meticulous manner, stimulating and
dividing the retaining ligaments while watching carefully for
any facial nerve branches that may be present. When SMAS flap
elevation reaches the zygomaticus major muscle, the SMAS is
completely released from this muscle and then resuspended.
Problems with this dissection include a limited subcutaneous
undermining so that the malar fat pad is not completely mobilized
to its medial extent. Also, the SMAS is not totally free because
its attachment to the orbicularis oris is not released. Therefore,
this deep plane procedure, while recontouring the jowl and cheek
effectively, results in an incompletely treated melolabial fold.
Barton along with Stuzin and Baker approached their extended
techniques differently from Mendelson. These surgeons also
mobilized the SMAS from the zygomaticus major, but in
addition, they liberate the SMAS from the obicularis oris muscle.
After completely and carefully releasing the SMAS, their
dissection continues medially elevating the malar fat pad beyond
the melolabial fold. This total release of SMAS allows a
long-lasting recontouring effect and the complete fat pad
elevation and redraping smoothes out the melolabial fold
effectively.
Hamra is the surgeon who, in 1990, coined the phrase deep plane
facelift which simply means that elevation of the malar fat pad
over the zygomaticus major muscle takes place in the deep
subcutaneous plane, lifting the entire fat pad to smooth the
melolabial fold. If undermining of the malar fat pad occurs in the
shallow subcutaneous plane, the rest of the fat pad remains fixed
to the zygomaticus muscles and the melolabial fold is not treated
effectively. Hamra performs much the same operation as Barton,
Stuzin, and Baker with complete SMAS release and malar fat pad
elevation, but he also feels that simply repositioning the fat pad
does not completely correct the infraorbital hollowing associated
with aging. Therefore, his flap also includes the orbicularis
oculi which he terms the composite flap. Also, in order to help
fill infraorbital bony defects, he releases the orbital fat with
an arcus marginalis incision. The composite flap also results in a
pleasant recontouring effect with excellent treatment of the
melolabial fold.
The subperiosteal facelift is a different deep plane facelift
approach that is based on an older concept that the bony
attachments of the facial mimetic muscles are responsible for the
deep SMAS fixation. Therefore, Psillakis, Tessier, and later
Ramirez designed and modified the subperiosteal approach to
recontouring. This approach utilizes both bicoronal and
Caldwell-Luc incisions to release the bony attachments of the
mimetic muscles and all other facial tissues in the subperiosteal
plane, and resuspends the entire facial soft tissue structures
like a mask. While apparently effective in achieving a
long-lasting result from the operation., this procedure does not
address the true problem of the melolabial fold because the malar
fat pad is not elevated from the deeper tissue and resuspended for
a smoothing effect.
CONCLUSION
Recontouring of the aging
face involves treatment of specific areas such as the melolabial
fold, mandibular jowling, and cheek ptosis in combination with
other necessary procedures. The surgeon should always remember the
important anatomical concepts including the muscular attachments
of the SMAS and the ptosis of the malar fat pad producing the
melolabial fold. Knowledge of the distribution of the facial nerve
including its occasional presence within the retaining ligaments
of the face and on the superficial surface of the mimetic muscles,
is vital to the safety of the facelift operation. The conventional
facelift operation provides a very effective treatment for jowling
and cheek ptosis, while the deep plane facelift better addresses
the melolabial fold and may produce a longer lasting effect,
although definitive studies are not available. In general, as long
as the surgeon strives to achieve the goal of aesthetic surgery,
which is to make the patient happy without incurring
complications, he or she will be successful in facial rejuvenation
surgery. |
