A Deep Dive on Deep Plane Facelift

Facelift is the big reset for facial aging, an important event that should be carefully considered.  There are different techniques.  Which one is best?  Why?  The big divide in facelift is between SMAS techniques and deep plane facelift.

What is the Deep Plane Facelift?

The deep plane facelift involves dissecting underneath the SMAS allowing direct division of the retaining ligaments so that soft tissues of the face can be mobilized and repositioned as a single unit.  The deep plane facelift is a technique that was first developed in 1990 by a plastic surgeon names Sam Hamra who trained at NYU in New York but was practicing in Dallas.  The intent was to provide a more complete and longer lasting correction.  Also, as with many new facelift techniques in the 1990’s, the focus was on improving the position of the midface with particular emphasis on greater correction of the nasolabial fold.  Research studies performed in the 1990’s and early 2000’s were not able to prove any of the potential advantages and Dr. Hamra had largely abandoned the technique towards the end of his career.  So why is the technique so popular today?  Is there new data that proves some advantages?

Dissection  has been simplified to make the procedure safer and reduce recovery while preserving the ability to release the SMAS and mobilize the tissues as a single unit.  Unquestionably, the technique can give excellent results.  But is it better?

Here’s my view:

There is still no evidence based medical data that proves an advantage for this technique.

Correction of lax neck skin, muscle banding in the neck and creation of a sharply defined jawline are the major focus of facelift/necklift surgery and align with the priorities expressed by most patients who rarely come in asking for cheek shaping or nasolabial correction as the major issue for having a facelift.

SMAS techniques still allow for release of retaining ligaments if they are preventing mobilization and for shaping of tissues in the midface.  However, these tissues are often lax enough to reposition as needed for maximal rejuvenation without deep release.

Fat grafting techniques, which were not in widespread use for facial re-volumization 1990, are commonly used today to amplify the degree of shape restoration in the face during a facelift.

A deep plane facelift allows only a single vector of repositioning of the unified tissues.  SMAS techniques are multiplanar, allowing the SMAS in the face and the mobilized muscles in the neck to be moved in different directions from each other and from the skin in the face and skin in the neck.  I believe this makes it easier to get a full and complete correction while preserving a natural look.  I focus on using techniques that maximize my ability to customize the procedure for each patient’s individual needs.  The SMAS techniques with a multiplanar approach allows me more flexibility than the deep plane approach.

SMAS techniques allow a range of approaches from imbrication of the intact SMAS, to release and mobilization of the SMAS with imbrication for augmentation of shape or even resection of redundant SMAS in a heavier face.  All of this can be done with or without fat grafting.

Important Take-Aways:

There is no right technique or best technique.  As an experienced facelift surgeon, I use individual modifications of  advanced techniques that are adjusted for the findings in each individual patient.  The knowledge, experience and artistry of the facelift surgeon is more important than any technique per se.  The surgeon’s clinical experience and judgement in applying whatever technique is selected is the most important component of getting an extraordinary result with a facelift.  This is different from device treatments where the technology brings what is special.

In skillful hands, a facelift leaves you looking natural, rested and like yourself with no obvious tell-tales that you’ve ever had plastic surgery performed.


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Doreen Wu (00:00):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I’m your cohost Doreen Wu I’m excited to be here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. Today we have a special guest Dr. Jason Bloom, facial plastic surgeon from Bryn Mawr Pennsylvania. The title of today’s episode is a deep dive on the deep plane facelift. Dr. Bass, everyone wants the best possible result when they undergo a major procedure like a facelift. The deep plane facelift seems to be a popular technique. Can you tell us more about this approach?

Dr. Lawrence Bass (00:43):
Sure. Doreen, I mean the basic definition of the deep plane facelift, it is a facelift that involves dissecting underneath the SMAS, the connective tissue in the face, allowing direct division of some of the retaining ligaments so that all of the soft tissue of the face can be maximally, mobilized, and repositioned. The procedure was initially developed by a surgeon named Sam Hamra in 1990 and Dr. Hamra, who was trained at NYU in plastic surgery, where I trained, uh, but practiced in Texas wanted ways to improve the facelift. And he was hoping to get a more complete correction by mobilizing the tissues more thoroughly and moving them in a group or a composite state over time. However, the amount of dissection involved raised some concerns and studies were done to see if it was either giving us a better correction or a longer lasting correction. And there were some studies that followed patients longitudinally over time, and some studies that treated twins, one with one facelift technique, a, a SMAS multi-component technique, and one with a deep plane technique and those studies did not in the end of the day show that there was an advantage to the technique at that point in time. And that point in time was somewhere around the year, 2000 just to put a round number on it. So by the end of his career, Dr. Hamra had largely abandoned the technique and agreed that it had not shown as much advantage as he had hoped.

Doreen Wu (02:37):
So plastic surgeons essentially looked at the technique and in large part moved past it, but all this time later, the deep plane facelift still seems to be a crowd pleaser. Why is that?

Dr. Lawrence Bass (02:49):
I’m gonna let our guest answer that question, but first let me introduce him. Dr. Bloom is a friend and colleague and we’re, we’re part of this group that see each other, not at home, but about when we’re working with companies, when we’re lecturing, when we’re attending meetings, uh, he is in a very experienced and talented surgeon, friend and colleague, uh, with extensive experience in facelift, making him a facelift expert. He did his facial plastic surgery training, likewise at NYU and Manhattan eye, ear, and throat hospital, uh, where I did. Uh, so I’ll let him add what the history of the procedure is going forward from that, that point in time, about 20 years ago.

Dr. Jason Bloom (03:41):
Well, first of all, thank you, uh, Larry, and thank you Doreen for having me on your podcast. It’s certainly a pleasure and honor to be here. Um, I have been doing, um, deep plane facelift in my practice for the past, about 12 years. Um, it’s interesting because, you know, Hamra originally developed this technique and he came out with his, uh, you know, essential paper in 1990 and to rejuvenate more of the nasolabial foldin dissecting deeper, he was saying, you know, it, it, it’s not a great look to have kind of a, a tight jaw line and still have some laxity or redundancy in the nasolabial fold. Um, his technique is, uh, or as he called it, the composite facelift later on involved is slightly different than what I do today.

Dr. Jason Bloom (04:45):
I mean, I think, um, what, what he did was dissecting underneath the orbicularis oculi muscle. And in, in lifting that up, there was concerned about prolonged swelling around the eye because that muscle is innovated by some of the nerves from underneath. And if you’re dissecting underneath that muscle, you can have some weakness in the eye. Um, so that definitely caused some pause for a lot of surgeons. I mean, what I do from a technical standpoint at this time is, um, I do a small amount of, um, dissection subcutaneously to the level of what we call the deep plane entry point, which is basically line from the lateral can the side of the eye to the angle of the mandible. At that point, we’re going underneath the SMAS, which is the connective tissues of the face, really the muscle, the musculature of the face.

Dr. Jason Bloom (05:44):
And it’s important when I’m talking to patients even is I explain to them is facelift facial rejuvenation surgery and facelift surgery is not a surgery of the skin. It is surgery of the muscle. And in order to get the most amount of lift or excursion of the muscle, it’s important to release. And I say, good lifting surgery result starts with really a complete release of the retaining ligaments of the face. And that’s in the cheek in the, along the jawline and then in the neck. So by releasing those, those ligaments, it allows for more mobilization of the tissues to resuspend it. So what I consider facial rejuvenation surgery is release and resuspension. So I do a little bit different than what Hamra originally talked about because I’m going over the eye muscle, the orbicularis muscle, but underneath the SMAS to release it.

Dr. Lawrence Bass (06:49):
So let me just back up for a second, because you raised an interesting point of history. The big thrust on facelift advances in the 1990s was an attempt to make a better correction of the nasolabial fold. I think that’s been transcended at this point by attempts to create better facial shaping in the mid face with cheek shape. And again, amplifying the degree of correction in the neck, which is really where the money is in, in face and neck lifting.

Dr. Jason Bloom (07:24):
Yeah. I’ll totally agree with that. Um, mainly because, um, having a great sharp jawline and neck will far exceed any kind of like volumization in the mid face in most of my patient’s minds. Um, one of the other reasons why I, I like this technique personally, is because of the dynamics of the, um, of, um, and really the physics behind what we’re doing. Many people use something called a high SMAS lift. And when you’re doing a high SMAS face lift, most of the tension or the, uh, the resuspension is out over the zygoma, lateral in the face, and then in front of the ear, like a backward seven, but when you’re doing like a deep, plane face lift, all of the resuspension is more anterior. So it’s a simple game of pulleys and levers. If you want to lift something in this case, let’s say the jowl or the midface, you get more correction. If your tension or your resuspension point is closer to your target versus further away, if you’re pulling away lateral in the face, you’re not, it’s harder, it’s a longer run to address the jowls and the midface

Dr. Lawrence Bass (09:00):
And how and direction concept has changed. Also, probably in the last 20 years. And Hamra actually talked about that. He had much to say in a negative way about lateral pull in the face, and some of the unnatural changes that could create and some of the limitations in how much correction you could obtain.

Dr. Jason Bloom (09:27):
Yeah, definitely. It’s more of a, what I say is a more vertical or superolateral kind of, um, movement of the SMAS in the face and more of kind of a lateral movement of the SMAS in the neck. So, I mean, you can see in some patients where they maybe have a good correction of the jowl, but there’s a point where it hasn’t been released in the midface. And it tends to give kind of like a bunching around the midface or a wind swept approach. The more lateral you bring the face, but natural correction and, uh, natural facial rejuvenation surgery is more of that kind of superior lateral or vertical vector approach in the face itself.

Doreen Wu (10:18):
That makes a lot of sense. It sounds like a great approach, Dr. Bass, is that your view as well, or are you doing something different?

Dr. Lawrence Bass (10:25):
Well, I’m not using a deep plane approach per se. I mostly do a multiplayer approach in my facelift rather than a single plane lifting. So there is extensive skin undermining within some sort of procedure addressing the deeper layers. And that procedure varies depending on the individual patient’s findings and what their facial shape is like, do they have a heavy face? Do they have a very gone, thinned out face that needs augmentation and needs a lot of shaping and suspension? So I like having the ability to go in different directions with different layers and adjusting the amount of correction rather than correcting the entire mass of soft tissue and a single layer. Sometimes I use imbrication sometimes I, in addition, add fat grafting, depending on the individual patient’s needs.

Doreen Wu (11:30):
I see how you have many different ways of adjusting for individual faces and needs. It’s important to customize every facelift to kind of meet each patient’s specific needs and their desired outcomes, which leads me to my next question. Dr. Bloom is the deep, plane facelift, a universal procedure in your practice, or is it best for certain kinds of faces or certain stages of aging? In other words, are there some exceptions to its universal use?

Dr. Jason Bloom (11:58):
Yeah, I mean, I would say that nothing is universal in my practice. Certainly. However, I, this is my preferred technique for about 90% of the lifts. I do. I think some of the cases that do well specifically with this approach are, um, a heavy jowled patient where we’re lifting up one composite flap and, um, you need some like a strong SMAS that you’re going to resuspend and it’s important if someone has heavy jowling to release completely some of the cases that might not need something is more of a thin skinned patient. I think the deep plane face lift does give you a fair amount of mid face augmentation as well. Um, so I tend to do less fat grafting, but a patient with thinner skin, um, just a thinner patient overall. That’s a great patient for fat grafting because a deep plane might not give you the amount of, as Larry was saying, like, midface augmentation or facial shaping that they need. The one other thing is patients with, um, you know, I don’t like to operate on smokers, however, um, some patients with maybe wound healing issues or diabetes, things that might not heal a longer skin flap as well. Most of the skin is attached to the underlying tissues with the deeper face deeper plain facelift. And there’s less skin undermining, which gives, um, which allows for a little bit less risk to the, the skin edges.

Dr. Lawrence Bass (13:48):
Yeah, that’s, that’s an important consideration and including various supplemental or augmentation type procedures as appropriate for the patient, you know, that that kind of customization is kind of sinequanone of facial rejuvenation. We always have to adjust for the individual patient.

Doreen Wu (14:13):
Both of you mentioned some other supplemental techniques or procedures that are commonly done with facelifts. What are some of these other ones besides fat grafting?

Dr. Jason Bloom (14:23):
I mean, typically when I say most of the patients in my practice who are between the ages of, uh, mid 50 to mid 60, about 85% of those patients in my practice are seeking some kind of aging face surgery. And within that I consider eyelid surgery face neck surgery, as well as something that’s become a little bit more popular recently is upper lip rejuvenation or lip lift surgery. All three of those are, um, signs of aging. So typically I think it’s infrequent this week, actually I’m doing two face lifts and both of them are just lower face and neck lifts. It’s, it’s been a while since I’ve done that without some kind of periorbital rejuvenation surgery. Um, additionally I do fat grafting when needed in some of the thinner patients. And then, um, in the patients who have a longer philtrum or a longer upper lip, I will shorten that with like a modified Bullhorn lip lift surgery.

Dr. Lawrence Bass (15:37):
I also think energy based treatments to try to take aging skin and make it look more youthful, uh, especially ironing out wrinkles, because that obviously creates a lot of aging appearance, but that older skin, even though we get it in the right place with the facelift, uh, it’s still older skin and we need to work on that either can confidently or at another sitting or a series of treatments to try to improve the youthful character of that skin.

Dr. Jason Bloom (16:13):
I, I totally agree with that. I mean, I can’t tell you how many times patients have come in and they want facial rejuvenation surgery, but they’re very concerned for example, about their perioral wrinkles and rhytids. And I say, well, this surgery is not gonna improve that. You need some kind of resurfacing or laser technique or deep chemical peel, something like that to improve the skin envelope. So doing that can confidently or as a stage procedure with facial rejuvenation surgery is extremely important.

Doreen Wu (16:46):
So Dr. Bass, after extensive discussion of all of these different techniques and other procedures, what are the important takeaways for people to know when considering a facelift?

Dr. Lawrence Bass (16:57):
Well, you know, people ask what’s the right technique or the best technique. And it’s really hard to do a large study and prove the benefits of one technique over another. So it means it’s hard to make hard claims about the advantages of one technique, but we’re expressing our individual clinical opinions about what works well in our hands, uh, experienced facelift surgeons, each use their own individual modifications of general techniques and they further modify for the individual patient to customize the result because everyone’s face is different. A talented facelift surgeon is more important than an individual technique doing something extraordinarily well and having the clinical experience and judgment to apply it appropriately to the individual face is really the key to getting great results. This is very different from device based treatments where the special sauce is in the device, more than in the operator, but with facelift, it’s really the experience of the operator regardless of the individual technique. The modern facelift is an unrivaled way to make a major reset for facial aging and in skillful hands, it leaves you looking perfectly natural, rested and looking like yourself, Dr. Bloom, do you have any to add to the list of takeaways?

Dr. Jason Bloom (18:27):
I mean, I could not agree more with what you’re saying. Um, patients trust the surgeon, they don’t trust a name procedure, and that’s why some companies that try to make a, the facelift or mini face lifts into a small procedure where they didn’t even meet the patients. I tell patients, let me, if, if you trust me to do your surgery, let me do what I do best. Don’t try to fit a surgeon into a different box, allow them to do what gets them a great result. You wouldn’t want me doing a surgery that I’m not comfortable with just for the sake of doing that surgery. So patients should pick a surgeon that they trust that has reputable results and, and trust that they’re going to look, um, rejuvenated and natural. And the beauty of today’s modern facelift surgery and facial rejuvenation surgery is that, um, we’ve seen and these things have evolved and, you know, gone are the days of like skin only facelifts, which looked very wind swept and pulled to a really naturally rejuvenating procedure that we do today.

Dr. Lawrence Bass (19:53):
I’d like to thank Dr. Jason Bloom for joining us for this episode and for his very thoughtful expert commentary.

Dr. Jason Bloom (20:01):
Thank you guys so much Dr. Bass Doreen for having me today. It’s always good to see you. Um, I look forward to seeing you guys in person some day soon. But again, thanks for having me. I always enjoy talking to you guys.

Doreen Wu (20:20):
I’ll also add my thank you to Dr. Bloom for his thoughts and insight. It has been a pleasure having you on here and thank you for being our very first guest on the podcast. I hope this episode has provided you with lots of food for thought, thinking about having a facelift is often an anxiety provoking experience, and there are many things to consider having some basis for understanding the different options available is very useful. If you have any remaining questions for Dr. Bass and Dr. Bloom, please reach out via email or Instagram, and we would be happy to answer them in a future episode. This is Doreen Wu, thanking you for joining Dr. Bass, Dr. Bloom, and me for this engaging discussion of the deep plane facelift. Be sure to tune into our next episode where we explore the double edged sword of injectable fillers in facial rejuvenation. As always, don’t forget to subscribe to our podcast, to keep up with all of the exciting content that is coming your way.

Speaker 4 (21:16):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.