Deep Plane Rhytidectomy

Rhytidectomy (facelift) is one of the most commonly performed plastic surgery procedures in the head and neck. Traditional approaches to facelift, such as superficial musculoaponeurotic system (SMAS) imbrication or plication procedures, can significantly improve changes in the lower face and in the neck caused by aging. ^[1] These procedures are discussed in the Medscape Drugs & Diseases article SMAS Facelift Rhytidectomy.

The deep plane facelift was developed as a modification of standard facelift techniques to correct facial changes caused by aging that are due to ptosis of midface structures (malar fat pad). The deep plane facelift also attempts to correct deep nasolabial folds. ^{[2, 3, 4]} Other techniques (excluding specific midface procedures) do not adequately address these problems.

In carefully selected patients, deep plane rhytidectomy can be safely performed with a high level of patient satisfaction. The surgeons' goal is to obtain a pleasing aesthetic result that appears natural and provides no evidence of an operation. This article discusses the preoperative evaluation and surgical techniques that help surgeons select patients who may benefit from a deep plane rhytidectomy procedure.

Traditional facelift techniques, such as SMAS imbrication or plication rhytidectomy, may adequately treat changes in the lower face caused by aging, such as jowling of the lower face or platysmal banding in the neck; however, these techniques do not adequately address aging changes due to ptosis of midfacial structures and a deep melolabial fold. The deep plane rhytidectomy evolved as a technique designed specifically to address aging changes in these areas.

A survey by Shehan et al, primarily of surgeons certified by the American Board of Facial Plastic and Reconstructive Surgery or the American Board of Plastic Surgery, found that with regard to midface rejuvenation techniques, respondents preferred deep plane rhytidectomy (18.60%) over subperiosteal lift (7.91%). ^[5]

Frequency

Not every patient with aging changes in the lower face has ptosis of the midface or a deep melolabial fold. Patients without may be candidates for other procedures that usually have a shorter healing period and involve less risk to the facial nerve, such as an SMAS flap, plication, or imbrication facelift.

Aging occurs as a natural phenomenon.

The deep plane facelift allows direct lifting of the malar fat pad with the overlying skin. This area can be repositioned with sutures to improve aging changes in the midface.

Obtain a general medical history. The patient should be in good enough health to undergo a 3- to 4-hour elective surgical procedure. Note any history of bleeding tendencies or the use of medications that may cause bleeding abnormalities. Patients should discontinue any anticoagulating medications for an appropriate period to prevent intraoperative bleeding problems.

Evaluate the patient's goals and expectations. This information is typically obtained during the initial consultation and should be reviewed prior to surgery to prevent any miscommunication. Confirm that the patient's goals are realistic and that these goals cannot be met with a less extensive rhytidectomy procedure or other cosmetic procedures.

The patient should clearly understand the risks and different options available to treat facial changes caused by aging before giving informed consent. In general, deep plane rhytidectomy has a higher risk of injury to branches of the facial nerve and takes slightly longer to heal than other facelift techniques.

Candidates for a deep plane rhytidectomy should have significant facial changes caused by aging in the region of the midface and melolabial fold.

The SMAS is a layer of muscle and connective tissue that overlies the parotidomasseteric fascia and envelops the mimetic muscles of the face and the platysma in the neck. Branches of the facial nerve leave the parotid gland and pass medially towards the midfacial musculature beneath the parotidomasseteric fascia.

If dissection in the lower face remains below the SMAS and above the parotidomasseteric fascia, injury to branches of the facial nerve is avoided. This sub-SMAS dissection can safely proceed medially as far as the facial artery and vein. Anterior to this point, the nerves innervate the perioral musculature, and the possibility of nerve injury increases. Dissection in the lower part of the face up to a level just below the origin of the zygomaticus major and minor muscles is performed in the sub-SMAS plane. By necessity, dissection in the midface to separate the malar fat pad and skin complex from the deeper structures is performed above the SMAS. As a result, the nerves innervating the zygomaticus major and minor muscle complex, which enter these muscles from their deep surface, are not injured. To accomplish this goal, the sub-SMAS dissection is stopped in the lower part of the face at a level approximately 1 cm below the zygomatic arch.

Identification of the orbicularis oris muscle and the origin of the zygomaticus major and minor muscles is a key part of the operation. Dissection is facilitated into the midface in a safe plane just above the orbicularis oris and zygomaticus major and minor muscles to the melolabial fold and into the upper lip, if needed. A thick subcutaneous flap is created that contains the malar fat pad attached to the skin and allows for repositioning of the malar fat pad–skin complex in a more youthful posterior-superior direction.

Anatomic details relevant to this technique are further discussed in Intraoperative details.

Relative contraindications include poor medical health, patients who require blood-thinning medications on a regular basis, patients with unrealistic expectations, and patients who smoke. It should also be used with caution in secondary facelifts unless the original procedure did not involve a sub-SMAS technique, as scarring from the original procedure may obscure the tissue planes and place the facial nerve at undue risk.

Although some authors advocate a deep plane facelift for patients who smoke because it provides a thicker flap and may preserve arterial perforators to the skin, any facelift in a patient who smokes has increased risk of postoperative wound complications.