Deep Plane Facelift and Vertical Dual-Plane Facelift
What is the Deep Plane Facelift?
The deep plane facelift, originally described by Sam Hamra in 1990, utilises a plane of dissection below the superficial muscular aponeurotic system (SMAS) of the midface. This approach allows the resection of key facial retaining ligaments. This very important step in facelift surgery makes a maximum mobilization of the superficial soft tissue of the face possible. The facial skin and the SMAS can be lifted together. To hold the skin-SMAS flap in the desired/rejuvenated position sutures are only required at the level of the fascia/SMAS and not in the skin, the deep plane technique creates a tension-free skin closure and ensures long-term results.
A properly executed deep plane facelift can produce dramatic and sustainable rejuvenation to the lower face and the midface with a very natural lift without any signs of pulling.
Some colleagues using this technique have rebranded it for PR reasons to "Vertical Restore", TCF lift or Auralift. All of these facelifts are deep plane lifts, and in my opinion this technique represents the cutting edge in facelift surgery.
What is the difference between a deep plane facelift and an extended SMAS lift?
The extended SMAS lift and the deep plane facelift use the same natural glide plane between the SMAS and the parotid-masseteric fascia. In both techniques the facial ligaments are disrupted or resected to achieve full mobilisation of the SMAS.
The difference is that in the extended SMAS lift, the skin of the face is detached from the underlying SMAS in a first step before mobilising the SMAS, then SMAS and skin are lifted separately. In a deep plane facelift the facial skin is hardly separated from the underlying SMAS and both layers, SMAS and skin are mobilised and lifted together as a composite flap.
What are the benefits of each technique? Which one do you prefer?
There is an ongoing debate as to which facelift technique is superior.
The main advantage of the extended SMAS lift is that the facial tissue can be lifted in 2 different vectors and thus a surgeon can individually influence the cosmetic outcome of the facelift. In the deep plane facelift, the pulling vector is one vertically oblique vector of about 60 degrees which creates a great lift of the cheek tissue, but fails to create extra volume over the midface. Studying the endless before-after photos of purely deep plane facelifts showed smooth but flat side view of a patient’s face.
The disadvantage of lifting skin and SMAS separately is the difficulty of lifting the fragile and thin SMAS layer. The goal of a good lift is to lift the sagged facial tissue that creates the much-hated bottom-heavy face of a patient who seeks a facial rejuvenation. During the process the SMAS can easily rupture which can make a lift less effective. In my practice over the years, I found it frustrating when I had to limit the extent of lifting due to the SMAS flap tearing.
Therefore, the deplane lift was and is a great technique to give the face the maximum lift that is needed for profound but nonetheless natural facial rejuvenation: By lifting the SMAS together with the skin, the much stronger skin will protect the SMAS from tearing. This is in my experience and opinion the greatest advantage of the deep plane facelift.
A further advantage of the deep plane lift is the tension-free closure of the skin compared to an extended SMAS-facelift which results in better/finer, and as follows, more invisible scars.
A further disadvantage of the extended SMAS lift versus the deep plane facelift is the compromised blood perfusion of the detached and lifted skin flap. Risks of skin necrosis are higher in patients with these facelifts. In deep plane facelift the composite flap of SMAS and skin provides much better skin blood skin perfusion. In smokers, who have to stop smoking 3-4 weeks before surgery, the deep plane lift would be the facelift of choice over the extended SMAS face lift.
What is the vertical dual-plane facelift?
The vertical dual-plane facelift is, in its base, a deep plane facelift. As I pointed out, the deep plane approach gives the patient the best lift, the best skin perfusion and a tension-free skin closure with fine scars. What is missed in the deep plane facelift is a 3-dimensionality of each side of the face. With the two-vector lift of the extended SMAS facelift I am able to create more volume over the midface and cheekbones. We should not forget that by resecting the main facial ligaments in a deplane or extended SMAS facelift I am fully mobilising the SMAS. While lifting it in a vertico-lateral vector of 60 degree + in a deep plane facelift and securing it in the lifted position, I realised that in most patients an additional, strictly vertical, lift of the fully mobilised SMAS is possible. This can be easily tested after the composite SMAS-skin lift has been secured in its new position. If this is the case, I open a second, the more superficial subcutaneous plane (thus "dual-plane facelift") over the cheekbone and midface and strictly vertically lift and plicate the exposed SMAS with vertical SMAS sutures. This additional vertical lift of the SMAS creates an extra volume over the cheekbone and upper midface. With this last step I create a more 3-dimensionality of the face with a more protruding cheekbone.
What are the facial ligaments and what is their importance in facelift surgery?
The retaining ligaments of the face are consistent anatomic structures that are present in predictable locations. On the one hand they are responsible for the structural stability of facial tissues by attaching the skin, subcutaneous tissue, SMAS, facial muscles to the bone and as such make sure that our face "doesn’t fall off". On the other hand, they divide the soft tissue of the face into spaces and compartments and their release is critical to achieving adequate soft tissue repositioning for a desired aesthetic outcome in facelift surgery. They also serve as helpful and convenient markers for branches of the facial nerve. Some of the facial ligaments of great importance in facelift surgery are the platysma auricular fascia, the zygomatic cutaneous ligament, the masseteric cutaneous ligament and the mandibular cutaneous ligament.
To adequately reposition facial soft tissues during a facelift, proper release of the facial retaining ligaments is necessary. By understanding the anatomy of these retaining ligaments, plastic surgeons can better achieve safe, satisfactory and enduring results.
What facelifts do and what facelifts don't release the facial ligaments?
All facelift techniques have the goal of manipulating the SMAS to lift it back in its youthful position. A pure skin lift is a very simple, but sub-optimal, way to perform a facelift by pulling only the facial skin over the the dropped/aged subcutaneous fat tissue and SMAS. A skin-lift won't be able to reconstruct the youthful position of the facial tissue under the skin to create the V/heart shape of the younger face. The result is a stretched look or a look of an aged face with smooth skin. For quick lunch-break facelifts under local anaesthesia this technique might still be used on the uninformed patient.
The technique of the SMASectomy will simply resect one or two strips of SMAS tissue at strategic places and simply adapt the resulting SMAS wound edges. This is a widespread technique which I have never been a fan of, since the result could be very "mask-like". Since SMAS tissue was resected rather than conserved, the much-needed build-up of facial volume, needed to achieve the illusion of a young face, could not be achieved. Since the facial ligaments were left totally intact, the deepened nasolabial folds or marionette lines could not really be smoothened as again is needed to achieve a younger appearance.
The SMAS plication lift introduced by a Swedish plastic surgeon in the early 1970s is a globally recognised facelift technique. After detaching the facial skin from the underlying facial tissue (fat, SMAS), sutures are placed strategically to lift the SMAS and the SMAS plicated. The facial ligaments are not released. The SMASectomy tissue was preserved which I find vital in treating an ageing face that generally loses its fat and thus volume. Surgeons have their specific preferences for the direction they plicate the SMAS to get the most rejuvenated outcome. Placing them more sideways doesn't result in a natural and rejuvenated look since the ligaments which fixate the facial tissue at strategic places in the face will block tissue which lies medial to these ligaments from being pulled into the desired position. I find it is more helpful to strictly vertically pull the SMAS with sutures which run from the middle of the face near the nasolabial folds to the side right in front of the ear. The further the tissue has dropped, the bigger the "bite" of the needle/suture will need to be to attach the lifted SMAS along the zygomatic arch (cheekbone). In this way the SMAS and jowls could be lifted and at the same time volume built up over the midface. In a last step the skin is lifted and draped over the new, younger facial contour. I achieve amazing results with this technique. Since the SMAS plication lift works superficially on the SMAS instead of where the extended SMAS or deep plane facelifts work, the danger for facial nerve damage is much lower and this facelift technique is considered as safe.
As explained in above, both the extended SMAS facelift, the deep plane facelift and my signature vertical dual-plane facelift dissect under the SMAS in the so-called "deep plane" of the face and release the facial ligaments. In this way the dropped facial tissue of the middle and lower face can be fully lifted when the flap is pulled up. Nasolabial folds, marionetted lines and jowls are drastically reduced and rejuvenated. The results of these facelifts are dramatic and natural at the same time.
Why choose the deep plane facelift or vertical dual-plane facelift?
As I explained above all facelifts which release the facial ligaments will result in a dramatic but still natural result.
The extended SMAS facelift has its advantage of a two-vector pull, the surgeon can lift the SMAS and the skin in two different directions as to the needs of the patient and the aesthetic understanding of the surgeon. The major disadvantage of this technique is that the perfusion of the skin is compromised by detaching it from the underlying SMAS in a first step but also that after the surgery swelling spreads more easily throughout the face and the healing time can be prolonged. Furthermore, it is questionable how resistant the layer of fibrous tissue which will build up between skin and SMAS is to pulling forces of gravity over time.
In a deep plane facelift skin and SMAS are hardly detached from each other and both layers are lifted together as a composite flap. Like this the skin is much better perfused with blood and risks of skin necrosis are lessened. Where I see a benefit of this technique, that is that the natural connection- also the ligaments- between SMAS and the face stay intact. Like this swelling after a facelift can spread less, leading to a less swollen face and shorter recovery time. Furthermore, the operated face may better resist the pulling forces of gravity and thus lead to a longer lasting result. All of these reasons made me choose a deep plane facelift over the extended SMAS facelift. Unfortunately, the results of a pure deep plane facelift looks smooth but lacks of three-dimensionality and build-up of volume over the midface. You can study the many before-after results of specialised deep plane surgeons, and you will see what I mean.
Often, at the end of the deep plane facelift, I noticed that I could lift the cheek of my patients slightly more in a strictly vertical direction. Due to the way the the incisions are made, to hide them to a maximum, the pull/lift of the composite flap of skin and SMAS is in a 60–70-degree direction. But since the facial ligaments have been released, this composite flap is fully mobilised and very often could be lifted additionally in a different, strictly vertical direction which would add additional volume to the midface and result in an even more natural and rejuvenated outcome.
With the desire to add more volume and three-dimensionality to my patients' faces after a facelift, I developed my signature vertical dual-plane facelift. Towards the end of the deep plane facelift after securing the composite flap in its lifted position, I detach the skin over the midface from the underlying SMAS and place strictly vertical SMAS plication sutures which lifts the SMAS more and additionally adds volume over the cheekbone and upper midface.
You can call my vertical dual-plane facelift a deep plane facelift with a twist. This low-risk addition to the deep plane facelift results in a more three-dimensional result of the patient’s face and thus achieves a more rejuvenated look which is highly desired.
Why does our cheek fall over a lifetime?
To understand facial ageing, you have to look at the anatomy of the face. From the surface to the depth, we find the skin, then a layer of fibrous fat (the SMAS), then the smile muscles and finally the bones. The deep plane is located just below the SMAS, immediately above the mimetic muscles. It is devoid of blood vessels and is a natural gliding plane for the cheek.
Over the years, two major natural forces will cause the cheek to descend along the natural gliding plane of the deep plane: gravity and the thousands of contractions of the muscles of the mouth. The fat in the cheek will go down but it will be blocked by ligaments. It is because of this that the nasolabial fold tends to worsen over the years and that the bitterness fold, and the cheek appear.
Who is the ideal candidate for a deep plane facelift or a vertical dual-plane facelift?
If you stand in front of the mirror and you can reposition your cheek with your fingers, you are a candidate for the deep plane or vertical dual-plane facelift. These facelifts can be done in women and men, to treat sagging cheek, loss of volume over the midface, bottom-heaviness of the face with jowls which make a face look longer and squarer and a soft and undefined jawline. These changes to the face already start in the late 30s and early forties and usually intensify from age of 50.
The only contraindications are a health problem that prevents anaesthesia, such as a heart problem requiring long-term anticoagulation or respiratory failure. Smoking increases wound healing problems, and you should stop at least 4 weeks before having surgery.
This is a method that is also particularly interesting for a second or third facelift, because you can correct the small technical defects related to the first facelift.
What is the typical age for undergoing a facelift?
In my opinion there is no typical age. Whether you are ready for a face or neck lift depends on how far the signs of ageing have advanced in your individual case AND if these signs of ageing are bothering to an extent that they diminish your joy of life, your self- consciousness and the way you socially interact.
Generally, we can say that visible signs of ageing will show in the early 40s and worsen from then on, again in an individually different pace.
How early and how fast we are ageing are dependant on the patient's genes but also on lifestyle, smoking, alcohol, nutrition, emotional and physical stress, continuous weight gains and losses and skin care. A definite acceleration of the signs of aging will occur during and after menopause in female patients.
Having said that, most patients feel they are ready for a facelift around 50 and older. At this point many patients already show advanced signs of ageing which are visible for everyone. The trend recently is to undergo a facelift earlier in life when the signs of ageing just start to show. To have a facelift in the (early) forties is not an exception. It always depends on the circumstances of each individual patient. What is acceptable for one patient might already be too much for another.
When a patient sees me for a consultation it is important for me to hear the patient's story to understand where she/he is coming from. Most important for me as a specialist plastic surgeon is to determine if there are indeed signs of ageing which make it worthwhile performing a facelift and if I will be able to achieve a visible improvement for the patient by performing it.
I will assess my patients and will give them my honest opinion if an improvement can be achieved by undergoing a facelift. I won’t give my opinion though if I think a facelift is necessary. Signs of ageing don’t necessarily mean that a person is unattractive in another person’s eye. It is solely the patient’s decision if they can continue living the way they look or not. After all, I want my patients to be happy.
Are the scars well-hidden after a facelift?
As I used to say, the best facelift is worth nothing if the scars are visible to everyone!
Having operated facelifts for the past 19 years, it is my patients' general request to choose the incisions, so the later scars are hardly visible. Lots of patients are deterred from going ahead with a facelift after seeing scars running along the temporal hairline. They had consultations and were told that these scars could be covered with different hairstyles. Well, yes, if somebody wears a short haircut, the hair can be left so long that it naturally falls over the temporal hairline, or patients have to wear their long hair open. Pulling the hair back in a ponytail will expose the scar along the hairline. Also coming out of the water with wet hair will expose short and long hair either way when it is clapped on to the head. Patients are told that the scars heal nicely still, they will be a straight fine light line running along the unregular temporal hairline. Also, I have seen patients developing wider and as such considered bad scars which need scar revision to make them less prominent.
I see many patients who come see me to relocate this scar behind the hairline but this not possible. I advise either to have the scars tattooed in the patient’s skin tone or to undergo hair transplants in front of the scars.
Even though this choice of incision is a legitimate approach, especially in a deep plane facelift, I believe it is avoidable. It is of the utmost importance to explain to the patient, in detail, what these temporal incisions mean for their emotional wellbeing going forward. Many patients complain that they are so conscious of the scars which they, of course, will always see, that their self-consciousness takes a hit when they socialise. They think that their opposites immediately spot and stare at their scars, making it obvious to everyone that the patient had a facelift. In the US it seems that patients stand more behind their decision to undergo a facelift than they do in Europe. Of course, it feels better to be envied for the looks according to the motto "I don't know how she/he does it- she/he looks fabulous" instead of "she/her just looks good because she/he had a facelift".
In my vertical dual-plane facelift I avoid these temporal incisions. Instead, my incisions end right underneath the hairline that extends from the temporal hairline usually descending or even horizontally to the ear. It doesn’t continue upwards along the temporal hairline. With a special twist in this cutting technique, it is possible to place all the sutures to hold the composite deep plane flap in place and avoid any puckering of the temporal skin.
The incisions then run right in front along the curve of the upper ear, behind the tragus, then again in front/along the earlobe and around it. Behind the ear the incision runs in the post-auricular crease and ends high up crossing into the hair in an descending arch. The incision that crosses from the ear into the hair will be widely covered by the helix of the ear.
The before/after results of a Deep Plane Facelift
You can find more before and after photos of facelifts in our gallery or by following us on our Instagram account: @drdirkkremer.
How much does a deep plane facelift cost?
The price of a cosmetic surgery operation depends on the expected operating time, the clinic and the equipment needed, and ultimately the expertise of the surgeon. In the hands of an experienced plastic surgeon in the UK, the price of a deep plane lift starts from 18,000 GBP. Having said that, my patients approach me again and again with quotes of surgeons of 50,000 GBP and up, in the US my patients report of quotes of 100,000 USD and up. I refer to them as "phantasy prices" with questionable motives.
To be clear: a deep plane facelift executed as it should be gives a patient a certain result, a great and natural result. When a patient pays double or quadruple the price of what another very experienced surgeon would charge, it is mostly in the assumption that the result the patient achieves will also be multiple times better than the result achieved with a deep plane facelift for the lower and reasonable price. This assumption unfortunately is wrong and only helps the surgeon. A properly executed deep plane facelift gets as good as it gets- no more nor less!
A facelift quote is necessarily personalized and Antoinette, my assistant, will send it to you discretely in an email after your first consultation.
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