South Florida Facelift

Deep Plane Face-Lift Norman Pastorek, MDa, Andres Bustillo, MDb,*

As is true for many other surgical procedures, the existence of numerous proponents of different methods of face-lift procedures indicates that there is no one best face-lift. The resolve of so many surgeons that they may have evolved a face-lift that gives consistent results indicates that many procedures probably give a comparable result. It is the surgeon's obligation to seek the truth about his or her level of satisfaction with outcomes. The ease and rapidity of a procedure and the accumulated experience with it mean little if the results are not excellent, durable, and achieved with minimal prob­lems. The goals of face-lift surgery are numerous. Foremost, it must be safe, reproducible, and natural looking. It must address the entire face, including the temporal region, the lateral face, the midface, the jaw line, the submental region, platysma band­ing, the lateral neck, and the retroauricular region. The scars should be inconsequential. The hairlines should remain unchanged. Ideally, the patient should return to normal functioning as quickly as possible. Discomfort should be minimal, and the results should be lasting.

Most experienced surgeons agree that skin-lifting alone and short flap procedures, which seem to be reinvented every few years, may have appeal in their ease but in the end always fail to live up to any promise of durability. Over many years, NP's personal evolution arrived at a superficial muscu­loaponeurotic system (SMAS) procedure with sub-mental liposuction. Although patients were happy, I wished for a better midface and nasolabial reju­venation and better control of the anterior neck. In 1996, as I was preparing to participate in a rhinoplasty course in Dallas, Dr. Sam Hamra invited me to come a day earlier so he could show me some of the new things he was doing with face-lifting. The deep plane face-lift, although not performed in my geographic region of the country, had a reputa­tion for being a difficult and dangerous procedure fraught with long-term healing sequelae. After re-viewing the literature, reading Dr. Hamra's text-book, and considering his reputation for being an honorable person, I went to the course with an open mind. It was a day that totally changed my way of thinking about face-lifting. I saw the deep plane procedure as the final measure in my personal face-lift evolution. I began performing the proce­dure immediately upon my return to New York.

The results in the jowl, midface, and anterior neck, where I had wanted improvement, showed great promise. The rumors that the postoperative course of these procedures would be difficult for patients with a long-term recovery a ''given'' proved to be precisely the opposite. As I spoke with indi­viduals who were quoted on stories of a prolonged

ecovery, I found it was all hearsay. Over the 9 years that I have performed the deep plane face-lift, I have changed it slightly, adding some steps that have made the procedure even more effective and safe and diminishing further the minimal post-operative course. Described herein is my personal approach to the deep plane face-lift.

Preparation
Medical evaluation

The patient is advised and cautioned on the intake of any aspirin or vitamin E–containing medica­tions. The use of alcohol is avoided at least 4 days preoperatively. The use of vitamin C is encouraged. All patients take vitamin K preoperatively. Smok­ing is not permitted for 2 weeks before surgery. Pa­tients must be aware that they are being accepted for surgery with a moral obligation that they will not smoke. The consequences of poor healing, poor scars, and possible skin necrosis are made abundantly clear. If the patient cannot stop smok­ing, he or she is not accepted as a candidate for surgery. Even if the surgeon provides a graphic description about the possible complications of smoking and documents that the complications will be the patient's responsibility, the surgeon must deal with the complications. The patient's friends see only the problematic course and the poor result.

Any medical or surgical problem that would pre­clude other elective surgery is a contraindication for face-lift surgery. The most common medical prob­lem seen in face-lift candidates is obesity. Although stories of an inability to lose weight may be com­pelling, it is always a mistake to perform a face-lift on the truly obese. The patient often equates the procedure with liposuction of the body and as a way to reduce a fat face without the need for diet­ing. Facial liposuction to reduce the jowl, cheek, preparotid, submental, and submandibular fat pro­vides multiple opportunities for irregularities and asymmetries. Pulling the skin posteriorly against the heavy weight of the fatty face may lead to thickened scars and a quick return of the facial skin to the anterior position. The slightly thinner appearance of the face following a liposuction face-lift may actually lead patients to increase their food intake after surgery. Medical evaluation and clearance of the individual patient are dependent on the pa­tient's health and the surgeon's judgment.

Psychologic evaluation

Most patients presenting for face-lift surgery are good candidates. Nevertheless, the surgeon's intui­tion is important in patient selection. The patient seeking facial rejuvenation to improve his or her self-image and self-esteem is ideal. The patient who is in a profession or business in which personal appearance is important is also an ideal candidate. The surgeon must be cautious about the patient who is requesting the surgery on the advice of, or under pressure from, another. A baseline truism must always be kept in mind—the patient should not expect the world to change in any way because of the surgery. The patient whose appearance is at an extreme (too sloppy, too perfect) should be sus­pect. The surgeon must recognize the obsessive-compulsive patient. These patients are extremely challenging postoperatively even when there is an excellent surgical result.

Esthetic evaluation

The patient who will benefit most from a deep plane face-lift is middle aged and concerned about the decent of the jowl just below the oral commissure, the deepening of the nasolabial sul­cus (secondary to decent of the malar fat pad), the accumulation of submental fat, loosening of the submental skin, and the development of anterior platysma bands. The appeal of the deep plane pro­cedure is its ability to elevate and suspend the malar fat and midface and, in the process, maxi­mally efface the nasolabial sulcus.

Preoperative marking

The initial line marks the attachment of the helix at the top of the ear and then traces the helical attach­ment to the tragus. It continues just behind the tragus downward to the earlobe, around the ear-lobe, and into the retroauricular sulcus, superiorly to a level of the helical attachment, and then curves into the mastoid hair-bearing area. If there is an enormous amount of submandibular and submen­tal skin redundancy, the marking is placed along the mastoid hairline. The marking is curved supe­riorly from the helical attachment into the tempo­ral scalp for 5 to 6 cm. The temporal hair-bearing skin will be elevated and sutured back in place without any elevation of the tuft of hair just above the ear. The purpose of the elevation of the temporal hair-bearing scalp is twofold: (1) it allows the placement of a secure suture between the ele­vated scalp and the underlying deep temporal fas­cia, and (2) it mobilizes the temporal scalp to the temporal line. The pull is entirely posterior with no superior component. It has been the senior author's experience that incisions around the tem­poral tuft leave an obvious scar; therefore, they are not recommended.

Fig. 1. Surgical marking has been completed. The hair is parted in the temple and mastoid areas. The malar eminence is identified, and lines are drawn along the direction of the zygomatic muscles from the eminence to the angle of the mandible and from the angle of the mandible along the body of the mandible. A dotted line paralleling the body of the mandible de-fines the inferior margin of the mandible.

The hair is parted and bound with small rubber bands. The origin of the zygomatic major and minor muscles is marked at the anterior inferior malar eminence. A line is drawn from this point to the oral commissure, marking the path of the zygo­matic major muscle. Another line is drawn from this same point to the attachment of the nasal ala, marking the path of the zygomatic minor muscle. The nasolabial sulcus occurs between the skin insertions of these two muscles. A line is then drawn from the zygomatic origin to the angle of the mandible. Another line is drawn from the angle of the mandible along the body of the mandible in an anterior direction. This line will provide guid­ance for the deep plane face-lift. It is also useful to outline with dots the inferior limit of the cervical skin elevation and to mark the anterior platysma bands [Fig. 1].

Face-lifting procedures can be performed under intravenous monitored anesthesia or general anes­thesia depending on the patient's degree of anxiety and the surgeon's comfort level with each type of anesthesia. Some patients can easily tolerate this procedure with a light intramuscular narcotic/tran­quilizer injection and local anesthesia. The patient who demonstrates the characteristics of attention deficit syndrome may not be an ideal candidate for intravenous anesthesia. The usual medication amounts given for sedation may cause an agitation that is relieved only when the sedation level sup-presses respiration. These patients do better under general anesthesia. The success of general or intra­venous monitored anesthesia is anesthesiolo­gist dependent.

Fig. 2.The area of submental and submandibular lipo­suction is defined.

Fig. 3. The platysma bands are sutured with simple buried sutures of 4-0 Mersilene. The submental inci­sion is made just slightly wider than the 10-mm fi­beroptic retractor. The sutures end just above the thyroid notch.

Once general or intravenous anesthesia is estab­lished, the subcutaneous anesthesia is begun. The senior author uses lidocaine 0.5% with epineph­rine 1:200,000. Four milliliters of sodium bicar­bonate 8.4% is added into each 50-mL vial of lidocaine. This buffering decreases the burning sen­sation of the local anesthesia and is especially important when the patient is under intravenous monitored anesthesia. Initially, the neck and right side of the face are injected. Once the neck por­tion of the procedure is completed and just before surgery on the right side of the face is begun, the left side of the face is infiltrated with local anes­thesia. This timing provides for optimal vaso­constriction and divides the total amount of local infiltrative anesthesia over a greater length of time. A 1.5-in, 25-gauge needle with a 10-mL syringe al-lows for gentle subcutaneous anesthesia placement. The infiltration can be performed with a larger sy­ringe and bore needle using a great deal more pressure for faster infiltration; however, there is considerably more pain with high-pressure rapid infiltration. The first incision can be made 15 min­utes following the infiltration of local anesthesia.

The Deep Plane Face-lift

The procedure begins with a submental crease inci­sion large enough to admit a 2.4-mm liposuction cannula. Fat is removed as needed from the sub-mental and submandibular region. A small cannula is used to avoid any skin surface irregularities that are more likely with a larger cannula. The cannula also aids in separation of the subcutaneous skin attachment from the platysma muscle. Enough fat should remain to give the neck an overall smooth appearance [Fig. 2]. The gracefulness of the neck results from the manipulation of the platysma and the redraping of skin and not from fat removal alone. Skeletonizing the platysma muscle with lipo­suction is an error. The appearance is not youthful and is difficult to reverse.

Once the fat has been removed with the cannula, a small additional amount of fat is removed at the lateral ends of the submental incision. This fat is located just under the mandible and is not easily suctioned. It accounts for the small elevations that may be seen postoperatively at each end of the submental incision. The fat is removed by direct excision. Most patients do not require removal of fat below the platysma muscle. This fat is denser and considerably vascular and is difficult to remove with the suction cannula. If it is removed sharply, the surgeon will encounter bleeding. The submen­tal incision must be wide enough to allow for the hemostasis effort.

In most patients who are candidates for a deep plane face-lift, the anterior platysma bands have become a factor in the appearance of the anterior neck. With the fat of the anterior cervical neck reduced, a 1 cm by 10 cm fiberoptic retractor is introduced into the submental incision. The ante­rior platysma bands are sought. It is helpful, but not essential, if these bands are marked preopera­tively on the cervical skin. Most patients have sepa­rate platysma bands that require suturing in the midline to eliminate the banding appearance. Oc­casionally, the anterior platysma bands are natu­rally bound in the midline. The separated bands can be sutured with continuous or individual simple sutures. The authors prefer to use multiple individual sutures of 4-0 Mersilene with the knots buried. These sutures are placed from just below the submental incision to just above the thyroid notch. It may be necessary to pick up deeper tissue in the more inferior sutures to secure a deepening of the cervical angle [Fig. 3]; however, if the suture just above the thyroid notch is too tight, it may accentuate the thyroid notch, bringing the Adam's apple into relief and creating a masculine profile in a female neck. Incision of the platysma muscle is usually not necessary or advised. Earlier publica­tions advocated platysma sectioning. Many irrepa­rable neck skin irregularities resulted from bold section of the muscle. The anterior band suturing and the posterior margin anchoring (described later) produce smooth tight necks without the need for muscle sectioning.

Fig. 4. The area of the temporal dissection is illus­trated. The blunt dissection over the deep temporalis fascia can be carried forward to the temporal line.

Attention is now directed to the lateral face. A marking incision is traced along the entire anterior marking. It is then deepened in the temporal region to a subcutaneous level up to a point at the helical attachment. The face-lift scissors are used to sepa­rate the tissues down to the deep temporalis fascia. This area is seen as a firm shiny pale gray-white surface below the frontal branch of the facial nerve. The surgeon's gloved index finger can be used to separate bluntly the superficial temporalis fascia (above) from the deep temporalis fascia (below). These tissues can be separated up to the temporal line [Fig. 4]. The skin is then separated from the tragus with a curved Steven's scissors. The tragus is fragile and handled with care. The skin is elevated from a point just above the tragus in a deep sub-cutaneous plane, moving in an anterior direction to the skin marked by the line between the malar eminence and the angle of the mandible. This ele­vation can be completed by observing the scissor tips as they elevate the skin without actually observ­ing the dissection [Fig. 5A,B].

Fig. 5. (A) The limits of the sharp dissection of the midcheek are illustrated. At this point, the anterior line of sharp dissection between the malar eminence and the angle of the mandible is the posterior margin of the deep plane dissection. The deep plane dissection is done following the retroauricular portion of the procedure. (B) The illustration shows the limits of the sharp dissection. (From Hamra ST. The composite rhydectomy. St. Louis: Quality Medical Publishing; 1993; with permission.)

Fig. 6. The superficial temporal artery has been tran­sected, and blunt finger dissection has continued the superficial dissection in a superior anterior direction toward the orbicularis muscle. The thin web of tissue dividing the temporal dissection from the cheek dis­section is the superficial temporalis fascia that con­tains the temporal branch of the seventh nerve.

At this point, there is deep plane of dissection over the deep temporalis fascia and a superficial plane over the lateral face. The superficial dissec­tion should not go below the line that has been marked along the body of the mandible. The tissue between the deep and superficial dissection con­tains the superficial temporal artery and vein. The tissue is transected with the scissors, including the artery and vein. Hemostasis is established. The dis­tal end of the artery is often in spasm and not bleeding and must be observed and secured with electrocautery. One should not carry the sharp dis­section anterior to this point. The frontal branch of the seventh nerve lies just anterior to the temporal artery. Transecting the superficial temporal artery will give the necessary posterior mobility to the skin flap. Further anterior blunt dissection is essen­tial to obtain major posterior mobility of the flap. The senior author has developed a method for this dissection. The subcutaneous plane is extended anteriorly and superiorly using the index finger wrapped in a single layer of surgical sponge. Push­ing forward the subcutaneous plane is maintained, keeping the superficial temporalis fascia below the dissecting finger. The frontal branch of the seventh nerve is protected in this fascia. The dissection can be advanced to the orbicularis muscle. The super­ficial temporal fascia will appear as a thin web [Fig. 6]. Any capillary bleeding on the surface of this fascia must not be cauterized. The bleeding is most likely secondary to the vasa vasorum asso­ciated with the nerve and will stop regardless of whether pressure is applied. Cautery here will risk injury to the frontal branch of the seventh nerve.

When this dissection is complete, the surgeon will recognize the remarkable posterior mobility of the facial flap. Deep plane dissection anterior to the line from the zygoma to the angle of the mandible is performed following the lateral cervical dissec­tion. A sponge is placed in the lateral facial dissec­tion, and the retroauricular area is addressed.

Fig. 7. The illustration shows the area of sharp dissec­tion in the retroauricular and lateral cervical area. The anterior margin of this dissection, at the angle of the mandible, defines the posterior margin of the plat­ysma muscle. SCM, sternocleidomastoid muscle.

Fig. 8. The surgeon must take care with the dissection as the posterior margin of the platysma is encoun­tered. The plane of easiest dissection at this point is beneath the platysma toward the external jugular vein. The surgeon must force the dissecting scissors to stay above the platysma muscle.

A retractor is used to hold the ear forward, expos­ing the retroauricular marking that has been carried onto the hair-bearing area at the level of the helical attachment. The skin is sharply dissected away from the mastoid and over the sternocleidomastoid mus­cle. The dissection is continued anteriorly to the angle of the mandible [Fig. 7]. A band of tissue must remain along the body of the mandible and from the angle of the mandible to the ear lobe. This mesentery incorporates the platysma muscle and its attachments to the cervical-facial skin as it crosses over the body of the mandible. The lower face dissection does not extend inferiorly to go over the body of the mandible, and the cervical dissec­tion does not extend superiorly to cross over the body of the mandible. If the skin line from the malar eminence to the angle of the mandible were continued onto the neck, it would mark ap­proximately the posterior margin of the platysma muscle [Fig. 8].

At this point in the lateral cervical dissection, the surgeon should switch to a fiberoptic-lighted re-tractor. A 10 cm by 2.5 cm retractor is satisfactory for most face-lift cases. The cervical dissection must bluntly separate the platysma muscle from the neck skin in a subcutaneous plane. It is easy to go below the posterior margin of the platysma muscle into deep cervical plane, and it is important to stay su­perficial at this point of the dissection. Once the platysma muscle can be seen beneath the spread­ing face-lift scissors, the pathway from the lateral to central neck is simple. If a spreading rather than cutting technique is used, there is usually little bleeding. An assistant holds the submental wound open with a small retractor to create an optical cavity in the submental area. This cavity will facilitate the dissection as the surgeon ap­proaches the central neck. The neck skin must be separated entirely from the underlying platysma muscle from just below the body of the man­dible to the approximate level of the thyroid notch. While pulling the neck skin posteriorly, the surgeon must ensure there is no tethering be­tween muscle and skin. Without complete separation of the cervical skin, the neck will soon loosen following the procedure, disappointing the patient and surgeon.

Fig. 9.(A) The illustration shows the surgeon entering the deep plane over the masseter muscle. Moderate downward pressure is required at the line between the angle of the mandible and the malar eminence. The surgeon watches to ensure the dissection is beneath the ascending fibers of the platysma muscle. (From Hamra ST. The composite rhydectomy. St. Louis: Quality Medical Publishing; 1993; with permission.) (B) The surgical photo-graph demonstrates the sharp demarcation between the masseter muscle below and the thin platysma mus­cle above.

The surgeon's attention is now directed to the anterior face where the deep plane lift is the final facet of the procedure. The larger fiberoptic retrac­tor is introduced into the facial wound. The under-lying tissue is attached from the malar eminence to the angle of the mandible. The first area to be addressed is located inferiorly over the masseter muscle. The face-lift scissors are placed over this area. As the scissors are opened, they are pushed firmly downward and flatly on the surface of the masseter muscle. The masseter comes immediately into view [Fig. 9A,B]. The color is a deep dark red, and there are thin vertical white striations that are peculiar to this muscle. The surgeon should be deep to the ascending bands of the platysma muscle. The platysma muscle is thin and pale as it crosses the mandibular body. It is easy to recognize if the dissection is too superficial. This area is relatively avascular and separates easily by opening the face-lift scissors at a right angle to the masseter. This blunt dissection is carried anteriorly to the area beneath the jowl fat. Because the jowl fat is mobi­lized by the deep plane face-lift, it is seldom neces­sary to remove it.

The deep plane dissection divides the face into thirds. The dissection over the masseter is the lower third. If the dissection is continued superiorly into the middle third, there is a danger that it can be carried deep to the zygomatic muscles. These mus­cles are innervated on their deep surface, and dis­section deep to them carries a risk of nerve injury.

Fig. 10. (A) The illustration demonstrates the superior third dissection over the zygomaticus major. If the dissection is attempted in the middle third of this area, the undersurface of the zygomaticus muscle will be exposed, raising the risk of nerve injury. (From Hamra ST. The composite rhydectomy. St. Louis: Quality Medical Publishing; 1993; with permission.) (B) In this surgical photograph, the scissors are above the zygomaticus muscle. The two arrows show the width of the muscle. The dissection will continue over the zygomaticus major until the minor is encountered lying in the same plane but in an anterior direction toward the nasal ala. (C) The illustration shows the appearance of the zygomaticus muscles and their anatomic direction at the completion of the deep plane dissection. (From Hamra ST. The composite rhydectomy. St. Louis: Quality Medical Publishing; 1993; with permission.) (D) The intraoperative photograph shows the zygomaticus major and the nerve supply coming into the undersurface of the muscle.

Fig. 11. Intraoperative photograph shows the com­plete dissection with the band of platysma muscle connected along the length of the mandibular body. The end of the connective tissue band at the angle of the mandible will be anchored to the connective tissue beneath the ear lobe to give a major firmness to the jaw line.

Fig. 12. Intraoperative photograph demonstrates the mobilized malar fat pad between the index finger and thumb. As the composite flap is pulled posteriorly, the malar fat moves upward onto the malar eminence.

The second part of the dissection is started at the upper third so that the dissection will occur over the superior surface of the zygomatic muscles. This dissection can be more difficult physically because the tissues are adherent. Using the fiberoptic retrac­tor, the deep subcutaneous plane is separated care-fully until the insertion of the zygomatic muscle is observed just anterior and inferior to the malar eminence. This muscle, even if enveloped in fat, will be seen to tent in a direction toward the oral commissure [Fig. 10A–D]. The dissection is contin­ued anteriorly until the zygomaticus minor origin is encountered. As this space is opened, the surgeon will note that the scissors are in a triangle formed by the malar eminence, the oral commissure, and the nasal ala. This dissection is beneath the malar fat pad, which is released and mobilized with this maneuver. Often, the twin nerves to the zygomat­icus major can be seen entering its undersurface. At this point, the upper and lower thirds of the deep plane procedure have been completed. The middle third is now dissected safely. The scissors are opened at right angles to the skin surface. The buccal nerve is in this space and usually clearly seen. Because the dissection is entirely blunt (ie, the scissors are opened slowly and firmly but never used to cut), there is little danger of injury to the nerve. The buccal fat will come into view beneath the buccal nerve. Occasionally, some of this fat pad may be removed in patients with unusual heaviness in the midcheek. In these cases, the fat is teased into the wound, the buccal nerve is moved aside, and the fat is then removed by electrocautery excision. Some bleeding is associated with excision of this fat pad. It is wise to maintain a purchase on the stump of the fat pad after excision until it is certain that no additional cautery is need. Once the middle third is dissected, the entire composite flap of mid-face skin and the malar fat pad becomes mobilized. As the flap is moved in a vector direction parallel to the body of the mandible, the malar fat pad can be seen to rise and become repositioned over the zygoma [Figs. 11 and 12].

Fig. 13. (A) Illustration shows the suturing of the posterior platysma muscle margin to the capsule of the sternocleidomastoid fascia. (From Hamra ST. The composite rhydectomy. St. Louis: Quality Medical Publishing; 1993; with permission.) (B) The posterior border of the platysma is tested for mobility at the time of closure. If the platysma is tight and cannot be drawn posteriorly, nothing needs to be done. If there is mobility and the posterior margin can be drawn posteriorly, several 4-0 Mersilene sutures are placed to the muscle edge toward the capsule of the sternocleidomastoid muscle where it is secured.

Fig. 14. Two 3-0 polydioxanone sutures, one deep and one more superficial, are placed between the connec­tive tissue–platysma muscle at the angle of the mandi­ble and the connective tissue density beneath the ear lobe. Once these two sutures are in place, the jaw line should be firm.   Fig. 15. Fibrin glue is sprayed thinly over the surfaces beneath the midface, cheek, and temporal areas. It is then sprayed over the platysma muscle, the sternoclei­domastoid area, and the mastoid area. The area is rolled from front to back in the cheek and neck to express any excess glue. Pressure is then applied uni­formly in a posterior direction for 3.5 to 4 minutes.   Fig. 16. The point of anchoring the composite flap to the deep temporalis fascia is determined by imagining a line from the nasal ala to the top of the ear parallel­ing the body of the mandible.   Fig. 17. A subcutaneous suture is placed in the com­posite flap and then anchored firmly to the deep temporalis fascia just above the ear. This attachment must be a powerful anchoring suture. Once placed, there is no movement to pressure along the zygoma. The suture stabilizes the malar fat pad on the ma­lar eminence.   Fig. 18. The neotragus is fashioned by carefully thin­ning the skin that will cover the tragus. Any evidence of thickness will decrease the esthetic appearance of the anatomic landmark.   Fig. 19. The final appearance of the neotragus. The incision needs to be just slightly on the inside surface of the tragus. If it is made too far on the inside, the repair becomes difficult and has no advantage.

Closure can now begin. Attention is directed to the posterior margin of the platysma muscle in the neck. If traction on the posterior platysma margin shows that it can move posteriorly, the muscle margin is sutured to give an additional tightness to the neck. Several sutures of 4-0 Mersilene are placed between the platysma and the fascia of the sternocleidomastoid muscle [Fig. 13A,B]. These su­tures are placed firmly, but should not be so tight as to separate the platysma muscle. The initial positioning of the flap is from the angle of the mandible to the dense connective tissue beneath the ear lobe. The mesentery contain­ing the platysma muscle at the angle of the mandi­ble is grasped with a large Brown-Adson forceps and drawn toward the undersurface of the ear lobe. In some patients, the distance from the man­dibular angle to the ear lobe is in the 2-cm range. When this tissue is drawn posteriorly, an immedi­ate firming of the jaw line is seen. Two 3-0 poly­dioxanone sutures are placed between the platysma muscle and the connective tissue under the ear lobe. In other patients, this distance (ear lobe to angle of the mandible) can be as much as 4 cm or more. In these situations, it is not possible to place a suture at the angle of the mandible and draw it to the connective tissue beneath the ear lobe. The surgeon must notice this ear lobe–mandibular angle distance preoperatively because an accommo­dation must be made. In these patients, the skin flap is undermined for a distance of only 2 cm between the ear lobe and the mandibular angle. A soft tissue bridge must remain posterior to the mandibular angle to allow a tight closure at this point. If a 4-cm gap is allowed, closure is not possible without leaving some of the suture mate­rial exposed [Fig. 14]. For the past 2.5 years, the authors have used fibrin glue (Tisseal) in all deep plane face-lifts. The immediate results in the first cases were so positive that it quickly became a standard part of the procedure. The technology is widely used at the authors' primary hospitals in cardiac, thoracic, transplant, and neurosurgical cases. It has been used in Europe for more than 25 years. The goal is to help fix and secure the composite flap in a posterior position, prevent hematoma, and de-crease bruising by eliminating the dead space be­neath the flap. The glue can be used in two ways. It can be an effective surface sealant when used in concentrated form (beneficial following cardiac and neurologic surgery). The diluted form is ad­vantageous because of the adherence that occurs between surfaces (eg, expanding the lung into a pleural cavity coated with the glue following tho­racic surgery). The diluted form must be used in deep plane face-lifts. This form of fibrin glue cures or sets over a 3.5- to 4-minute period and allows for a tight adhesion of the composite flap to the underlying facial tissues. One must fix the flap at the jaw line before using the glue; otherwise, the flap could be rotated too high or low. Once the jaw line sutures are set, the glue is sprayed sparingly over the cervical area, lateral face, and exposed temporal areas. Approxi­mately 1 mL is enough for the entire half face. The fiberoptic retractor facilitates exposure and spray­ing. The process takes about 10 seconds [Fig. 15]. The face is then ''rolled'' firmly with gauze sponges from medial to lateral over the face and neck to express any excess fibrin glue. Only a fine film of the glue is necessary for adhesion. If the glue is layered thickly, it may allow a pocket where the for a tight adhesion of the composite flap to the underlying facial tissues. One must fix the flap at the jaw line before using the glue; otherwise, the flap could be rotated too high or low. Once the jaw line sutures are set, the glue is sprayed sparingly over the cervical area, lateral face, and exposed temporal areas. Approxi­mately 1 mL is enough for the entire half face. The fiberoptic retractor facilitates exposure and spray­ing. The process takes about 10 seconds [Fig. 15]. The face is then ''rolled'' firmly with gauze sponges from medial to lateral over the face and neck to express any excess fibrin glue. Only a fine film of the glue is necessary for adhesion. If the glue is layered thickly, it may allow a pocket where the a second suture point for securing the composite flap. The 3-0 polydioxanone suture anchors the temporal hair-bearing skin to the deep temporalis fascia. The suture is placed to apply as much pres­sure as possible in advancing the flap posteriorly without displacing the hairline upward. In the face-lift procedure, the vector of lift is always in a vector paralleling the direction of the body of the mandible and not superiorly [Figs. 16 and 17]. A third suture is placed higher, anchoring the tem­poral hair-bearing flap (which was elevated to the temporal line to the deep temporalis fascia). The purpose of this suture is to maintain the elevation of the lateral orbital skin and the lateral brow.

The fibrin glue and the sutures provide an effective solid lift.

The retroauricular area is addressed by retract­ing the ear forward and advancing the mastoid skin in a superior and anterior direction. The excess skin is removed after the hairlines are matched. The skin is closed with steel staples and several subcutaneous 4-0 chromic sutures. The retroauricu­lar skin excess is then removed, and the wound is closed with a running 4-0 chromic suture. The ear lobe is closed at the conclusion of the procedure. At this point, the redundant skin remains draped over the ear anteriorly. The composite flap is se­curely fixed just above the ear and at the jaw line.

The anterior skin excision is performed carefully so that there is no tension in this wound closure. Enough tragal skin should be left to close easily the apical tragal incision. Once the skin has been excised, the wound is fixed just above and below the tragus with simple 6-0 Prolene sutures. The wound above the tragus is closed with a running locked 6-0 Prolene suture and the skin below the tragus with a running 6-0 Prolene suture. The neo­tragal skin is then thinned to the thickness of a full-thickness skin graft [Fig. 18]. Normal tragal skin is exceedingly thin. The neotragal skin must mimic the appearance of a normal tragus with a slight anterior depression [Fig. 19]. A thick blunt tragus postoperatively ruins the effect of a non‑operated look. The amount of skin left to cover the tragal cartilage must be adequate to allow clo­sure without pulling the tragus outward. This wound is closed with a 6-0 Prolene suture.

Because the fibrin glue effectively seals the opera­tive dead space and provides an additional degree of hemostasis, no drains are used. The opposite side is handled in a similar fashion. Lastly, the submental wound is closed. Usually, 0.5 mL of the fibrin glue remains and is sprayed into the submental space for adhesion and hemostasis. An assistant gently compresses the submental space while the surgeon sutures the submental crease wound. A moderate pressure bandage is applied. Although an argument could be made for not using any bandage because the fibrin glue has closed the dead space, the senior author believes that the bandage prevents the patient from turning his or her head inappropriately, is a reminder of the significance of the surgery, and seems to provide a degree of perceived and real protection for the patient.

Postoperative care

Immediate postoperative care after a deep plane face-lift does not differ from the routine care pro­vided after other approaches. The patient is seen the next day for a bandage change. The surgical areas are cleaned. The face is examined for any areas of crepitance, which would indicate a fluid collection. If present, this fluid is removed with an 18-gauge needle. In the authors' experience, fluid collection is rarely found, but it is important to remove if present. The patient is shown the ''pre-view'' appearance of the result. Usually, there is minimal bruising and edema. This finding has been the senior author's experience from the first deep plane face-lift performed. The use of fibrin glue has improved on the already minor postopera­tive sequelae. A light wrapping is applied to protect the sutured areas. The patient is seen on the fourth postoperative day for removal of the surgical wrap and removal of the sutures from the preauricular and submental areas.

The staples remain until the eleventh postoperative day. Patients may gently shower their face and wash their hair on the fourth day. The decision to remove staples on the eleventh day is the result of an in-office observation that there is a pinching sensation associated with staple removal that disappears after that day. On magni­fied inspection of the scalp wounds, a microsepara­tion of the wound can be seen associated with the ''ouch'' effect before the eleventh day. After that time, no pain is associated with staple removal, and there is no microseparation of the wound. Patients are asked to avoid alcohol, salty and spicy foods, and exercise that raise the cardiac rate for 2 weeks. Most patients benefit from the use of a woven elastic (Ace-type) bandage to give some pressure to the submental area while sleeping for 2 weeks. Most patients can see friends socially at 6 days and be back to work in 10 to14 days. Sun exposure of the scar is avoided in the early post-operative period.

Patients undergoing a deep plane face-lift are observed for the usual problems and complications following any type of face-lift. Complications with the deep plane lift are minimal. The senior author has seen two hematomas over a 9-year period of performing consecutive deep plane lifts, both in the retroauricular lateral cervical areas. These complications were resolved by removal of a mastoid staple, evacuating the hematoma, and reapplying a pressure bandage. No long-term sequelae were noted in these cases. There have been no hema­tomas in the anterior face. No patients have had seventh nerve, fifth nerve, or muscular weakness. Most patients require minimal postoperative pain medication. The posttragal incision has added to the imperceptible appearance of the scar in the lateral face. There have been no cases of post-operative infection. The lateral posterior vector pull of the composite cheek flap allows the hair line to remain unchanged at the temporal tuft, and the superior anterior vector of pull on the post-auricular skin allows the posterior hairline to match as well.

The deep plane face-lift is often combined with blepharoplasty and forehead lifting. If the proce­dure is performed in conjunction with a hairline forehead-brow lift, temporal portions of the deep plane lift are incorporated into the brow lift. The authors have long advocated a suspension tech­nique for lower lid blepharoplasty, which effec­tively elevates the lateral inferior lower lid over the orbital rim, complimenting the malar fat pad elevation of the deep plane lift.

The authors' experience with the deep plane face-lift has been positive. As discussed earlier, the initial concerns of a prolonged recovery were to-tally unfounded. In fact, the recovery time is improved when compared with the experience with the SMAS lift. The rate of revision surgery during the first few years following a face-lift has declined to the 2% range. Before the deep plane procedure, the rate had been approximately 10%, as reported by others. The nursing staff has identified likely candidates who will require a secondary or revision procedure as those who have ''Gumby'' skin. These patients have an inordinate stretchiness or alarm­ing elasticity to the facial skin and are counseled about the possible need for a secondary procedure if looseness beyond what is expected with normal aging occurs within 24 months of surgery. Before use of the deep plane approach, these patients were told that, in their particular situation, face-lifting would probably be a two-stage procedure. The addition of fibrin glue to the deep plane approach has provided an enormous benefit in the post-operative course and the longevity of the face-lift. When used appropriately, the immediate result is spectacular. The composite flap is draped over and tightly sealed to the underlying facial structures such that the flap cannot be mobilized in an ante­rior direction at all without preauricular or tem­poral sutures. The expense of using 2 mL of fibrin glue adds little to the overall cost of the procedure while the cost-to-benefit ratio is overwhelmingly positive. The low morbidity, rapid recovery, lon­gevity of the results, and enthusiastic patient response to the deep plane face-lift have had a positive effect on this facet of the authors' facial plastic surgery practice [Figs. 20–31].

Further readings

1. Baker SR. Tri-plane rhydectomy. Arch Otolaryngol Head Neck Surg 1997;123:1167–72.
2. Godin MS, Johnson CM. Deep plane-composite rhy­dectomy. Facial Plast Surg 1996;12(3):231–9.
3. Hamra ST. The deep plane rhydectomy. Plast Reconstr Surg 1990;86:53.
4. Hamra ST. Composite rhydectomy. Plast Reconstr Surg 1992;90(1):1–13.
5. Hamra ST. The composite rhydectomy. St. Louis: Quality Medical Publishing; 1993.
6. Johnson CM, Alsarraf R. The aging face: a systematic approach. Philadelphia: WB Saunders; 2002.
7. Kamer FM. One hundred consecutive deep plane face-lifts. Arch Otolaryngol Head Neck Surg 1996;122: 17–22.