The State of the Facelift: From Passé to Premium
The reputation of the facelift has come a long way in recent decades as techniques have improved and patients and physicians have increasingly recognized the limits of minimally invasive techniques.
By 2010 or so, the facelift was practically considered passé as minimally invasive techniques such as injections and relaxants gained traction and dissatisfaction lingered with the older superficial musculoaponeurotic system (SMAS) techniques that often led to an unnatural appearance, according to Neil A. Gordon, MD, director of head and neck aesthetic surgery at Yale School of Medicine in New Haven, CT, and founder of The Retreat at Split Rock in Wilton, CT.
The minimally invasive options were highly appealing to patients because they didn’t require surgery or anesthesia, and they were thought to solve the problem of looking unnatural, so the pendulum swung away from the facelift, he said. Plus, many believed at the time that aging was mostly about volume loss and not soft tissue redundancy. (See sidebar on the illusion of volume loss.)
FACELIFTS REGAIN FAVOR
However, around 2016, the “pendulum started to shift again, and the deep plane facelift started to become more recognized and accepted as a safe technique and a better technique that, because of how it’s done now, obviated the issues of looking unnatural or having a short-term result,” Dr. Gordon explained. In addition, the “concept of filler fatigue or people actually looking unnatural by avoiding surgery and filling up faces until they looked unnatural, that became a new paradigm that hadn’t previously been considered – that you can actually look unnatural by not having surgery.”
While minimally invasive approaches are appropriate in many cases, a facelift may be the most appropriate option to achieve the desired outcomes in certain patients. “The deep plane facelift has become the gold standard surgical technique, and we’re seeing more and more surgeons wanting to become proficient in this approach,” Dr. Gordon stated.1,2
There are currently two schools of thought regarding facelift approaches, according to Steven R. Cohen, MD, clinical professor of plastic surgery at the University of California San Diego and director of Faces Plus in San Diego, CA. “One is increasingly moving toward deep plane and deep neck surgery, which includes contouring the neck and shaving bulging submandibular glands, digastric muscles, and subplatysmal fat and shaping the jawline in new ways that are more surgically complex and done by fewer surgeons.” While this approach involves a great deal of anatomy and a steep learning curve, the results are superior to those achieved through other techniques when performed by a skilled surgeon.
“The other school of thought is moving toward less invasive approaches with hidden incisions, such as the ‘ponytail lift’ concept being promoted by my friend Dr. Kao in Los Angeles,” he said.
“My personal approach is to learn and apply the correct techniques in a bespoke fashion because not one technique addresses all situations and anatomic conditions,” Dr. Cohen explained. (See sidebar for his take on the latest facelift techniques.)
CURRENT FACELIFT TECHNIQUES
Steven R. Cohen, MD, describes the latest facelift approaches below. “In my opinion, it is important that all of these techniques are in the surgeon’s skill set,” he said.
Extended deep plane facelift with platysmal slings or hammocks. In this technique, the deep plane is entered at the junction of the fixed and mobile SMAS and elevated almost to the nasolabial fold. Using a Trepsat spreader makes this very fast and very safe. The deep plane is extended under the platysma laterally as well, freeing up the platysma from the deep cervical fascia.
Once completed, the SMAS-platysma flap is first sutured just below the mandibular border to emphasize the jawline. I will often fat graft a triangular wedge to emphasize the jawline and create more depth between the mandibular border and the neck. I use a 2.0 or 3.0 V-Loc suture and anchor the suture to the medial aspect of the mastoid process as this further accentuates the mandibular angle.
Once this suture is placed, I then suture the flap vertically to Lore’s fascia. The suture can be run along the same suture line to further elevate the SMAS. In essence, the vector in the midface is vertical and slightly medial. Once this is completed, the neck can be inspected, and a decision can be made about whether deep neck contouring needs to be performed.
Deep neck surgery. This may be done in younger patients alone or, in older patients or those with jowling, in conjunction with a deep plane facelift or even a plication-style facelift. In younger patients, the deep neck surgery can be performed in conjunction with a “ponytail” type of lift, but if excess skin and jowling are present, an extended deep plane facelift technique is used in the midface.
Deep neck surgery consists of addressing all components that produce contour abnormalities in the neck. The subcutaneous fat is reduced while taking care to leave a generous subcutaneous cover under the skin.
Next, the platysma is exposed and elevated with cautery contiguous with the lateral subplatysmal dissection. Once the underlying subplatysmal fat is exposed, I prefer to elevate an inferiorly based flap and not remove any of the fat until I have completed both the gland reduction and the anterior digastric reduction.
Once the gland capsule is exposed, I make an incision with electrocautery into the capsule and then expose the gland. The gland can be delivered with forceps, or a traction suture can be utilized to hold the gland up as one frees it from the surrounding capsule. Generally, more gland than might be expected is removed. I currently prefer using a LigaSure device which seals the gland as one removes it.
Once removed, the gland stump is injected with 20 units of Botox and then the capsule is closed with a 3.0 vicryl on an SH needle. The neck is reassessed by flexing the patient and looking for bulging of the anterior digastrics. If seen, these are trimmed and debulked with electrocautery. At this point, the subplatysmal fat can be trimmed as needed or can be used in men as a turnover flap to decrease the prominence of the thyroid cartilage if necessary.
Once the contour is improved, the platysma is closed with a running 2.0 or 3.0 V-Loc suture, anchoring this suture to the peri-hyoid fascia. Other measures can be performed if needed – for instance, the strap muscles below the platysma can be closed, the anterior digastric tendons can be approximated, and the anterior digastrics can be plicated. Lastly, the mylohyoid can be plicated if a bulge is still seen.
Once closure of the skin flaps is completed, several options exist for hemostasis. One, hemostasis should be meticulously achieved. Two, ARTISS tissue glue (Baxter, Inc.) can be sprayed, and three, a hemostatic net developed by Andre Ausvald of Brazil can be applied. Rarely are drains used in my practice, but they are an option as well. In addition to the hemostatic effect of the net, it aids in skin re-draping.
“Ponytail” type lifts or minimal incision, short-scar techniques. These approaches are applicable in younger patients in patients with limited skin laxity. An incision is made in the temporal hair, and dissection is performed under direct vision and with endoscopic visualization. The dissection proceeds along the deep temporal fascia, and once the zygomatic arch is reached, the dissection proceeds under the SMAS layer.
Once this is entered, one can rapidly dissect sub-SMAS with a Trepsat spreader. The dissection can proceed sub-periosteal under the orbicularis, and a cheek implant
can be inserted if desired. Most patients having these approaches benefit from or desire a temporal browlift, and this can be done in the sub-periosteal plane as well.
Stabilization is performed with 4.0 or 3.0 PDS using a long Keith needle through the skin and back through the same needle hole. Endotines can also be used effectively. The sutures are tied to the temporalis fascia. A small amount of skin may be removed from the temporal hair, or a gliding browlift suture with 4.0 nylon on as large a cutting needle as possible can be extended throughout the skin dissection. Lateral canthopexy can be carried out at the same time. This approach is effective for the “fox eye” look, which is lovely in the right patient and a bit odd in the wrong patient.
In patients with neck laxity, an incision is made behind the ear, and through this, the platysma and inferior aspects of the SMAS flap can be elevated to sharpen the jawline and improve some of the excess skin of the neck.
Mini facelift. For me, these are defined as scars around the ears, but no scar in the submental region. I perform both plication as well as extended deep plane elevation when I do a mini facelift, depending on patient findings.
Ben Talei, MD, director of the Beverly Hills Center for Facial Plastic and Laser Surgery in California, noted an ongoing shift in understanding regarding aging and facelift techniques. “Prior techniques worked around the idea of pulling and tightening with more extensive dissection, whereas the new paradigm is focused on release and repositioning of soft tissues without any tension or tightening, as well as restoration of deeper contours to redistribute crepey skin rather than elevating and pulling more of it,” he explained. However, he said there remains “some resistance from dogmatic thinkers, despite clear evidence of superior results gained by following more advanced philosophies.”
CURRENT TRENDS AND OPTIONS
“The world of facelifting is shifting to the mobilization of the deep plane,” Dr. Talei stated. Regardless of the patient’s sex or age, the “human face is the human face, and we get better results and preserved function when manipulating the deep plane without affecting the underlying muscles.”
He noted that a profound understanding of facial anatomy is the main factor that results in successful outcomes with a facelift, and thus the knowledge and ability of the surgeon are more important than the technique used: “Simply performing a deep plane doesn’t mean they’re performing a better surgery – the surgeon really has to understand the anatomy to achieve superior results.”
SPEAKING VOLUMES
In a paper published in 2015, Dr. Gordon explained that volume loss is not a major component in the aging process; it’s an illusion of volume loss.5 In an interview, he described the analogy of a half-liter bottle of water that is filled to the top: If that water were poured into a full-liter bottle, it would only fill the larger bottle halfway, but it would be the container – not the volume – that had changed.
“That volume loss can be an illusion because as the face ages and gravity affects the soft tissue, you get more face in a lower position, so the container is actually getting larger, and it’s not the volume that’s changing nearly as much as would be perceived – with aging, we now have a bigger face with the same volume,” he said. “The deep plane facelift, when properly executed, moves all the facial volume in a way that prior facelifts did not,” so surgeons can volumize the face by reduction, essentially making the container smaller again. “We use these analogies to illustrate that we’re not trying to be aggressive, we’re trying to be accurate.”
While there has been progress in the realm of the deep plane facelift, such as the advanced deep plane lift and more aggressive deep neck surgery, most of the newer technologies and other advances are aimed at creating “shortcuts to somehow create outcomes that are not surgical” that can be performed by a larger number of clinicians on consumers who want to avoid surgery, Dr. Gordon explained.
Much of the focus in research and development these days is on minimally invasive techniques, partly because a far greater number of clinicians can perform these procedures compared to the relatively small number of surgeons skilled in deep plane facelifts, he said.
“The two areas that we’re seeing improvements in are strings and energy devices: String lifts have become much more popular, and the strings are getting better,” according to Dr. Gordon. With this approach, the “outcome is temporary and cannot mimic a surgical result, but it is an avenue for people who don’t want surgery to be able to get an approach that’s not just filling the face.”
The energy devices are becoming more diverse, using different types of energy in different ways, he added, all with the goal of causing the soft tissue to contract or shrink.
Dr. Gordon noted that minimally invasive techniques carry their own risks of complications, and the long-term risks of these approaches remain unknown.
With less invasive facelift techniques, such as the minimal access cranial suspension (MACS) lift and plication,3,4 potential downsides are earlier recurrence and the need for revisions if the patient is undertreated, Dr. Cohen stated. “I feel there is more rapid recurrence in patients undergoing plication and mini lifts when what is needed is more extensive surgery.” On the other hand, more extensive surgeries may result in higher complication rates and longer healing periods.
In Dr. Talei’s opinion, SMAS plication techniques are anatomically illogical. “The skin is supported by the underlying structures, and destabilizing the skin with elevation off the SMAS should be avoided when possible,” he advised. Among other techniques, “Endoscopic deep plane techniques are interesting because they attempt to mobilize the correct plane; however, there are several limitations that make this surgery much more technically demanding.”
An extensive deep plane lift results in optimal improvements in appearance, duration, and function, and healing time typically depends on the amount of area dissected and surgical skill rather than the technique used, he said.
In practice, Dr. Talei said he constantly strives to improve his techniques and to learn from past failures, which has ultimately improved his understanding of facial anatomy and how to better manipulate the face. His most significant shifts have been toward hydratory restoration of the face using a technique he developed called PHAT (platelet hybridized adipose therapy), deeper recontouring of the neck, and doing less skin elevation and skin pull. “With these ideologies, I have catapulted my results to a new place where my before and after photos are more impressive and consistent from patient to patient,” he said.
Disclosures:
Dr. Cohen is the co-founder of MAGE (magegroup.co.uk).
Dr. Gordon reports no relevant financial conflicts.
Dr. Talei reports no relevant financial conflicts.
1. Gordon NA, Sawan TG. Deep-plane approach to the vertical platysma advancement: Technical modifications and nuances over 25 years. Facial Plast Surg. 2020;36(4):358-375. doi:10.1055/s-0040-1713842
2. Raggio BS, Patel BC. Deep plane facelift. StatPearls. Updated April 3, 2023. Accessed October 3, 2023.
3. Hijkoop LF, Stevens HPJD, van der Lei B. The minimal access cranial suspension (MACS) lift: A systematic review of literature 18 years after its introduction. J Plast Reconstr Aesthet Surg. 2022;75(3):1187-1196. doi:10.1016/j. bjps.2021.11.051
4. Joshi K, Hohman MH, Seiger E. SMAS plication facelift. StatPearls. Updated March 1, 2023. Accessed October 3, 2023.
5. Gordon NA, Toman J. Illusion of volume loss. Facial Plast Surg. 2015;31(1):80-87. doi:10.1055/s-0035-1544250
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