Contemporary Deep Plane Facelift: Evolutionary or Revolutionary?

We often look at new technologies as “revolutionary,” but in reality, many advancements are “evolutionary.” Neurotoxins were revolutionary as there was really nothing like them previously. Today’s injectable fillers were evolutionary as other substances were injected prior to modern formulations. Sometimes, however, there is not an exact fit with these definitions. For instance, laser technology was evolutionary in the field of light science but revolutionary in the field of cosmetic surgery. In some respects, every advancement is evolutionary as someone was working toward that end. Other times, something simply happens fast without a long and arduous evolution; hence, it may be a revolution. Credit cards are evolutionary while Bitcoin is revolutionary.

The roots of cosmetic facial surgery can be traced back to 1600 BCE with facial wound repair in Ancient Egypt¹ and nasal and eyelid repair and reconstruction in India in 600 BCE.² 

The ancient Indian surgeon Sushruta intuitively recognized that skin alone is an inadequate lifting structure.² In the Sushruta Samhita text, descriptions of facial reconstruction emphasized mobilizing deeper soft tissues rather than relying on surface skin tension—an early acknowledgment of layered anatomy.³ Deep plane facelift (DPFL) was already in gear. The Renaissance era produced flap-based facial reconstruction in the 1500s.⁴ During this period, Gaspare Tagliacozzi demonstrated that durable facial repair required manipulation of structural tissue planes, even though the terminology and anatomy were not yet defined.⁴

It was the work of the plastic and oral surgeons in World War I that led to modern cosmetic surgery.⁵ Given the number of severe, disfiguring facial injuries, a number of innovations in the field were made that led to truly elective cosmetic facial surgery being taught soon afterward.⁵

Work by plastic surgeon Dr. Harold Gilles, oral surgeon Dr. Varaztad Kazanjian, and contemporaries in facial trauma reconstruction highlighted the importance of composite tissue movement for natural, lasting results.^5,6 This evolution culminated in the formal description of the superficial musculoaponeurotic system (SMAS) by Paul Tessier⁷ and later by Mitz and Peyronie,⁸ providing the anatomic framework that made the deep plane facelift possible. The modern SMAS concept crystallized in the 20th century as surgeons transitioned from skin-only facelifts to anatomically based rejuvenation. Dr. Sam Hamra published deep plane techniques in the late 1900s.⁹ Modern deep plane techniques, thus, represent the logical endpoint of a long surgical trajectory: repositioning the face by mobilizing its true support layers, not merely redraping skin. Understanding this lineage reinforces that deep plane facelift surgery is grounded in enduring anatomic principles rather than procedural trend.

There exist two main branches of aesthetic surgery: surgical and nonsurgical. Although the ancient Egyptians were doing eyelid surgery, many of the people reading this article trained during a time when there were really no predictable nonsurgical procedures or devices as we know them today. While nonsurgical procedures have bloomed over the years, facelift surgery primarily remained similar until the past decade or so, when deep plane technique became popularized. There was a time when “mini lifts” were very popular, but now, with deep plane techniques, “maxi” lift would be more appropriate. 

Deep plane face and neck lift has evolved into less surgery but more result, which is somewhat of an oxymoron. The deep plane technique involves much less skin dissection than previous techniques. Whereas previous techniques may have undermined the skin to the center of the face, the contemporary deep plane skin dissection is about two finger breaths from the ear. That is the easy part (Figure 1). The second distinction that sets deep plane apart from previous lifts is that deep plane technique involves a much more aggressive sub-SMAS dissection that proceeds to the center of the face (Figure 2). That is the advanced part! The deep plane, as the name implies, involves the deeper structures of the face. When a surgeon operates in this space, we are working around the facial nerves, large-bore veins and arteries, and the submandibular glands (Figure 3). This requires a lot of experience and is not a technique for beginners. 

Due to the fact that less skin is undermined, the result never looks pulled when performed by experienced surgeons. The entire basis of DPFL is to have the SMAS carry the skin with it instead of 2 separate layers. It is simply a better procedure than other facial plastic surgeries. In the past, we operated above the SMAS; the contemporary DPFL technique is a deep procedure under the SMAS. As stated earlier, the conceptual roots of DPFL extend back thousands of years.

Is DPFL the best facelift technique and why?

I believe that this procedure produces results that stand above other facelift techniques (Figures 3 and 4). This technique requires experience and is not a procedure for the novice facelift surgeon.

The following are advantages of DPFL technique over previous approaches.

1. Composite Tissue Repositioning

Unlike skin-only or SMAS plication techniques, the DPFL elevates the facial soft tissues as a single composite flap of skin, muscle, and fat. This restores youthful anatomy by repositioning the malar fat pad and midface tissues en bloc, rather than stretching skin over descended structures. The result is a more natural contour with preservation of facial fullness.

2. Superior Midface and Nasolabial Fold Correction

Earlier facelifts primarily improved the jawline and neck, with limited effect on the midface. By releasing key retaining ligaments and mobilizing the malar fat pad, the DPFL provides improvement of the midface and nasolabial folds without relying on skin tension.

3. Reduced Skin Tension and Improved Scar Quality

Because lift vectors are borne by the SMAS and deeper tissues, skin closure is essentially tension-free. This leads to improved scars, less risk of tension dehiscence, and less chance of hairline and earlobe distortion.

4. More Natural Facial Expression

Aggressive skin dissection techniques can produce a “pulled” or operated appearance, particularly in animation. Deep plane elevation preserves facial subunits and vectors, resulting in dynamic, natural facial movement with reduced risk of lateral sweep or mask-like expression.

5. Longer-Lasting Results

Many surgeons feel that, by repositioning the true structural supports of the face, the DPFL addresses the primary anatomic drivers of facial aging. This results in greater durability compared with skin-only or limited SMAS techniques, which are more prone to early relapse due to skin creep and gravitational descent. I know of no statistically significant studies that can credit any facelift technique as “longer lasting” due to the thousands of variables patient aging, elastosis, heredity, lifestyle, etc.

6. Improved Correction of Jowling

Jowls are a deep-plane problem, not a skin problem. Deep plane dissection allows direct mobilization of jowl fat and SMAS, producing cleaner mandibular contouring without excessive lateral skin tension.

7. Anatomically Logical and Reproducible

Deep plane surgery follows predictable anatomic planes and ligamentous release points. When performed correctly, it provides consistent outcomes rooted in anatomy rather than variable skin elasticity or suture fixation strength.

8. Better Aging Trajectory

Many surgeons feel that patients tend to age more gracefully after deep plane facelift, maintaining facial harmony as tissues continue to age in a repositioned but natural configuration. Because DPFL relies on a composite flap (skin, fat, and SMAS), the aging is less drastic than putting most of the trust on the skin.

Is DPFL the only effective facelift technique?

Is Ferrari the best car? There are many angles to consider when answering a question about DPFL being the best technique. I don’t think it is the only rejuvenating facelift, but I do think it is the best one. Many surgeons perform other types of traditional facelift procedures and achieve good results. Finally, due to the marketing implications and demand for DPFL, I believe that there are practitioners who claim to be performing this technique but in reality are not, or perhaps they are performing a “mini” version of the deep plane facelift. Like all cosmetic interventions, patients should do their homework and anyone interested in DPFL should seek out a surgeon with significant experience. Any surgeon with a vibrant facelift practice that is performing contemporary DPFL should be able to show prospective patients hundreds of before and after pictures concerning this technique.

Figures 4 through 6 show DPFL cases with submandibular gland reduction. Operating in the deep plane has been a paradigm shift and game changer for face and neck rejuvenation. 

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Joe Niamtu III, DMD