Abstract
Background:
The deep-plane face lift is a widely used surgical technique for improving the appearance of the face and neck. But is it truly effective in providing optimal, reliable, and long-lasting results?
Methods:
The aim of this study was to analyze the outcomes of deep-plane face lift procedures. A retrospective study was conducted on 78 patients who underwent deep-plane face lift surgery. The follow-up period ranged from 0 to 24 months after surgery, during which the timing of recurrences in ptosis of the nasolabial fold, jowls along the jawline, marionette lines, and the central-lateral aspect of the neck was analyzed.
Results:
Early recurrences of these parameters were documented in all cases, occurring between 6 and 12 months during follow-up.
Conclusions:
The deep-plane face lift is a surgical technique that is not suitable for all face types and should be limited to very specific and more restrictive indications than previously imagined.
Takeaways
Question: Is the deep-plane face lift a reliable technique for all facial rejuvenation procedures?
Findings: Postoperative photographs of 78 deep-plane face lifts (1–12 mo follow-up) were evaluated by 3 plastic surgeons for recurrences in 4 areas: nasolabial fold, marionette lines, jawline, and neck. Early recurrences were observed between 6 and 12 months.
Meaning: Although widely used, the deep-plane face lift is not as safe and reliable as assumed. Due to its surgical basis, it is best suited for select cases with minimal skin and superficial muscular aponeurotic system laxity.
INTRODUCTION
The deep-plane face lift has emerged as a promising approach to facial rejuvenation in recent decades. This surgical procedure is less invasive and offers a quicker recovery for patients, thanks to the reduced detachment of both the subcutaneous tissue at a superficial level and the fixed superficial muscular aponeurotic system (SMAS) at deeper levels.
Originally described by Hamra1 in 1990, the deep-plane face lift involves dissection beneath the SMAS of the midface, allowing for the direct release of the major retaining ligaments of the face and maximum mobilization of the superficial soft tissues. This allows for better mobilization of the superficial soft tissue envelope, containing most of the facial fat, without the need for surface tension.2 By applying tension only at the fascia, the deep-plane technique creates a tension-free skin closure and promising long-term results.
The deep-plane face lift procedure is based on the release of all attachments of the SMAS and the creation of a thick musculocutaneous flap composed of skin, the entire subcutaneous cheek flap, and the platysma muscle.1 This technique avoids many complications related to other SMAS rhytidectomy procedures, such as facial hematomas, subcutaneous irregularities, and periauricular skin necrosis, especially in patients who smoke and patients with compromised vascularization.3,4
Regarding the surgical technique, 2 key points are important to consider:
A broad release of the facial retaining ligaments is crucial for achieving greater redraping of the face. These ligaments include the attachments of the medial aspect of the zygomaticus major, the anterior extension of the masseteric cutaneous ligaments, and the mandibular cutaneous ligaments. Additionally, releasing the cervical retaining ligaments, which limit the movement of the platysma during surgery, allows for more effective redraping of the platysma.5
Once raised, the platysma–SMAS flap can be mobilized, advanced, and suspended to the fixed SMAS along an oblique vector parallel to the long axis of the zygomatic major muscle.6
The aim of this study was to review the results obtained from a deep-plane face lift in our clinical practice and to make a critical analysis of early recurrences and failures linked to the application of this surgical technique.
The hypothesis to be refuted was whether the deep-plane face lift could really be a reliable technique capable of providing stable, optimal, and long-lasting results.
METHODS
To test the hypothesis of this study, we analyzed the outcome of the deep-plane face lift on 78 patients. The patients underwent a primary deep-plane face lift surgery to rejuvenate the appearance of their face and neck between January 2021 and December 2022.
All surgical procedures were performed by Dr. Antonio Distefano, a plastic surgeon with 20 years of experience in face lift procedures. In particular, the surgeon has performed numerous facial rejuvenation procedures in his clinical practice, including high and low SMAS face lifts, deep-plane face lifts, and SMASectomy.
All 78 patients were women; the average age of the patients at the time of surgery was 63 years (range: 49–72 y). All had moderate to severe soft tissue ptosis of the face and neck. The following exclusion criteria were applied: patients younger than 53 years characterized by a mild soft tissue ptosis, patients who had undergone previous face lift surgery, and the presence of medial platysma bands less than 3.8 cm apart.
All deep-plane face lift procedures were performed under general anesthesia or deep sedation with local anesthesia. The technique used was based on the Jacono and Parikh method, as outlined in “The Minimal Access Deep Plane Extended Vertical Facelift.”7 Preoperative markings were made in an upright position, with the deep-plane entry point extending from the lateral canthus to the mandible angle, and the subcutaneous dissection marked 1 cm anteriorly. (See figure, Supplemental Digital Content 1, which demonstrates the classic preoperative marking of the patient regarding the incision lines and both superficial and deep dissection, https://links.lww.com/PRSGO/E128.)
The skin incision extended from the temporal to the occipital hairline, passing through the posttragal and postauricular sulcus. After subcutaneous dissection, the deep plane was accessed by incising the SMAS from above the mandible to the lateral orbital rim, and the composite skin/SMAS flap was elevated off the parotid-masseteric fascia. (See figure, Supplemental Digital Content 2, which shows the SMAS incision line; once raised, the subcutaneous flap connects the lateral canthus to the angle of the mandible, https://links.lww.com/PRSGO/E129.) (See figure, Supplemental Digital Content 3, which shows the SMAS flap prepared according to the deep-plane face lift technique, repositioned superoposteriorly along a 60-degree vector and anchored to the fixed SMAS using the 3-0 Mersilene sutures, https://links.lww.com/PRSGO/E130.)
Superior dissection was performed along the lateral orbicularis oculi and into the premaxillary space. Zygomatic ligaments were released, and deep dissection continued medially to the nasolabial fold. After releasing mandibular and cervical retaining ligaments, deep neck dissection was performed. The SMAS–platysma flap was suspended using half-mattress sutures, anchored to the parotid and deep temporal fascia in a vertically oblique vector of 60 degrees.
Firm half-mattress sutures (3-0 Mersilene) were placed into the dissected SMAS cuff, and flap margins were sealed with interrupted sutures. A lateral platysmal myotomy was performed below the mandibular angle, and the platysma was anchored to the sternocleidomastoid fascia with suspension sutures. After resuspending the SMAS–platysma flap, redundant skin was excised, and the skin flap was suspended similarly to the deep-plane flap for tension-free closure.
The additional procedures that were performed simultaneously with the deep-plane face lift in some patients included upper and lower blepharoplasty, as well as a brow lift.
We reviewed postoperative photographs of 78 patients who underwent a deep-plane face lift. Postoperative photographs were taken at 1, 2, 4, 6, and 12 months after surgery. Photographs were taken in frontal, 45-degree, and lateral views. Three blinded observers, all facial plastic surgeons, were asked to evaluate the 1-, 2-, 4-, 6-, and 12-month postoperative photographs. Four aspects of the face and neck were rated on a 7-point Likert scale (1 = “none,” and 7 = “severe”): the severity of jawline contour loss (ie, jowls), the nasolabial fold, the marionette line, and the central-lateral aspect of the neck. These parameters were chosen by the authors based on their extensive clinical experience in the field.
A 7-point visual analog (Likert) scale8 was used to rate the photographs at these given points (Table 1).
Table 1.
The Observers Used a Visual Analog Scale to Rate the Patients’ Photographs
| Severity of jawline continuity loss (or jowls) | ||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 |
| None or mild recurrence | Moderate recurrence | Severe recurrence | ||||
| Severity of nasolabial fold | ||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 |
| None or mild recurrence | Moderate recurrence | Severe recurrence | ||||
| Severity of marionette line | ||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 |
| None or mild recurrence | Moderate recurrence | Severe recurrence | ||||
| Severity of central-lateral aspect of the neck | ||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 |
| None or mild recurrence | Moderate recurrence | Severe recurrence | ||||
The study adhered to the principles of the current Declaration of Helsinki but, because the surgery was conducted in private practice, the study was not approved by an institutional review board.
All patients provided written informed consent for the face lift procedure, as well as for the use of their photographs and data for scientific purposes, including publication.
RESULTS
To critically analyze the results obtained from the independent evaluations by the 3 reviewers regarding the quality of the outcomes, the enrolled patients were categorized based on their facial characteristics. The patients were grouped into 4 categories based on anthropometric features: round, square, oval, and triangular faces.9
Oval: The forehead is wider than the chin. The face length is one and a half times more than the width of the face.
Round: The length and width of the face are almost the same, and the cheekbones are the most prominent part.
Square: All face sizes are almost the same width (forehead, cheekbones, and jaw), with the jawline having a sharper angle.
Diamond: the cheekbone is the most dominant part, bigger than the forehead and jaw.
This categorization allowed for the assessment of the recurrence rate of the evaluated parameters based on the distinct skeletal morphology of each face. Furthermore, patients were stratified into 3 distinct age groups: patients younger than 55 years, patients between 55 and 65 years, and patients older than 65 years.
Table 2 presents the distribution of the analyzed faces by shape and age class.
Table 2.
The Distribution of the 78 Patients Enrolled in the Study by Age Group (Younger Than 55 y, Between 55 and 65 y, Older Than 65 y) and Facial Morphology
| Age < 55 y | Age 55–65 y | Age > 65 y | |
|---|---|---|---|
| Oval shape | 6 | 11 | 2 |
| Round shape | 3 | 18 | 5 |
| Square shape | 1 | 15 | 7 |
| Diamond shape | 2 | 5 | 3 |
Statistical analysis was performed on the average scores assigned by the 3 surgeons for each evaluated parameter, categorized by facial type and age group.
The observations are presented in Table 3, using the mean values of individual observations for each parameter evaluated during follow-up visits at 1, 2, 4, 6, and 12 months, stratified by age group.
Table 3.
Average Scores Assigned by the 3 Surgeons, Categorized by Facial Type and Age Group, During Follow-up Visits at 1, 2, 4, 6, and 12 Months
| 1 mo | 2 mo | 4 mo | 6 mo | 12 mo | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| <55 y | 55–65 y | >65 y | <55 y | 55–65 y | >zzs65 y | <55 y | 55–65 y | >65 y | <55 y | 55–65 y | >65 y | <55 y | 55–65 y | >65 y | |
| Round shape | |||||||||||||||
| Severity of jawline | 1 | 1.1 | 1.4 | 1.3 | 1.6 | 2.6 | 2 | 2.6 | 3.2 | 2.7 | 3.4 | 4.4 | 3 | 4.2 | 5.8 |
| Severity of nasolabial fold | 1 | 1 | 1 | 1 | 1 | 2 | 1.3 | 1.8 | 2.6 | 2 | 2.2 | 3.4 | 3 | 2.9 | 4 |
| Severity of marionette line | 1 | 1.2 | 2 | 1.3 | 1.7 | 3 | 2 | 2.6 | 3.2 | 2.7 | 3 | 4 | 3.3 | 3.9 | 5.4 |
| Severity of central-lateral aspect of the neck | 1 | 1.3 | 1 | 1 | 1.7 | 2.2 | 2 | 2.4 | 2.8 | 3 | 3.1 | 3.8 | 3 | 4 | 4.6 |
| Oval shape | |||||||||||||||
| Severity of jawline | 1 | 1 | 1 | 1.7 | 1.8 | 2.5 | 2.2 | 2.8 | 4 | 3 | 4 | 5 | 3.5 | 5.3 | 6.5 |
| Severity of nasolabial fold | 1 | 1 | 1 | 1.2 | 1 | 2 | 1.7 | 2 | 3 | 2.5 | 2.5 | 3 | 3.3 | 3.4 | 4 |
| Severity of marionette line | 1.2 | 1.3 | 2 | 2 | 1.8 | 3 | 2.7 | 2.8 | 4 | 3 | 3.6 | 4 | 4 | 4.6 | 5.5 |
| Severity of central-lateral aspect of the neck | 1.2 | 1.3 | 1.5 | 1.7 | 1.9 | 2.5 | 2.5 | 2.7 | 3.5 | 3.2 | 4 | 4.5 | 4 | 5.2 | 6.5 |
| Square shape | |||||||||||||||
| Severity of jawline | 1 | 1 | 1.1 | 1 | 1.3 | 2.1 | 2 | 2.1 | 2.7 | 2 | 2.5 | 3.1 | 3 | 3.6 | 4.7 |
| Severity of nasolabial fold | 1 | 1 | 1 | 1 | 1.2 | 2 | 2 | 1.9 | 2.3 | 2 | 2.2 | 3.4 | 3 | 3.1 | 4 |
| Severity of marionette line | 1 | 1.1 | 2 | 1 | 1.7 | 2.7 | 2 | 2.1 | 3 | 2 | 2.6 | 4 | 3 | 3.6 | 5.4 |
| Severity of central-lateral aspect of the neck | 1 | 1.1 | 1 | 1 | 1.1 | 2.3 | 2 | 2 | 2.9 | 2 | 2.5 | 3.4 | 3 | 3.3 | 4.6 |
| Diamond shape | |||||||||||||||
| Severity of jawline | 1 | 1.2 | 1 | 1 | 1.8 | 2.3 | 2 | 2.8 | 2.7 | 3.5 | 3.4 | 4 | 5 | 5.6 | 6 |
| Severity of nasolabial fold | 1 | 1 | 1 | 1.5 | 1.6 | 2 | 2 | 2 | 2.7 | 2 | 2.2 | 3.3 | 3 | 3 | 4 |
| Severity of marionette line | 1 | 1.2 | 2 | 1.5 | 1.4 | 3 | 2 | 2.2 | 3 | 2 | 2.8 | 3.7 | 3.5 | 3.4 | 5 |
| Severity of central-lateral aspect of the neck | 1 | 1.2 | 1 | 1.5 | 1.8 | 2 | 2.5 | 2.2 | 2.7 | 3.5 | 3 | 4.7 | 4.5 | 4.8 | 6.3 |
Based on the summary tables for the various classes, trends in evaluations over time were calculated. It emerged that the jawline is the parameter that deteriorates most rapidly over time across all age groups, whereas the nasolabial fold is the parameter that deteriorates most slowly over time across all age groups.
Focusing on the 55- to 65-year age group, which is statistically the most significant within our study, the recurrence trends for each parameter analyzed are illustrated in 4 graphs in Supplemental Digital Content 4–7, as slope lines specific to each facial type. (See figure, Supplemental Digital Content 4, which shows recurrence scores related to the jawline during follow-up for each facial phenotype class in a patient sample between 55 and 65 y of age, https://links.lww.com/PRSGO/E131.) (See figure, Supplemental Digital Content 5, which shows recurrence scores related to the nasolabial fold during follow-up for each facial phenotype class in a patient sample between 55 and 65 y of age, https://links.lww.com/PRSGO/E132.) (See figure, Supplemental Digital Content 6, which shows recurrence scores related to the marionette line during follow-up for each facial phenotype class in a patient sample between 55 and 65 y of age, https://links.lww.com/PRSGO/E133.) (See figure, Supplemental Digital Content 7, which shows recurrence scores related to the central-lateral aspect of the neck during follow-up for each facial phenotype class in a patient sample between 55 and 65 y of age, https://links.lww.com/PRSGO/E134.)
DISCUSSION
Face lift techniques vary widely, depending on the surgeon’s background and preferences. Although several methods are used, there is no consensus on which is the most effective. Regardless of the technique, successful facial and neck surgery requires a deep understanding of the facial structure, the forces at play, and the principles of rejuvenation.
Over the past 4 decades, the deep-plane face lift has become a leading technique for achieving optimal, reliable, and long-lasting aesthetic results with minimal complications. Although considered a valid surgical option, it has specific indications and numerous limitations. This article was prompted by the failures that authors encountered when applying the deep-plane face lift in their clinical practice. These experiences led them to critically review the fundamental aspects of the procedure.
In the authors’ clinical practice, regardless of variations in facial morphology, deep-plane face lifts yielded suboptimal outcomes in patients with significant skin laxity at the jawline. This was characterized by inadequate definition of the mandibular contour, limited improvement of the marionette lines, and suboptimal elevation of the malar soft tissues, as evidenced by only a modest enhancement of the nasolabial fold (Fig. 1). (See figures, Supplemental Digital Content 8–10, which show more perspectives, https://links.lww.com/PRSGO/E135.)
Fig. 1.
Example of early recurrence following a deep-plane face and neck lift. A and B, A 69-year-old woman presented with severe upper neck and submental laxity, enhanced central platysma bands, jowls, marionette grooves, and severe midface ptosis with deep nasolabial folds. C and D, Six months after deep-plane face and neck lift. Note that the patient presents an early recurrence of jowl ptosis associated with an unsatisfactory improvement of the nasolabial folds and marionette lines, which can be best appreciated in the three-quarter views (D). In the lower third of the face, the patient shows a poor definition of the jawlines and of the central-lateral aspect of the neck.
The reasons for this failure are to be found in the surgical technique underlying the deep-plane face lift. In fact, although the surgical results in the immediate postoperative period are optimal, early sagging of the soft tissues of the face and neck is expressed once the failure of the cicatricial fibrosis between the flaps occurs (Fig. 2) (Supplemental Digital Content 9, https://links.lww.com/PRSGO/E135).
Fig. 2.
Example of early recurrence following a deep-plane face and neck lift. A and B, A 67-year-old woman presented with mild midface and neck ptosis with moderate nasolabial and marionette grooves, undefined jawlines, and submental laxity. C and D, Postoperative photographs taken 2 months after the deep-plane face lift surgery. E and F, Eight months after deep-plane face and neck lift. Note the unsatisfactory correction of the midface with the recurrence of the nasolabial and marionette lines, which can be best appreciated in the lateral views (F). Furthermore, superolateral traction of the neck and jawline did not produce the expected results.
Additionally, the mobilization of the composite flap in the lower third of the face and the lateral half of the neck follows an inherently oblique vector, directed superolaterally along the axial orientation of the zygomatic major muscle. As a result, early recurrence of tissue laxity is observed along the jawline and the superolateral half of the neck. In the authors’ clinical practice, this recurrence became evident approximately 6–12 months postoperatively. On physical examination, it manifested as a skin drape along the jawline and swelling in the superolateral region of the neck (Fig. 3) (Supplemental Digital Content 10, https://links.lww.com/PRSGO/E135).
Fig. 3.
Example of early recurrence following a deep-plane face and neck lift. A and B, A 64-year-old woman presented with significant upper neck and submental laxity, bilateral platysmal banding, jowls, marionette grooves, and midface ptosis. C and D, Seven months after deep-plane face and neck lift. Note the early, dramatic recurrences of facial sagging with loss of the expected rejuvenating long-lasting effects in the middle and lower thirds of the face, especially the recurrences of nasolabial fold and ptosis of the jowls associated with unsatisfactory jawline redefinition and noticeable marionette grooves (D).
The authors noted that these recurrences occurred especially in cases of round-shaped faces, characterized by abundant subcutaneous adipose tissue, and in oval-shaped faces, characterized by excess skin and severe ptosis of the neck. In these situations, in fact, the oblique traction vector of the deep composite flap does not allow a vertical rotation of the SMAS–platysma flap at the level of the neck and the mandibular line.
Unlike the deep-plane face lift, the high SMAS technique uses a broader and more mobile SMAS–platysma flap, enabling rotational movement in the neck and complete vertical translation in the face. This allows for superior correction of the submandibular and superolateral cervical regions, enhanced jawline definition, better cheek redraping, and greater volumization of the zygomatic region compared with the deep-plane face lift. (See Supplemental Digital Content 11, which shows an example of a highly satisfactory result achieved 1 y after surgery performing high SMAS face lift technique, https://links.lww.com/PRSGO/E136.)
Other critical issues regarding the traction vectors used during a deep-plane face lift that should not be underestimated are:
the interfascial spaces created between the ascending flap and the fixed deep flap of the SMAS remain permeable. Virtual gaps arise where the deep fascia is weak. This can give rise to sliding of the composite flap, which happens due to the action of swallowing of the patient in the postoperative period, together with the release of the retaining ligaments. This does not occur during lateral SMASectomy, high SMAS, or traditional SMAS rhytidectomies.
The elevation of the malar portion of the SMAS at the orbicular aspect can sometimes create an unsightly fold, which can paradoxically worsen the tear trough deformity and the orbito-malar junction.
A key consideration in face lift surgery is the management of facial retaining ligaments. In the deep-plane technique, their release is essential for extended and deep mobilization of the SMAS–platysma flap. However, the authors consider this maneuver detrimental, as it compromises the fundamental anatomical support structures of facial soft tissues. The authors’ previous study, “Instrumental Analysis of Retaining Ligaments and Literature Review. What Can We Deduce?”10 demonstrated that these ligaments remain structurally intact with aging, unlike adipose compartments and bone structures, which undergo remodeling, and this does not justify their release during face lift procedures.
Facial retaining ligaments are crucial for maintaining individual aesthetics11 and anchoring soft tissues both at rest and during facial movements. In our view, releasing these ligaments, such as the anterior zygomatic cutaneous and masseteric cutaneous ligaments, weakens SMAS support, leading to early recurrence of the nasolabial fold and orbito-malar ptosis. The authors believe that only SMAS suspension sutures and the limited cicatricial fibrosis alone are insufficient for long-term deep-plane face lift results. In contrast, the high SMAS face lift involves a broader, more stable SMAS–platysma flap, allowing repositioning without extensive ligament release. In the authors’ practice, they adopt a conservative approach to the retaining ligaments, tunneling rather than severing them to preserve structural support and minimize vascular or nerve damage.
For long-lasting results, a face lift should mobilize the SMAS while preserving its natural forces and anchoring points, such as the retaining ligaments, which should be stretched rather than severed to enhance flap mobility. Insufficient subcutaneous dissection in the midface and lower face prevents proper skin flap repositioning in cases of severe ptosis, leading to early recurrence, particularly in deep-plane face lifts.
An additional important technical consideration concerns the treatment of the neck and platysma bands. In all patients enrolled in the study, the central portion of the neck was not surgically treated, in accordance with the procedure applied and codified by Dr. Jacono.
However, the authors observed that a deep neck lift cannot effectively correct both neck skin ptosis and central platysma bands, as evidenced by their early recurrence at 9–12 months during follow-up. These recurrences occur because the platysma-cutaneous ligaments are not interrupted. Furthermore, the raised SMAS composite flap has small dimensions, and the forced traction vector does not allow for the correction of the central aspect of the neck.
Additionally, although some patients had submandibular gland ptosis or hypertrophy, the authors consider surgical reduction or removal highly risky due to complications such as airway compression from deep bleeding, increased neurapraxia rates in revision surgery, and submandibular sialocele.12 Given these risks, we believe the procedure is not justified purely for aesthetic improvement.
A key consideration is postoperative downtime. The extensive detachment of the sub-SMAS and platysma flaps in the deep-plane face lift resulted in significant edema, persisting 15–30 days longer than in traditional SMAS or high SMAS face lifts. (See figure, Supplemental Digital Content 12, which shows a case of persistent postoperative edema after a deep-plane face lift procedure, https://links.lww.com/PRSGO/E137.) Although the deep-plane technique involves less skin and SMAS detachment and shorter surgical duration, recovery time is prolonged, particularly when combined with bichectomy.
In contrast, the high SMAS face lift had a shorter downtime despite larger subcutaneous dissection and preservation of facial retaining ligaments. Additionally, in the authors’ experience, the deep-plane face lift did not yield optimal results in round, chubby, or square faces with severe ptosis. The limited subcutaneous and SMAS detachment prevented adequate flap thinning and proper vectorial repositioning, failing to achieve both facial tightening and volume reduction.
The main limitation of this study was the small sample size of 78 patients, which was insufficient for definitive conclusions. However, the authors believe that future studies with larger, multicenter cohorts will strengthen the preliminary findings. This study was considered a pilot in facial rejuvenation surgery, as there was a lack of critical research on the proposed techniques. Further studies are needed to validate or challenge these results and improve methods, data collection, and analysis.
Another limitation is the use of the Likert scale to assess recurrence, which is prone to subjective bias. A more objective evaluation scale based on anthropometric parameters would improve the reliability of future data.
CONCLUSIONS
Deep-plane rhytidectomy has proven to be an effective face lift technique only in cases of faces with less skin and less SMAS laxity. At the neck level, it allows optimal results to be obtained only in the case of lateral ptosis with central bands that have a distance greater than 4.0 cm and that have a parallel direction, not a funnel shape.
In these cases, the suspension of all the anatomical areas treated was satisfactory in all types of faces, with the exception of very round and chubby ones. In the latter, the limited skin and muscle detachment do not allow both superficial and deep degreasing of the flaps. Furthermore, the traction of the SMAS is not satisfactory.
The deep-plane face lift is also indicated in nonserious cases of patients who smoke (from 5 to a maximum of 10 cigarettes per day) who have stopped smoking 1 month before and after the operation.
It is, therefore, a surgical technique that is not applicable to all types of faces and that must be limited to very precise and more restrictive indications than those previously imagined. This technique is certainly shorter from an operational point of view but with a longer postoperative downtime and less promising results on faces that require larger skin and fasciomuscular detachments. At the same time, there is a greater risk of nerve damage at the level of the zygomatic and marginal branches of the facial nerve. There is a 3.6% risk of facial nerve weakness with the deep-plane technique.13
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
PATIENT CONSENT
Patients provided written consent for the use of their images.
Supplementary Material
Footnotes
Published online 18 June 2025.
Disclosure statements are at the end of this article, following the correspondence information.
We conducted a critical review of our deep-plane face lift results from procedures performed between 2021 and 2022. Several criticisms have emerged regarding this technique, which have raised concerns about its adoptability and reliability in all situations. In fact, we observed early recurrences within the first year of follow-up, involving facial features that this technique was intended to correct.
Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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