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The deep plane facelift is a sophisticated surgical technique that involves elevation of a composite skin and fascial flap beneath the superficial musculoaponeurotic system, designed to achieve natural, long-lasting facial rejuvenation. By operating in this plane, surgeons can improve flap vascularity, directly release key facial retaining ligaments, reposition the malar fat pads, and address pseudo-herniated buccal fat contributing to jowling. Compared with more superficial techniques, the deep plane approach allows greater mobilization of the midface and lower face while enabling tension-free skin closure and durable aesthetic outcomes. This activity details understanding of facial anatomy, fascial relationships, facial nerve pathways, and the physiologic processes of facial aging. This course reviews the anatomical principles, surgical technique, and perioperative patient care needed to achieve optimal results with the deep-plane facelift. Participants will also gain an understanding of patient selection, anatomic landmarks, nerve injury avoidance, management of aging-related soft tissue changes, and recognition and mitigation of perioperative risks. This activity for healthcare professionals is designed to enhance the learner's competence in employing deep plane facelift techniques, informed surgical decision-making, and implementing an appropriate interprofessional approach when managing patients undergoing this procedure to optimize outcomes and minimize complications in facial rejuvenation surgery. Objectives: Select appropriate patients for deep-plane facelift based on an understanding of the procedure's indications. Identify intraoperative anatomical landmarks that facilitate an effective deep-plane facelift. Determine which postoperative findings represent complications to facilitate prompt management. Collaborate with all members of the interprofessional team to improve coordinated care and outcomes in patients undergoing a deep plane facelift. Access free multiple choice questions on this topic.

In contrast to other techniques, the deep plane facelift, initially described by Dr. Sam Hamra in 1990, utilizes a composite skin and fascial flap raised in a plane below the superficial musculoaponeurotic layer of the midface.[1] This technique improves the vascularity of the flap, permits repositioning of the malar fat pads to address deep nasolabial folds, and allows direct lysis of key facial retaining ligaments. The result is a mid- and lower facelift with a low risk of skin complications and maximum mobilization of the superficial soft tissues. By placing suspension sutures only at the level of the fascia, the deep plane technique creates a tension-free skin closure and ensures long-term results. Additionally, the deep plane technique provides access to address the pseudo-herniated buccal fat that contributes to jowling. Although the debate continues regarding which of the myriad rhytidectomy options is most appropriate for a given patient, a properly executed deep-plane facelift can produce dramatic and sustainable rejuvenation of the lower and midface (see Image. Deep-Plane Facelift).[2][3]

The well-vascularized flap created by deep-plane dissection decreases the risk of rhytidectomy-related healing complications; however, several complications may still arise.[34] Hematomas Hematomas occur in less than 2% of cases and must be addressed promptly to prevent infection, flap necrosis, skin expansion, or clinically significant blood loss (see Image. Upper Neck Hematoma). Prevention of hematomas requires meticulous intraoperative hemostasis as well as effective postoperative pain and nausea control, which will help to prevent hypertension and bleeding. Maintaining postoperative systolic blood pressure below 140 mm Hg has been shown to reduce the risk of hematoma formation.[35] Seromas occur in 4% of cases with deep-plane facelifts. Both hematomas and seromas require removal of the fluid, often with needle aspiration, and application of a pressure dressing. Recurrent or expanding hematomas are best managed in the operating room, where definitive hemostasis can be achieved more easily. Skin Ischemia Skin ischemia and sloughing occur in less than 1% of cases, most commonly in the preauricular region, which represents the distal aspect of the facial flap (see Image. Full-Thickness Skin Flap Necrosis). The rate of skin ischemia with deep-plane facelift is lower than with SMAS flap techniques, presumably because the deep-plane technique provides better flap vascularity. This complication is best managed with conservative wound care and minimal debridement, as necessary. Skin resurfacing may be required to reduce visible scarring, though this technique is often unnecessary. Infections and Nerve Injury Infections occur in less than 1% of deep-plane facelift cases but slightly over 1% in composite facelift cases. Facial nerve injury occurs in less than 1% of deep-plane facelifts, with permanent injury extremely uncommon (see Image. Rhytidectomy Complications). Despite the deep plane dissection, rates of motor nerve injury are largely consistent across facelifting techniques, with a slightly higher risk for composite rhytidectomy. In the vast majority of cases, no intervention is required, although contralateral botulinum toxin injection into the functional depressor labii inferioris muscle may improve lower lip symmetry during recovery.[36]

Infections occur in less than 1% of deep-plane facelift cases but slightly over 1% in composite facelift cases. Facial nerve injury occurs in less than 1% of deep-plane facelifts, with permanent injury extremely uncommon (see Image. Rhytidectomy Complications). Despite the deep plane dissection, rates of motor nerve injury are largely consistent across facelifting techniques, with a slightly higher risk for composite rhytidectomy. In the vast majority of cases, no intervention is required, although contralateral botulinum toxin injection into the functional depressor labii inferioris muscle may improve lower lip symmetry during recovery.[36] If facial nerve weakness is encountered immediately upon emergence from anesthesia, it may represent a nerve transection injury; however, facial nerve weakness is more likely the result of prolonged local anesthetic effect and should be given 12 to 24 hours to resolve before considering electrodiagnostic testing or facial nerve exploration and repair. Please see StatPearls' companion resource, "Facial Nerve Trauma," for further information. Furthermore, injury to the great auricular nerve occurs in up to 7% of cases. Great auricular nerve injury causes numbness in the inferior aspect of the auricle and the lobule, as well as the superolateral neck below and behind the pinna. These injuries may be permanent, but typically resolve spontaneously over a few weeks to a few months. Pixie Ear Deformity Pixie ear deformity is caused by excessive tension on the lobule during skin closure (see Image. Pixie Ear Deformity). Repairing a pixie ear deformity can be challenging, often requiring significant skin and soft-tissue rearrangement, with care taken to reposition the lobule superiorly and to avoid tension on the closure completely.[37] Alopecia Alopecia may be prevented with beveled incisions within hair-bearing areas and avoidance of cautery near hair follicles. First Bite Syndrome First bite syndrome is uncommon but may result from injury to and aberrant regrowth of sympathetic nerve fibers in and around the parotid gland. Botulinum toxin injections into the parotid gland may be helpful, although most instances of first bite syndrome are self-limited.[38]

The deep plane facelift represents an advanced facial rejuvenation technique that elevates a composite skin and fascial flap beneath the superficial musculoaponeurotic system to address midface and lower face aging. By releasing key retaining ligaments and repositioning descended fat pads, this approach corrects nasolabial folds, jowling, and malar descent while preserving flap vascularity and allowing tension-free skin closure. Durable aesthetic improvement depends on precise anatomic knowledge, careful technique, and appropriate patient selection, particularly in older patients with significant soft tissue descent. Optimal outcomes require coordinated interprofessional care before, during, and after surgery. Surgeons experienced in deep plane rhytidectomy lead operative planning and execution, while general practitioners and anesthesiologists assess perioperative risk factors and ensure medical fitness for anesthesia. Advanced practitioners, nurses, and surgical assistants support intraoperative safety and postoperative monitoring, enabling early detection of hematoma or facial nerve dysfunction.[41] Pharmacists contribute by reviewing medications that increase bleeding risk and advising on perioperative drug management. Ongoing communication among team members facilitates patient education, adherence to postoperative restrictions, and timely intervention for wound healing concerns, including consideration of adjunctive hyperbaric oxygen therapy when indicated, thereby enhancing patient safety, satisfaction, and team performance.

Pain and nausea control is critical, as lower pain and nausea levels may help to keep blood pressure levels lower as well, which decreases the risk of bleeding complications. Patients generally report peri-incisional pain for 3 to 4 days postoperatively, and the pressure dressing may exacerbate the discomfort. Opioid medications, scheduled acetaminophen, long-acting local anesthetics, and cold compresses are all effective means of reducing pain. To minimize edema and ecchymosis, the patient should wear the facelift dressing continuously for the first 24 hours, sleep with the head elevated for 1 week, and avoid strenuous activity for 2 weeks. The patient may be given a low-dose corticosteroid taper, Arnica montana (an herbal pain medication), or bromelain to help reduce bruising and swelling; however, definitive data on their efficacy are lacking.[14] Patients are asked to return at 1 day postoperatively for drain and dressing removal, and again at 1 week for wound assessment and suture removal. Photographic documentation should occur 6 to 12 months postoperatively.