Extended Deep Plane JACONO PDF

Extended Deep Plane
Facelift
Incorporating Facial Retaining Ligament
Release and Composite Flap Shifts to
Maximize Midface, Jawline and Neck
Rejuvenation
Andrew Jacono, MDa,b,*, Lucas M. Bryant, MDa
KEYWORDS
Rhytidectomy Face lift Deep plane facelift Facial retaining ligaments SMAS Platysma
Neck lift
KEY POINTS
Deep plane facelifting targets the mobile medial superficial muscular aponeurotic system, bypass-
ing the lateral fixed superficial muscular aponeurotic system dissected in these techniques.
Releasing facial and cervical retaining ligaments allows greater redraping of the superficial
muscular aponeurotic system and platysma during rhytidectomy.
Extending the deep plane flap inferiorly into the neck and incorporating a platysmal myotomy creates
a platysma hammock to define the inferior mandibular contour and support the submandibular gland.
Deep plane composite flaps of skin, the superficial muscular aponeurotic system, and malar fat can
be repositioned to volumize the midface and gonial angle.
INTRODUCTION tissue, which compromises the superficial fat

compartments of the face, and the underlying
To better understand the rationale behind deep parotidomasseteric fascia, within which lies the
plane facelifting and how it differs from lateral su- facial nerves. The thickest SMAS is found in the
perficial muscular aponeurotic system (SMAS) lateral face overlying the parotid gland. The
facelifting (high or low), an understanding of the SMAS attenuates as it travels from lateral to
complex anatomy of the SMAS and soft tissues medial in the midface, terminating at the lateral
of the face is necessary. The SMAS layer was first border of the zygomaticus major muscle2 (Fig. 1).
described by Mitz and Peyronie in 1976.1 The Sub-SMAS dissection techniques, first intro-
SMAS layer is continuous with the platysma mus- duced by Skoog in 1974,3 tend to allow for both
cle inferiorly and the temporoparietal fascia and improvement of aesthetic change as well as
galea aponeurotica superiorly. In the face, the increased longevity. The variance of SMAS
SMAS lies between the subcutaneous adipose mobility in different facial regions is important
plasticsurgery.theclinics.com
Disclosure: The authors have nothing to disclose.

a
New York Center for Facial Plastic and Laser Surgery, 630 Park Avenue, New York, NY 10065, USA; b Department
of Otolaryngology/Head and Neck Surgery, Albert Einstein College of Medicine, 1300 Morris Park Avenue,
Bronx, NY 10461, USA
* Corresponding author. New York Center for Facial Plastic and Laser Surgery, 630 Park Avenue, New York, NY
10065.
E-mail address: [email protected]
Clin Plastic Surg 45 (2018) 527–554

https://doi.org/10.1016/j.cps.2018.06.007
0094-1298/18/Ó 2018 Elsevier Inc. All rights reserved.
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528 Jacono & Bryant
Fig. 1. The superficial muscular aponeurotic system (SMAS) is found in the lateral face overlying the parotid
gland, is contiguous with the platysma inferiorly, and terminates at the lateral border of the zygomaticus major
muscle. Medial to this point the malar fat pad overlies the zygomaticus musculature.
when considering the optimal areas for surgical distinct mandibular border. As we will discuss
manipulation during facial rejuvenation. The lateral elsewhere in this article, deep plane facelifting
SMAS overlying the parotid gland is generally fixed adds volume and contour to the gonial angle
by the parotid cutaneous fascial attachments con- through composite flap shifts, improving the defi-
necting it to the underlying parotid gland. We refer nition of the jawline.
to this area as the “lateral fixed SMAS.” Release of The deep plane facelift enters the sub-SMAS
these attachments is required for successful mobi- plane at a line that traverses from the angle of
lization and redraping of the SMAS. SMAS plica- the mandible to the lateral canthus. This approx-
tion or imbrication techniques do not release imates the transition zone between the fixed and
these tissue attachments, so that redraping the the mobile SMAS. Traditional low SMAS and
jawline and medial facial tissues is more difficult. high lateral SMAS techniques elevate the fixed
In contrast, surgical procedures that release the SMAS that has not descended with age to ac-
lateral SMAS from its deep attachments allow for cess the mobile SMAS that has. The deep plane
more effective redraping of ptotic facial tissues. facelift bypasses lifting the lateral fixed SMAS
As the SMAS extends medial to the parotid and targets the descended mobile SMAS and
gland, it is not firmly adherent. A transition zone medial soft tissues (Fig. 3). The fixed lateral
can be seen topographically in the aging face SMAS is fibrous, adherent, and difficult to
where the medial mobile SMAS descends and dissect. The mobile SMAS is areolar in nature
the lateral fixed SMAS does not (Fig. 2). The area and easier to dissect. We believe this variation
of the lateral fixed SMAS involutes, creating a scal- in SMAS mobility makes facelifting procedures
loping or concavity over the gonial angle, and the that place traction on the medial mobile
neck and jawline lie in the same plane with no SMAS instead of the fixed lateral SMAS more
Extended Deep Plane Facelift 529
Fig. 2. Preoperative view of a 51-year-old woman demonstrating the “fixed” superficial muscular aponeurotic
system (SMAS) overlying the lateral face and parotid with a transition zone to the “mobile” SMAS medial to
the parotid where the jowl and lower face descends more readily.
effective in restoring a youthful appearance. The deep plane facelift also has biomechanical
This is true for both sub-SMAS and superficial advantages when lifting the medial soft tissue
SMAS plication, imbrication, and SMAS-ectomy ptosis of aging compared with lateral SMAS pro-
techniques. cedures. The sub-SMAS entry point and thus the
Fig. 3. The deep plane facelift enters the sub-superficial muscular aponeurotic system (SMAS) plane at a line that
traverses from the angle of the mandible to the lateral canthus, which exists approximately at transition zone
between the fixed and mobile SMAS. Traditional low SMAS and high lateral SMAS techniques elevate the fixed
SMAS that has not descended to access the medial mobile SMAS that has.
530 Jacono & Bryant
point of suspension for the deep plane flap is superficial facial fat compartments. The malar fat
anterior and closer to the ptosis in the midface, pad was further subdivided into medial, middle,
jowl, and neck so it allows for more effective lift- and lateral anatomic divisions. These fat pads
ing of facial ptosis. Hooke’s law helps us to un- are tethered by the zygomatic cutaneous retaining
derstand this concept. Facial tissues have ligaments.5 The nasolabial fat compartment lies
elasticity and are put on stretch during facelifting, immediately lateral to the nasolabial fold and is
thus acting like a spring. Hooke’s law states that tethered by fascial attachments to the zygomati-
the force, or in this case lift, on the spring (the cus major muscle. As aging progresses, the prom-
elastic facial tissues) is inversely proportional to inence over the malar region flattens with descent
the length of the spring. The deep plane suspen- of the cheek fat. Volume loss becomes noticeable
sion point is one-half the distance from the droop- in the upper and lateral midface, and hollowing of
ing midface and jowl when compared with the the lower lid–cheek junction is evident. This
suspension point of lateral SMAS approaches. descended cheek fat creates a synchronous in-
This means that anteriorly based suspension ex- crease and relative widening of the midfacial tis-
erts twice the lift on the medial facial tissues sues just lateral to the nasolabial folds (see
(Fig. 4). Fig. 7). The advance of these aging changes con-
Another difference between lateral SMAS and verts the heart-shaped face of youth into an
deep plane techniques is that the deep plane face- inverted triangle shape. These heterogenous
lift allows for soft tissue elevation of the midface, changes of the different facial fat compartments
whereas SMAS flap procedures anatomically has been confirmed in cadaveric and imaging
cannot. The SMAS terminates at the lateral border studies.6–8
of the zygomaticus in the midface (as described The deep plane rhytidectomy creates a com-
elsewhere in this article); therefore, elevation and posite flap of skin, subcutaneous fat, and malar
traction on this tissue layer cannot effectively exert fat medial to the zygomaticus major muscle after
force medial to this point (see Fig. 1). The upper releasing the zygomatic cutaneous ligaments.
and medial midface where the SMAS is absent is When this composite flap is repositioned vertically,
occupied by the cheek fat. Rohrich and Pessa4 it can be used to volumize the upper midface
divided the cheek fat into the malar and nasolabial (Fig. 5). The senior author performed volumetric
Fig. 4. The deep plane suspension point is one-half the distance from the drooping midface and jowl when
compared with the suspension point of lateral superficial muscular aponeurotic system approaches. This anteriorly
based suspension can exert more lift on the medial facial tissues. SMAS, superficial muscular aponeurotic system.
Fig. 5. (A) Midface volume augmentation can be achieved by elevating the descended malar fat pads without
addition of facial volume. This requires release of the zygomatic cutaneous ligament and vertical vector lifting.
(B, D) Preoperative and (C, E) 9-month postoperative views of a 59-year-old woman who underwent an extended
deep plane facelift. Notice the volumizing of the midface with repositioning of the cheek fat compartments.
analysis after vertical vector deep plane rhytidec- more extensive release of other facial retaining
tomy with a 23-month follow-up and demon- ligaments is performed as well. Additional liga-
strated that patients gain an average of 3.2 mL of mentous release includes the medial aspects of
midface volume per side. This is the consequence the zygomaticus major, the anterior extensions
of full composite flap release, allowing tension-free of the masseteric cutaneous ligaments, and the
redraping of cheek fat compartments.9 There is no mandibular cutaneous ligaments. We have also
statistical difference between the cheek volume extended the deep plane dissection below the
gain from vertical vector deep plane rhytidectomy, angle of the mandible inferiorly. In the neck, the
and that achieved 16 months after 10 mL of platysma is elevated from its posterior fascial at-
autologous fat transfer per cheek for midfacial tachments to the sternocleidomastoid muscle to
rejuvenation10 (see Fig. 7). When patients have approximately 5 cm below the inferior body of
insufficient volume reservoir to reposition, volume the mandible and anteriorly to the fascia overlying
supplementation with fat grafting, injectable fillers, the submandibular gland. This maneuver releases
or implant placement may be used as an adjunc- the cervical retaining ligaments that would other-
tive procedure. wise limit platysmal redraping. Incorporating a
Since the original description of deep plane rhy- platysmal myotomy inferior to the mandibular
tidectomy in 1990 by Sam Hamra,11 the senior border extending medially to the fascia overlying
author has developed modifications to further the submandibular gland creates a platysmal
improve rejuvenation of the midface, jawline, sling or hammock that supports ptosis of the
and neck. This article describes our volumizing gland and defines the submandibular contour.
extended deep plane facelift (Fig. 6). In brief, This extended sub-SMAS and subplatysmal
skin flap elevation is performed anteriorly up to approach can also mitigate the need to open
a preoperatively marked line traveling obliquely the central neck in patients with mild to moderate
from the angle of the mandible to the lateral neck laxity. Last, we have modified the redraping
canthus. The zygomatic–cutaneous ligaments and suspension of the composite deep plane flap
are lysed similar to Hamra’s technique, but a to volumize the midface and gonial angle, which
532 Jacono & Bryant
Fig. 6. Planes of dissection of the deep plane facelift, with a deep plane entry point from the angle of the
mandible to the lateral canthus, and our modification extending the deep plane for 5 cm below the angle of
the mandible with a platysma myotomy to the submandibular gland.
atrophy with age, thus improving cheek and the face and cervical regions (Fig. 7). Two types
jawline contour. of ligaments have been described. Osseocutane-
ous ligaments run from the periosteum to the
dermis. These include the zygomatic and mandib-
RELEVANT ANATOMY
ular ligaments. The second type of ligament is
Retaining Ligaments
formed from a coalescence of superficial and
Fully understanding the function and anatomy of deep facial fascia. Examples of this type of liga-
the facial retaining ligaments is paramount to suc- ment are the parotid cutaneous and masseteric
cessful rejuvenation of the aging face. If not cutaneous ligaments.12
released, the mobility of facial tissues will be The zygomatic retaining ligaments originate
greatly inhibited. With ligamentous release, any from the periosteum of the zygoma body and
applied traction to the lateral rhytidectomy flap extend through the malar fat pad and insert
can be fully transmitted to the medial facial soft tis- into the overlying dermis. The zygomatic retain-
sues, allowing a natural and complete redraping. ing ligaments fix the aging midface and cheek
These concepts can be viewed as a natural exten- fat. Biomechanical studies have shown that the
sion to the same reconstructive principles used zygomaticocutaneous ligament is the strongest
when soft tissues surrounding cutaneous defects of all of the facial retaining ligaments, elongating
are widely undermined and mobilized during local by a mere 9 mm.13 Additional tendinous attach-
flap closure. In such cases, it is well-known that ments run from the zygomaticus major and mi-
wide release allows for successful tissue redraping nor through the malar fat to the skin, reaching
and a durable, tension-free closure. the nasolabial fold overlying the maxilla medially.
Retaining ligaments are strong, fibrous attach- This is called the premaxillary space.14
ments that secure defined dermal regions to The mandibular cutaneous ligaments originate
deeper structures. They are present both within from the periosteum of the parasymphyseal
Fig. 7. Ligamentous attachments released in the extended deep plane face lift include the zygomatic cutaneous
ligaments, the maxillary ligaments, the anterior extensions of the masseteric cutaneous ligaments, the mandib-
ular cutaneous ligaments, and the cervical retaining ligaments.
region of the mandible. They similarly traverse elevation of the SMAS to the anterior border of
superficially and insert into the overlying dermis. the masseter.12 The parotidocutaneous ligament
The mandibular retaining ligaments limit lies along the parotid gland, and are bypassed
the mobility of the skin and soft tissue around as the sub-SMAS dissection in deep plane sur-
the prejowl sulcus. By tethering the skin at the gery begins anterior to their point of
mandibular border, it prevents anterior submen- termination.15
tal neck skin redraping during rhytidectomy. The cervical retaining ligaments of the neck are
The further posterior the ligament is displaced reproducibly found along the posterior border of
from the symphysis the greater tethering the platysma at its junction with the sternocleido-
effect it has in the neck. In our study of 108 pa- mastoid muscle, along the anterior inferior portion
tients, we found the average tethering point to of the parotid gland, and along the posterior body
be 5 cm lateral to the symphysis. This means of the mandible.16,17 They tether the platysma to
the surgeon would note a restriction of anterior the deeper cervical fascia along the angle of the
cervical skin redraping starting approximately mandible and along the anterior border of the
5 cm posterior to the pogonion (Jacono AA: SCM. Just like facial ligaments, the cervical retain-
Limitation of neck redraping due to mandibular ing ligaments restrict the surgeon’s ability to mobi-
ligament tethering, personal communication, lize and redrape the platysma if not released.
2013). Extending the deep plane subplatysmal dissection
Masseteric cutaneous ligaments lie along the inferiorly into the neck requires a lateral platysmal
anterior border of the masseter muscle. This liga- dissection to release the cervical retaining liga-
mentous confluence acts to tether the jowl poste- ments.18,19 We have performed anatomic studies
riorly. Complete ligamentous release requires that demonstrated that the cervical retaining
534 Jacono & Bryant
ligaments extend for 1.5 cm medial to the anterior hairline of the temporal hair tuft. We use a tem-
border of the SCM.20 Complete redraping of the poral hair tuft–sparing incision because the
platysma thus requires extended platysma flap deep plane technique causes large flap shifts
elevation past this point. that would result in removing the temporal hair
when skin is removed at the end of the surgery.
SURGICAL TECHNIQUE The temporal and occipital hairline portions of
Preoperative Marking the incision can be extended during the opera-
tion if further skin redraping is needed. When a
The patient is positioned upright to be marked pre- beveled trichophytic incision was used, the
operatively (Fig. 8). The rhytidectomy incision is long-term outcome commonly resulted in a
marked as well as the path of the temporal branch depressed incision in a significant percentage
of the facial nerve, and the deep plane entry point. of cases. We believe this occurs because the
The deep plane entry point is marked as a line skin of the anterior temporal region is thin and
extending from the angle of the mandible to the the skived edge of the beveled incision tends
lateral canthus. This places the area of SMAS to become devitalized and heal in a contracted
manipulation anterior to the fixed lateral SMAS. A fashion. This is different from the thicker anterior
horizontal line is drawn across the neck at the level forehead/scalp skin in the area of the frontal hair-
of the cricoid to mark the minimal inferior extent of line, where trichophytic incisions were first
neck skin elevation. We council male patients described. We have noted temporal scars that
about the potential for transposition of bearded are barely perceptible with this modification
skin into the ear canal with a retrotragal incision (Fig. 9).
and discuss a preauricular incision as an option. Coursing inferiorly from the temporal region,
The patient is allowed to decide on the approach. the incision should not be placed at the anterior
In our practice, approximately 75% of men choose edge of the helical crus cartilage because it can
the retrotragal approach for improved incision make the root of the helix seem to be unnaturally
camouflage. wide. It should be placed at the natural highlight,
which reflects the apparent width of the helical
Incision and Skin Flap Elevation crus. It should then traverse along the posterior
Skin incision is initiated with a No. 10 scalpel cut- edge of the tragus, but not on its inner surface
ting perpendicular to the skin at the dense as this can create an unnatural folding of the
cheek skin that blunts the tragus and can be a
tell-tale sign of a facelift incision. A small step
in the incision is placed at the inferior tragus to
preserve the natural depression at the intertragic
incisure. Around the earlobe, the incision should
continue 2 mm inferior to the lobule cheek junc-
tion to preserve the natural sulcus between the
lobe and the cheek. Posteriorly, the incision
should continue a few millimeters onto the pos-
terior conchal cartilage rather than directly in
the postauricular crease. This step helps to mini-
mize later inferior descent of the posterior auric-
ular scar into a more visible location with age. In
patients with less neck laxity, the incision ends
here. If the surgeon is uncertain of the amount
of neck skin that will need excision, the incision
can always be extended to remove redundancy.
In cases of more significant neck skin excess,
the incision is transitioned at the level of the
triangular fossa down the anterior aspect of the
occipital hairline posteroinferiorly. In the past,
we used a high transverse incision that was hid-
den in the occipital hair. This incision requires
Fig. 8. Important landmarks drawn preoperatively that the neck skin flap be shifted anteriorly and
include the trajectory of the temporal branch of the vertically to prevent hairline margin step offs,
facial nerve, the deep plane entry point, incision lines, which limits the amount of redundant neck skin
and inferior extent of neck skin elevation. that can be removed.
Fig. 9. Postoperative preauricular facelift incision. (A) Preoperative and (B) 12 months postoperatively. Postoper-
ative views of a 53-year-old woman who underwent an extended deep plane facelift. (C) Notice well-healed tem-
poral scar and well-camouflaged retrotragal incision with preservation of infratragal hollow.
536 Jacono & Bryant
After the initial rhytidectomy incision is made,

the facial subcutaneous flap is elevated with
a No. 10 scalpel. The skin flap is elevated
anteriorly approximately 2 cm to allow for
placement of an Anderson multiple prong
retractor. The retractor is used to place superior
and lateral tension on the flap. Direct counter-
tension is placed by an assistant manually
retracting the skin in the opposite direction
and the flap is backlit to visualize the subdermal
plexus (Fig. 10). Flap elevation continues with
facelift scissors, tips pointed upward, making
small, forward-snipping motions to create an
even-thickness flap. The intensity of the transil-
luminated light gives the surgeon the ability to
gauge the thickness of the flap and create a uni-
Fig. 11. The preauricular subcutaneous flap ends at
form depth. Subcutaneous elevation in the
the marked line of the deep plane entry point.
cheek ends approximately 2 to 4 mm beyond
the marked line of the deep plane entry point
This dissection is continued to the midline and infe-
(Fig. 11). The deep plane facelift approach
riorly to just below the level of the cricoid (Fig. 12).
poses no risk to the frontal branch because
Attention is directed to the mandibular cuta-
the dissection is superficial in the subcutaneous
neous ligaments. The mandibular cutaneous liga-
plane where the frontal branch exists, and the
ments are released using the same backlit skin-
sub-SMAS dissection is begun at the deep
under tension method as the rest of the skin flap,
plane entry point, which is 2 cm anterior and
releasing the ligaments in a subcutaneous plane.
parallel to the course of the frontal branch of
In cases with more fibrous and dense ligaments,
the facial nerve.
dissection can be aided through the submental
The postauricular skin is then dissected in a
incision and a sharp curved iris sharp scissor can
similar fashion and connected to the facial dissec-
be used instead of facelifting scissors (Fig. 13).
tion. Once dissection has reached the anterior
border of the SCM, the inferior and medial subcu-
taneous/supraplatysmal dissection in the neck is Deep Plane Dissection: Release of the
accomplished with a lighted retractor to provide Zygomatic–Cutaneous Ligament, Zygomaticus
tension and facelift scissors using a vertical blunt Major Muscle Fibrous Attachments, and
spreading. Dissecting on top of the supraplatysmal Masseteric Cutaneous Ligaments
fascia during the medial neck skin elevation pre-
An Anderson 5-prong retractor is placed at the ante-
serves a blanket of fat on the skin flap that prevents
rior extent of the skin dissection parallel to the deep
irregularities and adhesions between the deep
plane entry point line. The flap is held under vertical
dermis of the skin and the platysma postoperatively.
tension away from the body and a No. 10 scalpel is
Fig. 10. Elevation of the subcutaneous flap to the

deep plane entry point is performed with a facelift
scissor with the flap back lit with an operating room Fig. 12. Neck flap subcutaneous dissection is continued
light to visualize the subdermal plexus and maintain to the midline using a longer lighted retractor and long
uniform flap thickness. facelift scissors.
Fig. 15. The sub-superficial muscular aponeurotic sys-

tem dissection continues anteriorly with vertical
spreading motion with a facelift scissor until the
masseteric cutaneous ligaments are released to the
Fig. 13. Release of the mandibular ligaments requires anterior border of the masseter.
dissection to the posterior edge of the tethering point
and inferiorly to the lower edge of the mandible as it
transitions to neck. dissection through the inferior part of the deep plane
flap is continued under the platysma below the
mandibular border and onto the neck to facilitate
used to incise the SMAS layer and expose the deep later release of the platysma from the sternocleido-
plane (Fig. 14). The incision extends from the mastoid muscle.
mandible to the to the orbital rim near the lateral The zygomatic ligaments are isolated by blunt
canthus. A lighted retractor is again used to create dissection of the superior extent of the deep
vertical tension away from the body and vertical plane entry point in the prezygomatic space.14
blunt dissection with facelift scissors is performed Here, the dissection plane lies superficial to the
to elevate the composite flap of skin and SMAS off orbicularis oculi muscle. Once the lateral border
the parotid–masseteric fascia. The masseteric cuta- of the orbicularis is identified, the prezygomatic
neous ligaments are released, allowing for more space can be easily dissected with blunt finger
complete repositioning of the jowl (Fig. 15). Com- dissection. This dissection is carried medially
plete ligamentous release requires elevation of the into the premaxillary space, ending at the nasal
composite flap to the anterior border of the facial crease. This technique was originally
masseter.12 Another dissection endpoint is the described as the FAME or finger-assisted malar
facial artery, which can be palpated and visualized elevation by Aston21–24 (Fig. 16). Because
in the sub-SMAS plane. Elevation of this flap SMAS is not present medial to the zygomaticus
continues superiorly until resistance is reached at major, the composite flap in this area is
the zygomatic osteocutaneous ligament. Blunt composed of skin and the malar fat pad.
Fig. 14. (A) An Anderson 5-prong retractor is placed at the anterior extent of the skin dissection parallel to the
deep plane entry point line. (B) With vertical tension on the retractor, a No. 10 scalpel is used to make the incision
into the deep plane.
538 Jacono & Bryant
Fig. 16. Elevation of the superior aspect of the deep plane pocket. (A) Blunt dissection at the superior extent of
the deep plane entry point, creating a plane superficial to the orbicularis oculi muscle (B). (C) Blunt finger dissec-
tion medially to free it to the deep plane to the nasal facial crease. Note the circular hashed marking that iden-
tifies the location of the zygomatic ligaments.
At this point, the zygomatic osteocutaneous superficial to the zygomaticus protects the facial
ligaments have been isolated between the upper nerve branches, which innervate the zygomati-
and lower composite deep plane flaps. These lig- cus muscle from its deep surface. After sharp
aments tether the SMAS/platysma complex to release of the dense ligaments, blunt dissection
the malar bone and must be released to accom- continues along the plane of the zygomaticus
plish vertical elevation of the composite flap. major and minor until the premaxillary space
Sharp dissection of the ligaments is initiated and nasolabial fold is reached (Fig. 18). A dense
with a No. 10 scalpel staying superficial to the maxillary ligament at the inferior border of the
zygomaticus musculature (Fig. 17). Staying premaxillary space is bluntly dissected to com-
plete midface release.14
Release of the Cervical Retaining Ligaments

With the deep plane now free, the only remaining
point that tethers the SMAS–platysma complex
from moving vertically is the cervical retaining lig-
aments. The deep plane flap in the neck is
marked from the gonial angle to the anterior
border of the sternocleidomastoid muscle
extending 5 cm inferiorly into the neck. A lighted
retractor provides countertraction and the pla-
tysma muscle is partially incised. After incision,
Fig. 17. Release of the deep plane flap with sharp the remaining fibrous and ligamentous attach-
dissection of the zygomatic ligaments using a No. 10 ments at the anterior border of the sternocleido-
scalpel cutting from superior to inferior and staying mastoid muscle are released with gentle, blunt
superficial to the zygomaticus musculature. scissor dissection. This dissection continues
Fig. 18. (A) Deep plane flap is released through the zygomatic ligaments and (B) elevated to the nasolabial fold.
anteriorly and connects with the subplatysmal Dissection immediately under the platysma in
dissection plane that was previously created dur- the neck below the gonial angle is a safe plane
ing the facial dissection. The anterior limit of the protecting the marginal branch of the facial
platysma flap is the anterior border of the sub- nerve, analogous to dissection just underneath
mandibular gland so that the platysma flap can the SMAS in the cheek is a safe plane protecting
suspend gland ptosis (Fig. 19). the facial nerves. The nerves above the gonial
The dissection plane immediately below the angle are in the parotidomasseteric fascia and
platysma ensures that the marginal mandibular below it in the superficial cervical fascia. These
and cervical branches of the facial nerve down layers are contiguous. The marginal branch
remain deep, on the superficial cervical fascia. would be at risk if dissection under the SMAS
Fig. 19. Release of the cervical retaining ligaments. (A) Surgical marking of the lateral platysmal border at its
connection to the sternocleidomastoid muscle extending 5 cm below the angle of the mandible. (B) A No. 15
scalpel is used to make a broad and gentle incision until a lip of tissue is obtained, the edge grasped and sharp
dissection within the sternocleidomastoid muscle fascia is continued for approximately 1 cm, (C) Subplatysmal
flap freed after bluntly dissect through the ligaments 3 cm anterior to the sharply elevated flap.
540 Jacono & Bryant
patients, the average vector approached 60 rela-

tive to the Frankfort horizontal plane25 (Fig. 21).
Suture suspension begins with a half-mattress su-
ture connecting the SMAS cuff at the deep plane
entry point to the parotid masseteric fascia in the
preauricular region for suspension of the inferior
portion of the flap.
It is important to note that redraping of the
inferior deep plane composite flap create
improved mandibular contour. With age, the
area over the lateral fixed SMAS and gonial
angle becomes concave, blunting the jawline
as it transitions into the neck. The inferior part
Fig. 20. The deep plane flap is typically sutured at 5 to
of the composite skin and SMAS deep plane
7 nearly equidistant points along the cuff formed at
the deep plane entry point to the preauricular and flap is fixated at the level of the gonial angle.
deep temporal fascia. This volumizes the gonial angle and creates
a more distinct mandibular/jawline contour
(Fig. 22).
and platysma is continued medial to the facial ar- The superior portions of the flap in the upper
tery where the nerves become more superficial. cheek are suspended to the deep temporal fas-
Therefore, dissection in this region should be cia. Importantly, the point of flap suspension for
avoided. the upper flap is to the deep temporal fascia
2 cm above the zygomatic arch, similar to the
Deep Plane Flap Suspension high and lateral SMAS facelift. Repositioning
the ptotic midface revolumizes the upper cheek
Because the skin flap was raised slightly beyond
over the zygoma. Volumetric analysis with
the deep plane entry point in the face, this cuff of
23 months of follow-up has shown that this sus-
SMAS tissue is used for suture suspension. Five
pension technique give patients an average gain
to 7 suspension sutures are placed (the author’s
of 3.2 mL of volume in each hemi midface9 (Figs.
preference is 4-0 nylon with PS-2 needle in most
23 and 24).
cases). The angle of flap suspension transitions
from vertically dominant at the mandibular angle
Lateral Platymsa Suspension in the Neck and
to horizontally dominant near the orbit (Fig. 20).
Skin Closure
This maximizes elevation of the cheek fat pads
while preventing distortion of tissues in the temple After resuspension of the composite flap in the
region and lateral to the eye. The vector of lift for face is finished, attention is directed to redraping
the composite flap in deep plane rhytidectomy is of the cervical platysma. A horizontal myotomy of
vertical oblique. The individual’s anatomy dictates the platysma is performed parallel to the inferior
the exact angle. In a study of more than 300 margin of the mandible for approximately 4 cm,
Fig. 21. (A) The flap is suspended vertically at an angle that maximizes elevation of the cheek fat pads and rev-
olumizes the midface. (B) Suture suspension along vertically oblique vector of 60 .
Fig. 22. (A, B) The inferior part of the composite skin and superficial muscular aponeurotic system (SMAS)
deep plane flap is fixated at the level of the gonial angle. This volumizes the gonial angle and creates
a more distinct mandibular/jawline contour. Preoperative view of (C) a 56-year-old woman, (E) a
57-year-old woman, and (G) a 58-year-old woman. (D, F, H) The same patients at 12 months postoperative
after volumizing extended deep plane rhytidectomy with composite flap repositioning to augment the
gonial angle.
ending at the area over the submandibular gland. submandibular region and away from the cervi-
The inferior platysmal tab is anchored to the comental angle. This platysmal flap places
mastoid fascia with a 3-0 nylon suture and posi- its maximal tension at the most anterior extent
tioned just below the margin of the mandible of the myotomy, allowing for support of the
(Fig. 25). The vector of pull runs along the submandibular region, elevating any ptotic
542 Jacono & Bryant
Fig. 23. (A, C) Preoperative and (B, D) 9 months postoperative views of a 57-year-old woman who underwent an
extended deep plane facelift with zygomatic ligament. Notice the volumizing of the midface with repositioning
of the cheek fat compartments.
extended deep plane facelift with zygomatic ligament. Notice the volumizing of the midface with repositioning
of the cheek fat compartments.
544 Jacono & Bryant
Fig. 25. (A) Horizontal myotomy of the platysma performed parallel to the inferior margin of the mandible for
approximately 4 cm ending at the area over the submandibular gland. (B) Intraoperative view of horizontal my-
otomy of the platysma performed parallel to the inferior margin of the mandible for approximately 4 cm ending
at the area over the submandibular gland. (C) The inferior platysmal tab is anchored to the mastoid fascia with a
3-0 nylon suture and positioned just below the margin of the mandible creating a platysma hammock that ele-
vates the ptotic submandibular gland. Mandibular contour. (D) Note contour improvement of jawline and upper
neck with tension placed on platysmal hammock. The circle marked on the skin is the location of the submandib-
ular gland.
submandibular tissues, while concomitantly the lateral brow to avoid a dog ear deformity.
increasing a hollow below the angle of the Deep, everting 4-0 Vicryl sutures are placed
mandible that exists in youth. Interestingly, this along the temporal incision prevent depression
also places more traction on the platysma ante- and spreading of the scar over time. Skin closure
riorly and can help to smooth out platysmal is completed with everting 5-0 nylon vertical
bands, avoiding the need to open the neck mattress sutures. The remainder of the incision
(Figs. 26–28). Additional sutures are used to is closed with 5-0 nylon sutures anteriorly, 5-
redrape the incised platysmal edge over the ster- 0 nylon sutures behind the ear, and 4-0 nylon su-
nocleidomastoid muscle. A Jackson-Pratt drain tures in the occipital hairline (Fig. 30). The major-
is placed in the hairline, and positioned in the ity of anterior sutures are removed after 4 to
lower neck until the next morning. 5 days.
After resuspension of the face and neck, We perform subcutaneous liposuction in the
attention is turned to redraping of the skin. The neck in less than 10% of our patients, and only
facial skin is suspended in the same plane as when they have significant supraplatysmal fat
the composite flap. The majority of the skin is excess, which can be grasped and clearly iden-
removed vertically in the temporal region tified before injection. In general, we prefer to
(Fig. 29). Because the cervical skin has been leave the natural blanket of fat between the
lifted off the platysma, redraping does not need skin and platysma to avoid forming depressions
to equate the platysmal lift vector. Adequate from adhesions and retraction. When performing
elevation of the temporal skin in the subcutane- submental liposuction we use modern tech-
ous plane avoids bunching. In patients with niques that mitigate the chance of commonly
more significant laxity, the temporal incision noted irregularities.26–35 In general, we have
must be carried along the hairline superior to found that elevating the neck skin flap before
extended deep plane facelift. Note improvement in anterior neck cording without opening the neck.
546 Jacono & Bryant
extended deep plane facelift with platysma hammock suspension of the submandibular gland and improvement
in anterior neck cording without opening the neck.
extended deep plane facelift with platysma hammock suspension of the submandibular gland and improvement
in anterior neck cording without opening the neck.
liposuction controls the amount of fat on the we use a 3-mm flat-tipped liposuction cannula to
neck skin and decreases the risk of postopera- then remove supraplatysmal fat and sculpt the
tive topographic irregularities. After flap elevation neck (Fig. 31).
548 Jacono & Bryant
deformity occurring postoperatively. Last,

midline plication is indicated when intraopera-
tively the midline platysmal redundancy remains
after the lateral platysmal lift is performed bilater-
ally. If it is determined preoperatively that the pa-
tient will require anterior platysmaplasty, this is
performed before rhytidectomy. Increasing the
number of procedures performed in the submen-
tum increases the chances of irregularities, and
each maneuver must be performed precisely
and in a metered fashion.
A small submental incision is made and the
submental skin is dissection with a curved iris
scissor. Once an entry skin flap has been
made, a skin hook is used to place the cervical
Fig. 29. The majority of the skin redundancy is skin under traction, while subcutaneous flap
removed vertically in the temporal region. elevation continues using a blunt curved scissor
(Metzenbaum).
At this point, the medial edges of each side of
Adjunctive Submental Procedures and
the platysma muscle are identified. The subplatys-
Platysmaplasty
mal plane is extended laterally to the anterior
Our main indications for rhytidectomy without border of the submandibular gland. The intrapla-
opening the neck is if the submental platysmal tysmal fat is dissected away from the platysmal
and skin laxity is corrected when the surgeon borders using blunt dissection and bipolar cautery
places 3 fingers at the deep plane entry point, for hemostasis. This midline mobilization of the
a line from the angle of the mandible to the platysma is extended approximately to the inferior
lateral canthus, on both sides of the face and border of the cricoid. The interplatysmal and sub-
moves the skin vertically. If the patient still has platysmal fat is then removed from the submental
significant neck redundancy with this maneuver area using suction monopolar cautery. Once the
and platysmal cording exists, then a midline pla- fat is removed, the subplatysmal flap is extended
tysmaplasty is indicated in addition to the verti- laterally.
cal neck lift. We use 3 other indications for a The anterior belly of the digastric muscle is
midline approach. If widely separated midline identified, and is sculpted with monopolar
platysma bands exist, midline plication is used suction cautery if it contributes to submental
to bridge their dehiscence. This is described as fullness as identified on preoperative photo-
a DeCastro type III decussation pattern.36 Addi- graphs. The neck is irrigated, and the midline
tionally, a midline approach is used when sub- platysmaplasty is closed using interrupted,
platysmal surgery, such as subplatysmal fat buried 4-0 Vicryl sutures. There are key sutures
removal, is performed to prevent cobra neck used when closing the midline platysma. The first
Fig. 30. (A) Preauricular and (B) postauricular skin closure.
Fig. 31. (A) Preoperative and (B) 12 months postoperative views of a 59-year-old woman who underwent a modi-
fied, extended deep plane facelift without midline platysmaplasty but requiring supraplatysmal liposuction after
skin flap elevation.
suture is placed at the cervicomental region. rhytidectomy reproducibly carries substantially

Here, the platysmal edges are sutured to the lowered tuck up rates of 3% to 4%, which is statis-
midline hyoid fascia to prevent separation and tically significant.18,41
a midline banding after healing.37 Additional Studies on medium-term efficacy show that
interrupted 3-0 Vicryl sutures similarly adhere less invasive SMAS approaches have a greater
the platysmal edges to the deep submental tis- recurrence of neck laxity than jowl reformation.38
sues along the length from the chin to the hyoid There are few long-term follow-up data available
to aid in cervical definition. The platysmal corset for review. Patients presented for secondary
continues inferiorly to the level of the cricoid facelifts after primary SMAS plication rhytidec-
(Figs. 32–34). tomy on average 9 years later.42 Secondary
facelifts were sought after primary SMAS flap
Special Considerations in Deep Plane rhytidectomy on average 11.9 years later, sug-
Rhytidectomy gesting this is a slightly more durable procedure;
however, the data remain too limited to draw
Efficacy conclusions and the significance of this informa-
There is a paucity of data comparing efficacy of tion is unclear.43
rhytidectomy by technique. Short-term follow-up
has shown higher efficacy in techniques using Complications
more aggressive SMAS manipulation, boasting It is important to clarify that more aggressive
fewer secondary procedures and happier pa- dissection with deep plane techniques does
tients.38 The need for tuck up varies widely among not portend an increased risk to the patient.
rhytidectomy techniques and surgeons. SMAS The rates of facial nerve damage and hematoma
plication and imbrication techniques have been in deep plane rhytidectomy has been shown to
shown to carry the highest tuck up rates of up to be equal to those of less invasive tech-
21%39 and up to 50% at 2 years.40 More extensive niques.18,41 Our incidence of temporary facial
skin flaps with extended SMAS dissections have a nerve injury with an extended deep plane
lower tuck up rate of 11%.41 The deep plane approach is 1.2% in a prior study reviewing
550 Jacono & Bryant
Fig. 32. (A, C) Preoperative and (B, D) postoperative views of a 62-year-old woman with excessive platysmal
redundancy. She required a concomitant midline corset platysmaplasty suspended to the hyoid fascia with an
extended deep plane facelift.
Fig. 33. (A, C) Preoperative and (B, D) 12 months postoperative views of a 56-year-old woman with excessive pla-
tysmal redundancy. She required a concomitant midline corset platysmaplasty suspended to the hyoid fascia with
an extended deep plane facelift.
323 patients who underwent this technique with suturing techniques that can cause temporary
the primary author,44 and has remained stable traction injury.45
on follow-up review of more than 800 cases. Deep plane surgery bears an improved risk pro-
This temporary facial nerve injury rate is the file in some aspects when compared with the
same as less invasive SMAS plicating and traditional less extensive surgeries. It is associated
552 Jacono & Bryant
Fig. 34. (A, C) Preoperative and (B, D) 12 months postoperative views of a 70-year-old woman with poor submen-
tal contour requiring concomitant subplatysmal lipectomy, digastric reduction and midline corset platysmaplasty
suspended to the hyoid fascia with an extended deep plane facelift.
with lower rates of skin flap sloughing and need for 10. Gerth DJ, King B, Rabach L, et al. Long-term volu-
tuck up procedures.18,41 metric retention of autologous fat grafting processed
with closed-membrane filtration. Aesthet Surg J
2014;34(7):985–94.
SUMMARY
11. Hamra ST. The deep-plane rhytidectomy. Plast Re-
The volumizing extended deep plane rhytidectomy constr Surg 1990;86(1):53–61 [discussion: 62–3].
is a safe procedure with superior outcomes in 12. Stuzin JM, Baker TJ, Gordon HL. The relationship of
facial rejuvenation. A comprehensive understand- the superficial and deep facial fascias: relevance to
ing of the facial anatomy and pathophysiology of rhytidectomy and aging. Plast Reconstr Surg 1992;
aging is imperative to incorporate this procedure 89(3):441–9 [discussion: 450–1].
successfully. The extended deep plane facelift in- 13. Brandt MG, Hassa A, Roth K, et al. Biomechanical
corporates additional ligamentous release of the properties of the facial retaining ligaments. Arch
face and neck to create durable redraping of Facial Plast Surg 2012;14(4):289–94.
face and neck ptosis redraping. This includes the 14. Wong CH, Mendelson B. Facial soft-tissue spaces
zygomatic cutaneous, masseteric cutaneous, and retaining ligaments of the midcheek: defining
mandibular cutaneous, and cervical retaining liga- the premaxillary space. Plast Reconstr Surg 2013;
ments. Deep plane dissection creates composite 132(1):49–56.
flaps that can be redraped to volumize the midface 15. Furnas DW. The retaining ligaments of the cheek.
and gonial angle along the jawline, thus improving Plast Reconstr Surg 1989;83(1):11–6.
cheek and jawline contour. 16. Feldman JJ. Neck lift my way: an update. Plast Re-
constr Surg 2014;134(6):1173–83.
17. Connell BF. Contouring the neck in rhytidectomy by
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Extended Deep Plane JACONO PDF

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INTRODUCTION tissue, which compromises the superficial fat

Disclosure: The authors have nothing to disclose.

Clin Plastic Surg 45 (2018) 527–554

After the initial rhytidectomy incision is made,

Fig. 10. Elevation of the subcutaneous flap to the

Fig. 15. The sub-superficial muscular aponeurotic sys-

Release of the Cervical Retaining Ligaments

patients, the average vector approached 60 rela-

deformity occurring postoperatively. Last,

Fig. 30. (A) Preauricular and (B) postauricular skin closure.

suture is placed at the cervicomental region. rhytidectomy reproducibly carries substantially

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Extended Deep Plane JACONO PDF

Uploaded by

Copyright:

Available Formats

Extended Deep Plane JACONO PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

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Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

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Extended Deep Plane JACONO PDF

Uploaded by

Copyright:

Available Formats

Extended Deep Plane

INTRODUCTION tissue, which compromises the superficial fat

Disclosure: The authors have nothing to disclose.

Clin Plastic Surg 45 (2018) 527–554

After the initial rhytidectomy incision is made,

Fig. 10. Elevation of the subcutaneous flap to the

Fig. 15. The sub-superficial muscular aponeurotic sys-

Release of the Cervical Retaining Ligaments

patients, the average vector approached 60 rela-

deformity occurring postoperatively. Last,

Fig. 30. (A) Preauricular and (B) postauricular skin closure.

suture is placed at the cervicomental region. rhytidectomy reproducibly carries substantially

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patients, the average vector approached 60 rela-