Natural facelift longevity: A unique observation in a deep plane facelift case series

Aesthetic & reconstructive surgery of the face and oncologic reconstruction of the head and neck remains one of the most interesting surgical specialties as there are ample diffi cult surgical challenges. The fi eld of preservation rhinoplasty advances aesthetic nose surgery results with elevation of soft tissue structures off periosteum or perichondrium to preserve soft tissue characteristics and prevent unfavorable scarring, with the intention to produce longer lasting results that are less subject to change over time [1]. As the fi eld of rhinoplasty advances, so does facial rejuvenation surgery with the intention to produce similar long lasting youthful changes to the face that are not subject to long-term scarring changes. Translating Abstract


Introduction
Aesthetic & reconstructive surgery of the face and oncologic reconstruction of the head and neck remains one of the most interesting surgical specialties as there are ample diffi cult surgical challenges. The fi eld of preservation rhinoplasty advances aesthetic nose surgery results with elevation of soft tissue structures off periosteum or perichondrium to preserve soft tissue characteristics and prevent unfavorable scarring, with the intention to produce longer lasting results that are less subject to change over time [1]. As the fi eld of rhinoplasty advances, so does facial rejuvenation surgery with the intention to produce similar long lasting youthful changes to the face that are not subject to long-term scarring changes. Translating the preservation rhinoplasty concepts to the face, the deeper dissection can theoretically lead to more predictable long term results.
The deep plane facelift technique was fi rst described by Hamra [2], where a sub-SMAS dissection creates a skin fl ap that can release the retaining ligaments of the face and rejuvenate the nasolabial fold caused by ptosis of the malar fat pad. The deep plane facelift technique with platysmal dissections in the neck results in a musculo-fasciocutaneous fl ap with excellent blood supply [3]. In his own evaluation of cases, Hamra conceeded recurrence of the nasolabial fold after one to two years post deep plane facelift, despite continued improvement in the periorbital regions [4]. Despite this, in the We present an observation where the deep plane technique demonstrates longevity in patients who had a previous subcutaneous or limited SMAS facelifts by comparing photographs of patients who underwent a deep plane facelift and a previous subcutaneous facelift such that the patients served as their own control.

Methods
The deep plane facelift technique used during the period was standard among all patients. The subcutaneous dissection started at the ear for three centimeters and then transitioned to a sub-SMAS dissection to the zygomaticus major and the upper lip. The dissection remained subcutaneous above the level of the zygomatic arch to the orbicularis oculi. The subcutaneous dissection was then joined to the sub-SMAS dissection in the cheek after transecting the malar retaining ligaments so that the cheek could be elevated. The SMAS fl ap was then pulled posteriorly and superiorly and sutured to the SMAS anterior to the tragus and to the mastoid posteriorly.
A retrospective chart review was conducted on all patients who underwent deep-plane rhytidectomy by the junior author between 2008 and 2020 and the senior author between 1978 and 2015. No patients received facial resurfacing except for perioral fractional CO2 in one patient in the photographs. In the chart review, we selected random patients to evaluate healing time to determine photographically if healing was prolonged.
During the course of the review, so the junior author could learn, the junior author reviewed the senior author's results and techniques. In the course of the review and learning process, we encountered four patients who underwent a subcutaneous or limited SMAS rhytidectomy years prior to their deep plane rhytidectomy and then compared the photographs with regard to the neck, jowls, nasolabial folds, and malar fat pad at an equivalent post-op time interval. In this manner the patient served as their own internal control and the deep plane had actually been performed later in life. The photographs were evaluated for signs of facial aging with regard to the nasolabial folds and jowls.

Results
Satisfaction was high with the deep plane facelift. Examination of before and after results yielded natural looking results with correction of the neck, jowls, nasolabial folds, and malar fat pad. The deep plane facelift showed stable results at one year post-operatively (Figures 1-4).
To assess speed of recovery we evaluated photographs at early post-op intervals. The rate of post operative swelling and bruising were similar to subcutaneous or limited SMAS facelifts during the early postoperative period ( Figure 5      days. In general, we encouraged patients to restrict activity in the two week post-operative period as patients healed quickly and often wished to resume exercise prematurely.
When we then examined the four patients during the study period who had undergone a deep plane rhytidectomy and prior subcutaneous or limited SMAS rhytidectomy. This subset of four patients did not undergo skin resurfacing of any type.
The fi rst photograph in the series is of a 52 year old woman who is 3 years post-operative from a subcutaneous rhytidectomy and in the next series she is 55 years old and 3 years post-operatively from a deep plane rhytidectomy ( Figure 9). The nasolabial folds and jowls remained corrected 3 years post-operatively from the deep plane compared to the subcutaneous rhytidectomy despite being three years older.
The second photograph in the series is a 70 year old woman who is 2 years post subcutaneous rhytidectomy and in the second set of photographs, she is 73 years old and 3 years post deep plane rhytidectomy ( Figure 10). Again, notice that the jowls and nasolabial folds remain corrected after the deep plane rhytidectomy despite being 3 years older.
The third patient in the photographic series is 58 years old and 10 years post a subcutaneous rhytidectomy and in the second series, she is 68 years old and 10 years post a deep plane rhytidectomy ( Figure 11). The nasolabial folds and jowls remain more youthful after the deep plane rhytidectomy.
The last patient in the photographic series is 58 years old and 6 years post subcutaneous rhytidectomy and in the second series, she is 64 years old and 6 years following a deep plane rhytidectomy ( Figure 12).     The result is a composite fl ap that includes the malar fat pad, which now is mobilized and can be repositioned to restore youthful contour to the face. When the short and long-term photographic results were examined the patients who had the deep plane facelifts had a natural "undone" appearance.
In our experience with the deep plane facelift, because more soft tissue can be mobilized with less tension on the skin, the rhytidectomy has a more natural-appearing look, and fewer secondary signs of rhytidectomy.
We concede that there are few patients in our comparison to observe and this is an obvious limitation of our chart review.  Figure 11: Longevity. In the before photograph, the patient is 58 years old, 10 years post-op from subcutaneous rhytidectomy and blepharoplasty. In the after photograph, the patient is 68 years old, 10 years post-op from deep plane rhytidectomy and coronal brow lift. a long lasting result in patients who underwent a secondary facelift using a different surgical plane and it was completed safely.

Summary
The deep plane facelift appears to give highly durable results, a natural-appearing facelift result, and an adequate acceptable recovery time with patient satisfaction.