Background

Historically, rhytidectomy began during the early twentieth century as a very limited procedure involving minimal subcutaneous undermining and excision of redundant skin.5 The modern concept of facelift surgery began in 1974, when Skoog6 described a subplatysmal technique in a deeper anatomic plane of the face that he believed was useful for facelift surgery. The research conducted by Mitz and Pey-ronie,7 which identified and clarified the relationship and dynamics of the superficial musculoaponeurotic system (SMAS) and the platysma, fostered a generation of surgeons, the senior author included, who advocated the aesthetic benefits of the SMAS lift. The 1980s generated a number of variations of the SMAS technique, most having to do with vectors of pull and management of the midline platysma fibers. The senior author in 1981, and Owsley in 1983, each described a sub-SMAS and subplatysmal dissection with superoposterior suspension of the lower face and neck combined with subcutaneous undermining and lateral traction of the mid- and upper cheek to produce a "bidirectional" rhytidectomy.8,9 During this same period, a few practitioners of the Skoog technique modified and advanced the subplatysmal concepts that culminated in the refinements described by Lemmon and Hamra. In 1980, Lemmon and Hamra10 published a variation of the Skoog technique involving a series of 577 patients. Lemmon and Hamra reported fewer contour irregularities in the face and a longer-lasting result in the neck with no increase in complications. After improving on his initial operation, Hamra11 originally described the deep-plane rhytidectomy in 1990. Since that time there has been increased acceptance and use of the deep-plane technique, which is used by the authors and described in this chapter.

The senior author's experience with the SMAS technique began during the mid-1970s and involved approximately 2500 facelift operations over the next 15 to 20 years. The results were found to be aesthetically superior, more predictable, and longer lasting than had been obtained with the previous, less extensive, dissection techniques. Nevertheless, some inadequacies and small problems associated with the SMAS technique ultimately served as the incentive to search for an improved facelift technique. In 1996 the results of Kamer's12 first 100 consecutive deep-plane facelifts were analyzed and reported, demonstrating the benefits of this technique and the lack of associated complications. Since that report, the senior author has performed the deep-plane operation predominantly, and the results have been under continual assessment.

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