In the senior author's practice, which spans a career in facelifting of 25 years, the biplane facelift has become the workhorse operation and is used for most patients. Newer innovations, including the use of laser dissection and the skin-sparing tech nique described later in this chapter, basically have not altered the approach that has been in use for more than 15 years. In patients who are seeking additional upper facial rejuvenation, the biplane facelift can easily be combined with either a direct or endoscopic coronal lift. However, for patients who are concerned primarily about upper facial rejuvenation, the extended subperiosteal coronal lift is still the operation of choice.
In the senior author's opinion, no other operation provides the elegant upper facial rejuvenation that is characteristic of this operation. This is especially true when there is an indication to correct a downward slope of the lateral canthal region. Although the technique of the extended subperiosteal coronal lift is beyond the scope of this chapter, it is important to understand that, when this operation is selected, lower facelifting must be sharply modified.
The plane of dissection for the subperiosteal lift extends down to the mandible, making it essential to avoid additional mid-face dissection when carrying out lower lifting. For this reason, when lower facelifting is combined with a subperiosteal lift, a biplane neck dissection is performed, but very little subcutaneous undermining is carried out in the face. A subperiosteal lift effectively lifts not only the upper face but also the midface; subcutaneous dissection in the cheek area is only necessary to remove redundant skin.
Regardless of the facelift technique used, there will always be some secondary relaxation. We suggest to all our lower facelift patients that they consider a secondary tuck (a mini-facelift) 12 to 24 months after the original surgery. When this secondary procedure is carried out, it is done under local anesthesia and involves reopening the incision around the ear, both anteriorly and posteriorly. Very limited undermining is carried out, and the skin is slightly advanced and excised.
The wound is subsequently closed in two layers, using 4-0 Monocryl and a running 6-0 plain gut. No dressings are applied, and patients are able to return to essentially normal activity the day after surgery. In spite of the limited undermining and advancement, it is remarkable how this procedure enhances the effect of the original operation.
Over the course of many years, we have had a considerable number of patients who have returned every few years for a secondary tuck, effectively eliminating the need for a second facelift. Because of the limited morbidity and risk associated with the procedure, we believe this technique deserves more widespread emphasis. Because of the network of subcutaneous scar tissue that has developed through the subcutaneous dissection of the facelift, this secondary tuck seems to provide a very strong and lasting lift that far exceeds what one would anticipate from so minor a procedure.
Since its introduction by Hamra,17 the term deep-plane facelift has been widely used. The term can be confusing because not every surgeon is following the technique as originally described by Hamra, but the term has generally come to be accepted as a type of facelift that is carried out in a plane deeper than the subcutaneous plane.
The term sub-SMAS is commonly used for this type of dissection, but we prefer to avoid use of the term SMAS, again because there is often confusion on the part of surgeons as to the precise meaning of this term. As one approaches the anterior border of the parotid, the SMAS becomes so thin as to become an almost microscopic layer. For that reason, we prefer to use the term musculofascial layer as described by Jost and Levet.16
When carrying out a deep-plane dissection, it is essentially the same as simply using the deeper plane of the biplane lift (see below). Although the deep-plane lift sacrifices some of the versatility of the biplane lift, it does offer an advantage of safety, as the subcutaneous flap is very limited and, in fact, after the excess skin is trimmed, it becomes nonexistent. For this reason, we tend to favor the deep-plane approach in patients who are smokers and diabetics, and increasingly for patients who are undergoing combined laser resurfacing with facelift. Because the biplane facelift is our workhorse operation, the technique is described in some detail.
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