The deep-plane technique can be considered for most cases of primary rhytidectomy, except in the unusual situation, when simple skin redundancy is the only concern. It is particularly effective for advanced jowls and heavy nasolabial folds and for patients who smoke or have some other condition that predisposes them to compromised vascularity or infection. Patients with extremely thin skin in whom minor subcutaneous irregularities would be more evident are also better suited for the deep-plane rhytidectomy, as are those who are suceptible to hypertrophic scarring.
Revision of a primary rhytidectomy that involved dissection in the sub-SMAS plane could conceivably increase the risk of facial nerve injury due to distortion of surgical landmarks by scar tissue. This will not be determined until more of these patients present for revision. Other contraindications are not specific to the deep plane technique and include patients with
Numerous techniques are available to the facelift surgeon performing a rhytidectomy. The SMAS lift has been the most widely used for more than two decades and has yielded consistently good results. The deep-plane lift is based on similar principles but represents an evolution in technique in order to provide for improved aesthetic results that are longer lasting. The main difference between techniques is the establishment of a well-vascularized compound flap of facial skin, fat, and muscle that allows for more extensive dissection, greater tissue mobilization, and skin closure under less tension. There is no objective proof as to the aesthetic superiority of one facelift technique over another, and there probably never will be. Therefore, it is left to individual surgeons to determine which technique works best in their hands for their particular patients.
Kamer and Frankel—CHAPTER 26
1. Baker DC. Deep dissection rhytidectomy: a plea for caution. Plast Reconstr Surg 1994;93:1498-1499
2. Lassus C. Cervicofacial rhytidectomy: the superficial plane. Aesth Plast Surg 1997;21:25-31
3. Hamra ST. Letter to the editor; reply. Plast Reconstr Surg 1998;101:550-551
4. Pina DP. Aesthetic and safety considerations in composite rhytidectomy: a review of 145 patients over a 3-year period. Plast Reconstr Surg 1997;99:670-678
5. Passot R. La chirurgie esthetige des rides du visage. Presse Med 1919;27:258
6. Skoog T. The aging face. In: Plastic Surgery: New Methods and Refinements. Philadelphia: WB Saunders; 1974:300-330
7. Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;58:80-88
8. Kamer FM, Halsey W. The two layer rhytidectomy. Arch Otolaryngol 1981;107:450-453
9. Owsley JQ SMAS-platysma face-lift. Clin Plast Surg 1983;10: 429-440
10. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year experience with 577 patients. Plast Reconstr Surg 1980;63:283-297
11. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 1990;86:53-61
12. Kamer FM. One hundred consecutive deep-plane face-lifts. Arch Otolaryngol Head Neck Surg 1996;122:17-22
13. Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg 1996;98:1135
14. Hamra ST. Composite rhytidectomy and the nasolabial fold. Clin Plast Surg 1995;22:313-323
15. Hamra ST. Composite rhytidectomy: finesse and refinements in technique. Clin Plast Surg 1997;24:337
16. Furnas DW. The deep-plane rhytidectomy (discussion). Plast Reconstr Surg 1990;86:62-63
17. Yousif NJ, Gosain A, Matloub HS, Sanger JR, Madiedo G, Larson DL. The nasolabial fold: an anatomic and histological reappraisal. Plast Reconstr Surg 1994;93:60-69
18. Yousif NJ, Gosain A, Sanger JR, Larson DL, Matloub HS. The nasolabial fold: a photogrammetric analysis. Plast Reconstr Surg 1994;93:70-77
19. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg 1995;22:295-311
20. Kamer FM, Frankel AS. SMAS rhytidectomy vs. deep-plane rhytidectomy: an objective comparison. Plast Reconstr Surg 1998;102:878-881
21. Duffy MJ, Friedland JA. The superficial-plane rhytidectomy revisited. Plast Reconstr Surg 1994;93:1392-1401
22. Whetzel TP, Mathes SJ. The arterial supply of the face lift flap. Plast Reconstr Surg 1997;100:480-486
23. Schuster RH, Gamble WB, Hamra ST, et al. A comparison of flap vascular anatomy in three rhytidectomy techniques. Plast Reconstr Surg 1995;95:683-690
24. Ramirez OM, Pozner JN. Subperiosteal minimally invasive laser endoscopic rhytidectomy: the SMILE facelift. Aesth Plast Surg 1996;20:463-470
25. Guyuron B, Michelow B, Schmelzer R, Thomas T, Ellison MA. Delayed healing of rhytidectomy flap resurfaced with CO2 laser. Plast Reconstr Surg 1998;101:816-819
SMAS Surgery versus Deep-Plane Rhytidectomy
Howard A. Tobin and Angelo Cuzalina
Facelifting dates back to the early 1900s. A few surgeons in Europe and in the United States were experimenting with the removal of small skin strips from in front of and behind the ears.1 Dr. Jacques Joseph,2 in 1921, and Dr. Bettman,3 in 1920, were the first surgeons to publish before-and-after photographs of their facelift results. During the first 60 years of facelift surgery, dissection was limited to the subcutaneous plane. It was not until the 1950s in the United States that the "classic" wide skin undermining facelift became the norm. This technique was not significantly challenged until Skoog4 in 1974.
Facelift surgery in the first half of the twentieth century was considered to be an act of extreme vanity. Surgeons who performed such "risky and unnecessary" operations were looked down upon by society and the medical community. Increased public demand and affluence have led to a dramatic rise in facelifting. Consequently, the number of facelift techniques has also markedly increased.
Successful manipulation of facial tissues other than skin for facelifting began during the early 1970s due to a better understanding of facial anatomy as well as surgical anesthesia improvements. In 1974 Skoog first described his "deep-plane" facelift, which emphasized the presence of an interconnected "skin-fat-musculofacial unit" that, if elevated together, improved facelift results. Owsley5 further described use of the platysmal muscle for lifting in 1977. Other surgeons quickly began reporting additional techniques involving the platysma.6'7
Innovations over the past 20 years have led to the development of the "composite,8,9 deep-plane,10 subperiosteal,11-13 laser, and endoscopic14 facelifts. Skoog's elevation of the platysma muscle in his advancement flap sparked the interest in the musculofas-cial plane or superficial musculoaponeurotic system (SMAS), initially described in 1976 by Mitz and Peyronie.15 The SMAS was more accurately detailed in 1984, when Jost and Levet's publication challenged the previous SMAS concept.16 There continues to be a great deal of disagreement, as well as confusion, regarding the best plane of dissection, not to mention the definition of surgery. The manipulation of a musculofascial plane to achieve improved and longer-lasting results has become common practice for many cosmetic surgeons. Elevation of this musculofascial plane is a key component of the biplane facelift described in this chapter.
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