Best Facelift: Deep Plane vs. SMAS

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The title of today's episode is "Best Facelift: Deep Plane vs. SMAS." Dr. Bass. Everyone wants to look their best and if they're going through a facelift, they want to get the best possible result. Most people do a lot of research to pick the best facelift surgeons who use the most advanced techniques.

Dr. Lawrence Bass (00:40):
I agree. Most patients have a few consultations and do a lot of due diligence before going ahead with a facelift.

Doreen Wu (00:48):
So what are the basic techniques that patients are choosing from these days?

Dr. Lawrence Bass (00:53):
The big split is deep plane and SMAS facelifting. That's the big divide currently in the techniques being used.

Doreen Wu (01:05):
Give us the rundown. What is the history of how we got to these two techniques?

Dr. Lawrence Bass (01:10):
Facelift, which is over a hundred years old, started as skin only facelifts. And back in the 1960s, facelifts were still skin only facelifts. A little more dissection was done over a larger area, but just a space being opened up between the skin and the deeper tissues so that the skin could be tailored flat. Starting in the 1970s, dissection deep to the skin started to be done as part of the facelift, and this was SMAS lifting. And SMAS stands for subcutaneous musculoaponeurotic system. So it's basically the muscle and connective tissues in layers that are under the skin and under the subcutaneous fat that's just under the skin. And people started modifying these tissues, pulling on them, releasing them, and repositioning them, doing a variety of different things in order to get a more complete correction and a more durable correction. And that worked out in large measure. And by the 1980s, many, many surgeons, not all but many, were performing SMAS facelifts for most of their facelift.

(02:47):
In the 1990s, the Deep Plane Facelift was born, and this was developed by a man named Sam Hamra, who we've talked about before on the podcast. And he was a plastic surgeon who trained at NYU at the Institute of Reconstructive Plastic Surgery, where I trained, although he trained some time before I did, and was practicing down in Dallas. And there was a lot of attention in the 1990s on ways to boost the cheek and get a more complete correction of the nasolabial fold that fold between the cheek and the upper lip. People were trying to get that as flattened out as they could, and so Dr. Hamra thought and really deep plane is composite face lifting, if you lift the SMAS and the skin as one unit, a composite together, he was hoping to get a more complete draping of that midface area, and that's what the deep plane facelift was really about. Now, since that time, there was a lot of study of the deep plane and the deep plane has evolved in some ways to reduce some of the nerve injury risk and some of the swelling and recovery time. But some people favor lifting as a unit and some people favor lifting skin and SMAS separately.

Doreen Wu (04:17):
Now that we know the history behind the SMAS and deep plane approaches, I'm curious what is the intent of these techniques?

Dr. Lawrence Bass (04:25):
So the intent is always to get the most youthful appearance possible, the greatest correction of all of the features. But as I said, deep plane was really focused on midface correction and the advantage of maybe getting that more completely corrected where SMAS techniques were developed both for midface and the neck. And there have been some more recent developments in what's called deep plane neck work, although that's really part and parcel of what's been done with SMAS techniques over time. So the intent is to get those areas corrected the best way they can.

Doreen Wu (05:16):
What do you do in your facelifts Dr. Bass and why do you take that approach?

Dr. Lawrence Bass (05:21):
So I was very well trained because Dr. Hamra trained at NYU, he would come up every year and lecture and demonstrate with live surgery. And so I'm trained in deep plane techniques as well as SMAS techniques, but most of the time I do a SMAS technique in my facelift, and it's what I think of as a multiplanar SMAS. In other words, we're lifting the face in multiple planes, the skin, the connective tissue in the cheek area, the connective tissue in the jowl area, the superficial muscle, the platysma muscle, which is part of the SMAS in the neck. And each of those components can be both positioned and shaped individually. And I kind of feel that that gives more flexibility, and we know as the face ages that different parts of the face shrink and descend differently from each other. So I feel that that better allows correction of what needs to be done in each individual's zone rather than being compelled to move everything as a monounit or composite.

Doreen Wu (06:42):
Can you talk about some of your unique modifications to the technique and why you choose to do them?

Dr. Lawrence Bass (06:48):
So one, change in the face as we age is a loss of projection where shrinking, losing bone muscle and fat volume and skin and connective tissue is sagging. So that tends to flatten the face and the classic skin pulling techniques and pull in more of a backward direction tends to accent that flattening effect. So modern facelifts tend to involve a more vertical component of lift, at least at the skin level. But in addition to that, rather than pulling tissues in a straight line direction, I like to rotate the tissues into position because that allows greater flattening in areas that you wanted like the gel area while accenting the projection in areas that you want and have lost projection with aging like the cheek area, which flattens out over time, rotating that into position helps shape the face, accent the projection and restore youthful shape.

Doreen Wu (08:05):
No two patients faces are the same, which in turn means no two facelifts are the same. What kinds of variations are made for individual patients?

Dr. Lawrence Bass (08:14):
That's a great question and really a critical issue. You said it exactly right. No two faces are the same, and no two facelifts should be exactly the same. Your facelift needs to be customized to your individual facial features. So this involves a lot of considerations. So for example, sometimes we're fat grafting along with lifting and tailoring the skin. Sometimes we're doing very conservative fat removal. For example, in the gel area where there's an excess of fat and we want a very modest removal, sometimes we add a chin implant to alter the angle of draping and get better leverage on the re draping. We also should shape the cheek as part of the facelift that again, typically flattens and loses projection. But how we're going to shape that cheek depends on what you look like in youth, what gender you are, men's cheeks and women's cheeks look differently, what your ethnicity is and your basic facial shape. So that's all going to vary what you're going to try to produce. In the neck area, there's a lot of variation in what you do to tailor the muscle layer in the neck based on what's giving you a good response, what that person's neck anatomy is, their bone anatomy and looking at their muscle dynamics when they animate, that's all going to affect what techniques you choose to employ in that individual facelift.

Doreen Wu (10:00):
Let's look ahead at what's to come. Tell us, what is happening at the forefront of facelift surgery today?

Dr. Lawrence Bass (10:07):
So facelift surgery continues to evolve, and if we look at facelift surgery from decades ago to today, it hasn't really undergone revolutionary changes, but it's undergone literally decades of evolutionary changes and these changes continue today. So people are working on further incision reduction, so the incisions are shorter, they're shorter now than they were in the 1980s, but they're looking at other ways to further reduce incisions. People are looking at ways of limiting dissection to more focused areas rather than a broad-based dissection, and they're looking at improved correction in the neck with advanced muscle division techniques and muscle repair techniques. And there's also a lot of examination of ways to minimize recovery time, for example, looking at ways to minimize bruising with the procedure so that recovery time is shortened.

Doreen Wu (11:16):
Lastly, Dr. Bass, can you give our listeners some parting takeaways from this episode?

Dr. Lawrence Bass (11:20):
Well, we said in the title, best facelift is a deep plane or SMAS, but both approaches can achieve excellent results in experienced hands. There is no best in that regard. Each surgeon has refined what they do to get excellent results, and an experienced surgeon who has refined his or her technique and customizes it for each individual patient, that's more important to a great result than the textbook application of technique X or technique Y. So overall, you need an experienced surgeon who carefully assesses your needs, who plans with your concerns in mind and customizes the plan for your features. Not a cookie cutter facelift, but a custom facelift. Of course, surgeons need to be meticulous and you'd like to find a surgeon you're a good fit with, that you feel comfortable working with. Finally, the really important area in face lifting is getting a sharp defined jawline.

(12:37):
That's a very strong feature on a man's face. It's a very graceful feature on women's faces and getting a clean and not saggy neck and the excellence and completeness of the result in the neck is really where the money is in facelift in terms of making you look younger because sagging or hanging skin in the neck is an obvious feature of age and not just a decade or two into age, but several decades into aging. And so cleaning that area up, which I believe is the focus of SMAS techniques and the ability to do that zonally and multiplanar, is really what the excellent facelift is all about.

Doreen Wu (13:31):
Thank you, Dr. Bass for sharing your insight and expertise with us about techniques in modern facelift surgery. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.