Facial Rejuvenation – Advances in Facelift Surgery
INTRODUCTION Plastic and reconstructive surgeons are always at the forefront of ideas, innovations and observations to find ways to improve aesthetic techniques and to continuously achieve better results. It is difficult and useless to determine if one lifting technique is better than another as the results can be interpreted differently based on objectivity or subjectivity. Additionally, the results of a technique can vary significantly when performed by different surgeons based on experience or preferences. Hamra first introduced the deep plane face lifting technique in 1988 and 1989, which was Information About Vein Therapy
later published in 1990. [1-3] The deep plane rhytidectomy was designed to rejuvenate the nasolabial fold caused by ptosis of the malar fat pad. At the time, Hamra was modifying Skoogs’ techniques with platysmal dissections in the neck and designed the deep plane to include cheek fat in the facelift flap which resulted in a robust musculocutaneous flap with excellent perfusion. 
Critics of the deep plane lifting technique claim that the deep plane technique is associated with prolonged recovery, an increased incidence of nerve injury, and no greater long-term or aesthetic benefit.  Our experience with deep plane lifting does not support this claim. Subcutaneous lifts or SMASs are not without perceived limitations such as skin necrosis at the incision sites, skin irregularities due to the thin nature of the flap and less vascularity. Additionally, there may be a greater potential for hematoma formation with superficial lifting. The consequences of these complications are well known.
Since deep face lifting requires a thicker flap consisting of the skin, subcutaneous tissue and SMAS, it ensures better vascularization. In the past, there have been attempts to compare the deep plane with other rhytidectomy techniques. [3,5] It is often difficult to compare the two techniques as there is variability between patients, variation in techniques between surgeons and the number of identical twins monitored and undergoing different techniques are too few. Here we present a comparison between subcutaneous and subcutaneous lift or limited SMAS by comparing photographs of patients who have undergone a deep face lift and a previous subcutaneous lift in such a way that the patients served as an internal control.
METHODS AND RESULTS A retrospective chart review was conducted on all patients undergoing deep plane rhytidectomy between 1993 and 2008. Deep plane lifts were performed as described by Hamra with modifications.  Most patients had a medial and lateral platysma suture, which is different from that described by Hamra. Four patients were identified who had undergone a deep plane rhytidectomy as a secondary rhytidectomy and who had had a previous subcutaneous rhytidectomy. Postoperative photographs of the same long-term interval from their primary and secondary rhytidectomy were evaluated. The photographs were evaluated for signs of facial aging. The four patients during the study period who had undergone deep rhytidectomy and previous subcutaneous rhytidectomy had compared their pre- and post-operative photographs. All previous rhytidectomies have been performed by renowned certified plastic surgeons. In all patients, the correction of the nasolabial folds and cheeks remained for longer than the interval of their previous subcutaneous lift. In all patients, the cheeks and neck remained corrected longer than the time interval of their previous subcutaneous lift.
DISCUSSION A myriad of facelift techniques are described in the plastic surgery literature. There is no one technique that is absolutely the best, as there are more variables. There has been a recent trend towards much more limited dissections based on the preconceived premise that extensive sub-SMAS dissection leads to a higher likelihood of facial nerve injury, more bruising and swelling, and a prolonged overall recovery time. Traditional rhytidectomy techniques, while effective in addressing aging changes in the lower face and neck, are less effective in addressing aging changes in the mid-face and melolabial folds. The variety of techniques designed to address this problem area over the past decade indicates the difficult nature of the problem and the desire for its correction. Some surgeons believe that deep or composite face lift leads to longer lasting results. Despite these convi