Deep Plane Lift in East Paris

When I was a student, facelifts consisted solely of lifting and pulling the skin. The scars were considerable. Patients had long and difficult after-effects. Their faces looked drawn. It was difficult to hide the fact that they’d had a facelift. Under the pressure of aesthetic medicine, facelifts have become less and less invasive and, above all, more effective. The real effect of a facelift was barely three years. It had to be shown that much more could be achieved in terms of rejuvenation with short follow-up periods compatible with an active professional life.

Facelifts have become more democratic, and are therefore mainly aimed at working people. Patients must be able to recover within a fortnight at most. The modern facelift aims to minimise scars, and in all cases to make them unnoticeable. It takes into account the ageing of the skin itself. The aim is not simply to tighten withered skin, but to restore its youthfulness. The work is three-dimensional. We no longer want these drawn, flat faces with no relief. We have to work with volumes, erasing some and recreating others. A great deal of work is now done on the muscles themselves, and not just on the skin. It is no longer the skin that bears the strain of the facelift, but the muscular plane. In addition, a better understanding of facial ageing has made it possible to consider tightening certain muscle fibers, while relaxing others, sometimes within the same muscle, such as the skin muscle of the neck.

Facelifts have become conservative, i.e. tissue-friendly, removing less skin or fat. In extreme cases, no skin is removed at all; reconstituting lost volumes is sufficient. At last, neck plastic surgery has become permanently effective, with predictable results. It took a lot of trial and error to achieve this result. We can now restore a graceful neck by guaranteeing a 90 to 110° angle between the neck and the face, without removing any skin. More on this later. The mid-facial area is now taken into account. Maxillofacial surgery has also made it possible to accentuate the rejuvenation of certain areas through actions on the bones of the face, either through bone cuts known as osteotomies, or through small associated prostheses, to enhance the cheekbones or erase nasolabial folds that are resistant to injection techniques.

Several advances have made this possible. Previously, scars were simply hidden in the hair and in a crease in front of the ear. But as the facelift was essentially based on skin traction, the scars ended up enlarging and becoming visible, prohibiting certain hairstyles. They often gave the appearance of earlobes pulled downwards, thus modifying the anatomy of the ear and marking the facelift for good. Today, facelifts are no longer considered to be based on skin tension. Once certain muscles have been re-tensioned (and others relaxed), the skin should be applied without tension.

In addition, a significant part of the scar may be hidden inside the ear in the external auditory canal. A new suturing technique called trichophytic suturing makes scalp scars invisible, allowing hair to grow back through them[1]. We owe this advance to a South Korean hair surgeon I had the opportunity to visit in 2015 at his institute in Seoul, Dr. Dae Young Kim. Finally, a recent innovation from Brazil reduces the risk of haematomas to almost zero, while dispensing with drains and considerably reducing the after-effects[2].

Facelifts have become conservative, i.e. tissue-friendly, by removing less skin or fat. In extreme cases, no skin is removed at all, and the reconstitution of lost volumes is sufficient. At last, neck plastic surgery has become permanently effective, with predictable results. It took a lot of trial and error to achieve this result. We can now restore a graceful neck by guaranteeing a 90 to 110° angle between the neck and the face, without removing any skin. More on this later. The mid-facial area is now taken into account. Maxillofacial surgery has also made it possible to accentuate the rejuvenation of certain areas through actions on the bones of the face, either through bone cuts known as osteotomies, or through small associated prostheses, to enhance the cheekbones or erase nasolabial folds that are resistant to injection techniques.

Several advances have made this possible. Previously, scars were simply hidden in the hair and in a crease in front of the ear. But as the facelift was essentially based on skin traction, the scars ended up enlarging and becoming visible, prohibiting certain hairstyles. They often gave the appearance of earlobes pulled downwards, thus modifying the anatomy of the ear and marking the facelift for good. Today, facelifts are no longer considered to be based on skin tension. Once certain muscles have been re-tensioned (and others relaxed), the skin should be applied without tension.

In addition, a significant part of the scar may be hidden inside the ear in the external auditory canal. A new suturing technique called trichophytic suturing makes scalp scars invisible, allowing hair to grow back through them[1]. We owe this advance to a South Korean hair surgeon I had the opportunity to visit in 2015 at his institute in Seoul, Dr. Dae Young Kim. Finally, a recent innovation from Brazil reduces the risk of haematomas to almost zero, while dispensing with drains and considerably reducing the after-effects[2].

Another recent advance in facial rejuvenation is the treatment of the salivary glands. It involves the ageing of the salivary glands. We have four main glands: the two parotid glands and the two submandibular glands. With age, they tend to hypertrophy and ptosis.

This, of course, varies from one person to another, but is always encouraged by iterative weight gain/weight loss. Hypertrophy of the parotid glands tends to result in a “pear-shaped” face. Previously, treatment was complex, requiring surgery that risked damaging the facial nerve.

A much simpler, and highly effective, alternative is to plicate the fascia covering the gland. In the case of submandibular glands, it is essential to diagnose hypertrophy and ptosis prior to facelift surgery.

Otherwise, once the neck has been trimmed and the muscles re-tensioned, the glands may paradoxically appear much more prominent. If they are enlarged, they should be partially removed. This is now a well-codified and safe technique. If they are simply ptosis, they can be secured upwards.

Illustrative drawings by the author aimed exclusively at understanding the targets of rejuvenation surgery (non-contractual, these are drawings only).

[1] Kim CK, Kim DY, Kim JY. Asymmetric dermal-subdermal suture in trichophytic closure for wide hair transplantation donor wound. Dermatol Surg. 2013;39(7):1124-1127.

[2] Auersvald A, Auersvald LA. Hemostatic net in rhytidoplasty: an efficient and safe method for preventing hematoma in 405 consecutive patients. Aesthetic Plast Surg. 2014;38(1):1-9.

[3] Le Dr Vladimir Mitz est le premier à avoir décrit le SMAS (système musculo aponévrotique superficiel) qui a révolutionné la prise en charge des liftings. The Superficial Musculo Aponeurotic System (Smas) In The Parotid And Cheek Area. Mitz, Vladimir, Peyronie, Martine Plastic and Reconstructive Surgery: July 1976 – Volume 58:80-88.

[4] Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg. 1995;19(5):421-425.

[5] Coleman SR. Structural fat grafting. Aesthet Surg J. 1998;18(5):386-388.

[6] Barbara Hersant, Jonathan Bouhassira, Mounia SidAhmed-Mezi, Luciano Vidal, Mayoura Keophiphath, Barbara Chheangsun, Jeremy Niddam, Romain Bosc, Aurelie Le Nezet, Jean-Paul Meningaud, Anne Marie Rodriguez. Should platelet-rich plasma be activated in fat grafts? An animal study. J Plast Reconstr Aesthet Surg. 2018;71(5):681-690.