Deep-Plane Face-lift vs Superficial Musculoaponeurotic System Plication Face-lift: Title and subTitle BreakA Comparative Study FREE

Subcutaneous dissection and skin excision to lift the face was first described at the beginning of the 20th century, with very modest excisions. ^{Article - Article} Subsequent studies, ^{Article - Article} although more extensive, still involved basically a subcutaneous face-lift. This situation prevailed until 1974, when Skoog ^Article described a procedure for elevating the platysma in the neck and lower face without detaching the skin. Just 2 years later, Mitz and Peyronie ^Article first described the deep layer of the superficial facial fascia and coined the term "superficial musculoaponeurotic system" (SMAS). Since the mid 1970s, there have been countless articles ^{Article - Article} describing various face-lift procedures involving manipulation of the SMAS-platysma complex and other descriptions involving dissection in the deep planes of the face. Although other procedures have been developed, including subperiosteal face-lift ^Article and triplanar face-lift, ^Article most surgeons in their standard operations tend to prefer SMAS plication or deep-plane face-lift; some physicians use both of the latter procedures, depending on the circumstance of the patient. Hamra ^Article has been a major innovator and proponent of deep-plane face-lift among plastic surgeons. Kamer, ^Article who learned the deep-plane technique from Hamra, is a major advocate among facial plastic surgeons; Baker, ^Article a plastic surgeon, and Mangat, a facial plastic surgeon, have been proponents of the SMAS approach. ^Article It was believed by many surgeons that the results of SMAS face-lift were outstanding and long-lasting for the neck but not as good or more temporary for the melolabial fold region. Proponents of deep-plane face-lifts have suggested that results in the melolabial fold are better from an aesthetic point of view and longer lasting than with SMAS face-lifts.

Between 1972 and 1996, one of us (F.F.B.) performed SMAS-platysma plication-type face-lifts. In 1997, there was a shift toward performing more deep-plane face-lifts, as well as SMAS face-lifts. With a documented series of SMAS plication and deep-plane face-lifts, a study was designed to evaluate the early (6- to 18-month) postoperative results. We objectively evaluated correction of the melolabial fold, jowl, and cheek skin by deep-plane vs SMAS face-lift. A review of the literature did not find a study that attempted to do this. One study ^Article compared the rate of tuck-up procedures after SMAS vs deep-plane face-lifts, but it was based on subjective criteria.

Between October 1, 1997, and April 30, 1999 (19 months), one of us (F.F.B.) performed 101 rhytidectomies (60 deep-plane face-lifts and 41 SMAS plication face-lifts). This study reflects the experience of the senior author's (F.F.B.) techniques, which may not apply to other surgeons' variations of deep-plane and SMAS plication face-lift. Preoperative and postoperative photographs in frontal, oblique, and lateral views were obtained for 40 patients; these patients had at least 6 months of recovery time. Twenty of these patients underwent SMAS plication face-lift and 20 underwent deep-plane face-lift. Patients were randomly selected from a pool of patients who were available for postoperative photographs. In a randomized manner, the sets of photographs were numbered 1 through 40. Four sets of photographs were made. The sets were then sent to 4 board-certified facial plastic surgeons, each of whom is an experienced, recognized expert in rhytidectomy. Participants were asked to evaluate the aesthetic improvement in the melolabial fold, jowl, and cheek areas. Some patients had also undergone other facial procedures, such as forehead lift, blepharoplasty, and laser resurfacing of the perioral region and lower eyelid regions. Participants were asked to disregard these areas and to concentrate on the region in question only. Participants were asked to remember that the object of surgery is not to totally efface the melolabial fold, since this gives an unnatural look. Rather, they were to judge the result for naturalness and how it achieves a more youthful and rested appearance. They were asked to rate the results as excellent, good, average, acceptable, or poor ( Article ).

The survey results were tabulated as follows: a score of 5 was given to an excellent result, 4 to a good result, 3 to an average result, 2 to an acceptable result, and 1 to a poor result. The overall average score was 3.75 for SMAS face-lifts and 3.64 for deep-plane face-lifts.

Based on the scores, patients were then divided into 3 categories. The best category had scores greater than 4.00. The average category had scores between 3.00 and 3.99. The poorest category included scores less than 3.00. There were 17 patients each in the best and average categories and 6 in the poorest category. In the best category, there were 10 SMAS and 7 deep-plane face-lifts (average patient age, 62.3 and 68.3 years, respectively). In the average category there were 7 SMAS and 10 deep-plane face-lifts (average patient age, 66.9 and 68.6 years, respectively). In the poor category, there were 3 SMAS and 3 deep-plane face-lifts (average patient age, 69.7 and 61.7 years, respectively).

Patients were further divided into the following age groups: 50 to 59 years, 60 to 69 years, and 70 to 80 years. In the youngest group, deep-plane face-lifts had an average score of 3.00 and SMAS face-lifts had an average score of 4.30. In the middle age group, the average scores were 3.30 for deep-plane face-lifts and 3.81 for SMAS face-lifts. The average scores for the oldest age group were 3.79 for deep-plane face-lifts and 3.29 for SMAS face-lifts. Overall, the 5 best scores included 4 SMAS face-lifts, with an average patient age of 55 years ( Article ), and 1 deep-plane face-lift in a 61-year-old patient ( Article ).

An exact χ² test was used to test for an association between the type of face-lift (deep-plane or SMAS) and the percentage of average ratings in the poorest, average, and best groups. No statistically significant association was found (P = .70).

The data were analyzed similarly for the 3 age groups. In the youngest group, no association was found between the type of face-lift and the percentage of average ratings in the poorest, average, and best categories (P = .33).

Twenty (12 deep-plane and 8 SMAS) face-lifts were performed in the middle age group. No association was found between the type of face-lift and the percentage of average ratings in the poorest, average, and best categories (P = .83). The means of the average ratings did not statistically differ (P = .45), but there was a trend toward the SMAS technique.

Fourteen (7 deep-plane and 7 SMAS) face-lifts were performed in the oldest group. No association was found between the type of face-lift and the percentage of average ratings in the poorest, average, and best categories (P = .59). The means of the average ratings also did not statistically differ (P = .17), but there was a trend toward deep-plane face-lift.

In the poorest category, patients who underwent SMAS face-lift tended to be older ( Article ) and those who underwent deep-plane face-lift tended to be younger. Paradoxically, 2 patients 70 years and older in the SMAS group were in the best category ( Article ) and 1 patient in the deep-plane group was in the poorest category ( Article ).

Although the results do not show statistically significant differences, there are trends among the 3 age groups. Patients aged 50 to 69 years had a trend toward obtaining a better result from SMAS plication face-lift. In patients aged 70 to 80 years, the deep-plane face-lift had a trend toward better results.

In conclusion, the goal of rhytidectomy is to improve facial appearance without causing any permanent adverse effects, such as facial nerve damage. Deep-plane face-lift, even when performed by experienced surgeons, places branches of the facial nerve at more risk during dissection than the SMAS plication technique. In fact, Hamra ^Article recently published his results of a long-term study to decrease the nasolabial fold by repositioning the malar fat. The article concludes by stating that "only direct excision will produce a permanent correction of the aging nasolabial fold." ^Article The results of the present study reveal that deep-plane face-lift does not offer superior results over SMAS plication face-lift in patients younger than 70 years. However, deep-plane face-lift may give slightly superior results in patients 70 years and older. Based on the objective results of this study, SMAS plication face-lift is recommended in patients younger than 70 years.

Corresponding author and reprints: Ferdinand F. Becker, MD, Advanced Facial Cosmetic and Laser Surgery Center, 5070 Highway A1A, Suite A, Vero Beach, FL 32969-1229 (e-mail: patientrelations@ffbeckermd.com).

Accepted for publication May 13, 2003.

We thank the following surgeons for their participation in this study: Edward H. Farrior, MD, Tampa, Fla; Michael J. Sullivan, MD, Columbus, Ohio; Stephen W. Perkins, MD, Indianapolis, Ind; and J. Regan Thomas, MD, Chicago. In addition, we thank the Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago, for assistance with the imaging preparation for this article.