The Facelift Masterclass: Deep Plane, SMAS, Mini, Neck, and Eyes Explained

Dr. Brahme (00:00):
There are probably as many facelifts as there are plastic surgeons, but what you really want to talk about is what's the depth of the facelift?

Announcer (00:11):
You're listening to the La Jolla Cosmetic Podcast with Monique Ramsey.

Monique Ramsey (00:16):
Everyone's talking about facelifts right now, deep plane this, mini that. And honestly, it's gotten confusing. There are more options, more names, and more marketing than ever and it's hard to tell what's real and what's just a trend at a catchy label. I'm Monique Ramsey and the surgeons that I work with at La Jolla Cosmetic Surgery Center have spent the last few years explaining all of it one piece at a time. So I pulled those conversations all into one place for you. Think of it as your facelift masterclass, what the procedures actually are, which one fits which face and how to see through the hype so that by the end you can walk into a consultation already knowing the language.

Dr. Riedler (01:03):
A deep plane facelift will address basically everything from the cheek down. So sagging cheeks, jowels, nasolabial folds, marionette lines, and then the neck as well. If you have downturn mouth corners, it kind of helps turn those up. A SMAS facelift does, I would say a lot of those things, but tends to be less effective in really lifting the cheek and affecting the mouth corners, nasolabial folds and marionette area.

Monique Ramsey (01:41):
So who would you say is a good candidate for a deep plane facelift?

Dr. Riedler (01:45):
Anyone who is bothered by aging changes in the cheeks, lower face neck, like jowels, sagging cheeks, marionette lines, nasolabial folds, loss of a defined neck and jawline, skin irregularities, muscle bands, all the lovely things that happen as we age.

Monique Ramsey (02:11):
So pretty much everybody's a good candidate at a certain age, right? So tell me, Dr. Riedler, why do you think this deep plane facelift has become so popular?

Dr. Riedler (02:22):
I think it's because people want natural, long lasting, undetectable results. And now there's just so much more awareness, so much more awareness and information out there. I think people are more open to talking about having had surgery or wanting surgery, all those things. So they're kind of becoming more informed and learning about what the different options are. And I mean, I personally love the deep plane facelift because I feel like it gives you natural long lasting results. You don't want to have a done appearance. You want invisible incisions. And so in my hands, I think that gives the best result.

Monique Ramsey (03:10):
So that's the deep plane everyone's asking about. But here's the thing, it isn't automatically the right answer for you. A facelift isn't one operation. It's a whole range from a small refresh to a full lift and a good surgeon chooses based on your face, not a brochure. Here's how they actually decide. If somebody comes in and they want to talk to you about consultation to refresh their face, at what point do you determine you might be pushing the barrier for a short scarface lift and maybe a full is better or is it more based on the patient's goals?

Dr. Smoot (03:49):
Well, both, but mostly I've got to look at what you're trying to accomplish. Now there are gals that come and say, "I just want a short scar, a mini lift." No, you've got way too much laxity. It will not look good. That's why I said when I pull the skin up, I want to see what happens around the ear. If it doesn't pleat or bunch up there, then yeah, you can do a mini. If it does, it's not going to be a good choice. At least that's how I determine who's candidate for it.

Monique Ramsey (04:16):
That's a pretty easy test for all of us to be able to do at home too, is just kind of pull up. If you pull by the ear, does it make a pleat below? And none of us want that walking around.

Dr. Smoot (04:26):
No, you don't.

Monique Ramsey (04:30):
Now the minute you start researching this on your own, you're going to hit a wall of marketing, branded lift names, 10 minute promises before and afters that look a little too good. Some of it's real and some of it isn't. Let's separate the two.

Dr. Brahme (04:49):
There are probably as many facelifts as there are plastic surgeons because everybody develops their own little tweak on the facelift operation. But what you really want to talk about is what's the depth of the facelift? A mini facelift is usually just tightening the skin a little bit. It's about a two hour operation and you don't do any really work on the deeper structures. So it's just a little skin nip and tuck and it looks nice. It looks nice for a shorter period of time because you're only relying on the skin to keep that nice tightness that you have achieved right after surgery. But the fact is that after a year or two, the skin relaxes. It can be a good operation for somebody who's young and I'm talking in their 30s and 40s who just wants to look a little bit smoother and really doesn't have a serious aging concern with wrinkles and sagging and so on and so forth.

(05:59):
So that's the mini facelift that can often be done just under local anesthesia with a little bit of sedation. And like I said, it doesn't last all that long. The standard facelift that most, I would say probably 80% of people are doing is a SMAS facelift. The SMAS stands for superficial aponeurotic muscular system and it is the connective tissue that lives deep to the skin and the fat and it is a very strong layer. And if you tighten that layer, you tighten the skin along with it and you'll see that you'll have a ton of extra skin that you don't need. And it's nice because the tension of the operation is not on the skin, it's on the deeper structures. So it looks more natural. It is more long lasting. And finally, what's along the news cycle right now is a deep plane facelift and the deep plane facelift goes on step even deeper than the SMAS facelift and really the difference is not that great.

(07:09):
It's a longer recovery. It's a deeper plane. It is more swelling and most importantly, it has a higher risk of nerve damage. Now there are two kinds of nerves in the face. There is the sensory nerves which provide sensation and feeling to the face. And then there's the motor nerve, which supplies animation and those nerves, the motor nerves live deeper and so they are at higher risk with a deep plane facelift. So those are the three different basic types. They're based on how deep in the layers of your face you go and how long they last. And a good facelift should last about 10 to 12 years, maybe 15.

Monique Ramsey (08:01):
Here's something people don't expect. You can have a beautiful facelift result and still look older than you are because the giveaway isn't always the face, it's the neck and that's its own conversation.

Dr. Salazar (08:16):
As we discuss different options for treating the neck, we could go anywhere from having just some energy device treating your neck to try to obtain some shrinking of the tissue, just like hybrid of frequency energy, lasers, any other technique. Little commercial here, Ellacore, which is a new device that we have integrated to our practice I would say fits into the next level, which would be removing a little bit of skin to obtain that shrinkage, to obtain that retraction of the tissue, but you remove many, many, many small pieces of skin that are not going to leave a scar. But once everything has healed, then turns out that you have eliminated a certain percentage anywhere from six to seven to 8%. And if you repeat it, you can talk about 24% of skin. Have you repeated it two, three times. So that's the next level, I would say, of treating your neck in a non-invasive or minimally invasive way.

(09:19):
Then you can talk about doing some liposuction to the neck, very, very small neck incision here, another one behind the ear, another one behind the other ear lobe. And by doing that, you can go in and you can actually scoop some of that fat out and then allow the skin to retract. And so that's another one. You can have or undergo something that's more invasive and comprehensive, which is basically a face and neck lift. So either you can choose to have just purely the neck lifted and maintain your incision a little smaller, a little shorter, or you can go for the full face and neck TZ plasty traditionally is a surgery that was designed or mostly performed in men. It's a surgery that, I mean, men due to different reasons, I don't know, surgical stigma or they sometimes come in and say, "Doctor, just take care of this. I don't want to have any other incisions. I cannot accept that I'm having a facelift neck lift. I just take care of this and I don't care."

Monique Ramsey (10:26):
It's too much.

Dr. Salazar (10:27):
It's too... Right. So sometimes that happens and that's the case and this traditionally has been a surgery that's been more practice in man. Recently we had a patient, a female patient that specifically asked for this surgery and we examined her. We analyzed her different skin characteristics, the amount of fat, the amount of subcutaneous tissue she had. We addressed her muscles of her neck and we determined that we need to cinch those muscles and bring them together and it turns out that she was a very good candidate for this surgery.

Monique Ramsey (11:04):
Same goes for the eyes. You can refresh everything around them, but if the eyes still look tired, that's what people will notice first. It's one of the most common things our patients bring up.

Dr. Riedler (11:17):
For the upper eyelids, it tends to be more kind of heavy excess skin, hooding, feeling like they look tired. For the lower eyelids, people often will also say that the lower eyelids kind of make them look tired, but it's more like puffiness or bags or excess skin as well. So it's a little bit of a different kind of goal or complaint that I see regarding upper versus lower eyelids. But in general, I think most people come in saying, "I want to look refreshed. I'm tired of people asking me if I'm tired." Even if I am tired, I don't want to look like it. And when I'm not tired, people still ask me if I'm tired. So the main things that I'm considering for patients who come in with eye concerns is brow lift, upper eyelid, upper blepharoplasty, which can either just be the skin or sometimes the fat that's bulging in the center and then lower blepharoplasty, which can also involve the skin or often the fat that's bulging as well.

(12:29):
And I often like to combine the lower blepharoplasty with fat transfer because often people have in addition to bags or bulging, they have some hollowing down here too. And so I think that really is a nice addition to make a fully smooth contour. Patients are typically very comfortable when they wake up in recovery and our recovery nurses always make sure that they're comfortable and pain free. And then during the first 24 hours or even over the first few days, patients don't have a whole lot of pain. Usually their kind of maximum pain level is maybe like a three out of 10, which isn't too bad.

Monique Ramsey (13:11):
Oh, wow.

Dr. Riedler (13:11):
Yeah. It's more like discomfort, swelling, bruising, some pressure. Those are the main kind of symptoms during recovery, but it's really not that painful.

Monique Ramsey (13:23):
In that first 24 hours, is there anything they have to do with their eyes?

Dr. Riedler (13:28):
Yeah. So for the first week or so, I have patients use acute hydrogen peroxide just to kind of clean along the incision lines and then put antibiotic ointment on and then for the second week they'll do kind of a similar thing just with Aquaphor ointment. The most important things really to do are to keep your head elevated, to reduce the bruising and swelling, to not be really active or do anything that's going to make your blood pressure jump up because we want you to heal as well as possible and as quickly as possible.

Monique Ramsey (14:00):
You mentioned earlier some bruising. Is it typical for upper or lower or both and how much bruising is it? Does it look like somebody punched you in the face or is it just sort of black and blue a little bit?

Dr. Riedler (14:13):
It honestly varies a lot from patient to patient, but you can count on some degree of bruising, whether it's a little or a lot, like I said, it kind of depends on the patient and what you've had done, but the bruising, bruising and swelling both kind of peak around two or three days after surgery and I would say the bruising typically lasts about 10 to 14 days. The swelling lasts a little bit longer. So the majority of the swelling goes away within two to four weeks after surgery, but it really takes at least six months for all of the swelling to go away.

Monique Ramsey (14:52):
So that's the whole map, the deep plane, the neck, the eyes. The real takeaway, there's no single best facelift. There's the one that's right for your face at the right time with a surgeon who will tell you the truth about what you actually need. If you're starting to think about it, that conversation is the best first step. I'm Monique Ramsey. Thanks for being here.

Announcer (15:17):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I - 5 San Diego Freeway in the XiMed building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram @LJCSC. The La Jolla Cosmetic Podcast is a production of The Axis, T-H-E-A-X-I-S.io.