Deep Plane Facelift

The ultimate guide to the most advanced surgical techniques in facial rejuvenation

 A facelift is a common term in everyday culture, but what exactly does it involve, and who is the ideal candidate for it?

 The end goal of a facelift (or Rhytidectomy) is to restore a youthful appearance, leaving the face refreshed and skin tightened whilst maintaining your own natural features.

There are many techniques discussed when it comes to facelift surgery, however the first step to understanding the facelift procedure and various options available is to understand what it is that we are trying to restore. What happens to the face as we age?

The ageing process.

The aging process affects us all. Genetics and lifestyle will dictate how quickly this process occurs for you but the principles remain the same.

Aging affects all the layers of the face – the skin, the fat (both superficial and deep), the fine facial muscular layers, and the bone.

 As we age the skin loses collagen and elastin, which are important molecules for creating a structure. As a result, the facial skin becomes thinner and less elastic with variable amounts in excess (loose skin).

 The fat loses its structure and reduces in volume in some areas (atrophy), whereas in some other areas can increase in size (hypertrophy). Specific attachments of facial tissues- called the ligaments- start to loosen up causing a descent (called ptosis) of the different fat compartments.

 The most important anatomical structure concerning facial aging is the S.M.A.S, which is the abbreviation for Superficial Musculo-Aponeurotic System.

 The SMAS layer is located between the superficial fat and a deeper layer, which contains facial muscles and the facial nerve branches. The SMAS extends from the cheek bone (zygoma) to the jawline (mandible). As it approaches the neck, the SMAS becomes a more distinct muscular layer, called the Platysma muscle.

With aging, both the SMAS in the face and the Platysma in the neck become looser and weaker and provide less support against gravity. It is this loss of support and attachment that is responsible for most of the signs of facial aging. This is why SMAS and Platysma are the most targeted tissues during face and neck rejuvenation surgery

Overall the aging of each layer of the face leads to an alteration in the facial shape. The youthful triangular or “V” shape of the face is reversed to a more square shape, with widening of the lower face and flattening of the cheek area.

 There are volume changes in different areas and is the meticulous reversal of these volume discrepancies via augmentation, resection, or repositioning of tissue that is key to youthful natural results following facelift surgery.

Georgios has been featured in the Tatler Cosmetic Surgery guide 2024 “Best for faces ” section, and recommended by the Sunday Times as the “rising star” in deep plane Face and Neck surgery.

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What are the main areas that can be addressed with a facelift?

The face can be divided into specific areas called facial aesthetic subunits based on their three dimensional contour. During your initial consultation Mr Orfaniotis will carefully examine these subunits to identify your specific needs and create a bespoke surgery.

 Below is an outline of the most common signs of aging specific to the different facial subunits that need to be targeted during a comprehensive facial rejuvenation approach. Based on your concerns Mr Orfaniotis will be able to guide you through what specifically you would benefit from.

·       Midface

o   Malar fat atrophy and descent with flattening of the upper cheek area

o   Hollowing of the Eyelid / cheek junction (tear trough deformity)

o   Deep Nasolabial folds

o   Excess or ptosis of the buccal fat pad

·       Lower face

o   Presence of jowls showing as excess fat and skin that fall over the jaw border.

o   Loss of definition of the jawline with irregular mandibular shape

o   Loss of projection of the posterior jawline

o   Obscured definition between face and neck

o   Presence of “marionette” lines (melo-mental and melo-labial folds)

·       Neck

o   The skin becomes thinner and its laxity contributes to the presence of wrinkles and pleats

o   The Platysma becomes attenuated and redundant with the formation of vertical bands.

o   Fat accumulates to both the subcutaneous and sub-platysma fat spaces.

o   increasing bulging of the digastric muscles, which are found deeper to the platysma.

o   Ptosis of the submandibular glands.

·       Lip and Perioral area

o   Loss of upper lip volume with soft tissue descent.

o   Thinning of the vermillion border with less definition of the cupid’s bow and philtral columns.

o   Bony resorption, which makes the lip look less prominent

o   Vertical lengthening of the upper Lip complex, which appears deflated.

o   Perioral rhytids (smokers or lipstick lines)

For those patients seeking only Lip procedure, please see our separate blog on Lip Lift surgery.

·       Periorbital Area

o   Lower eyelid area. Laxity of the lateral attachment (canthus), fat herniation (bags), Tear trough deformity.

o   Upper Eyelids

o   Temples

o   Forehead and eyebrow.

Who is a good candidate for a facelift?

Anyone who has issues with laxity of facial tissues and sagging of the face and neck region, whereby structures have descended from their original position would be suitable for a facelift. A facelift procedure re-suspends the deep facial tissues back to their original position, restores volume, and removes excess skin to provide tightening and lifting.

 The ageing process is unique to your own genetics and environment so there is often a broad age range of patients affecting both women and men. In relatively young patients it may be that only a targeted lower face lift is required to restore the youthful natural appearance. If there are significant jowls and neck involvement, then a full facelift procedure may be indicated.

To be suitable for facial surgery under Dr Orfaniotis patients need to be non-smokers, with a normal and well controlled blood pressure, and with a BMI of less than 30.

 What are the types of Facelift?

There are many types of facelift which can be classified based on the type of work performed on the SMAS, and on the extent of the incisions.

 Based on the depth of SMAS dissection there are 2 main types:

-       Superficial SMAS procedures. This is the simplest type of intervention and can be either a plication, imbrication, or limited excision of the SMAS.

-       Sub- SMAS procedures. These are more complex techniques, which involve raising a SMAS flap. Sub-SMAS facelifts can be further subdivided in:

o   Lateral SMAS approaches (High or Low)

o   Deep Plane Surgery . This is the most advanced facelift technique and requires detailed anatomical knowledge and surgical experience in the face and neck, hence not every cosmetic surgeon is able to offer it.

The terms “mini” or “minimally invasive” facelifts refer to the length of the incision, which is limited to the front of the ear. These “mini” facelift versions usually involve superficial SMAS work only. An example of a mini facelift is the MACS lift.

Many surgeons over the years have developed some minor variations of the standard facelift techniques and gave those various different names, hence the confusion around the many types of facelifts.

 Mr Orfaniotis performs the most advanced Extended Deep Plane facelift technique, most frequently combined with a Deep Neck Lift.

What is a Deep Plane Facelift?

The term deep plane refers to an anatomical space located between the SMAS layer and the deeper tissue in the face and neck. By entering into this deeper space, the SMAS (and the platysma) can be completely released from the underlying tissues, allowing for a more effective, tension-free suspension.

The SMAS and Platysma become free not only from the skin but also from the deeper layers, where the masseter muscle and the facial nerve branches are found. The separation (or undermining) however of the skin flap from the SMAS is less extensive, leaving skin and SMAS attached together for majority of the dissected area, hence the term “composite flap”.

During the dissection into the deep plane the undersurface of the SMAS and platysma muscle is carefully peeled off from the delicate branches of the facial nerve. The SMAS layer is also released from some strong fibrous attachments, called ligaments, which fix the tissues to the bone. The most important two ligaments are namely the zygomatic and the masseteric. The Platysma is also elevated from it’s strong attachments to the parotid, called cervical ligaments.

The facial nerve has 5 different branches, which are responsible for moving the fine muscles of facial expression, called mimetic muscles. In view of this, performing a Deep Plane facelift requires an in-depth knowledge of the facial nerve anatomy, and meticulous dissection in order to visualize these very fine nerves and protect them from any accidental injury.

Mr Orfaniotis has developed an expertise in facial anatomy combining his extensive experience in both reconstructive and cosmetic surgery. Georgios is a board certified Plastic surgeon and a BAAPS member, and one of the few surgeons in the UK who is comfortable to truly offer the most advanced deep plane surgery technique to his patients.

What are the advantages of the Deep Plane technique?

Although the Deep Plane is technically a more challenging and lengthy procedure compared to superficial SMAS facelifts , it offers a number of advantages, which made it the go-to choice for natural, long-lasting results in modern facial rejuvenation surgery.

Firstly, the entry point of the deep plane is closer to the medial soft tissues compared to other SMAS flap techniques. This allows direct access to the drooping areas of concern that need re-suspension. This is a significant biomechanical advantage compared to the traditional facelifts . Through meticulous tissue handling and dissection Mr Orfaniotis is able to perform an extensive release and directly access the ptotic medial facial soft tissues. This allows a very effective re-suspension of the SMAS and platysma with no need to apply excessive tension.

Releasing the ligaments and other dense fibrous attachments in the deep plane allows for the SMAS and platysma to be re-suspended with minimal tension. This is very important in terms of the longevity of this technique as there is less risk of early failure and snapping of the SMAS suspension sutures from too much tension. This tensionless suspension technique is largely responsible the natural results achieved with deep plane surgery; the face is rejuvenated but without the unattractive look of excessively pulled tissues (the unwanted “wind tunnel” effect of the facelift patient). In addition, there is less risk of suture “cheesewiring” through the SMAS, a situation that often creates dents or other irregularities in the face.

Another advantage of the deep plane technique is the improvement that can be achieved in the midface region. By freeing up the ligaments during the extended deep plane facelift, it is possible to access and reposition the ptotic midface fat compartments and restore the volume and projection on the malar eminence. This is not possible with conventional facelifts where the zygomatic ligament remains uninterrupted and the effect on the midface is minimal.

Finally, with the extended deep plane dissection in the neck it is possible to free up the platysma muscle to approximately 5 cm below the jawline. A platysma flap is then created via a back-cut and this flap is re-suspended to the mastoid area creating a crisp, youthful jawline. The posterior jawline, which has lost volume with age, can be also augmented by repositioning SMAS tissue.

Mr Orfaniotis offers 2 types of Deep Plane facelift:

-   Short scar, with the incision running from the temporal hairline to just a few centimeters behind the earlobe. This short scar approach is best suited for patients who mostly have lower face concerns, with mild to moderate jowling and without significant excess neck skin. This is the same approach with Jacono’s M.A.D.E.(Minimal Access Deep Plane Extended) facelift version. Despite the shorter incision it is still possible to perform extended Platysma dissection and improve neck contour and jawline definition. One of the biggest benefits of this approach is that there is no visible scarring for patients that like to wear their hair as a pony tail.

-       Full scar Deep Plane. The incision is extended to the mastoid region and the posterior hairline in the occipital area. The extra incision is required in order to manage heavier necks with significant excess skin and avoid irregularities from bunching up the redundant skin behind the ear. This is the most commonly used approach and is often combined with a browlift to address laxity in the temporal and forehead area.

What other facial procedures can be performed at the same time with Facelift

-       Deep Neck Lift. This is performed via an additional incision in the submental area (under the chin) and is indicated for patients who have symptoms and signs of neck heaviness. To learn more about Georgios’ signature Deep Neck Lift click here.

-       Fat grafting

 -       Lip Lift. A lip lift procedure is commonly performed alongside Facelift surgery and the 2 procedures can be complementary to each other, also sharing the same recovery time and process. Click here to find out more about LIp LIft.

 -       Brow Lift. Mr Orfaniotis is able to offer a number of brow contouring techniques; the most commonly used is the Temporal (endoscopic style), with a 3-cm incision hidden in the temporal hairline. This procedure also described as a temporal brow “ reset”, is often required alongside a deep plane Face and neck lift to address temporal and forehead laxity, which can get worse and present as “bunching” following a vertical lift of the tissues. This brow reset gives a more balanced rejuvenation and is not associated with Gliding (GBL), temporal, or direct browlift.

 -       Upper and Lower blepharoplasty. Mr Orfaniotis’ preferred approach for lower blepharoplasty is the transconjuctival with fat repositioning and minimal or no external scarring.

 - Buccal fat reduction. The buccal fat pad can be reduced in patients who have it in excess and has become ptotic with ageing. A ptotic buccal fat that has not been treated during a facelift can become noticeable after surgery and appear as a recurrence of jowling. Mr Orfaniotis is able perform buccal fat reduction when this is required through the deep plane approach and with no need of additional incisions.

-       Chin Liposuction. This is very rarely performed and is only reserved for those young patients who genetically have excess subcutaneous fat (over the platysma). Chin liposuction is not an alternative to neck lift

How does Fat-grafting work and when is it indicated in facelift surgery?

Mr Orfaniotis commonly performs fat grafting as part of the facelift procedure in order to restore volume that has been lost from specific facial areas.

Fat is normally harvested from areas where there is excess, most commonly abdomen and thighs. Mr Orfaniotis uses the most recent advanced techniques in facial fat transfer and performs micro- and nano- fat grafting, whereby the fat is processed and filtered

 Micro- Fat grafting is used to replace volume and increase projection following fat and bone resorption in the malar and temporal area, whilst nano- grafting is used in the more superficial layers such as the tear trough and fine peri-oral wrinkles. Nanofat has a beneficial effect on the skin quality making the skin look vibrant and alive.

 Fat can also be transferred to the; peri-orbital area, cheek (if there fat recession), lips, chin and jawline. 

What will the scars look like from a facelift?

The length of your incision and the position of the scar will depend on the specific areas that are being addressed during your surgery.

In a full facelift procedure that addresses all areas of the face and the neck the scar will wrap around the ears anteriorly and posteriorly in the crease behind the ears. It will also extend into the hairline behind the ear and anteriorly up into the temporal hairline. The exact location of the scalp hairline extension is chosen depending on your individual hairline to maximally hide the scar. For those patients who have mild skin excess the incision runs anterior to the ear and extends only a few centimeters behind the ear. In most cases however the incision wound continue around the the back of the ear with a limited extension to the occipital hairline. Mr Orfaniotis keeps this posterior incision short, in order for the scar to be hidden patients wearing their hair as ponytail, as well as male patients. For patients who already had a facelift, the design of the incisions may vary to allow reposition of unsightly scars from the previous surgery.

 These specific positions are chosen as they are natural contours of the face and as such do not catch the light so there is a natural camouflage. The scar is a thin scar.

 The scar healing process can take up to a year before scars are fully mature. During the first month or two the scar can have a redder appearance as part of the natural inflammatory process the body has in response to healing. After this period the scar colour starts to fade away.

 At one-week post-operatively Dr Orfaniotis will explain and demonstrate the scar massage process that should be followed. This will help improve the appearance of scar in terms of texture and colour and can help fade the scars quicker. Dr Orfaniotis recommends using a silicone based scar gel that you apply once a day to the area, taking 5 minutes to massage the product in.

What is the recovery after a facelift?

A few hours after the procedure you will discharged from the clinic would be able to go to your accomodation accompanied by a friend or family member. You will need someone to stay with you for the first 2 days. As Mr. Orfaniotis uses local anesthetic during the procedure you should be comfortable after the surgery. Adequate pain medication will be given to you upon discharge, as well as antiobiotics and anti-sickness medication if required.

 After the procedure there will be a garment around the head that needs to stay in place for one week. We would advise to rest for 48 hours post-operatively and sleep on your back. You would be able to return to work after 3 weeks. Dr Orfaniotis advises no strenuous activity for 2 weeks, and no gym activity or sports for a further 4 weeks. This is because strenuous activity can interfere with this early wound healing process and increase the risk of bleeding.

A compression garment to protect the area should be worn for a minimum a week after surgery followed by 2 weeks of nightime . This not only helps protect the area when you sleep but also helps reduce any swelling. There can be some bruising after surgery, more likely in those patients who require additional procedures. Bruising can take up to 3-4 weeks to settle and is usually worse after fat grafting and/or eyelid surgery. Some idendations and irregularities may still be present up to 8 weeks after surgery. If you had a combination of deep plane Face and Neck lift there will be residual swelling on your neck, which takes up to 4 months to settle.

 During this first month, skincare is to be kept minimal with no active ingredients such as retinoids, skin lighteners, or chemical exfoliants. Daily SPF should be worn daily for this first month post-operatively and where possible avoid sun exposure. Following your wound review appointment at one week, make-up can be worn and hair can be washed. Scar massage can commence from one week after the suture removal as mentioned above.

Adjuvant therapies.

The skin is not only subject to the natural aging process, but it also suffers from external damage from the sun and pollution over the years that can result in issues with pigmentation or a crepey texture.  If your skin is particular damaged, Dr Orfaniotis may recommend additional adjuvant treatments to complement the surgical procedure, such as hyperbaric oxygen and post-operative manual lymphatic massage. This may also include pre surgical treatment with a specialist skincare regime or laser treatment.

 Skincare regime post-op is also important in order to maintain results and Dr Orfaniotis also offers patient-specific advice on this as standard as part of the procedure price.

Price – starting from £17,500 (does not include deep neck lift)

Anaesthetic: General (fully asleep). The short scar facelift version can also be performed under local anaesthetic and sedation (twilight anaesthesia) for suitable patients.

Length of stay – Daycase or Hospital overnight stay

Time in theatre – 4-6 hours, depending on additional procedures.

Drains. Mr Orfaniotis occasionally uses drains, especially when a deep lift with submandibular gland reduction is carried out. He also uses a technique of quilting suturing on the skin, which is called “Hemostatic net”, which adheres the tissues and reduces the risk of bleeding. Both drains and the hemostatic net will be removed at your 1st post-op appointment at 48h.

Aftercare
We have created a very comprehensive care protocol for patients undergoing facelift surgery, and is all included in your package.

We collaborate with the fantastic team at Surgical Recovery London and together we provide a first-class recovery and aftercare service. This also includes additional pre-operative consultations with a recovery specialist doctor to prepare you physically and mentally for this journey. We will provide you with specific recommendations according to your treatment plan and health history, which will enhance your recovery.

Following your surgery you will have a team of specialists available to assist you 24/7 and make your recovery journey safe and pleasant.

Your first appointment will be within 48h after your surgery where the dressings will be taken down and the wounds will be inspected and cleaned carefully. At this appointment we will provide you with everything you need during your recovery, including an antibiotic ointment, antimicrobial facial wash, facial serum, silicone gel, as well as specific instruction on when and how to use them.

Your next appointment will at 7 days post op where your wounds will be cleaned and the anterior sutures will be removed. The sutures behind the ear and the skin staples in the posterior hairline will be removed at 12-14 days post op.

What are the complications and risks with Face and Neck Lift surgery?

Bleeding: It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-operative bleeding occur, it may need draining surgically. If a collection of blood accumulates within the face or neck (a haematoma) this may need draining.

Seroma: A seroma is a collection of fluid beneath the skin or within the tissue at a surgical site. If this occurs there is the possibility it will need to be drained with a needle, it may resolve itself or require an operation to drain it. Rarely seromas can cause adhesions and changes of the skin texture, a condition also known as fibrosis.

Infection

Poor Scarring: All surgery leaves scars, some more visible than others. Scars can appear thick, red and raised all or part of the way along the incision line (a hypertrophic scar) or more rarely can involve tissues beyond the incision itself (and can resemble a badly healed burn), this is known as a keloid scar. Additionally, scars can tether to underlying structures or become abnormally pigmented. It is possible that additional treatments may be required for adverse scarring.

Delayed healing: Wound disruption or delayed wound healing is possible. Some areas of the treated region may not heal normally and may take a long time to heal. This is normally managed with frequent dressing changes. Previous skin tightening treatments such as HIFU can reduce the blood supply to the skin and contribute to delayed healing or even tissue necrosis. Smokers have a greater risk of skin loss and wound healing complications.

Skin discoloration / swelling: Some bruising and swelling normally occurs following surgery. The skin in or near the surgical site can appear either lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration may persist for long periods of time.

Sensory changes: With any form of surgery small nerve branches that supply the skin will be cut. This can lead to patches of numbness around the surgical site. It is possible that following surgery you can develop abnormal sensation in the area where you have had surgery and this may take the form of pins and needles (known as paraesthesia), hypersensitivity or even pain in response to normal touch (known as allodynia). Such problems may be related to nerves becoming entrapped within scar tissue and further surgery may help. It may be necessary to take medication to control any such symptoms on a permanent basis. Numbness following surgery is normal and usually resolves after 12 to 18 months. It is not unusual to experience shooting pains within the face and neck for up to a year following surgery (this is part of the healing process and represents nerve regrowth).

Suture extrusion: As well as stitches (sutures) in the skin, you will have deeper sutures to hold the SMAS tissues, platysma and other structures in place. These sutures are usually made from material which is broken down by the body – often called dissolving sutures. Some people can develop redness in an area of the incision that is fully healed (3 or more weeks following surgery) and it appears that pus comes out. Such areas are normally managed with simple dressings. It is possible to develop multiple suture extrusions at the same time or at different times during the healing process.

Skin and fat necrosis: If the blood supply to the skin is insufficient following surgery (which can be for a variety of reasons) it can necrose (die). If this happens the skin will form an eschar (scab) which may need to be removed surgically. Dressings are likely to be required for a period and further surgery may be needed to correct adverse scars.

Skin contour irregularities: Contour and shape irregularities may occur after face and neck lift surgery. Visible wrinkling or puckering of the skin may occur and may require additional treatment if problematic. Any fluid collections that occur beneath the skin can also lead to contour irregularities and may require additional treatment.

Tightness and restricted movement: As part of the surgery the deeper tissues of the face and neck are tightened to produce a change in appearance. For some patients that can result in limitations of movement (such as ability to open the mouth fully, lift the chin up or turn the head to either side). Such limitations usually resolve within a few months of the surgery, but some patients may experience a persistent feeling of restriction.

Facial nerve injury: There is the potential for injury to the nerve (or branches of the nerve) that moves the muscles of the face. The ability to raise your eyebrows, close your eyes, smile or move the lips may be affected as a result of this. This can produce weakness of the affected muscles (and asymmetry of movement between sides of the face) or paralysis (resulting in complete loss of movement in the affected region). Any such deficit is likely to be temporary (resolving in a few weeks to months) but in very rare circumstances may be permanent.

Salivary gland leakage: The salivary glands may be reduced as part of a face and neck lift procedure . This can lead to leakage of saliva from the cut edge of the gland. This will result in a collection of saliva under the skin that may require repeated drainage (or some other form of intervention) until the leakage seals itself.

Hair loss and hairline changes. It is normal to lose hair follicles 1 to 2mm either side of a skin incision. Additionally, it is possible to lose hair in any region of skin that has been elevated (this is particularly relevant for male patients in the beard area). Such loss may be temporary or permanent.

Asymmetry. The 2 sides of the face and neck are different in every person. These pre-existing asymmetries between sides will have an impact on the outcome of your surgery. Particular areas of asymmetry frequently seen include: Skin fold and wrinkles, facial bone , brow eyes nose and lip, volume asymmetry, and finally asymmetries in the ear position and earlobe shape.