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SMAS vs. Deep plane

Postby MissJ521@aol.com » Sun Nov 25, 2007 8:34 pm

Hi Harri,

The illustration you have looks to me like what Baker describes which is cutting out a strip of SMAS parallel to the NLF and then suturing together which will take the jowl area with it. So, I would definitely say, it's what Baker describes and does.
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Postby harri » Mon Nov 26, 2007 2:43 am

MissJ521@aol.com wrote:Hi Harri,

The illustration you have looks to me like what Baker describes which is cutting out a strip of SMAS parallel to the NLF and then suturing together which will take the jowl area with it. So, I would definitely say, it's what Baker describes and does.


Thank you Miss J. A picture paints a 1000 words and all I've read so far is lots of words about the Baker smasectomy. :? That pix made the penny drop for me.

My interest is that some top UK surgeons are doing this lift instead of the more invasive smas lifts although it seems they have modified it (don't they all :lol: ) to include the neck muscles at the side.

It's interesting that there are 2 schools of thoughts because other top UK surgeons are still doing the extended smas.

The MACS is also popular in the UK as it is so easy to do but the Baker is offered as the alternative to it for the 'younger' patient.

My confusion is that some surgeons are seeing all their patients as younger these days - could it be if all you have is a hammer, everything seems to look like a nail :?:
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Postby harri » Mon Nov 26, 2007 4:45 am

Image

This is a good pix showing the differences in the flap created for different facelift techniques.

You can see the skin peeled back and how deep/far each goes into the smas layer.

More extensive SMAS management is obtained by creating a limited SMAS flap or an extended SMAS flap. The SMAS flap is created in addition to the skin flap, and is separately repositioned.
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Harri/diagram

Postby suekk » Mon Nov 26, 2007 8:59 am

Harri,
I have spent the weekend reading everything on this site trying to understand this whole SMAS vs. deep plane lift, and I am still kind of unclear. I see you posted a diagram, but I cannot see it well on my screen. Can you give me the website address so I can pull it up and maybe see it better?
I just can't quite understand the extended SMAS vs. the deep plane difference. Any help would be appreciated. Thanks
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Postby harri » Mon Nov 26, 2007 11:47 am

Suekk I don't think the diagram is that clear - the writing on it is quite faint anyway but I think the term deep plane is confusing anyway because sometimes it seems to be interchangeable with extended smas. Deep can mean further across towards the nose as well as deeper / further under the smas.

It's all to do with the size of the smas flap raised and the pix does show that.

From left to right the pix are labelled

Subcutaneous (skin flap only)
Skoog
Subcutaneous with smas
Deep plane
Composite

If you want to know about the composite lift try googling Hamra. To my mind this is the true deep plane lift. And it's scary. :twisted:

I had an extended smas and this is similar to the standard/conventional smas but the smas is undermined further in towards the nose.

All facelifts tighten the smas in some way but the true smas lifts to my mind create a smas flap.

The mini lifts just plicate the smas (fold it over and stitch it) without raising a flap - have a read of Denenberg's site which has a tutorial of the smas plication lift. He describes how the skin is lifted but makes no mention of a smas flap.

The Baker smasectomy doesn't have a flap either. Instead a wedge of smas is removed as shown in Dr Yang's diagram which I was questioning.

If you have a look at the facelift forum on www.lookyourbestuk.com I've written a few stickies about facelifts that you might find useful. They're still WIP though.
Last edited by harri on Mon Nov 26, 2007 1:38 pm, edited 2 times in total.
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Postby harri » Mon Nov 26, 2007 11:50 am

Maybe this table helps - the classification into small, medium and large is where I've decided to draw the lines. I decided if a lift doesn't have a smas flap it is in the small category. My opinion only. :lol:

Small
Skin Only Skin flap created. No manipulation of deeper tissues. Limited benefit.
SMAS Plication Skin flap created. SMAS is folded on itself. No SMAS undermining. Straightforward, limited anesthetic requirements.
S-Lift and Variants Skin flap created. SMAS is plicated with purse string type sutures. No SMAS undermining. Similar to SMAS plication with sutures elevating the SMAS and platysma. Limited anesthetic requirements.
Lateral SMASectomy Skin flap created. SMAS overlying parotid is resected and tightened. No SMAS undermining. Little risk of nerve injury. Limited recovery time.

Medium
SMAS
Conventional Skin flap created. Separate SMAS flap created. Flaps advanced independently. Increased risk of nerve injury. Benefit over plication alone is uncertain.
Extended Skin flap created. Separate SMAS flap created. Flaps advanced independently. Similar to conventional SMAS lift with greater degree of SMAS flap undermining.

Large
Composite
Single flap of skin, orbicularis oculi, cheek fat, and platysma is created. Flap advanced as a single unit. Successor to “Deep Plane” face-lift. Relatively long recovery period. Addresses midface descent. Increased risk of nerve injury.
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Postby MissJ521@aol.com » Mon Nov 26, 2007 2:36 pm

Harri,

I think sometimes, some PSs approach the SMAS with a dissection close to NLF but then the pull the whole thing back as a flap and then might fold over the back part near the ear. When it's UNDER the SMAS, it's called 'deep plane'. But I don't think they 'deep plane' the thing that far down near the NLF. With Bakers, strip of SMAS he cuts out, which is near the NLF, it does appear like tension as to pull that part of the face is NOT FAR away from it and may do a better job in some people.

In general, words alone don't describe those things. Hence a lot of confusion relating the words back to the dissections. I think it's better to just look at dissection diagrams which as you know, are hard to find at lay levels.
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Postby harri » Mon Nov 26, 2007 3:38 pm

This is how Gnter answered the question

Jack Gunter who is world-renowned for rhinoplasty says the choice of surgeon is more important than the choice of plane for a face-lift. :pimp:


"What is the difference between a deep plane facelift and the usual SMAS facelift? Are the results longer lasting? What are the advantages of undergoing this procedure?"


Answered by Jack P. Gunter, M.D.
Dallas, TX


There are three planes on the face that can be used for face lifting: the superficial plane (under the skin), the mid plane (under the SMAS) and the deep plane (next to the bone). Each of these has its proponents and some plastic surgeons use a combination of these approaches.

Proponents of the deep plane lift feel like they can better restore the cheek contour (by lifting the cheek pad) and soften the nasolabial fold (the fold running from the corner of the nose to the corner of the mouth). They feel that corrections will be more secure because fixation is to the periosteum (the strong adherent covering of the bone). However, many of these surgeons will change to the mid plane (sub SMAS) when doing the jowl area and to the superficial plane in the neck as these areas are better controlled in those planes.

Proponents of the deep plane facelift feel the results last longer and can be more dramatic than results of lifts in the mid plane or superficial planes. However, there are no valid scientific studies to tell us if this is true. The main disadvantages to the deep plane lift are that it is technically more difficult to perform, takes longer in the operating room and there is more down time for the patient.

In summary, it is my feeling that the choice of surgeon is more important than the choice of plane. Most of the surgeons whose work is well known perform the mid plane facelift and some combine it with the deep plane and/or the superficial plane. Very few are doing superficial plane only.
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Postby MissJ521@aol.com » Mon Nov 26, 2007 3:55 pm

Gunter seems to be calling subperiosteal; "deep plane". See--that's what I mean by the 'words' are confusing. The "deep plane" (that most PSs refer to) is usually UNDER THE SMAS. Under the smas is still in the soft tissue though. It's just the part with more facial nerve risk and paratoid gland.

I have no clue WHY Gunter is using the word "deep plane" to mean "subperiosteal" (next to the bone). Really, most PSs would call the plane "next to the bone" SUBPERIOSTEAL PLANE and not "deep plane" and would refer to under the smas as "deep plane" where Gunter calls that "mid plane".
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Postby harri » Mon Nov 26, 2007 4:34 pm

I think the most important thing is to understand what YOUR surgeon means by the terms he uses. :lol:
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Postby harri » Tue Nov 27, 2007 2:19 am

The developer of the MACS lift is a very well respected plastic surgeon, and I believe in his hands it gives nice results. However, I am not a proponent of any technique involving short-cuts or suture suspension in facelift surgery, since the incisions required are similar but the results are generally less smooth and effective from what I have seen (even in those published in the leading journals as good outcomes).

Facelift surgery as much or more of an art form as any plastic surgery operation. Getting the most natural-looking result from a facelift, in my opinion and in my practice, requires lifting both the skin and deep layer (SMAS), sometimes together (deep plane) and sometimes separately.

The problem with using long, looping sutures to suspend the face is that it does not create as natural and smooth a vector of pull, and does not adequately lift the midface area. To do this the surgeon usually has to undermine the SMAS layer in the mid and lower face, and this is something that not all facelift surgeons do - but the best ones won't have it any other way.


Every surgeon has a different opinion about the best type of facelift. Above is Dr Mani's.

First they cut round your face and lift the skin and then the true smas lifts go on to dissect the smas and lift a smas flap. The size (extent) of the smas flap can be standard (conventional smas lift) or extended towards the nose (extended smas lift).

Dr Mani is saying when they lift the skin and smas TOGETHER it becomes deep plane - they've gone under the smas to lift in one piece instead of separate flaps. The composite lift described by Hamra lifts a bigger area of the skin and skin together, including the muscles round the eye.

Gunter is saying they switch between planes in different parts of the face - it seems to be that area round the nose where they lift skin and smas together (a composite flap is skin and smas together).

So I understand the conventional smas lift and the composite (Hamra).

What I am unclear about is the difference between the extended smas and the deep plane. If there is a difference it's that the bit of the flap towards the nose is skin and smas lifted in one piece. ie they have gone under the smas and raised it in one chunk instead of dissecting the skin from smas and then dissecting the smas.

Sorry I'm rambling. :lol:

I think part of the confusion (for me) is that Dr Yang has described the smasectomy (Baker) as a smas lift. There is no smas flap raised in the smasectomy - it's just a strip of smas removed as the diagram clearly showed.
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Postby harri » Tue Nov 27, 2007 4:48 am

I've seen surgeons refer to the extended smas as deep plane (deep towards the nose instead of deep under the smas).

I've also seen surgeons refer to the Mask lift as deep plane. This is a completely different type of lift. It's a subperiosteal (cut to the bone) midface vertical facelift done via an endoscope with small incisions, no cuts round the ear. There is no skin removed. As described by Ramirez.

I believe Bichonfrise had this in Lithunania to lift her midface. She also had a lower face smas lift at the same time to lift her lower face.

So you're confused because it is confusing suekk :lol:

But an important distinction which separate the mini lifts from the proper smas lifts is whether a smas flap is created.

The smas plication lift merely tightens the smas with sutures.

The smasectomy cuts a strip of smas out.

A smas lift proper has a smas flap.

http://www.faceliftboston.com/face-lift-procedures.htm

I just wonder what posters mean when they ask about the deep plane lift? If you read this article it seems to describe the traditional smas lift as the smas plication (described by Denenberg) and the deep plane has having a smas flap.

During a deep plane facelift, the SMAS layer is separated off the underlying deeper structures (i.e. chewing muscles, facial nerve etc.).


In the late 1960s, Skoog described a sub-platysmal plane of dissection that left the skin and platysma together as a single unit. Skoog’s initial work prompted surgeons to create deeper planes of dissection. The deeper tissues were left attached to the overlying skin and repositioned as a single unit. In the early 1990s, Hamra described the composite rhytidectomy. This technique involves creating a deep plane of dissection for tissue suspension. A unified flap that consists of skin, platysma, midface cheek fat and orbicularis is created, elevated, and repostioned. This approach seeks to add, among other things, cheek fat and nasolabial fold correction into the facelift procedure.5 Concern has been expressed with regard to the relatively long recovery period from these deep plane dissections


So it's easy to distinguish facelifts that don't have a smas flap from those that do but then there are different sort of smas flaps.

The skin and smas can be dissected in separate steps and the flaps re-positioned separately.

Or the Skoog way develped by Hamra where a thick flap containing everything is dissected and lifted in one go.

These were the techniques illustrated in that diagram - I did find a clearer pix of it but it was a slide in a PDF file.
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deep plane vs. SMAS harri and MissJ

Postby suekk » Tue Nov 27, 2007 7:43 am

Thanks so much for putting all the information on the board to help me. Harri, you really went to alot of work, and I surely appreicate it. I have read it three times, and I am less confused, though still confused, but I feel like I have some understanding. Wow, its really technical. I did want to ask whats the difference between plication and imbrication in reference to SMAS. Does it make a difference in the outcome?
Thanks again, I will continue reading.
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Postby harri » Tue Nov 27, 2007 8:24 am

http://www.lookyourbestuk.com/forum/vie ... hp?t=11420

There's a post about plication / imbrication in this thread.

Plication means to fold and suture over.

Imbrication means to cut and suture.

So these are just words and I think they seem to be used in different contexts so it becomes a bit confusing.

There is the smas plication lift as described by Denenburg and Naderi calls his lift a smas imbrication lift or modified composite. The difference here I think is that Denenberg isn't cutting a flap and Naderi is. Denenberg is just using plication sutures to fold and pull the smas up whereas Naderi is elevating a smas flap - so imbricate seems to mean to dissect the smas flap itself.

However, I think they can also use plication and imbrication techniques once they have elevated the smas. With plication they fold up the excess and with imbrication they dissect it. I seem to have got plication on one side and imbrication on the other side (the fattest side).

It's impossible to evaluate all the different techniques. There are many many studies and they all seem to reach the conclusions the surgeons wanted to reach. :lol: But Naderi would say the imbrication causes scar tissue and this is what helps the lift stay up. However, I think he is talking about the creation of the flap here.

I'm trying to understand facelifts as a layman and I'm struggling so maybe I'm the blind leading the blind. Sorry! Basically I'm very surprised that people keep asking about deep plane lifts because they're very difficult to do and have bigger risks. I thought the extended smas was the most popular lift in the US today.

Certainly Baker has made a plea for caution, hence his smasectomy. The modified Baker smasectomy is gaining ground in the UK too. If you notice Dr Yang uses the word imbricate when he describes the smasectomy too - i.e cutting out a strip of the smas vertically and stitching it back together. So it's just a word used in several contexts (as all words are :lol: ).
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Postby harri » Tue Nov 27, 2007 9:08 am

To simplify - Dr Naderi says lifts which rely on suspension sutures will not last long because the sutures will eventually give way like cheese cutters cut thru cheese. He calls his lift the smas imbrication lift.

My surgeon says a MACS lift is like a tailor altering a coat without taking up the lining. He does the extended smas.

The key thing is that they both think creating a smas flap is the key to longevity.

Where we have got confused is with the different smas flaps, standard, extended or composite.

I think understanding the difference between lifts with no flaps (plication, MACS, Baker smasectomy) and lifts with flaps is the first step.

And of course, some surgeons would argue both Dr Naderi and my surgeon are wrong. :lol: And Dr Naderi and my surgeon would argue with each other whose flap was the best. :lol:
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