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SMAS vs. Deep plane

SMAS vs. Deep plane

Postby clbh1234 » Mon Oct 22, 2007 5:58 pm

For those who believe both approaches are valid, what is the advantage of one vs. the other? Is deep plane believed to last longer than SMAS? Is one more 'natural' looking than the other?
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Postby shambo » Tue Oct 23, 2007 10:03 am

afraid i really dont know,but i believe a good surgeon will take the best of several precedures to achieve the results wanted.
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Deep plane vs. SMAS facelifts

Postby MillenniumFPS » Tue Oct 23, 2007 9:46 pm

clbh1234,

These are excellent questions that have been studied by facelift surgeons from the 1990's to the present. I will try to explain the deep plane technique versus the SMAS technique as well as the controversy as best I can using layman's terms.

Deep plane facial dissection
Based on surgical principles of mobilization, advancement and healing

The deeper you lift up the tissues, the easier it is to pull or advance that tissue over to the new position, where it will heal.

Analogy: Imagine yourself trying to move a large area rug over a few inches.
Image
Because the area rug has a lot of surface area, if you lift up 10% of this area rug and pull it, it is very difficult to do!! There is too much area of the rug creating friction which prevents you from moving the area rug more than a few inches at best. If you lift up 20-30% of the rug and try to move it, it is a little bit easier to move it a further distance. If you lift up half or more of the rug, it is the easiest method to move the rug as much or as little as you need.

Diagrams of the Facelifting techniques
ImageSMAS Facelift Image Credit: http://www.centrplastiki.ru
ImageExtended SMAS Image Credit: http://www.centrplastiki.ru
ImageDeep plane Facelift Image Credit: http://www.centrplastiki.ru

Dr. Kamer's Personal perspective
Revision rates significantly higher with previous rhytidectomy techniques
o 21.7% SMAS plication tuck rate (short skin flap)
o 11.4% Extended SMAS rhytidectomy tuck rate (long skin flap)
o 3.3% deep plane tuck rate

Kamer FM, Frankel AS. SMAS rhytidectomy versus deep plane rhytidectomy: an objective comparison.Plast Reconstr Surg. 1998 Sep;102(3):878-81.

Why is there a significant discrepancy in the touch-up (tuck-up) rates?
ImageExample of a a plication suture (the circle at the top.) Two passes of the suture thread is placed apart on the surface of the SMAS layer (pink layer.) When this knot is tied come of the excess slack on the SMAS can be taken out by folding the muscle underneath this plication suture. The excess SMAS is left intact under the new surface layer SMAS. This extra SMAS can not be felt through the skin. (Sorry, I couldn't find a better example of a plication suture. If I do find one, I will replace this one.)

Since one surgeon performed all of these procedures, we can assume the the skill level of the surgeon with all three techniques is the same, so we can compare the techniques directly. If one technique is not working as well, we can eliminate surgeon ability or skill out of the equation. Why did the SMAS plication method have such a high tuck-up rate. Well, lets look at the technique itself and see how much mobilization and advancement we can get with this SMAS plication technique. If we look at the SMAS plication or SMAS imbrication method (see above photo), you can see that the SMAS may only move about 1/2-3/4" tighter. If the SMAS layer stretches a little bit, it may end up being not be tight enough which leads to a tuck-up. Let's now compare this to the extended SMAS and Deep plane technique.

Duct tape analogy:
Image
Lets imagine the SMAS (seen in the above diagram in yellow) as a layer of duct tape. This SMAS layer is strong and does not stretch very much (only a little bit) and when lifted up has a strong adhesive surface (when healed) that can be used to hold up the tissues of the face in the lifted position. The overlying skin can be thought of like a thin rubber sheet. If we only pull on the skin it tends to stretch out, but the SMAS or duct tape can hold some tension or strength if we use it to lift the jawline and cheek. So when we perform the an extended SMAS or deep plane facelift, we cut the SMAS (duct tape) and peel it back. With the deep plane facelift essentially we are peeling the duct tape as far down toward the nasolabial folds (smile lines) then lifting the entire SMAS and skin together as a unit before laying it back down and suturing it into place to heal. The more that the SMAS is lifted up in the deep plane the more the surface area there is for the SMAS (duct tape) to stick in its new position. The deep plane facelift allows for the most mobilization and advancement as well as the most surface area for healing. So if every part of the basic principles of plastic surgery are maximized, it makes sense that the tuck-up rate for deep plane facelift (3%) is significantly lower than the SMAS plication facelifts (22% tuck-up rate). The extended SMAS also does this but to a lesser degree (11% tuck-up rate)

The Controversy
Another way to look at it is, if the SMAS facelift works 80% of the time, then are we doing the deep plane facelift unnecessarily 80% of the time and it is only really necessary 20% of the time? If it is difficult for a surgeon to distinguish when to use which procedure, then they will perform the deep plane facelift on everyone, so that they can minimize the need for tuck-ups. Is the risk to the facial nerve higher with the deep plane facelift than the SMAS facelift? Yes. The SMAS facelift surgeons will look at it a different way, they never ever want to have a facial nerve injury for any of their patients, so they can justify a higher tuck-up rate, because at least they are keeping the patient safer. Daniel Baker wrote an article titled: Baker DC: Deep dissection rhytidectomy: a plea for caution. Plast Reconstr Surg 1994 Jun; 93(7): 1498-9. The deep-plane surgeons will say that their rate of facial nerve injury is negligible in their hands so they can have the best of both worlds.

Which looks more natural? Some say that the deep plane facelift lifts the cheek fat pad better than the SMAS technique, but some SMAS techniques can also get this type of improvement. Dr. Aston performed an interesting study in the 90's comparing the two methods.
Ivy EJ, Lorenc ZP, Aston SJ Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg. 1996 Dec;98(7):1135-43; discussion 1144-7.
Presented is a prospective study comparing limited SMAS (lateral SMASectomy), conventional SMAS, extended SMAS, and composite rhytidectomies. Randomized patients received either a limited SMAS or conventional SMAS face lift on one side and an extended SMAS or composite rhytidectomy on the other. ... The study comprises 21 patients, ... No discernible differences in facial halves were noted again. Differences between facial sides on the 6- and 12-month postoperative photographs were not detectable. We conclude that for routine facial plasty, comparable clinical outcomes are obtained at 6 months and 1 year with limited (lateral SMASectomy) and conventional SMAS face lifts compared with extended SMAS and composite rhytidectomies. All procedures are lacking in their improvement of midface ptosis and the nasolabial folds. The increased surgical risks, morbidity, and convalescence associated with those more extensive procedures do not seem to be warranted in the average patient.



It hasn't been proven that one technique lasts significantly longer than the other. If a patient was able to get an equivalent improvement (both 10 year improvements) at one year with either technique, I think that both will last equally long. However, if the patient could get significantly tighter result with the deep plane technique along with a longer chronologic improverment relative to the SMAS technique, then from this standpoint the deep plane would take longer to return to the original age (15 year improvement versus 10 year improvement.)

See my explanation on how long a facelift should last. http://messageboards.makemeheal.com/vie ... hp?t=61255

So after this lengthy explanation, what's the conclusion?
    1. Both techniques are valid.
    2. The results from these techniques look approximately the same even when performed even on different halves of the face.
    3. The deep plane technique has a lower tuck-up rate relative to SMAS technique.
    4. The risk for facial nerve injury is higher with deep plane facelifts than SMAS techniques.

If the surgeons can't agree on one type of facelift technique, then the potential patients should be better informed regarding which risk they prefer, the rarer risk of facial nerve injury or the higher risk of getting a tuck-up.

If there are any more specific questions, please don't be shy, I'm happy to answer them as best as I can.

Best,

Dr. Yang

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My online posts are not a substitute for a physician evaluation and examination and should not be considered as medical advice.

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Postby harri » Wed Oct 24, 2007 2:55 am

Surgery Was an Experiment in Disguise; A Faulty Study


Published: June 29, 1998

To the Editor:

You report that doctors at Manhattan Eye, Ear and Throat Hospital conducted a study in which they performed a different kind of face lift on each side of a patient's face (news article, June 21).

But any comparison of techniques on opposite sides of the face ignores the fact that the sides are connected and inalterably related.

When unequal stress is placed on the two sides of the face, there is always some equilibration. Only if vastly different stress is created might differences be seen. The question of which face lift -- aggressive or conservative -- works better hasn't been answered because this cannot be determined by the proposed study model.

DICRAN GOULIAN, M.D.
New York, June 21, 1998


I think we always end up not knowing what to believe. :lol:
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Subperiosteal

Postby jamesuk » Wed Oct 24, 2007 4:19 am

Dear Dr Yang

Perhaps we could go one stage further and compare to the Deep Plane lift to the Subperiosteal lift. How does this compare?

What are the anamotical variations with this?

e.g Is the masseter muscle fully elevated from the bone or is the elevation above this?


Thanks!
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Postby clbh1234 » Wed Oct 24, 2007 8:11 am

Thank you so much Dr. Yang for your meticulous answer. It's so helpful and I appreciate your generous time. My follow up question would be, might a doctor not be certain which type of lift might benefit you more in the consult, but know better once he 'opens you up'? (not saying that's bad, it just makes sense) That's of course assuming the PS is equally comfortable with all three techniques.

Then a second question... is there a type of face (older vs. younger, or perhaps just more vs. less skin elasticity, heavier vs. thinner) where the deep plane may be more indicated?
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Deep plane vs. SMAS continued

Postby MillenniumFPS » Wed Oct 24, 2007 10:10 pm

Harri,

Part of our training in medicine is to read and critically analyze studies and papers to determine whether or not there is any validity in the conclusion and whether or not the study was flawed or could be improved. During our training, we have journal club meeting where a list of papers are given to be read ahead of time then later discussed somewhat like what we are doing on this forum.

What can the general public believe, if the surgeons can't agree? I think that we may have to agree to disagree. Both sides have valid points and the debates can go on for decades. What's the alternative? Should all surgeons and scientists only believe in the status quo and not question or try to improve the existing techniques. Where would we be today? Skin only facelifts? Dr. Sydney Coleman was a proponent for fat grafting when most of his contemporaries were telling all of their patients that fat grafting doesn't work. Yet, he developed a system that could predictably recreate volume in the face and body. Now, everyone is doing it, microfat grafting, brazilian butt lifts, etc.

Harri, here are a few abstracts for you to look at.
Litner & Adamson. Limited vs Extended Face-lift Techniques: Objective Analysis of Intraoperative Results
Deep-Plane Technique. Commentary by Dr. Frank Kamer
Superficial Musculoaponeurotic System vs Deep-Plane Face-lift. Commentary by Ferdinand Becker
Becker & Bassichis. Deep-Plane Face-lift vs Superficial Musculoaponeurotic System Plication Face-lift: A Comparative Study

I'd like to know what you think. Obviously there are two different camps, the SMAS vs. the Deep Plane group. We can discuss it later on this week.
_________________________________________________

JamesUK,

I want to finish up the SMAS vs. Deep Plane discussion first. I will give your questions full attention later on this week.

_________________________________________________

clbh1234,

Excellent follow up questions. Its only natural to ask these questions. The plastic surgeons in the field also ask then design studies to try to answer them.

My follow up question would be, might a doctor not be certain which type of lift might benefit you more in the consult, but know better once he 'opens you up'? (not saying that's bad, it just makes sense) That's of course assuming the PS is equally comfortable with all three techniques.

Litner & Adamson. Limited vs Extended Face-lift Techniques: Objective Analysis of Intraoperative Results
This study compared all three methods, on a 32 patients. During each operation, the least invasive technique SMAS plication was first performed and the amount of overlapping excess skin was measured, then the SMAS imbrication (removal of a strip of muscle before sewing the edges together), then the deep plane. The results were: mean skin excesses were 10.4, 12.8, and 19.4 mm for the plication, imbrication, and deep-plane lifts, respectively.

So knowing this information, if you could perform all three techniques with equal expertise and you have the desire to give your patient the best possible result, which one would you choose? The weakness of this study is that this is an intraoperative measurement, and there is no long term follow up. If the results of the deep plane looked as good as the SMAS plication, then why make the facelift harder than it needs to be? Which leads to the second question and the second paper.

Then a second question... is there a type of face (older vs. younger, or perhaps just more vs. less skin elasticity, heavier vs. thinner) where the deep plane may be more indicated?

Becker & Bassichis. Deep-Plane Face-lift vs Superficial Musculoaponeurotic System Plication Face-lift: A Comparative Study. This study compared the before and after results (at 6-18 months) of 20 SMAS plication facelifts versus 20 deep plane facelifts performed by the same surgeon. 4 facial plastic surgeons graded the photos for improvement of the smile line, cheek, and jawline. What was the conclusion? The deep plane facelift did not offer superior results over SMAS plication facelift in patients younger than 70.

What sense can we make of this? If someone is younger and does not need much of a lift (lets say 10 mm of lift) to have a nice natural result, a SMAS plication facelift should be able to deliver on that lift. If you have an 75 year old patient who needs 25 mm of lift to get enough lift to get a nice result, then a deep plane facelift may be a better procedure for that patient. So the more they are sagging the deeper you go, the less they are sagging the more superficial the facelift

You asked me how long a facelift would last http://messageboards.makemeheal.com/vie ... hp?t=61255. I explain to my patients that the longevity of the facelift correlates to the amount of improvement received (10 year improvement => 10 year longevity; 3-5 year improvement => 3-5 year longevity of the facelift) One question that is yet to be answered is whether or not performing the deep plane facelift will produce a longer lasting lift than the SMAS lift. This would be a very difficult study to design. But if it were true, then maybe a patient would get a 10 year improvement, but hypothetically it may take 11-15 years to get back to the original point. The fact is a person's facial age is determined by more than just their neck and jawline, if their face is shrinking and hollowing as they age, the deep plane facelift will not prevent that from happening. A successful fat transfer on the other hand, if stable at one year, can maintain its results much longer.

Food for thought.

Best,

Dr. Yang

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Postby MissJ521@aol.com » Wed Oct 24, 2007 10:46 pm

I've never been too comfortable with that being an experiment the patients were not knowing about as I don't think they consented to having 2 sides of face done differently.



harri wrote:
Surgery Was an Experiment in Disguise; A Faulty Study


Published: June 29, 1998

To the Editor:

You report that doctors at Manhattan Eye, Ear and Throat Hospital conducted a study in which they performed a different kind of face lift on each side of a patient's face (news article, June 21).

But any comparison of techniques on opposite sides of the face ignores the fact that the sides are connected and inalterably related.

When unequal stress is placed on the two sides of the face, there is always some equilibration. Only if vastly different stress is created might differences be seen. The question of which face lift -- aggressive or conservative -- works better hasn't been answered because this cannot be determined by the proposed study model.

DICRAN GOULIAN, M.D.
New York, June 21, 1998


I think we always end up not knowing what to believe. :lol:
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Postby harri » Thu Oct 25, 2007 4:55 am

A while ago I wrote a long rambling thread trying to evaluate the different types of facelift

http://lookyourbestuk.com/forum/viewtopic.php?t=5818

I think it was Gunter who said the choice of surgeon is more important than the choice of plane and that was my conclusion too. :lol: I ended up more confused than when I started.

Surgeons cannot agree on their use of terminology let alone on their techniques. One surgeon's deep plane lift may be totally different to another's and I struggled to even conclusively define the basic types of lift. I settled for deep plane being the Hamra type of lift but someone has just said another term for a Mask lift is a deep plane lift. Others think deep plane is just an extended smas.

Surgeons don't usually seem to offer us different types of lift but are adept at persuading us that their pet lift is just perfect for us. :lol:

Surgeons like the rest of us are a product of their experiences, good and bad. And yes Miss J we are the guinea pigs in their experiments.

I don't know whether we are lucky or unlucky to have so much information available to us on the internet. A little learning is a dangerous thing........But the most valuable information is the feedback about the surgeons themselves from the patients who have been there and done that.

However, I find it all fascinating and thank you Dr Yang for the time you are taking to explain things so clearly.
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Harri's Blog

Postby MillenniumFPS » Thu Oct 25, 2007 10:31 am

Hi Harri,

I just read your blog. Your research on the different types of facelift is excellent. I think anyone who is looking for good information about facelift should read your blog. It pretty much covers everything.

http://lookyourbestuk.com/forum/viewtopic.php?t=5818

When we read about the studies comparing Deep plane vs. SMAS it does get very confusing for the reader (layperson or even the plastic surgeons) to figure out which is better. In the end to simplify the thought process, what should the patient expect from a facelift:
    1. youthful neck and jawline (which hopefully makes the patient look about 10 years younger, but not necessarily how they looked 10 years ago though.)
    2. a long lasting result (if the improvement is stable at one year, it is unlikely that it will all of a sudden fall at a certain point in time.)
    3. a smooth post-operative recovery, without facial nerve injuries, or healing issues.


One thing that is overlooked with discussing facelifts is whether or not a necklift is performed, and if it is, how is the neck lifted. If we think back through all the facelifts that have fallen, I think it would be interesting to ask the MMH members if they had a formal necklift with their facelift. A formal necklift would have a 3/4"-1.5" inch incision under the chin. If you did not have that, then you did not have a necklift, maybe a little bit of liposuction.

Lets take a poll of the facelifts that fell and see if they actually had a necklift. I think that this poll will demonstrate a pattern, which should be consistent with my observations. This information may help people decide more which surgeon to choose if one recommends a facelift without necklift versus another who recommends a face and necklift together. I also have an observation about the long term tightness of a facelift which some people experience and others don't.

Which will give a better result: A Facelift without necklift or a Face and Necklift together?

I'm taking the afternoon off to take my 3 year old son to the new Butterfly Exhibit at the Museum of Natural History. Later on today or tomorrow, I will expand on my experiences with my facelift technique and why I think the necklift portion of the facelift, makes more of a difference in the ultimate facelift result than the SMAS versus Deep plane part of the procedure. I will use diagrams and use examples from my own patients.

Enjoy the rest of the day.

Best,

Dr. Yang

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www.Twitter.com/GeorgeYangMD
www.Facebook.com/GeorgeYangMD
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My online posts are not a substitute for a physician evaluation and examination and should not be considered as medical advice.

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Postby MissJ521@aol.com » Thu Oct 25, 2007 11:15 am

Hi Dr. Yang,

I've had neither a lower face lift nor a neck lift BUT since I get gads and gads of patient photos and feedback (which they send me) and meet up with a lot of patients, allow me to participate by using that large sample group as 'proxy'.

First, I will say, that the determination needs to be made as to what is what on the lower face and underchin area and what is most likely doing what. For example a jowl could be as simple as some accumulated fat to be displaced higher to look better or it could be some complex combo of stuff like a ptotic salivary gland combined with fat DEEP to the superficial platysma muscle or some looseness of anterior neck triangle muscles deep to the platysma. Something that's best determined if the doc is actually 'poised' to do a cut below the chin (as in neck lift) to look in there and 'see' what is doing what and address from there.

So, ya, I'd say, the patient is better served by consulting with a doc that is 'poised' to consider a neck lift along with a lower face lift and will help with those types of determinations rather than just going to a doc who is 'hard selling' a face lift only procedure that gives an implied promise that the lower face lift only procedure is going to also address some of the areas under the chin that 'belong' to the under chin incision needed for the neck lift part.

Secondly, even in reference to just the superfical muscle; the platysma, the platysma muscle overlays BOTH part of the lower face AND the neck area. So even with the superficial plane of platysma (SMAS plane)--as in a surgery that does not go underneath it, I would say it is better that the doc be 'poised' to displace the platysma from 2 different places ie; near the ear (as in lower face incision) and under the chin (neck lift incision).

Not saying that both 'have to' be done. But best if doc is 'poised' to evaluate 'what is what' and poised to do both.

As you probably realize, that can be difficult for a doc if a patient goes in there after saying seeing a TV commercial that implies that only a type of lower face lift needs to be done.

I know me and you have discussed the "cheese wire" phenomena before: the act of depending on the lower face lift part to suspend or hold up too much of the neck part in which the tension of the sutures depended on to do that is so much that the sutures end up cutting through the tissue and the neck lift part is lost in a short period of time. But I am hoping you will elaborate on that part when you get back from the 'flutterby' exhibit. LOL
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Postby harri » Thu Oct 25, 2007 11:29 am

I'm pleased you liked my research Dr Yang but I'm embarrassed to say it was all done after my facelift :oops:

I spent a lot of time researching the surgeon (for a rhinoplasty actually) and basically just turned up on the day for a facelift.

But that way can work too :lol:
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Bumping up this thread

Postby MillenniumFPS » Sun Nov 18, 2007 4:39 pm

Hi Claire48,

This thread has a nice discussion about deep-plane vs SMAS facelifts. Harri also wrote a blog in the past discussing her research on different facelift techniques.

Best,

Dr. Yang

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www.Twitter.com/GeorgeYangMD
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Postby Bugjune » Sat Nov 24, 2007 11:08 pm

A lot of food for thought here! At 51, I had a PS recommend deep plane lift to fix a slight jowling along my jawline. Considering the MFL, neck lift and other work I'd had done (by a different surgeon) a mere 2 years previously, it just seemed a bit too invasive. Plus, I just was not comfortable with the risk factor for permanent facial paralysis that comes with a deep plane lift, so I've put any plans for correcting my jowls on the back burner for now.

In my dreams I see a tiny incision made just behind each droopy jowel. Excess skin is cut away, and the skin is pulled back towards my neck past the jaw bone. A tiny incision no more than 1/2-3/4" on each jowl is all that's needed! Why can't I do that? The rest of my jaw line is clean and tight enough. Yeah, I'm dreamin' .... :cry:
Vaser High Def lipo on torso, neck & knee lipo, Neck, Midface lift, Brow Lift, Upper Eye Bleph, Lower Face lift, IPL, Sclerotherapy, Restylane, Juvederm, Botox and fat injections. Um, what's missing?! I've had it all.
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Postby harri » Sun Nov 25, 2007 4:51 am

Image

I'm a bit confused here.

Is this a pix of a smasectomy (Baker?) rather than a smas lift as described by Dr Naderi (smas imbrication as opposed to plication).

I can see a skin flap but I can't see a smas flap being raised in this pix. I also see an inverted L-shaped scar typical of the smasectomy.
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