S05E101 What's the BEST Facelift Technique?

Join hosts Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic as they dive into the intricate world of facelift techniques. Addressing the ongoing controversies within plastic surgery, the panel discusses traditional facelifts, superficial facelifts, and the deep plane facelift, a technique gaining resurgence. The surgeons emphasize a tailored approach for every patient, debunk common marketing myths, and highlight the complexities and risks associated with each method. Tune in to understand what makes each technique unique, and why individualized care is paramount in achieving the best cosmetic results.

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S05E101 What's the BEST Facelift Technique?

TRANSCRIPT

[00:00:00]

Dr. Sam Jejurikar: Welcome, everyone, to yet another edition of Three Plastic Surgeons and a Fourth. As always, I am Sam Jejurikar in Dallas, and I'm joined by Dr. Sam Rhee, who can be found on Instagram at at Birkin Cosmetic, who's in Paramus, New Jersey. Dr. Salvatore Pacella in La Jolla, California, who can be found on Instagram at At San Diego Plastic Surgeon and Dr.

Lawrence Tong, who is joining us today, despite being a little bit under the weather, who's in Toronto, Canada, and whose Instagram handle is at Yorkville Plastic Surgeon or

Dr. Lawrence Tong: Surgery.

Dr. Sam Jejurikar: Surgery. I'm so close. I always goofed that up today. I think we're going to be talking about a topic that our viewers will find interesting because there's a lot of controversy in the plastic surgery world about different types of facelifts, you know, and there's lots of nuances to facelifts, types of incisions.

Whatnot, but today we're going to focus on different planes [00:01:00] or different depths of facelifting technique and specifically, we're going to talk about traditional facelifts, more superficial facelifts and something known as the deep plane. So, before we get into the meat of it, um, Dr. Pacella, will you read a disclaimer, please?

Dr. Salvatore Pacella: This show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care.

Never disregard professional medical advice or delay seeking advice because of something on the show.

Dr. Sam Jejurikar: So, I think what's prompting us to talk about this topic today is, you know, controversies within plastic surgery about the various depth of facelifting technique have existed for, At least 30 or 40 years, and the deep plane facelift is not a new technique. It was a technique that, um, you know, was popularized by Sam Hamra, who's a Dallas plastic surgeon in the 80s and 90s, [00:02:00] but it's made a resurgence, and a lot of patients are coming in to talk to all of us wanting, um, You know, wanting to know more about this.

So, the question I have for you guys is, do you guys do the same facelift procedure on everyone? Do you guys do deep plane facelifts? Just sort of curious about what your approach is to facelifting patients.

Dr. Salvatore Pacella: Yeah, so just one thing you said there, Sam, um, the deep plane facelift is not a new technique, but it is a new hashtag, okay? And so that's what's kind of making the resurgence is, um, a popularity in that kind of hashtag, and that's kind of fueled by some media stuff, some literature stuff, and it's, it's kind of fun to watch because It is, it is providing, in my opinion, a better value for, for patients and a longstanding result.

So, uh, to answer your question, um, I would say that, you know, anatomically in the human body, there is no other, That is as [00:03:00] variable as the human face, okay? Even if, as I'm sitting here looking at the, um, you know, our faces on this podcast, you know, some of us have big parotid glands, some of us have big SMAS, or muscular layers, others have thinner skin, uh, you know, look at Larry, he's pretty slender and thin.

Um, his parotid gland is going to be very small. Uh, Samir, you, you have masoteric hypertrophy, so your parotids probably will be massive if I ever did a facelift on you. So it, and the anatomy is so variable. And so, you know, to me, every single time I do a facelift, I have a new approach. And it's not, not necessarily a new approach, but a tailored approach, I should say.

And, um. And sometimes the approach is modified based on what I see anatomically. So, in some patients that have not had a facelift before, it's fairly easy to do a straight stand, uh, [00:04:00] straightforward, uh, deep plane facelift. In some patients who have potentially had surgery before, I may do more of a composite or a deep plane elevating a small amount of a strip of skin.

So, it is exceptionally variable. And I think that's a good thing because it tailors. The procedure exactly to what the patient needs.

Dr. Sam Jejurikar: So, specifically Pacella, it sounds like you're advocating an individualized approach for patients, but what is a deep plane facelift? You're talking about it, but for people that don't even know, but have heard this term, what is it?

Dr. Salvatore Pacella: Larry, you want to

Dr. Lawrence Tong: Sure. So, first of all, we'll go even more basic than that. What most people describe as a facelift is a procedure that is going to rejuvenate the neck and the face. So, it's a combination of doing something like this for the face and doing something like this for the neck. That's commonly what is accepted as a facelift.

So, when faces were first Performed when they, when they first done as a surgical procedure, a lot of times they were just done as what's called a skin only facelift, which [00:05:00] is a procedure where they just lifted the skin, pulled the skin back, removed a little bit of skin. They did that for the face and the neck.

And that was a skin only facelift. And then as time evolved, surgeons started to notice that they might get better results if they were doing things to the deeper layers of the face. So under the skin, um, The next layer deeper is sort of the muscle layer, and surgeons started, um, manipulating that. And specifically, there's a layer on top of the muscle called the SMAS layer, and that is a layer that surgeons also started to manipulate.

And so it evolved to a procedure where they were tightening the SMAS. And then after that, Um, a newer technique came out where they actually went even deeper than that. They went under the SMAS and they started lifting the SMAS and not necessarily lifting as much of the skin. So the skin was attached to the SMAS and they [00:06:00] pulled that deep.

So the deep plane facelift is basically a procedure where the plane of dissection is underneath the SMAS and it's. noteworthy that it's a sort of a more challenging procedure because that's where the nerves are, the nerves that move the muscles of the face. So it is a little higher risk, but it can give sort of a higher reward in selected patients.

So basically a deep plane facelift is a, is a, is a type of facelift where the dissection is deeper and the goal is to get more, sort of better elevation and also Potentially a longer lasting result in the long term.

Dr. Sam Rhee: I,

Dr. Salvatore Pacella: You know, the other, the other point of why to do a deep plane facelift is how things are mobilized in the face. So the main reason is there's a, there's a series of ligaments that are along the face in these regions. And The deep [00:07:00] plane, if you're in a safe plane, you can easily, um, release those ligaments so that you can get a better pull of the face in an upward fashion.

And so that, that's the main reason to, to do it. But, you know, what I might also say is, life is a game and you just have to play it.

Dr. Sam Rhee: You have to play it. Uh,

Dr. Sam Jejurikar: what do you, do you perform a high volume of deep plane facelifts in your practice?

Dr. Sam Rhee: I never have done a deep plane in my practice. Uh, and I think the reason is, is that there has continued to be discussion and no consensus in our specialty in regards to which facelift is the best facelift. I don't think there are certain things that we have come to agree upon as surgeons about certain techniques, uh, certain procedures being the most efficacious, and I don't I don't think [00:08:00] we've come to any agreement about which facelift technique is the best technique, uh, universally.

Uh, there are people who advocate skin only, and they said there's nothing, and there's research to show that they'll point out to studies that there's no long term benefit to doing anything other than a skin only facelift. There are people who do SMAS facelifts, or different variations of SMAS facelifts, SMASectomies, or, um, You know, extended smash faceless, where they go even farther medially.

And then there are those who do deep plane. And so without a lack of consensus, my approach, and I also never trained, honestly, with someone who routinely did deep planes, um, uh, which wouldn't necessarily stop me if that was the best way. Uh, overall to do it, but everything I ever trained with was some sort of extended SMAS or SMASectomy or SMASplication or some type of SMAS procedure.

And the results I got [00:09:00] from those procedures were great, especially when I added some fat to it and, um, you know, adjusted the vectors a little bit. I, I have watched videos and seen demos of deep plane facelifts and, uh, it, it, it honestly scares me a little bit. I mean, I, I am not, um, you know, the, when you don't know the surgical anatomy well, that's where the fear sets in.

And as, Pacella said, Sal said, you know, uh, everyone is different. And so when you're like sitting there tediously, picking out all these little nerve branches and trying to figure out what goes what, like, to me, that, that's not a place I, I necessarily want to be in for what our specialty has not, uh, universally proclaimed to be of long term or overall benefit.

That's, that's my thinking on it.

Dr. Salvatore Pacella: You know, the tech, the technique is, is really not for the faint of heart. Um, you know, and I think, um, One of my [00:10:00] mentors, Fouad Nahai, who's a prolific plastic surgeon in Atlanta, um, when I was a fellow there, I asked him, you know, how long, after how many years do you think you felt comfortable doing, um, a facelift?

And he said, how many years have I been in practice now? At that point I think it was like 25. He's like, well, I haven't quite gotten there yet, you know. And so it is, it is an operation that when I see it on my schedule, I, every single night before Review the anatomy again. The morning of, I review the anatomy again as a refresher and map out in my mind exactly how I'm going to do it.

And I would say that I rarely do that for any other operation 16 years in practice. It is a high high anxiety and Tremendously rewarding operation.

Dr. Sam Jejurikar: yeah. I, you know, I feel [00:11:00] fortunate because of, Uh, training at Manhattan Eye and Ear. I got to train with people who did high volumes of deep plane facelifts, where it's a technical nuance because I think people are using the term deep plane to involve any manipulation of the deep plane or the SMAS layer, um, but deep in a true deep plane facelift, the skin is raised as a composite flap of skin and the deep plane, but I trained with people that did those.

I trained with people that did extensive SMAS manipulation. I trained with people that did SMASectomies. But what it seemed as though were the most important things were one, the experience of the surgeon, the guys that did a lot of facelifts, consistently got great results, and there was one surgeon there in particular, Dan Baker, who did a prodigious volume of facelifts, who sort of revolutionized a more limited manipulation of the SMAS, either a SMASplication or a SMASectomy.

And his results were unbelievable. And the other thing that I think, I think is the biggest advancement to facelift techniques in the [00:12:00] last 20 years is the addition of volume. I've known all of these guys for 25 plus years and thinking about how we all look 25 years ago, the biggest difference in our faces is that we've lost a ton of facial volume.

And, you know, we keep revisiting the same manipulation, having the same arguments, the same manipulation about the smashed layer, but ultimately I think you need an individualized, tailored approach to every patient. And I don't know if you guys remember the twin studies that were done sort of in the mid 90s where they're, um, you know, cause for the viewers, plastic surgery meetings are sort of this interesting clash of egos where you get, particularly in the world of facelift surgeons, where you get People that are champions of their own technique and they do it on everyone.

And they had two sets of identical twin studies. I think it was like 1995. And on one, it was Sam Hamra, who was the, you know, the proponent of the deep place, deep plane facelift. And on the other was Dan Baker on the other twin. And I think it was Owsley and Oscar Ramirez for the other ones. And they looked at the patients a year out, six years [00:13:00] out and 10 years out.

And honestly, I think Dan Baker's patients look the best, but that's, that's a matter of debate. So, I don't know. I think, I think ultimately people want to feel like they're getting the best plastic surgery procedure. And sometimes in this age of social media advertising, they are led to believe that in all cases, a deep plane facelift is the best.

Dr. Lawrence Tong: Yeah, I think that's true. I sort of had an evolution throughout my career because when I started, I started doing a procedure, which was basically a SMAS flap. That's basically where we elevate the SMAS. So it's technically, you could call it, uh, some form of a deep plane. And, um, You know, that procedure was not as nerve wracking as, you know, the current, um, quote unquote deep plane is, but it was still a procedure where you went under the SMAS, uh, that's where the nerves are, and if, if you, uh, went then, went very medial, then you would start seeing the nerves, and I probably used [00:14:00] that technique for the first five years of my career.

Then, actually, I, I did hear a lot about what, uh, Dan Baker was doing, and I started it. trying, uh, the Smasectomy and, uh, Smasplication. And what I found was there actually was no difference in my, in my results. And the reason, uh, why I eventually switched over to Dan Baker's technique was mostly because it was safer, it was less surgical time, and if there was no beneficial, um, benefit.

You know, no benefit in terms of result. Why, why increase that risk? Now, later on in my career, I have done some limited deep plane facelifts, and I've sort of found the same thing. It's not really that much different. Maybe I need to do a lot more to see a difference, but I would agree with what Sam just said.

It's probably surgeon dependent and not necessarily technique dependent.[00:15:00]

Dr. Sam Rhee: I think, uh, when we talk about deep plane facelifts, the issue always is, is that as, uh, Sal said, a lot of it is marketing. And people People out there will say deep plane facelifts, and we as surgeons really know what a true deep plane facelift is. It is nerve wracking, it is anxiety producing, it is a, it's a difficult procedure to do.

And yet, surgeons out there marketing will casually throw that out as a term when they are not doing anything close to a deep plane facelift, not even. And so, I think What really matters when patients are looking for faceless is you have to look at the surgeon's results, not what quote technique they're using, because that can be very misleading.

And I think surgeons can take advantage of that lack of understanding of the [00:16:00] anatomy and, and, and the type of technique to make it sound like what they're doing is better than somebody else, when it's really. Not even what they're advertising.

Dr. Lawrence Tong: I just, I just want to make a comment for the viewers. Um, the reason why this procedure is potentially very nerve wracking is because if you, if a patient has the nerve injured, they're going to have some degree, potentially some degree of paralysis in the face. Meaning your face is going to look crooked when you smile and when you speak.

And generally, if it's a true injury, that's not, there's no way to, to fix that. So that's why of us on the panel are, um, You know, stressing, uh, that it is a challenging procedure and should not be taken lightly.

Dr. Sam Rhee: So when you do the procedure, how do you approach your dissection? Because I will tell you I've, and if I see a nerve branch, I'm [00:17:00] freaking out. Like, I'm like, that's, I really even shouldn't be this far.

Dr. Salvatore Pacella: Well, so, you know, I, I do more of a, kind of a bi laminar facelift, if you will. Not a tr not in the sense of the hammer technique or the Kono technique where they're lifting up a little bit of skin and then diving deep. I've, I've found that procedure very confusing and very easy to get lost, and I don't like the fact that you can't.

Manipulate the skin in a different vector than the, than the, um, the muscle. So I lift up all the skin as far as I can go, release these ligaments down here. I think this is a key component to release these ligaments subcutaneously right at the mandible. That's what gets rid of these jowls. And then I start the deep plane basically at the level of the platysma.

Cause to me, the platysma is pretty thick. It's very easy to identify. And it's probably the safest place. to start because you know where the marginal mandibular branch is going to be. As long as [00:18:00] you stay underneath the muscle, you can, you can get at it. So once I've elevated the, and now I also have done this dissection first, and so I've connected these two planes so I could see the platysma from here and I could see the platysma from here.

Okay. Um, so then once I've elevated the platysma, I then transition that into the mid face. To me, this is the most challenging part to do right here, right? As you elevate this up, I'm watching for the parotid gland. I'm seeing if there are any nerve fibers coming out of the parotid gland. I know I'm gonna, I want to stay above that.

What's, what's exceptionally confusing is determining the difference between nerves and ligaments, okay? And so those two look almost identical and You, what you think you're cutting a nerve, you're actually, what you think you're cutting a ligament, you could be cutting a nerve and vice versa, right? So there's a lot of sort of discontinuous stretching and undermining that I do to kind [00:19:00] of elevate that area.

Um, and that, that's kind of how I approach this dissection. So like at this point of the dissection, I'm focused as tightly as I can, you know, going systematically, exceptionally slow. And so it's, that's kind of the main way I approach it.

Dr. Sam Jejurikar: Yeah. So you're doing more of an extended SMA technique than a, than a true deep

Dr. Salvatore Pacella: a composite deep plane, right? But, technically speaking, it is still a deep plane facelift, because it's the same extent of dissection. It's just whether or not you elevate the skin or not, right?

Dr. Sam Jejurikar: Absolutely, absolutely. No, and I, I definitely do a decent number of those as well. I think Patella's explanation is almost exactly the same way I do it. I, I tend to inject a lot of local. into the SMAS when I'm doing it as well. That makes the dissection a little bit easier. Um, you know, but it is incredibly nerve wracking.

And, you know, if you do see a facial nerve injury in your patient post operatively, you feel pretty good that it's [00:20:00] going to resolve, but those many weeks or months while you're dealing with it, It's nerve wracking because your patients all look like they've had a stroke, which is not the desired outcome after a facelift, obviously.

Dr. Salvatore Pacella: So for the listeners out there, There's this, um, I, I, maybe these guys will share this, this feeling. So, you know, doing an extended SMAS, deep plane facelift, brow bleph, all in one, you know, this is anywhere from a five to eight hour operation many times, right? So you, when you're done with the operation, you feel a tremendous sense of relief because, you know, your body has been like this the entire time, okay?

Like looking underneath the skin, all right? And then that. That elation and celebratory feeling is directly squashed once you go to recovery and your patient is waking up and the first thing you do is you're like, Hey, hey, can you smile for me? Show me your teeth. Raise your eyebrows? [00:21:00] Okay. That's like, until I can, can do that, I, I, I won't sleep the rest of the week.

You know?

Dr. Sam Jejurikar: I don't, I don't do that till post

Dr. Lawrence Tong: I don't, I don't do that either.

Dr. Sam Jejurikar: like you do that right after there's still all that

Dr. Salvatore Pacella: Yeah, well, but, but, but I take the chance because sometimes the local has gone away and sometimes I see it. So I, I agree. If. If it's, it's only beneficial if it's positive, meaning I can see the movement. If they're not, I, you know, by the next day, I'm sort of absolutely looking for it. You know, and I have them come first thing in the morning, the next morning, so that I can see them.

Dr. Lawrence Tong: Yeah, I, I usually just expect that, that their face is not going to move symmetrically right after, like, if you're checking them post op. So, um, if you go in with that attitude, then it's, it's, uh, you won't have to lose any sleep. But,

Dr. Sam Rhee: Sal's the kind of person who tends to open up the presents right away as opposed to waiting until Christmas morning. He just, he wants to check early.[00:22:00]

Dr. Sam Jejurikar: from a plastic surgeon standpoint, we all agree that doing a deep plane manipulation, whether, uh, It's a true composite deep plane lift or an extended smash. It's certainly more nerve wracking, but do you guys believe that the incidence of nerve injury in an experienced surgeon's hand is greater with a deep plane manipulation versus more superficial techniques?

So

Dr. Salvatore Pacella: A hundred percent, yes. I mean, there's, anatomically makes sense, right? I mean Even if the nerves are stretched, you know, or irritated a bit. Um, so, yes, I would say that's true. It may still be very low, exceptionally low, but absolutely higher, no question.

Dr. Sam Jejurikar: then what do you make of all these surgeons who claim they've had no nerve injuries yet to hundreds or thousands of these procedures?

Dr. Salvatore Pacella: Yeah, I, I think that's, I think that's some, uh, aggressive marketing.

Dr. Sam Rhee: Haha, that's a nice way of putting it. Haha.

Dr. Lawrence Tong: I [00:23:00] think it's possible, but I totally agree with Sal. If you're going into the plane where the nerves are versus you're operating in a plane where the nerves aren't located, you're going to get more risk of injury to the nerve when you're in that plane. There's a saying in plastic surgery circles is if you're, if you're not getting complications, you're not, you're not operating enough.

And so, even if you are very experienced, you are going to get an injury at some point. And, you know, for the claims of never having had an injury, it might be never having had a permanent injury. I mean, um, temporary injuries aren't that unusual. And we've just said, you know, by definition, if you see somebody whose face doesn't really move for the first couple of weeks, comes back, that's a temporary injury.

Um, So, I think that, um, yeah, it is, it is a bit of marketing if, if somebody claims that they've never had a, a nerve injury.

Dr. Sam Jejurikar: what do you think, Sam?

Dr. Sam Rhee: Uh,

Dr. Sam Jejurikar: [00:24:00] Sal.

Dr. Sam Rhee: no, I agree, I, I don't, uh, I don't think anyone who does true, uh, I mean, I don't remember what Sam Hamra's complication rate was with that in terms of permanent nerve injury. But I think what's really telling is what you said. Like, there have not been any studies that have shown that that type of technique is definitively better.

And so if anyone who says that is out there, they're, they're lying. That's, that's not what the research and the literature supports. And, um, Uh, but ultimately, it is the experience of the surgeon that determines the outcome and success more than anything else. And, and for any procedure, especially, uh, you know, the more technically involved procedures, it's always surgical experience.

It's not the technique or, um, you know, what they specifically do or do not do. Um, it's really about that individual and What their experience and [00:25:00] skill, uh, represents. Oh

Dr. Salvatore Pacella: facelift, you know, whether or not you're Lifting up near, far, wherever you

Dr. Sam Jejurikar: you are Ha ha ha ha ha ha ha!

Dr. Sam Rhee: my God.

Dr. Sam Jejurikar: Uh, well

Dr. Salvatore Pacella: your heart will go on.

Dr. Sam Jejurikar: Ha ha Odd Celine Dion reference, but okay. Well, the reason Getting back to where we were, the reason I asked that question Meta analysis published last year or the year before where two people we've had on this podcast, Dr. Rorick and Dr. Abbasio were the last and first author on it. And when they looked at the meta analysis, they said, You know, all this self reported data amongst, you know, cause again, published data is from surgeons themselves.

They're publishing their own data. We're not looking at each other's stuff. Published, the published rates of nerve injury are actually, [00:26:00] basically the same between more superficial and more deep manipulation. But I don't think any surgeon believes that, including those of us that do deep plane manipulation.

Um, So I thought that was interesting. And yes, what Sam said was true as well, that, um, there is no published data or long term study. And when we've done, there's been a couple of twin studies that are out there that really definitively shows that one technique is better. So I think we're all coming to the same conclusion that Pacella said early on in the show, that you have to take an individualized approach to the patient.

Do you guys do the same technique on every patient? Any of you?

Dr. Lawrence Tong: no.

Dr. Sam Rhee: absolutely not.

Dr. Salvatore Pacella: Well, you know, I, I would say that the generalized approach is the same, meaning the incisions are relatively the same design, the elevation of the SMAS with the way I started is relatively the same. It's just the [00:27:00] extent of. The vector, where you're pulling, where you, where you want additional volume, where you're putting the fat, how aggressive you're going to be, what sutures you use, you know, that, that's all kind of tailored based on what, you know, what we find in the, in the operating room.

I

Dr. Sam Jejurikar: yeah, I totally agree with that. And I think, um, you know, we've all changed things in terms of how we do things over the years. Um, we all have discovered techniques that we like more as we get more experience, but ultimately I think we all, you know, have developed a technique that we feel pretty comfortable, um, is durable, provides durable results for our patients.

So I feel like we've exhausted this topic unless you guys have any more you want to add.

Dr. Lawrence Tong: No, I, I, yeah,

Dr. Sam Jejurikar: All right.

Dr. Lawrence Tong: I think I'll, I'll, I'll have one comment. You know, for patients out there, you got to look at, um, we [00:28:00] talked a lot about marketing. Sometimes you will see a lot of, uh, marketing where if you actually look at the patient who's having, you know, the surgery. They're not really that old looking.

And so if you start off with a patient who's fairly young looking to start off with, they're going to look really, really good no matter what technique you use. So just keep that in mind. Like, see if you, you see examples where the skin is, is very saggy, if everything is, is very lax. Because if you, if you're starting off with a patient who's like in their late 40s or early 50s doing these surgeries, they're always going to look good no matter what technique you use.

And that's part of the, you know, the, the marketing that, that goes out there.

Dr. Sam Jejurikar: Okay. Well, gentlemen, it was a pleasure as always and until we meet again, take care.