Deep Plane vs. SMAS: Battle of the Face Lifts

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:08):
Hey, Dr. Koehler.

Dr. Koehler (00:11):
Hey Kirstin.

Kirstin (00:11):
What's up?

Dr. Koehler (00:14):
Not much.

Kirstin (00:14):
Do you know what we're talking about today?

Dr. Koehler (00:18):
No. What are we talking about?

Kirstin (00:20):
We are going to get into the nitty gritty of the two most popular face lift techniques.

Dr. Koehler (00:26):
Okay.

Kirstin (00:27):
The deep plane face lift and the SMAS face lift.

Dr. Koehler (00:31):
Sure. Alright. What do you want to know?

Kirstin (00:34):
Can you give us some history of face lift techniques?

Dr. Koehler (00:38):
You know the techniques for face lift has really evolved because the earliest face lifts were skin only. People would just undermine the skin and then pull the skin tight.

(00:51):
Yeah. Well, and that's where sometimes people kind of got these weird appearances because the skin was pulled tight. And a lot of times I'll have people say, well, I really don't like these lines here. Well, if somebody pulls that skin really tight and gets rid of your nasal labial folds, I mean, it doesn't look proper. It looks like you were in a wind tunnel. So there's certain things that we do. Yes, we want you to look as youthful as possible, but the other key to face lift is making you look as natural as possible. With a SMAS technique and with a deep plane, we're elevating the skin, that's the first thing that happens is the skin is lifted up. But then it's what you do to that next layer underneath the skin that's different. And with the SMAS techniques, you either take a little strip of that tissue out.

(01:39):
Okay. So that layer is called the SMAS, the superficial musculoaponeurotic systems, big long word, but it's the musculofascial layer. And so some people will take a little strip of that out and then it gets repositioned with sutures to a higher location. Whereas the deep plane face lift, you actually get below or into that layer and you elevate that along with the skin attached to it all the way, pretty much to the nasal labial fold here. And then that entire layer is lifted up and secured with suture. So the main difference is with a SMAS technique, you're just taking a strip out and you're not really continuing that dissection further forward and releasing all the ligaments that sort of help retain the face. Whereas a deep plane face lift, you're actually, you have to release all of those ligaments to get everything free and then you reposition the tissues.

(02:45):
And so the big difference is with a SMAS technique, you can actually get very nice results. So let me just start off by saying that I think both techniques in the hands of a good surgeon, you can give good results. People who tend to gravitate to certain procedures for various reasons, whether it's because they get more predictable results or faster recovery or whatever it is, there's reasons why people will choose a technique one over the other. But the main, I guess, reason that people that do deep plane face lift really like the deep plane face lift is that when it's done properly, it actually does have a pretty remarkably fast recovery. And because you're releasing all of the ligaments and repositioning everything, when you re-secure everything with the sutures, there's really no tension at all on the skin, and that flap really isn't under a lot of tension.

(03:44):
And so in terms of a longevity of a result, you're relying less on the strength of your suturing technique with a deep plane face lift. Whereas with a SMASectomy, you have to really secure everything up with sutures. And yes, it can hold, but also sometimes sutures don't hold as well. And so the thought is is that if you looked at a face lift that you did with a deep plane versus a SMASectomy in two years, five years, 10 years, perhaps the patient that had the deep plane face lift in 10 years time would be looking better than somebody that maybe had a SMAS technique.

Kirstin (04:24):
So longevity is better with the deep plane.

Dr. Koehler (04:29):
Yeah, I think you get a longer lasting result with a deep plane face lift.

Kirstin (04:33):
So you typically do a deep plane face lift, but are there any modifications that you perform compared to someone else?

Dr. Koehler (04:42):
Oh, I'm sure, like if you compare, if you looked at five surgeons that do deep plane face lifts, there would be similarities in that, their techniques. But there also would be lots of little nuances. And it can sometimes be little things like the type of suture a person prefers to use or how they close certain deep layers or structures. And some people like to, in some of our patients, we shave down the saliva glands in the neck to get a good neck contour and re-establish the jawline. But that's not required. We don't do that routinely with every patient. But in the ones that need it, we do that. And there's some surgeons that would never trim those glands. They just don't feel it's necessary. So there's lots of little variations. And there's the science of deep plane face lift, and then there's the art of deep plane face lifting. And the art part is really what distinguishes maybe one surgeon from another, their view of how to reposition things and I guess their concept of what looks good.

Kirstin (05:44):
So are there other variations for individual patients that you might make? I know like you said, you may do the saliva glands for some people and not other people. Are there other things that you may change from one person to the next?

Dr. Koehler (05:59):
Yeah, I mean, the techniques are really, it has to be tailored for every patient. So sometimes a consult comes in, they say, well, I would like a face lift, a deep plane face lift even. And that's when the surgeon evaluates things and you go, okay, well, maybe you'll also need a brow lift. We've talked about this I think before, it's like sometimes if you don't address the brow and you lift all this up, you can get some bunching of the skin. And so you can eliminate that by doing a brow lift. Or with the neck, sometimes I occasionally will have people where I actually don't even need to make the incision up underneath the chin, whereas I would say probably 90% of my face lifts, we do make that incision under the chin so that we can tighten the muscles in the midline of the neck, and also if need to get to the gland to shave down the hanging part of the gland.

(06:50):
So those variations in the technique of whether or not we need to open the midline, whether we need to combine other surgical procedures like fat grafting or brow lifting or other things to give us the enhancement to the result that we're going for. I mean, that's where it's not a one size fits all operation. But yeah, I would say that the technique for the deep plane face lift is definitely, that is my go-to for face lift. And there may be times where we may, on people who've had maybe multiple prior surgeries, we may have to modify that technique just to be as safer and try to protect nerves and whatnot.

Kirstin (07:30):
Is recovery time or I guess the difficulty of the recovery about the same for either one?

Dr. Koehler (07:37):
Well, years ago I would've probably said that the SMASectomy was a quicker recovery than doing the deep plane face lift because there's actually less dissection. You do the skin undermining, and then you take out that little strip and then you close it and then close skin. But with the original way that I did deep plane face lifting, I did a lot more skin undermining. So there was a lot more of the skin that was elevated in addition to doing the deeper plane work. And so the dissection was more involved, the results were good, but I would say the recovery was maybe a little bit more than the traditional SMAS face lift. But now you'll hear people talking about different versions of deep planes where we don't do nearly as much skin undermining. And I would say that, yeah, when I can, I absolutely do that. And in those patients, the recovery is significantly, I think it's much quicker than what we were seeing with some of the SMAS techniques.

Kirstin (08:37):
I was very surprised when I first started working here. Just being a person out in the wild, you think a face lift is, not that it's not invasive, but that a face lift is crazy invasive and it's this huge surgery, but then patients come in here post-op day seven, and you're like, oh my God, you had a face lift a week ago. Not that you would never know, but it just is not as crazy of a recovery as I imagined it to be, I guess is what I'm trying to say.

Dr. Koehler (09:05):
Yeah, no, I think with a lot of the modifications that we've done, there's certain medications that we use to help decrease bruising and swelling, and just the anesthetic technique, the surgical technique. Things have improved over the years. And although there's many parts of this procedure that haven't changed in many years, that we're still finding ways to improve recovery for sure. And the deep plane face lift, although on social media, it seems like it's the latest crave, the latest thing everybody's doing, back in the eighties, the deep plane face lift was also something that was called a composite face lift back then, which is, I won't get into the differences, but it was a deep plane face lift. And I think the one thing about deep plane face lifting is you definitely want to see somebody who's experienced doing the deep plane. Because the one disadvantage that I would say of doing deep plane face lifting is it definitely puts the nerves in a vulnerable location because of the dissection.

(10:11):
Now, if you're experienced doing this, I think it's extremely safe. I don't think it's any more dangerous than a SMASectomy, but again, in the hands of somebody who is familiar with the technique and does this operation, it's not an issue. But I would say for a less experienced surgeon who maybe is not, doesn't really do a lot of deep plane face lifting, I mean, I'd rather have a surgeon do a SMASectomy if that's what they've done their whole careers than try to do a deep plane face lift when that's not what they routinely do.

Kirstin (10:42):
I want to rewind about 20 seconds. What were you doing in the eighties?

Dr. Koehler (10:45):
Oh, well, I wasn't doing anything.

Kirstin (10:47):
Oh, okay. That's why I was checking.

Dr. Koehler (10:50):
You weren't even born yet, so I don't even know why you're worried about it.

Kirstin (10:53):
I was, I was. I was around for about five minutes. So while every patient is different, is there a ballpark that you may give patients for how long their results will last, and especially deep plane versus SMAS? Because we've already said that deep plane probably will give you a little longer lasting results.

Dr. Koehler (11:17):
Yeah, nobody's ever done that study. And so really, it's all just subjective opinion. There's not a study that says, oh, the deep plane lasts longer. And that's another thing that can be a surgeon opinion, but that's not in the medical literature. There's nothing that says that it lasts longer. In fact, there's been some studies on twins that had face lifts where they had one technique on another twin had a different technique. And you know, the bottom line is you can get a good result with all of 'em. Now, to your first question of like, well, how long does a face lift last and does it last longer with another? That is the impossible question that every surgeon deals with when talking to a patient. And I think there's so many variables. So if you do a face lift on somebody that's aged 50, that is not the same as doing a face lift on somebody that's aged 70, even if neither one of them ever had surgery before the skin elasticity, the health of the tissues can be significantly less.

(12:20):
It can be a harder operation at 70 than at 50. And even though the operation can go perfectly the same on both patients, and you follow them a year or two later, I mean, if you have poor skin elasticity, yeah, the longevity of your results is not going to be as good. So I typically tell people, yes, if you do a face lift in your earlier years, let's say fifties, early sixties, you're going to get a longer lasting result than if you chose to do it in your late sixties or early seventies. As we age, it's almost like an acceleration, right? You look at how somebody ages between the ages of 50 and 60 and look at 60 to 70, and there's definitely difference in that. They're both 10 years, 10 years went by, but the 10 years from 60 to 70, I think as you see, more significant age changes. So to that point, yeah, we typically tell people, hopefully in 10 years time, you're still looking better than if you hadn't done the procedure. But it's a really hard question to answer.

Kirstin (13:16):
Let's talk about scars.

Dr. Koehler (13:18):
Okay,

Kirstin (13:19):
Everybody wants to hear about scars when we're talking about surgery. So are the scars or the incisions located in different places for deep plane versus SMAS?

Dr. Koehler (13:30):
So the skin incisions can be done the exact same for both techniques. So typically they are pretty much the same. So it's going to be sort of in the sideburn into the crease of the ear, back around the ear, and then into the hairline. And there's definitely some variations, but the skin incision, you could have the same exact skin incision for both techniques. Okay. So the difference between these two techniques is what's done beneath the skin, not on the skin surface. So you can make the exact same skin incisions for both techniques, and you would never be able to, from the skin incision say, oh, this person had a deep plane face lift. You couldn't answer that question looking at the scars from a patient. And in fact, that's sometimes when you're going back and doing a revision face lift for someone, unless you have that actual operative note, you are really kind of, you don't know what was done before.

(14:19):
And that can sometimes be a challenge just because of the anatomy has been distorted and whatnot. But anyhow, yeah, so the skin incisions could be the same, but the placement of those incisions is critical to achieving an aesthetic scar. And there are factors that maybe would change the placement of an incision. So for instance, in a female patient, a lot of times we'll put that incision right in the tragus, so almost inside of the front part of ear. And if you did that for a man and if they have a thick beard, when you lift that skin and reposition it and trim it, now you've got beard hair growing on the tragus of your ear. And that's already a challenge as you get older and your hair starts growing in different places you don't really want it to. But now it's really hard, cuz you can't shave your tragus.

(15:13):
So now that might not be a problem if a male has a very fair beard or not much beard hair at all. You could possibly do laser hair removal or electrolysis depending on the color of the hair. But sometimes for a male patient, we'll put that incision in front of that part of the ear. And so that's a modification just based off of the gender of the patient. But also that incision may be modified by the anatomy of the way the ear is shaped, and some people who have a little bit deeper what we call the pre portrayal like sulcus. If it's a little deeper, then sometimes we'll put the incision in that deeper part because recreating that when we lift everything and reposition the skin is sometimes hard to do. So these are little finer points of face lift surgery. And I guess the point is that as long as your surgeon is recognizing when those variations are going to be needed to get the best possible outcome, again, it's not one incision fits every person.

Kirstin (16:13):
Well, is there any research happening right now? I know techniques evolve and approaches evolve. Is anybody looking at any other technique right now that you may be doing in 10 years?

Dr. Koehler (16:27):
I mean, I'm sure that there's always people pushing the boundaries when it comes to face lift techniques. I wouldn't say that there's necessarily research, and as I mentioned earlier, there's the science of face lift, which is knowing the anatomy and where the nerves are and how to avoid them and all that sort of thing. And then there's the artistic form. So I mean, I don't really know that, yes, there's been changes in face lift surgery over the past 20 years, but really there's been nothing, I don't think there's anything that's just earth shattering. I think it's really just surgeons refining their skills, and it's finding that doctor that has a good foundation in the science, but has the artistic view to give you the result you're looking for.

Kirstin (17:17):
I love that. Science and art. Okay. Do you have a burning question for Dr. Koehler or me? You can leave a

Dr. Koehler (17:26):
A voicemail?

Kirstin (17:28):
Yes, a voicemail on our podcast website. What is it Dr. Koehler?

Dr. Koehler (17:33):
Our podcast website?

Kirstin (17:35):
AlabamatheBeautifulPodcast.com.

Dr. Koehler (17:38):
Oh.

Kirstin (17:38):
We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (17:42):
Thanks, Kirstin.

Kirstin (17:43):
Go back to making Alabama beautiful.

Announcer (17:46):
Got a question for Dr. Koehler? Leave us a voicemail at AlabamatheBeautifulPodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.