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This article provides the facial plastic surgeon with anatomic and embryologic evidence supporting use of the deep-plane technique and understanding the evolution of the technique over decades to the vertical platysma advancement for optimal treatment of facial aging. The original description of the deep-plane rhytidectomy described a basic subsuperficial musculoaponeurotic system dissection in the midface. This plane of dissection provides access to deeper anatomic structures. A detailed description of the procedure is provided to allow safe and consistent performance. Insights into anatomic landmarks, technical nuances, and alternative approaches for facial variations are presented.

The relationship of the skin, the superficial and deep fat compartments, and the ligaments that connect these structures is key to performing any rhytidectomy. In order to successfully mobilize, elevate, and reposition the facial soft tissues, a detailed understanding of facial anatomy is required. This article details the anatomy of the midface and neck that is essential to understanding and performing the face-lift operation.

The use of energy-based devices as surgical tools during rhytidectomy was introduced in early 2007 to 2008 and occurred when the first fiber laser was approved for laser lipolysis. It became evident that the fiber laser-assisted rhytidectomy could offer several advantages compared with conventional rhytidectomy. The use of energy devices now includes temperature-controlled radiofrequency and helium plasma devices. Energy devices continue to offer advantages compared with knife and scissor approaches: improved hemostasis; an ability to dissect into areas without full flap elevation; and the shrink-wrap late effects of collagen remodeling after energy-based treatment, which improves the results of rhytidectomy.

As a facial plastic surgeon gains experience, further improvements can be gained with more aggressive surgery, but complications begin to occur when more aggressive measures are undertaken. Therefore, the ideal technique is one that maximizes rejuvenation while minimizing adverse effects. The senior author has found that the aggressive techniques in the region of the neck have improved dramatically the overall initial and long-term results for the neck portion of the rhytidectomy. More aggressive treatment of the midface during the modified deep plane rhytidectomy does not necessarily improve the overall long-term results, however, and can increase the complication rate.

The various rhytidectomy techniques share a common goal of safe repositioning of the facial soft tissues with a lasting effect. This article reviews rhytidectomy approaches and the current methods and practice patterns of the senior author. It includes a discussion of the extended sub-superficial musculoaponeurotic system rhytidectomy technique, which, in the opinion of the senior author, offers the best result with respect to neck rhytids, cervicomental angle and jawline definition, and improvement of jowling. With its ability to be readily coupled with a deep plane dissection, when indicated, this technique becomes indispensable in the facial plastic surgeon's armamentarium.

Traditional superficial musculoaponeurotic system (SMAS) facelifting surgery uses a laminar surgical dissection. This approach does not treat areas of facial volume loss, and requires additional volume supplementation with fat grafting or fillers. The novel volumizing extended deep-plane facelift uses a composite approach to the facelift flap. By incorporating a platysma myotomy in the extended deep-plane flap, a novel composite transposition flap can be created that revolumizes the posterior jawline, recreating a defined convex jawline of youth. Special attention is paid to the deep anatomy of the face, and the need for release of the facial ligaments.

Facial aging is a multifactorial process with many articles over decades supporting various theories of varying causes. It is generally thought that aging occurs as a combination of changes in skin quality, gravitational descent of tissue with interaction of retaining ligaments on the ptotic tissue, and facial volume loss or the appearance of volume loss. The most significant cause of volume loss is skeletal remodeling and bone loss, which manifests as characteristic shadows and hollows on the face in conjunction with soft tissue changes that are yet to be completely elucidated.

Complications of rhytidectomy are well known, yet often preventable. A thorough preoperative history and physical along with realistic patient expectations provide the surgeon and patient with insight into potential complications and postoperative management. Understanding of surgical pitfalls and avoidance are crucial in beginning to manage facelift complications. Possible complications of facelift techniques should not discourage surgeons from pursuing a particular technique as the majority of complications are temporary. Though, a strong patient-physician relationship is critical when complications occur. Complications may be frustrating for both the patient and surgeon, yet are overwhelmingly temporary and manageable without surgical intervention.

Absorbable suture suspension is one of the newest minimally invasive treatment trends for lifting and repositioning ptotic facial tissue. The Silhouette Instalift is a convenient in-office procedure that provides a unique and advanced clinical treatment for a natural looking midfacial lift. Research has shown that most patients characterized the Silhouette Instalift as immediately effective and were pleased by enhancements. The procedure has an improved safety and efficacy profile over the predecessor, barbed suture thread lifting, coupled with reduced risk of complications and recovery time compared with rhytidectomy. Absorbable suture suspension should be considered a workhorse in nonsurgical esthetic treatments.

Please verify edit, "complications could". All operations have sequelae. These are to be expected and must be told to patients. With surgery, the risk of complications is ever-present albeit infrequent. Facelift surgeons have ethical and intellectual duties to fully inform patients of these risks. Surgeons also must have strategies to reduce the risks, knowledge in how to manage each potential risk, and ability to help patients understand how complications could have occurred and how to cope with them. This article discusses facelift complications, the causes thereof, and how to assess a problem, manage each complication, and comfort a distraught patient.

Rhytidectomy techniques have evolved since the early 1900s. As the understanding of facial anatomy and the aging process expanded, the superficial musculoaponeurotic system (SMAS) became a focal point in developing longer-lasting, natural results. Further evolution led to various approaches in repositioning the SMAS layer, including subperiosteal, composite, and deep plane rhytidectomies. This article describes the nuances of SMAS rhytidectomy, the biplanar SMAS imbrication technique, and adjuvant procedures used. This biplanar SMAS technique has been refined over more than 25 years and has proved to be a reliable and safe technique that leads to high patient satisfaction with minimal complications.

Facial analysis techniques traditionally separate the upper, middle, and lower facial thirds as distinct entities without guidance in achieving aesthetic youthfulness. There is now an opportunity to develop better analytical tools and specific algorithms to help create an overall harmony to the face and restore a youthful appearance. Facial anatomic subunits have similar three-dimensional qualities based on underlying anatomic structures, craniofacial skeletal modeling, superficial and deep facial fat compartments, skin thickness, facial muscle activity, and curvature (flat, convex, concave). This article discusses using the relationships of the facial anatomic subunits to obtain more consistent and natural facial rejuvenation outcomes.

Management of the platysma is key to achieving an ideal neck contour during rhytidectomy. This article reviews platysmal anatomy, indications for platysmaplasty, preoperative patient assessment, surgical technique for midline platysmaplasty, postoperative management, long-term outcomes, and the senior author's experience and philosophy on midline platysmaplasty in the setting of lateral superficial muscular aponeurotic system facelifting.

Systematic reviews and meta-analyses hold a unique position in the pyramid of evidence. They can provide transparent and rigorous summaries to answer many clinical questions in facial plastic surgery. They can also identify areas of research deficiency, create new knowledge, and support guidelines or policies. A well-conducted systematic review follows a structured process to minimize bias and ensure reproducibility. When appropriate, a meta-analysis is incorporated to provide a statistical synthesis that combines the results of individual studies. This powerful quantitative method is becoming more prevalent in facial plastic surgery. This article provides a practical framework to understand and conduct this valuable type of research.

Aging of the face is inevitable and undeniable. This process includes a loss of skeletal support, soft tissue volume depletion, and a decrease in skin elasticity. The contribution of these 3 factors varies between individuals with noticeable hereditary influence. Characteristic ethnic features have been described in the literature, but as societies have changed, many of these ethnic variations have blended together. Facial cosmetic procedures must to be tailored to address these variations in anatomy, and consideration must be given to enhancing the facial skeleton, adequately lifting the soft tissues, and planning careful incisions to be closed under no tension.

Jowling, submental lipoptosis, and platysmal banding can affect self-image and reduce quality of life, leading one to seek facial and neck rejuvenation. With realistic expectations, a facelift can provide the desired improvement in appearance and sense of well-being. Before any intervention, a detailed history, focused examination, communication of expected outcomes with the assistance of preoperative digital imaging, and discussion of perioperative instructions are of utmost importance. Although many techniques exist, the modified deep plane extended superficial muscular aponeurotic system rhytidectomy with submentoplasty reliably delivers a significant improvement with lasting results.

Rhytidectomy remains a challenging surgical procedure for even the most experienced aesthetic plastic surgeons. The challenges are compounded by complications that are inherent to this procedure and place added pressure on the doctor-patient relationship. Expectations for both parties are high and the margin for error nil. This article presents a personal approach to the avoidance and management of complications associated with facelift surgery. It presents the author's personal approach as a plastic surgeon in the practice of aesthetic plastic surgery over the past 25 years. Clinical pearls are provided to obtain optimum results in rhytidectomy and limit associated sequelae.

Because modern facelift patients desire a less-invasive approach or minimally invasive approach to reduce visible scarring and decrease the recovery phase, achieving the surgeon's goal of optimal, reliable, and long-term aesthetic results with few complications becomes a challenge. The authors use the terms minimal access and traditional access to describe rhytidectomy approaches based solely on incision size. A short-incision, minimal-access approach with a deep-plane extended dissection is presented. A preoperative physical examination maneuver to evaluate a patient's candidacy for a minimal-access approach and guidelines for when to include platysmaplasty with the procedure to further improve cervicomental contour are described.

Photodocumentation in facial plastic surgery is essential in the perioperative setting, and with meticulous uniformity and standardization it serves as the primary tool for surgical planning and critical analysis of results. Accurate photodocumentation is dependent on strict and consistent use of equipment, lighting, and patient positioning. The purpose of this article is to review the principles of standardization in perioperative patient photography for common facial plastic procedures and to provide the facial plastic surgeon with the tools necessary to develop consistent and accurate patient photographs.

Aesthetic improvement of the neck and cervicomental angle remains one of the most challenging aspects of surgical facial rejuvenation. Individuals may become dissatisfied with the appearance of their neck because of changes in skin quality, submental fat, and muscle tone or anatomic position related to aging, weight gain, weight loss, sun damage, and other causes. To achieve the patient's desired result, surgeons use various techniques, either in isolation or in combination. Careful preoperative evaluation of the patient's anatomy dictates the most appropriate procedure, ranging from laser skin resurfacing to sub-superficial muscular aponeurotic system (sub-SMAS) rhytidectomy with an extended platysmaplasty. This article reviews the techniques that are available and the decision-making process in choosing the appropriate technique for the individual patient.

Rejuvenation of the mid- and lower face in the male patient can be challenging. Historically, most of these procedures were performed on female patients. However, an increasing number of men are seeking rejuvenative procedures and because of this trend, it is imperative that facial plastic surgeons become facile with the nuances of male mid- and lower facial rejuvenation. Failing to understand the important differences between male and female patients can lead to pitfalls during the perioperative period. The conscientious surgeon should be mindful of these differences, beginning with the male cosmetic consultation and proceeding through to the postoperative period. The goal of this article is to review the principles of male mid- and lower facial rejuvenation.

No nonsurgical technique can come close to rejuvenating the face like a cervicofacial rhytidectomy. However, one of the most difficult areas to improve during a facelift is the midface. The multi-vector high superficial musculoaponeurotic system (SMAS) facelift and extended lower-lid midface lift are important techniques that can adequately address the midface during rhytidectomy. The multi-vector high SMAS facelift is a natural extension of a traditional SMAS plication or imbrication facelift. The extended lower-lid midface lift can be an important adjunct during a facelift or as an independent procedure to address the midface.

Early facial rejuvenation focused largely on the upper and lower thirds of the face. More recently, improvements in understanding of midfacial aging and anatomy have paralleled the development of endoscopic and minimally invasive surgical techniques. The midface is now understood to include both the lower lid subunit and the cheek down to the nasolabial fold. Many surgical techniques for midface rejuvenation have been used, including skin tightening with direct excision, skin-muscle flaps, isolated fat pad transposition, and subperiosteal lifting. The methods of endoscopic subperiosteal midface lifting and endoscopic malar fat pad lifting are discussed.

Aging of the midface is a complex aesthetic problem requiring an individualized and multifaceted surgical approach. The objective of harmonious rejuvenation of the entire face as well as increasing patient interest in midface rejuvenation mandates surgical familiarity with these techniques. Midface rejuvenation procedures have evolved from traditional laterally based rhytidectomy techniques with superolateral elevation to modern centrofacial approaches designed to achieve more vertical vectors of elevation. These approaches are informed by an evolving understanding of the multiple processes that contribute to the aged appearance of the midface and are based on lower blepharoplasty surgical techniques.

Rhytidectomy techniques have advanced greatly since their inception a century ago. Today, a rich array of procedures is available, ranging from limited and minimally invasive approaches to extensive dissections. The evolution of rhytidectomy is outlined herein, along with a review of the relative indications and advantages of commonly practiced procedures.

Complications after rhytidectomy can be distressing for the patient and surgeon. Although meticulous surgical technique and a complete understanding of the causes of adverse outcomes can minimize the risk for severe complications, an open and honest rapport with the patient when complications do occur is essential for effective management. This article discusses the likely etiologies of face-lift complications, techniques to prevent them, and helpful treatments when complications occur.

Careful analysis of a rhytidectomy patient is an important aspect of facial plastic surgery. Surgeons and physicians are successful when they diagnose patients correctly and apply the correct treatment plan. The skilled facial plastic surgeon appropriately evaluates the patient physically and emotionally then performs the correct surgical maneuvers to achieve the desired results. The focus of this article is the senior author's 20 years of experience in analyzing faces, and the goal of this article is to assist surgeons in achieving postoperative patients who are happy and "natural looking."

This article provides the facial plastic surgeon with anatomic and embryologic evidence to support the use of the deep-plane rhytidectomy for optimal treatment of the aging neck. An anatomic basis is established that demonstrates this technique's ability to maximize neck rejuvenation through its direct relationship to midface soft-tissue mobilization. A detailed description of the procedure, aimed at providing safe and consistent results, is presented with insights into anatomic landmarks, technical nuances, and alternative approaches to facial variations.

This article reviews evaluation and techniques for neck rejuvenation. It includes a detailed overview of cervical rhytidectomy and discusses the potential complications associated with surgical correction. A review of clinical outcomes in the literature is also included.

The authors' vertical neck lifting procedure is an extended deep plane facelift, which elevates the skin and SMAS-platysma complex as a composite unit. The goal is to redrape cervicomental laxity vertically onto the face rather than laterally and postauricularly. The authors consider this an extended technique because it lengthens the deep plane flap from the angle of the mandible into the neck to release the cervical retaining ligaments that limit platysmal redraping. This technique does not routinely use midline platysmal surgery because it counteracts the extent of vertical redraping. A majority of aging face patients are good candidates for this procedure in isolation, but indications for combining vertical neck lifting with submental surgery are elucidated.

Since its approval for use in 2007, many surgeons have been using the laser for subcutaneous use, primarily for lipolysis, facial neck and body contouring, and skin tightening. Techniques have recently evolved to enable use of the subcutaneous laser with concurrent skin resurfacing techniques for improvement of photoaging and acne or facial scarring. The technique shows great promise in patients with facial aging and photodamage who are not deemed candidates for rhytidectomy surgery. With strict patient-selection criteria of mild to moderate facial laxity and mild to moderate photoaging, the procedure can be gratifying for the surgeon and patient alike.

The greatest fear of using lasers subcutaneously in the face is that facial motor nerve injury will occur. With SmartLifting procedures, this is not a complication that occurs provided the laser and surgical guidelines are followed. We have seen several short-term, marginal mandibular neuropraxias in several patients, all of which resolved within weeks. There have been no permanent nerve injuries in any patient undergoing SmartLifting procedures. There is temporary interruption of cutaneous sensory nerves during the rhytidectomy, and the resolution of the temporary sensory deficits is identical to the resolution of non-laser-elevated rhytidectomies.

Surgical approaches for rhytidectomy continue to evolve. For the past 26 years, the senior author has used a graded approach in combination with the modified deep-plane facelift, consistently achieving natural-appearing results and satisfied patients. This article outlines the analysis of the patient, preoperative preparation of the patient, an algorithm for adjunctive procedures to achieve a youthful yet balanced face, the associated surgical technique, and also possible complications.

The surgical management of the patient with the heavy face and neck requires an appreciation of the multiple anatomic and physiologic factors responsible for the associated displeasing appearance. Preoperative planning and patient selection are key components in achieving optimal outcomes. Furthermore, while approaches and techniques applied in traditional facelifts are beneficial, additional or modified maneuvers are often necessary to produce the desired outcomes in this challenging patient group.

Cosmetic rejuvenation of the lower face can be accomplished effectively with facelift surgery; however, aesthetic outcomes are significantly improved when surgical traction combined with midface volume restoration is achieved and perpetuated. Incorporating the current understanding of the evolving process of facial maturation, this article puts forth an approach to full-face rejuvenation involving the continued treatment of the facelift patients with injectable filler materials for years after the surgical procedures. Beyond a three-dimensional approach, this "four-dimensional" method can achieve persistent, effective, natural-appearing outcomes that can be maintained successfully and dynamically over time.

Optimizing outcomes for rhytidectomy patients involves careful evaluation for conditions likely to benefit from adjunctive facial contouring and/or skin resurfacing procedures. On an individual basis, concurrent procedures should be performed only if benefits far outweigh any added risk and patient safety is not compromised. In this manner, physicians may improve practice productivity and overall patient satisfaction.

Despite the variety of novel facial rejuvenation technologies available today, the reference standard for correction of the senescent jaw line and neck remains rhytidectomy. This article describes the purse-string facelift, a vertical facelift that moves away from traditional techniques that use a horizontal vector of subcutaneous muscle-aponeurotic system repositioning. The vertical facelift can counterbalance the effects of gravity and natural facial aging and can reposition the facial soft tissues into a more youthful position more directly and correctly. Rather than multiple, separate sutures to support the suspended tissues, the purse-string technique offers two distinct advantages: operative expediency and a tenacious suture anchor based on the periosteum of the posterolateral zygomatic arch.

The extreme interest in developing new surgical approaches to rhytidectomy and to refining those techniques over the last two decades has resulted in considerable improvement in surgical results. This has taken the form of a more natural and youthful restoration of the face by together lifting forehead, midface, and lower face. This approach produces a more harmonious balance of the upper and lower portions of the face than was possible before the introduction of mid-facelifting techniques. Added to this has been the emphasis by some surgeons of restoring tissue volume to the face by using autogenous fat injections. One can conclude that the most favorable results in facelifting occur when the lower cheek is rejuvenated by dissecting beneath the superficial musculoaponeurotic system to create an advancement flap together with the lifting of the cheek fat of the midface posterosuperior.

Facial feminization surgery (FFS) is the general term for a group of specific procedures that are used in an attempt to alter the perceived gender of an individual's face. These procedures include many commonly offered by facial plastic surgeons, such as rhytidectomy, brow lift, cheek implantation, and lip augmentation. Several procedures performed less often by most facial plastic surgeons also are involved, including scalp advancement, frontal cranioplasty, and reduction mandibuloplasty. Often, a challenge greater than the technical is the interpersonal interactions with patients. This article describes unique situations related to FFS.