The Facelift Has Gotten a Little Work Done

The deep plane facelift (particularly the latest iteration, called the extended deep plane) is said to most dramatically hoist fallen cheeks. During the procedure, surgeons cut into, raise, and go under the SMAS (fibrous tissue covering the facial muscles) into the so-called deep plane layer, where they untether various ligaments to fully free up and resuspend the face. (All modern facelifts manipulate the SMAS along with the platysma muscle, which rises from the collarbone, spans the neck, and marries with the SMAS along the jaw. While deep plane facelifts reposition the SMAS from below, SMAS procedures address this layer from above.) Another hallmark of the deep plane lift: The soft tissue layers of the face (the skin, fat, and SMAS) are uprooted and moved as a cohesive unit rather than being divided through the fat and treated separately as is customary with SMAS facelifts.

We’ve seen the deep plane method catch fire in recent years with certain Insta-famous surgeons supplying the fuel.With so much hype clouding the term, obscuring its finer points like smoke does a skyline, it’s become difficult to distinguish medicine from marketing. When surgeons brand their facelifts with clever names like AuraLyft, Vertical Restore, and Ponytail Lift, they can unintentionally thicken the haze, adding to patients’ confusion. (For the record, each of these unique procedures is a version of the deep plane facelift.) Cultish demand for the deep plane has even led some surgeons to apply the label to lifts that don’t fit the bill. “On social media, everyone talks about doing a deep plane facelift, but I know exactly what they do, and over half of them don’t do anything related to that,” Dr. Rohrich tells me.

Despite what your favorite TikTok surgeon might say, the jury remains deadlocked on whether deep plane facelifts truly offer better results than SMAS operations. It’s a major point of debate in the plastic surgery world and few peer-reviewed studies have formally attempted to compare outcomes with any sort of rigor. (There’s this one from 2009 evaluating different techniques on two sets of identical twins, and this oft-cited review from 2004, declaring that deep plane lifts do not offer “superior results” in patients under 70.) “To my knowledge (and I know the literature pretty well), nobody has shown one facelift to be superior,” says Dr. Rohrich, who served as editor in chief of the medical journal Plastic and Reconstructive Surgery from 2005 to 2022. In his opinion, “good surgeons using good techniques get good results, no matter what technique they use.” (Dr. Rohrich performs a type of SMAS lift that he’s coined the lift-and-fill facelift.)

It can be downright dangerous for a surgeon to attempt a deep plane procedure if they’re not truly proficient. Because the delicate nerves that move the face reside in the deep plane (under the SMAS), some surgeons consider this approach riskier than traditional SMAS lifts. “I can’t tell you how many patients I’ve seen who’ve had a quote-unquote deep plane facelift and have had issues,” Dr. Rohrich says. “Redoing some of those has really been a challenge.”

Anyone can claim to perform a deep plane facelift, of course, but how do you really know what they’re doing when you’re out cold on the table? “If someone asked me [that question], I could say, ‘I present on it [at medical conferences] 14 to 15 weeks out of the year, and every day that I operate, I have three surgeons looking over my shoulder, observing me,” says Dr. Nayak. (That’s a lot of witnesses.) Other surgeons say the same. Bona fide facelift specialists are teaching on the regular and working to advance the surgery.

Deep plane enthusiasts have been proselytizing about the “preservation facelift” since last fall when Dr. Nayak introduced the concept at an aesthetics meeting in Istanbul. This modification to the extended deep plane technique is not one singular advancement, Dr. Nayak explains, but a compilation of ideas conceived by five surgeons with a common mission: to minimize trauma to the skin during surgery and improve the recovery period for patients.

Per deep-plane doctrine, you want to limit the amount of skin you lift off the underlying muscle since it’s this peeling away that causes “most of the stress to the tissues” and “most of the surgical recovery” involved with a facelift, Dr. Nayak says. That said, getting from point A to point B safely requires deep plane surgeons to travel “immediately under the skin in several different areas,” notes Dr. Nayak. “We can’t start in the deep plane, because we’d violate important nerve territory and you wouldn’t be able to pick up your eyebrows anymore.” So, in front of the ears, surgeons stay shallow until they reach a safe SMAS entry point.

The preservation facelift aims to further shrink requisite skin flaps (what doctors call the skin that’s lifted). By keeping more of the skin connected to the deeper tissues, Dr. Nayak says, surgeons can stave off many of the issues associated with larger skin flaps, including bleeding and assorted post-op problems like bruising, swelling, and delayed healing.

Doing so means changing the “portal of entry” into the deep plane layer to a spot that’s closer to the incisions in front of the ears, says Ben Talei, MD, a double board-certified facial plastic surgeon in Beverly Hills, who pioneered this aspect of the preservation facelift. Similarly, when tightening below the jaw and in the neck, surgeons should leave a greater portion of skin attached rather than freeing it up completely, as they’re classically taught to do. (Dr. Nayak credits this part of the procedure to Italian plastic surgeons, Mario Pelle Ceravolo, MD, and Alessandro Gualdi, MD, PhD, as well as Toronto-based double board-certified facial plastic surgeon Michael Roskies, MD.)

In expert hands, says Dr. Nayak, “preservation surgery is safer and faster with better results and fewer unpredictable [post-op] complications.” When less skin is stripped from muscle, more capillaries are spared, which enhances blood flow to speed recovery. Dr. Talei has seen less tissue damage, spider veins, and skin darkening after preservation surgery. And since there’s much less area for fluid to accumulate, the risk of seromas goes down (these pockets of fluid can interfere with healing). Dr. Nayak used to routinely place drains during facelifts to siphon away fluids during the first few days of recovery, but since adopting the preservation method, he’s been able to retire them in most cases. “It’s been a revelation,” he says.

The first scientific study on the preservation facelift is currently pending publication.

Remember those branded facelifts I mentioned? The “ponytail lift” may be the most ubiquitous (and bastardized) of the bunch. Alluding to the elevating effect of the high, tight hairstyle, the term (along with “ponytail facelift”) has long been trademarked by Chia Chi Kao, MD, a board-certified plastic surgeon in Santa Monica, but is frequently usurped by other providers to sell miscellaneous treatments, including thread lifts. FYI, “My ponytail lift is not a thread lift,” asserts Dr. Kao.

Rather, it’s a deep plane facelift, performed endoscopically (using tiny, lighted cameras and minimal incisions), according to a series of protocols, which allow him to treat “from the top of the forehead to the bottom of the neck,” he says, while avoiding the classic tells of a facelift— scars traversing the ears as well as obviously distorted earlobes, sideburns, and hairlines.

“Plastic surgery is a form of deception,” says Marc Mani, MD, a board-certified plastic surgeon in Beverly Hills. “If you have something that’s noticeable, you don’t look better or younger, you look like a liar.” The most glaring giveaway of a facelift might be the lengthy scar in front of the ears, which Dr. Mani finds to be a “big deterrent” for patients—actors, in particular—considering a facelift. “I can get it to be invisible,” he says, but most people prefer to avoid it altogether. For some, it’s scarless or bust: Roughly 40% of Dr. Mani’s endoscopic facelift patients and 90% of Dr. Kao’s come from out of state or overseas. (Doctors Mani and Kao are widely considered to be the country’s leading endoscopic deep plane facelift surgeons.)

To be clear, the endoscopic facelift is not new. For decades, plastic surgeons have performed various kinds of facelifts through small scalp incisions under the guidance of lighted cameras. And for almost as long, these “scarless” techniques have been dismissed as sort of gimmicky and ineffective for all but a small niche of patients with the most modest sagging. People with pronounced laxity tend to require skin removal, which can only be done by cutting around the ears. In other words, those dreaded incisions don’t just give surgeons a way into the face, they give excess skin a way out.

According to Dr. Talei, who does not perform endoscopic facelifts but is renowned for his deep plane expertise, older endoscopic techniques that tunneled down to bone caused tons of swelling and produced results that lasted, on most people, about a year and a half. But the more novel and “technically challenging” endoscopic deep plane facelifts can be “a really good option for select patients who don’t need a big lift,” he says. “They’re not just marketing.”

As this procedure’s approval rating grows so too does evidence supporting its efficacy. In 2023, Dr. Kao and Dr. Mani published separate peer-reviewed articles detailing their respective endoscopic approaches. Dr. Kao is hopeful that his paper, analyzing 600 consecutive ponytail cases over 22 years, will sway “naysayers who say it doesn’t work or is only for young people.”

Dr. Kao offers four distinct “ponytail” operations, each designed to tackle an increasing degree of laxity. While his youngest (and tautest) patients leave the OR with just four tiny slits hidden in their hair, those in their mid-40s, 50s, and 60s may have additional incisions behind (or, rarely, in front of) the ears to take out redundant skin from the face and neck.

With the least invasive of his procedures, Dr. Kao can tighten “all the way down to the angle of the jaw through incisions in the temple area,” a maneuver that “came to me maybe six years ago,” he says. For a long time, he couldn’t see how to do it safely without injuring a major facial nerve. Eventually, inspiration struck as it so often does: “I figured it out in the shower.”

Dr. Mani’s endoscopic technique mimics his conventional deep plane approach, save for the incisions, which he conceals in the hair of the temples and behind the ears (sparing the scar in front of the ears). Unlike Dr. Kao, who performs ponytail procedures exclusively, Dr. Mani operates endoscopically in 60% to 70% of patients. He’ll otherwise perform a regular deep plane facelift with traditional incisions.

Both doctors say the longevity of their endoscopic lifts rivals that of standard deep plane procedures and that complication rates and recovery periods are virtually identical. When speaking of safety, Dr. Mani tells me that the endoscope actually gives him an edge by making “the nerves look like giant snakes,” so he can avoid them more easily.

However, navigating an endoscope—a skill not every surgeon possesses—can prolong an already lengthy procedure. Dr. Kao’s most complex facelifts can take 10 to 12 hours, twice the time of a standard deep plane facelift. Some view this as a potential drawback, particularly for older patients who ultimately wind up needing incisions in front of the ears anyway, the very thing they’re aiming to avoid with an endoscopic lift. If there’s a possibility that those incisions will be necessary to remove excess skin, says Dr. Nayak, the patient may be better off with a regular deep plane lift that “gets them off the table three hours earlier.”

Lately, every time I open Instagram, I land on a lecture about submandibular glands and the importance of contouring them to take a neck lift to the next level. (I follow plastic surgeons the way normal people do celebrities.) Inevitably, digastric muscles and subplatysmal fat enter the chat. (Again, my echo chamber, er feed, may look a little different than yours.)

I’ll save you the Google search: Submandibular glands make saliva and are tucked beneath the jawbone on the sides of the neck. The digastrics are small muscles in the jaw. And subplatysmal fat is nestled deep in the central neck. Since all of these structures can make a neck look full or bulky, even after the platysma has been tightened, many surgeons like to whittle them down in what’s known as a deep structural neck lift.

While some folks are born with outsize glands and generous fat deposits under the platysma, others notice these features enlarge and droop with age, changing the contour of the neck. “When we take out the fat and trim the salivary glands, then we’re left with a new relative bulging of the digastric muscles,” explains Dino Elyassnia, MD, a board-certified plastic surgeon in San Francisco. “So we shave off a little piece of those muscles as well to get the neck to look really smooth.”

To create the sleekest neckline in most patients, it’s not enough to tighten the skin and platysma and suction away fat from under the skin, Dr. Elyassnia maintains. “To truly and permanently change the shape of the neck,” he says, tailoring the deep tissues is crucial. He does so in almost every neck lift he performs. (Deep neck sculpting is not only for patients who think their neck looks thick nor is it just about slimming the neck; rather, it’s a way to optimize results for the best possible neck contour, which patients have come to expect.) For years, though, only a subset of surgeons ventured into the deep neck. “In my 15 years of practice, I went from being one of the few who was doing it to now it seems like everybody wants to do it,” says Dr. Elyassnia.

Dr. Nayak says he “sculpts the deep neck foundation in probably 95% of neck lifts.” He, for one, isn’t surprised by the booming interest in the procedure. “Things that work predictably and reproducibly gain in popularity,” he says.

The cons? Deep neck work can increase recovery time, says Dr. Elyassnia, explaining that “a regular neck lift looks pretty good by two weeks [after surgery] and feels soft by three months. A deep neck lift also looks good at two weeks, but takes six to nine months to soften completely.”

Salivary leaks, which Dr. Elyassnia likens to seromas, can also happen. While manageable, they can be “a nuisance for patients,” he says, requiring extra follow-ups. Some surgeons have raised concerns about dry mouth resulting from submandibular gland reduction, but Drs. Elyassnia and Nayak insist that when done properly, the procedure shouldn’t interfere with healthy salivary flow. The submandibular glands are one of three main pairs of salivary glands supported by thousands more minor salivary glands and only the “overgrown” portion is removed. More serious risks, like nerve injury and bleeding, are directly linked to technical skill and anatomical expertise, so make sure your surgeon is a master of deep neck surgery.

Photographer: Hannah Khymych
Sittings Editors: Tchesmeni Leonard, Kat Thomas, Tascha Berkowitz
Hair: Tina Outen
Makeup: Alex Levy
Set Design: Jenny Correa
Manicure: Yukie Miyakawa
Model: Rhenny Alade