Origin
- Hamra 1990: a Skoog-type sub-SMAS dissection extended over the zygomaticus muscles and past the nasolabial fold, creating a musculocutaneous flap of skin, cheek fat and platysma; 403 patients (PMID 2359803).
- Hamra 1992, composite rhytidectomy: adds the orbicularis oculi to the flap so platysma, cheek fat and orbicularis move with the skin; 167 patients (PMID 1615067).
- Zygorbicular dissection as the midface plane in composite rhytidectomy (PMID 9774027).
- Kamer 1996: 100 consecutive deep-plane lifts, no hematoma beneath the cheek flap, 97% of patients pleased at 6 months (PMID 8554742).
- Kamer and Frankel 1998: tuck rate 11.4% after SMAS lifts against 3.3% after deep-plane lifts in 634 patients (PMID 9727459).
- Hamra 2002, 20 patients from the 1990 series: SMAS repositioning lasted longer than nasolabial fold improvement; malar fat gains at 1-2 years were lost long term (PMID 12172164).
Extended deep plane (Jacono)
- MADE vertical facelift (minimal access deep plane extended), 153 patients: zygomatico-cutaneous ligament release plus lateral platysmal myotomy; revision 3.9%, hematoma 1.9%, temporary nerve injury 1.3% (PMID 22065880).
- Composite rotational flap for the jawline, 89 patients: gonial area volume +3.5 cc; mandibular defining line 7.1 cm to 9.8 cm at 19 months (PMID 30418482).
- Platysma hammock flap, 123 patients: platysmal banding, skin laxity and gland visibility scores fell at 18-21 months; satisfaction 88.9%-96.2% (PMID 35446382).
- Meta-analysis of 183 studies: temporary nerve injury highest with high lateral SMAS (1.85%) and composite (1.52%); major hematoma deep plane 1.22% (OR 1.67 vs plication); permanent injury did not differ by technique (PMID 30768122).
Current practice (2021-2026)
- AAFPRS survey, 150 surgeons: 90% perform deep-plane facelifts; surgeons under 20 years in practice more likely to (P = .04); longevity not associated with deep plane (P = .3); higher nerve injury associated with deep plane and frequent gland reduction (PMID 41251721).
- Limited delamination extended deep plane, 6 surgeons, 3,964 patients: hematoma 1.9%, seroma 2%, revision 0.8% (PMID 39072376).
- Vector analysis, 71 patients: mean SMAS lift vector 70.8 degrees; women more vertical than men (71.3 vs 65.4) (PMID 38657095).
- Mastoid crevasse fixation: +8.1 mm gonial depth (PMID 37767973).
- Complete platysma suspension with vertical midline platysmaplasty (PMID 39212629).
- Asian patients, 61 deep-plane lifts: 98% satisfied; no hematoma; neurapraxia 1.6% (PMID 40183553).
- Deep-plane anatomy and nomenclature (PMID 38354840).
- Facial nerve considerations: temporary palsy risk appears to rise as dissection extends (PMID 38198817).
Anatomy behind the plane
- 50 cadaver heads: nerve branches are embedded within the deep fascia; dissection must stay in its most superficial level (PMID 37036327).
- 50 cadaver heads: no-release lifts drag retaining fibers and rely on fixation; full release with redraping preserves deep fascial architecture (PMID 37747400).
- Midface deep fascia forms the floor of the deep plane (PMID 36261112).
Deep plane against SMAS: comparative evidence
- Split-face randomized study, 21 patients, 1996: extended SMAS and composite sides looked better on the table; no detectable difference at 6 and 12 months (PMID 8942899).
- Identical twins, four techniques including composite, 10-year photographs (PMID 19319071).
- Meta-analysis 2025, 21 studies, 2,896 patients: satisfaction deep plane 94.4%, SMAS 87.8%; complications 17.2% and 10.3% (PMID 40801931).
- Systematic review 2026 (Stuzin, Rohrich), 17 articles: medially based deep-plane techniques have not been shown to improve midface appearance or longevity (PMID 41100833).
- AI age estimation, 100 deep-plane and 100 SMAS patients: no difference in estimated age reduction (PMID 42775335).
- ABPS tracer data 2006-2021, 3,400 facelifts: SMAS plication 40%, flaps 35%, SMASectomy 22%, MACS 6%; subperiosteal 1%; skin-only 8% (PMID 38302713).
Glossary
- Deep plane: sub-SMAS plane whose floor is the deep fascia (PMID 36261112).
- Composite flap: skin, fat, SMAS/platysma and orbicularis lifted as one unit (PMID 1615067).
- Extended deep plane: deep-plane release carried into the neck and jawline with platysma management (PMID 30418482).
- Zygomatico-cutaneous ligament: cheek ligament released in the deep plane (PMID 22065880).
- Tuck: small secondary tightening after a facelift (PMID 9727459).
- Mastoid crevasse: mastoid fixation site for platysma suspension in deep-plane neck lifting (PMID 37767973).
- Limited delamination: deep-plane variant with less separation of skin from the SMAS flap (PMID 39072376).
Papers
| PMID | First author | Year | Journal | Title | Finding |
|---|---|---|---|---|---|
| 2359803 | Hamra ST | 1990 | Plast Reconstr Surg | The deep-plane rhytidectomy. | Hamra: deep-plane rhytidectomy, 403 patients (landmark) |
| 1615067 | Hamra ST | 1992 | Plast Reconstr Surg | Composite rhytidectomy. | Hamra: composite rhytidectomy, 167 patients (landmark) |
| 9774027 | Hamra ST | 1998 | Plast Reconstr Surg | The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. | Zygorbicular dissection for the midface (landmark) |
| 8554742 | Kamer FM | 1996 | Arch Otolaryngol Head Neck Surg | One hundred consecutive deep plane face-lifts. | Kamer: 100 deep-plane lifts, 97% pleased (landmark) |
| 9727459 | Kamer FM | 1998 | Plast Reconstr Surg | SMAS rhytidectomy versus deep plane rhytidectomy: an objective comparison. | Tuck rate 11.4% SMAS vs 3.3% deep plane (landmark) |
| 12172164 | Hamra ST | 2002 | Plast Reconstr Surg | A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure. | Malar fat repositioning: long-term failure (landmark) |
| 22065880 | Jacono AA | 2011 | Aesthet Surg J | The minimal access deep plane extended vertical facelift. | MADE vertical facelift, 153 patients (landmark) |
| 30418482 | Jacono AA | 2019 | Aesthet Surg J | A Novel Extended Deep Plane Facelift Technique for Jawline Rejuvenation and Volumization. | Extended deep plane jawline: +3.5 cc gonial volume |
| 35446382 | Jacono AA | 2022 | Aesthet Surg J | The Effect of a Novel Platysma Hammock Flap During Extended Deep Plane Facelift on the Signs of Aging in the Neck. | Platysma hammock flap, 123 patients |
| 30768122 | Jacono AA | 2019 | Aesthet Surg J | A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques. | Meta-analysis 183 studies: complications by SMAS technique |
| 41251721 | Pak KY | 2026 | J Craniofac Surg | Evaluating Facelift Outcomes and Technique Trends in the United States. | AAFPRS survey: 90% perform deep plane |
| 39072376 | Roskies M | 2024 | Facial Plast Surg Aesthet Med | Limited Delamination Modifications to the Extended Deep Plane Rhytidectomy: An Anatomical Basis for Improved Outcomes. | Limited delamination, 3,964 patients |
| 38657095 | Talei B | 2024 | Aesthet Surg J | Vectorial Analysis of Deep Plane Face and Neck Lift. | Vector of lift, 71 patients |
| 37767973 | Talei B | 2024 | Aesthet Surg J | The Mastoid Crevasse and 3-Dimensional Considerations in Deep Plane Neck Lifting. | Mastoid crevasse fixation |
| 39212629 | Timberlake AT | 2025 | Plast Reconstr Surg | Complete Platysma Muscle Suspension in Deep-Plane Face-Lift Surgery. | Complete platysma suspension |
| 40183553 | Wong CH | 2025 | Plast Reconstr Surg | Deep Plane Face Lift in Asian Patients. | Deep plane in 61 Asian patients |
| 38354840 | Talei B | 2024 | Facial Plast Surg | The Detailed Anatomy of the Deep Plane of the Face and Neck with Current Nomenclature. | Deep plane anatomy and nomenclature |
| 38198817 | Azizzadeh B | 2024 | Facial Plast Surg | Facial Nerve Considerations for the Deep Plane Facelift and Neck Lift. | Facial nerve considerations in deep plane lifts |
| 37036327 | Minelli L | 2024 | Plast Reconstr Surg | The Deep Fascia of the Head and Neck Revisited: Relationship with the Facial Nerve and Implications for Rhytidectomy. | Nerve branches lie within the deep fascia |
| 37747400 | Minelli L | 2024 | Plast Reconstr Surg | Anatomy of the Facial Glideplanes, Deep Plane Spaces, and Ligaments: Implications for Surgical and Nonsurgical Lifting Procedures. | Glideplanes and release vs no-release lifting |
| 36261112 | Andretto Amodeo C | 2022 | Facial Plast Surg | The Deep Fascia of the Infraorbital Region, Deep Plane, and Suprafibromuscular Facelift: New Anatomy for Safer Facelifting. | Midface deep fascia is the deep-plane floor |
| 8942899 | Ivy EJ | 1996 | Plast Reconstr Surg | Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. | Split-face RCT: no difference at 12 months (landmark) |
| 19319071 | Alpert BS | 2009 | Plast Reconstr Surg | Identical twin face lifts with differing techniques: a 10-year follow-up. | Identical twins, four techniques, 10 years (landmark) |
| 40801931 | Khoury S | 2025 | Aesthetic Plast Surg | The Deep Plane versus SMAS Facelift: A Systematic Review and Meta-Analysis. | Meta-analysis deep plane vs SMAS |
| 41100833 | Schultz KP | 2026 | Plast Reconstr Surg | Demystifying Deep Layer Face-Lift Techniques: A Systematic Review of Superficial Musculoaponeurotic System Techniques. | Systematic review: deep plane not shown superior |
| 42775335 | Tan SJ | 2026 | Plast Reconstr Surg Glob Open | Comparing Deep Plane and Superficial Musculoaponeurotic System Facelifts Using Artificial Intelligence-Based Age Estimation. | AI age estimation: no difference by technique |
| 38302713 | Stein MJ | 2024 | Aesthetic Plast Surg | Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery. | ABPS 3,400 facelifts: technique shares 2006-2021 |
Open questions / controversies
- Longevity: no controlled study shows deep plane outlasts SMAS techniques (PMID 41100833, PMID 41251721).
- Nerve risk: temporary injury higher with composite and high lateral SMAS in pooled data (PMID 30768122); association with deep plane in survey data (PMID 41251721).
- Complication totals: 17.2% deep plane against 10.3% SMAS in a single-arm meta-analysis with heterogeneous definitions (PMID 40801931).
- Evidence base: outcomes are mostly single-surgeon series and surgeon-rated photographs (PMID 39072376).