Deep-Plane Approach to the Vertical Platysma Advancement: Technical Modifications and Nuances over 25 Years

Abstract

In this article, we will provide the reader with the anatomical and embryologic evidence supporting the use of the deep-plane approach in rhytidectomy and insight into the evolution of the technique into the vertical platysma advancement. The original description of the deep-plane technique only described a basic superficial muscular aponeurotic system dissection in the midface with the ability to use tension on the flap without aesthetic consequences. This plane of dissection provides additional advantages not previously described, including access to deeper anatomical structures such as the buccal fat pad, and allows in vivo assessment and treatment of jowling. We describe how extension of this dissection and selective release of facial ligaments allows us to optimize treatment outcomes and longevity, especially in cases of difficult anatomy or revisions. Further advancements include case-specific facial volume enhancement, created by complex flap design, and facial narrowing by preauricular contouring and parotid hypertrophy treatment. Insights into anatomical landmarks, technical nuances, and alternative approaches for facial variations are presented.

Fat Augmentation as Adjunct to CORE Facelift Surgery

“…20 CORE facelift techniques have evolved into the golden standard in facelift surgery, as they promise to reposition the sagged tissues, the superficial medial cheek fat pad, and the deep medial cheek fat pad (DMCF) perhaps most importantly, into a more youthful position, in addition to improving the jawline. [38][39][40] This standard is advocated both "bottom-up" as well as "topdown. "…”

“…From a top-down perspective, some of our leading surgeons have pragmatically and convincingly demonstrated superior results with CORE facelift techniques. 22,38,39 Some debate remains however, as to how (in which plane) to safely and most effectively release and mobilize the midface fat pads, that partially lie anterior to the zygomatic major muscle. 42 The discursive dialogue between "pragmatists" and "foundationalists" so to say, is one of the oldest in medicine, and is unlikely to be resolved, certainly not by this article.…”

Guiding the Facial Rejuvenation Journey: Fulfilling the Complete Role of Surgeon and Aesthetic Practitioner

“…Emphasis on full release of the zygomatico-cutaneous ligament has been a key feature in maximizing improvement in the midface by vertical advancement of the ptotic malar tissue. Recent refinements by Jacono 14 advocating greater midface elevation and mandibular ligament release and by Gordon and Sawan 16 advocating concurrent modification of the buccal fat pad may provide even greater contouring and improvement. One of the keys to understanding the power of these techniques is their ability to allow effective repositioning of descended malar, buccal, and jowl fat pads, in many cases restoring adequate volume to contours lost to both aging-associated volume loss and volume descent.…”

“…Proponents of these approaches argue that in addition to better correction at the midface and jowl, these techniques provide longer-lasting correction and a more natural appearing result. [14][15][16] Combining the potential advantages of each of these techniques, Beaty described a systematic approach to individualizing the deep tissue technique based upon the progressive evaluation intraoperatively of each particular patients anatomy and needs, then utilizing the combination of techniques best suited for that individual. 17…”