Every deep plane facelift I perform tells a slightly different story. The anatomy varies, the degree of aging differs, and the tissues respond in ways that no textbook can fully predict. What follows is a step-by-step walk-through of a deep plane facelift as I perform it in the operating room — the decisions I make, the landmarks I follow, and the observations that guide me from incision to closure. I have written this account so that patients considering this procedure — and colleagues interested in technique — can understand what actually happens during the several hours that define this surgery.

— Dr. Umut Zereyak

Patient positioning and anaesthesia

Before the patient enters the operating room, the most important work has already been done. I perform all pre-operative marking with the patient sitting upright and awake, usually in a quiet room adjacent to the theatre. This is essential because gravity reveals the true position of the jowl, the depth of the nasolabial fold, the descent of the malar fat pad, and the laxity of the platysma bands in the neck. Once the patient is supine under general anaesthesia, gravity pulls the tissues posteriorly and these landmarks disappear. If I relied on markings made with the patient lying down, the entire procedure would be built on false information.

I mark the planned incision line, the anterior extent of the skin flap, the position of the zygomatic arch, the course of the frontal branch of the facial nerve, and the areas where I expect to encounter the retaining ligaments. I also mark the midline of the neck and the anterior borders of the platysma bands if they are visible.

The patient is then brought into the operating room and positioned supine on the table. The head is placed on a padded horseshoe headrest and elevated approximately fifteen to twenty degrees — enough to reduce venous pressure in the face without compromising the surgical field. General anaesthesia is induced, and the anaesthesia team maintains a mean arterial pressure that minimises bleeding while ensuring adequate cerebral perfusion. I inject a dilute tumescent solution of lidocaine with adrenaline along the planned incision line and beneath the skin flap. This provides vasoconstriction and a hydraulic plane that assists with the initial dissection. I allow ten to fifteen minutes for the adrenaline to take full effect before I begin.

The face and neck are prepped with an antiseptic solution and draped to expose both sides fully. I always operate on both sides in the same session — it is the only way to ensure perfect symmetry in ligament release and flap repositioning. The hair is not shaved; it is secured with small elastic bands to keep it out of the operative field. I stand at the head of the table throughout the procedure, moving from side to side as needed.

The incision: where and why

The incision design in a deep plane facelift is critical because the scar is the one visible trace the surgery leaves behind. I use a modified incision that begins in the temporal hairline, follows the natural curve of the temporal tuft, and then descends along the junction of the ear and the facial skin — the preauricular crease. In women I favour a retrotragal approach, hiding the incision behind the small cartilage flap of the tragus so that it becomes virtually invisible once healed. In men, where the tragal skin is thicker and hair-bearing, I place the incision just in front of the tragus to avoid distorting the sideburn.

The incision continues around the earlobe — I am very careful here to maintain the natural contour of the lobule, because a pixie-ear deformity from excessive tension is one of the telltale signs of poorly executed facelift surgery. Behind the ear, the incision follows the post-auricular sulcus and then curves gently into the occipital hairline. The total incision length is approximately twenty to twenty-five centimetres per side, but once healed it is remarkably well concealed.

Why this specific course? The preauricular placement allows me to redrape the skin in a primarily posterior and superior vector — the natural direction of youthful tissue position. The temporal extension gives me access to the lateral brow and temporal region. The post-auricular component allows neck skin to be redraped without bunching. Every centimetre of this incision serves a specific purpose, and I modify it slightly for each patient depending on their hairline position, skin quality, and the degree of correction required.

Skin flap elevation: the first plane

I begin the dissection by elevating the skin flap off the underlying SMAS. Using a combination of sharp scissor dissection and a lighted retractor for visibility, I raise the skin in a plane just deep to the subdermal fat. This is a thin, relatively avascular plane when you are in the correct layer — the tissue separates with a characteristic gentle resistance and a clean appearance.

The skin flap extends anteriorly to a point approximately four to five centimetres in front of the ear. I do not raise the skin flap all the way to the nasolabial fold — this is a fundamental difference from traditional facelift technique. In a deep plane approach, the skin and the deeper tissues will be moved together as a composite flap once I enter the sub-SMAS plane. Excessive skin undermining is unnecessary and, in fact, harmful: it devascularises the skin, increases the risk of haematoma, and prolongs recovery.

At this stage I can see the surface of the SMAS clearly. It appears as a glistening, fibrous sheet overlying the deeper facial structures. The SMAS varies considerably between patients — in some it is thick and robust, in others it is thin and almost translucent. I note its thickness because it influences how I will handle the transition into the deep plane. Small perforating vessels cross from the SMAS into the skin flap, and I cauterise these meticulously with bipolar diathermy. Haemostasis at every stage is non-negotiable. Even a small amount of bleeding obscures the surgical field and increases the risk of post-operative haematoma — the most common complication of facelift surgery.

Entering the deep plane: the critical transition

This is the moment that defines the procedure — the step that separates a deep plane facelift from every other type of facelift surgery. At the lateral border of the skin flap elevation, I identify the edge of the SMAS and make an incision through it, entering the plane beneath. The entry point is typically at the level of the angle of the mandible, just anterior to the parotid gland.

What I feel when I enter the sub-SMAS plane is distinctive. The tissue suddenly gives way to a loose, areolar layer — almost like passing through a curtain into an empty room. This is the plane that Hamra described in his original 1990 publication, and it remains one of the most elegant anatomical spaces in facial surgery. The sub-SMAS plane is relatively avascular because the blood supply to the face runs within and superficial to the SMAS, not beneath it. This means that once I am in the correct plane, bleeding drops dramatically and visibility improves.

From this point forward, the skin and the SMAS move together as a single composite unit. This is the fundamental advantage of the deep plane approach: instead of pulling on the skin in one direction and the SMAS in another, the entire soft tissue envelope is repositioned as one layer, exactly as it descended during aging. The result is a natural restoration of facial volume and contour rather than a tightened or windswept appearance.

The facial nerve is the structure I am most conscious of during this phase. The frontal branch crosses the zygomatic arch superficially, running within or just deep to the temporo-parietal fascia. I stay deep to the SMAS and superficial to the parotid-masseteric fascia, which keeps me in a safe zone above the nerve branches. The marginal mandibular branch, which controls the depressor muscles of the lower lip, runs along the inferior border of the mandible and is protected by staying in the correct tissue plane. I have a detailed three-dimensional understanding of the course of each branch, and I verify my position by identifying known anatomical landmarks at every stage. The facial nerve is not merely a structure to avoid — it is a structure I deliberately navigate around, and this navigation is built into the design of every dissection step.

Releasing the retaining ligaments

With the composite flap elevated in the sub-SMAS plane, I encounter the retaining ligaments — the dense fibrous structures that anchor the soft tissues of the face to the underlying bone. These are the reason that aging produces the specific pattern of descent we see: the nasolabial fold deepens, the jowl forms along the mandible, and the mid-face flattens. Each ligament must be released individually and completely for the composite flap to move freely.

I begin with the zygomatic ligament, which is the most significant ligament for mid-face rejuvenation. This structure originates from the body of the zygoma and passes through the malar fat pad to insert into the overlying skin. It is located at the anterior border of the masseter muscle at the level of the zygomatic arch — the area known in the surgical literature as McGregor's patch. When I reach this ligament during dissection, there is an unmistakable change in tissue resistance. The composite flap, which has been advancing relatively freely, suddenly stops. I can feel the tethering through my instruments and through my fingertip placed on the skin surface. I divide the zygomatic ligament under direct vision using sharp dissection, staying immediately superficial to the periosteum of the zygoma. The moment the ligament is fully released, the entire cheek complex drops forward into my hand — this is one of the most satisfying moments in the procedure because it confirms that the malar fat pad is now free to be repositioned.

Next, I release the masseteric ligament, which runs from the anterior border of the masseter muscle to the overlying SMAS and skin. This ligament is broader and less defined than the zygomatic ligament — it presents as a series of fibrous condensations rather than a single discrete band. I release it along the entire length of the anterior masseter border, which frees the lower cheek and the tissue overlying the buccal fat pad. Releasing this ligament is what allows correction of the jowl and the pre-jowl sulcus.

The mandibular ligament is the third major structure I address. It originates from the periosteum of the mandible at the anterior portion of the jowl region and tethers the soft tissue directly to the bone at this point. This is the ligament responsible for the sharp demarcation between the jowl and the chin — the reason the jowl hangs as a distinct bulge rather than a gradual slope. I release it carefully, staying on the bone surface and protecting the marginal mandibular branch of the facial nerve, which runs in close proximity. Once the mandibular ligament is divided, the jowl tissue becomes completely mobile and can be repositioned posteriorly and superiorly with the composite flap.

With all three major ligaments released, the composite flap is now fully mobilised. I can move the entire cheek and jowl complex in any direction — superior, posterior, or a combination — and the tissue follows without resistance. This is the freedom of movement that defines a true deep plane dissection. In a standard SMAS facelift, where the ligaments remain intact, the surgeon is pulling the SMAS against its own anchors. The result is tension at the suture line and limited repositioning. In the deep plane approach, with the ligaments released, there is no such limitation.

The malar fat pad: repositioning the mid-face

With the zygomatic ligament released and the composite flap fully mobile, I turn my attention to the malar fat pad — the key structure for mid-face rejuvenation. Intraoperatively, the malar fat pad is a well-defined, lobulated mass of yellow fat that sits directly over the cheekbone. In a youthful face, this fat pad sits high on the malar eminence, producing the full, convex cheek contour that defines an attractive mid-face. With aging, the zygomatic ligament elongates and the malar fat pad descends medially and inferiorly, sliding off the cheekbone and accumulating above the nasolabial fold. This descent is responsible for the deepening of the nasolabial fold and the flattening of the cheek that are hallmarks of facial aging.

What I observe intraoperatively is that the malar fat pad, once freed from the zygomatic ligament, can be lifted back to its original anatomical position with remarkably little force. I elevate the composite flap in a superomedial vector, watching the malar fat pad glide back over the cheekbone. As it moves, the nasolabial fold softens visibly — I can see the crease becoming shallower in real time. This is the mid-face correction that is impossible in a standard SMAS facelift, where the zygomatic ligament remains intact and the malar fat pad cannot be repositioned.

In some patients, I also perform subperiosteal release along the inferior orbital rim and the maxilla to address the lid-cheek junction — the area where the lower eyelid meets the cheek. This allows the orbicularis oculi muscle and the overlying tissue to be elevated, smoothing the transition between the lower eyelid and the cheek. In patients undergoing simultaneous lower blepharoplasty, this step is performed through the lower eyelid incision and integrated into the mid-face elevation. The result is a seamless, continuous improvement from the lower eyelid through the cheek to the nasolabial fold — a three-dimensional correction that treats the mid-face as a single aesthetic unit.

If the patient has significant volume loss in the mid-face — which is common in patients with thinner faces or those in their sixties and beyond — I may also perform targeted fat grafting to the malar region. The fat is harvested from the abdomen or inner thigh, processed through centrifugation, and injected in small aliquots using a blunt cannula. The combination of structural repositioning through the deep plane approach and volume restoration through fat grafting produces a result that neither technique alone can achieve.

Platysmaplasty: addressing the neck

The neck is addressed as an integral component of the deep plane facelift. The platysma muscle is a thin, broad sheet of muscle that extends from the chest and clavicle up to the lower face, where its fibres interdigitate with the SMAS. With aging, the medial borders of the platysma separate, creating the vertical platysma bands that are visible in the anterior neck. The muscle also descends, contributing to the loss of the cervicomental angle — the clean, defined junction between the chin and the neck that characterises a youthful profile.

I approach the platysma through the same deep plane dissection. From the post-auricular portion of the incision, I elevate a flap in the sub-platysmal plane along the neck, releasing the platysma from its deep attachments. I can see the platysma bands clearly at this point — they appear as two parallel ridges of muscle running vertically down the anterior neck, separated by a gap that widens with age. The tissue between and behind the bands often contains excess subplatysmal fat, which I remove conservatively using direct excision or liposuction, depending on the amount and the patient's skin quality.

For the platysmaplasty itself, I make a small incision beneath the chin — typically two to three centimetres in length, hidden in the submental crease. Through this incision, I identify the medial borders of both platysma muscles and bring them together in the midline using a running permanent suture. This midline plication recreates the sling-like support that the platysma provided in youth. I perform the plication from the level of the hyoid bone superiorly to the mentum, ensuring that the entire visible portion of the neck is addressed.

What I observe immediately after completing the platysmaplasty is a dramatic improvement in the cervicomental angle. The neck transforms from a broad, obtuse profile to a clean, defined contour. The platysma bands disappear, and the jawline becomes crisp and continuous from angle to angle. This step complements the lateral work of the deep plane dissection — the deep plane repositions the jowl and lower face, while the platysmaplasty restores the anterior neck. Together, they produce a complete lower face and neck rejuvenation.

Redraping and closure

With the composite flap fully mobilised and the platysmaplasty complete, I begin the process of redraping and closure — the final sculpting of the result. I return to each side and reposition the composite flap in the planned vector. The direction of repositioning is primarily posterior and superior — matching the direction of the original youthful tissue position. I secure the deep layer first, placing several permanent sutures from the SMAS component of the composite flap to the deep temporal fascia superiorly and to the periosteum of the mastoid process posteriorly. These sutures bear the structural load of the repair. They hold the SMAS and the repositioned fat compartments in their new position permanently.

With the deep layer secured, the skin falls into its new position under no tension whatsoever. This is the hallmark of a well-executed deep plane facelift: the skin closure is tension-free. I trim the excess skin — which can be surprisingly generous, sometimes three to four centimetres — and close the incision in layers. The deep dermis is closed with absorbable sutures, and the skin edges are approximated with a running subcuticular suture or, in some areas, fine interrupted nylon sutures.

The no-tension principle is critical. In older facelift techniques — particularly SMAS plication and SMAS-ectomy — the skin bore significant tension because the SMAS was not adequately mobilised. This led to widened scars, pixie-ear deformities, hairline distortion, and an operated appearance. In the deep plane approach, all tension is on the deep sutures anchoring the SMAS to bone and fascia. The skin simply drapes over the new contour like fabric over a mannequin.

A light compressive dressing is applied, wrapping gently around the head and under the chin. This dressing provides mild compression without restricting blood flow and is worn for the first forty-eight hours. All sutures used are dissolvable — partial removal is performed at day five.

What I observe at the end of surgery

Before I apply the final dressing, I spend several minutes examining the result. Even with the mild oedema that is already beginning at this point, the transformation is visible and, for me, the most rewarding moment of the entire procedure.

What I look for first is the continuity of the jawline. In a successful deep plane facelift, the jawline should be crisp and unbroken from the chin to the angle of the mandible on both sides. The jowl is gone — not pulled tight, but genuinely absent because the tissue has been repositioned to its original anatomical location above the mandibular ligament. If I can run my finger along the jawline and feel a smooth, continuous contour without any step-off or bulge, I know the mandibular ligament release was complete.

Next, I examine the nasolabial fold. It should be softened — not eliminated, because a completely absent nasolabial fold looks unnatural — but visibly improved compared to the pre-operative state. The malar fat pad should be sitting high on the cheekbone, producing a gentle convexity in the mid-face. If the cheek contour looks full and natural rather than flat or pulled, the zygomatic ligament release and malar repositioning were successful.

I look at the neck in profile. The cervicomental angle should be acute and clean, with no residual platysma banding and no excess skin or fat beneath the chin. The transition from the neck to the jawline should be smooth and defined.

Finally, I assess symmetry. Perfect symmetry is impossible in any face — all patients have pre-existing asymmetry — but the degree of improvement should be closely matched on both sides. I compare the position of the malar fat pad, the depth of the nasolabial fold, the contour of the jawline, and the cervicomental angle on each side. If I see a discrepancy, I address it before applying the dressing.

The one observation that gives me the most confidence about the long-term result is the absence of tension on the skin. When I can see that the skin is sitting naturally on the new contour, without any pulling or distortion, I know that the result will age gracefully. The deep structures are holding the position. The skin is simply following. This is what produces a facelift result that looks natural at one year, at five years, and beyond — because the repair is structural, not superficial.

Every patient is different, and every deep plane facelift presents its own set of challenges and decisions. But the principles remain constant: complete ligament release, composite flap mobilisation, tension-free skin closure, and meticulous attention to the three-dimensional contour of the face. These are the principles that guide every procedure I perform.

References

Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86(1):53-61.
Jacono AA, Parikh SS. The minimal access deep plane extended vertical facelift. Aesthet Surg J. 2011;31(8):874-890.
Rohrich RJ, Ghavami A, Constantine FC, et al. Lift-and-fill face lift: integrating the fat compartments. Plast Reconstr Surg. 2014;133(6):756e-767e.
Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):441-449.

Inside a Deep Plane Facelift: Step-by-Step Intraoperative Notes