Deep Plane Facelift in São Paulo, Brazil

I recommend the Deep Plane Facelift for:

• people generally between 45 and 75 years old, with significant laxity of the face and neck;

• anyone who notices they have lost jawline definition and that the neck shows bands or excess skin;

• anyone who has already tried minimally invasive procedures without the expected result;

• anyone seeking a natural, long-lasting result, not a change of identity;

• patients in good general health, with a complete cardiac evaluation within normal limits.

I do not recommend — or I postpone — when:

• the patient smokes and cannot stop 4 weeks before and 4 weeks after surgery: nicotine compromises flap circulation, and the risk of skin necrosis becomes unacceptable;

• there is uncontrolled heart disease or a coagulation disorder;

• the expectation is a result without surgery, or looking like someone else;

• there is significant emotional instability at the time of the decision — the right surgery at the wrong time is the wrong surgery;

• the real issue is volume or skin quality, not tissue position: in that case the facelift is not the answer, and I say so at the consultation.

Age by itself is not a contraindication. What matters is clinical status. I have operated on patients from 72 to 78 years old with excellent outcomes, with cardiac and anesthesia evaluations within the expected range.

When I assess a patient at the first consultation, I follow an order that doesn't change. First, skin quality: thickness, photoaging, elasticity. Then, the position of the deep tissues: where the malar area sits, how much of the nasolabial fold is due to descent versus volume, and the state of the jawline contour. Next, the neck: whether there is excess skin, platysma bands, fat above or below the muscle, and the state of the cervicomental angle. Finally, the eyelids and forehead, because the facelift does not treat the upper third, and the patient needs to know that before deciding.

What makes me change my plan: a patient who comes in asking for a facelift, but whose main complaint is in the eyelids, will hear that blepharoplasty addresses more than a lift would. A patient with a very compromised neck and a reasonably good face may need a complete neck lift more than an extensive facelift. And a patient with very thin, photoaged skin needs to know that a lift repositions tissue but does not replace the skin.

It's always important to remember that the Deep Plane Facelift is not indicated empirically for every patient. I evaluate each case individually to determine whether Deep Plane is indicated or whether other options are better suited to that anatomy, such as a mini lift, SMAS plication, SMASectomy, or High SMAS facelift. Deep Plane is not a superior technique in every respect; in selected cases, however, deep release can achieve a mobilization of tissue that more superficial techniques do not offer in the same way. During this evaluation, I check:

• the degree of laxity and displacement of the facial structures

• degree of bone resorption

• tissue mobility

• jaw mobility

• amount of excess skin

• skin quality

The surgery is performed under general anesthesia at Hospital Albert Einstein and is a 4- to 6-hour procedure when I combine it with a neck lift. In elective planning, I aim to keep the initial plan within a safe operating time. When associated procedures would bring the plan to or beyond that safe window, I prefer to split it into two surgical stages — a safety practice I adopted long before it became a regulatory requirement in São Paulo.

The incisions are placed in naturally camouflaged areas: in front of the ear, following the contour of the tragus, behind the ear, and within the scalp. From there, I enter below the SMAS and release the retaining ligaments — zygomatic, masseteric, and mandibular. This is the step that sets the Deep Plane apart from any other technique: once the ligaments are released, the block of deep tissue rises back toward where it originally sat, and the skin is simply redraped, without tension.

In the neck, I address the platysma — the muscle that forms the bands — and excess cervical skin, refining the angle between the chin and the neck. When there is deep fat, it is addressed in the same procedure. At the end, closure is done without tension, with fine sutures; some are absorbable, and I remove the rest in the office between 7 and 10 days.

In most cases, I do not use a drain, because I perform a hemostatic net: a transdermal suture that approximates and temporarily fixes the undermined skin to the deep planes, reduces the potential space beneath the flap, and can limit the expansion of small bleeds. Recent literature describes low hematoma rates in series using this strategy, but the hemostatic net does not replace careful surgical hemostasis or the immediate evaluation of an expanding hematoma. The technique requires careful execution to reduce the risk of skin marks, ischemia, or necrosis. In selected situations, in addition to the hemostatic net, I may place drains.

A facelift is surgery, and surgery carries risks. I prefer that the patient know what they are, and what I do when they happen, rather than hear that they are “minimal.”

• Hematoma — an accumulation of blood beneath the flap in the first hours. It is the most frequent complication of facelift surgery (even though it is rare) and the most urgent: it grows quickly, creates asymmetry on one side, and hurts. That's why the patient stays overnight in the hospital with the team on watch, and why I control blood pressure and medications that affect clotting before surgery. If it occurs, it is drained — the same day, at the hospital.

• Bruising (ecchymosis) — the purplish discoloration of the skin, which is not a complication: it is an expected sign that turns yellow and resolves on its own within two to three weeks. Unlike in the past, when patients left facelift surgery with extensive bruising, current surgical tactics during the procedure allow us to keep bruising to a minimum.

• Facial nerve injury — when it occurs, most of the changes described are temporary and can recover within weeks to months; permanent injury is rare. Work in the deep plane requires detailed knowledge of the anatomy of the facial nerve branches and careful technical execution.

• Altered sensation in the skin of the face and ear — common and transient, in most cases.

• Skin necrosis — rare, but the risk increases significantly with smoking and nicotine exposure, as well as with vascular factors, tension, and compromised flap perfusion. It is one of the reasons I require smoking cessation during the perioperative period.

• Widened scar or hair loss along the scalp incision — avoided with tension-free closure; when revision is needed, it is not done before 12 to 18 months.

• Infection — rare, with prophylactic antibiotics and a hospital setting.