Choosing the technique — Which layer is mobilised and in which direction it is repositioned
The spectrum of techniques ordered by the layer they mobilise, plication versus imbrication, the abandonment of the biplanar technique, the orientation of the vector and its adaptation to glandular ptosis.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Techniques differ by two decisions rather than by their name: which layer is mobilised and whether the retaining ligaments are released.
- The vertical vector displaced the horizontal one for a demonstrable reason: the horizontal vector displaces the oral commissure posteriorly and produces a recognisable deformity.
- Orientation is not measured with a protractor: it is obtained by following the direction of the zygomaticus major, the anatomical reference for the vector.
- Ptosis of the submandibular gland modifies the design: it changes where the platysma is opened, how far the subplatysmal dissection extends and how many points of tension are applied.
- Comparative evidence places the deep plane at higher satisfaction and a higher complication rate than SMAS techniques, so the choice is one of indication rather than of school.
The spectrum of techniques
With the indication established — the analysis behind it is in Facial ageing and assessment — the technique remains to be chosen. The nomenclature of rhytidectomy techniques has proliferated to the point of hindering comparison, yet the criterion that orders them is simple and reduces to two variables: which layer is mobilised and whether the retaining ligaments are released. On these depends the reach of the correction, since a procedure that does not release the ligaments cannot displace the tissue medial to them, and it is precisely that tissue which forms the sulci. The table below orders the three principal options by that criterion, with their indication and their limit.
Techniques ordered by the layer they mobilise
| Technique | Manoeuvre | Indication and limit |
|---|---|---|
| Short scar facelift | Preauricular incision with minimal S-shaped retroauricular extension. The SMAS is not elevated and the ligaments are not released: only plication or imbrication of the SMAS | Patients under 50 without significant medial displacement. It corrects neither the nasolabial sulcus nor the prejowl. Tension falls on the skin, with greater risk of necrosis and recurrence at around 5 years |
| Lower-third and neck lift | S-shaped incision without temporal extension combined with a submental incision. Deep plane limited to the lower third and neck | Patients with predominant cervical laxity and little midfacial involvement. Repositioning of the jowl is limited |
| Deep plane | A composite flap of skin, subcutaneous tissue, SMAS and platysma is elevated, and the retaining ligaments are released before traction | It is the technique that corrects the sulci, acting on the mobile SMAS and not only on the fixed portion, following the organisation described in The layers of the face. It maintains the result in the short and long term. Its development is in Deep-plane facelift, step by step |
Plication and imbrication
Both terms designate fixation of the SMAS and are often used interchangeably, although they correspond to distinct manoeuvres and to distinct techniques. Plication consists of suturing the SMAS onto itself without opening or dissecting it: a fold that creates no flap. Imbrication consists of suturing a previously dissected SMAS flap, which requires crescentic excision of the supraparotid preauricular portion to avoid excess bulk. From this follow their respective indications and their behaviour over time, summarised in the table.
| Plication | Imbrication | |
|---|---|---|
| Manoeuvre | Suture the SMAS onto itself, without opening or dissecting it | Suture the already dissected SMAS flap in the deep plane |
| Excision | No excision required | Crescentic excision of the supraparotid preauricular portion |
| Associated technique | Short scar facelift | Deep plane |
| Durability of the result | Short term | Short and long term |
The abandonment of the biplanar technique
For years skin and SMAS were dissected separately and resuspended along independent vectors. The justification was a reasonable hypothesis: that skin ages horizontally while the SMAS-platysma complex ages vertically, so each layer should be treated in its own direction. The results did not confirm the hypothesis. The biplanar technique produced a set of recognisable deformities that led to the present composite technique: elevation of a single flap of skin, subcutaneous tissue, SMAS and platysma and resuspension of the whole along a common vector.
The four deformities characteristic of the biplanar technique
- Lateral sweep deformity, from cutaneous traction without repositioning of the deep plane.
- Posterior displacement of the oral commissure, or joker line, a direct consequence of horizontal cutaneous tension.
- Early cervical recurrence, from insufficient adjustment of the cutaneous component in the neck.
- Absence of volumetric repositioning, because the displacement affected the skin and not the block that determines contour.
The orientation of the vector
The direction in which the flap is resuspended determines the result more than the magnitude of traction applied. The horizontal vector, directed towards the earlobe, was the standard for decades and produces two undesirable effects: it displaces the oral commissure posteriorly and tightens without repositioning. The vertical vector, oriented superiorly, acts on the structures that determine contour: it restores malar projection and definition of the mandibular border. Jacono and colleagues documented by three-dimensional analysis that vertical traction of the midfacial SMAS restores volume in that region in a sustained manner, which provides the objective basis for the preference.
Comparison of the two vectors
| Horizontal vector | Vertical vector | |
|---|---|---|
| Direction | Towards the earlobe | Superiorly, following the orientation of the zygomaticus major |
| Effect on the commissure | Posterior displacement, with the resulting labial deformity | Superior displacement |
| Effect on contour | Limited: it tightens without repositioning volume | Restores malar projection and definition of the mandibular border |
| Behaviour over time | Recurrence of the submental contour from insufficient tension, at times within the first year | Maintains submental tension and definition of the cervicomental angle |
How the orientation is obtained intraoperatively
- Suspension is performed between 60 and 70 degrees to the horizontal through the tragus.
- That angle requires no measurement: it is obtained by following the direction of the zygomaticus major, whose orientation coincides with the optimal vector described.
- Usual distribution: SMAS at 60 degrees, platysma at 80 and skin passive, which in a composite facelift settles at around 50-60 degrees.
- The first suspension stitch is placed at the gonial angle, joining the SMAS-platysma complex to the mastoid fascia or, failing that, to the supraparotid SMAS.
The vector adapts to the submandibular gland
Ptosis of the submandibular gland changes the aim of the vector, and with it three decisions of the design. The reason is mechanical. Without glandular ptosis the problem is one of contour: it is enough to define the mandibular border, and for that the tension is best applied as close to that border as possible. With glandular ptosis the problem is one of containment: the gland descends below the mandibular border and must be supported, so the platysma has to behave as a hammock. And a hammock needs two things that simple tightening does not: a longer, more mobile flap and a second anchoring point that closes its lower end.
The design in each scenario
| Without glandular ptosis | With glandular ptosis | |
|---|---|---|
| Aim of the vector | To define the mandibular border | To define the border and contain the gland above it |
| Where the platysma is opened | More anteriorly, close to the territory to be tightened | At the posterior insertion of the platysma, over the sternocleidomastoid: the more posterior the incision, the longer the available flap |
| Subplatysmal dissection | Some 2 cm: enough to mobilise the border | Up to 4 cm, reaching the facial vessels: it frees the flap across its whole width so that it can be tensioned over the gland |
| Points of maximal tension | One, over the mandibular ligament | Two: the mandibular ligament and the cervical angle. The first defines the border; the second closes below and prevents the gland from escaping |
When suspension is not enough
Platysmal suspension contains the gland but does not reduce it. Where glandular volume is what overhangs the contour, two documented and opposing positions exist: some authors advise against resection for the risk of creating submandibular concavities, and others perform partial resection of the superficial lobe systematically. The available evidence favours partial resection over suspension alone when the gland is responsible for the contour, since suspension tends to yield. The decision is taken before operating, by palpation at examination, because it conditions the whole design described. The technical development is in Platysmaplasty and cervical contour.
Comparative evidence between deep plane and SMAS
A recent systematic review with meta-analysis compared the deep plane with SMAS techniques across 21 studies and nearly 2,900 patients. The result is not univocal: the deep plane achieved higher patient satisfaction, around 94 % versus 88 %, and also a higher overall complication rate, around 17 % versus 10 %. The correct reading is not that one technique surpasses the other but that the increment in result is accompanied by an increment in risk. The consequence is that the choice is one of indication: in a young patient with moderate laxity, a SMAS technique offers a favourable ratio; in a patient with established sulci and medial displacement, correction requires the deep plane and with it its complication profile.
With the layer, the vector and the cervical design decided, execution remains. The complete deep-plane sequence — marking, incisions, undermining, ligamentous release and repositioning — is developed in Deep-plane facelift, step by step.
References
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- 4.Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90(1):1-13.
- 5.Jacono AA, Parikh SS. The minimal access deep plane extended vertical facelift. Aesthet Surg J. 2011;31(8):874-890.
- 6.Jacono AA, Malone MH, Talei B. Three-dimensional analysis of long-term midface volume change after vertical vector deep-plane rhytidectomy. Aesthet Surg J. 2015;35(5):491-503.
- 7.Jacono AA, Bryant LM, Alemi AS. Optimal facelift vector and its relation to zygomaticus major orientation. Aesthet Surg J. 2020;40(4):351-356.
- 8.Mendelson BC, Tutino R. Submandibular gland reduction in aesthetic surgery of the neck. Plast Reconstr Surg. 2015;136(3):463-471.
- 9.Khoury S, Almubarak Z, Khan H, Boldt G. The deep plane versus SMAS facelift: a systematic review and meta-analysis. Aesthetic Plast Surg. 2025;49(21):5895-5903.
Related specialty: Facial Lifting & Rejuvenation