A facelift is not a fixed technique that a surgeon learns once and then repeats unchanged for years. Every facelift evolves with new anatomical insight, with the experience I accumulate myself and with what I see colleagues do in the operating room. In this article, I explain why my Deep Plane Facelift is a different procedure today than it was five years ago, and why that is exactly the point.
I have just returned from Los Angeles, where I once again spent several days with colleagues who focus almost exclusively on aesthetic facial surgery. Yet this story does not begin there, and it does not begin this year. Over the past five years, I have made a habit of visiting other facial plastic surgeons and observing their work up close. That has taken me to New York, Beverly Hills, Los Angeles, London and Rome. Not to find one new technique to replicate in my own operating room, but to understand how others arrive at their choices. The more procedures I see and the more I operate, the clearer it becomes that a facelift is never a single standardized technique, but one that keeps evolving.
The anatomy of the face does not change. The facial nerve (nervus facialis), which controls the muscles of facial expression, takes exactly the same course today as it did twenty years ago. The same is true of the retaining facial ligaments, the SMAS and the platysma. The SMAS (superficial musculoaponeurotic system) is the layer of connective tissue and muscle beneath the skin of the face, and the platysma is the broad, thin muscle of the neck. Anatomy therefore remains the compass.
Our knowledge of it does keep growing more refined. Above all, the surgical approach to that anatomy is constantly changing. New anatomical studies appear, and existing techniques are adjusted. Sometimes a concept presented as new turns out to build on something that was already described twenty or thirty years ago. Aesthetic surgery simply has a fondness for the word “new,” but novelty is not automatically an improvement.
SMAS plication (folding and suturing the SMAS) and SMASectomy (removing a strip of that layer) illustrate this well. I no longer consider them, on their own, a complete solution for facial aging. When the deeper layers age, the correction has to happen at that level as well. Within a modern Deep Plane Facelift, however, those same older techniques can be valuable additional tools for correcting another anatomical layer. It is not about old versus new, but about understanding which principle makes sense where. Progress means keeping what works, letting go of what performs less well and sometimes rediscovering an old principle within a modern approach.
Certain aspects of surgery are hard to learn from a book, a video or a scientific article. Standing next to a colleague in the operating room, you not only see what happens but also understand why. That is why I visit other surgeons regularly. In recent years, I have spent time with Neil Gordon, Andrew Jacono, Ben Talei, Mike Nayak, Dominic Bray, Keon Parsa and Marc Levin, among others. I was also a guest of Michele Pascali in Rome and Greg Bran in London. They are surgeons with different backgrounds, and each looks at the same anatomical problem in their own way.
One surgeon treats the neck differently from another. Some place more emphasis on releasing the retaining facial ligaments, while others have a very personal way of handling the SMAS. The dissection (the surgical separation of the tissue layers) is more extensive in some hands and more limited in others. The vector (the direction in which tissue is moved) differs too. Each surgeon has a different approach to the platysma and the deep neck as well. Sometimes I see something and immediately think it could be an improvement. Sometimes I only understand much later why someone performs a particular step. And sometimes I see something and know at once that I do not want to do it myself. That, too, is learning.
Los Angeles, and Beverly Hills in particular, is a unique place for this. Nowhere else in the world do so many facial surgeons work so close together. That means a great deal of experience and a high surgical volume, but also rivalry: techniques are constantly compared and quickly refined. The differences rarely lie in spectacular new procedures, but in nuances of a few millimeters or in the order of the steps. One detail does not change a surgical approach. Hundreds of details, gathered over many years and in dozens of operating rooms, do. That is why I keep traveling to observe: not to bring a Hollywood facelift home, but to add a few new pieces to my own approach each time.
If someone asks me exactly which facelift technique I perform, I find it hard to answer in a single word. My facelift is not a procedure I learned from one surgeon, but a surgical mosaic. Certain ideas come from operations I saw in New York, others from Beverly Hills or Los Angeles, still others from London or Rome. Added to that are my training in head and neck surgery and in craniomaxillofacial surgery (the skull, jaws and face), my anatomical background and the scientific literature. And above all: everything my patients and their results have taught me over the years.
This is where the term Deep Plane becomes interesting. Many surgeons use it, which creates the impression that the results are comparable. In practice they are anything but, because Deep Plane is not a surgical protocol. The term describes only the deep plane in which the surgeon works, beneath the SMAS. How far does the dissection extend, and which vector is used? What happens to the layers outside the dissection area, from the SMAS to the deep neck? A single procedure involves hundreds of such decisions, and it is precisely those that make the difference.
To me, a sufficiently extensive release (the freeing of the deeper retaining facial ligaments) is the foundation of modern facelift surgery. Aging tissues do not sag simply because the skin slackens. They also remain tethered by those ligaments, and that anchoring prevents them from being moved freely. Unless the surgeon releases that anchoring sufficiently, the face cannot be repositioned anatomically.
That, however, is not where the procedure ends. Layers beyond the deep plane age as well, with laxity, volume loss or localized excess tissue as a result. This is where additional techniques come in: a SMAS plication or SMASectomy, imbrication (suturing tissue in an overlapping fashion) or selective suspension (lifting and anchoring specific deeper layers). Some surgeons use them sparingly, others far more extensively. Gradually, my facelift has become a combination of principles that I have found anatomically logical, reproducible and effective.
“The same name, but not the same operation.”
Without a doubt. My facelift today is not the same procedure as the one I performed five years ago. Yet there has never been a single moment when I stepped off a plane and decided to do everything differently from Monday onward. That is rarely how surgical evolution works.
One step in the dissection becomes slightly more extensive, another more limited. A ligament is released more consistently. I look at the transition between face and neck differently, working more broadly in one area and more conservatively in another. And sometimes, after years, I come back to a principle that has long existed, but that I now understand far better than I did the first time. Each of these changes seems small. Taken together over five years, they amount to a noticeably different procedure, and that is precisely the intention.
My yardstick is simple: I hope that my latest facelift is the best I have done so far, and the next one better still. Surgery is never perfect: every patient has a different anatomy, and every procedure remains a sequence of choices. But every patient adds something. What I see a colleague do, what I read and the results I reassess months later all change how I look at the next patient.
My facelift is therefore not a finished technique. It is a procedure built gradually out of anatomy, experience, literature and ideas gathered in operating rooms around the world. Not a copy of any one surgeon's technique and not a collection of isolated maneuvers, but a whole in which all those influences have come together. And that mosaic will keep changing.
“Never finished. Always better.”
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