Botti's Deep Plane Face Lifting Technique
According to Facelift 2015 by Chiara Botti, Giovanni Botti (2015), mini-invasive or “soft” techniques that seem to attract doctors and patients more than real surgery.
Without anesthesia, swelling, bruising, and so forth, nothing can magically bring about the result of a well-done facelift. There are no “thread lifts” or fillings or endopeels or weird devices using radiofrequency, ultrasound, or shock waves—the list could go on forever—that can compare with a properly performed facelift.
In order to give patients natural and long-lasting results, doctors must use an effective and individualized technique, even if it implies a relatively long down time.
Five Facial Layer
To immediately improve the appearance of an aging and sagging face, it is enough to pull back the soft tissues with a fingertip applied to the cheek. Starting from this simple observation, more than a century ago, the operation called facelift was conceived, which, in short, consisted in fact of repositioning the ptotic soft tissues into their original position.
The five facial layers. Layers 1 to 5, ranging from superficial to deep, are as follows: Skin (epidermis and dermis); Subcutaneous layer (superficial fat); Facial muscles and SMAS; Retaining ligaments and spaces (deep fat); and Periosteum and deep fascia.
Initially, this was limited to the removal of a segment of skin, more or less extended around the ear, closing the wound with sutures. Then, a wider subcutaneous undermining was introduced, complemented by plication of the underlying adipose tissues
Why Deep Plane?
To obtain a true correction of the ptotic soft tissues of the face and neck, it would be necessary to first elevate them all together following a deep plane of dissection and then move them back into their original position.
The regular facelift involves getting under the skin layer only and just folding the muscle layer over itself to tighten it.
The surgery is taking place under the skin. The muscle is not released. Rather sutures are placed to fold it onto itself. Because the muscle is not released from the deeper layers, this technique may cause stretching and tension and the result may not be as long lasting.
A deep plane facelift repositions tissues on a level below the SMAS, releasing certain ligaments and remodeling deeper attachments.
This variation of facelift allows the surgeon to achieve more thorough lifting without tightly pulling tissues, thereby creating maximal results while retaining a natural-looking appearance. It is also thought to have potential to help facelift results last longer. Surgeons may also reposition fat pads in the cheeks, creating the appearance of a more lifted mid-face area.
Face Lifting: Technical Details
The preoperative examination makes it possible to give the patient correct and precise information concerning surgical techniques and possible complications, besides deciding upon any variations in approach.
It needs to be decided, together with the patient, if the operation is to be limited to the lower part of the cheeks and neck, or if it must be extended to the mid-face and temporofrontal areas. One also needs to choose if it is necessary to perform a concomitant dermabrasion to correct wrinkles and skin blemishes, a blepharoplasty (with canthopexy when required), for eyelid problems, a regional lifting (upper lip or eyebrows), or other procedures which help obtain a more harmonious and complete result.
Among the latter, a main role is played by those techniques which are aimed at restoring lost volumes due to osteoadipose atrophy.
The Mid Face Area
When the soft tissues of the midface area are severely ptotic, it is necessary to resort to a vertical lift, undermining subperiosteally, and anchoring the flap, preferably to the bone.
It is useful to combine this type of facelift with appropriate lipofilling in the subcutaneous plane. In less severe cases, it can be sufficient to extend a “classical” cervicofacial lift to the area below the lower eyelid.
It is preferable to at first extend cranially the preauricular cutaneous incision, possibly remaining within the scalp, at 2 to 3 cm from the hairline. Starting from the temporal incision, one should carry out a deep undermining between the superficial and deep temporal fascia, until the hairline is reached. From then on, the dissection will continue in the subcutaneous plane, as already described, extending as far as the lateral canthus, and the lateral portion of the malar bone.
As it concerns the sub-SMAS undermining, it will be necessary to carry the facial incision above the anterior portion of the zygomatic arch so as to permit the medial deep undermining between the anterior cheek fat pad and the elevator muscles of the lip (zygomaticus major and minor).
Palpating the inferior border of the zygomatic arch, where it thickens to join with the malar bone, the skin is anchored to the periosteum by the zygomatic ligament, which must be released with prudence to avoid damaging the branch of the facial nerve that runs nearby. Finding the zygomaticus major muscle, which inserts right in front of the ligament, will allow one to slide with the Trepsat forceps toward the nasolabial fold in the correct plane, which will be nothing but the cranial extension of the usual deep dissection in the cheek.
Repositioning, Anchoring and Trimming the Composite Flap
After having completed the deep undermining, it must be extended enough to correct all of the deformities, the mobility of the composite flap (SMAS, fat, skin) is verified, and, if necessary, a trim of its anterior margin is performed.
Then, it is elevated along a superolateral vector, and anchored under appropriate tension to firm anatomical structures. It can also be split into two smaller flaps at the level of the gonial angle, so as to pull the caudal flap posteriorly and the cranial flap superiorly.
This division with more posterior tension on the caudal flap accentuates the cervical angle, while predominately superior traction (without splitting the flap) is perhaps more effective in correcting the laxity in the inferior portions of the neck.
The main anchoring points are four. The first is the periosteum over the mastoid bone; the second is Lore fascia, in front of the earlobe. The third is the periosteum over the posterior third of the zygomatic arch; the fourth is the deep temporal fascia. The flap can be anchored with absorbable sutures (we use 2–0 Vicryl), because in a short time fibrotic adherence will develop that will provide stability of the repositioning.
Other intermediate sutures interposed between the main sutures will complete the SMAS fixation. The excess myofascial tissue can simply be trimmed, or folded over on itself for further augmentation, used to reinforce the retroauricular suspension, or to harvest grafts for lips, glabellar furrows, nasolabial folds, or tear troughs, and so on.
Most difficulties that are encountered with this type of surgery concern finding the proper dissection plane and the proper amount of traction to be applied to the different tissue layers. It is indeed not at all easy, especially for a beginner, to be sure that one has reached the proper depth of dissection, which will allow the elevation of the superficial musculo-aponeurotic system (SMAS) in a risk-free manner even in the area which is medial to the anterior border of the parotid gland where the facial nerve is no longer protected by the gland itself.
In conclusion, with the sufficient knowledge, skilled technique & ample practice it is possible to offer excellent results to the majority of patients asking for a facelift procedure.
Facelift 2015 by Chiara Botti, Giovanni Botti (2015)
Surgical Anatomy of the Midcheek: Facial Layers, Spaces, and the Midcheek Segments by Bryan C . Mendelson, Steven R. Jacobson (2008)
What is a deep plane facelift? + More innovations to take your facelift results to the next level by American Board of Facial Cosmetic Surgery (2021)
DEEP PLANE FACELIFT by Dr Mark Samaha Montreal Facial Plastic Surgery (2022)
Deep Plane Facelift in Sydney By Dr Jason Roth (2022)
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