The SMAS plays a role in a face-lift, regardless of the technique used. SMAS plication, derived from the Greek word plica, which means “to fold,” consists of suturing or folding the SMAS on itself, whether a strip of SMAS is removed or not. SMAS imbrication, derived from the word imbricate, means “to layer, as in roofing shingles.” In this instance, the SMAS is undermined as a flap and overlapped in one or more superior or superolateral directions. Many studies have been published regarding the various techniques of handling the SMAS and the preponderance of opinions would suggest that there is no clear advantage of the deep plane versus other techniques of handling the SMAS.

Hamra’s classical deep plane face-lift is often misunderstood regarding the SMAS. By definition, the SMAS envelopes the mimetic muscle of the face and neck, so whenever the dissection is deep to the mimetic muscles of the face, it is considered sub-SMAS. By this anatomical definition, the original deep plane procedure is superficial to the SMAS in the neck, below the SMAS in the lower face (as it is an extended dissection below the platysma), and above the SMAS in the upper face (as the dissection is above the zygomaticus major and minor and the inferior orbicularis oculi muscles). The transition point in the face between the sub-SMAS in the lower face and the deep subcutaneous dissection in the upper face is the inferior border of the zygoma, where the nerves to the zygomaticus muscles emerge. In essence, the term “deep plane” refers to both the lower face sub-SMAS dissection and the upper face, which is really only a deep subcutaneous dissection.

In patients with a more advanced degree of aging, I do still use the extended SMAS imbrication in the lower face similar to that described by Hamra, but stop the sub-SMAS dissection at the level of the inferior border of the zygoma. I do not do the “deep plane” in the upper face, but rather undermine the skin to release the zygomatic retaining ligaments and plicate the malar adipose tissue pad in a superolateral direction ( Video 11.1). I do undermine the skin somewhat more anteriorly than in the classical deep plane face-lift because it allows for a different vector of the skin than the SMAS flap. The mandibular retaining ligaments are also released while the skin is being undermined. In younger patients with less aging face changes, I often elevate a shorter flap and perform SMAS excision with plication.

For many years, I approached the neck with subcutaneous adipose tissue sculpting, removal of a small amount of platysma and subplatysma adipose tissue inferiorly to the level of the hyoid or just slightly inferior, and plication of the platysma muscle inferiorly to the level of the hyoid with many instances performing horizontal division of the anterior aspect of the platysma for several centimeters just inferior to the level of plication. This was generally my first step in the face-lift sequence. Later, when the SMAS was undermined in the face, it was continued under the posterior border of the platysma in the neck, and a posterior pull on the muscle was applied. In essence, the midline was secured with the platysma plication, and the posterior pull on the platysma tightened the neck. When I studied the results with this technique, the frequency of recurrence of platysma bands and the amount of long-term definition that was achieved were disappointing. Platysma bands recurred, in as early as a year or less, and in the difficult neck, the definition was less than desired.

About 5 years ago, after I analyzed my results, I radically changed my approach to the neck. Feldman had pioneered a technique that he called a “corset platysmaplasty” that at first glance did not make much sense, in that all of the work was done anteriorly without significant posterior pull on the platysma. Common sense would suggest that aging is influenced by gravity and the loss of elasticity and that a posterosuperior pull against gravity would make more sense. In spite of this, I tried this technique and was immediately impressed with the results (Video 11.1). The skin of the neck is undermined through a submental incision and the medial platysma borders are undermined laterally for several centimeters down to the level of the cricoid. This releases some of the platysma-retaining ligaments, which exposes the subplatysma adipose tissue and the anterior belly of the digastric muscles. Often, the inferior aspect of the submandibular glands can be seen. Almost always, the subplatysma adipose tissue is removed in its entirety, usually including the prelaryngeal adipose tissue as well. Occasionally, bulging anterior belly of the digastric muscles may need to be reduced. I have not reduced the submandibular glands through this approach because of potential complications, but I think that results in some patients would be better if this were performed. A complete corset platysmaplasty is performed, starting at the level of the submental incision, down to the level of the cricoid with a running suture that inverts the medial edges of the platysma muscles. Using the same continuous suture, the original suture line is inverted by suturing the platysma on itself from the cricoid back up to the submental incision, with excursions laterally as necessary on both sides of the midline to further tighten any bulging of the muscle that is identified. This creates a true corset, with lateral pleats, so the platysma completely conforms to the underlying anatomy. It is the second inverting row as one comes superiorly that really defines the neck, and this is clearly seen when one gets back up to the level of the hyoid and then to the level of the submental incision. The only posterior pull on the platysma in the neck when doing the lateral aspect of the face-lift is in the area of the angle of the mandible to increase definition.

Since I began to extend the undermining of the skin and use SMAS flaps with imbrication combined with the true corset platysmaplasty described above, the results have improved and decidedly longer lasting in the face and in the neck. This is the primary focus and purpose of this chapter. If extensive midface aging is present, the addition of a transtemporal or transblepharoplasty midface lift also improves the result and increases its longevity.