When your face ages, there are levels in the facial tissue: skin, soft tissue and fat, muscle, bone. There is a surgery which is a “skin only” facelift, where only the skin is tightened. The traditional facelift I was taught at Stanford and in my fellowship was a SMAS facelift, where you tighten the fascial layers and then tighten the skin- two levels of tightening. The deep plane works differently. In this you release at the transition between the thicker tissue in the midline and the thinner lateral cheek tissue, releasing ligaments to mobilize the tissue more laterally. When I looked this up online, beware of what AI will tell you- you are not releasing the facial muscles or moving deep fat pads directly. The deep plane facelift is doing what the traditional facelift did- you mobilize the deeper tissue, fixate it, and when that is done then you address the excess skin. Two layers. Two different vectors.
I liked this journal article as it tries to give a framework to stage facial aging and what recourse you should do. They created 4 groups, which I generally agree with, but I disagree with the treatment and the age of the patients.
We all want facelifts without scars. So when I saw this article in the Aesthetic Journal October 2025, I really wanted to see what it said. I too am seeing all the actress seemingly age backwards. So what are they doing? Some of them may be doing this.
I am not going to get into the details of this operation because the underlying focus is on cable sutures for suspension (I am not sure what he is using for his cable suspension- absorbable? barbed?). He also does not remove any skin except for Group 3b and Group 4. His fat grafting is minimal. The OR times are long.
For details, please see the article “Endoscopic Deep Plane Facelift: A Classified Approach.” in the Aesthetic Surgery Journal October 2025. It is well thought out, and he is offering an alternative to the “Ponytail facelift.”
This is such a tricky thing to talk about.
This is an area where you will find differences between surgeons in what they believe. How aggressive are they? What is their aesthetic? Do they do fat grafting? What technique do they use? SMAS? Deep Plane? Do they remove the submandibular gland?
One plastic surgical meeting I went to had 4 renown plastic surgeons show their facelift results. They all had their branded, different way of doing a facelift which they thought was the best. The remarkable thing? All of their results were great and aged well. You couldn’t “see” one was better than another, despite being done using different techniques.
I am not a fan of threadlifts or suture suspension lifts. (Read my threadlift blogs) With threadlift and suspension suture lifts, you are not undermining and advancing the deep tissue broadly. You are not removing skin. This has the benefit of fewer scars and less swelling/downtime. If you do remove skin, so you will have a scar, why not open it up to get a broader, more comprehensive release and lift? The operative time was 8-10 hours for 3b and 4 groups. This is 2-4 hours longer than most open facelifts.
I thought the author got beautiful results, but I am not going to advocate for a 30 year old to get a facelift- endoscopic or not. I would love to see the difference between this technique and simple hyaluronic acid filler. For older patients, I think the small increase in scar amounts for a traditional deep plane facelift is worth the deeper tightening, broader surface area, shorter operative time, and skin removal. Again, please read the blogs on threadlifts, and know this is my point of view.
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