The Art and Science of Extended Deep Plane Facelifting and Complementary Facial Rejuvenation Procedures

Abstract

Dr Jacono and the team at Quality Medical Publishing (St. Louis, MO) have produced a handsome volume dedicated to his personal surgical approach to the treatment of facial aging. The book, at 500 pages, closely follows the size, format, and high standard established by previous QMP hardcover books in aesthetic surgery, with plenty of beautiful illustrations and clinical color photos, and easy-to-read text. The first portion of the book focuses on Dr Jacono’s approach to facelifting. Dr Jacono, a respected facial plastic surgeon from New York, has been developing and refining this technique for over a decade. The first 4 chapters add up to nearly one-half of the book and thoroughly discuss the rationale, safety, and effectiveness of the technique; the relevant surgical anatomy; anatomic changes associated with aging; and the facelift technique itself, which is the longest chapter and very comprehensive. For those unfamiliar with the author’s facelift approach, I will try to summarize. First, the “deep plane” portion of the title is a reference to the work of Dr Sam Hamra, who in 1990 published a paper with a then-new technique utilizing that particular title. Like Dr Hamra’s method, Dr Jacono’s dissection into the deep plane starts on a line between lateral canthus and the angle of the mandible, dissecting deep to the malar fat pad and superficial musculo-aponeurotic system (SMAS), and over the mimetic muscles forward to the naso-facial crease. This develops a composite flap, which is not delaminated or separated from the skin, as in most lateral SMAS-based techniques. Jacono’s procedure differs from that discussed in Hamra’s 1990 paper in several key aspects: he performs a sub-platysmal dissection in the neck, beginning laterally and extending 5 cm below the angle of the mandible, and then makes a 4-cm superior platysmal myotomy, approximately 1 cm below the mandibular border, which is employed to contour the neck. Jacono also stresses the need to release the facial retaining ligaments—the zygomatic cutaneous, masseteric cutaneous, mandibular cutaneous, and cervical retaining ligaments—to obtain appropriate tissue mobility. He describes his anatomic approach to do so in detail, because these ligaments are so often in proximity to facial nerve branches. Numerous intra-operative photos are shown, detailing each step of the procedure, with pearls on incision placement, flap elevation, sub-SMAS dissection, fat contouring, and suspension of the flap and skin closure, and multiple cases are shown with long-term follow-up photos. Interested readers can get a flavor for the book by looking at the author’s recent publications in Facial Plastics Clinics of North America and ASJ.