What Is a Deep Plane Facelift? Procedure, Results, and Recovery Explained

What Is a Deep Plane Facelift?

A deep plane facelift, also known medically as a deep plane rhytidectomy, is a surgical facial normalisation procedure that addresses the deeper anatomical layers of the face. Where a traditional facelift typically targets the SMAS layer separately from the skin, the deep plane approach works beneath this layer entirely, releasing the deep retaining ligaments of the face, specifically the zygomatic and mandibular ligaments, and lifting the skin, fat, and muscle as one unified composite flap.

The result is a repositioning of the facial soft tissues to a more youthful position, rather than a lateral pull that simply tightens the surface. Sagging in the midface, jowls, deep nasolabial folds, loss of jawline definition, and neck laxity are all addressed through a single, comprehensive procedure. Because tension is borne by the deeper structures rather than the skin, the incisions heal with minimal visible scarring.

Dr Cotrufo describes the deep plane approach as the most advanced and comprehensive technique available for facial normalisation. His practice of the technique is grounded in direct training under Dr Andrew Jacono in New York, who has published the most extensive body of scientific data on deep plane surgery in peer-reviewed plastic surgery journals.

How a Deep Plane Facelift Differs from a Standard Facelift

The distinction between a deep plane facelift and a standard SMAS facelift is not simply one of degree: it is one of anatomical approach.

In a standard SMAS facelift, the skin and the SMAS layer are treated as separate structures. The skin is lifted and pulled laterally, with the SMAS addressed independently. This produces a horizontal tension that can, particularly over time, lead to an appearance that looks tight or unnatural.

In a deep plane facelift, the dissection goes beneath the SMAS entirely. The surgeon works in the plane between the SMAS and the deeper facial muscles, releasing the ligaments that anchor the facial tissues and then lifting everything, skin, fat, and muscle, as a single unit. The direction of lift is predominantly vertical rather than lateral, which restores facial volume and proportion rather than simply stretching tissue sideways.

The practical consequences of this difference are significant:

No tension on skin sutures. Because the deeper structures bear the tension of the lift, the skin is repositioned without strain. This is why, in Dr Cotrufo’s practice, deep plane facelift scars are typically barely visible within a few months of surgery.

More natural-looking results. The absence of lateral skin tension is what prevents the pulled or wind-swept appearance sometimes associated with older facelift techniques. The face looks like a younger, normalised version of itself, not an altered version.

Better blood supply to lifted tissues. The deep plane dissection preserves the perforating blood vessels that supply the elevated flap, which promotes faster healing and reduces the risk of complications such as skin necrosis.

Greater longevity. A standard facelift typically produces results lasting five to eight years. Deep plane results consistently last 10 to 15 years, because the deeper structural correction is more durable than a surface lift alone.

How the Procedure Is Performed

Consultation and planning

Dr Cotrufo does not proceed with facelift surgery without at least two consultations. The first consultation involves a detailed examination of facial structure, skin quality, and the degree of tissue descent. He asks patients to bring photographs from a period in their life when they were most comfortable with their appearance. The aim is a gracious normalisation: returning a patient to where they have already been, not to somewhere new they would need to adapt to.

The consultation also examines the areas immediately contiguous to the primary surgical targets. The mid-face, lower face, and neck are the core focus of a comprehensive deep plane approach, but Dr Cotrufo also assesses the lower eyelids, upper lip, forehead, brow position, and lower neck and chest wall. The existing harmony of the face cannot be distorted by surgery, and any procedure must be planned with a clear understanding of its impact on the surrounding structures.

The surgical technique

A deep plane facelift at Dr Cotrufo’s practice is performed as a day case under deep sedation or TIVA (total intravenous anaesthesia). General anaesthesia is not required. Incisions are made along the natural hairline and around the contours of the ear, positioned to be as discreet as possible. Where neck work is included, a small incision beneath the chin may also be used.

Working beneath the SMAS layer, the deep retaining ligaments are released, freeing the composite flap of skin, fat, and muscle. This flap is then lifted at a predominantly vertical vector, typically around 60 degrees, and repositioned to restore youthful facial contours. Excess skin is trimmed, and the incisions are closed in layers, with no tension placed on the skin sutures.

On the question of the submandibular gland: some surgeons routinely resect the gland as part of neck contouring. This is not something Dr Cotrufo offers regularly. The deep plane approach, with a hammock suspension of the SMAS to the mastoid area, creates a natural lifting of the submandibular gland. This achieves a very effective aesthetic result for the neck while avoiding the additional risks and operating time that come with direct gland resection.

If fat redistribution or a platysmaplasty (tightening of the neck muscles) is required, this is performed during the same procedure.

Combination procedures

A deep plane facelift is frequently combined with complementary procedures depending on the individual patient’s anatomy and goals. The lower eyelids and the mid-face are the areas Dr Cotrufo most commonly addresses alongside a deep plane approach. Where a patient has a noticeably elongated upper lip, a lip lift is recommended at the same time, because rejuvenating the mid-face without addressing the lip will make the ageing of that segment look more pronounced by comparison. Brow lifting and fat grafting may also be discussed at consultation.

Who Is a Good Candidate for a Deep Plane Facelift?

The procedure is most appropriate for patients in their forties, fifties, sixties, and seventies with moderate to significant facial sagging, though good overall health and realistic expectations matter as much as age. Dr Cotrufo also sees a younger population of patients seeking correction of dysharmonic facial development, where the deep plane approach can restore structural balance even in the absence of significant ageing.

Patients who tend to benefit most are those with:

• Sagging or descent of the midface and lower face
• Jowling or loss of jawline definition
• Deep nasolabial folds that have not responded to non-surgical treatments
• Neck laxity or banding of the platysma muscle
• Reduced facial volume and proportion that filler is no longer adequately addressing
• Facial deflation following significant weight loss, including that associated with Mounjaro, Ozempic, or similar medications

Patients must be in good general health and must be willing to stop smoking for a minimum of six weeks before surgery. Smoking significantly impairs blood supply to healing tissues and increases the risk of complications including skin necrosis. Patients on blood-thinning medications such as aspirin will be asked to discontinue these approximately ten days before surgery.

Patients seeking a more conservative correction, or those at an earlier stage of facial ageing, may be better suited to a standard SMAS facelift or a mini facelift. Dr Cotrufo will advise on the appropriate procedure at consultation.

Deep Plane Facelift Recovery: What to Expect

Days one to three. Patients return home following their day case procedure. Swelling and bruising are at their peak during this period. The head should be kept elevated at all times, above the level of the hips and shoulders. A responsible adult should be present for the first few days. Most patients are comfortable managing at home with standard prescribed pain relief.

End of week one. Sutures are typically removed between days six and ten. Visible bruising begins to reduce.

Weeks two to three. Most patients are comfortable returning to social activity and desk-based or home-working roles between two and three weeks after surgery. Close-up professional or social commitments in this period should be planned around.

Week three onwards. Light exercise can resume. Some temporary tightness or mild changes in sensation around the face may persist but resolve as the tissues settle.

Six weeks. Full recovery. Swelling has substantially resolved.

Three to six months. Final results are visible once all residual swelling has cleared and the tissues have fully settled. Scars continue to fade over this period.

Results from a deep plane facelift typically last 10 to 15 years. Genetics, sun exposure, skincare habits, and lifestyle all influence longevity. Patients can expect to look consistently younger than they would have done without the procedure, with the ageing process continuing from the improved baseline rather than reversing.

Risks and Complications

A deep plane facelift is a major surgical procedure and carries inherent risks. I believe in absolute transparency when discussing them with patients, and I will not proceed until I am satisfied that a patient fully understands the process and has had sufficient time to reflect.

The generic risks that apply to all surgery include infection, unfavourable scarring, bleeding, asymmetry, and irregularities. For the deep plane facelift specifically, the most common complication is bleeding, particularly in the area around the neck and behind the ear. This is why post-operative drains are used in many cases. Bleeding is also statistically more common in men than in women.

Today, thanks to advances in both anaesthesia and surgical technique, including the use of tranexamic acid and the move to deep sedation rather than general anaesthesia, the risk of bleeding has been reduced very significantly. Our hematoma rate is below 2%.

The most serious complication I could envisage is damage to the facial nerve. In some cases this can be permanent, though in the majority of cases there is a good recovery, which may not always be complete but does return the patient to adequate facial function. Based on the most recent meta-analyses in the literature, this complication is reported with an incidence of approximately 1 to 1.5%. By operating meticulously within the correct deep plane spaces, I aim to keep this risk as low as possible.

Smokers face a significantly elevated risk of skin necrosis due to impaired circulation. The deep plane technique’s preservation of the blood supply to lifted tissues reduces, though does not eliminate, some of these risks relative to more superficial approaches.