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The core of any facial plastic surgeon's skills come from their training in fellowship, which follows their residency training. The premier body for fellowship training in facial plastic surgery is the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Established surgeons learn from their colleagues by visiting them in the operating room and by engaging with them through medical literature and at meetings. True advancements in surgical techniques are more likely to be published in reputable journals than kept within the surgeon's operating room. Moreover, these advancements usually improve upon previous innovations in an iterative process where the wisdom of a surgeon's colleagues is built upon. Those surgeons who advanced early facelift techniques (e.g., Suzanne Noel) set the stage for improvements based on an evaluation of the strengths and weaknesses of those techniques and an improved understanding of the anatomy of the face and neck. No truly innovative technique ignores history. The deep plane facelift as developed by the plastic surgeon Dr. Sam Hamra (1, 2, 3, 4, 5) was a combination of the advancements made by previously developed techniques, specifically the SMASectomy facelift, and new understandings of facial anatomy. The extended deep plane facelift, a technique developed by my AAFPRS fellowship director Dr. Andrew Jacono, advanced upon the deep plane facelift technique as developed by Dr. Sam Hamra (6, 7, 8, 9). This blog post seeks to explain the differences between the deep plane facelift and extended deep plane facelift. As a result, this blog post will explain why these techniques were such an incredible improvement on previous facelift techniques. It is important to seek not only a fellowship-trained but also a double board-certified facial plastic surgeon if you have aesthetic concerns about your face and/or neck. The Deep Plane Facelift Does Not Address the Side of the Neck The most significant difference between the deep plane facelift and the extended deep plane facelift is that the deep plane facelift does not address the side of the neck in a deep plane. In contrast, the extended deep plane facelift "extends" the deep plane facelift technique into the side of the neck (6, 7, 8, 9). This involves the release of tension points called cervical retaining ligaments that restrict the ability to tighten the muscle around the neck surgically unless released, much like the two important ligaments in the face and jawline released during deep plane facelift surgery. The Extended Deep Plane Facelift Can Speed Up Recovery One relatively minor difference between the two techniques as described in the literature makes a potentially large difference on the length of recovery. The initial description of deep plane facelift involved lifting the eye muscle itself. This can sometimes result in more prolonged swelling around the eyes and increases the risk of temporary weakness in the eye muscle at this location. In contrast, the extended deep plane facelift goes over the muscle, preserving its continuity, thereby decreasing the risk of prolonged swelling and temporary muscle weakness around the eyes. Dr. Harmon is One of the Few Surgeons in the World Fellowship Trained in the Extended Deep Plane Facelift by Dr. Andrew Jacono The extended deep plane facelift requires extensive training to perform. Dr. Harmon is one of the few surgeons in the world – and the only surgeon in the Cincinnati, OH area – trained in the extended deep plane facelift by its creator, Dr. Andrew Jacono. As a result, he is uniquely qualified to perform this technique both for a first facelift and for a secondary/revision facelift on patients who have undergone a facelift with other, older techniques in the past. As always, an in-person consultation is important to understand whether the extended deep plane facelift is appropriate for an individual. Trust Your Face to a Facial Plastic Surgeon It is important to seek a fellowship-trained specialist in plastic surgery of the face and neck when you have concerns about your face or neck. Why Choose Dr. Harmon The mission of Harmon Facial Plastic Surgery is to help people along their journey towards self-confidence, to feel good about feeling good. Dr. Harmon is a double board-certified facial plastic surgeon Dr. Harmon values making patients feel welcomed, listened to, and respected. Dr. Harmon graduated with honors from Cornell University with a Bachelor of Science degree in molecular biology. Dr. Harmon earned his medical degree from the University of Cincinnati. Dr. Harmon underwent five years of extensive training in head at neck surgery at the prestigious residency program at the University of Cincinnati. Dr. Harmon then underwent focused fellowship training in cosmetic facial plastic surgery through the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) with the world-renowned surgeon, Dr. Andrew Jacono, on Park Avenue in New York City. Request a Consultation Request a consultation with Dr. Harmon at Harmon Facial Plastic Surgery in Cincinnati. Visit our clinic. You will learn more about Dr. Harmon's credentials, style, and approach. Build a relationship with our dedicated team. Do not stop searching "plastic surgery near me." Get in touch with us to learn more. Contact Us References Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990 Jul;86(1):53-61 Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992 Jul;90(1):1-13. Hamra ST. Composite rhytidectomy and the nasolabial fold. Clin Plast Surg. 1995 Apr;22(2):313-24. Hamra ST. Composite rhytidectomy. Finesse and refinements in technique. Clin Plast Surg. 1997 Apr;24(2):337-46. Hamra ST. Building the Composite Face Lift: A Personal Odyssey. Plast Reconstr Surg. 2016 Jul;138(1):85-96. Jacono AA. Face-Lift Surgical Techniques. Facial Plast Surg Clin North Am. 2020 Aug;28(3):xv-xvi. Jacono AA. A Novel Volumizing Extended Deep-Plane Facelift: Using Composite Flap Shifts to Volumize the Midface and Jawline. Facial Plast Surg Clin North Am. 2020 Aug;28(3):331-368. Jacono AA, Alemi AS, Harmon JJ, Ahmedli N. The Effect of a Novel Platysma Hammock Flap During Extended Deep Plane Facelift on the Signs of Aging in the Neck. Aesthet Surg J. 2022 Aug 1;42(8):845-857. Jacono A, Bryant LM. Extended Deep Plane Facelift: Incorporating Facial Retaining Ligament Release and Composite Flap Shifts to Maximize Midface, Jawline and Neck Rejuvenation. Clin Plast Surg. 2018 Oct;45(4):527-554.

Almost every surgical procedure in every surgical subspecialty has post-operative bleeding as a risk. This includes facial plastic surgery procedures. And while the risk of bleeding – also known as a hematoma – is low, it is something surgeons work hard to further reduce the risk of, especially with neck lift surgery and facelift surgery. The interventions discussed in this blog post include the use compression dressings, the placement of drains, hemostatic (Auersvald) netting, tissue glues (e.g., Tisseel©, Artiss©, and Platelet-Rich-Plasma [PRP]), and Tranexamic Acid (TXA). Current research does NOT indicate which intervention or combination of interventions is best to reduce the risk of bleeding. It is important to seek not only a fellowship-trained but also a double board-certified facial plastic surgeon if you have aesthetic concerns about your face and/or neck. Meticulous Surgical Technique Meticulous surgical technique that minimizes bleeding and addresses the source(s) of bleeding carefully and while minimizing the effects to surrounding tissue is likely the best method for reducing the risk of bleeding after surgery. Blood Pressure Control The major risk factor for bleeding is significantly elevated blood pressure. That is why optimal blood pressure control prior to surgery and maintenance of adequate blood pressure control can reduce the risk of bleeding. It is possible for an individual's blood pressure to be higher than normal before surgery due to anxiety about the procedure. This typically dissipates as the patient relaxes and they receive anesthesia medications. Blood pressure post-operatively is typically affected by pain, nausea, and vomiting, which is why tailoring the pain control regimen and nausea control regimen can decrease the risk of bleeding in some individuals. However, our experience at Harmon Facial Plastic Surgery has been that extended deep plane facelift surgery generally does not cause significant pain and the anesthesia administered generally does not cause significant nausea when compared with other approaches. Compression Dressings Tight dressings around the face and neck have been used historically as a compression dressing meant to reduce the risk of bleeding. However, the use of this needs to be balanced against the risk of constricting the skin too much such that the skin loses adequate blood flow from compression. We at Harmon Facial Plastic Surgery do not use tight compression dressings after surgery for this reason. Drains Drains have also historically been used to reduce bleeding and bruising after surgery. And while this has not been definitively proven in the literature, the mechanism makes sense – as evidenced by the fact that fluid collecting in the drains is not collecting in the body. The drains generally remain in for a very short period. That is why we place drains post-operatively in all patients. Their upkeep is straightforward and simple. They generally cause little discomfort. Hemostatic Netting Hemostatic, or Auersvald, netting involves the placement of stitches/sutures in areas where skin has been lifted for 48 to 72 hours to temporarily secure the skin against the deeper tissue until it has had some time to heal. Patients with a history of significantly elevated blood pressure and/or individuals for whom more bleeding than usual is encountered in surgery may be a better candidate for such an intervention than others. This technique makes sense, but like all the interventions discussed, more research is required to determine whether it is one of the best approaches. Tissue Glues Tissue glues are products made with the patient's own blood or that are procured from a company that serve to seal blood vessels and tissue layers to each other during surgery. Products made by the body include Platelet-Rich-Plasma (PRP) and other similar concentrations of blood components that are "activated" to form an adhesive gel. Those products procured by companies include, but are not limited to, Tisseel© and Artiss© fibrin sealants. It is important to note that tissue sealants procured from companies are made from blood products from other humans, similar to the use of cadaveric rib cartilage for nose (rhinoplasty) surgery. A 2016 meta-analysis evaluating the effectiveness of fibrin tissue sealant (e.g. Tisseel©, Artiss©, and PRP) demonstrated a statistically significant rate of reduction of hematoma for Artiss© only. Furthermore, the study demonstrated a statistically significant rate of reduction of hematoma for patient undergoing older, often less effective and less natural appearing methods of facelifting but not for deep-plane facelift surgery (1). Of note, Dr. Harmon utilizes the extended deep plane facelift approach. One may consider the use of tissue sealants on a case-by-case basis when one suspects an individual who may be at a higher-than-normal risk of bleeding after surgery. Tranexamic Acid (TXA) The origins of the use of TXA are in orthopedic, cardiac, and trauma literature. Relatively little has been published in the aesthetic surgery literature regarding the use of TXA to prevent bleeding. TXA has been given intravenously (IV), included in injected local anesthesia mixtures injected into the surgical site, and applied topically to the surgical site during surgery. The evidence is currently not clear whether there is one safest, most effective approach to the use of TXA. And, as with all medications, the potential benefits, risks, and alternatives need to be considered with the use of the medication to reduce bleeding. A review of the evidence demonstrates the current data shows an improvement in the intra-operative bleeding, operating time, and drain output, but no statistically significant difference in the rate of bleeding after surgery (2). It must also be noted that injecting or applying TXA topically is a United States Food and Drug Administration (FDA) off-label use of the medication. There is No Method or Combination of Methods that is Considered the Definitive Treatment to Reduce Bleeding and Bleeding Can Occur Regardless of How the Patient is Optimized Research remains non-specific as to which intervention or combination of interventions is best to reduce the already relatively low risk of bleeding during and after surgery. The Laryngoscope, one of the premier publications in the field of head and neck surgery, commonly publishes articles called "Best Practices" where contributors review the available literature to conclude about a common clinical question. Kleinberge A. and Spiegel J., in their article "What is the Best Method for Minimizing the Risk of Hematoma Formation After Rhytidectomy [Facelift]?" determined that "the current literature does not definitively support one particular method for reliably preventing post-operative hematoma after rhytidectomy" and "there is no replacement for meticulous surgical technique and adequate intraoperative hemostasis" (3). Larger, better designed studies are required to elucidate this. However, it is important to ask whether your surgeon has engaged with the medical literature and comes to their decisions about intra-operative and post-operative care in a thoughtful manner, weighing the potential risks and benefits of any and all of the above interventions. In the end, there is currently not one perfect method or methods. Each of the above methods could be implemented and the low risk of bleeding would remain. Seek someone who you trust understands how to evaluate and respond if something such as a bleed does occur. Trust Your Face to a Facial Plastic Surgeon It is important to seek a fellowship-trained specialist in plastic surgery of the face and neck when you have concerns about your face or neck. Why Choose Dr. Harmon The mission of Harmon Facial Plastic Surgery is to help people along their journey towards self-confidence, to feel good about feeling good. Dr. Harmon is a double board-certified facial plastic surgeon Dr. Harmon values making patients feel welcomed, listened to, and respected. Dr. Harmon graduated with honors from Cornell University with a Bachelor of Science degree in molecular biology. Dr. Harmon earned his medical degree from the University of Cincinnati. Dr. Harmon underwent five years of extensive training in head at neck surgery at the prestigious residency program at the University of Cincinnati. Dr. Harmon then underwent focused fellowship training in cosmetic facial plastic surgery through the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) with the world-renowned surgeon, Dr. Andrew Jacono, on Park Avenue in New York City. Request a Consultation Request a consultation with Dr. Harmon at Harmon Facial Plastic Surgery in Cincinnati. Visit our clinic. You will learn more about Dr. Harmon's credentials, style, and approach. Build a relationship with our dedicated team. Do not stop searching "plastic surgery near me." Get in touch with us to learn more. Contact Us References Giordano S, Koskivuo I, Suominen E, Veräjänkorva E. Tissue sealants may reduce haematoma and complications in face-lifts: A meta-analysis of comparative studies. J Plast Reconstr Aesthet Surg. 2017 Mar;70(3):297-306. Soltany A, Alhallak N, Al Aissami M. Tranexamic acid in rhytidectomy: a scoping review. Ann Med Surg (Lond). 2023 Sep 1;85(10):4964-4968. Kleinberger AJ, Spiegel JH. What is the best method for minimizing the risk of hematoma formation after rhytidectomy? Laryngoscope. 2015 Mar;125(3):534-6.

There are many reasons individuals seek revision, or secondary, facelifts. Regardless of the reason, deep plane facelift surgery including the extended deep plane facelift is usually the superior approach. It is important to seek not only a fellowship-trained but also a double board-certified facial plastic surgeon if you have aesthetic concerns about your face and/or neck. Some Individuals Were Happy with Their Previous Facelift But it is Time for a Secondary Procedure No facelift technique stops the aging process. As a result, the age-related changes in the face that were treated with a facelift progress, usually over a period of years. Patients who undergo older facelift techniques tend to notice a recurrence of loose skin, muscle, and fat more quickly (i.e., many years earlier) than those who undergo deep plane facelift surgery. Many individuals loved their results from their first facelift but would like a secondary procedure to lift what has fallen again. Other Individuals are Concerned About Incomplete Treatment of the Signs of Facial Aging or Poor Cosmetic Results Some individuals feel their facelift results did not adequately treat the signs of facial aging that concerned them. Inadequate treatment of the neck with a facelift can result in persistent, severe, hanging skin and muscle. The neck can be better addressed specifically with the extended deep plane facelift. Facelift techniques that are not deep plane techniques do not lift the cheeks, which can make the face appear unnatural when the jawline is partially addressed but the cheeks are not. Many surgeons add large volumes of fat to the face to mask the lack of a cheek lift. However, as previously discussed, this can distort the natural appearance of the cheeks by leaving the drooping volume in an unnatural position while adding more volume where the natural volume should be located. Other individuals experience poor cosmetic results making their face appear distorted and unnatural. Individuals who undergo facelift techniques that are not deep plane are at a significantly increased risk of multiple abnormalities. First, they are at an increased risk of poor healing and abnormal scarring at the incision sites due to the presence of significant tension on the skin. Second, they are at an increased risk of a pixie ear deformity, which is the adherence of the earlobe to the side of the face, which then stretches out down the side of the face as the incisions heal. Third, they are at an increased risk of appearing "windswept" or abnormally stretched horizontally, which can result in an unnatural purse string appearance with tethering at the jawline and a widened mouth. Deep Plane Facelift Surgery is the Best Facelift Technique to Address the Signs of Facial Aging Comprehensively in a Revision Procedure Please see the following blog post to understand why the extended deep plane facelift – and deep plane facelift surgery generally – is the best technique to address the signs of facial aging comprehensively and naturally in individuals who have previously undergone a facelift. There is a great deal of scarring of the tissue deep to the skin after any facelift procedure. As a result, the blood supply to the skin is weaker than prior to surgery. Deep plane facelift surgery is a superior approach to a secondary facelift because it preserves thicker, healthier tissue when lifted and more of the surgical work occurs in areas of the face that are previous untouched, and therefore, safer to navigate. Trust Your Face to a Facial Plastic Surgeon It is important to seek a fellowship-trained specialist in plastic surgery of the face and neck when you have concerns about your face or neck. Why Choose Dr. Harmon The mission of Harmon Facial Plastic Surgery is to help people along their journey towards self-confidence, to feel good about feeling good. Dr. Harmon is a double board-certified facial plastic surgeon. Dr. Harmon values making patients feel welcomed, listened to, and respected. Dr. Harmon graduated with honors from Cornell University with a Bachelor of Science degree in molecular biology. Dr. Harmon earned his medical degree from the University of Cincinnati. Dr. Harmon underwent five years of extensive training in head at neck surgery at the prestigious residency program at the University of Cincinnati. Dr. Harmon then underwent focused fellowship training in cosmetic facial plastic surgery through the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) with the world-renowned surgeon, Dr. Andrew Jacono, on Park Avenue in New York City. Request a Consultation Request a consultation with Dr. Harmon at Harmon Facial Plastic Surgery in Cincinnati. Visit our clinic. You will learn more about Dr. Harmon's credentials, style, and approach. Build a relationship with our dedicated team. Do not stop at searching "plastic surgery near me." Get in touch with us to learn more! Contact Us