Lower Surgical Face Lifting: Biplane Approach for Natural and Long-Lasting Results
Facial aging presents a multifaceted challenge that demands a sophisticated and individualized surgical approach. In their research, Krutyansky and Cuzalina (2025) introduce the biplane facelift, a refined technique that combines the benefits of both superficial and deep plane facelifts. This hybrid approach allows surgeons to achieve a natural, enduring result by addressing both the skin and underlying musculofascial layers. The article explores the principles behind the biplane method, its surgical steps, patient selection criteria, and key considerations for optimizing outcomes based on their extensive study.
Understanding the Biplane Approach
The biplane approach is a deep plane dissection technique commonly used in facelift procedures, focusing on elevating both the skin and underlying musculofascial layers. It involves dissecting in two distinct planes to address different layers of tissue, providing a more comprehensive and natural lift. This approach is particularly beneficial for patients who require greater elevation of the face and neck, especially when traditional superficial approaches don’t provide enough lift or when a natural appearance is desired.
The biplane approach is described as "opportunistic", meaning that the extent of the deep plane dissection is not strictly defined by specific anatomical landmarks but is instead guided by the necessary tissue elevation for each individual patient.
In practice, this means that the surgeon adapts the dissection depth and approach based on the patient’s unique anatomy and the required level of lift, making it a more flexible and customized technique compared to more traditional, fixed approaches.
Comparison with Other Facelift Techniques
There are several facelift methods commonly used in aesthetic surgery, each with its advantages and limitations:
Traditional Skin-Only Facelift: Primarily relies on skin excision and redraping, often leading to a tight, unnatural appearance and limited longevity.
SMAS Facelift: Targets the underlying SMAS layer, but without deeper ligament release, limiting its ability to lift the midface effectively.
Deep Plane Facelift: Provides significant elevation of the deeper structures but can be more invasive and carries a longer recovery period.
Biplane Facelift: Combines elements of both SMAS and deep-plane approaches, allowing a balanced and natural lift with long-term results while maintaining a moderate recovery timeline.
The biplane facelift is preferred over these methods because it avoids the unnatural tightness of skin-only facelifts, enhances midface and neck definition better than SMAS lifts, and offers a safer alternative to fully deep-plane dissections while maintaining long-lasting results.
Surgical Technique of the Biplane Facelift
Incision Placement:
Start by making the typical incisions in the temporal, periauricular, and mastoid regions as described in your procedure.
The incision should extend from the temporal region, just above the zygomatic arch, and curve downward in front of the ear, passing below the mandibular border and continuing into the posterior platysmal border.
Superficial Plane Elevation:
Elevate the skin first in the superficial plane (above the SMAS layer), using facelift scissors or electrocautery. Be careful not to damage superficial structures like the superficial temporal artery or the greater auricular nerve.
The skin should be undermined, but not excessively, to maintain adequate tissue coverage while also minimizing the risk of complications like alopecia in the hair-bearing scalp region.
Deep Plane Elevation (Biplane Dissection):
Once the skin has been lifted, you then perform the deeper dissection in the second plane, which involves separating the SMAS or musculofascial layer (just beneath the skin) from the cervical platysma and other deeper structures.
This deep dissection should be performed using electrocautery to avoid any damage to underlying nerves or vascular structures. Pay close attention to important structures like the buccal branch of the facial nerve and Stensen’s duct.
The dissection plane should stay just above the parotideomasseteric fascia (near the jawline) and below the platysma to ensure the right depth. It’s essential to maintain a smooth, controlled plane to prevent injury.
Fine-Tuning the Dissection:
Continue the dissection in a posterior-superior direction, and adjust your angle as necessary to avoid injuring the marginal mandibular nerve along the inferior border of the mandible.
The vectors of elevation should be tailored based on the patient's anatomy:
For the mid-face, elevate more superiorly.
For the lower face, elevate more anteriorly.
In some cases, you may release the deeper tissues to further refine the lift or provide additional support.
Securing the Tissues:
Once the dissection is completed and adequate elevation is achieved, secure the elevated tissues using anchoring sutures. These sutures are usually placed from the temporal region and connected to the cervical platysma to hold the tissue in place while the skin is redraped and sutured.
The tension should be minimal, thanks to the deep plane release, which allows for a more natural and smooth appearance without excessive skin tension..
Patient Outcomes and Research Findings
Clinical data from Krutyansky and Cuzalina's research supports the effectiveness of the biplane facelift. Their findings show that over 90% of patients maintain visible aesthetic improvements for at least 8-12 years postoperatively. Compared to traditional deep-plane facelifts, the incidence of nerve injury and excessive scarring is significantly lower. Patient satisfaction is also high, with 85-95% reporting improved self-confidence and facial aesthetics. The recovery process is relatively efficient, with most patients resuming normal activities within 10-14 days and full healing occurring over several months. Additionally, the combination of SMAS and deep-plane manipulation enhances jawline definition and midface support better than SMAS-alone techniques.
Advantages of the Biplane Approach
By addressing both superficial and deep structures, the facelift maintains its effectiveness for a longer period. The multi-layered approach ensures natural results, avoiding the over-pulled appearance of traditional facelifts. Releasing key retaining ligaments allows for better repositioning of sagging tissues, enhancing midface and neck contouring. This technique also distributes tension more evenly, reducing strain on the skin and minimizing the risk of wide scars. While the recovery timeline is more extensive than a standard SMAS lift, it is often faster than a full deep-plane facelift.
In summary, the advantages of the biplane facelift include:
Long-lasting results by addressing both superficial and deep structures.
Natural appearance without the overly tight look.
Enhanced midface and neck contouring through precise tissue repositioning.
Reduced risk of scarring due to balanced tension distribution.
Moderate recovery time, shorter than a deep-plane facelift.
Limitations of the Biplane Approach
The biplane facelift requires advanced surgical expertise, as it involves both SMAS and deep-plane techniques. The intricate dissection process increases the duration of the procedure, making it more time-intensive. While rare, improper deep dissection may heighten the risk of facial nerve injury. Additionally, this technique is not suitable for all patients, particularly those with minimal skin laxity, who may achieve better results with less invasive options.
In summary, the considerations of the biplane facelift include:
Technical complexity requiring proficiency in SMAS and deep-plane techniques.
Longer operative time due to intricate dissection.
Potential risk of nerve injury if deep dissection is not performed correctly.
Limited suitability for patients with minimal skin laxity.
When to Consider the Biplane Approach
The biplane approach is typically used when greater elevation of the face and neck is needed, especially when the traditional superficial approach doesn’t provide enough lift or when a more natural look is desired.
It is especially useful for older patients or those with significant facial sagging, as it allows for more extensive dissection and repositioning of the deeper tissues, such as the SMAS (superficial musculoaponeurotic system) and platysma muscle, which can provide better, longer-lasting results.
It is also chosen when the goal is to avoid over-tightening the skin, which could result in an unnatural appearance or tension-related complications. This approach helps achieve a smoother and more youthful contour.
When Not To Use the Biplane Approach
Avoid using the biplane approach if the patient does not require significant deep tissue elevation, or if the tissues are too thin or delicate, making deep dissection risky. It's also not typically recommended for younger patients with minimal facial sagging, as their skin elasticity may not require such an extensive technique.
Conclusion
The biplane approach enables a more dynamic and effective lift by targeting both the superficial and deeper layers of tissue. It is especially beneficial for patients with significant facial sagging, providing a natural, long-lasting result while minimizing skin tension and reducing the risk of complications. By performing deep tissue elevation in a controlled manner, the biplane approach achieves a more youthful, smoother contour, making it a preferred technique for complex facelifts. The "opportunistic" nature of the technique adds a layer of flexibility, allowing the surgeon to adjust dissection depth based on the patient’s specific needs, ensuring a tailored outcome. As with any surgical technique, meticulous execution and patient selection are key to achieving predictable, lasting results.
Reference:
Krutyansky, Artem & Cuzalina, Angelo. (2025). Upper and Lower Face Lifting Surgery. 10.5772/intechopen.1008262.
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