The extended supraplatysmal plane (ESP) face lift

Our quest for the ideal face lift procedure has taken us on a journey from skin to bone, with continued controversy about which plane is the most optimal for dissection. Recent magnetic resonance imaging and clinical studies have strongly suggested that central facial aging, especially jowling, is mainly due to skin and fat ptosis, not laxity of the thin platysma aponeurosis/SMAS layer. It is the author's opinion that the so- called SMAS should be called the platysma aponeurosis. Recent studies show it is anatomically and functionally a continuation of the cervical platysma muscle. Unless fat is left on this muscle-fascial layer during dissection, the plastysma aponeurosis/SMAS itself is too thin to contribute to the stigmata of aging. Therefore, complete repositioning, ligament release, and sculpting of all fat above this layer is crucial for a successful face lift. The inferior-distal zygomatic and mandibular ligaments are important contributors to jowling. The subSMAS techniques are not able to release the mandibular ligament without jeopardizing the distal branches of the marginal mandibular nerve. The extended supraplatysmal plane (ESP) face and neck dissection is directly on top of the platysma aponeurosis/SMAS. It extends distal to the zygomaticus major muscle, allowing the release of all five osteofasciocutaneous ligaments and the contouring and repositioning of all five facial fat collections without the need to violate the thin platysma aponeurosis (SMAS). It is a deep, complete, and distally extended subcutaneous face lift sparing the subcutaneous arcuate vessels. In more than 400 consecutive patients, this has resulted in a natural, uniformly reproducible, and youthful appearance with a shorter recovery and minimal complications.