Deep-plane face-lift as an alternative in the smoking patient.

O ver the past 30 years, face-lift surgery has progressed from a more limited skin elevation with no treatment of the superficial muscular aponeurotic system (SMAS) to more extended elevation of the skin and SMAS. Hamra popularized the traditional deep-plane technique lifting the SMAS and skin as a compound unit with a thicker, well-vascularized flap. This flap is elevated in a sub-SMAS dissection in the inferior cheek and superiorly transitioning to a supra-SMAS plane just superficial to the zygomaticus muscles in the superior medial cheek. The effects of nicotine on wound healing and flap viability have been associated with superficial skin necrosis and hematoma in the patient undergoing a face-lift. The risk of complications is increased with extensive subcutaneous face-lifts. There have been numerous studies examining the detrimental effects of smoking and wound healing (eg, Rees et al and Mosely and Finseth). The major effect of nicotine on wound healing is that it increases platelet adhesiveness and increases blood viscosity, leading to an increase in thrombotic microvascular occlusion and eventually tissue ischemia. The survival of a face-lift flap depends on adequate blood supply and oxygenation. Most surgeons consider smoking a relative contraindication to performing any type of face-lift. To decrease the chance of skin necrosis, some have adjusted their techniques by performing more limited undermining of the skin. This compromises the degree of correction of facial laxity and long-term results. Smoking can double the chances of hematoma collection postoperatively. The purpose of our study is to show that a deep-plane face-lift with extensive undermining can be performed safely in smokers with limited postoperative complications.