Deep plane facelift in Thessaloniki and Athens, Greece

A deep plane facelift works beneath the SMAS, the fibromuscular layer that lies under the skin and fat. The retaining ligaments are released, so the midface, the jawline and the neck are lifted as a single unit instead of by pulling on the skin. Hamra first described the technique in 1990 [1].

The deeper the tissues are mobilised, the more stable the result; a superficial lift does not last as long. The deep plane technique rests on a detailed understanding of the facial retaining ligaments [6, 7].

Technique	What is lifted	Ligaments	Tension on the skin
Skin only (traditional facelift)	Skin	Not released	High
SMAS plication	Skin, with a fold of the SMAS	Not released	Moderate
High / vertical SMAS	Skin and SMAS separately	Partly	Moderate
Deep plane	Skin, fat and SMAS as one	Yes	Low

The deep plane facelift treats the midface (down to the corners of the mouth) and the lower face (jawline and neck). The forehead and eyes have their own procedures: a forehead lift and blepharoplasty (eyelid surgery). For isolated concerns there are also the neck lift and the midface lift.

A deep plane facelift suits men and women with moderate to marked laxity of the face and neck, usually after the age of 40. Whether it is right for you depends on your anatomy, the quality of your tissues and your general health, not on your age alone.

The forehead and eyes are treated with an endoscopic forehead lift or blepharoplasty, often in the same operation.

Preparation starts at the consultation, where we look at your face as a whole and agree a plan. Before surgery you will need blood tests and, depending on your age and medical history, a cardiac check. If you smoke, nicotine stops about a week before and a week after the operation.

What happens at the consultation?

Each face needs a holistic assessment, so that the overall result looks natural and youthful without looking overdone. A deep plane facelift reverses a large and important part of facial ageing, but it is sometimes better combined with other procedures, so that the whole face looks the same age and the upper and lower face stay in proportion. We discuss this together at the consultation.

What tests and instructions apply before surgery?

You will need pre-operative blood tests and, where needed, a cardiac assessment, depending on your age and history. If you smoke, I recommend stopping, or switching to nicotine-free vaping, for about a week before and a week after surgery. If you take blood thinners, the plan is always agreed with the doctor who prescribed them (see “What are the risks of a deep plane facelift?”). The date of surgery is set once the tests are complete.

How do I choose a deep plane facelift surgeon?

The deep plane technique has a demanding learning curve, because the ligaments are released close to the branches of the facial nerve, and it needs specific training. Volume and specialisation in the technique matter. Questions worth asking any surgeon:

1. Which technique do you use, and do you release the ligaments?
2. How many deep plane facelifts do you perform a year?
3. Can I see cases at least one year after surgery?
4. Where is the operation done, and who gives the anaesthetic?
5. Who follows me up after surgery, and how?

A deep plane facelift is done under general anaesthesia (anesthesia) and takes 3 to 5 hours. Through incisions around the ear I release the main facial ligaments and lift skin, fat and SMAS as one unit, almost vertically, against gravity. The skin is closed without tension, using absorbable stitches.

The operation can also be done under local anaesthesia with sedation, but I do not recommend it: general anaesthesia allows precise surgery in a still field and keeps blood pressure under control. The operation takes longer when it is combined with deep neck surgery, a temporal lift or other procedures. The way the tissues are lifted differs fundamentally from other facelift techniques, mainly because of the depth at which they are mobilised and the vector of the lift.

Releasing the ligaments and the vector of the lift

The key step for an effective lift is releasing the five main facial ligaments, the connective tissue that holds the skin and soft tissues in place [6, 7]. Once released, the tissues are secured in their new position to strong structures such as the temporal and parotid fascia and the mastoid process.

The lift follows a vector of 60–70 degrees. In other words, the tissues are lifted almost vertically, directly against gravity, which is more effective and looks more natural than a sideways pull. Another advantage is that skin undermining on the face is limited, usually to 2–3 centimetres, which leaves little dead space for bruising and reduces healing problems. Where needed, the tissues can also be folded to add volume to the cheeks.

The neck: face and neck lifted as one

The dissection in the deep plane starts at about the corner of the eye and continues without a break down to the neck, beneath the mobile part of the SMAS and the platysma, the most superficial muscle of the neck. The face and neck are therefore lifted as one unit, which is far stronger and more effective.

Sometimes, as well as the lift backwards, the centre of the neck needs to be approached through a small incision under the chin, for a “hammock” fixation of the platysma that better corrects the “double chin” under the jaw. When needed, the deeper structures of the neck are also corrected (deep neck surgery), and the result can be refined with neck liposuction. If your concern is mainly the neck, see the neck lift page.

Incisions and stitches

To hide most of the scarring, the incisions are placed around the ear, in natural creases and within the hair. Depending on how much excess skin there is, the incision may start in front of the sideburn, run down beneath it and continue behind the tragus in women, or in front of the tragus in men so that the beard line does not shift. It then passes under the earlobe, rises behind the ear and runs down towards the hairline.

The hairline and the position of the hair do not change, and the shape of the ear is not affected. The skin is closed without tension, so that the scar does not widen or distort the area around the ear. I close with continuous, intradermal, absorbable stitches, so there are no stitches to remove.

Haemostatic net and drains

At the end of the operation I place a haemostatic net in every patient and remove it on day 1. Together with a medication that reduces bleeding, it reduces bruising and swelling, and most patients do not need drains. I use drains in men and in patients who take blood thinners.

Combined procedures

When a deep plane facelift is combined with a lift of the upper third of the face (the forehead, brows and eyes), we call it a “total facelift”. Common combinations in the same operation:

• deep neck surgery (the deeper structures of the neck) and a temporal lift;
• an endoscopic forehead and brow lift, and blepharoplasty;
• a lip lift (lifting the upper lip);
• fat transfer and nanofat;
• changes to the shape of the face, such as rhinoplasty or a silicone chin implant;
• laser or fractional RF skin treatment for the fine lines around the mouth.

Each combination adds to the length of the operation and of the anaesthetic.

Hospital stay

Patients who live locally usually go home the same day. Patients travelling from further away stay one night in the hospital. Surgery takes place at Interbalkan Medical Center in Thessaloniki or at Athens Medical Center in Marousi, Athens.

Allow 10 days of full downtime and about 3 weeks before you can be seen socially without visible signs of surgery. Pain is mild, with a feeling of pressure in the neck for 2 to 3 weeks. The final result settles over 6 to 12 months.

Recovery has three stages. In the first 3 weeks the swelling and bruising settle. At 6–8 weeks there is a firmer swelling in the cheeks and under the jaw, which softens without visible distortion. At 6–12 months the final result is in place.

DowntimeDays 1–10

SocialWeeks 2–3

Firm swellingsoftens by week 8

RemodellingMonths 3–6

Final resultMonths 6–12

Day 1I remove the haemostatic net

Day 5Check that all is going well

Day 10Walking, light activities

Week 3Back to work and social life

Month 1Exercise

Weeks 6–8The firm swelling softens

Months 3–6Numbness fades, scars lighten

Months 6–12Scars mature

Patients from abroad: 5–10 days in Greece (minimum 5)

In person

In person

Video · 10 days

Video · 1 month

Video · 6 months

Video · 1 year

1. DowntimeDay 1I remove the haemostatic netVisit at the practice
2. Day 5Check that all is going wellVisit at the practice
3. Day 10Walking, light activitiesVideo call

Patients from abroad: 5–10 days in Greece (minimum 5)

1. SocialWeek 3Back to work and social life
2. Firm swellingMonth 1ExerciseVideo call
3. Weeks 6–8The firm swelling softens
4. RemodellingMonths 3–6Numbness fades, scars lightenVideo call at 6 months
5. Final resultMonths 6–12Scars matureVideo call at 1 year

Visit at the practiceVideo call; I do every check myself

Recovery varies from person to person and is not always predictable.

When	What you feel	What you can do
Day 1	Swelling, a feeling of tightness	Check-up; I remove the haemostatic net
Days 1–10	Swelling, bruising, tightness in the neck; mild pain, controlled with simple painkillers	Rest at home with your head raised; the stitches dissolve
From day 10	Fluid gradually settles	Walking and light activities; make-up to cover any marks if needed
Weeks 2–3	Swelling goes down; numbness in the cheeks and ears, pressure in the neck	Gradually more activity
Week 3	Socially presentable	Back to work and social life
Month 1	Some residual swelling	Exercise
Weeks 6–8	The firm swelling in the cheeks and under the jaw softens	Normal activity
Months 3–6	Remodelling: numbness fades, scars lighten	Normal activity
Months 6–12	Tissues soften, scars mature	Final result

Recovery and the appearance of the scars vary from person to person and are not always predictable.

Plan to stay in Greece for 5 to 10 days after a deep plane facelift; the minimum is 5 days. Patients travelling from abroad spend the first night in the hospital, and the stitches are absorbable, so there is nothing to remove before you fly home.

A typical stay looks like this:

• Night of surgery: one night in the hospital.
• Day 1: check-up and removal of the haemostatic net.
• Day 5: check-up; this is the minimum before you leave.
• Flying home: from day 5, after your final check the day before the flight; plan 5 to 10 days in Greece in total.

Your face will look different for a while, and this can cause a problem with your passport. If you fly home before the second week, you may need a medical certificate; we issue it for you.

Once you are home, I see you by video call at 10 days, 1 month, 6 months and 1 year.

Before you travel, arrange someone to help you for the first days and, if you would like it, nursing care at home; all follow-up checks are done by me. For the first 10 days you will be resting at home with your head raised, taking simple painkillers.

The final result shows at 6 to 12 months. Because the tissues are lifted in the deep plane rather than by tension on the skin, the face does not look pulled, and your features, expression and the position of your mouth are preserved. Normal ageing continues, but from a better starting point.

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Deep plane facelift

Woman, 50–60 · Deep plane facelift · 3 months after · Surgeon: Dr Prodromos Papaioannou

Results vary from patient to patient.

I avoid an overdone, “frozen” or overfilled look; the aim is a fresh, rested and natural face. In my experience the deep plane facelift is superior in both how natural the result looks and how long it lasts, and it is effective whatever your age or degree of laxity. Long-term studies show that most patients still look younger than before surgery 5 years or more later; the deep plane result lasts well because the ligaments are released and the tissues repositioned without tension. Keeping your weight stable is a condition for this. After 5–6 months the scars usually allow you to wear your hair pulled back without them showing. A skin treatment such as laser resurfacing enhances the result, because it removes fine surface lines.

In a meta-analysis of 41,141 patients, deep plane facelifts had a complication rate similar to simpler SMAS techniques [2]. The most common early complication is a haematoma (hematoma), which specific measures help prevent. Temporary weakness of a facial nerve branch is rare. I explain the risks for your own case at the consultation.

Complication	How common	Prevention and treatment
Haematoma	The most common early complication; the literature reports 1–15% [3]	A medication that reduces bleeding, into the vein and in the local anaesthetic; a haemostatic net for every patient, a drain for men and patients on blood thinners (see below)
Temporary weakness of a facial nerve branch	Rare; about 0.7% with the deep plane technique, no permanent injury in the meta-analysis [2]	Recovers over weeks to months
Skin necrosis	Rare; much more likely in smokers	Stop nicotine, or switch to nicotine-free vaping, \~1 week before and after; hyperbaric oxygen for heavy smokers
Numbness	Common, temporary	Fades gradually over 3–6 months
Temporary change in facial muscle movement	Not rare, temporary	Resolves with no clinical consequence
Pressure in the neck	Common, temporary	Lasts 2–3 weeks
Firm swelling in the cheeks and under the jaw	Common, temporary	Softens over 6–8 weeks
Scars	Visible in the first months	Placed in natural creases and the hair, closed without tension; mature over 6–12 months

Smoking. I ask you to stop nicotine (including nicotine vaping) one week before and one week after surgery. A pack a day or more counts as heavy smoking and can change the surgical plan; in that case I also suggest hyperbaric oxygen to support healing.

Blood thinners. Always in agreement with your cardiologist or the doctor who prescribed them. If they can be stopped safely one week before surgery, that is enough. If not, we switch to injectable blood thinners for at least 7–10 days and then return to your usual treatment.

The cost depends on the extent of the operation, any combined procedures, the length of surgery and the hospital. I do not publish prices: you receive a quote after your consultation and examination, once we have agreed your plan. These are the factors that shape it:

• The extent: the face alone, or also deep neck surgery and a temporal lift.
• Combined procedures: forehead lift, blepharoplasty, lip lift, fat transfer.
• The length of the operation and the overnight stay in the hospital.
• The hospital: Thessaloniki or Athens.