Why a Houston Plastic Surgeon Turns Down Deep Plane Facelift Requests
Patients walk into Houston consultations asking for a deep plane facelift by name. They have read that it is the technique behind natural results, the one that repositions the midface instead of pulling skin. Part of that holds up. Part of it is marketing that has outrun the surgery.
Leo Lapuerta, MD, FACS, a triple board-certified plastic surgeon in the Houston metro, has performed more than 30,000 surgical and non-surgical procedures across three decades. He recommends the deep plane approach when a patient’s anatomy calls for it, and he talks patients out of it when a shorter operation would produce the same face.
What the technique changes
Facial aging follows a pattern. Soft tissue under the skin descends, the ligaments anchoring it stretch, and the skin follows the tissue down. Every facelift technique reaches that descent from a different depth.
A skin-only lift tightens the outer layer and leaves the descended tissue where it fell. Surgeons abandoned the approach decades ago because the results faded within a few years.
A SMAS facelift works one layer deeper. The SMAS is a sheet of fibrous tissue and muscle sitting between the skin and the deeper structures of the face. Tightening it restores support without loading the skin with tension, and for many patients it produces a durable result.
A deep plane facelift releases the ligaments tethering the SMAS to the deeper facial structures, then repositions the SMAS and the skin as one unit. Freeing those ligaments lets the midface and the nasolabial fold move in ways they cannot while the SMAS stays anchored.
Who the operation suits
Dr. Lapuerta considers the deep plane approach for patients who show descent through the midface rather than laxity confined to the jawline, nasolabial folds that fillers no longer soften, volume that has shifted downward instead of disappearing, and enough tissue thickness to tolerate a deeper dissection. Patients in their late fifties and sixties often fit that description. So do patients in their forties who have lost a large amount of weight, since rapid volume loss accelerates ligament stretch.
Who should hear no
A deep plane facelift takes longer and involves a deeper dissection near the branches of the facial nerve. That trade makes sense when the anatomy requires it. It makes none when a simpler operation reaches the same result.
The cases Dr. Lapuerta redirects include laxity confined to the lower face and jawline, where a SMAS or lower lift reaches the problem without the deeper dissection; complaints centered on skin texture and sun damage rather than descent; faces where volume loss dominates and fat transfer accomplishes more than lifting; and patients whose medical history or medication raises the risk of a long operation.
A surgeon who recommends one technique to every patient is describing a preference, not a plan.
The question that predicts the result
Technique selection matters less than how many times the surgeon in front of you has performed that operation. Case volume and years in practice track patient-rated satisfaction better than the name of the procedure does.
Dr. Lapuerta trained at Stanford, earned his medical degree at UT Southwestern, completed general surgery at St. John’s in Detroit and his plastic surgery fellowship at St. Joseph in Houston, where he now serves as Chairman of Plastic Surgery. He holds faculty appointments at UT Houston, UT Medical Branch in Galveston, and the Houston Methodist plastic and reconstructive surgery fellowship, and he operates in his own QuadA accredited facility in Pearland with a physician anesthesiologist on every case.
Ask any surgeon three questions at consultation. How many of these have you performed. May I see before and after photographs of patients whose starting anatomy resembles mine. Which technique are you recommending for me, and what would change your mind.