u/DrLucasBoehm

I’m a plastic surgeon who specializes in deep plane facelifts. I want to use this case to walk through the actual anatomy driving the visible result.

The anatomic problem aging creates — specifically

Facial aging is not simply skin laxity. That’s a critical misconception that drives a lot of undertreated patients.

What’s actually happening is a composite process operating at multiple tissue depths simultaneously:

The retaining ligaments of the face — particularly the zygomatic cutaneous ligaments (McGregor’s patch), the masseteric cutaneous ligaments, and the mandibular ligaments — are fibrous condensations that tether the overlying soft tissue envelope to the underlying facial skeleton and deep fascia. With age, these ligaments attenuate. The soft tissue they were suspending — the malar fat pad, the buccal fat, the SOOF (suborbicularis oculi fat) — descends along predictable vectors.

The result is the constellation of findings we associate with facial aging: malar flattening, deepening of the nasolabial fold, jowl formation at the mandibular border as the descended cheek fat pad overrides the mandibular ligament, and loss of the cervicomental angle as the platysma weakens and subplatysmal fat accumulates.

This patient presented with all of it: prominent jowling effacing the mandibular line, midface descent with a deepened nasolabial fold, platysmal banding, and excess subplatysmal fat producing a blunted neck-chin angle. Her skin quality was good. The issue was structural.

Why the plane of dissection determines everything (almost)

A traditional SMASectomy or SMAS plication operates on top of or within the SMAS, leaving the retaining ligaments intact. The skin and SMAS are repositioned, but the tethering anatomy that caused the descent in the first place is never released. You’re working against fixed points. The vector of pull is therefore oblique and posterior — which is why superficial plane lifts can produce that telltale lateral sweep, and why tension on the skin closure is higher, predisposing to visible scars and earlobe distortion.

The deep plane dissection enters the sub-SMAS plane and carries the dissection anteromedially to directly release the zygomatic and masseteric cutaneous ligaments under direct visualization. Once those ligaments are released, the entire composite flap — skin, SMAS, and adherent facial soft tissue as a single anatomic unit — becomes mobile. It can be advanced superiorly and posteriorly along a more natural vector without skin tension, because the skin is not being asked to do the work of repositioning.

This is the mechanical distinction that matters: in a deep plane lift, the soft tissue is being repositioned to where it originated. In a superficial plane lift, the SMAS layer is being tightened and the skin is being pulled back to from where it has fallen. The clinical difference is naturalness of result, longevity, and the indirect improvement of the nasolabial fold — which improves not because it is excised or filled, but because the malar fat pad sitting above it has been restored to its native position.

What happened in this specific case

Frontal view: The jowling that had been overriding the mandibular border is resolved. The jawline is continuous and uninterrupted from the chin to the angle of the mandible. The nasolabial folds are softened — not eliminated, because that would look operated — through superior repositioning of the malar fat pad. The midface has a fuller, more convex contour because the descended soft tissue has been returned to the zygomatic eminence rather than sagging off of it.

Lateral and oblique views: The neck result is where the anatomy becomes particularly instructive. Preoperatively, she had both supraplatysmal and subplatysmal fat excess, along with visible platysmal diastasis — the separation of the paired platysmal muscles at the midline that produces vertical banding and a poorly defined cervicomental angle.

The neck was addressed through a separate submental incision. Direct lipectomy was performed in the subplatysmal plane to address the fat depot sitting behind the platysma. A corset platysmaplasty was then performed — the medial borders of the platysma were reapproximated in the midline with suture restoring the muscular sling that defines the anterior neck contour. Posteriorly the SMAS was anchored via the Mastoid Crevasse technique to elongate the jawline and give it depth.

The cervicomental angle in the postoperative lateral views reflects this combined approach: it is acute, well-defined, and anatomically appropriate rather than artificially sharp.

Incision and earlobe anatomy: One of the surgical details I pay close attention to is the relationship of the closure to the tragus and earlobe. Pixie ear deformity — inferior and anterior displacement of the earlobe — occurs when the skin flap is closed under excess tension, pulling the lobule out of its natural position. Because the deep plane composite flap is repositioned under no skin tension, the earlobe closure is tension-free and the lobule hangs at its native angle.

Longevity — the anatomic argument

Deep plane results are consistently reported to last longer than superficial plane results. The anatomic argument for why is straightforward: the retaining ligaments have been released and the soft tissue repositioned relative to the skeleton. The reattachment of the composite flap in its new position, combined with scar maturation at the new attachment points, creates durable fixation. The recurrence of descent requires the new adhesions to re-attenuate — a process that takes considerably longer than the progressive stretching of a SMAS tightening repair done under tension.

This is not to say deep plane facelifts are permanent. They are not. But the architecture of the repair is fundamentally more stable in my hands.

Appropriate candidacy — this doesn’t work for everyone

This patient was a good candidate: significant but not extreme soft tissue descent, good bone structure, non-smoker, realistic expectations, adequate skin quality. Deep plane surgery in patients with very thin skin, severe photodamage, or heavily fibrosed tissue from prior surgery requires significant modification of technique.

The operation is also longer and the recovery more involved than superficial alternatives in my experience. Swelling is greater because the dissection is deeper and more extensive. She was significantly edematous for the first two weeks, presentable socially by three to four weeks, and largely settled at 3-4 months — which is when these images were taken. Final result continues to refine for up to twelve months as residual deep edema resolves.

Lucas M Boehm, MD

Consona Plastic Surgery and Aesthetics

One of the questions I get most often in breast consultations is about scars. Specifically: why does one person end up with a lollipop or J scar and others end up with an anchor scar?

The answer is about tissue. Specifically, how much excess skin you have and where that excess lives.

Let me walk through the three main mastopexy incision patterns and the clinical logic behind each.

The Periareolar (Donut) Lift — What It Is and Where It Fits

A scar that runs only around the border of the areola. Minimal, well-concealed, and appealing on paper.

The periareolar lift is appropriate for VERY mild ptosis — nipple position that’s at or just slightly below the inframammary fold, with minimal or no skin excess. This lift is used primarily when you need to resize the areola or slightly reposition it. It is not meant to do much lifting at all.

But I use this rarely and selectively, because it has real limitations. The tension is distributed circumferentially around the areola, which means over time you can get areolar widening and flattening — the very thing patients were trying to avoid. It’s not a lift for significant ptosis, and using it for the wrong patient leads to a result that won’t hold.

The Lollipop (Vertical) Lift

A scar around the areola plus a vertical component running down to the inframammary fold. This is the incision pattern I use most often for mastopexy and augmentation-mastopexy.

It’s the right choice for moderate ptosis — nipple position below the fold with a moderate amount of skin excess in the horizontal dimension. Meaning the vertical incision allows you to remove skin to narrow the breast and create better projection.

The scar runs down the front of the breast, which sounds alarming to patients when I first describe it. But in practice, it heals well and it’s not visible in clothing. One underappreciated advantage: the vertical incision pattern encourages the tissue to project forward rather than spread laterally, which produces a more youthful, rounded shape over time.

Occasionally there will be a small J extension to the vertical scar that extends laterally. This allows the surgeon to improve the lateral portion of the breast and slightly shorten the distance from the nipple to the inframammary fold when necessary.

The Anchor (Wise Pattern) Lift — When More Skin Demands More Scar

Periareolar + vertical + a horizontal scar running along the inframammary fold.

This is the appropriate choice when there’s significant ptosis combined with substantial skin excess — meaning you need to reposition the nipple, tighten the horizontal width of the breast (via the vertical scar) and shorten the distance from the nipple to the inframammary fold (ie remove the vertical excess of skin in the lower pole) via the horizontal Inframammary fold incision. It gives the surgeon full control over the entire skin envelope: you can remove redundancy in every direction, which is critical when the breast has been significantly deflated (after major weight loss or multiple pregnancies) or when the tissue is very lax.

The trade-off is the inframammary scar. It sits in a natural fold, and in most patients it heals in a position that’s hidden in clothing and swimwear. But it’s still a scar, and patients need to understand that going in.

I don’t consider the anchor pattern a step backward or a more aggressive choice. I consider it the right tool for certain tissue presentations — specifically those where the vertical pattern alone can’t adequately address the volume of skin excess without distorting the result.

The Decision Framework

When I’m planning a mastopexy, I’m evaluating three things:

1. Nipple position relative to the inframammary fold. This tells me the degree of ptosis I’m correctly.

2. Volume of skin excess and where it lives. Predominantly in the lower pole? Lateral excess? Both?

3. Tissue quality. After weight loss or nursing, the skin has different elasticity characteristics than in a younger patient with minimal stretch.

What I never do is choose an incision pattern based on what sounds least alarming to a patient. That’s how you end up with a result that doesn’t hold, and a patient who needed a revision six months later.

I tell every male patient who comes in concerned about their eyes that the goal is to make you look rested. Not necessarily younger - but rested. 

This patient came to me with classic findings for a man his age — heavy dermatochalasis of the upper lids, pseudoherniation of orbital fat creating that tired, puffy lower lid appearance, and a heavy brow that was compounding everything by pushing excess skin down onto the upper lid platform. He wasn’t coming in because he wanted to look younger. He was coming in because people kept asking him if he was tired or stressed — and he wasn’t.

That’s the real chief complaint in periorbital aging.

What I actually did:

Upper blepharoplasty with conservative skin excision. The word conservative matters here. Over-resection of the upper lid is the #1 cause of that hollow, operated-on look — especially in men, where a heavier brow and more robust lid platform means you have less margin for error.

Lower lid fat repositioning, not excision. This is a philosophy point. Excising lower lid fat trades one problem (puffiness) for another (hollowing and skeletonization over time). Repositioning that fat over the orbital rim fills the tear trough, softens the lid-cheek junction, and ages gracefully.

Brow — I addressed this conservatively using stabilization sutures through his upper blepharoplasty incision. In men, a heavy, slightly lower brow is masculine and appropriate. The goal wasn’t to lift it aggressively. It was to restore it to where it belonged without feminizing the upper face.

Look at the oblique view:

This is where periorbital results are really judged. The oblique tells you whether the lid-cheek transition is smooth, whether the fat repositioning landed naturally, whether the brow sits right. In this patient, the transition from lower lid to cheek is seamless — no residual bag, no new hollow, no operated crease.

Why men are a different conversation

Men tolerate less visible change before looking “operated on.” Scars that are acceptable in a female upper lid crease are conspicuous in a man’s thicker skin. The brow position that looks refreshed on a woman looks startled on a man. You have to think about male periorbital anatomy differently from the start — not just do the same operation more conservatively.

This guy looks like himself. Rested. Sharp. Nobody’s going to ask him if he’s tired anymore.

That’s the whole point.

One of the most technically demanding procedures in all of breast surgery is a breast lift with implants (augmentation-mastopexy) in a patient who has lost significant weight. I wanted to create an educational post on this because I feel like most patients are given an oversimplified version of what this operation actually involves.

The photos I’m sharing here represent a patient who lost a meaningful amount of weight. She came to me with significant ptosis (drooping), poor skin quality, and volume deflation — a combination that’s extremely common after weight loss, pregnancy, or both. She wanted to feel like herself again. Not dramatically different. She wanted fullness, lift, and natural results that would actually last.

The Problem with Weight-Loss Breast Tissue

After weight loss, the breast tissue that remains is fundamentally different from what it was before. The skin envelope has been stretched. The soft tissue has lost its elasticity and internal structural integrity. The Cooper’s ligaments — the natural internal support system of the breast — have been attenuated.

This matters enormously when you’re planning an augmentation-mastopexy, because you’re not just lifting and adding volume. You’re asking a compromised tissue system to hold up that volume long-term. Without addressing the underlying structural deficit, you’re building on a weak foundation.

Implant Sizing: Restraint is a Clinical Decision

One of the most common mistakes I see — both in consultations with patients who’ve had previous surgeries elsewhere, and in planning discussions — is the instinct to go larger. The logic seems intuitive: she lost volume, so replace it generously.

But in the post-weight-loss breast, larger implants create more tension on already-compromised tissue. Long-term that tension translates to:

1. Accelerated inferior pole stretch
2. Early bottoming out
3. Potential for wound healing complications

For this patient, we chose an implant size that restored a natural, proportionate fullness without overloading the tissue. The goal was a result that looks like her — refreshed, lifted, feminine.

The Role of Internal Support - “The Internal Mesh Bra”

This is the part of the procedure that most directly affects longevity and it’s often not discussed with patients.

The internal bra I use is made from poly-4-hydroxybutyrate (P4HB). I use it routinely in augmentation-mastopexy patients — particularly those with post-weight-loss or post-pregnancy tissue — as an internal bra. It’s placed to reinforce the inferior pole and support the implant-tissue interface while the body deposits new collagen around it. Over approximately 18 months, the mesh resorbs and is replaced by organized native collagen — the patient’s own structural tissue.

I think of it this way: the mastopexy (lift) reshapes the external skin envelope, the implant restores internal volume, and mesh provides the internal scaffolding that allows both to hold their position over time. Without it, in a high-risk tissue environment like post-weight-loss skin, you’re relying entirely on already-compromised tissue to do a job it may not be equipped to do long-term.

If you’re considering this procedure after weight loss, the questions I’d encourage you to ask your surgeon:

1. How does my tissue quality impact the surgery?
2. What is your philosophy on implant sizing in patients with compromised soft tissue quality?
3. Do you use any form of internal support, and why or why not?
4. What does your revision rate look like for augmentation-mastopexy?

This is a complex operation. The margin between an excellent result and a disappointing one is narrower than in most breast procedures. Surgeon experience, implant selection, and internal support are not interchangeable variables — they’re interdependent decisions that have to be made together, with your tissue in mind.

One of the most technically demanding procedures in all of breast surgery is a breast lift with implants (augmentation-mastopexy) in a patient who has lost significant weight. I wanted to create an educational post on this because I feel like most patients are given an oversimplified version of what this operation actually involves.

The photos I’m sharing here represent a patient who lost a meaningful amount of weight. She came to me with significant ptosis (drooping), poor skin quality, and volume deflation — a combination that’s extremely common after weight loss, pregnancy, or both. She wanted to feel like herself again. Not dramatically different. She wanted fullness, lift, and natural results that would actually last.

The Problem with Weight-Loss Breast Tissue

After weight loss, the breast tissue that remains is fundamentally different from what it was before. The skin envelope has been stretched. The soft tissue has lost its elasticity and internal structural integrity. The Cooper’s ligaments — the natural internal support system of the breast — have been attenuated.

This matters enormously when you’re planning an augmentation-mastopexy, because you’re not just lifting and adding volume. You’re asking a compromised tissue system to hold up that volume long-term. Without addressing the underlying structural deficit, you’re building on a weak foundation.

Implant Sizing: Restraint is a Clinical Decision

One of the most common mistakes I see — both in consultations with patients who’ve had previous surgeries elsewhere, and in planning discussions — is the instinct to go larger. The logic seems intuitive: she lost volume, so replace it generously.

But in the post-weight-loss breast, larger implants create more tension on already-compromised tissue. Long-term that tension translates to:

1. Accelerated inferior pole stretch
2. Early bottoming out
3. Potential for wound healing complications

For this patient, we chose an implant size that restored a natural, proportionate fullness without overloading the tissue. The goal was a result that looks like her — refreshed, lifted, feminine.

The Role of Internal Support - “The Internal Mesh Bra”

This is the part of the procedure that most directly affects longevity and it’s often not discussed with patients.

The internal bra I use is made from poly-4-hydroxybutyrate (P4HB). I use it routinely in augmentation-mastopexy patients — particularly those with post-weight-loss or post-pregnancy tissue — as an internal bra. It’s placed to reinforce the inferior pole and support the implant-tissue interface while the body deposits new collagen around it. Over approximately 18 months, the mesh resorbs and is replaced by organized native collagen — the patient’s own structural tissue.

I think of it this way: the mastopexy (lift) reshapes the external skin envelope, the implant restores internal volume, and mesh provides the internal scaffolding that allows both to hold their position over time. Without it, in a high-risk tissue environment like post-weight-loss skin, you’re relying entirely on already-compromised tissue to do a job it may not be equipped to do long-term.

If you’re considering this procedure after weight loss, the questions I’d encourage you to ask your surgeon:

1. How does my tissue quality impact the surgery?
2. What is your philosophy on implant sizing in patients with compromised soft tissue quality?
3. Do you use any form of internal support, and why or why not?
4. What does your revision rate look like for augmentation-mastopexy?

This is a complex operation. The margin between an excellent result and a disappointing one is narrower than in most breast procedures. Surgeon experience, implant selection, and internal support are not interchangeable variables — they’re interdependent decisions that have to be made together, with your tissue in mind.

Lucas M Boehm, MD

Consona Plastic Surgery and Aesthetics

Sharing an on-table before/after from a recent tertiary revision rhinoplasty I performed. The patient had her 2 prior rhinoplasty procedures with other surgeons - her septum had been harvested for grafting purposes, she had never had osteotomies either. Her goals were to reduce the width of her nose, drop her dorsum slightly, and refine her nasal tip.

What we were working with:

This patient had a bulbous, poorly defined tip with excess width. On the birds-eye view, the tip lobule was round with no clear definition. On exam, she had significant scar tissue formation in the nasal tip. The lateral showed a slightly over-projecting dorsum.

What we did:

Open ultrasonic dorsal preservation rhinoplasty to narrow the width of her nose and reduce her dorsum. Because her prior surgeries never addressed this part of her nose I was able to utilize a dorsal preservation technique for a more natural appearing dorsum. Her nasal tip was incredibly scarred and after removing her prior cartilage grafts I was able to shape the tip cartilages and stabilize them in position with a rib graft anchored to her remaining septal cartilage.

Why revision rhinoplasty is a different animal:

Revision rhinoplasty is widely considered one of the most technically demanding procedures in plastic surgery — and for good reason. Every revision case presents a unique set of challenges that simply don't exist in primary surgery.

The most significant issue is scar tissue. Prior surgery leaves behind fibrosis throughout the nasal layers, which distorts normal tissue planes, limits visibility, and makes dissection significantly more difficult. Tissue that would separate cleanly in a primary case has to be carefully freed from surrounding scar, increasing both operative time and the risk of inadvertent injury.

Cartilage is the second major challenge. Many revision patients have had cartilage removed, repositioned, or weakened by prior surgery. When structural support is compromised, you often can't simply suture your way to a result — you need to rebuild. That frequently means harvesting cartilage grafts from the rib to restore the framework before any refinement work can even begin.

Skin and soft tissue behave differently the second (or third) time around as well. Thickened, less-pliable skin from prior scarring doesn't drape and contract the way native tissue does. This limits how much visible refinement is achievable and makes predicting the final result harder — even for experienced surgeons.

Finally, revision patients often carry the emotional weight of a prior outcome they were unhappy with. Managing expectations honestly and transparently — particularly around healing timelines — is as important as the surgical planning itself.

Important context:

These are same-day photos taken immediately post-op. Rhinoplasty swelling in the lower third takes 6–12 months to fully resolve, and revision cases can run even longer due to the scar tissue factors described above. The structural work is done; the skin envelope softens and contracts over time, and the refinement becomes more apparent as healing progresses.