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Deep Plane Facelift

Dr. Rad is a specialist in facelift in Washington DC. He focuses the majority of his practice on a specialized method of facelift called “deep plane” facelift, a meticulous technique that blends technical ability and artistry at the highest level. Different techniques in facelift vary in how the surgeon treats the various layers, or “planes” or tissues in the face. The term “deep plane” refers to the muscle fascia layer (i.e. “plane”) which lies beneath the skin/fatty layer which is the most superficial layer. The “deep plane” refers to elevating the facial muscle layer, termed “SMAS,” and limiting the dissection of facial skin. This is the key to natural results, imperceptible scars, and longevity of youthful appearance.

Think of layers of an onion, the outside skin being the superficial layer, and as you peel away the layers you get deeper into the onion. The reason Dr. Rad’s deep plane technique is so powerful because the muscle/fascia layer has strength and can hold a lift as compared to the skin/fatty layer which is relatively weak and elastic and cannot hold a lift. This is why early facelifts that focused on tightening skin had poor results because the skin just stretched right back out. Surgeons learned that the deep muscle/fascia layer is much more powerful and reliable because it has tensile strength. But few surgeons can perform deep plane surgery safely and effectively because the facial nerve branches that control facial movement are close by. So it requires tremendous depth of experience to navigate delicate facial nerves and muscle anatomy carefully.

Dr. Rad trained at some of the world’s top medical institutions at Duke University and Johns Hopkins Hospital, and he has been certified by the American Board of Plastic Surgery since 2010. Dr. Rad has honed his method of facelift through thousands of operations since 2009 when he was Director of Aesthetic Surgery at Johns Hopkins. With Dr. Rad’s approach, a well executed facelift can remove 15-20 years of aging changes naturally, beautifully, as if time reversed direction.

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A good candidate for a deep plane facelift is someone who has noted increasing tissue laxity that is beginning to show aging. Loose tissues tend to show up in the neck, under chin area, jowls along the jawline, marionette (“puppet lines” from corners of the mouth), and nasolabial folds. Lax tissues begin to impart a square appearance to the face, hiding the underlying youthful heart shape and clean neck and jawlines. Under eyes tend to show hollowing because of midface cheek fat descent, pulling volume away from the lower eyelids which can also show bulging under eye bags. Patients who’ve reached the limit of non-surgical approaches, such as fillers and Botox, and who want a natural refresh, may be good candidates. Dr. Rad’s deep plane technique can be used for healthy patients of all ages and Dr. Rad has taken care of patients from age 30 through 80. Dr. Rad always fine-tunes his approach to each patient’s unique anatomy to achieve subtle yet stunning results.

  • Minimizing or Eliminating Facelift Scars – Dr. Rad will place small incisions hidden in the natural crease behind the ear. Depending on the degree of tissue movement that is required to achieve the desired results in the front of the ear or behind the tragus. This is how he achieves minimal scarring that is not visible to anyone.
  • Natural Results – Dr. Rad’s technique focuses on a tissue elevation and “redraping” of skin which avoids unnatural stretching of skin. This avoids a “wind tunnel” look and instead enhances natural facial architecture. Furthermore, Dr. Rad is so meticulous in the distribution of tensions as not to distort the natural anatomy of the ears, hairline, or mouth as is common in less experienced hands. Aesthetically, this translates to a refreshed, rested and simply more attractive appearance.
  • Maximal Longevity – Dr. Rad addresses the deeper layer of tissue, the SMAS muscle layer, when performing the lift. This is crucial for a long lasting result because the SMAS can hold tension whereas skin cannot. While many surgeons tighten skin under the false promise that a “lunch time lift” is safest and equally rejuvenative, this is akin to building a house of foam girders – it simply won’t hold up over time.
  • Minimally Invasive – Dr. Rad always endeavors to hide scars and the scars sometimes can be completely invisible even while wearing hair in a ponytail. Targeted surgical dissection and manipulation is the hallmark of Dr. Rad’s technique and this translates to rapid recovery and days, not weeks, for returning to normal activity.
  • Hiding the Evidence of the Work – Distortions of the earlobe and tragus, the small isthmus of cartilage covering the ear canal, are telltale signs of facelifting and occur in less experienced hands. Dr. Rad’s technique features incisions behind the tragus or not at all in front of the ear thus eliminating the possibility of unwanted distortions.

“In facial aesthetic surgery, details are everything.”

- Ariel N Rad, MD, PhD, FACS

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01Artistry

Artistry is at the heart of facelifting because together we are searching for restoration to a prior youthful appearance. All surgeons have a different degree of aesthetic sense, some more than others. Dr. Rad’s eye is trained to evaluate a face both holistically and at the smallest details, looking for asymmetries and optimal contours. Dr. Rad routinely requests that you send photos of your face from prior decades starting in your teen years through to your current age. By comparing photos across the decades Dr. Rad is able to see how your face changed through the years, and this gives him insight into how best to restore your prior youthful appearance naturally and harmoniously. Dr. Rad spends time with you to formulate the best plan to achieve your goals. This often requires a combination of procedures, from deep plane face and neck lift, to brow lift and blepharoplasty, as well as fat grafting. Each procedure is intended to correct subtle signs of aging. But keep in mind that the art lies in the hands performing the procedures, not the procedures themselves. Just as a beautiful piano concerto stands in its own beauty, it’s the pianist who brings it to life, some better than others. Likewise, surgeons have different skill levels and aesthetic nuance, and bring to life the best results to varying degrees of ability. The level of artistry required to achieve natural, beautiful and long lasting results requires tremendous nuance. As Dr. Rad frequently says, “millimeter changes throughout the face can synergize beautifully into stunning yet natural results.” These details are reflected in surgeons’ before/after photographs which is why you must evaluate these with an aesthetic eye. You have only 1 face and so listen to your instincts when you look at surgeons’ results.

02Safety

Experience is everything when it comes to safety. Dr. Rad has performed thousands of face lift operations and he routinely performs 3-5 facelifts per week. He prides himself in achieving beautiful, natural results for both women and men, and he operates with safety at top of mind by working with expert anesthesia and nursing teams at DC’s top hospital-based surgery centers. In Dr. Rad’s hands, facelift surgery entails low risk and safety is always top of mind. Dr. Rad’s innate familiarity with facial anatomy, knowledge of safe navigation of the delicate nerves, muscles and blood vessels, and working with expert anesthesia and nursing teams, all translate to keeping patients safe.
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03Technique

The technique involves the following process:
1. Dr. Rad makes exact incisions along natural contours in front of the ears (“pre-auricular”) and behind the ears (“post-auricular”), so they are hidden from view. Dr. Rad’s preference is to place the pre-auricular incision behind the tragus, the small isthmus of tissue just in front of the ear canal, because this is an opportunity to hide the scar line in its most exposed location. Most surgeons place the incision straight down in front of the tragus, making it more visible even though theoretically it can hide within a vertical skinfold; however, after face lift the skin fold is no more, having been smoothed by the lift, thus exposing the scar line.

2. Through these incisions, Dr. Rad elevates the skin within the subcutaneous fat plane in order to expose the muscle layer, the “superficial musculoaponeurotic system” (“SMAS”), and the platysma. Often Dr. Rad uses a short under-chin incision to tighten neck muscles and reduce fatty deposits and bulging glands (called “deep neck sculpting”) which creates beautiful neck contours.

3. Dr. Rad limits skin “undermining” or separation from underlying muscle/fascia layer – this minimizes post-operative swelling, improves blood flow through the skin which optimizes scar healing, reduces risk of poor wound healing, and skin is naturally redraped without tension. This is a key difference from a SMAS facelift which releases the skin and superficial fatty layer from the muscle/fascia layer which sometimes is necessary with very lax cheek tissues and deep nasolabial folds.

4. Dr. Rad releases the facial ligaments – called “osteocutaneous ligaments” – that connect the midface tissues to our facial bones in order to fully mobilize lax cheek tissues and lift them upwards, thus reversing sagging. Not releasing ligaments can result in recurrent laxity and therefore it is a key step. Release of ligaments is a standard in deep plane facelift and “SMAS” lift techniques, though requires deep experience in the surgeon to be able to identify and differentiate ligaments from facial nerve branches.

5. Once ligaments are released, Dr. Rad elevates and resuspends the muscle/fascia layer called the “SMAS” and platysma layer – this is a crucial step to achieve the most natural results and avoid a windswept appearance that is common in skin-only lifting techniques. Tension on scars is minimized, the single most important technical detail to make facelift scars imperceptible.

6. After underlying facial tissues are restored to a lifted position, Dr. Rad artfully removes excess skin and incisions are closed in a tension-free manner. Here, it is crucial not to remove excess skin so that widened scars, “pixie ear deformity” and “ear canal show” deformity are avoided.

7. A light dressing is applied after which you can return home or to your hotel. The procedure is performed on an outpatient basis in almost all cases and, for safety, patients are routinely cared for by skilled private nurses for 48-72 hours.

04recovery

Recovery is a process of tissue healing and feeling back to normal that requires time. The length of time depends on which facial areas are treated, the complexity of surgery, and individual healing factors. The key principle of surgery that Dr. Rad always adheres to is minimizing surgery to achieve best results, thus minimizing healing and recovery time. Since each case is different, Dr. Rad will guide you through the recovery process with comprehensive information based on your unique situation.
Recovery is not painful after a deep plane facelift and mild/moderate tightness is normal. Swelling peaks in 2-3 days then rapidly decreases. Patients can resume most normal activities almost immediately, including walking, child care and basic pet care, except heavy lifting. Most patients taper off stronger pain medicine in a few days as pain is not a significant part of recovery. You will see Dr. Rad within a day or two, then again one week after surgery.
Moderate bruising and swelling will distort your facial features for the first week after a deep plane facelift. However, during the first through second weeks swelling and bruising rapidly resolve and visible signs of surgery dissipate over 2 weeks. Looking “normal” to others is a process that takes a few weeks, and some will require more time, others less. It depends on your innate tissue healing physiology. Returning to work in 1-3 weeks is common, depending on the degree of comfort you have with others potentially seeing any evidence of surgery. Return to exercise is between 3-8 weeks, depending on your baseline level of intensity.

05Aftercare

Care post-surgery is important for both your recovery and results whether at your home or at a hotel. For your safety, as you’ll be somewhat sleepy, you will need a responsible adult to stay with you for at least the first night. If you’re interested in having an experienced private duty nurse, we can help facilitate this care.
Once home or in a hotel, you will mostly rest, although you should be able to perform “activities of daily living,” meaning being up and about and doing basic self care. Since your head will be wrapped, you’ll defer showering until your first post-op appointment with Dr. Rad 1-2 days after surgery.
During the daytime you should walk 10-15 minutes each hour and should not be on bed rest. Pain is relatively mild and most patients need a mild pain medicine to help them sleep. Tissues react with swelling and bruising that distorts facial appearance and causes facial muscles not to work normally, but this is normal and temporary. Cold compresses and head elevation helps with comfort and swelling.
Since nausea is not uncommon after anesthesia, no matter how light the anesthesia given, nausea prevention is essential and straightforward by taking an anti-nausea medicine such as Zofran (Ondansetron). Nausea side effects typically wear off in 24-48 hours. Other side effects of anesthesia include feeling a bit groggy or “out of it”, but this is relatively mild and wears off quickly. Dr. Rad recommends not planning important work-related activities or phone calls as you will not feel your sharpest.
Drinking liquids is most important to maintain hydration. Dr. Rad recommends Gatorade, or Drip Drop and Liquid IV electrolyte replacement powders mixed in water. If neck lift has been done then patients often feel some neck tightness that is normal, common and temporary. You will see Dr. Rad within the first few days to check on your early healing.

06longevity

Your vision for your results will emerge through detailed consultation with Dr. Rad, meticulous examination of your anatomy, and careful pre-surgical planning. While Dr. Rad’s surgical approach is unique for each patient, the goal of naturalness remains constant.
Over the course of 2-6 weeks post surgery, results will continue to develop with long-term recovery experienced around 6 to 12 months after the procedure. By this point, the majority of swelling and bruising should have resolved, and you should start seeing the full results of your deep plane facelift. However, it’s important to note that individual healing rates can vary, and it may take several months for all swelling to completely dissipate and the final outcome to be evident.
To enhance your results and “protect your investment”, Dr. Rad recommends consulting with Dr. Sherber for laser resurfacing, injectable neuromodulators such as Botox or Daxxify, a results-oriented skincare and sun protection regimen, and non-invasive skin tightening with Thermage FLX. Just like regular tune-ups or oil changes to keep your car running well for many miles, you can maximize the “mileage” you gain from your deep plane facelift through these maintenance treatments under Dr. Sherber’s care.

To see Before & After results, visit our gallery page.

Deep plane facelift before and after results
Deep plane facelift before and after results
Deep plane facelift before and after results

frequently askedQuestions

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Why choose Dr. Rad?
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Ultimately you’re looking for a surgeon with 3 attributes: a focus on facelifting as the majority of his/her practice, consistent artistry as shown by many beautiful results that inspire you, and a focus on patient safety which you can tell by where the surgeon performs surgery, where s/he trained and board certification. Dr. Rad’s credentials speak for themselves and you’ll discover Dr. Rad’s skill, passion and artistry for yourself.

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Can I achieve similar results non-surgically?
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No: the deep plane facelift is unparalleled in the results that can be achieved in skilled hands.

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What anesthesia is used for a Facelift?
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Facelift procedures require anesthesia to ensure patients’ comfort and safety during surgery. The choice of anesthesia depends on various factors, including surgeon preference, the extent of the procedure, the patient’s health status (presence of heart, lung, kidney or endocrine illnesses), and patients’ preference. The 3 most common types of anesthesia used for facelift surgeries are:

1. General Anesthesia (GA)

Patients are asleep and are unaware during the surgery. During GA, the anesthesia team administers a combination of anesthetics to optimize the depth of anesthesia while minimizing side effects. This usually involves propofol for quick induction, and inhaled gas anesthetic for stable maintenance, and an array of anti- medicines to reduce nausea side effects, the most common issue with GA.

In terms of what patients experience, your last memory of the process is rolling into the OR, and then the next memory is waking up in the recovery room. You feel nothing or experience nothing of surgery. Dr. Rad’s anesthesia teams are exceptionally skilled in ensuring comfort and safety. Patients do not experience “waking up” episodes, nor do they have any memory of the procedure.

GA involves administering intravenous medications and inhaled anesthetic to induce sleep and keep the patient pain-free throughout the procedure. This involves an airway tube (“endotracheal tube”) which serves two purposes: (i) to deliver the inhaled anesthetic which gives long lasting anesthesia, and (ii) protects your windpipe preventing any fluids, secretions or phlegm from getting into your lungs which can cause a pneumonia or airways spasm/constriction (“laryngospasm”). Without protection of your airway, such as with IV sedation only, the risk of airway/lung problems is higher.

Patients awaken quickly because the depth of anesthesia is not nearly as deep as required for other types of surgery (think liver, kidney or heart surgery). Within 15-20 minutes you are awake enough to remove the airway tube, and then you are rolling to recovery. Typically patients stay for a couple or a few hours in recovery before going home.

This type of anesthesia is needed when deep plane face and neck lift with deep neck sculpting (gland reduction) is being done.

Dr. Rad advises not thinking of GA as “being on a breathing machine” or being dangerous. Rather, the anesthesia machine is supporting your natural breathing and protecting your airway. In fact, GA is for comfort and safety. In the hands of a board certified anesthesiologist (with whom Dr. Rad always works) in the safest possible environment (accredited hospital-based surgery centers) GA is very safe, in fact it is much safer than the cumulative risk of driving a car every day.

2. IV Sedation with Local Anesthesia

In some cases, combining sedation with local anesthesia (injected numbing medicine) is used. In this case, patients often receive propofol for the IV anesthetic to induce sedation and which helps them relax and feel drowsy during the procedure. While the patient is not fully unconscious with this approach, they are generally not aware of the surgery and experience little to no discomfort.

This does not involve the inhaled anesthetic as in GA, and does not require an airway tube. You are breathing on your own and the anesthesiologist will maintain your level of anesthesia with propofol and other IV medicines. Oxygenation is supported with supplemental oxygen.

Patients may be a candidate for this type of anesthesia for shorter procedures and neck lift that does not involve deep neck sculpting.

3. Local Anesthesia Only

This type of anesthesia is the simplest of all, and involves injecting numbing medicine throughout the tissues to be lifted. Dr. Rad uses local anesthetics routinely in the office and this does not require going to an OR.

We start with applying topical numbing which dulls sensation, then injected numbing medicine is given while you are awake.

Patients are candidates for this approach when undergoing in-office mini-face lifts, upper blepharoplasty, buccal fat reduction and direct brow lifts.

Overall, the choice between these types of anesthesia will be discussed during the pre-operative consultation with the surgeon. The surgeon will consider the patient’s medical history, the complexity of the procedure, and the patient’s preference when deciding on the appropriate anesthesia.

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Where does Dr. Rad have hospital operating privileges?
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You may hear that the safest plastic surgeons have “operating privileges” at major hospitals. “Operating privileges” allow surgeons to perform surgery at that hospital, and they are granted following a 6-month process of evaluating a surgeon’s background.

Dr. Rad’s credentials have rigorously been vetted by the top hospitals in DC and northern Virginia, specifically Sibley Hospital (DC), Inova Fairfax Hospital and Fair Oaks Hospital (northern VA), and George Washington University Hospital (DC). This means that his training, board certification and safety record meet the high standards of these top hospitals in DC and northern Virginia.

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What skincare should I use to optimize my healing after a Facelift?
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Proper skin care is critically important as your tissues will be inflamed after surgery. “Inflammation” is a common term that is commonly associated with harmful internal processes. However, inflammation is a normal process whereby the immune system is activated to heal tissue trauma caused by surgery. This is a normal part of healing. However, too much inflammation can be harmful and so we must be sure to avoid anything that can irritate your skin or worsen inflammation.

It is important to use the right products immediately after surgery. Dr. Rad recommends avoiding products that have stimulatory ingredients such as retinols and using gentle skin care with products that have high concentrations of antioxidants to calm and soothe inflamed skin. Drs. Sherber and Rad recommend the following curated, science-backed products for daily use after facelift surgery (you may order products online or ask our staff for these products from our Boutique). Products are at different price points but we have vetted these products for their high quality ingredients and calming formulations for optimal facelift healing.

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How do I prepare for a Facelift?
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If you are planning to undergo a facelift, it is important to properly prepare for the procedure to ensure the best possible outcome. Here are some tips to help prepare for a facelift:

  • Follow your surgeon’s instructions: Your surgeon will prepare for the procedure to ensure the best possible outcome. Follow these instructions carefully to avoid any complications.
  • Stop smoking: Smoking can interfere with the healing process, and it is recommended to stop smoking at least two weeks before the procedure.
  • Avoid blood-thinning medications: Some medications, such as aspirin and ibuprofen, can increase the risk of bleeding during and after surgery. Avoid these medications at least two weeks before the procedure.
  • Arrange for someone to drive you home: You will need someone to drive you home after the procedure as you will feel groggy from the anesthesia.
  • Prepare a comfortable recovery area: Prepare a comfortable area for you to rest and recover after the procedure.
  • Stock up on supplies: make sure to stock up on supplies like ice packs, gauze, and comfortable clothing before the procedure
  • Follow a healthy diet: A healthy, well-balanced diet can help improve the healing process, so make sure to eat plenty of fruits and vegetables leading up to the procedure.

It is important to have a thorough consultation with your surgeon to properly understand the procedure and discuss any specific preparations that need to be made.

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What is the cost of a deep plane facelift surgery at SHERBER+RAD?
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In Dr. Rad’s DC practice, the cost for facial aesthetic lifts starts at $20,000+ for targeted in office “mini lift”, starts at $40,000+ for more advanced face and neck lifts, (“deep plane” or ponytail methods), starts at $60,000+ for surgeries combining other procedures (blepharoplasty, brow lift, fat grafting, etc.), $75,000+ for complex anatomy and corrective work, and up to $150,000 for extensive total facial surgery requiring more than 1 operation such as face/neck lift, rhinoplasty, facial bone augmentation or shaping, custom facial implants, blepharoplasty and brow lift, etc.. Note that pricing is customized for each patient and these guidelines do not necessarily apply uniformly. These are approximate ranges and total cost depends on multiple factors: your unique anatomy, goals, complexity of the procedures, recommended techniques, whether corrective work is needed, in-office or hospital-based operating facility, and combining multiple procedures (increasing concessions apply for multiple procedures).

Although you may receive varying cost estimates from other practices, keep in mind that your surgeon’s education and training, plastic surgery board certification, his/her experience (at least 8 years of experience after residency is recommended), and aesthetic artistry and surgical skill (i.e., talent) of your surgeon are important factors in pricing. Dr. Rad’s practice is solely focused on facial aesthetic surgery and delivers the best facelift Washington, DC has to offer. His artistry is unmatched. His goal for every patient is to achieve nuanced and natural results with minimal recovery, and we have mechanisms in place to bring them within financial reach.

Testimonials

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“Dr. Rad is not only a skilled and talented surgeon but a kind and compassionate doctor, who treats the whole person. For me, he exemplifies medical excellence.”

“He is the most gifted physician that I’ve ever met. Dr. Ariel Rad is in the top-echelon of physicians. He has a brilliant brain and a big heart. His skills as a surgeon are unparalleled.”

“He was very thorough, knowledgeable and most of all empathic to my situation.”

“He is not only a great surgeon, but an artist.”

“He is very skilled, his manner is absolutely delightful, and he is a truly kind, considerate person”

“He is an expert in his field. He is brilliant and very caring. I will never forget how compassionate he was on the day of my surgery”

“Dr. Rad is one of the world's best! His artistic eye and incredible skill shows in my incredible face lift results. His ability as a surgeon is surpassed only by his kindness and approachability as a person.”

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