Deep Plane Facelift Surgery Explained: Fat Grafting, Neck Contouring & What to Expect in Recovery

Choosing to undergo facial rejuvenation surgery is one of the most personal decisions you can make. It requires not only courage but also complete trust in your surgeon's abilities. The journey from consultation to recovery reveals the intricate blend of art and science that defines exceptional facial plastic surgery.

Watch the Full Facelift Journey

See the complete patient experience from consultation through surgery and recovery in Episode 2 of The Anatomy of Confidence.

Watch the Video: https://youtu.be/PXABbrrumds?si=F9qCQJRqZBxSn9sm

The Decision to Move Forward

Timing matters when it comes to facelift surgery. Many patients begin exploring their options years before they actually proceed. At age 50, one patient consulted multiple surgeons, only to be told it might be too early. The concern? Having the procedure done prematurely could mean needing a revision sooner than ideal.

Five years later, at 55, the message changed completely. Every consultation confirmed the same thing: the timing was perfect, especially for addressing neck laxity. This patience and careful timing often leads to more satisfying, longer-lasting results.

Finding the Right Surgeon

The selection process deserves serious attention. Consulting with multiple surgeons isn't excessive; it's smart. One patient interviewed five different doctors before making her choice. Even with a surgeon husband providing guidance, she conducted her own thorough research.

What sealed the decision? The combination of technical expertise and artistic vision. Dr. Gould emphasizes that facial surgery demands both elements. Understanding nerve pathways and vascular anatomy provides the scientific foundation, but artistry determines the aesthetic outcome.

"You want to get into someone's face, right? You want to take what they look at every day. It's such a huge responsibility," Dr. Gould explains. "Having that science knowledge is really important, but it has to be topped off with artistry. You have to have a good blend of artistic nature and understanding of science."

Understanding the Comprehensive Approach

Facial aging doesn't happen in isolation. It affects the entire side of the head, which is why addressing just one area often falls short of optimal results.

The Multi-Layered Strategy

Dr. Gould's approach targets multiple concerns simultaneously:

Primary Procedures:

• Lower face and neck lift for jowls and neck laxity
• Temporal brow lift to address upper face aging
• Addressing the temple area to offset heaviness around the eyes
• Creating better support for the lower eyelid-cheek junction

Complementary Treatments:

• CO2 laser resurfacing for skin quality
• Fat grafting for volume restoration
• Regenerative fat treatments for improved skin health
• Lip lift for better upper lip visibility

This comprehensive strategy recognizes that moving the entire side of the head creates more harmonious, natural-looking results than targeting isolated areas.

The Science of Fat Grafting

Fat grafting has evolved into a sophisticated procedure that goes far beyond simple volume replacement. The technique requires understanding cellular biology and following precise protocols to maximize results.

Harvesting and Processing

Even in thin patients, adequate fat can be harvested from strategic areas including the medial thigh, medial knee, and flank regions. The incisions are intentionally placed asymmetrically, offset by one to two centimeters, so they don't appear surgical.

The harvesting technique matters tremendously. Using specialized cannulas with sharp, cheese-grater-like holes allows the surgeon to cut fat cells cleanly rather than tearing them. This preservation maintains cellular integrity and improves survival rates after injection.

The Three-Layer Separation Process

After harvesting, the fat undergoes careful processing:

1. Oil layer (top): This inflammatory component must be removed as it can interfere with healing
2. Fat layer (middle): The viable cells used for structural grafting
3. Fluid layer (bottom): Contains blood, platelets, and growth factors

Contrary to what you might expect, removing all blood from the mixture isn't ideal. The platelets and growth factors in blood actually support fat cell survival and integration. The goal is purified but not sterile-looking fat.

Structural vs. Regenerative Fat

Dr. Gould employs two distinct types of fat grafting:

Structural Fat Grafting adds volume to areas like the cheeks, temples, and hands. The goal is for these fat cells to survive and permanently restore lost volume. In thin patients especially, this creates a better foundation for lifting procedures.

Regenerative Fat (Nanofat) serves an entirely different purpose. By passing the fat through a downsizer 20 times, the cells are intentionally destroyed, leaving behind only stem cells and growth factors. This mixture doesn't add volume but dramatically improves skin quality by increasing blood supply, oxygen, and nutrient delivery to the skin itself.

Understanding which type to use where demonstrates the scientific precision behind optimal outcomes.

The Reality of Fat Survival

Not all injected fat survives. Each fat cell needs neighboring cells to provide oxygen, nutrients, and blood supply. A thin patient with naturally minimal facial fat can't suddenly accommodate massive volume increases in one session.

For example, if a patient has 10cc of natural facial fat, injecting 10cc more brings the total to 20cc. Their tissue can support this amount. To progress from 20cc to 40cc requires a secondary fat grafting session about a year later.

This secondary procedure offers significant advantages:

• No general anesthesia required
• No operating room needed
• No tissue elevation, meaning less inflammation
• Better fat survival rates
• Superior outcomes

Most patients now return for secondary fat grafting at the one-year mark, a protocol improvement suggested by observant nursing staff who noticed that patients could benefit from additional volume.

The Crevasse Technique for Jawline Definition

Creating a beautiful jawline requires more than simply removing excess skin. Dr. Gould's Crevasse technique focuses on achieving a 90-degree angle beneath the jawline, which distinguishes truly exceptional results from average outcomes.

The process involves:

• Reattaching the platysma muscle to the mastoid bone
• Creating natural depth and definition
• Balancing the tissue so it appears as though it's always been positioned that way
• Achieving a delicate, soft, yet clearly defined jawline

This technical precision transforms the neck and jawline from aged and loose to youthful and crisp.

Addressing the Submandibular Glands

Some patients present with enlarged submandibular glands that create fullness beneath the jawline, regardless of skin tightness. These glands can significantly impact the neck contour.

Removing these glands requires navigating around critical structures including the external jugular vein and other important vessels. It's delicate work, but the improvement in jawline definition can be dramatic, creating the clean, square jawline that defines youthful neck contours.

Why Hands Matter

If your face and neck look rejuvenated but your hands show prominent veins, tendons, and age spots, the contrast can undermine your overall results. Dr. Gould addresses this by performing fat grafting to the backs of the hands.

Using a blunt cannula with a side-facing hole, fat is carefully injected into the dorsum of the hand through tiny incisions. This technique:

• Adds volume to minimize visible tendons and veins
• Reduces shadows that emphasize aging
• Improves skin quality through growth factors
• Creates harmony between facial and hand appearance

The result? When you reach for a glass of wine, your hands match your refreshed facial appearance.

Incision Placement and Scar Management

Previous brow lift surgery had left one patient with a visible, hypopigmented (lightened) scar along the frontal hairline. Rather than re-entering through this obvious scar, Dr. Gould placed new incisions behind the hairline where they would remain hidden.

This decision reflects an important principle: just because a scar already exists doesn't mean it's the best entry point for revision surgery. Creating new, better-concealed incisions often produces superior long-term aesthetic outcomes.

The Calm Before Surgery

The pre-operative marking session serves multiple purposes beyond planning incision sites. It's an opportunity for the surgeon to demonstrate the calm, focused energy that will define the procedure itself.

Patients often arrive expecting to feel anxious. Instead, many report feeling surprisingly comfortable and relaxed. This emotional state matters because positive energy typically carries through the entire surgical journey and recovery period.

Dr. Gould notes that patients who start happy usually end happy, bringing positive energy that influences every stage of their experience.

The Operating Room Experience

On surgery day, the entire team focuses exclusively on a single patient. This dedicated attention ensures both safety and optimal outcomes.

"There's no place we'd rather be. There's no one else we'd rather be operating on," Dr. Gould tells his patients. This isn't just reassurance; it reflects the reality that surgical excellence requires complete presence and focus.

The anesthesia team provides what's affectionately called "vein champagne," a medication that creates deep relaxation similar to having two or three glasses of champagne. This comfortable sedation makes the transition to general anesthesia smooth and anxiety-free.

Technical Precision in Action

Throughout the procedure, anatomical landmarks guide every decision. The sentinel vein, for example, indicates the likely location of the nerve supplying the forehead. By identifying this vein, Dr. Gould can safely navigate past it to access deeper structures while protecting the nerve.

This kind of anatomical knowledge, combined with meticulous surgical technique, separates good outcomes from exceptional ones. Every step is purposeful, guided by understanding of the underlying structures and how they'll respond to repositioning.

The Immediate Post-Operative Period

Waking up after surgery can feel disorienting. Significant swelling is normal, and asymmetry is common in the first hours and days. One side often swells more than the other initially.

Patients report various sensations:

• Sore throat from intubation
• Tightness when swallowing
• Overall facial tightness
• Concerns about the swollen appearance

Dr. Gould addresses these concerns immediately during the recovery room visit, showing before-and-after photos to help patients see past the temporary swelling to the underlying improvements.

What Makes Results Exceptional

The jawline transformation often becomes the feature that patients themselves appreciate most. While others may notice the eyes looking prettier or the overall refreshed appearance, patients looking in the mirror fixate on the dramatic improvement in neck and jawline definition.

This makes sense. The neck is often the primary concern driving people to seek facial rejuvenation. Seeing that specific area dramatically improved provides tremendous satisfaction.

Recovery Expectations

The immediate post-operative period requires patience and self-care:

• Take the first day slowly
• Accept help from nursing staff for basic activities
• Don't push yourself too quickly
• Understand that significant swelling is temporary
• Trust that the final results will emerge over three months

While results always look promising on the operating table, the true outcome reveals itself gradually as swelling resolves and tissues settle into their new positions.

The Philosophy of Natural Results

Throughout the entire process, the goal remains creating results that look natural, refreshed, and like an enhanced version of yourself, not like someone else entirely. This requires:

• Understanding facial proportions and balance
• Respecting ethnic and individual features
• Avoiding over-correction
• Creating results that age gracefully
• Ensuring incisions remain hidden

Why Training and Experience Matter

Facial plastic surgery combines multiple disciplines: understanding aging anatomy, mastering surgical techniques, developing artistic vision, and maintaining the judgment to know when to do more versus when restraint serves the patient better.

Dr. Gould's approach demonstrates this integration. The science informs every decision, from fat processing protocols to nerve preservation techniques. The artistry determines proportions, symmetry, and the overall aesthetic outcome.

The Journey Continues

Facial rejuvenation surgery isn't a single event but the beginning of a journey. The relationship between patient and surgeon extends well beyond the operating room, encompassing:

• Careful preoperative planning and consultation
• Meticulous surgical execution
• Attentive post-operative care
• Long-term follow-up
• Potential secondary procedures like additional fat grafting

This comprehensive approach to patient care ensures not just good results, but exceptional, long-lasting outcomes that enhance confidence and quality of life.

Making the Decision

If you're considering facial rejuvenation surgery, take your time. Consult with multiple surgeons. Ask detailed questions about their approach, training, and philosophy. Look at before-and-after photos, but remember that your results will be unique to your anatomy and goals.

Most importantly, choose a surgeon who combines technical excellence with artistic vision, someone who listens to your concerns and creates an individualized plan rather than applying a one-size-fits-all approach.

The journey may feel daunting initially, but with the right surgeon and realistic expectations, facial rejuvenation surgery can be truly transformative, not just for your appearance but for your confidence and how you present yourself to the world.