PRS Journal Club: Deep Plane Rhytidectomy, Pollybeak Prevention in Open Rhinoplasty, and Private Equity in Aesthetic Surgery

Aesthetic plastic surgeons are faced with a myriad of options in both clinical practice and practice management, including closed versus open rhinoplasty; deep plane versus superficial musculoaponeurotic system (SMAS) plication in face lift; and, finally, whether to maintain ownership of an aesthetic surgery private practice or sell to private equity. Private equity has transformed the employment landscape for many subspecialties, with many practices transitioning from physician-owned practices to larger, private equity–owned entities, particularly in specialties such as dermatology and orthopedic surgery. Plastic surgery recently has emerged as a target for private equity acquisition, but the benefits and downsides of private equity mergers versus physician-owned practices remain unclear. Other controversies in the field include the benefits and risks of the deep plane face lift compared with other supra-SMAS techniques, as well as the role of preservation in rhinoplasty, notably pertaining to preservation of the Pitanguy ligament. In the October of 2025 edition of PRS Journal Club, we discuss these 3 topics about the business of aesthetic surgery and facial aesthetics. In the first article, “Private Equity Investment in Plastic Surgery Clinics: A Scoping Review,” Roth et al.1 conducted a scoping review, pooling 8 articles discussing private equity acquisition of plastic surgery practices. Across the articles, key benefits of private equity acquisition included operational improvements, reduced administrative burdens, enhanced technology access, practice expansion, and improved profitability; downsides of private equity acquisition included loss of autonomy, misaligned objectives and visions of the practice, and aggressive cost-cutting leading to compromised quality of care. After plastic surgery residency, a high percentage of graduates seek nonacademic jobs in either private or group practices, with the number of solo practices declining over the past decade.2 Concurrently, private equity acquisition of solo or group practices has increased over the past decade in plastic surgery.3 As the integration of private equity in plastic surgery practices introduces complexity to employment options for private practice plastic surgeons, more studies on the pros and cons of private equity acquisition and more residency training on the business of plastic surgery are increasingly important.4 In the second article, “The Influence of the Pitanguy Ligament on the Supratip Break Point in Open Rhinoplasty” Şirinoğlu et al.5 assessed the influence of Pitanguy ligament preservation, excision, or reconstruction in a series of 120 patients undergoing open rhinoplasty. They found that repair of the Pitanguy ligament was associated with the greatest depth of the supratip break at 12 months and the lowest incidence of pollybeak deformity. Elimination of dead space and prevention of pollybeak deformity are challenging problems in modern rhinoplasty, particularly for patients with thick skin. Various interventions have been proposed,6,7 including supratip sutures, nasal tip defatting, and the use of adjunctive medications, including retinoids. Recently, with the re-emergence of preservation rhinoplasty, preservation or reconstruction of the Pitanguy ligament has also been proposed as a method to allow for a supratip break and to prevent formation of a pollybeak deformity, especially in patients with thick skin.8 The next steps of this work include prospective studies matching patients based on skin thickness, ethnicity, retinoid use, and intraoperative cartilage grafts for tip support (ie, septal extension graft versus columellar strut), to ascertain the role of Pitanguy ligament reconstruction independent of other patient factors influencing pollybeak risk. Finally, in “Deep Plane Face Lift in Asian Patients,” by Wong et al.9 review their approach to the deep plane face lift in Asian patients. The authors report that deep plane techniques are especially advantageous for Asian patients, given the anatomically wider bizygomatic projections of the Asian face, the decreased reliance on skin tension in deep plane techniques, and the higher incidence of hypertrophic scars in the Asian population. They reviewed their experience in 61 patients, reporting a 98% satisfaction rate, with only 1 incidence of cervical branch neuropraxia, which resolved after 8 weeks, and 2 cases of superficial skin epidermolysis. Based on their experience and outcomes, they concluded that the deep plane face lift is a safe option for Asian patients seeking rhytidectomy. Since the introduction of the deep plane face lift by Hamra,10 controversy persists regarding the optimum face lift technique. Although deep plane techniques have gained popularity over social media, some surgeons caution against the techniques because of the higher risk of facial nerve injury. To date, head-to-head comparisons in the literature have been limited.11,12 Given the subjective nature of aesthetic surgery and relative lack of evidence-based data in aesthetic surgery, whether supra-SMAS or deep plane techniques are superior in terms of safety and longevity may never be answered conclusively in the scientific literature. More retrospective reviews in specific ethnicities and patient populations, similar to the present study by Wong et al., are necessary to advance the field and our overall understanding of the safety and outcomes of different rhytidectomy approaches. Overall, these articles add to the plastic surgery literature about the business of private practice, technical refinements for deep plane face lift in an Asian population, and techniques to reduce pollybeak deformity in open rhinoplasty. As practice types and surgical techniques continue to evolve, continued encouragement and incentivization of research and literature contributions from private practice aesthetic surgeons are essential to promote continued advancement in the field of aesthetic plastic surgery. DISCLOSURE The authors have no relevant financial disclosures to report.