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Facelift

Facelift

Mark A. Jabor, M.D.

Television is flooded with heavily advertised facelift procedures or remedies with catchy names.  Many claims are made about wonderful results, minimal scars, and little downtime.   There is no universally accepted terminology for describing a facelift. To add to the confusion, some doctors and companies have trademarked clever names for marketing purposes which have no real application in medical terminology or description.  One of the “hot & new” catchy “lift” names recently used is neither a surgical procedure nor a facelift.  This article will alleviate some of the confusion surrounding facelift terminology, techniques and, hopefully, will simplify understanding of the procedure. 

The Aging Process

Let’s spend a short time discussing facial aging. Gravity, time, and extrinsic factors, such as sun damage, contribute to facial aging.  Most people are aware that combining facial aging plus the effects of gravity, results in loss of skin elasticity and underlying support. These factors lead to sagging skin, texture changes and the development of wrinkles. What is less well recognized is volume loss of the face in general. The skin loses collagen becoming thinner. Muscle atrophy occurs, with diminished fat as well as bone loss. Not only is fat lost, but the fat pads (compartmentalized fat of the face) descend and change location in comparison to the youthful face.   Ultimately, these changes result in shifting of fullness from the cheek area to the lower face leading to a hollowing of the upper face.  This complex constellation of events leads to the typical appearance descriptive of the aging face. 

  In youth, the face resembles an inverted triangle with the majority of fullness existing in the cheek area with less fullness in the lower face. In middle age, the face now appears squarer.  The fullness in the cheek area resembles that of the lower face. With progressive aging, the inverted triangle flips and becomes a standard triangle. The majority of the fullness is absent from the mid-face and cheek area, shifting to the lower face (see fig. 1). Some of the typical changes seen with the aging face are as follows: slight descent of the eyebrows with the outer orbital bone becoming more prominent combined with temporal hollowing, the orbital area is sunken and may have an overall shape change, the lower eyelid may have fat bulging with separation of the lower eyelid and cheek junction leading to a “tear trough”, loss of volume plus descent of the middle and outer cheek area, deepening of the nasolabial folds (laugh lines), descent of the corners of the mouth, accentuation of jowls, loss of the acute angle of the neck, and overall skin alterations leading to texture changes and color changes along with wrinkling. 

Comparing Youthful and Aging Face

Figure 1 Comparison of the youthful and aging face

Terminology

“Facelift” terminology encompasses several options. In general, most plastic surgeons will agree that the term facelift refers to a lifting procedure that focuses on improvement of the mid-face, lower face, and neck.  The types of lifts and incisions used vary between plastic surgeons.  Some people apply the term “complete” facelift. This refers to a facelift procedure (as explained) in combination with upper and lower eyelid surgery as well as a brow lift.  The discussion from this point on will deal exclusively with a facelift and not with eyelid or brow surgery. In general, the different type of facelifts performed includes, Lower Facelift, Minimal Incision/Mini-Facelift, Neck Lift, and a Mid-facelift. A brief discussion of each follows.  

The Lower Facelift (Standard Facelift) has an incision that begins at the temple, extends around the front of the ear, continuing behind the ear into the hair-bearing area on the back part of the upper neck (See fig. 2).  This also includes an incision under the chin to access the front part of the neck. This is usually performed with liposuction of the neck, direct fat removal from the neck and platysmal plication.  Platysmal plication refers to suturing together of the separated thin muscle at the front part to the neck that often form “bands” as part of the aging process (See fig. 3). See before and after examples, figures 4 & 5.

Lower Facelift Incision Result

Figure 2 Lower Facelift Incision

Platysmal Plication Results

Figure 3 Platysmal Plication (suturing of the underlying muscle)

Before and After Facelift 1

Before and After Facelift 2

Before and After Facelift 3

Figure 4 Before and After Lower Facelift

Before and After Facelift 4

Before and After Facelift 5

Before and After Facelift 6

Figure 5 Before and After Lower Facelift

A Minimal Incision/Mini-Facelift begins with an incision at the side-burn area, hugs the front of the ear but ends at the ear lobe (see fig. 4). No incision is made under the chin. Generally, some liposuction of the neck is involved as well. This is basically the face portion of a lower facelift. This procedure gives improvement from cheeks to neck. However, not as much improvement of the neck is achieved as with a Lower Facelift. This is, in essence, the facial portion of a Lower Facelift. See before and after examples, figures 7 & 8.

Mini-Facelift Incision

Figure 6 Mini-facelift incision

Before and After Mini-Facelift

Before and After Mini-Facelift 2

Before and After Mini-Facelift 3

Figure 7 Before and After Mini-Facelift

Before and After Mini-Facelift 4

Before and After Mini-Facelift 5

Before and After Mini-Facelift 6

Figure 8 Before and After Mini-Facelift

A Neck Lift has an incision under the chin as well as an incision that starts behind the ear and ends in the hair-bearing skin of the neck (see fig. 5). However, in younger patients only a small incision behind the ear is necessary.  Neck lift includes liposuction of the neck, direct fat removal from the neck and platysmal band plication (see fig 6).   This is basically the neck portion of the lower facelift. The neck lift gives improvement of the neck only. It is essentially the neck portion of a Lower Facelift. See before and after examples, figures 11 & 12.

Posterior Neck Lift Incision

Figure 9 Lower Facelift Incision

Platysmal Plication Results

Figure 10 Platysmal Plication (suturing of the underlying muscle)

Before and After Neck lift

Figure 11 Before and After Neck Lift

Before and After Neck Lift

Figure 12 Before and After Neck Lift

A Mid-facelift requires incisions either in the lower eyelid area or the temporal hair area, or both, and improves the mid-face or cheek area only.  Mid-facelift is either performed by itself or with eyelid or brow surgery.  I rarely perform this procedure since the same result can be obtained by fillers (fat, Juvederm, Radiesse, etc) to the cheek area without surgery. Also, note that improvement of the midface occurs with both a Lower Facelift and a Mini-Facelift.

What occurs with a facelift? It is a vast over simplification to say a facelift is merely an incision with the lifting and pulling of the skin.  Inclusive techniques of the modern facelift start with an incision, continue with elevation of the skin and, most importantly, places tension on the layer beneath the skin that surrounds the facial muscles. (This layer is called the Sub-Muscular Aponeurotic System, commonly referred to by its acronym SMAS.) This layer of tissue is a tough, non-elastic layer which resists relaxation when tension is placed on it. The vector of pull on the SMAS is vertical or straight up and down, this “pull” improves the face and neck creating a natural result without a “windblown” appearance. After a strong pull is placed on the SMAS layer, the skin is re-draped, excess skin is trimmed, and the incision sutured back together.

The SMAS is the workhorse of a facelift procedure by accomplishing three things. One, tension, which is well maintained with passage of time, is placed on this strong non-elastic tissue layer. Two, this technique lifts the deeper structures of the face, including the fat pads, which migrate downward with gravity over time, allowing for improved “re-volumization” of the face. Third, the SMAS assumes most of the tension. This allows the skin to be closed with little to no tension promoting minimum scarring.  This lifting procedure is often combined with liposuction of the neck and direct fat removal from the front part of the neck if the fat happens to lie in a deeper plane.  This method makes up what is generally considered a modern facelift which improves laxity of the cheeks, lower face and neck and “de-bulks” a heavy neck.

Additionally, it is important to note that a very essential aspect of facial rejuvenation is volume restoration of the face.  The facelift procedure adds significant volume to the mid-face or cheek area by repositioning fat pads back to their normal place, but often times this is not sufficient due to loss of volume as previously discussed.  In 90% of the facelifts I perform, I employ fat transfer (fat injections) to further augment volume depleted areas of the face.  A small amount of fat is harvested superficially, usually from the abdomen or hip. The fat is separated from blood and fluid, placed into small syringes followed by injection into areas of the face that suffer from significant volume loss.  Fat is a wonderful material to utilize for volumizing for many reasons.  Fat is natural and ordinarily in plentiful supply with no risk of rejection and very small chance for infection.  Stem cells found in fat may also complement the rejuvenation process. The disadvantage of fat is the degree of longevity of the results can be unpredictable and supplemental fat transfer touch up for facial areas may be necessary. This minor procedure is easily accomplished in the office using local anesthesia. 

When judging the results of a facelift, everyone’s ultimate goal is to have a procedure that is natural looking in addition to being concealed from others. Scarring remains the most common post-surgical stigmata of a facelift. This does not have to be the case.  With correct planning, incisions can be placed in inconspicuous locations.  Minimum tension on the skin dramatically minimizes scars. In general, if an incision (and ultimately a scar) does not follow a straight line but is “broken”, the eye perceives a diminished and less noticeable scar.  This important, technique sensitive, concept is demonstrated by extending the path of the incision around the front of the ear. I prefer an incision that begins across the side burn area, subsequently “hugging” the front of the ear, proceeding behind the ear, and finally into the junction between the hair-bearing and non-hair bearing skin of the neck.  Using this technique, there is virtually no distortion of the hairline (either at the temple area or the neck). The scar is well concealed in front of the ear since it follows the natural contour of the ear. This technique takes more time for closure but, in my opinion, minimizes the visible scar (see figure 7). An incision that drops straight down from the side burn area to the earlobe, without “hugging” the ear, is easily noticed by the eye.  In addition, an incision that lays in the hair-bearing area of the scalp, removing hair-bearing skin, can ultimately distort the hairline and promote hair loss. These seemingly small preventative techniques make obvious scarring and distortion much less common.

Concealed Scar Around Ear

Figure 13 Concealed scar around the ear

As with any surgical procedure, the optimum likelihood for success is customizing a procedure suitable for the individual patient.  Beware of the physician employing heavily advertised catchy phrases that designate the same procedure for each and every patient. There is no “one” procedure that is appropriate for or suits every patient.  If the only thing one has to work with is a hammer then everything is a nail. Your skilled board certified plastic surgeon is adept at recommending a range of diverse procedure options to benefit the aging face. Experience and artistry really do make a difference.

The most common facelift procedures I perform are the Lower Facelift, Mini-Facelift, and Neck Lift in descending order. These are generally performed with liposuction of the neck, direct fat removal from the neck and the use of fat transfer to volumize depleted facial areas. All of these procedures can be performed under local anesthesia in the office in the correctly selected patient.

Chin Augmentation

It is important to note, that in a subgroup of patients the jaw or chin is very recessed.  This leads to a very “weak” unappealing profile. If this is not addressed, the result will be sub-optimal. In most situations, this can readily be remedied with a chin implant. The implant can be placed via an externally (below the chin) or intra-orally incision, through the mouth. I prefer the external approach to minimize chance for infection. This is the same incision used for platysmal band plication.   Implants come in a variety of sizes and can be trimmed for customization (see figure 8).

Recovery

Recovery is usually straight forward and discomfort is usually very well tolerated.  Drains, if necessary, are removed the next day and sutures are removed in 6 days. Make up or concealers can be applied at about 6 days as well.  There are variable degrees of swelling and bruising afterwards.  Patients generally take a week off of work.

Summary

In my opinion, the greatest difference between the Lower Facelift and the Minimal Incision/Mini-Facelift is the noteworthy improvement in the neck area. If the neck has significant laxity, and maximum improvement is required in the neck area, the Lower Facelift is a superior procedure (see figure 9). On the other hand, if the neck is not the main area of focus, but rather the mid and lower face, a less invasive Minimal Incision Facelift will give equally good results with a reduced incision. The Neck Lift procedures work well for the patient that only desires improvement of the neck. The choice is an interactive decision between the plastic surgeon and the patient.  In general, patients usually seek consultation for facelifts in their later forties or early fifties.

The results of a facelift, as with all cosmetic procedures, depends upon two core points. One, confirm the proper, most beneficial, procedure or approach for each patient, as discussed above.  Two, scrutinize the anatomy of the patient before any surgical procedure.  The evaluation includes assessing the degree of deficiency of skin elasticity, the amount of sun damage, the underlying bony anatomy, the angle of the neck-jaw junction, and overall volume depletion to name a few. The more severe these existing factors are, the more difficult it is to achieve a “home run” result even though improvement is certainly observable.  It is essential for the plastic surgeon to establish realistic expectations for the outcome of a facelift or any cosmetic procedure. The patient with realistic expectations of what a procedure can achieve and, more importantly, what it cannot accomplish is usually very satisfied with the results. 

Every patient would like a facelift procedure that is minimally invasive (preferably with no incisions at all), little to no recovery time, maximum results, and inexpensive. To my knowledge, no such procedure exists. Be cautious of catchy infomercial or website promises. Almost undoubtedly, there will be disappointment. Remember the old adage, “if it sounds too good to be true it probably is”. The best time to get things right surgically is the first time. Revision surgeries are usually much more difficult in light of the fact that previously the anatomy was altered.

Be your own best advocate. Research your doctor.  Study the proposed procedures. Most importantly, check your doctors’ credentials and qualifications to confirm he/she is a board certified plastic surgeon and well versed and experienced in these types of procedures (see my article on board certification). Experience and artistry really do make a difference. 

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