What is a facelift?
A facelift or rhytidectomy is a procedure where facial aging is addressed through tightening the skin and underlying structures of the face. Commonly this is combined with a neck lift which addresses aging, fat deposits and loose skin over the neck. No other plastic surgery procedure is subject to so much variation in technique and marketing gimmicks compared to facelifts!
Nature of the problem
As we all age, there are three things that happen.
- Loss of facial fat
- Gravity related changes
- Skin changes due to sun exposure and aging
In any one person, one or more of these factors may predominate. A facelift only addresses the gravity related changes that are typically manifested as jowls and excess skin and soft tissue over the central neck. A modern facelift also includes fat/filler injections to correct volume deficiency and skin resurfacing with a peel or laser.
Why the gimmicks?
Ever heard of the no scar facelift, weekend facelift, short scar facelift, minimally invasive facelift and any number of patented facelift techniques that promise youth with no down time and scars? These are all marketing gimmicks to attract patients. Our personalities are incomplete without our faces and we all strive to look young. Nowhere is age more noticeable than in the face! Facial rejuvenation is a multimillion dollar industry and several products and patented facial procedures promise a lot for the aging face; but deliver little.
Dispelling the myths
- No facelift is possible without a scar; selected individuals with minimal aging related changes and fat loss, can be treated with fat or filler injections alone. Every other form of surgical facelift will have a scar; although when done skillfully the scar is concealed and not visible, calling this a no scar facelift is just dishonest marketing.
- Facial aging is secondary to complex factors; a simple skin pull may look acceptable for a few weeks; but skin was designed to be elastic and with time regains its elasticity with return of aging changes. Besides, when pulled too tight, it causes a windswept appearance with which we are all familiar.
- Would you trust your teacher if you were told that you could learn a new language and be fluent reading and writing it in less than a week? Or your doctor if you were told that there is a pill that can cure cancer with just one dose? Yet, many with advanced facial aging choose to have a well marketed face lift procedure that sounds too good to be true.
So what really are the components of a well done face lift?
Facelifts have evolved and come a long way over the last several decades as our understanding of aging has changed. Early facelifts were skin only lifts; Incisions are made around the ear and hairline such that they can be concealed. The skin over the outer part of the face and most of the neck was separated from the underlying deep tissue. The excess skin was removed after traction in an upward and outward direction/vector and the incisions were closed. The problem with skin only lifts were two fold. The deeper tissue that was also part of the aging problem was not addressed. All the tension was placed on the skin which resulted in widening of the scars, unnatural results and early recurrence of aging. Skin was made to be a covering; inherent elasticity of the skin causes rebound when placed under too much tension. A youthful face is one where skin is draped around deeper tissue that is not slack and is well padded with fat. The concept behind modern facelifts is to replicate this ideal structure of the youthful face.
Although there are several legitimate variations, a modern well designed facelift utilizes three principles. 1. The tissue underlying the skin, the SMAS (acronym for Subcutaneous Musculo Aponeurotic System) is modified in some fashion, either with sutures to plicate it or elevated as part of a sub SMAS deep plane facelift. 2. Although the overlying skin is separated from the SMAS as in a skin only lift, the skin now redrapes the contours created by modification of the underlying SMAS. Although skin excess is addressed, the skin is closed such that all the tension is on the deeper SMAS. Hence the resulting scars are inconspicuous and the face does not appear pulled. To give an analogy: imagine a chair draped by a blanket. A skin only lift attempts to pull the blanket tight over the chair to give the chair a better contour while a SMAS lift physically modifies the wooden framework of the chair itself and redrapes the blanket around it to give it better shape.
Methods of SMAS modification
There is no bigger contention among plastic surgeons doing facelifts than the method employed to modify the SMAS.
- Plication: sutures are placed to lift and tighten the SMAS. It is the simplest and most common method of modifying the SMAS. Although surgeons doing this technique go to great extents to justify it as being equal to deep plane facelifts, in my opinion it is not the most effective option. The SMAS is held down in several locations by ligaments; simply attempting to tighten it with sutures is in my opinion inadequate. Although it is better than a skin only lift, I feel that better and longer lasting results are obtained with deep plane techniques
- SMASectomy: The SMAS is cut beneath the skin along a line from the corner of the eye to the outer corner of the jaw bone. The cut edges when approximated tighten the underlying facial structure. The skin is then redraped over it.
- Deep plane/SMAS lifts: The SMAS is cut and a plane of dissection is developed beneath it. The ligaments attaching the SMAS to deeper structures are released. The released SMAS is then pulled along the appropriate vector and anchored with sutures. Skin is then redraped over it.
- High SMAS lift: In a traditional SMAS lift, the point of entry into the SMAS is such that the midface cannot be elevated. The midface is the part of the face above a line connecting the corner of the mouth to the ear canal. Traditional facelifts including SMAS lifts that are not classified as high SMAS lifts do NOT address the midface. Only a high
SMAS face lift addresses the midface. The term high refers to the point of entry into the SMAS. A high point of entry allows a mechanical vector to be high enough that the midface is elevated when traction is applied to the SMAS after dissection. When the midface is not addressed in a facelift, there is an imbalance as the lower face appears tightened while the midface is not elevated proportionally.
So why is a high SMAS lift not commonly performed?
A high SMAS lift is a technically challenging procedure that takes dedication to master. It also takes longer to perform as the dissection involved is more tedious. For most plastic surgeons this procedure is not worth their time as they could possibly perform several easier procedures in the time it takes to perform a high SMAS lift. However, there are surgeons that want the best result and are willing to spend the time and effort to master this technique. Also, residency programs that train plastic surgeons do not typically teach these procedures as the number of plastic surgeons that perform this procedure are few and far apart.
My approach to face lifting
My preferred technique is a lamellar high SMAS lift. I also frequently add fat injection to facelifts to replace the fat lost with aging. In addition to adding volume, fat also changes the skin tone, decreases pore size and results in a younger looking skin likely through a stem cell effect. Many patients also benefit from a skin peel or laser resurfacing to correct sun damage and rhytids (wrinkles)
Lamellar: The dissection is in layers (lamella). The SMAS is dissected separately from the skin. However, crucial attachments of the SMAS to the overlying skin are preserved in the central midface. A lamellar dissection allows the SMAS and skin to be elevated along different vectors. Aging happens along different vectors as far as the SMAS and overlying skin are concerned. A non-lamellar high SMAS lift allows the skin and SMAS to be repositioned only along one vector. In other words, when the SMAS is elevated, the skin elevates along with it in the same direction. In a lamellar dissection, the SMAS with the midface attached to it is elevated along one vector while the rest of the skin over the outer and lower face is lifted along a slightly different vector, creating a very natural result.
What is a neck lift?
A neck lift is a procedure that addresses aging changes over the neck and is frequently combined with a facelift. In fact, the term facelift is quite often used loosely to also include a neck lift. In a neck lift, excess fat above and below the level of the platysma muscle (a thin flat muscle just beneath the skin) is removed and the neckline is sculptured. Sometimes additional procedures including modification of underlying deeper bulky muscles/glands is done. The platysma muscle on each side is then sutured together and tightened over the midline of the neck to produce a pleasing neck contour. The excess skin is then pushed outwards and removed at the incisions around the ear and the skin is sutured closed with fine sutures. A neck lift utilizes the same incisions as a facelift but in additional a 3 to 4 cm incision is required beneath the chin if the platysma muscles need to be addressed. Quite often, a facelift alone produces significant improvement to the neckline in patients without advanced aging in the neck.
Who is a good candidate?
Patients with facial aging manifesting as jowls, a flattened and descended mid face, lose skin and fat deposits and loose skin over the neck are good candidates for a face/neck lift. Since aging in the face also happens over the eyelids and forehead, for best results these structures also need to be addressed. The best candidates have good underlying bone structure, and are healthy without significant medical problems.
Limitations of face/neck lift
As discussed before, a facelift will not address the volume loss that happens with age. Skin changes and certain rhytids/wrinkles will also not be affected. Although typically most patients will appear 7 to 10 years younger, individual results vary. Besides, the procedure will not stop aging and normal aging related changes will continue after the procedure.
Most patients who undergo a face/neck lift can be discharged home after surgery. However, some patients especially those who choose to have additional eyelid and brow procedures may prefer to stay overnight in a hospital or have a nurse supervise them at home. Bruising and swelling are expected after this procedure and can take several weeks to return to normal. However in most patients, by two weeks the resolving bruises can be well covered with makeup. I recommend patients to give it at least 3 months before attending important functions or be in a family photograph. Drains are used after this procedure and can remain in place for three to five days. Showering can resume in 24 hours.
Questions to ask your surgeon before face/neck lift
- What facelift technique do you use? SMAS dissection places all the tension on this deeper layer and avoids a pulled look. Among SMAS techniques, a high SMAS procedure has the advantage of repositioning the midface.
- What is the status of my midface? Are you going to address this during the facelift? Isolated mid face procedures can cause an imbalance when combined with traditional facelift procedures. A high SMAS facelift repositions the midface in addition to the rest of the face.
- What modifications are planned for the neck? Is there excess fat beneath the platysma muscle that needs to be addressed? Deep fat that is not addressed can cause residual fullness in the central neck
- Do I have fat loss over the face? Is fat injection planned? As discussed above, most patients have loss of facial fat when they enter their mid 30’s. Although a patient may decide not to have fat injections done, for best results, it is usually required.
- Do I have skin changes that need a peel or laser resurfacing? Facelifts only address the gravity related component of aging.
- Am I a suitable candidate for a short scar facelift? Although short scar facelifts are popular, many patients are not suitable candidates as they have advanced aging and need longer incisions to address these changes effectively. A short scar facelift under these circumstances will promise much but deliver little.
- Where are my incisions placed in front of and behind the ear? Typically the incision in front of the ear curves into the tragus (the projection in front of the ear canal). However, some surgeons place it in front of the tragus where the scar can be very visible. Similarly, incisions behind the ear are sometimes placed into the hairline under the misleading impression that scars will be less visible. Although this is acceptable in a younger patient where there is no skin excess, most individuals need removal of excess skin and in these patients the hairline is displaced resulting in an unsightly appearance.