Facelift

FACELIFT - a patient's guide
Dr John de Waal - Plastic Surgeon, Auckland

Introduction

As the name suggests the procedure involves the lifting or resuspension of the face. This produces a rejuvenated appearance. As one ages gravity and diminished skin elasticity take their toll and the facial tissues droop.

The excessive drooping of soft tissue in some places gives the appearance of deep wrinkles. The resulting problems are variously described by features as 'jowls', 'baggy eyelids', and a 'turkey gobbler neck'.

While various creams and good skin care can reduce the rate at which these changes take place they are an inevitable consequence of aging. Surgical correction addresses the problem by resuspending the tissues involved and removing excess stretched tissue. It 'turns the clock back' but 'doesn't stop it ticking'.

The procedure performed depends on the facial features one is trying to rejuvenate and can in fact be a combination of procedures. The term facelift then can mean many things.

The Traditional Facelift

The term facelift classically refers to procedures performed to address changes in the lower two-thirds of the face; i.e. resuspending cheeks, defining the jawline and removing excess neck skin. Cuts used to perform this are placed around the ears and carry through into the hair behind the ears. The tissue (skin and deeper tissue) over the cheeks and neck is freed up, resuspended, the excess cut away, and the tissue sewn into its new position. Techniques can be included to give the impression of wider cheekbones.

Other procedures can be added to or used in isolation from this basic design to address specific facial areas.

The Brow/Forehead

Wrinkles here are addressed with a 'Browlift'. The tissues of the brow are again freed up and resuspended. This diminishes forehead wrinkles and lifts the eyebrows. it gives the upper eyelids a less heavy appearance. A browlift is now frequently performed using a special instrument called an endoscope which enables the procedure to be performed through small cuts in the hairline.

Eyelids

A so called 'blepharoplasty' addresses the problem of 'baggy eyelids'. Cuts are made in the shadow area of upper eyelids and immediately beneath the lashes of lower eyelids, and again tissue resuspended and excess removed. Bulging fat deep in this tissue is often also removed. The cuts in the eyelids generally heal exceptionally well and are difficult to detect even on close inspection.

Neck

As well as the removal of excess skin and increasing jawline definition which occurs as a consequence of a facelift, the 'turkey gobbler' appearance of the neck can be directly addressed by the tightening and repositioning of some of the neck muscles and the liposuction of excess fat.

Lips

Thinned lips can be given a fuller appearance by injections (collagen, artecoll, restylane) or the insertion of strips of tissue (dermis, fascia etc) or various materials (e.g. gortex) into the lips. The materials used can be artificial or natural (from your own body). Injectable materials run the risk of a lumpy result. The use of artificial 'plumping materials' tend to have a higher rate of complication.

The Operation - what to expect

A 3 - 5+ hour operation depending on what you have done

Drains and/or a head bandage for about 12 hours to reduce the risk of bleeding

A one night hospital stay

Stitch removal at 4 - 7 days

7 - 10 days for most of the swelling to settle and the bruising to be settling to the stage that any residual is easily disguised

A feeling of tightness in the skin and some change in the feeling of the skin. These return largely to normal but may take a few weeks to do so

Possible complications:

The overall complication rate is low but this is a moderately large operation and problems can arise. Possible complications include:

Hematoma - blood can accumulate under operated tissues. If it does, it needs to be removed (surgically) as it can compromise the survival of the tissues involved.

Nerve damage - the most feared of facelift complications - it is very rare although it is not unusual to have a temporary weakness of the lips in the first 1 - 2 days following the procedure.

Hair loss - around the scar line in the hair making it more apparent. If this occurs it is often temporary. If it becomes noticeable it can be addressed.

Skin loss - around the cuts the blood supply is poorest and sometimes marginal - some tissue can become infected and needs removing leaving a gap - this then heals but usually with a poor scar.

Scars of poor quality - occasionally scars become more apparent than ideal. There are many factors involved in good scar formation and while in most cases they can be avoided or revised, troublesome ones occasionally do occur.

It should be noted that smoking considerably raises the incidence of complications - particularly hair loss, skin loss, infection and scars of poor quality. Some surgeons will not perform facelifts on smokers unless they have not smoked for at least 4 - 6 weeks prior to surgery.

Types of Facelifts:

There are many variations on facelifts which get given various names - sometimes they are differences in name only, sometimes just small variations. There are basically three types of facelift and many variations therein.

The Subcutaneous Facelift - So called 'skin only', 'first generation' lifts in which the skin and some underlying fat is freed up, pulled tight, the excess removed, and the skin stitched back. This was the basis of the early facelifts and was popular until the early 70's. Its shortcoming is that skin stretches if put under tension (as shown by the tummy in pregnancy). This means that the facelift tends to last only a short time - the skin restretching quickly. To counter this, the skin was stretched extraordinarily tight - giving the tight, flat look of some of the early Hollywood stars. A related problem is that the tension on the scars is very high and they tend to stretch. Problems related to hair loss around the scar, infection etc tend to be higher therefore.

A newer variant - the so called SACS lift where the level of dissection is just below the fat plane, so deeper than the traditional subcutaneous facelift, has enjoyed some recent popularity. It is popular as it is quick, without the higher risks of the traditional facelift but most would argue not as long-lasting as other techniques.

The SMAS lift - Variations on this are the most popular facelifting techniques and used by the majority of facelift surgeons. The principal is to lift the SMAS layer (superficial musculo-aponeurotic system). This is the layer deep to the skin and fat of the face and includes the muscle tensioning layer and the facial 'fat pads'. These, like the skin, drop with age. Most argue that they contribute most of the weight that stretches the skin. By repositioning these structures to their rightful position, one finds that when the skin is simply draped back there is a large excess to cut away - it does not have to be stretched as in the subcutaneous lift. Repositioning the fat pads restores the youthful triangular shape to the face and widens the cheek bones. The lack of tension on the skin minimises the complications of hair loss, scar widening etc, and the more youthful look lasts longer, as the deeper layer, not just the superficial layer, gets restored to its rightful place.

Variations of this technique include 'limited SMAS', 'extended SMAS', 'SMAS plication', 'the composite facelift', 'second', 'third' and 'forth' generation facelifts. The 'extended SMAS' variation is probably the most preferred facelift performed by the majority of facelift surgeons.

The Subperiosteal Facelift - Extending the concept that it is not just the skin that has sagged by all the underlying structures, the subperiosteal or 'mask' lift has attempted to lift all face structures by lifting tissues 'off the bone' and lifting everything as a unit. Proponents argue it lifts everything and avoids cuts around the ear (which are the least hidden of facelift scars). Opponents say - the face drops more in the top layers than the deep and so the deepest plane is not the best; it has a much higher risk of facial nerve damage and the overall results are not as good as SMAS procedures when the two techniques are shown side by side.

Some techniques combine elements of the above three procedures - 'multiplanar facelifts'.

Summary

Facelifts produce good results when done well. They are, however, a moderately big procedure and not without risk. It is important then that you seek out a well trained surgeon who is experienced in facelift surgery if considering this type of surgery.