Facelifting & Necklifting

As people age, the effects of gravity, alterations in skin elasticity and significant changes in the facial and neck fat distribution can be seen. Deep creases form between the nose and mouth, the jawline grows slack and jowly and folds and fat deposits appear around the face and neck.

A facelift (medically known as rhytidectomy) improves the most visible signs of aging by removing excess fat, tightening underlying muscles, and redraping the skin of your face and neck. The facelift is the single most important and beneficial treatment for most patients older than age 40 years who wish to maximally address facial-aging changes. A facelift can be done alone, or in conjunction with other procedures such as eyelid surgery. If you’re considering a facelift, this information will give you a basic understanding of the procedure when it can help, how it’s performed, and what results you can expect. It can’t answer all of your questions since a lot depends on your individual anatomy.

QUICK FACTS

IDEAL FACELIFT CANDIDATE

Laxity of the face and neck skin
Droop and prominence of jowls
Mild or moderate wrinkling of the skin

FACELIFT ADVANTAGES

Resuspension of the deep soft tissues of the face
Removal of excess skin and redraping of skin, making it taut, not overly tight

COMMON FACELIFT TECHNIQUES

Short Scar Facelift
MACS Facelift
Classical Facelift
SMAS Plication Facelift
SMASectomy Facelift
Deep Plane Facelift

FACELIFT STATISTICS

Length of surgery: 3 to 4 hours
Back to Work: 12 to 14 days
Return to Exercise: 7 to 10 days (light exercise), 3 to 4 weeks (moderate exercise), 6 weeks (strenuous exercise)

Am I a good candidate for facelift surgery?

The ideal candidate for a facelift has a face and neck that have begun to sag, but whose skin still has some elasticity and whose bone structure is strong and well-defined. Most patients are in their forties to sixties, but facelifts can be done successfully on people in their seventies or even eighties as well. A facelift can make you look younger and fresher and it may enhance your self- confidence in the process.

The face usually portrays the first visible signs of aging. Both gravity and diminished volume result in the facial features of aging. Most patients requesting evaluation for facelift feel that their facial features do not reflect their youthful spirit and energy level. They are looking for ways to refresh and rejuvenate their appearance. There are many different variations of the facelift procedure that smooth the skin of the face and neck, tighten the underlying tissues and muscle, and remove excess skin.

Facelift for various age groups:

Facelift in the 40’s: The JOWL decade. Patients who seek improvement in the appearance of the aging face in their 40’s are most frequently interested in elimination of early jowls. Of course, aging changes vary tremendously between patients of different skin types, bone structures, genetics, ethnic groups etc., but the earliest correctable sign of facial aging, not including the eyelids, is frequently the appearance of jowls, or at least the sagging of the lower cheek, even if there is not yet an actual jowl. The skin elasticity in these patients is usually of good quality and surgical correction is usually excellent.

Facelift in the 50’s-60’s: The JOWL and NECK decades. Patients seeking an improvement in the appearance of the aging face in their 50’s and 60’s have often developed both changes along the jawline (jowls) and changes in the neck. The other category of patients in this time period is the re-do or revision facelift patient; that is, the patient who had a facelift procedure previously and returns either because of dissatisfaction or because the aging changes have progressed. Skin elasticity in this age group is still good and the results are usually excellent.

Facelift in the 70s-80’s: The JOWL and NECK and DEFLATION decades. Patients seeking improvement in the 70s and 80s often have the triad of jowls, changes in the neck and deflation (fat loss) in certain areas. As mentioned above, the other category of patients in this age group are those who have had previous procedures. Patients in the 70s-80s often require elimination of the jowls, improvement of neck laxity, and replenishing of facial fat with fat grafting. Different facial shapes age differently: The thin face tends to lose fat and require fat grafting. The heavier face tends to sag more than the thin face, and may not require the fat grafting that the thinner face might. The results in this age group are also gratifying although the skin quality is not as good as younger patients and some residual excess skin is often seen under the chin when the swelling has resolved. This age group is also extremely pleased with facelifting.

How will my plastic surgeon evaluate me for a facelift?

Facelifts are very individualized procedures. In your initial consultation the surgeon will evaluate your face, including the skin and underlying bone, and discuss your goals for the surgery. If you decide to have a facelift, your surgeon will explain the techniques and anesthesia he or she will use, the type of facility where the surgery will be performed, and the risks and costs involved. Don’t hesitate to ask your doctor any questions you may have, especially those regarding your expectations and concerns about the results.

During the pre-operative consultation, your surgeon will perform a history and physical examination. During your physical examination, your facial bone structure, underlying skin structure, skin thickness, texture, and elasticity as well as the extent of facial wrinkles and folds will be assessed. This information will be used to formulate a surgical plan and the goals of the procedure will be discussed. Generally, a facelift is a very versatile procedure,

and your surgeon will explain the technique that he or she feels most comfortable with and that offers the lowest risk. Your plastic surgeon will select the surgical technique that he or she feels will obtain the best outcome for you based on your discussions regarding the outcome you wish to achieve.

Common aging changes in the face

Common aging changes

Forehead and glabella creases.
Ptosis of the lateral brow.
Redundant upper eyelid skin.
Hollowing of the upper orbit.
Lower eyelid laxity and wrinkles.
Lower eyelid bags.
Deepening of the nasojugal groove.
Ptosis of the malar tissues.
Generalized skin laxity.
Deepening of nasolabial folds.
Perioral wrinkles.
Downturn of oral commissures.
Deepening of labiomental crease
Jowls/jowling
Loss of neck definition and excess fat in neck. 16. Platysmal bands.

Before Facelift surgery

Your surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain vitamins and medications. Carefully following these instructions will help your surgery go more smoothly. If you smoke, it’s especially important to stop at least a week or two before and after surgery; smoking inhibits blood flow to the skin, and can interfere with the healing of your incision areas. If your hair is very short, you might want to let it grow out before surgery, so that it’s long enough to hide the scars while they heal. Whether your facelift is being done on an outpatient or inpatient basis, you should arrange for someone to drive you home after your surgery, and to help you out for a day or two if needed.

If you are a smoker, you will be asked to stop smoking well in advance of the surgery. Certain medications that increase the risk of bleeding such as Aspirin, non-steroidal anti-inflammatory medications, and some vitamins/homeopathic regimens should be discontinued prior to surgery. If your hair is short, you may want it to grow out enough to cover your incisions while they heal. Any chemical processing of your hair should be performed prior to surgery since you cannot have any of these procedures for a month of more after surgery. If your facelift will be performed on an outpatient basis, be sure to arrange for someone to drive you home and stay with you for at least the first night following surgery.

The Day of Surgery

Anesthesia for a Facelift

Most facelifts are performed under local anesthesia, combined with a sedative to make you drowsy. You’ll be asleep and relaxed, and your face will be insensitive to pain. However, you may be mildly awake at times and feel some tugging or pulling. Some surgeons prefer a general anesthesia. In that case, you’ll sleep through the operation.

Your facelift will be performed in a JCI-Accredited hospital.

Medications are administered for your comfort during the procedure. You and your plastic surgeon will have decided in advance what type of anesthesia is to be used – either intravenous sedation (twilight) or general anesthesia. For your safety during and after the operation, various monitors are used to check your heart, blood pressure, pulse and the

amount of oxygen circulating in your blood. When surgery is completed, you will be taken into a recovery area. A bandage may be wrapped around your face. Sometimes small tubes will be inserted beneath the skin to drain away fluid that might otherwise accumulate. There is surprisingly very little discomfort experienced after facelift surgery. However, any discomfort you may experience will be controlled with pain medication as needed. You may be permitted to go home after a few hours, although some patients may stay overnight in a hospital or surgical facility.

Surgical technique: How is a facelift performed?

A facelift usually takes three to four hours or somewhat longer if you’re having more than one procedure done.

Every surgeon approaches the procedure in his or her own way. The exact placement of incisions and the sequence of events depends on your facial structure and your surgeon’s technique but incisions usually begin above the hairline at the temples, extend in a natural line in front of the ear (or just inside the cartilage at the front of the ear), and continue behind the earlobe to the lower scalp. If the neck needs work, a small incision may also be made under the chin.

incisions

Types of facelift incisions. All incisions are hidden and minimally visible after healing

In general, the surgeon separates the skin from the fat and muscle below. Fat may be trimmed or suctioned from around the neck and chin to improve the contour. The surgeon then tightens the underlying muscle and membrane (SMAS), pulls the skin back, and removes the excess. Stitches secure the layers of tissue and close the incisions; metal clips may be used on the scalp.

SMAS-ectomy

SMAS-ectomy: The most common facelift technique we use involves the removal of a strip of the SMAS (Subcutaneous Musculo-Aponeurotic System) and re-approximation of the edges in order to tighten and lift the deeper tissues. The neck muscle (platysma) is also anchored behind the ear in order to lift the neck and under-jaw areas.

Following surgery, a small, thin tube may be temporarily placed under the skin behind your ear to drain any blood that might collect there. The surgeon may also wrap your head loosely in bandages to minimize bruising and swelling.

The facelift procedure continues to evolve. Over the years, the procedure has changed from simple skin lifting tomore complex deeper plane lifting techniques. Today, many different techniques exist, with outcomes that are consistently reliable and durable. The modern trends in facelifting at the present time are best summarized as follows:

Volume versus tension—Placing tension on the skin is an ineffective way of lifting the face and is responsible for the “facelifted” look and for unsightly scars and distortion of the facial landmarks such as the hairline and ear. The current trend is toward redistributing, or augmenting, facial volume, rather than flattening it with excessive tension.
Less invasive—That the more “invasive” techniques have not yielded benefits in proportion to their risk combined with the public demand for rapid recovery has led to simplified procedures.
Facial harmony—The goal is to help a patient look better, not weird or operated on. Excessive tension, radical defatting, exaggerated changes, and attention to one region while ignoring another may result in disharmony. The face is best analyzed and manipulated with the entire face (and the entire body) in mind, not the individual component parts, lest the “forest be lost for the trees.”
Recognition of atrophy—The process of aging involves not only sagging of the tissues and deterioration of the skin itself but atrophy of tissues, especially fat, in certain areas. Most patients are best served with limited defatting and may require addition of fat to areas of atrophy.

The results are a reversal of the effects of gravity and tightening of soft tissues of the face to restore a more youthful contour to the face. Most commonly, the facelift procedure is combined with an eyelid lift (blepharoplasty), and frequently with fat transfer (autologous fat grafts).

Recovery

There isn’t usually significant discomfort after surgery; if there is, it can be lessened with the pain medication prescribed by your surgeon. (Severe or persistent pain or a sudden swelling of your face should be reported to your surgeon immediately.) Some numbness of the skin is quite normal; it will disappear in a few weeks or months. Your doctor may tell you to keep your head elevated and as still as possible for a couple of days after surgery, to keep the swelling down. If you’ve had a drainage tube inserted, it will be removed one or two days after surgery. Bandages, when used, are usually removed after four to five days. Your scalp may take longer to heal, and the stitches or metal clips in your hairline could be left in a few days longer. It is important to realize that the amount of time it takes to recover from Facelift surgery varies greatly between individuals. Your surgeon may also advise you to use ice packs intermittently. You should avoid Aspirin and non-steroidal anti- inflammatory medications for the first few days after your surgery. Smoking and exposure to second-hand smoke should be avoided to prevent delays in the healing process. Once the dressings and drains are removed, puffiness and discoloration may be more pronounced in some portions of the face than others. Do not be alarmed by any unevenness or temporary asymmetry – this is normal. Most swelling is usually noted in the first 3-5 days, and most bruising resolves within 10-12 days. Concealing makeup is usually permitted after the first week. You may experience numbness to the face post-operatively, which usually resolves within several months. Some patients find that mild swelling persists for many weeks. Most stitches are removed within a week of the surgery. Straining, bending, and lifting should be avoided during the early post-operative period as these activities may predispose you to bleeding. Your surgeon will give you specific instructions that may include caring for the dressings and incisions, directions for your analgesics and other medications, specific concerns to look for, and when to follow up in the office to monitor your healing process. It may take several months for the swelling to fully resolve, and up to 6 months for the incision scars to fully fade. Avoidance of factors that could reduce the benefits of the surgery, such as excessive unprotected sun exposure and cigarette use, is vital.

You should be up and about in a day or two, but plan on taking it easy for the first week after surgery. Be especially gentle with your face and hair, since your skin will be both tender and numb, and may not respond normally at first. Your surgeon will give more specific guidelines for gradually resuming your normal activities. They’re likely to include these suggestions: Avoid strenuous activity, including heavy housework for at least two weeks (walking and mild stretching are fine); avoid alcohol, steam baths, and saunas for several months. Above all, get plenty of rest and allow your body to spend its energy on healing.

At the beginning, your face may look and feel rather strange. Your features may be distorted from the swelling, your facial movements may be slightly stiff and you’ll probably be self-conscious about your scars. Some bruising may persist for two or three weeks, and you may tire easily. It’s not surprising that some patients are disappointed and depressed at first. By the third week, you’ll look and feel much better. Most patients are back at work about ten days to two weeks after surgery. If you need it, special camouflage makeup can mask most bruising that remains.

Results of Your facelift

The chances are excellent that you’ll be happy with your facelift-especially if you realize that the results may not be immediately apparent. Even after the swelling and bruises are gone, the hair around your temples may be thin and your skin may feel dry and rough for several months. You’ll have some scars from your facelift, but they’re usually hidden by your hair or in the natural creases of your face and ears. In any case, they’ll fade within time and should be scarcely visible.

The results of your facelift may be subtle or dramatic, depending on your appearance prior to the surgery as well as the specific goals that you and your plastic surgeon have established. Since the healing process is gradual, you should expect to wait several weeks for an accurate picture of your “new look”. Additional minor changes or settling may occur over several months following your Facelift surgery.

Having a facelift doesn’t stop the clock. Your face will continue to age with time, and you may want to repeat the procedure one or more times-perhaps five or ten years down the line. But in another sense, the effects of even one facelift are lasting; years later, you’ll continue to look better than if you’d never had a facelift at all.

Understanding Risks

When a facelift is performed by a qualified plastic surgeon, complications are infrequent and usually minor. Still, individuals vary greatly in their anatomy, their physical reactions, and their healing abilities, and the outcome is never completely predictable.

Complications that can occur include hematoma (a collection of blood under the skin that must be removed by the surgeon), injury to the nerves that control facial muscles (usually temporary), infection, and reactions to the anesthesia. Poor healing of the skin is most likely to affect smokers. You can reduce your risks by closely following your surgeon’s advice both before and after surgery.

Fortunately, significant complications from facelifts are infrequent. Every year, thousands of people undergo successful facelift surgery and are pleased with the results. However, anyone considering surgery should be aware of both the benefits and risks. These are best discussed on a personal basis with your surgeon or one of their qualified staff members.

Some of the potential complications that may occur include hematoma (an accumulation of blood under the skin), infection, and reactions to anesthesia. While plastic surgeons are trained in techniques for safely manipulating facial skin and tissues, injury to underlying structures is possible, though usually temporary. Facelift incisions are usually quite inconspicuous; however, this is not entirely predictable due to individual variations in healing. You can help minimize certain risks by following the advice and instructions given to you by your plastic surgeon both before and after surgery.

RELATED PROCEDURES

Facelift surgery is frequently combined with other facial rejuvenative procedures. For those individuals who desire additional plastic surgery enhancements, particularly geared toward achieving and maintaining a youthful balance of all parts of the face, your facelift may be combined with eyelid lift (blepharoplasty), chin implant (chin augmentation), liposuction of the neck, neck lift (platysmaplasty), fat transfer (autologous fat grafts) or a chemical peel.

Most commonly, the facelift procedure is combined with an eyelid lift (blepharoplasty), and frequently with fat transfer (autologous fat grafts).

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