Definition
Indications
Procedure
Surgery
Recovery
Risks
Instructions
Definition
The facelift is an operation that rejuvenates the middle and
lower third of the face. The overall face can be aesthetically
divided into three components : forehead, mid-face (cheek) and
neck. A facelift actually is a mid-face lift which, almost
always, is done in conjunction with the neck, the so-called face
and neck lift. Adding a forehead or brow lift. would constitute a
full face lift. But since aging in the mid face and neck occurs
more rapidly than it does in the forehead, not every patient, who
is a good candidate for a mid-face and neck lift, needs to
undergo a forehead lift. Facial rejuvenation surgery must be
customized to each patient. The aesthetic and formidable
challenge is to create a natural appearance where patients look
like themselves, but younger.
Indications for a facelift include: 1. Deepening of the smile lines (so-called nasolabial folds which run from the base of the nose to the corner of the mouth), 2. Jowl formation, which is an accumulation of cheek fat and skin along the border of the lower jaw adjacent to the chin and 3. Sagging cheeks which are the cause of the previous two indications.
Sagging of the cheek tissues around the mouth create an inverted U-shape appearance which gives the person a saddened or sometimes even mean look. Sagging of the cheeks away from the lower eyelids gives a tired and aged look. The weight of the heavy cheek skin stretches out the much thinner lower eyelid skin which leads to a rounding out appearance of the lower eyelid, another undesirable look of aging. The aesthetic effect of a mid-facelift can be simulated in the mirror by pulling up on the cheek from a point above the cheeks and to the side of the eyes.
Neck Lift
Indications for a neck lift include 1. Sagging of the neck skin and 2. Relaxation and visibility of the superficial neck muscle known as the platysma. There is a right and a left platysma muscle. When they descend away from the neck platform, the midline edge of each muscle becomes a visible band and the youthful neck contour is lost. The aesthetic effect of a neck lift can be visualized by pulling the sagging neck skin up and towards the back of the neck.
Forehead (Brow) Lift
The primary indication is sagging or descent of the brows down to or over the palpable upper eye socket bone which creates a tired, fatigued eye appearance. The aesthetic effect of a lift can be simply assessed by pulling the brows up with your hands and looking in the mirror. The second indication is the development of horizontal lines in the forehead and vertical lines in the frown area.
Mid Face
In the mid-facelift, sagging cheeks are elevated back onto the cheekbone area from where they descended- therefore, in principle, a mid-face lift is a restorative procedure or one that reverses the signs of aging. Incisions run from the hair in the temple area down to the front of the ear, then curve in and follow the undulations of the front of the ear, then follow around the ear lobe, turn upwards in the crease behind the ear and then over into the hair behind the ear.
The mid-facial i.e. cheek skin is elevated down toward the level of the nasolabial fold, the jowls, below the lower jaw and on to the neck. Excess fat along the jowl or neck is conservatively trimmed. Most of the fat does not represent a true excess but actually is fat that has fallen downward as a result of gravity and mainly needs to be re-elevated from where it came, that is the cheek area.
Then, once the skin has been lifted, the supporting or muscular layer of the face, so-called SMAS, is evaluated for laxity. If the SMAS is loose, it is tightened with sutures. The aging process varies significantly in patients - some manifest more aging at the skin level and thus need more attention there, others age more at the deeper SMAS level and need more restoration there. Each patient must be individualized to their own degree and level of aging. The aesthetic challenge of a facelift is to create a natural, refreshed, youthful appearance, not a tight or pulled look. Again, surgery has to be customized to the needs of the patient.
Neck
In the neck lift, an incision is made underneath the chin. The skin is undermined from the midline towards the sides. The midline platysma muscle bands are sutured together. Then, from the facelift incisions, the neck skin is undermined from the side towards the midline, thus completely freeing the neck skin. The side edges of the platysma muscles are then freed and tightened out to the sides with sutures. Any excess fat in the neck,on top of the muscle, is carefully trimmed. When all is finished, the neck muscles have been fully tightened and the skin has been lifted and redraped, reestablishing a youthful neck line.
Forehead
Click on 'Forehead' to link to a separate page.
Before surgery, the patient should have a complete medical check-up including laboratory work and EKG to be sure the individual's health is optimal. Blood pressure must be normal. All smoking must be stopped at least two to three weeks prior to surgery to minimize the risk for healing complications. The surgery involves several hours depending on how much rejuvenation needs to be done. Surgery is done in the safety of the hospital environment. A board certified anesthesiologist monitors the patient throughout and provides a light general anesthetic to allow the patient to sleep through the entire surgery. Local anesthesia is utilized for local pain management reducing the need for administration of narcotics. Monitored sedation may be used in selected patients.
The patient must remain in the hospital overnight. The hospital has rooms especially designed for plastic surgery patients. By next morning, patients may go home although some may prefer to stay another day. Drains placed at the time of surgery, to remove undesired fluid accumulations, are discontinued prior to discharge. Pain is rarely a significant issue and is controlled with oral pain medications. Prophylactic antibiotics are used for four days.
The patient should plan on about two weeks for resting and recovery. After two weeks or less, one can return to work and social interaction. All sutures are removed in seven to ten days. Healing continues for several months and usually becomes optimal around three to six months. Exercise should be avoided for about one month following surgery.
Bleeding
Significant bleeding or hematoma formation after surgery occurs in 1 to 2 % of patients, usually in the first 24 hours while the patient is still in the hospital. This will require a return to the operating room for surgical evacuation. To minimize this risk, strict bed rest must be observed in the first two to three days. If a hematoma is properly treated, no long term problems result although a patient will have more bruising.
Aside from large hematomas, much smaller hematomas can occur, usually noticed as little irregularities or areas of fullness. This is more common and is treated non-surgically with warm ( never hot) compresses and Arnica, a homeopathic medication. Meticulous attention to stopping any bleeding during surgery is very important to reduce this risk which, fortunately, is more of a nuisance than a serious problem, though it does the delay the final result.
Bruising
Significant bruising is rare. It is more common with eyelid surgery. Some bruising can occur in the neck. Most bruising takes about three weeks to resolve. Arnica is quite helpful and prescribed for all patients.
Nerve Injuries
There are two types of nerves - motor and sensory. Motor nerves allow facial expression. Sensory nerves provide feeling.
There is a about a 1 % risk for motor nerve injuries which could result in facial asymmetries. These injuries are usually temporary and heal in three to six months.
Injury of a large sensory nerve in the neck can result in prolonged localized pain in the neck or behind the ear if the nerve heals unfavorably (neuroma formation). This is very rare. Generalized facial pain has been described but is extremely rare and represents an underlying neurologic disorder.
All patients will experience temporary numbness in the lifted facial and neck skin areas. Sensation returns by about three months.
Scarring
Scar formation, in particular keloid, is always a variable. Most patients, however, make excellent facelift scars especially when time and care was taken during surgery to hide and suture the incisions carefully.
Skin Necrosis
Particularly in smokers, localized skin necrosis can occur, causing a delay and worsening of the eventual scar. It results from inadequate blood and oxygen supply to the skin edges. Since this is a circulatory problem, it is much more common in smokers. When this happens, it is usually behind the ears and out of direct sight.
No aggressive skin peels, with a carbon dioxide laser or phenol or concentrated TCA acids, must be done on lifted face or neck skin until several months after surgery. Lifting the skin from below and attacking it from above with lasers or chemical peels can overwhelm the circulation and invite skin necrosis. If little or deep skin undermining was done, light peels can be safe, but the surgeon better be experienced with peels (laser or acids) and have very good judgment.
In most healthy, non-smoking patients, skin healing problems are very rare. Smokers must be advised to cease all smoking, including secondary, at least two to three weeks before surgery. Also, surgery has to be more conservative in smokers since excessive tension on the facial skin can precipitate skin necrosis.
To avoid skin necrosis problems, patients must remember to never expose the lifted facial skin to extreme heat such as hot compresses, blow dryers or hot water. When showering, the water stream should never hit the face directly.
Click here for face lift information from the American Society of Plastic Surgeons (ASPRS).
For before and after facelift patient instructions, click here.