Facelifts: A Contemporary Perspective

Abstract

The premium that our society has placed on youthful appearance has driven an ever increasing number of patients to seek facial rejuvenation. As the demand for these procedures has increased so has the expectation that these procedures can be performed more safely while ultimately delivering a more natural appearance than has historically been possible. More focused (and often times less invasive) procedures have been developed to better serve the needs of our patients.

Introduction

It is an unfortunate reality that we live in a Western society that does not revere age. Coupled with this is a public perception that with aging usually comes some element of physical and /or mental deterioration. A great many people (many of whom are “baby boomers”) find that they “feel” much younger than they look and want their physical appearance to better match their perception of their own retained youth as they plan for the added years that accompany ever increasing life expectancies in this country. The economic downturn, in recent years, is also forcing many people to delay planned retirement often times requiring that they compete with job candidates many years their junior.

Evolution of Techniques

Along with a desire to look younger is an even stronger desire to look “natural” and it is this fact that drives plastic surgeons to reinvent many of the traditional techniques for facial rejuvenation. Although photos in the media often show faces that appear surgically altered and unnatural, this can be readily avoided by utilizing hybrid surgical techniques supplemented by other non-surgical modalities such as Botox injections ^{1, 2} and the use of various injectable fillers.

Historically, facelift techniques have been based on skin-tightening maneuvers producing the all too familiar “pulled” look. Modern techniques apply the tension to the underlying muscle and/or fascial layers in the neck and face allowing the skin to re-drape in tension-free fashion.³ There is no longer a need to perform “complete” facelifts on all patients as isolated neck lifting or lower face lifting can, in many cases, provide exceptional results with significantly reduced amounts of surgery. Rapid-recovery facelifts combine techniques which tend to produce less swelling and bruising and may allow a more rapid return to normal activities of daily living. This can decrease the cost and downtime for patients, many of whom are anxious to get back to their normal routines as quickly as possible after surgery. Facelift incisions may also be modified so that they are largely hidden within the hairline or inside of the ear and some necklifts can be performed using only an incision in the submental crease and sometimes a small incision in the crease behind each ear (Figures 1, 2 and 3). These isolated neck enhancement procedures may involve the use of permanent “suspension sutures” which can help define the critically important angle between the neck and jaw line as well as enhancing the jaw line itself.^{4, 5, 6}

Figure 1.

Before (top) and After (bottom)

51-year Old Female. Pre- and Nine Days Post Rapid-Recovery Facelift

Figure 2.

Before (top) and After (bottom)

48-Year Old Male. Pre- and Eight Months Post Mid-Face/Neck Lift

Figure 3.

Before (left) and After (right)

56-Year Old Female. Two Years Post Mid-Face/Neck Lift

Patient Safety

Anesthetic techniques have improved dramatically assuring far greater safety and patient comfort both during and following surgery. Autologous “fibrin glue” can be prepared from a small amount of the patient’s blood drawn during surgery. This produces a gel-like material that can be applied to the raw surface areas during surgery reducing bruising and bleeding and accelerating the healing and recovery process. However, all surgical procedures involve risks and facelifts are no exception. Bruising and bleeding (hematomas) can be reduced by avoiding aspirin and anti-inflammatories for several weeks before and after surgery and the use of Arnica Montana, taken orally post-operatively, may also be of benefit. Wound healing problems can be dramatically reduced in frequency and severity if patients are 100% nicotine-free for a period of four weeks before and after surgery. The use of antibacterial scrubs prior to surgery may reduce the risk of infection and meticulous surgical technique may reduce the chances of seventh cranial nerve injuries and other complications. However, it takes months to see the final result after these surgeries and, although patients may look good in short order, they need to be prepared to limit their social and physical activities during the weeks following surgery.

Innovations

In recent years there has been a new appreciation of the fact that the fat volume seen in young faces tends to diminish with age. As a result techniques to add fat back into faces have become extremely popular.^7,8 The senior author’s personal experience with this technique dates back some 10 years and many of these fat grafts are still present when these patients are seen in long-term follow up. A preferred donor site for fat graft material is the abdomen where it can be harvested with a micro-liposuction cannula through a 1–2 mm incision. When judiciously placed in the face, these grafts can be extremely effective especially when used to rejuvenate the area below the lower eyelids and in the upper cheek in those patients who commonly complain that the contour and shadowing in this area makes them look tired.

In select cases where there is an element of fat excess in the neck and/or jowls, accompanied by limited skin laxity, Laser Assisted Liposuction (L.A.L.) can be performed as an office procedure under local anesthesia.^{9, 10} A micro-cannula (1 mm in diameter) containing a 600 micron YAG laser is introduced through one or more incisions each measuring approximately 1–2 mm. The laser energy is used to liquefy the fat as well as deliver heat to the undersurface of the dermis. This encourages skin retraction and tightening. Many times this can be used very successfully as a stand-alone procedure or as a way for patients to “buy some time” before undergoing more extensive facial procedures. If fine wrinkles or pigment changes associated with sun exposure are a concern a variety of lasers may be used on the skin’s surface to reduce these and can either be combined with surgical procedures or performed separately in an office setting. As previously mentioned Botulinum Toxin A, as well as any of a number of injectable materials, can temporarily improve facial contour and aesthetics.¹¹

Conclusion

In all cases patients need be well informed and have realistic expectations before electing to undergo a facelift. They may do well to seek multiple opinions as these surgeries are very technique-dependent and there is often more than one procedure which might be appropriate in any given case. If a patient finds a procedure that sounds too good to be true, it probably is. Caveat Emptor! With proper patient selection and surgical technique facelifts may offer patients exactly what they want; an opportunity to age gracefully enjoying a youthful appearance that better matches their outlook and lifestyle.

Biography

David Caplin, MD, MSMA member since 1976, is a Clinical Instructor in the Division of Plastic Surgery at Washington University School of Medicine, St. Louis. Chad Perlyn, MD, PhD, is faculty at Department of Surgery, Florida International University College of Medicine.

Contact: gfts27@aol.com