Facelift Chapter

Facelifting

Facelifting was first performed in the early 1900s and for most of the 20th century involved skin undermining and skin excision. A revolution occurred in the 1970s when the public became exponentially more interested in the procedure and Skoog described dissection of the superficial fascia of the face in continuity with the platysma in the neck. Since then techniques have been described that involve every possible skin incision, plane of dissection, extent of tissue manipulation, type of instrumentation, and method of fixation. Many of these “innovations” provide little long-term benefit when compared to skin undermining, and expose the patient to more risk. The trends in facelifting at the present time are best summarized as follows:

1. 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.
2. 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.
3. 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.”
4. 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.

Facelifting addresses only ptosis and atrophy of facial tissues. It does not address, and has no effect on, the quality of the facial skin itself. Consequently, facelifting is not a treatment for wrinkles, sun damage, creases, or irregular pigmentation. Fine wrinkles and irregular pigmentation are best treated with skin care and resurfacing procedures (see Chapters 13 and 44). Deep creases, such as the labiomental creases, may be improved by facelifting. Other facial creases, however, will not be improved by facelifting (nasolabial creases), and even if improved somewhat, will still require additional treatment in the form of fillers or muscle-weakening agents (see Chapters 45 and 46).

The above disclaimer not withstanding, 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.

Patients have individual aging patterns determined by genetics, skeletal support, and environmental influences (Fig. 49.1). Some combination of the following, however, will occur in every patient (those characteristics improved by facelifting are in bold print):

1. Forehead and glabellar creases
2. Ptosis of the lateral eyebrow
3. Redundant upper eyelid skin
4. Hollowing of the upper orbit
5. Lower eyelid laxity and wrinkles
6. Lower eyelid bags
7. Deepening of the nasojugal groove and palpebral-malar groove
8. Ptosis of the malar tissues
9. Generalized skin laxity
10. Deepening of the nasolabial folds
11. Perioral wrinkles
12. Downturn of the oral commissures
13. Deepening of the labiomental creases
14. Jowls
15. Loss of neck definition and excess fat in neck
16. Platysmal bands

A minority of aging characteristics is improved by facelifting. Those that are addressed, however, are of fundamental importance to the attractive, youthful face. The facelift confers another benefit that is more difficult to define. Aging results in jowls and a rectangular lower face. A facelift lifts the jowls back into the face, augmenting the upper face and narrowing the lower face, producing the “inverted cone of youth.” This change in overall facial shape from rectangular to heart-shaped is subtle but real, and is a benefit that no other treatment modality can provide.