Facelift

The first reported facelift surgery, involving elevation of the muscle layer in addition to the skin layer, termed the extended SMAS technique, was first described by Skoog as late as 1974. The extended SMAS facelift is regarded as the state of the art in facelift technology allowing for effective facial rejuvenation without the telltale signs of facelift surgery.

By using this technique, surgeons are able to utilize aggressive pull on the elevated muscle layer to hoist the skin layer in order to minimize undue tension on the pull of the skin layer. By minimizing the pull on the skin layer, redundant skin can be eliminated without an unnatural result often termed as the “windblown” look.

Good candidates for facelift surgery demonstrate a multitude of facial aging changes. Facial aging changes have been classified by “age decade” interval changes. In the 30 to 40-year range, patients will notice the appearance of upper and lower eyelid skin redundancy. Some patients may notice hollowed out lower eyelids as the cheek tissues begin their descent down the face. Over the out edge of their eyelids, patients will also notice wrinkles called Crow’s feet (name based on observed pattern).

Between 40 and 50 years, patients will notice more generalized facial wrinkles and more prominent folds around the lips. Theses laugh line folds extend upward (named nasolabial folds) and extend downward (named marionette lines). Some patients will notice their jawlines become less distinct. In 50 to 60 years, patients will notice an increasing the deepening of the wrinkles and folds. Patients will notice poorly defined jawlines as the cheek tissue bunch just outside the marionette lines and rounding of the neckline.

In 60 to 70 years, patients will notice exaggeration of all of the above signs as well as the increasing hanging of the neck skin which may obscure the chin and jawline.

Facelift surgery involves elevating the skin and muscle layer in order to redrape and trim redundant facial tissues that have sagged secondary to the effects of gravity and facial aging. The gold standard in facelift surgery is called the extended SMAS technique facelift surgery and utilizes extended muscle elevation (called the SMAS) in addition to fixing the elevation of the skin.

By lifting the deeper muscle layer, the surgeon is able to hoist and eliminate the sagging and redundant facial tissues including the skin and fat tissues without placing undue tension on the actual skin tissue layer. By minimizing tension on the skin layer, patients can expect more natural results with optimum healing of surgical incision lines.

Finally, appropriately placed incision lines and meticulous repair of surgical incision lines will ensure well-hidden surgical scars.

On your initial visit, your surgeon will evaluate your health status by obtaining blood work. If you are 50 years or older you will need to have an EKG of your heart to rule out any heart conditions.

If you are a smoker, you should quit for 1 month prior to your facelift surgery to minimize the risks of skin compromise especially if your surgery will require removal of significant redundant skin. In addition, it is prudent to quit smoking for 6 weeks following surgery to ensure a well-healed surgical incision.

Finally, you will need to arrange for a friend if you don’t have a spouse to care for any small children who may need to be lifted or carried as any lifting increases the head pressures and increases the risk of bleeding.

Since your surgery will require general anesthesia, you must take several precautions prior to surgery.

First, you will have to avoid eating and drinking after midnight on the day before surgery. This precaution ensures that your stomach is clear of digested foods that could potentially be aspirated and contaminate your lungs during the induction of anesthesia.

Since you will have anesthetic medications administered throughout the process, you will remain groggy for several hours and will require a ride to and from the surgery center. You should choose a caretaker who is conscientious and who can spend the first night with you.

Patients who undergo facelift surgery are extremely satisfied with their surgery and their more youth appearing faces. By providing a thorough preoperative workup, safe intraoperative course, and frequent postoperative visits, patients should expect a speedy recovery and return to a more aesthetically pleasing and youthful neck and facial contour. Patients are extremely pleased following facelift surgery and demonstrate increased physical and mental confidence.

Since facelift surgery will require general anesthesia or intravenous sedation, it must be performed in an operating room that is part of a hospital institution or outpatient surgery center.

Less frequently, patients may be operated on in an in-house office-based operating room, but it is of utmost importance for patients to make sure that the office facility is accredited by a surgical accreditation body such as AAAASF.

For the gold standard facelift surgery (extended SMAS technique) general anesthesia or intravenous sedation is required. This is because in order to appropriately pull the muscle layer in addition to the skin layer, local anesthetic solution alone will not suffice.

Patients will awaken from general anesthesia or intravenous sedation to find their face covered by a bacitracin ointment and their neck and ears covered by a compression dressing. The compression dressing ensures the maintenance of an even facial and neck contour and avoidance of blood or plasma filled pockets postoperatively.

In addition, patients will have drain lines placed to avoid blood or plasma filled pockets postoperatively; these drains are removed within 24 to 48 hours following surgery.

At your postoperative visit at 1 week following surgery, your compression garment will be removed and stitches along your ear will be removed.

At 10 days following surgery, sutures under your chin and along the back of your ear and neck will be removed. Swelling and bruising is typically minimal and resolves over the first week following surgery. Arnica gel is recommended for patients demonstrating increased bleeding in order to avoid excessive postoperative bruising.

Patients are asked to avoid lifting weights greater than 15 pounds for the first two weeks. Additionally, patients are asked to strenuous physical activity for the first 4 weeks in order to avoid compromising their results. Patients can expect full recovery at one month following surgery. Patients may even schedule important social engagements as early as 6 weeks following surgery.

Patients can expect to return to work at 10 days following surgery if they work in the back office and do not have to be fully presentable. For patients who deal with consumers or are in sales, 2 to 3 weeks off of work may be more prudent. Finally, if patients have physically strenuous jobs, then one month of downtime is recommended prior to return to work.

There are several side effects that have been associated with facelift surgery and included:

a) Prolonged swelling up to 2 weeks is not uncommon due to the extent of both skin and muscle elevation that is required prior to redraping and trimming of tissues required to eliminate the signs of facial aging.

b) Temporary bruising is often associated with facelift surgery due to the extent of tissue elevation required to obtain long-lasting facial rejuvenation results. Bruising is minimized by a meticulous stoppage of all small bleeding vessels (hemostasis) and by compression dressings utilized postoperatively. Most bruising subsides within 1 to 2 weeks.

c) Temporary facial numbness is a direct result of elevating redundant skin prior to redraping and trimming extraneous skin tissue. As such, disruption of sensory nerves (nerves that help you feel) is unavoidable. Fortunately, patients should expect the full return of facial sensation and resolution of numbness over several months.

d) Prolonged swelling up to 3 months is not uncommon due to poor lymphatic drainage especially following open rhinoplasty. Lymphatic drainage is compounded by extended surgical incisions used in open rhinoplasty and placed across the bottom of the nose (columella) when the nasal tip must be altered.

e) Surgical scar redness: Hyperemia of the incision around the ear and neck is to be expected and will resolve over the first month. Layered closure of the incision line is performed in order to minimize the tension of the incision line and to enhance incision healing. In addition, by utilizing the underlying muscle to hoist the redraped skin, the tension on the skin incision line is further reduced. Finally, avoiding cigarette smoking for one month prior to surgery and six months following surgery is essential to optimizing healing.

a) Postoperative bleeding may occur following facelift surgery since the face has numerous blood vessels supplying it. Patients are tested preoperatively to ensure that they do not have a bleeding disorder. For patients identified as having a bleeding tendency, intraoperative administration of DDAVP (a blood clotting factor) is administered to avoid bleeding complications. Appropriate clotting of facial vessels (hemostasis) during the operation avoids postoperative bleeding. In addition, external compression provided by the neck binder further prevents postoperative bleeding.

Finally, patients are asked to avoid straining, lifting, and pushing over the first two weeks following surgery in an attempt to minimize increasing head pressures which may induce bleeding.

b) Deep vein thrombosis (DVT) may occur in the legs immediately following surgery. DVT refers to the clotting off of leg veins which may result in compromised blood flow return from the legs; a more critical consequence may develop from this clot if it is dislodged and travels to the lungs causing pulmonary emboli. Although rare, pulmonary emboli are the leading cause of death following surgery. Measures are taken intraoperatively to avoid such a complication.

c) Poor facelift scarring is seldom observed when the facial surgical incisions are repaired following a properly performed facelift that utilizes the facial muscle layer to hoist up the skin layer. By placing the tension on the facial muscle layer, the skin layer is redraped gently without undue tension which results in well healed and hidden incision lines. Patients who smoke are prone to poor scarring and are asked to stop smoking for 4 weeks prior to and 6 weeks following surgery.

d) Local skin infection is uncommon and associated with individual patients with poor healing tendencies secondary to medical illnesses. Diabetes, nutritional deficiencies, and smoking are to blame for local skin infections. Well-controlled sugar levels in diabetic patients, optimizing nutrition, and cessation of smoking are critical to avoiding infections.

e) Skin tissue compromise leading to skin loss is rare following facelift surgery and is associated with smokers. Smokers are asked to stop smoking for 4 weeks prior to and for 6 weeks following surgery. If patients are unwilling to stop smoking, then patients are recommended to undergo mini facelift surgery which minimizes skin elevation in order to maximize the preservation of skin vascularity.

f) Muscle function deficit is a rare risk of facelift surgery and is caused by inadvertent injury to motor nerves which motor muscles. This complication is minimized by patients choosing board-certified plastic surgeons who have appropriate training and experience performing facelift surgery.