Thursday, April 30, 2009

Facelift, Midfacelift and Neck Lift 2

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To make things easier I first give the prospective facelift patient a mirror for them to point out areas of concern. That way I can be assured to address these in my overall assessment. I then use a top down approach to evaluate the frontal hairline (high, low or average), brow drooping, presence or absence of forehead wrinkles and crows' feet at the outer corners of the eyes, temple wasting or concavity, aging changes of the eyelids (bags, drooping-ligament laxity, excess skin, nasojugal groove depth), nasolabial fold (laugh line) depth, amount of excess cheek skin, cheek surface contour and bone visibility, presence of vertical skin folds just in front of the ear, marionette line depth, severity of jowls, upper lip height and upper incisor show, neck fat, excess skin and muscle banding and finally the patient's overall health condition. Since a large portion of these patient's are elderly with multiple medical problems on multiple medications an Internist is frequently involved to ensure a safe operation with a smooth recovery.
facial aging

This approach allows me to come up with a plan of action specific to each patient and make sure their initial concerns are addressed. Browlift or foreheadlift and eyelid surgery are added as necessary. What exactly is done to the temple, eyelids and forehead again depends on the patient and will be covered in future blog(s). The main concern with forehead lifting is to avoid injuring the nerve to the muscles that raises the eyebrows and maintenance of the temple hairline. Even the best of surgeons will have the occasional patient who has temporary injury to the nerve. Shifting of the temple hairline backward though is related to the skin incision pattern in the temple area and more easily prevented with good surgical technique.

Virtually all non-endoscopic facelift operations involve an incision around the ear. The design of this incision is extremely important to avoid bad easily visible scars. Historically this was placed in front of the ear, brought down through the notch of the earlobe and then up around the back of the ear with a back cut onto the side of the head or nape of the neck. Since the procedures were initially performed exclusively on women this incision was considered less important because the women could just cover any bad scars with their hair. In order to allow the women more leeway in their hairstyles and make the procedure more amenable to men with shorter hair or even balding men this incision was refined. The current best approach is an inverted Ω. A horizontal segment is placed in the sideburn, the incision then comes down in front of the ear behind the triangle cartilage in front of the ear, down the notch of the earlobe, up the backside of the ear and then horizontally on the side of the head. This breaks up the scar so it is less visible and places the back cut up in the hear bearing scalp where it is easily hidden. If the incision is sutured under minimal tension after removal of excess skin the resulting scar can be very hard to see. When the incisions were placed on the nape of the neck they tended to widen and the women could never wear their hair up.

historical incision vertical in temple, in front of ear and down nape of neckHistorically the incision around the ears came down vertically from the temple, in front of the ear, around the back and then along the nape of the neck. This approach resulted in a more visible scar in front of the ear, a backward shift of the temple hairline and a wide visible scar on the back of the neck.

inverted omega incisionThe current inverted omega approach does not move the temple hairline back, hides the scar in the convolutions of the ear and hides the back cut behind the ear in the hair bearing area on the side of the head. Many surgeons now place the back cut at a level between what is shown here and that in the first set of photos above. Back cuts at that level are still prone to widening due to the tension of closure and side to side head movements after surgery. Back cuts at this level however are technically more demanding and require a bit more operating room time.

If there are no jowls present & the corners of the mouth do not need rejuvenation I only make an incision in front of the ear, remove excess cheek skin & tighten the deeper tissues. This procedure would be closest to the originally described S-lift. As the aging changes become more severe with downward slanting corners of the mouth & jowls the skin incision has to be extended around to the back of the ear in order to address these areas. The back cut described above allows for the removal of excess neck skin. If there is a significant amount of excess neck skin it cannot be addressed by the original S-lift alone. As you can see I adjust the incision around the ear to meet the patient's needs.

Once the appropriate incision is made around the ear the non-bone tissue under the skin is addressed. In the cheek area this means incising, vertically lifting and suturing that tissue to recreate the more youthful cheek contour. The aged face cheek prominence is at the same level as the corners of the mouth while in the younger face it is at the level of the bottom of the nose. The amount of vertical lifting that is required or possible varies from patient to patient.

facial contours in the aged and rejuvenated face
The tracing shows the change in cheek contour and the improvement in the jawline with a softening of the jowl.

As mentioned above the non-bone tissue of the cheek is vertically lifted and sutured in place. The facial skin on the other hand is excised and closed in an obliquely upward outward directed closure. These tightening vectors are very important because if they are not followed the end result look is very unnatural.

The typical facelift procedure involves suturing the muscle bands in the neck together in the midline. I also partially divide this muscle horizontally to weaken it so the surgery results last longer. Adjunctive procedures such liposuction of the cheek and/or neck, free fat grafting, blepharoplasty, forehead lift, laser resurfacing, chemical peel, chin implants etc. as needed are frequently performed at the same operation as facelifts.

Stem cell facelift is just a facelift with the injection of liposuctioned fat from elsewhere on the body. Proponents of this approach emphasize "stem cell" because everyone has stem cells in the fat and for marketing reasons. The regular measures employed to maximize the survival of injected fat will preserve the stem cells in that fat. I just use the term free fat grafting as more complicated terms just obscure what is actually being done.


The Quicklift has recently been over marketed as the facelift to beat all facelifts, performed under local anesthesia with little or no down time. In reality it is a modification of the S-lift. The S incision is extended around the ear to address jowls. The non-bone tissue under the skin is cut and sutures placed to give a vertical lift of these deeper tissues. By making that cut the result is longer lasting than just placing lifting sutures as in the original S-lift. However the dissection under the skin is limited so patients with a lot of excess skin or long upper lips will have inadequate lifting and muscle bands in the neck cannot be treated with this approach. In short this procedure adds some of the components of a standard old fashioned facelift to the S-lift. It works well in appropriate patients but does not address the needs of every patient. Furthermore it is not really anything knew or earth shattering. It is a rehash of techniques that have been around for years.

Subperiosteal facelift refers to lifting the facial soft tissue off the bone and raising it up with a suture passed through the cheek mass just on top of the bone, passing that suture to the temple and then through the temple muscle. As the suture is tightened the lifting occurs. The suture is an absorbable one that dissolves within a month and a half. While regular facelifts pretty much heal within 2 weeks to 4 weeks it takes about 4 weeks after a subperiosteal facelift just for the soft tissue to stick back down to the bone. Once that occurs the swelling can then begin to resolve. Usually that takes up to an additional 2 weeks ( hence the total of 6 to 8 weeks after surgery for recovery from a subperiosteal surgery) . I give my patients the option of having this procedure if the upper lip is long and the edges of the upper incisors are not visible in repose. Not everyone who is a candidate wants the procedure because of the significantly longer recovery time and higher risk of deeper surgery.

subperiosteal facelift

Facelift is really a term I use for a number of procedures that can be grouped together in various combinations to meet a specific patient's needs/wants. The goal is to soften the nasolabial fold, correct platysmal neck muscle banding and change the facial contour from the aging trapezoid shape to a more youthful U or V-shape. This can only be achieved by raising the deeper tissues in the cheek vertically in addition to excess skin removal in an upward and outward oblique direction. Attempting to achieve these results solely by removing cheek skin from in front of the ears creates an outward sideways pull and can result in bad skin scars, an unnatural pulled look and failure to improve the facial contour.

As mentioned above possible problems associated with the procedure are nerve damage to facial muscles, blood under the skin, loss of skin in front of the ears and bad scarring. The nerve damage is usually temporary and is most frequently to the muscle that raises the eyebrow. The risk is of course greater if the muscle is lifted off the bone as in the subperiosteal approach. Blood under the skin appears as a bump and may require a return to the operating room but usually can be removed with a small needle within 5 or 7 days of surgery. Because the skin is lifted off the deeper tissue its blood supply is severed. The skin that is most affected by this is that directly in front of the ear. If there is a lot of excess skin this is less likely because more skin in front of the ear is removed. The risk increases in patients who smoke, are exposed to tobacco smoke or sleep with pressure applied to this area. Usually only the outermost layers of the skin are involved but even this can affect skin pigmentation that requires make up cover.


Most of the facelifts done today are actually only different parts of what we used to consider a facelift to be. That is because people in general now get facelifts at an earlier age. Since everyone ages differently and their facial parts age at different rates the procedures have to be individualized. For example the person who has more advanced aging in the lower face and little aging in the neck area should not get the same procedure as someone who has advanced aging of the neck area. In those cases a midface lift is more appropriate.
midface lift Los Angeles
Mid-face Lift

Facelifts are therefore in effect a group of different procedures and each of those has its own lifespan of effectiveness. Furthermore the procedures do not stop the biologic clock so everyone of these patients to continues to age. A combination of genetics and self maintenance like limiting direct sunlight exposure and not smoking then govern the speed of that aging process.

In general if the right procedure of the facelift group of procedures is done in the right patient who takes care of him or herself after surgery the results should have a 5 to 10 year life span.

Because different facial components age at different rates in different people there is no best age to get the procedure. So it is not better to get a facelift procedure at age 55 than age 65. You get the procedure when the conditions warrant it and you are healthy enough to withstand the procedure. Getting parts of the original procedure at a younger age may result in the need for less aggressive procedures when you are older but increases the number of procedures you have during your lifespan and increases the risk of ending up looking like you have had too much plastic surgery.

Facelifts are facelifts and other procedures are other procedures that are not directly interchangeable. So to ask which last longer is not a fair question. Laser resurfacing does things that a facelift cannot do and vice versa. One should not be used as a replacement for the other. The same logic applies to injectable fillers and botox. There are an increasing number of under qualified doctors out there who may not even be surgeons trying to sell patients only on procedures that fall within their capabilities for example a non-surgeon recommending fillers over facelift surgery when in fact surgery is the best option because he/she is not capable of doing the surgery. Prospective patients need to be aware of such situations and avoid them.

Facelift, Midfacelift and Neck Lift 1
Facial Aging and Rejuvenation
MidFace Lift
Facelift with eyelid surgery and treatment of neck muscle bands
Facelift with free fat grafting
Facelift for men - male facelift

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