Facelift

The cosmetic facelift is a surgery of rejuvenation.

There are many types of facelifts, but my personal classification is that there are two primary classes: short-acting and long-acting. I would define a short-acting facelift as one where the beneficial effects last less than four years. There are several relatively minor procedures which can give pleasing results but are often relatively short-lived, in my experience. I would include among these the one-stitch facelift and the Silhouette lift. Other techniques, such as variations of SMAS surgery and minimal access facelifts (MACS lift), will usually last much longer. I think the reason for this is the dynamic and anatomical problems that need to be reversed when trying to rejuvenate the face.

There are a number of different anatomical facets to ageing. On the outside is ageing of the skin itself and this depends on its type and how one has protected it from the sun, wind, cold, smoking and hard living over the years. Good skin care and non-surgical treatment can certainly slow down ageing and improve or even rejuvenate skin. A good lifestyle (moisturisers, retinoids, hydroquinones, microdermabrasion, Hydrafacials and even Botox) certainly have important roles in skin maintenance and rejuvenation.

Historically the facelift was designed to tighten the skin, and essentially it was de-gloved superficially in order to do this. This would result in the classical facelift scars that run from the hairline, then hugging the ear in front and behind, and back in to the hairline. This allowed the entire skin to be mobilised, pulled and tightened. The evolution of modern concepts of ageing acknowledged that facial droopiness (also called facial ptosis) was caused not just by skin laxity but also changes in the tension of the fine ligaments that rivet the skin to the deeper structures of the face. As one ages the forehead, brow, the mid face (with its facial fat such as the buccal fat pads), the jowls and the skin of the neck all start to migrate downwards. A cause of this is the layer under the skin known as the SMAS (Superficial Muscular Aponeurotic System), which loses its tightness with age. This layer wraps the deeper parts of the face from the neck to the head. It is contiguous with the superficial muscles of the neck (known as platysma) and the deeper layers of the scalp (the Galea). Also the fattiness or chubbiness of the face disappears as fat moves or disappears with time.

The traditional facelift evolved to manipulate and tighten the SMAS and also the platysmal. The confusing nomenclature originates from the different ways surgeons tighten and pull the SMAS. Essentially, the type of facelift carried out depends on the way the face has aged. The forces that cause the face to mature are significant and strong. Therefore surgical facelifting techniques to rejuvenate have to resist the continued affects of ageing, which never cease. Therefore, any rejuvenation surgery has to be robust enough to resist this.

In reality, none of these methods will halt the effects of time.

The question of longevity is multifactorial but surgery, which causes significant repositioning and tightening of the SMAS and the platysma, will last longer. In my opinion as a generality, in younger patients with minimal facial laxity, the techniques that I have classified as “short acting” can be used. It does raise the question that for these mild cases whether anything surgical should be done, and as with all cosmetic surgery this is a judgement call between patient and clinician.

In mild to moderate facial sagging the direction or vector of laxity is usually vertical (try pulling your facial skin upwards vertically while looking in a mirror to see if this applies to you). If these patients also only have moderate drooping of the neck then a MAC lift works well. It is called a MAC lift because the resultant scarring is shorter and does not extend behind the ear. The SMAS is tightened with a suturing technique known as imbrication. For older patients the surgery often is more complex because the skin and the neck is usually much more affected and droopy. The neck muscles do need tightening and the vectors of lift are more complicated. The direction of pull has to be both vertical and oblique. The SMAS and platysma are tightened with techniques usually different from the methods used in the MAC lift. Also the skin itself is so ptotic that direct tightening is also needed. The surgery is therefore more extensive for this group of patients and the scaring becomes traditional.

Sometimes the face does not age uniformly in the sequence that I have described. The patient may be only worried about the neck or the jowls. With others the midface or the brow and forehead maybe the areas of concern, see browlift and silhouette facelift for information on the technique. Many patients complain that they look tired but do not feel so. Ageing, unfortunately, does make us appear fatigued. Naturally definitive reasons for tiredness should be excluded! It is really important to understand these concerns and the clinical areas, which could be causing their anxieties. Total facial rejuvenation of the face could involve all three regions of the face (forehead-brow, midface and the lower face-neck). Also rejuvenation is not just about tightening in the correct direction or vector. It can also require replacement of volume caused by fat loss in the face to areas such as the cheeks as well as removing unwanted fat especially under the chin. So additional procedures such as minimal gentle liposuction and lipo-filling are often carried out in addition to the facelift at the same time.

Artists have known for a long time that the eyes express the soul. It is not uncommon for bagginess and ageing of the upper and lower eyelids to be corrected at the same time as a facelift. The techniques for this are discussed in my section on blepharoplasty.

In summary, I do believe that the correct analysis of the way a patient’s face has aged is very important. This will allow the correct technique to be used along with appropriate additional treatments.

Frequently Asked Questions (FAQs) View all

How soon after a facelift can I have my face peel done?

A gentle peel can be done at the same time as a face lift. However, usually one should wait until 6 weeks has passed after a full facelift to consider having a facial peel.
Interestingly, some people confuse these two procedures: the chemical peel is done to improve the condition of the skin while the facelift is done to deal with the mechanics of the face. Great question!

Can I have my eyelids done at the same time as a facelift?

Yes, there are many procedures that can safely performed at the same time. Eyelids and facelift are two.

How is the risk of infection during surgery minimised?

Infection is prevented by the appropriate surgical technique. This means very strict sterility of instruments and the technique has to be meticulous. The environment and correct theatre air flow conditions are very important and there are very strict safeguard controls concerning this. We also reduce infection rates by making sure that the patient is fit and healthy and is MRSA negative pre operatively.

What makes a good cosmetic surgeon?

This is a complex question in reality. Firstly a cosmetic surgeon must be a good doctor. Cosmetic surgery should be no different from any other form of healthcare delivery. To be a good cosmetic surgeon one should have had thorough training. Experience and judgement are the keys. Also an ability to have the emotional intelligence required to fully understand the needs and expectations of the patient and to make sure that there is no mismatch with what is possible.

The bottom portion of my nose is quite wide, can it be changed?

This procedure is known as a tip rhinoplasty. It involves adusting the size and shape of the cartilaginous skeleton that has a major and important influence on the size and shape of the nasal tip. The procedure can either be carried out as a “closed operation” which involves scarring inside the nostril but often an open approach is used which results in a small scar on the collumellar (the bridge of delicate skin between the nostril).

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