What Is Face Lift

Introduction

Astonishing progress has been witnessed in the field of cosmetic surgery over the past few decades. More and more individuals are turning to plastic surgery to refine perceived imperfections and reverse signs of ageing. Facelift, or rhytidectomy, derived from the Greek words ‘rhytis’, meaning wrinkles and ‘ektomi’, meaning excision, literally translates to the ‘cutting out of wrinkles’.¹ In medical terms, a facelift refers to an invasive cosmetic procedure that alters the soft tissue framework beneath the skin, lifting and pulling it back to achieve a firmer and more youthful appearance whilst maintaining an as natural look as possible.²

Facelifts were once stigmatised because of their negative reputation as cosmetic procedures but have since gradually gained popularity. The first documented facelift surgery took place in 1901, but it started attracting attention after World War I with increased demand for facial reconstructions. The stepping stone that revolutionised facelifts was the introduction of the superficial muscular aponeurotic system (SMAS) technique in 1976.³

Nowadays, numerous distinct techniques have been developed for skin rejuvenation, focusing on individual variations in fat and skin deposition, patient needs, and the target location of the face and neck. Facelifts aim at smoothing wrinkles, providing a tighter and lifted effect, and eliminating excess fat and sagging skin.⁴ Ongoing research on facial anatomy has elucidated the exact mechanisms behind the plethora of skin rejuvenating techniques, including facelifts, resulting in a decline of major complications associated with the procedure, guaranteeing more positive outcomes.¹

Ageing indicators for facelift

Facelift procedures are always tailored to match individual facial characteristics and requirements, following a thorough evaluation of each patient’s morphological features. They are performed to rejuvenate the face by reducing signs of ageing, including:

• Sagging and excess skin on the face: The reduction of collagen and elastin, which provide skin elasticity and firmness, causes lax skin. Internal and external factors, such as facial fat depletion, smoking, UV radiation, and environmental pollutants, can also impact skin laxity⁵
• Descending or reduced facial fat: Two fat compartments, the superficial and deep fat layers beneath the skin, are responsible for shaping and volumising the face. The SMAS is situated between these compartments, and numerous ligaments passing through all soft tissue layers anchor the skin to the facial skeleton. Due to ageing and gravitational forces, these ligaments begin to deteriorate, leading to the descent and reduction of fat compartments.⁶
• Deep facial creases, especially the nasolabial fold, Fat pad descent, facial skeleton degeneration, gravity, and reduced collagen and elastin along with external ageing factors all contribute to the formation of deep wrinkles.⁶
• Jowls: Repeated use of facial muscles or expressions, along with gravity, weaken the SMAS, leading to a recession of muscles, fat, and skin that results in jowl formation.⁵
• Poorly defined jawline, loose skin or excess fat on the neck (double chin): Declines in collagen and elastin, and excess fat, can alter the neck’s appearance. Overactivity of the platysma muscle in the neck, occurring with ageing, leads to the formation of neck bands.⁷

Types of facelift procedures

Numerous facelift techniques have emerged to cover all the individual cases’ diverse needs. Minimal incisions, reduced side effects, and shorter downtime are prioritised with more recent techniques. Complementary procedures may also be recommended to enhance results. The most common facelift procedures include:

• Subcutaneous facelift: This technique involves excision of skin only, leaving intact fat, SMAS and muscular compartments. This skin-targeted procedure, while not as popular today, targets sagging and excess facial skin without affecting deeper tissues. Due to the tension put on the skin only, potential drawbacks of this procedure include incision scarring, less enduring results, and a higher risk of recurrence.⁸
• SMAS facelift: This technique has gained extreme popularity for its ability to address age-related signs in deeper tissues. It involves SMAS plication, the folding and suturing of SMAS, and could potentially include imbrication (segment elimination). It aims not only for skin tightening but also for suspending soft tissue under the skin, causing less tension and yielding more satisfactory results. Commonly used to reduce jowls, it is considered a safe technique, although facial nerve damage is a possible risk.⁹
• Minimal access cranial suspension (MACS) lift: This technique involves smaller incisions on the hairline of the temples, resulting in less scarring and quicker recovery. It is less invasive and it is recommended for rejuvenating the lower part of the face and neck by vertically lifting skin and soft tissue. Younger patients without excessive skin laxity benefit more from this technique.⁸
• Deep plane facelift: This technique addresses problems in the middle part of the face, including the cheeks and nasolabial folds. It involves a rearrangement of deeper compartments of the face, such as muscles, fat, and ligaments to reshape the midface in older patients, providing more natural results.¹⁰

Candidacy for a facelift

A precise patient profile that aligns with specific criteria is essential for undergoing a facelift. Candidates considering a facelift must be in good health, without any serious medical conditions that might hinder the body’s healing processes, psychologically stable, and willing to quit habits such as smoking, alcohol, and drug use. Surgeons conduct a thorough assessment of a patient's medical and pharmacological history, informing them about the procedure’s steps, risks, and benefits, and discussing patients’ goals. Candidates with realistic expectations, and meeting facelift criteria, collaborate with surgeons to choose the most suitable facelift technique to achieve ideal results. The optimal age of candidates is typically around 50 years of age.^11,12

The facelift procedure

Consultation and preoperative preparation

Following the initial evaluation of a patient’s profile, a more comprehensive screening occurs. Surgeons analyse facial photographs to track ageing signs and examine asymmetries in various facial regions to determine the appropriate technique. Several months before the procedure a detailed examination of skin analysis, physical assessment, and medication history, including supplements and vitamins, is performed. To minimise the risk of bleeding, patients must avoid aspirin, anticoagulants, and anti-inflammatory drugs several weeks before the procedure. Patients over 50 years old are required to undergo an electrocardiogram along with extensive blood testing. Smoking cessation at least 3 months prior to the surgery and hypertension regulation must be concluded preoperatively.¹²

Operational steps

When the surgeon is assured that the patient’s medical profile is indicative of a facelift, the procedure may occur, which consists of the following steps:

1. Anaesthesia: Either general or local anaesthesia with sedation is used during a facelift. Surgeons discuss with patients the most suitable method according to individual characteristics, procedure duration, and potential complications.¹³
2. Incision: Different operative techniques necessitate distinct incision types. Surgeons provide a detailed explanation of the incision sites preoperatively. Possible sites include:¹²
   • Hairline: Within or before the hairline along the temporal triangle
   • Around the ears: Either in front of the ear before the tragus or on the tragus, mostly preferred for uniform colour and texture
   • Lower scalp: Behind the earlobe, either horizontally towards the back of the scalp or along the hairline
   • Under the chin: The exact location depends on the individual case
3. Procedure: According to the pre-selected technique, surgeons work on the skin, SMAS, fat, or muscular level. Each approach has varying difficulties and safety profiles, which influence the duration, post-operative recovery time, and results. These aspects are all meticulously discussed between surgeons and patients.¹³
4. Closure: The type of stitches placed in the incision depends on the technique used and discussed before surgery to estimate scarring.¹³

Recovery and aftercare

After the procedure, patients spend the night in the hospital under controlled medications for blood pressure, pain, and nausea to minimise the risk of haematoma. Surgical bandages and drainage tubes are strategically placed to assist in swelling reduction and are changed or removed based on the doctor’s instructions. Typically it takes 6 weeks for patients to resume their regular routine, but the final results become fully evident after several more months. Doctors provide detailed directions regarding diet, medications, and stitches care. Regular follow-up appointments are crucial for ensuring, best results and preventing complications.¹²

Risks and complications

Similar to other invasive surgical procedures, a facelift is associated with various early and late complications, including:¹³

• Haematomas: The accumulation of blood outside a blood vessel can cause bruising and swelling. Recognition and prompt treatment are imperative to avoid more severe consequences like skin necrosis. Major risk factors for haematoma formation include being assigned male at birth sex, aspirin use, and high blood pressure.
• Facial nerve injury: The incidence depends on the technique used and the surgeon’s experience. It can be either permanent or resolved over time.
• Skin necrosis: Cigarette smoking is a significant risk factor that can induce skin necrosis after a facelift
• Scarring: The tension applied to the skin determines the extent of scarring. The technique used and the closure of incisions affect scar formation and can also be hidden along the hairline.
• Hair loss: Impairment of hair follicles on the incision site may lead to temporary or permanent hair loss. The latter can be confronted with a hair transplant.

Conclusion

The ageing process, coupled with the effects of gravity, smoking, and alcohol consumption, contributes to the formation of visible signs of skin ageing, such as wrinkles and sagging skin. Today’s scientific and medical innovations have allowed people to successfully combat ageing and gravity. While various non-invasive cosmetic procedures are available and offer remarkable results for skin ageing, facelifts stand out as a groundbreaking solution in the field of cosmetic surgery.

Attaining a successful facelift involves crucial steps, including maintaining an optimal mental and physical state. It is extremely important to consult with a certified surgeon with experience and a record of satisfied patients. A skilled surgeon will guide you in deciding the ideal facelift technique adapted to your skin’s specific needs, ensuring that your expectations are met. Furthermore, a comprehensively informative discussion on the risk factors associated with the surgery is essential. Having rational expectations regarding the results of a facelift is also vital, and open communication with your doctor about your exact prospects is key.