Facelift Surgery

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The goal of facial aesthetic surgery is to reverse the signs of aging without leaving telltale signs. A facelift is not intended to make a person look fundamentally different, just fresher. It is an effective way to “turn back the clock” and the beneficial effects will last about ten years. When properly performed there is a natural appearance that never looks tight. Scars are usually inconspicuous, even with short hairstyles.

Most women become candidates for facial aesthetic surgery sometime after forty (men after fifty). The criteria to determine when one is ready are not rigid and the decision is always somewhat arbitrary. Early aging signs may be considered insignificant to some individuals but more disturbing to others. Facelifts are never performed on a purely preventive basis, however. The primary disadvantage to delaying corrective surgery is that progressive aging changes may require a more aggressive procedure. The result may not be as good due to the normal loss of skin elasticity that occurs with increasing age. The best candidates are generally between ages 45 to 55. You are probably a good candidate for facial aesthetic surgery if you have specificaging signs such as a loose neck or jowls that you find troublesome.

It is logical to seek the least amount of surgery necessary to achieve the desired improvements. However, many are unrealistic in expecting that either some type of simple “tuck”, liposuction of the neck, or nonsurgical means such as treatment with radiofrequency waves will reverse decades of progressive aging changes. This is rarely possible and the results of “doing less” are usually disappointing. Objection to the concept of needing a “complete facelift” is counterproductive when aging changes are advanced enough to warrant it.

A complete facelift only addresses signs of aging in thelower half of the face and the neck. It does not treat the eyes or forehead. It is particularly effective in tightening loose neck skin and re-establishing a smooth jaw line devoid of jowls. While it improves the cheeks it does not completely eliminate deep laugh lines between the nose and corner of the mouth (nasolabial folds). Fat grafts can be injected into the nasolabial folds to soften them. However, the longevity of fat grafts is unpredictable and several injections may be necessary over time to achieve a permanent build-up of fat.

The normal facelift incision pattern starts within the scalp an inch above the ear and courses downward following the curve of the ear. It then disappears inside the ear behind the small protruding cartilage called the tragus to emerge at the top of the earlobe where it courses within the earlobe crease to the bottom of the ear. Placing the incision behind the tragus (inside the ear) avoids a visible scar on the cheek in front of the ear. The incision then travels in the crease behind the ear for a variable distance depending on the type of facelift being performed (regular or short-scar). Those who have a high sideburn or have had a facelift before may require a short horizontal incision under the sideburn. This is necessary to prevent unwanted displacement of the sideburn upwards during the course of the procedure. All facelift scars are permanent but fade with time. Although their final thickness and color are not completely predictable most will have inconspicuous scars after one year. The scars may be somewhat thicker in some areas behind the ears in some who have a regular facelift. It is not necessary to cut the hair at the time of surgery.

Facelifts almost always require more than just skin tightening. Using aggressive skin removal alone to restore facial shape can result in a distorted and unnatural appearance. Almost all patients benefit from tightening of the SMAS layer under the skin in order to remove jowls, restore cheek contour, and soften nasolabial folds. The SMAS layer is made of fibrous fat tissue that is strong. It overlies the facial muscles which themselves are never manipulated in any way during a facelift. Tightening of the SMAS layer is important to achieve a natural appearance. It minimizes the amount of skin removal necessary and thereby helps avoid a “pulled” look. Those who have had a facelift before have already had most of the excess skin removed. A repeat facelift in these individuals focuses more on SMAS tightening with little if any additional skin removal.

Aging sometimes results in the development of neck bands. These bands usually occur as two vertical folds of skin that actually consist of loose muscle edges. Minimal bands are often successfully eliminated by simply tightening the neck skin and muscle from each side as part of the facelift procedure. However, prominent bands require a separate incision under the chin in order to gain access to the loose muscle edges. These edges are sewn together in the middle to eliminate the visible bands. This adjunctive procedure is a routine part of facelift surgery when prominent bands are present.

There are several variations in facelifts that are more limited in scope and intended for those with more minimal aging changes. A short-scar facelift, for example, is an excellent choice for younger patients (less than 55) who have modest aging changes restricted to the lower cheeks but otherwise have a near normal neck contour with minimal skin laxity. This procedure eliminates most of the scars that are placed behind the ears in a complete facelift. A necklift is an option that is sometimes applicable to those who have the opposite situation: mild aging changes restricted to the neck with normal cheeks and a smooth jaw line. This procedure represents the lower half of a complete facelift. It is used infrequently because the scars behind the ears tend to become thick with this technique.

Aging of the upper face is often addressed at the same time as a facelift in order to achieve balanced rejuvenation. Changes in the eyelids (excess upper eyelid skin and lower eyelid fat pouches) and the forehead (sagging eyebrows, deep vertical furrows between the eyebrows, and deep horizontal forehead creases) may suggest that an eyelidplasty and/or browlift be performed at the same time as the facelift. A browlift requires separate incisions on each side that are about one inch long and hidden in the scalp. The forehead and eyebrows are lifted through these incisions and anchored to the bone with dissolvable fixation devices. Scalp skin is not routinely removed except in those over 65 that exhibit extensive sagging of the forehead tissues. Eyelid incisions required for eyelid improvement (blepharoplasty) are hidden in natural creases. Please review the separate information letter on eyelid and brow surgery for greater detail on these adjunctive procedures.

A facelift is not intended to completely eliminate fine lines and other textural problems of the skin although these conditions are often partially improved. Chemical peels and dermabrasion are adjunctive procedures that specifically address these issues. Fine lines around the eyes and mouth, for example, are commonly treated with one of these methods at the same time as a facelift.

The cartilages of the nasal tip continue to enlarge through life and may contribute to an aged appearance. The nasal tip often becomes prominent and droops. Nasal tip-plasty (reducing the size of the tip and raising it slightly) can enhance the results of a facelift in selected individuals. This is a simple procedure that focuses on the tip without changing the rest of the nose.

Thinning of the upper lip often occurs with aging and is a more difficult issue to treat successfully. Injection with fat grafts usually yields very transient improvement. More aggressive treatment with the implantation of an alloderm graft (derived from cadaver skin) may provide a more long lasting result.

A chin implant is often recommended for those who have a weak chin. This will significantly improve the profile while only having a subtle effect on the frontal view. The implant is inserted through an incision under the chin and is permanent. There is very little awareness of its presence once healing is complete.

There are factors less subject to surgical controls that influence the outcome of facial surgery. These include the thickness and elasticity of the facial skin, the degree of wrinkling and sun damage, the amount and distribution of facial fat, the underlying bone structure, individual healing tendencies, hormonal influences, heredity, and previous injections of silicone and other substances into the face. The best surgical effort will likely achieve a more modest result in the presence of thin and inelastic skin, severe wrinkles, a paucity of facial fat, and unfavorable bone structure, for example.

The most common complication that can occur after a facelift is a hematoma. This happens in less than 2 percent. A hematoma results when blood collects as a lump underneath the skin. It may require a brief return to the operating room within twenty-four hours of surgery. Development of a hematoma does not have any adverse effect on either short-term recovery or the final aesthetic result. Other problems such as infection, eye irritation, delayed healing, or excessive scarring are uncommon. Facial nerve injury with weakness of a part of the face can occur on a transient or permanent basis. This is extremely rare. The vast majority of patients do not have any complications.

Smoking interferes with blood supply to the face and may result in other complications such as skin loss. It is essential to stop smoking completely for at least three weeks before surgery. This includes the use of nicotine containing gum. Simply cutting back on smoking is not enough. Failure to stop completely may result in skin loss behind the ear or on the cheek in front of the ear. Delayed healing and disfiguring scars can result and may require revisional surgery for correction.

Facelift surgery usually is performed in the office as an outpatient procedure. Operating time varies depending on the severity of the aging changes and other factors. In general, a facelift alone requires about 3 hours. Eyelid surgery adds one hour, and a browlift, if needed, another hour. Dermabrasion and chemical peels also add time. All surgery is performed entirely by Dr. Hidalgo.

Surgery is usually performed with deep intravenous sedation in which there is no awareness. Preferences can be discussed with the anesthesiologist prior to surgery. The anesthesiologist is a board certified physician who is present for the entire procedure. After surgery there is very little pain and most patients do not request pain medication.

Private duty nurses are required for 12 to 48 hours after surgery. These nurses are specially trained to take care of facelift patients. Friends who are nurses but not plastic surgery trained and physician spouses are not acceptable substitutes. The nurses are arranged through our office but charge separately for their services. The nurse meets our patients at the office following surgery and escorts them either home or to the hotel to continue postoperative care there.

Stitches are removed in one week by the nurses. Patients from out of town are able to go home at this time. Taking stitches out is not generally painful but there may be moments of brief discomfort. Swelling and discoloration usually subside in two weeks. Make-up to cover residual bruising may be applied to the face and lower eyelids as soon as one week after surgery. Eyelid makeup that includes mascara, eye shadow, eyeliner, and artificial eyelashes may be applied beginning about ten days after surgery. Hair may be washed several days after surgery and colored four weeks after surgery.

Flying is permitted ten to fourteen days after surgery and driving after two weeks. Mild cardiovascular exercise such as a stationery bike or walking outdoors can begin several weeks after surgery. It is best to wait as long as six weeks before resuming more intense exercise and activities such as jogging, weightlifting, ball sports, yoga, pilates, and skiing.

Copyright © 2007 David A Hidalgo, M.D.


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