Face-Lift (Rhytidectomy)

Surgery Overview

A face-lift is the most extensive way to remove or reduce the appearance of wrinkles and sagging of the face caused by age. The skin is literally lifted off the face so that the skin and the tissues beneath can be tightened and the skin can be repositioned smoothly over the face.
For the procedure, you are either given general anesthesia or a sedative through an intravenous line and local anesthesia to numb your skin. Next, the surgeon makes an incision that starts in the temple area and circles the ear. The skin is raised, and the muscle and tissue underneath is tightened. The surgeon may remove some fat and skin. The skin is then redraped over the face and the incision is sutured. The incision usually falls along the hairline or in a place where the skin would naturally crease so that it does not show after the surgery.
The surgery usually takes several hours. You may be able to go home that day, but people sometimes spend one night in the hospital.

Types of Surgery

Common approaches can be summarized as follows, with the common terminology used today:

  • ا1st generation, or the mini-lift

  • 2nd generation, or the subcutaneous facelift

  • 3rd generation, or the superficial muscular and aponeurotic system (SMAS) facelift

  • 4th generation, or the deep plane facelift

  • 5th generation, or the thread lifting facelift procedures

  • 6th generation, or the minimal access cranial suspension (MACS) facelift

Mini-Lift
The mini-lift is the original facelift made popular in Paris, France, by Dr. Noel in the 1920’s. Mini-lift, as the name implies, refers to techniques with limited, small incisions. It (Figure below) effects an elliptical excision of skin in front of the ear to remove the extra, sagging skin. Mini-lift does little for other areas of the face; however, it is quick and easy to accomplish under local anesthesia in the office.

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The Subcutaneous Facelift
The subcutaneous facelift (Figure below) is a two-fold extension of the mini-lift. First, the incision around the ear is lengthened to reach above and behind the ear. Second, the undermining of (or cutting under) the skin is more extensive, sometimes extending completely over the neck and face. In undermining the skin, the surgeon temporarily releases the fascia and muscles holding the skin so he can pull the skin into an improved position. The surgeon uses his judgment to determine the extent of undermining needed in each case. Still, the subcutaneous facelift addresses only excess skin, not the deeper structures such as fat pads, connective tissues, and muscles. Since only skin is being pulled, this ‘skin-only’ facelift often results in a ‘pulled’ look that many want to avoid. It is no longer commonly used.

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SMAS Facelift
In addition to excising extra skin, as in the subcutaneous facelift, the SMAS facelift (Figure below) addresses the deeper SMAS layer under the skin. The SMAS layer, or superficial muscular and aponeurotic system, is a sheet of muscle and connective tissue (fascia) joined together in the cheek area. The SMAS layer contributes to facial expression. As facial skin ages, there is a gradual loss of elasticity in the top layer of the skin as well as in the SMAS membrane. As the skin loses its elasticity, gravity causes the cheek skin area to sag along the jaw bone, creating fleshy jowls and sometimes a double chin. In turn, this drooping down of the lax area of the cheek pushes the cheek fat pads to sag forward, thus deepening of the nasolabial folds. The result is a common look in an aging face.

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To conclude, the SMAS facelift addresses both the upper skin and the deeper SMAS layer around the cheek unit with deeper undermining. Compared to the mini-lift and the subcutaneous lift, the result lasts longer and is more extensive. It also accomplishes a less ‘pulled’ look.

Deep Plane Facelift
The deep plane facelift technique was developed to address the shortcomings of the previous generation facelift methods. It was accomplished by cutting deeper, even down to the bone, to reposition thicker planes of the face, including the upper cheeks and mid-face (Figure below). Naturally, there is more swelling and the risks of complications are higher with this method.

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The Thread Lifting Procedures
Since 1st generation facelifts, surgeons have attempted facelift improvements by inserting wire or various sutures under the skin to pull the relaxed skin into a tighter position. A patented approach using a blue barbed nylon suture was developed in Russia in the late 1990s. Since then variations of threading these permanent sutures under the skin abound.

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In the thread lifting procedures, 4-12 sutures with a long needle are threaded into the deeper, soft tissue structures (Figure above). Once the suture is in place, it is pulled, anchoring the barbs into the soft tissue and lifting it. The ends of the exposed sutures are snipped, leaving the suture buried beneath the skin. No skin is removed nor incision made.
Bruising, swelling, and tenderness of the area often accompany these procedures. Complications include uneven puckering of the face and recurrence of sagging if the wire is not properly placed or does not hold. Furthermore, the non-slip wires do not allow for a natural movement of the tissues and affect facial expressions.

MACS Facelift
MACS is one of latest innovations in facelift techniques. As the name—minimal access cranial suspension—implies, this technique allows correcting the sagging facial features through a short, minimal incision and by elevating the skin vertically by suspending it from above (Figure below).
The incision is reduced to the fold in front of the ear and follows the hairline above the ear in a zig-zag pattern, making the scar blend with the hairline. In the end, the scar becomes virtually invisible. Once the incision is made, the surgeon elevates the highlighted area of the skin (Figure below) to gain access to the deeper tissues. The surgeon weaves in 2-3 sutures from the firm positions on the top, down and up again suspending the facial structures upward as if pulling on purse strings. Each suture is positioned to restore a specific area of the face. The accomplishments include re-establishing the support of the lower eyelid or the descended cheek, smoothing the nasolabial fold, and tightening the upper and middle neck. (See Figure below, purse string sutures from left to right.)

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MACS facelift is safer than the earlier generation lifts because less skin is raised, decreasing risks of bleeding and nerve and other damage. Not undermining so deep under the skin also shortens recovery time. Finally, patients appreciate the short scar and the more natural, rather than the ‘windswept,’ look.

What to Expect After Surgery

Your face will be bandaged after the surgery. The dressings are usually removed 1 to 2 days later. If a drainage tube has been placed (usually behind the ear), it will also be removed 1 to 2 days after the surgery. Your doctor will remove your stitches within 5 to 10 days.
Your doctor may prescribe medicines to relieve pain after the surgery. Expect to have swelling and bruising of the face. Cold compresses can help relieve these side effects. Your doctor may instruct you to keep your head elevated and still as much as possible.
It is important to avoid smoking and even second-hand smoke for 2 to 4 weeks before and after surgery. Tobacco smoke increases the risk for skin and tissue death and will delay your face’s healing process and make scarring worse.
Most people can return to their normal activities 2 to 3 weeks after a face-lift.
At first your face will feel stiff and will probably look and feel strange to you. This is normal, but it is important to be prepared for it.
Numbness of the skin may last for months after the surgery. Your skin may feel rough and dry for a few months. Men sometimes have to shave in new places because the skin has been rearranged, but laser hair removal or electrolysis can be used for beard hairs that have shifted to a new position.

Why It Is Done

Face-lifts are done to make an older face look younger by eliminating wrinkles, lifting sagging muscles, and tightening the skin.

How Well It Works

Having a face-lift can make your face appear younger and healthier. Your face will continue to age, but a face-lift does indeed “take years off” your face. For some people, this may increase self-confidence and reduce anxiety over growing older.
A face-lift can reduce signs of aging to a great extent. But it cannot reverse sun damage to the skin, or remove all facial wrinkles around the eyes, below the nose, and around the lips. For best results, you may want to have a face lift and then treat any skin damage.
The effectiveness and safety of your face-lift surgery depends heavily upon the skill of your surgeon.

Risks

Problems that may be caused by having a face-lift include:

  • Reactions to the anesthesia.

  • Bleeding under the skin.

  • Infection.

  • Damage to the nerves that supply the muscles of the face. This can cause paralysis or spasm in the face, but the effects are usually temporary.

  • Hair loss (alopecia).

  • Tissue loss.

  • Scarring.

  • Blood clots in large veins traveling up to the heart and lungs (pulmonary embolism). This is not common.

As with all cosmetic procedures, there is also the risk that the results will not be what you expected. But an experienced plastic surgeon can usually give you a very clear idea of what to expect after surgery.

What to Think About

As with other cosmetic procedures, you are more likely to be happy with the results of your face-lift if you have clear, realistic expectations about what the surgery can achieve and you share these with your plastic surgeon.
Insurance companies do not cover the costs of face-lifts. It is important to find out what the total costs of the procedure will be, including fees for the operating facility, the anesthesiologist’s and surgeon’s fees, medicines, office visits, and other services and materials.