A face lift is a procedure which lifts sagging tissues of the lower face and neck. It is a procedure that has been present for decades, and is constantly evolving and improving. The contemporary techniques focus on elevation of the deeper tissues of the face and neck, rather than simply pulling the skin tightly. Thus the results tend to be not only more natural appearing, but also longer lasting. Most patients appear more youthful and rested. This discussion will provide you with the important information you need to understand face lifting procedures.
As we age, our faces change. There are three types of changes that occur in most people. First, the skin quality declines. Fine lines and wrinkles develop and the skin tone changes wherein brown and red areas of discoloration arise. Secondly, people experience volume loss. Faces deflate over time as the “baby fat” that softens our anatomy is lost. Lastly, our skin and deeper tissues sag over time because of laxity. Face lifting only addresses the last category.
Therefore, individuals who benefit from face lifting are those with sagging skin and soft tissue. This is usually seen as “jowls”, as well as sagging tissue of the neck. A face lift is a surgical procedure performed in an operating room with anesthesia, so the patient has to be healthy enough to undergo this. Many surgeons avoid performing this procedure in smokers, because there is a higher chance of poor results and complications.
Most surgeons perform face lifts under either general anesthesia (completely asleep) or using local anesthesia with sedation (kind of like undergoing a colonoscopy). The operation can take anywhere from an hour or two for some of the “minilift” procedures, to 6 hours or more when the it is combined with procedures for the eyelids and/or eyebrows.
The incisions for face lifting are generally started in front of the ear (often partly in the ear to hide them better), and wrap around the back of the ear. Depending on the extent of work needed, the incision may also may extend upward - into the hair of the temple, and back behind the ear into the hair of the scalp. Often, the surgeon will make an additional incision underneath the chin in order to remove neck fat and tighten the thin sheet like muscles of the neck called the platysma.
In 1976, Drs. Mitz and Peyronie described a layer of tissue under the skin of the cheek that they called the superficial musculo-aponeurotic sheath (SMAS). This report changed the way face lifting procedures would be performed from that time forward. Before their report, face lifts were performed by lifting the skin only, pulling tightly and then removing the extra skin. This “skin lift” provided results that did not last long and often looked “pulled”. Many surgeons refer to the SMAS layer as the “muscle” layer when explaining the procedure to the patient.
Addressing the SMAS layer has several advantages. By lifting the SMAS layer, the jowls and lower facial volume can be repositioned and lifted more effectively. In addition, the results of the procedure will last longer if the SMAS layer is lifted. Finally, the result will look more natural and less “plastic”, if the SMAS layer is used.
Today, there are many different techniques for manipulating the SMAS layer. Some surgeons choose to the cut through the SMAS, lift underneath it for a certain distance, and then pull it vertically and secure it with sutures. Others remove a section of the SMAS and then reattach the cut edges. Some use multiple “plication” sutures to fold the SMAS on itself and effectively lift the jowls. Some commonly employed techniques are known by the following terms:
This involves lifting under the SMAS tissue and then pulling it upward and backward. The overlying skin and soft tissues are lifted along with this deeper tissue.
Hamra introduced this technique in 1990. The SMAS layer is elevated further than in the SMAS lift technique and ligaments are released in an attempt to elevate the sagging fat of the cheek. Some feel that the deep plane technique leads to greater improvement in the “midface” – the area between the lower eyelids and the lower lip – including the “nasolabial” (or “melolabial”) fold that runs from the nose to the lips.
The SMAS layer continues from the face down to the lower neck. It is continuous with the thin, sheet like platysma muscles. Aging platysma muscles cause the vertical “turkey” bands that many people develop in the neck. Thus, face lifts do typically lift and tighten the neck tissues as well. If there is excess fat in the neck, then this can be removed by liposuction or direct fat excision. The muscles can be further tightened, and “bands,” corrected, by suturing the muscles together through an incision underneath the chin. This is called a “corset” platysmaplasty – because the muscles are tightened like a corset.
There is quite a bit of variation in this, depending on how extensive a face lift is performed, if additional procedures are done at the same time, and even the tendency of any particular patient to bruise. In general, there is quite a bit of swelling and bruising. It is greatest the first week, and then begins to dissipate rapidly. Most patients will take about three weeks for the majority of the bruising and swelling to resolve. By that time, most will feel comfortable in public. Additional healing continues for several months.
Every surgical procedure has certain risks. Fortunately, the percentage of patients who have surgical complications is low. The most common complication is a hematoma. This is a collection of blood underneath the surface of the skin. It occurs in about 5% of cases. Another complication is damage to the facial nerve – this could result in weakness of the face (facial paralysis) in one or more areas. It is rare – less than one percent of cases will have long-term facial nerve injury. Temporary facial nerve weakness is a bit more common. Other potential complications include visible scarring, infection, hair loss, and skin necrosis (skin not surviving, and healing by scarring). These are rare. Another consideration is the risk that you will not be satisfied, and may desire another surgery to get more improvement, or to “fix” an area that doesn’t heal well. In approximately 10-15% of people with extensive loose neck skin, a revisional procedure is warranted.
Face lifting techniques continue to evolve and improve. Contemporary techniques all involve lifting of the deeper tissues of the face in order to create a more youthful and rested appearance. There are many variations on that theme, and it can be pretty confusing to the consumer and potential patient. In the end, it is safe to say that many different versions of the face lift can produce very satisfying results, and it is the skill and experience of the surgeon that matters the most.
The deep-plane rhytidectomy. Hamra ST. Plastic and Reconstructive Surgery. 1990 Jul;(1):53-61.
Rhytidectomy with lateral SMASectomy. Baker D. Facial Plastic Surg. 2000; 16(3):209-13.
SMAS rhytidectomy vs. deep plane rhytidectomy: an objective comparison. Kamer FM, Frankel AS. Plast Reconstr Surg. 1998 Sep; 102 (3):878-91