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FACELIFT SURGERY
RHYTIDECTOMY
MELOPLASTY
INTRODUCTION:
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The history of
face-lifting dates back to the early 1900’s.
A surgeon by the name of Hollander is
credited with first describing the facelift
operation. Early on, the operation consisted
of simply removing skin and “pulling” it
closed. In the early 1970’s, surgeons gained
a better understanding of facial anatomy. It
was then that more reliable methods of
face-lifting were developed. Recently,
face-lifting procedures have been refined to
address specific anatomic areas that change
with aging.
Facial aging begins in the mid thirties with
the formation of dynamic wrinkles. These are
wrinkles produced by the continuous action
of the facial muscles. This analogous to
folding a paper continuously over and over
again. At one point, the paper will form a
crease. In much the same way, the skin
invariably becomes wrinkled at the site
where the muscle acts on it. These tend to
be the first signs of aging in most persons.
They are typically located in the forehead,
between the eyebrows (glabellar region) and
around the eyes (crow’s feet).
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As the years go by and the facial tissues
loose elasticity and collagen begins to lose
its strength, other folds and wrinkles begin to
develop. These are known as “ static “ folds
because they are not subjected to muscular
movement. Examples of these are the
nasolabial folds, which run from the nose to
the lateral most portion of the lip and
marionette lines. Early on theses may be
corrected with minimally invasive procedures
to fill in the depressions. However, as they
become deeper, lifting procedures are
usually needed to help eliminate these.
As the aging process continues, the facial
tissues continue to weaken and descend.
Additionally, fat may undergo resorption in
addition to downward displacement. This is
particularly noticeable in the area of the
midface, or the cheekbone. There, a natural
mound of fat exists. The downward
displacement of this fat is what actually
creates the nasolabial fold. In the lower
face, jowls are created as the facial
tissues sag inferiorly. In the area of the
neck, fat begins to collect in area
underneath the chin. The skin in this area
also begins to loose elasticity and hangs
down. This is sometimes referred to as a “
turkey gobbler” neck deformity.
IS FACELIFT SURGERY FOR YOU?
The majority of patients that undergo the
facelift operation do so in their late
fifties or early sixties. Occasionally,
facial aging procedures such as neck lifts
may be done earlier. Patients are many times
confused about what exactly a facelift
corrects. This uncertainty can be compounded
by the advent of the different types of
facial rejuvenation surgery that have been
developed in the last decade.
The preoperative consultation usually
involves a discussion with the surgeon about
the specific issues that are a concern to
the patient. The physician will then discuss
the possible surgical and non-surgical
procedures which may be used to treat the
patient. This conversation should include
all of the risks, benefits, indications, and
alternatives to the each of the specific
procedures discussed. The patient should be
encouraged to ask questions and exchange
thoughts and ideas with the surgeon. The
best patient is a well informed patient.
The physical examination then follows. This
part of the consultation focuses on the skin
type ( light skin versus darker skin ) and
skin texture. Patients with rough, scaly,
sun exposed skin can undergo the surgery,
but the skin texture will not be improved.
Topical retinoic acid treatments are best
for improving this skin condition. The
underlying bony structure and neck anatomy
also have a large influence in the final
result. That is, patients with strong
underlying bone structure, such as cheek
bones and chin tend to have very good
results. Patients with small chins may
benefit greatly from a mentoplasty, or chin
implant at the time of the surgery.
The examination continues with the forehead.
Here, brow position is examined. The ideal
woman’s brow is at the orbital rim medially
and arches at its highest point laterally.
The man’s brow should lie just at the level
of the orbital rim. This will determine
whether a brow lift is needed in conjunction
with the facelift. Again, the brow lift
procedure (discussed elsewhere) is not meant
to remove the forehead wrinkles, but instead
to elevate the brows. The eyes are then
examined to determine whether a
blepharoplasty ( eyelift ) is needed. Moving
inferiorly, the position of the malar fat
pad (cheek fat pad) is determined. A descent
in this area should alert the physician that
a midface lift ( either via deep plane
facelift or temporal midface lift ) should
be discussed. Next the jowls and neck are
examined for the amount of laxity and fat to
be addressed.
Attention should then be paid to the
individual characteristics of each patient.
For example, the way the ear attaches to a
person’s face. Notes should be made so that
it is placed back in the same position. If
the patient does not like the way it is
attached, this may be a good time to speak
to the surgeon about changing it. Blemishes
or moles may be addresses so that they may
be easily removed during the operation.
The facelift operation can be done under
local anesthesia with either a light,
moderate or heavy sedation as well as with
general anesthesia. This should be discussed
with your surgeon so that a mutual decision
that is comfortable for both is reached.
Both have pros and cons, which are discussed
in another chapter. The anesthesia should
only be administered by a board certified
anesthesiologist. Occasionally, a nurse
anesthetist can provide anesthesia. This
should only be done under the direct
supervision of a board certified
anesthesiologist.
The procedure can be carried out in either
an outpatient surgical facility based in the
surgeon’s office or a free-standing one.
However, the patient should make sure that
the facility has passed the state surgical
center codes and is certified by the
appropriate ambulatory surgery credentialing
board. Alternatively, it can be performed in
a hospital. Healthy patients tend to be done
in the outpatient facilities. Patients who
are healthy, but may have a medical
condition, such as controlled high blood
pressure, are usually done in the hospital
for safety precautions. All patients
undergoing this procedure should have a
medical examination and medical clearance
before the surgery by their primary care
physician. It is important to stop all
aspirin containing and anti-inflammatory
products (naproxen, ibuprofen) ten days
before surgery. Acetaminophen should be the
only over the counter pain medication taken
ten days before surgery. Vitamins such as A,
ginko biloba, and St. John’s wart should be
discontinued because they may cause
bleeding. All vitamins and herbal products
consumed should mentioned to the surgeon, as
they may have effects on the clotting
mechanism. Alcohol should also be avoided
for five days before surgery to avoid
bleeding and bruising.
UNDERSTANDING THE SURGERY:
The traditional facelift operation is aimed
at improving the neck and the facial jowls.
This procedure is appropriate for those
patients that have a sagging neck and jowls,
but do not have midface descent. In this
operation, the skin is raised from the
deeper tissues in the face and neck. These
underlying tissues, known collectively as
the “ SMAS” are then tightened. The skin is
the draped back and the excess is trimmed.
The surgery can take from two and a half
hours if only the facelift is being
performed to four hours if a blepharoplasty
(eyelift) is being performed in conjunction.
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The surgery
involves incisions in front of the ear,
underneath it, and then in back of the ear
and into the hair. In men, the skin can be
incised in front of the tragus, to avoid
having the beard grow close to the ear once
the skin is draped back. Alternatively,
the skin can be incised in a standard
fashion and the hair follicles removed from
the inside of the skin. Occasionally, some
surgeons carry the posterior incision into
the hairline, making it visible when the
hair is raised. The superior-most portion of
the incision can be directed in two ways,
according to surgeon preference. The
important point is to make sure that the
surgeon does not change the hairline, giving
a “bald” look to the temporal area. |
This is can be a
tell-tale sign of a facelift. There is
another incision just underneath the chin
which is used to suction the fat from the
neck and to tighten the neck muscles. Once
the skin incision is made, the skin is
separated from the deeper tissues of the
face along the entire side of the face,
cheek, and neck. This undermining is done on
both sides of the face and the spaces
created on either side of join in the neck
below the level of the lower jaw.
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In the last
decade, more thorough facelift operations
have been developed in an attempt to correct
the sagging midface in addition to the
sagging neck and jowls. These are
collectively known as “deep plane “
procedures because once the skin is elevated
from the underlying tissues, the surgeon
lifts these underlying tissues (or SMAS)
from a underneath, instead of above them.
The ultimate effect is that the cheek fat
pad is elevated and placed back in its
anatomic position. These types of facelifts
can be done through the same traditional
incisions. Some surgeons approach this “
deep plane “ from a temporal incision above
the ear in the hairline |
in addition to
the traditional incisions. Patients that
have significant midface descent should
inquire with their surgeon regarding this
concern.
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No matter what
technique is utilized, at the end of the
operation the skin is pulled taught without
undue tension. The excess skin is removed
and the skin edges are approximated and
sutured together. Some surgeons choose to
use sutures for the entire incision while
others prefer small metal surgical staples
for the part of the incision which is behind
the hairline. At the end of the operation,
most of the incision is either behind the
ear or covered by hair except for the
incision just anterior to the ear and the
one just under the chin.
After the surgery, the patient is taken to
the recovery room. The majority of patients
are discharged home the same day.
Occasionally, surgeons may keep the patient
overnight. The patient should have a
caretaker with them for about two days. This
person will help with feeding, ambulating,
and other chores. This person does not need
to be a medical professional.
The facelift operation, like all surgery,
does have risks aside from those of
anesthesia. The highest risk patients are
smokers. Patients who smoke should refrain
from smoking for approximately two weeks
before the surgery. The nicotine patch is
not a substitute for smoking cessation as
far aesthetic surgery is concerned. Nicotine
causes the small blood vessels to become
more narrow, and decreases the blood flow to
the skin. The potential complication of a
smoker is the death of the facial skin,
resulting in a poor outcome with facial
scarring and infection. Other complications
of the facelift operation include hematomas,
or collections of blood under the facial
skin. These are rare, but they do occur.
Treatment involves draining it as soon as it
is recognized. Another complication possible
is injury to the parotid gland, one of the
salivary glands which is located in front of
the ear. This injury can result of pooling
of saliva into a cyst which might need to be
treated with pressure dressings, and
sometimes requires drainage.
Whenever incisions are made, there is the
potential for abnormal scarring. However,
most unsightly scars encountered in patients
having gone through a facelift are either
the result of poor incision planning or
excessive tension on the skin. Permanent
facial weakness from nerve damage is very
rare. Occasionally, the nerve may become “
bruised “ during the surgery, and a
temporary weakness results. This can last up
to two to three months and usually resolves.
It is common, however, to feel some numbness
in the area of the ear. This lasts several
weeks and is the result of the incision
around the bottom of the ear. Infection is
rare in the face, but can happen as
previously mentioned to patients who smoke.
The human body is not symmetrical and there
may be slight differences from one side of
the face to the other. This is normal even
in patients who have not had surgery and
should not concern the patient unless it is
highly noticeable.
WHAT TO EXPECT AFTER THE SURGERY:
The night of the surgery should be spent
relaxed, possibly watching television.
Activity should be kept to a minimum. A
liquid diet is best for the first eighteen
hours after anesthesia. The face will be
wrapped with a tight bandage used to keep
the skin flat. Pain should be minimal. Any
significant pain should be reported to the
physician immediately, as this may signal
bleeding under the skin. This is extremely
rare, but possible. If a blepharoplasty was
performed, some bruising will be visible on
the eyes. Ice compresses should be applied
to the eyes and face while the patient is
awake. It is also recommended that the
patient keep the head elevated whenever
possible, as this tends to reduce swelling.
Ice packs applied without pressure to either
side of the face might also be helpful.
The surgeon will remove the bandage on the
first day after the surgery. It is normal
for some bruising to appear in the neck.
Occasionally some blood collects behind the
ears and it is painlessly removed in the
office. The surgeon will then apply an
ace-type bandage with Velcro that is worn
for approximately four to five days while
healing occurs. On the fourth or five
post-operative visit the small sutures in
front of the ear and under the chin are
removed. Patients can usually shower and
wash their hair after this second visit. On
or about the tenth post-operative visit, the
tiny staples in the posterior incision ( in
the hair ) will be removed if they were
used. The face may remain with mild swelling
for approximately two weeks. After the
second week, about 80 % of the swelling will
have subsided. Only the patient is aware
that the face is somewhat swollen. It is not
noticeable to the average person. Hence, the
patient can resume most of the daily
activities. It is recommended that physical
activity, such as running or lifting be
resumed only after the fourth week. The
remainder of the swelling resolves in the
third week.
THE NEW YOU:
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The final
results of a facelift are visible between
the sixth and eight week post-operatively.
The results of a facelift operation usually
turn back the clock approximately ten years
and the results last about ten years. Most
patients who undergo facial rejuvenation
surgery are extremely happy with the
results.
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The information provided above is for educational
purposes only. Individual results may vary. A
personal consultation with your plastic surgeon is
the best way to gain information about your
particular complaint, and about potential treatment
options to address the same.
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