Plastic Surgery Office - About Facelifts

About Facelifts

by Jeffrey C. Salomon, M.D., FACS

It is said that beauty is only skin deep, and that is true. Ask any of the millions who have had a facelift.

The facelift, rhytidectomy, in medical terminology began in the early 1900s, but did not gain popularity or social acceptance until the 1970s. Now it is one of the most common procedures done to reduce the effects of aging and redefine facial features. Facelifts have become something of a status symbol. Women have the most facelifts, but men account for 20 percent and that number is growing. Regardless of sex the motivation is identical, the desire to look younger. In this culture that stresses youth in social and business life, facelifts are one way of slowing the clock.

How your face ages depends on genetics and environment. If you are fair or have red hair you can expect your skin to age faster than people with darker complexions do. Genetic traits probably relate to the amount of elastic fiber in the skin. It is elastic tension that keeps the skin tight and youthful. To get an idea of how elastic your skin is pinch your cheek or the skin around your eyelid and see how quickly it snaps back. Normally the skin should snap right back.Environmental factors are also important. Sun damage reduces the amount of elastic fibers and makes the skin appear lax and weathered. Smoking is also bad for the skin; it reduces the amount of oxygen getting to the skin causing premature aging. The dieter’s cycle of weight loss and gain also increases skin aging. The skin stretches and deflates and the elastic fibers rupture and lose elasticity; facial skin loosens and sags.

As we get older the facial skeleton gets smaller. The scaffolding that supports the skin shrinks and the skin sags and the face looks older. This starts at around age fifty-five.

Facial aging is predictable. Rhytids, fine lines and wrinkles, appear. As the loss of elastic fibers continues the number of rhytids increases. The facial skeleton shrinks, and gravity slides the soft tissue down off your cheekbones creating folds at the edge of the nose and mouth. Jowls form at the jaw line. Excess skin on the neck–"turkey gobbler"–appears.

If you are seriously considering a facelift, there are some things you need to know. Choosing a surgeon is one. There are many people trying to sell facelifts and it is hard to know where to turn. Ads on TV, in magazines, and the yellow pages all promise the youthful look you long for. Plastic surgeons are not the only ones who perform facelifts. There are facial plastic surgeons–otolaryngologists–and other surgeons, even some dermatologists, who perform facelifts. Your best bet is to know the background, training and experience of the surgeon before committing to the operation. Even then you need to choose carefully. Be sure you know as much as you can before agreeing.

Finances also need to be considered. Facelifts are cosmetic surgery not covered by medical insurance. You can expect to pay $5,000 to $20,000 plus hospital, anesthesia and medication costs.

From the surgeon’s perspective, the best candidate for a facelift is a patient with a thin face and a well-defined facial skeleton. Patients who have fat deposits under the chin are often good candidates for a modified facelift and simple liposuction. Patients with plump or fatty faces are not good candidates for the procedure.

Patients with any significant medical disorder that may compromise their ability handle anesthesia or to heal are not good candidates. Patients on anticoagulants or who have significant heart disease or connective tissue disorders are generally not good candidates. Smokers too are not good candidates, unless they have stopped smoking for an extended period. Any condition that can affect overall health may preclude the procedure.

The road to a new face begins with the surgical consult. You should have a list of questions for the surgeon and be able to describe the parts of your face that you think will benefit from a facelift. You will want to know are if the surgeon can recommend other procedures that may be better for you, such as liposuction or laser skin resurfacing. Ask the surgeon about his background, training and experience. Ask about the costs and payment options. Some surgeons accept credit cards. There are also companies that specialize in cosmetic surgery financing. Find out the policy for cancellation of the surgery and about small touch-up procedures for those areas that you are dissatisfied with after surgery.

Ask where the surgery is going to be performed. If it is to be done in the physician’s office, is that office accredited and equipped to handle unforeseen anesthesia and other medical problems? Are they equipped to resituate a cardiac arrest? Also what type of anesthesia is to be used and who will be administering it? In some cases it is the surgeon, in others it is an anesthesiologist or nurse anesthetist. This is important because your general health condition may require that an anesthesiologist be present. Also, you may have a choice between general and sedative anesthesia.

During the consult the surgeon should come to a firm diagnosis about the problem areas of your face and what treatment will be done. You will want to know how long the recovery is going to be, how much time you will miss from work and the costs for medications, dressings and follow up appointments.

At the end of the consult you should receive a contract and disclaimer form. This form outlines the procedure to be done the cost, and possible complications and other policies and conditions. Be sure to read it carefully before signing. It may be a good idea to take it with you read it over and return it later.

While you are getting the facelift you may want some other procedures as well. Facelift surgery can be combined with eyelid surgery–blepharoplasty, brow lift, facial liposuction and occasionally rhinoplasty. Sometimes chin implant or chin advancement is also done. Facelift surgery is not usually combined with surgery on other areas of the body such as breast augmentation or abdominoplasty (a tummy tuck). A facelift is a very labor-intensive procedure that takes several hours. The more procedures done at one time, the greater the potential for unsatisfactory results and postoperative complications.

For several weeks before surgery you should discontinue any blood thinners such as Coumadin, aspirin or Ibuprofen any non-steroid inflammatory drugs. If you smoke you should not smoke for several months before surgery.

The surgery itself involves the skin, the underlying soft subcutaneous tissues and the facial skeleton. Between the facial skeleton and the overlying skin are the soft tissue structures that have fat, facial muscles and fibrous supportive soft tissue called fascia or superficial musculoaponeurotic system (SMAS.) There is also the salivary parotid gland of the cheek, facial blood vessels and nerves that give sensation to the cheek and ears and nerves that move facial muscles that animate the skin.

A variety of surgical procedures come under the heading of a facelift. Some of these involve tightening the SMAS, rotation or relocation of facial fat pads, and division and tightening of the superficial muscles of the neck. Some are called deep plane facelifts, others are called mini facelifts and still others vertical facelifts, and on and on. All of these procedures have in common tightening the facial skin.

The usual operation involves an incision that extends from the temporal, hair-bearing scalp down in front of the non-hair-bearing area in front of the ear, passing behind the earlobe and then crossing into the hair-bearing scalp behind the ear. Through this incision the facial skin, with or without the subcutaneous soft tissues, are mobilized and rotated up and backward. Excess fat and skin are then removed from the areas that have been lifted. Then the areas are re-draped and sutured into position.

Often, separate incision is made on the neck under the chin that gives access to fat and bands of muscle in the neck. These structures are appropriately divided and tightened and excess neck skin is re-draped behind the ear into the scalp. This skin tightening smoothes out the neck and jowls the surgeon can re-rotate soft tissue and skin into the normal position on the cheekbones.

Some surgeons use the endoscope to approach the surgery. This involves smaller incisions but the operation takes longer. Whatever the method the longevity of a facelift is improved by tightening the SMAS tissue in addition to tightening the skin tissue.

Facelifts do not remove fine lines around the mouth. These are best treated with facial resurfacing using a laser, dermabrasion or chemical peels. Skin resurfacing is not usually done at the same time as the facelift because the risks of complications are increased when both procedures are done together.

The actual time the surgery takes depends on several factors, including the procedures done and the speed of the surgeon. A facelift can take anywhere from one hour to six hours.

Postoperative care is relatively straightforward. Some surgeons use drains, others do not. Some surgeons use large bulky compressive dressings, others do not. There is a wide spectrum in actual performance and care of facelift patients.

The initial dressing changes are done at the surgeon’s office within the first few days. Pain is controlled with medication. Any severe pain should be reported at once to the surgeon, as it may indicate a hematoma.

As with any surgery facelift surgery has risks. You need to weigh the balance between the potential benefits and the potential risks. This is a very important consideration in cosmetic surgery because it is surgery that you do not have to have. All surgery has the risks of infection, bleeding, anesthetic related coma, and death. Your decision should not be taken lightly. Your surgeon should acquaint you with all the potential complications during the consult. Complications can be minor or major the major ones can be permanent and result in functional problems or deformities. Also complications can lead to repeat surgical procedures or hospitalization and additional costs.

There is also the possibility that a facelift that results in complications will take an emotional toll. You should give thought to the high stress and emotional cost that may occur with deterioration in your facial appearance from complications or an adverse event.

Like almost anything, facelifts do not last forever. The ultimate longevity of a facelift is dependent on skin type, smoking and weight loss and gain and sun exposure. The older you are and the more damaged your skin the more likely you will need a secondary facelift. If you have your first facelift when you are in your 40’s or 50’s it will last longer than one you have in your 60’s or 70’s. A secondary facelift uses the same scars that were used in the first facelift. Facelift scars are usually fine lined and easy to hide. Your facelift can be a secret only you and your surgeon know.

The facelift is surgery you do for yourself to look better and feel better about how you look. The operation is one that you should consider well before proceeding. Yet with the thousands of facelifts done each year it is a procedure that is usually safe and gives a pleasing result. Since beauty is only skin deep it is all we have to work with.