Rhytidectomy
A facelift, technically known as a rhytidectomy 'wrinkle', and ἐκτομή 'excision', the surgical removal of wrinkles), is a type of cosmetic surgery procedure intended to give a more youthful facial appearance. There are multiple surgical techniques. Surgery usually involves the removal of excess facial skin, with or without the tightening of underlying tissues, and the redraping of the skin on the patient's face and neck. Surgical facelifts are effectively combined with eyelid surgery and other facial procedures and are typically performed under general anesthesia or deep twilight sleep.
According to the most recent American Society for Aesthetic Plastic Surgery facelifts were the third most popular aesthetic surgery in 2019, surpassed only by rhinoplasty and blepharoplasty.
Cost varies by country where surgery is performed. Prices were quoted ranging from US$2,500 to US$15,000 as of 2008. Costs in Europe mostly ranged £4,000–£9,000 as of 2009.
History
Cutaneous period (1900–1970)
In the first 70 years of the 20th century, facelifts were performed by pulling on the skin on the face and cutting the loose parts off. The first facelift was reportedly performed by Eugen Holländer in 1901 in Berlin. An elderly Polish female aristocrat asked him to: "lift her cheeks and corners of the mouth". After much debate, he finally proceeded to excise an elliptical piece of skin around the ears. The first textbook about facial cosmetic surgery was written by Charles Miller entitled The Correction of Featural Imperfections.In the First World War, the Dutch surgeon Johannes Esser made one of the most famous discoveries in the field of plastic surgery to date, namely the "skin graft inlay technique," the technique was soon used on both English and German sides in the war. At the same time, the British plastic surgeon Harold Delfs Gillies used the Esser-graft to school all those who flocked towards him who wanted to study under him. That's how he earned the name "Father of 20th Century Plastic Surgery". In 1919, Dr Passot was known to publish one of the first papers on face-lifting, this consisted mainly of the elevating and redraping of the facial skin. After this, many others began to write papers on face-lifting in the 1920s. From then, the aesthetic surgery was being performed on a large scale, form the basis of the reconstructive surgery. The first female plastic surgeon, Suzanne Noël, played a large role in its development and she wrote one of the first books about aesthetic surgery named Chirurgie Esthetique, son rôle social.
SMAS period (1970–1980)
In 1968, Tord Skoog introduced the concept of subfacial dissection, therefore providing suspension of the stronger deeper layer rather than relying on skin tension to achieve his facelift. In 1976, Mitz and Peyronie described the anatomical Superficial Musculoaponeurotic System, or SMAS, a term coined by Paul Tessier, Mitz and Peyronie's tutor in craniofacial surgery, after he had become familiar with Skoog's technique. After Skoog died of a heart attack, the superficial muscular aponeurotic system concept rapidly emerged to become the standard face-lifting technique, which was the first innovative change in facelift surgery in over 50 years.Deep plane period (1980–1991)
Tessier, who had his background in the craniofacial surgery, made the step to a subperiosteal dissection via a coronal incision. In 1979, Tessier demonstrated that the subperiosteal undermining of the superior and lateral orbital rims allowed the elevation of the soft tissue and eyebrows with better results than the classic face-lifting. The objective was to elevate the soft tissue over the underlying skeleton to re-establish the patient's youthful appearance.Volumetric period (since 1991)
At the start of this period in the history of the facelift, there was a change in conceptual thinking, surgeons started to care more about minimizing scars, restoring the subcutaneous volume that was lost during the ageing process and they started making use of a cranial direction of the "lift" instead of posterior.The technique for performing a facelift went from simply pulling on the skin and sewing it back to aggressive SMAS and deep plane surgeries to a more refined facelift where variable options are considered to have an aesthetically good and a more long-lasting effect.
Indications
A facelift is performed to rejuvenate the appearance of the face. Aging of the face is most shown by a change in position of the deep anatomical structures, notably the platysma muscle, cheek fat and the orbicularis oculi muscle. These lead up to three landmarks namely, an appearance of the jowl, increased redundancy of the nasolabial fold and the increased distance from the ciliary margin to the inferior-most point of the orbicularis oculi muscle. The skin is a fourth component in the aging of the face. The ideal age for face-lifting is at age 50 or younger, as measured by patient satisfaction. Some areas, such as the nasolabial folds or marionette lines, in some cases can be treated more suitably with Botox or liposculpture.Contraindications
Contraindications to facelift surgery include severe concomitant medical problems, both physical and psychological. While not absolute contraindications, the risk of postoperative complications is increased in cigarette smokers and patients with hypertension and diabetes. These strong relative contraindications consist primarily of diseases predisposing to poor wound healing. Patients are typically asked to abstain from taking aspirin or other blood thinners for at least one week prior to surgery. Patients motivations and expectations are an important factor in order to determine the patient's medical status. A psychiatric illness leading to unreasonable expectations for the surgical outcome, such as a distorted perception of reality, can be a contraindication to surgery. Some kinds of hypersensitivity to anesthesia are a contraindication.Surgical anatomy
- SMAS
- Facial musculature
- Facial nerve
- Retaining ligaments
- Nasolabial folds
- Melolabial folds
- Greater auricular nerve
- Vascularisation
Procedures
In the traditional facelift, an incision is made in front of the ear extending up into the hairline. The incision curves around the bottom of the ear and then behind it, usually ending near the hairline on the back of the neck. After the skin incision is made, the skin is separated from the deeper tissues with a scalpel or scissors over the cheeks and neck. At this point, the deeper tissues can be tightened with sutures, with or without removing some of the excess deeper tissues. The skin is then redraped, and the amount of excess skin to be removed is determined by the surgeon's judgement and experience. The excess skin is then removed, and the skin incisions are closed with sutures and staples.
SMAS lift
The SMAS layer consists of suspensory ligaments that encase the cheek fat, thereby causing them to remain in their normal position. This procedure is often performed in tandem with blepharoplasty as an ancillary procedure. Resuspension and securing the SMAS anatomical layer can lead to rejuvenation of the face, by counteracting aging and gravity caused laxity. Modifications to this technique led to development of the "Composite Facelift" and "Deep plane Facelift."Deep-plane facelift
In order to correct the deepening of the nasolabial fold more accurately, the deep plane facelift was developed. Differing from the SMAS lift by freeing cheek fat and some muscles from their bone implement. This technique has a higher risk at damaging the facial nerve. The SMAS lift is an effective procedure to reposition the platysma muscle; however, the nasolabial fold is according to some surgeons better addressed by a deep plane facelift or composite facelift.Composite facelift
As well as in the deep plane facelift, in the composite facelift a deeper layer of tissue is mobilised and repositioned. The difference between these operating techniques is the extra repositioning and fixation of the orbicularis oculi muscle in the composite facelift procedure. The malar crescent caused by the orbicularis oculi ptosis can be addressed in a composite facelift.Mid face-lift
The mid face area, the area between the cheeks, flattens and makes a woman's face look slightly more masculine. The mid face-lift is suggested to people where these changes occur, yet without a significant degree of jowling or sagging of the neck. In these cases a mid face-lift is sufficient to rejuvenate the face opposed to a full facelift, which is a more drastic surgery.The ideal candidates for a mid face-lift is when a person is in his 40s, or if the cheeks appear to be sagging and the nasolabial area has laxity or skin folds.
To achieve a younger appearance the surgeon makes several small incisions along the hairline and inside the mouth, this way the fatty tissue layers can be lifted and repositioned. This way there are practically no scars. The fatty layer that lies over the cheekbones is also lifted and repositioned. This improves the nose-to-mouth lines and the roundness over the cheekbones. The recovery time is rather short and this procedure is often combined with a blepharoplasty