FACELIFT
Introduction
The young individual has a firm, smooth face with only a few lines and wrinkles. The skin feels tight because it fits snugly over the fatty tissue, muscle and bones of the face.
As the individual ages, the skin loses its elasticity, the muscles of the face lose tone and stretch and the fatty tissue shrinks in volume. The eventual result of this is that lines and wrinkles begin to appear and they become more prominent due to the effects of gravity and muscular action.
The most notable changes occur under the chin and upper neck (turkey neck and double chin), outer eyebrows (crow's feet), inner cheek area (jowl lines and furrows) and skin folds at the corner of the mouth.
Independently very fine lines appear where the skin is very close to the underlying muscle e.g. upper and lower eyelids, upper lip and forehead. The nose becomes sharper and longer in relation to the other facial features.
The rate of ageing in a particular individual depends on a host of variables. Apart from inherited factors other aspects that are important to the ageing process are skin type, exposure to sunlight, diet, alcohol consumption, smoking and stress.
The purpose of a facelift operation is to raise and tighten the facial skin thereby eliminating or decreasing overhanging folds or lines and to correct the effects of ageing on the deeper structures by tightening and relocating muscles, which have stretched and drooped. Redundant deposits of fat are also removed.
The standard facelift operation is effective in the neck, chin, cheeks and temporal regions i.e. the lower two thirds of the face and neck. The forehead and eyelid regions are not included in the standard operation and require separate procedures that may be combined with it.
It is not possible to eliminate every line, wrinkle or furrow in a facelift procedure. Prominent lines or wrinkles that remain will require additional treatment e.g. skin abrasion, filler injections eg fat implants, synthetic filling agents.
Nature of operation
The patient is admitted starved on the morning of surgery. A general or twilight anaesthetic is usually administered.
The incision begins in the temple behind the hairline, curving downwards to the top of the ear. (Fig below). The incision continues in the crease in front of the ear or slightly inside the ear canal behind the little protrusion of cartilage called the tragus. The incision used is specifically designed to be as inconspicuous as possible in any particular patient. In men special care has to be taken to preserve the normal shape of the sideburns. The incision proceeds underneath the earlobe and then upwards in the groove behind the ear. It finally extends horizontally inside the hairline towards the back of the head.
The skin is then gently lifted (undermined or dissected) from the immediately underlying deeper tissues to free it and allow it to be moved upwards. Skin undermining can be very extensive in the modern facelift, extending into the eyelids, over the cheeks to the corners of the mouth and then over the jaw line into the neck to meet the dissection from the opposite side in the midline.
Excess fat in the neck that causes a double chin can also be removed and the neck muscles tightened to produce a rejuvenation of the jaw line.
Once the skin has been adequately undermined and all ancillary procedures to the deeper tissues completed, it is stretched upwards and backwards and stitched into the correct position after the excess has been trimmed.
A modern facelift does not depend on all the structures of the face being lifted by being dragged upwards with the skin. Instead the deep structures are secured into their best position and the overlying skin then redraped over them. This gives a much more natural and also long lasting effect.
At the end of the operation, dressings are placed over the incision lines and the face is bandaged.
Postoperative Management
Strict bed rest is advised in the immediate postoperative period to reduce the risk of bleeding. Patients are usually advised to sleep with the head elevated for a few days. Quick movements, bending, straining and lifting should be avoided initially and if possible, sneezing.
Bandages and drains are generally removed after twenty four to forty eight hours and the hair is washed. Aspirin and alcohol are forbidden for at least two weeks before and after surgery. A liquid or soft diet is recommended for a few days to ease discomfort.
The hair should be washed frequently to help prevent wound infection, which is especially liable to occur behind the ear.
Most patients are discharged from hospital after one or two days to attend follow up after a week to ten days for review and suture removal.
Full recovery can take several weeks. Most patients should be fit to continue their normal activities in a few days and be confident to appear in public after about a week to ten days.
Postoperative sequelae and complications:
In addition to the post operative complications mentioned previously under "Factors Common To All Surgical Procedures" the following deserve specific attention.
Bleeding : Bleeding can occur, as after any operation, and if severe, the face swells up alarmingly resulting in a collection of clotted blood under the skin flap called a haematoma. Less severe bleeds can be treated simply by aspirating the blood with a needle or by massaging the collection of blood towards the incision line so that it can be evacuated.
A large expanding haematoma has to be dealt with promptly as an emergency as it can cause irreversible damage to the skin flap called flap necrosis (See below). This is because the blood supply is cut off as a result of the severe tension in the skin flap produced by the expanding haematoma.
Very small amounts of blood, which may not always be apparent after the operation, can produce prolonged lumps and irregularities during the recovery period.
Bruising & swelling : In most cases there should be minimal bruising and swelling. If bleeding occurs under the skin flap after the drains have been removed there is a strong likelihood that bruising will take a few weeks to subside completely. Gentle massage with skin creams helps swelling and bruising to resolve. Complete recovery can take up to six months but most patients should be fit to face the public confidently after a week to ten days.
Infection: This usually occurs in the wound in the groove behind the ear. Local wound hygiene and antibiotics are used to treat this problem.
Numbness : This is common in the neck and cheek areas as well as around the ear. The numbness usually resolves within a few weeks. Very rarely, areas of numbness especially on the ear can be permanent.
Change in normal hair pattern : In all patients the hairline will be altered. This occurs invariably because the facial skin has been moved to a new position as a result of stretching it. The hairline in front of and behind the ear is largely affected. In males the sideboards will be altered in position and it may be necessary to shave behind the ear.
Hair loss : This can occur in the scalp adjacent to the incision lines. The hair growth usually recovers but it can take many months. Sometimes the hair loss may be permanent and needs further surgery to correct it. Rarely, patchy areas of alopecia (hair loss) can occur in the temple temporarily for reasons which are unclear.
Nerve injury : On rare occasions, damage to any of the nerve branches, which activate the facial muscles, can produce weakness or paralysis of that muscle or group of muscles. This can result in asymmetrical facial movements, weakness or paralysis of the face.
Most cases of facial weakness following facelift surgery will resolve spontaneously. Rarely further surgery to repair a nerve may be required in severe cases. Thankfully this complication is very rare in experienced hands.
Flap necrosis : This occurs where an area of the skin flap dies, ultimately resulting in an ugly scar. It is an extremely rare complication in experienced hands.
It occurs as a result of impairment to the blood circulation in the skin once it is lifted from the deeper tissues and stretched. The cause is often unknown but it is more common in heavy smokers or in association with a haematoma (see above) In severe cases further surgery may be required to improve the scarring.
Scars : The incisions are placed where they are most inconspicuous so scarring is not a major problem in facelift surgery. However scars may get infected and stretch or thicken, requiring further treatment at a later stage.
Pigmentation : This can occur over sites of bruising and may be permanent.
Ventriloquist Dummy Look : The popularity of cosmetic surgery in recent years has yielded its own unique set of unfavourable circumstances. One of these is the increasing number of ageing starlets and celebrities who have had too many facelifts which ultimately give a permanent pulled appearance, referred to by our surgeons as the Ventriloquist Dummy Look.
Many patients are understandably concerned beforehand that they may end up with an unnatural appearance. This condition only occurs after the facial skin has suffered repeated, frequent facelifts, which eventually exhausts its elasticity. It is highly unlikely to occur after one facelift or after a few well-spaced, expertly performed operations.
Results
Patients who are good candidates for a facelift are likely to gain a very gratifying result. They can look years younger and this can be a great boost for their confidence, both in social situations and at work. The improvement in appearance can be dramatic and is usually even more so when combined with blepharoplasty and dermabrasion to the upper lip.
It is important to realise that the ageing process will continue after a facelift operation. Ageing is a complex phenomenon and depends on many factors. Because of the complexity of the ageing process, the rate of ageing is unique to every individual. In simple terms however, a person who has had a facelift will not look as old after ten years than if he/she didn't have a facelift.
Having a facelift does not affect the rate of the ageing process. Sooner or later, the signs of ageing will return and this can sometimes be in as little as several months but is usually a number of years. The operation can then be repeated.
