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Face Lift


Overview

When the term face-lift is brought up, many people think of a skin tightening procedure. This, in fact, used to be true up until about 10 years ago. At that time plastic surgeons began serious evaluation of the causes of facial aging. What we have discovered is that skin stretching over time is only a small part of the aging process. Other factors not previously considered but very important have been found to be the major contributors. Facial rejuvenation requires that all the contributing factors be corrected in order to produce the most aesthetically pleasing, natural result. The fruit of this research is that face-lifting is much more predictable and effective at re-creating the youthful appearance we once had.

If you look at any model, male or female, you will see high cheeks that are full of fat. Now, look at an older person. You will see that this facial fat has fallen from the cheek area and now is located in the fold above the upper lip and in the jowl area at, or even below, the mandibular border. The results of facial aging are quite predictable but only a small part of it is because of skin stretching.

It is a very exciting time in plastic surgery because we are just beginning to ”solve the puzzle” of facial aging. Even though facial aging affects the entire face and neck, sometimes a patient is really only concerned with a particular area such as the neck. In this situation, only the neck needs to be addressed. Many times patients decide to have only their neck done because it bothers them the most. Frequently, they are so impressed with the results that they later have their face and forehead addressed as well. This is an excellent way to approach facial rejuvenation. You should only have corrected what really bothers you. You can always come back and have other things done.

Most doctors technique for face-lifting addresses ALL the causes of facial aging. It is not a skin pulling procedure that is commonly practiced. Primarily, it involves elevating the facial fat that has fallen into the upper lip/cheek fold and into the jowl area. This fat is then suspended back up to the cheek area where it should be. This has a three-fold effect. It helps to reduce the prominent upper lip/cheek fold and also re-creates a fuller cheek area similar to that of youth. In addition, elevating the fat from the jowls exposes the mandibular border. This effectively widens the face at the cheek level and narrows it within the jaw area. By doing this, an elegant triangular shape is recreated. Look at yourself and an attractive young model and then at a person with obvious facial aging. The youthful model will have a triangular shape whereas the face of the older person will have a more rectangular shape. Many doctors have developed sophisticated techniques to recreate this triangular shape without an operated look.

Now, with the fat and muscles properly re suspended the skin is draped over the face and any excess skin is removed. The skin does not look tight or unnatural.

As far as the neck is concerned, our doctors have developed a unique technique utilizing suture suspension to elevate the tissues of the neck. This dramatically tightens the hanging skin and eliminates the banding under the chin that is so common with aging. This creates a neck with a high, sharp angle above the Adams apple like that of youth. This is discussed in more detail within the neck-lifting section of this web site.

The results of face lifting and neck lifting are quite dramatic. They can easily take 10 to 20 years off of your apparent age. You must, however, understand that the aging process never stops. So, eventually the procedure may need to be repeated in 10 to 15 years. Some people say,Why bother? For them, it doesn't matter. But for most people, if they can turn the clock back 10 to 20 years, it has a huge impact on their state of mind and subsequently quality of life.

Benefits

The benefits of face lifting are numerous. As mentioned above, the effect of “turning back the clock” is profound in terms of state of mind and quality of life. The results can be summarized as follows.

  • Elevates fat that has fallen down to the fold above the upper lip and back into the cheek area.
  • Elevates fat in the jowl area and also back into the cheek area. Markedly reduces facial wrinkles and excess skin.
  • Markedly improves the fold above the upper lip known as the nasal labial fold. Markedly reduces jowling or the hanging skin at the jaw line.
  • Creates a youthful, triangular facial shape. Can address neck without touching the face or vice versa to accomplish the desired results.

Are you a good candidate?

No one is immune to facial aging. It is true, some ethnicities tend to age slower, but the descent of facial fat and muscles, as well as the stretching of skin, occurs in everyone. If it bothers you, you should have something done. If you look at your face and think that you look older than you feel, this may actually make you feel older somewhat like a self-fulfilling prophecy. Good candidates include those with the following.


  • Jowling or fat accumulation along the jaw line.
  • Markedly pronounced fold above the upper lip otherwise known as nasal labial fold.
  • Saggy facial skin.
  • Deep facial wrinkles.
  • Deep circles underneath the eyes.
  • Loss of cheek fat.
  • Loss of youthful look.
  • Corners of mouth have fallen down.

The candidates for neck lifting are referred to the neck lift section.

It should be mentioned that face lifting does not improve the texture of the skin. This is best managed with chemical peeling or laser skin resurfacing which would be done separately from the face lift.

Possible complications

The most common complication after face lifting is inadequate resuspension of the facial tissues. The cause of this is usually because the facial fat has faded away with time so that it is not available for resuspension. In this case, it may be beneficial to transplant fat into the areas where it no longer exists. This is rarely necessary. Other risks include asymmetry, nerve injury, infection, blood and fluid collection, and unfavorable scarring. A list of possible complications is provided by the American Society of Plastic Surgery and this will be discussed and given to you during your consultation.

Do's and Don'ts prior to surgery

  • Medications. Certain medications thin your blood and should not be taken within 3 weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should not be used within 3 weeks of surgery. Your doctor will go over this more thoroughly prior to the procedure.

  • Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask your doctor for something to help you sleep.

  • Smoking. It is imperative that you do not smoke within 3 weeks before and after any surgery but especially so for face lifting. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood for infection, wound healing problems, and scar formation. It also affects your airway, therefore, making anesthesia much more difficult.

  • Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. Please discuss all medications with your plastic surgeon and the anesthesiologist.

  • Washing. It is important to thoroughly wash your face and scalp the morning of surgery. Use more conditioner than normal so that your hair is manageable and easy to comb. Do not forget to wash inside your ears just like your mother told you. After washing your hair comb it straight back or straight down. Do not apply any clips or rubber bands. Do not apply any make up or hair spray.

  • Arrival. It is best to arrival on time so things go smoothly. Please be sure to have someone else drive you.

  • State of mind. Remember, this should be a happy and exciting time. A certain amount of nervousness is normal but you should not be overly anxious. Excessive worrying can actually be detrimental and you should discuss this with your doctor prior to surgery so that something can be prescribed to make sure you remain calm.

Anesthesia

The anesthesiologist will discuss with you what type of anesthesia is best for you prior to the procedure. He/she will take into consideration your medical history, the procedure, and your personal wishes.

General anesthesia is often the best type of anesthesia for face lifting.

After the procedure

The procedure itself will take about 3 to 4 hours but may take longer if other procedures are also being done.

Immediately. Right after the operation you will be watched for 1 or 2 hours and encouraged to walk around. You will be given as much pain medication as necessary both immediately after the operation and for the postoperative period. Of course, there will be swelling and bruising but there is surprisingly little pain. You will have a big head dressing on as well as ice packs to help keep the swelling down. You must not lay with your head down for the first week so that your face does not swell.

That evening. It is recommended that you take it easy. You can walk around, eat, but not too much more. You must sit and lay with your head up on at least 3 pillows. You should take as much pain medication as necessary and try to go to sleep early. Apply ice packs every 2 hours for the first 24 hours. You will be given medication to help keep the swelling down as well as to prevent infection.

First 48 hours.You can take a cool shower the next day. Just be gentle. Let the cool water run over your scalp. It is important to have someone help you shower. Your hair will be a disheveled with possibly some blood in it. Apply a generous amount of conditioner first to untangle your hair and then wash your hair gently. Reapply another generous amount of conditioner and then comb your hair straight back. Be careful as the comb may get caught up in the sutures or staples. The incisions will continue to ooze for about about 3 days. You will see your palstic surgeon in his/her office the first or second day after surgery. At that time, he/she will take the dressings down, clean up the area, apply antibiotic cream, make sure things are going well, and then reapply another head dressing.

First week. At about day 3 you can move around normally. The majority of the bruising and swelling will go away in about 3 weeks.

Beyond. Swelling will not completely resolve for about 6 months but, as mentioned above, the majority of it will be gone by 3 weeks. Skin contraction will not start until about 4 weeks after the procedure and will continue to contract until about 6 months. The final result will not be evident until 6 months when all the swelling has resolved and skin contraction is complete but you will certainly notice a significant improvement right away.

Recovery time

The swelling and bruising will resolve in about 2 to 3 weeks. Some people with sedentary jobs go back to work after 10 days. If your job, however, requires strenuous activity then it may take as long as 4 to 6 weeks to return to work. Most people return to work in about 2 to 3 weeks.

Consultation

We have outlined below what you can expect from your face lift consultation. Read carefully, as there are many suggestions that will save you time, clear up questions, and help you convey to your plastic surgeon what you want to accomplish.

Health History

All cosmetic surgery consultations begin with a thorough health history. This is especially true if general anesthesia is being used, but also applies to local anesthesia. Breast augmentations are usually done under general anesthesia. Rarely, if the implant is placed above the muscle, local anesthesia can be utilized. Prior to meeting with your plastic surgeon you will be given a health history questionnaire to fill out in the waiting area. There are five areas of your health you will be asked about. Be sure to answer it with detail so that your surgery and anesthesia can be optimized for you.

  • General Health

General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are: high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.

What will the plastic surgeon do if I have medical problems?

In short, he/she will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.

If you have a health problem or are over 50 years of age you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the health problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.

If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating that you are able to tolerate surgery.

If you are not able to tolerate general anesthesia it may be possible for your breast augmentation to be done under local anesthesia if the implant is placed above the muscle. This must be discussed with your plastic surgeon.

Be sure to let your plastic surgeon know if you have ever had a blood clot.

  • Past Surgical History

On your questionnaire you will be asked about previous surgeries. Be sure to identify any problems you may have had with anesthesia. Of particular concern are previous cosmetic surgeries especially if you do not like the result and are interested in revision. With breast augmentation it is especially important to mention all breast surgeries including breast biopsies.

  • Medications

Be sure to list all medications you take including aspirin and over-the-counter medications. These are important as they may increase bleeding and affect your surgery. It is extremely important to stop taking aspirin and aspirin containing products at least 10 days before surgery. Tylenol is a good alternative. Here is a partial list of aspirin containing products and other products to be avoided prior to surgery.

  • Allergies to Medications

Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information! Nausea is not an allergy but it is important to mention as well.

  • Smoking, Drinking and Drug Use

These three will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a face lift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 2-3 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring,
and/or infection.
With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case smoking cessation is strongly advised but is not mandatory.

What Do You Want To Change?

It is important that you have a clear idea of what you want changed when you go for consultation. The least favorite thing a plastic surgeon wants to hear is: What do you think I need done?

Look in a mirror and identify what bothers you. Be specific. It is helpful to break up the face region into six parts. 1) Eye Brow 2) Upper Eyes 3) Lower Eyes 4) Temple Area 5) Cheeks 6) Jaw Line. Evaluate each one of these areas individually as this is what the plastic surgeon does in his exam. A face lift does not address the first 3 problems. If you are concerned about these areas you may be best treated by having a brow lift, upper blepharoplasty, and/or lower blepharoplasty in conjunction with your face lift. Click on these areas to see if you want more information and discuss this during your consultation.

Common complaints

  • Temple: Crow's feet, droopy skin
  • Cheeks: Loose/hanging skin, loss of cheek fullness, large nasolabial folds
  • Jaw line: Jowling
.

Ideal Facial Shape

  • Temple

  • Smooth without a hollow

  • No wrinkles when not smiling

  • Cheek

  • Full with the most prominent point just under the lateral eye

  • No nasolabial fold when not smiling

  • Smooth when not smiling

  • Jaw Line

  • Border should be clearly visible without jowling

  • Triangular in shape


Physical Exam And Treatment

The key to the face physical exam is to determine exactly what is causing the problem. Below is a typical sequence that an experienced plastic surgeon uses to evaluate the neck and what can be done to correct problems.

Temple

With aging, facial fat either descends or goes away, or a combination of both. In the temple region this causes a sunken area characteristic of aging droopy skin also is a result. Crow's feet with smiling are not uncommon and are acceptable as long as they are minimal. Permanent wrinkles and/or deep lines during smiling give an aged appearance. A face lift will elevate some of the descended temple fat as well as smooth out the wrinkles. Wrinkles with smiling will not be eliminated but should be improved. Concurrent lower blepharoplasty may be necessary to treat significant crow's feet

Cheek

Similarly, facial fat in the cheek descends or goes away. As it falls it bunches up just above the nasolabial crease giving the typical fallen face appearance. During your consultation, your plastic surgeon will pinch this area and elevate the fat upward, thus, simulating a face lift. During a face lift, the surgeon will reposition this upward by 1 of 3 methods.

The Three Most Common Face Lift Methods


Subcutaneous Face Lift

The skin is undermined to an appropriate level determined during the physical exam. The skin is then advanced laterally and slightly upward to put it back where it was during youth. This effectively tightens the skin and smoothes out the facial contour. Care is taken to put all the skin tension above and behind the ear so that there is minimal tension in front of the ear itself. This avoids an operated look.

Subcutaneous Face Lift with Fat Suspension

This is a Subcutaneous Face Lift but in addition the descended fat is elevated back into position with sutures.

SMAS Face Lift

SMAS is an acronym for Superficial Musculo-Aponeurotic System. It is a fibrous/muscular layer under the skin. Above it lies the cheek fat. Below it sit the facial muscles that animate the face. A SMAS face lift will elevate the SMAS and thus, concomitantly, elevate the facial fat and muscles.

It has been shown that all three types of face lifts can achieve excellent results. Which is best for you depends on what needs to be corrected and what your plastic surgeon is most comfortable with.

Jaw Line


Like the cheek, your plastic surgeon will evaluate your jaw line by pinching the soft tissue on top of it and elevating it to see what is the best treatment. Jowls are a combination of fat and SMAS that have descended with age. During a face lift this tissue is re-suspended back into the cheek area where it belongs.

Typical Face Lift Incisions