Facelift or Rhytidectomy
Facelift or Rhytidectomy
Facelift surgery or rhytidectomy are general terms applied to a variety of procedures that involve raising the facial skin so that hanging folds or lines are eliminated. Ordinarily, they involve the skin of the neck, the region under the chin, the cheeks and temporal regions. The forehead and eyebrows are sometimes included in this operation: or they may be included in a separate procedure. Eyelid surgery is frequently performed in conjunction with the facelift surgery.
All of these operations have undergone many modifications in recent years. A study of the overall aging process has received increased attention, its outward signs have also become easier to understand. At present, many of the underlying structural changes can be corrected surgically with an excellent degree of improvement. My aim is to produce an entirely natural appearance, avoiding the tell-tale “pulled” or gaunt look.
What happens to the facial structures as we get older?
The younger individual has very few facial lines and the soft tissues are generally firm and smooth, showing little mobility. The skin seems to fit snugly over the muscle and bone. There is also a rather firm fatty tissue lining just under the skin, which fills out the various tissue contours, leaving an overall smooth appearance. As the individual ages, this fatty tissue decreases in volume; it actually shrinks, causing the skin to fit more loosely. Essentially the same process takes place when loss of weight causes the overlying skin to sag. In addition to the surface contour changes and the more loosely fitting skin, various linear marks become evident where the facial muscles attach to the under surface of the skin.
The skin folds become more prominent as a result of gravity and muscular action. The most profound changes, at least where appearance is concerned, take place under the chin and upper neck, at the outermost portion of the eyebrows and at the skin folds near the corner of the mouth. Sagging also takes place rather prominently along the border of the lower jaw producing the so-called “jowl” fullness. Independent of the overall process, very fine lines appear where the skin is very close to the underlying muscular fibres. These changes are perhaps most noticeable in the region of the upper and lower eyelids, the upper lip and forehead, and the side of the eye (“crow’s feet” or “smile lines). The nose becomes sharper and, surprisingly enough, even somewhat longer in relation to the other facial features. This change combines with dental ridge shrinkage or denture replacement and soft tissue change in the chin area, which exaggerate the nasal change. Contour imperfections of the nose become more noticeable as the overlying soft tissues decrease in volume. Everything does not happen at the same time, and certainly the same degree of change does not take place in all areas.
There are several other factors that have a direct bearing upon the rate and degree of the aging process. These are essentially genetic characteristics specific enough to be used in forecasting potential developments. Generally, those individuals who have dry and thin skin covering (red or blonde hair) have more profound aging signs that take place earlier. Overexposure to sunlight for prolonged periods has a tendency to dry the skin and will definitely produce earlier wrinkling. While the suntan may look great, it often has an undesirable effect in the long term.
Surgical correction of these facial conditions may be directed to several different areas in sometimes-different ways. Here again, it must be said that while the foregoing description deals in generalities, the individual must be studied carefully to determine which specific areas may require direct attention. In the absence of notable lower facial change, attention is frequently directed entirely to the eyelids or brow area, since these are the earliest to show fullness or redundancy. Under some circumstances, elevation of the nasal tip as a modified nasal procedure will create a sufficiently youthful appearance so that treatment of other areas may be deferred. The removal or, more often, the camouflaging, of frown lines just above the nose may also have a similar effect (see non-surgical procedures).
Classically, the basic face lift surgery operation is designed to lift and remove the sagging skin while supporting the underlying facial musculature. There are various modifications in the basic procedure, all of which are designed to concentrate upon the most prominent deformities. It is essential that the incision is placed in such a position that it is difficult to see even under close inspection.
Along with the development of better surgical methods, there has been a significant change in opinion concerning the optimum time for facelift surgery. There is no need to wait until hanging folds or almost irreversible changes have taken place; while correction is perfectly possible in the late sixties or seventies, overstretched muscles with lack of tone, particularly in the eyelid region, become more difficult to repair. Facelift surgery preference has shifted to the early forties, or perhaps earlier under some circumstances, when limited corrections can often be made to maintain youthful appearances for an extended time. The selection of patients in the earlier age group must be based upon the character of tissue aging and the degree of improvement that might be anticipated.
Finally, there are several misconceptions regarding the facelift surgery and eyelid operation, as well as the general aging process that require additional explanation.
- There are no medications, creams, cosmetics or exercises that can significantly affect the aging changes herein described. Skin softening creams may be employed to some benefit to keep the skin in a healthy condition. The structural changes, which go on below, however, are not affected. So-called chin supports or facial muscle exercises are worthless; the latter may, in fact, be harmful. Constant vibration massage may result in more rapid shrinkage of the underlying delicate fatty tissue and produce the opposite result from that which was intended.
- The results of a properly performed face lift can be long lasting. The procedure cannot stop the aging process. Unfavourable appearances can, however, be altered and delayed sufficiently to be helpful for many individuals in their adjustment to various social pressures.
- There are no substitutes for the face lift operation if sagging is predominant and muscle tone is poor. Tightening the skin alone in small areas without separating and re-draping it over the underlying structures will be of extremely limited value. The “mini face lift ” performed in fifteen minutes will not last any time at all.
- Over correction with restriction of facial motion is totally avoided.
I perform the face lift operation by an open technique with or without endoscopes assistance. In some individuals a sub-cutaneous face lift suffices whereas in others it is necessary to tighten the SMAS layer at the same time. This extremely effective technique allows less extensive surgery with a more subtle and completely natural look. Fat preservation and redistribution is utilized along with this method.
The procedure takes approximately 2-2 ½ hours and the patient may require two nights hospital stay. Sutures are all removed by the twelfth day and the patient is most presentable by this time. Bruising will have subsided and most of the swelling will be resolved. The pre-auricular incision (i.e., the incision in the front of the ear) is made on the posterior aspect of the tragus so there is no scar visible on the cheek. The incision behind the ear is carried high up into the hairline and is well disguised.
What are some of the risks?
In a well-performed and controlled facelift surgery operation, there may still be some limited blood collection under the skin. This can be treated during the follow up office examination and will not affect the overall results. Larger collections require earlier and more vigorous treatment and possibly the reopening of the part of the surgical incision to remove clotted blood or to close small bleeding points. This complication is unusual, however. There may be some temporary lag in the normal motion of the facial muscles. Most often, this delay is due to swelling and will gradually subside without permanent change. Skin loss is an extremely rare occurrence.
A number of other conditions must also be anticipated in the early facelift surgery postoperative period. There will be a feeling of numbness and tension in the neck and cheek areas as well as around the ear. This is the result of separating the small sensory nerve fibers in the skin during the operation, and will disappear within the first four to six postoperative weeks. Swelling and bruising of the skin (particularly the lower face and neck) varies but usually lasts approximately ten to fourteen days. It subsides gradually during the early postoperative period leaving no ill effects. Temporary swelling around the eyes is also not uncommon shortly after the face lift surgery.
Recent developments to improve results in these difficult cases include special management of the neck muscles. Frequently changing the position and direction of muscle tension can eliminate the vertical skin folds. This may be combined with selective removal of excess fatty tissue under the chin (with liposuction). The benefits are most rewarding.
A separate “forehead lift” may be undertaken when there is notable downward positioning of both brows and extensive folds with linear marking of the forehead (see brow lift).
Generally, the entire operative procedure with all its modifications has been extremely successful and has provided significant personal satisfaction to many individuals. Apart from the specific risks noted, the procedure is not hazardous to the patient’s physical wellbeing and can be recommended as an appropriate solution to many of the aging signs that some individuals find objectionable.
Please remember that the patient must follow postoperative instructions carefully in order to achieve the very best results.
Plastic Surgeon Dr. Saul Braun operates from the Netcare Rosebank Hospital, situated in the up-market Northern Suburbs of Johannesburg.