Lifting the Face, Part Two: Surgical Options

In part two of this three-part series on lifting the face, I will discuss differences in surgical options. As I mentioned in the first part, removal of extra skin is not possible to any significant degree with nonsurgical interventions. More importantly, addressing deeper tissue that actually creates the long-lasting, youthful appearance in a facelift is not addressed at all with nonsurgical procedures, despite what device or product manufacturers may claim.

To understand the differences between surgical procedures, one must have a basic understanding of what these surgeries are designed to do, and this will require a little bit of history.

Facial rejuvenation has been performed since ancient times. However, the modern era of facial aesthetic surgery began in the 1920s with the development of a continuous, uninterrupted incision hidden along the hairline and ear in order to allow removal of extra skin. It was already recognized one hundred years ago that “mini” incisions did not allow enough skin to be removed to produce improvement in skin wrinkles and loose, sagging skin. Although the continuous incision has been improved upon by better camouflaging of the incision and determining how to avoid the “operated-on” look (caused by distorting the sideburn, parts of the ear, and the hairline) the basic idea of a continuous incision has remained good practice for over a century.

A revolutionary development in facelift surgery occurred in the 1970s with the recognition of a deeper layer of tissue within the face that allows lifting of the face without putting tension across skin. Skin has a covering function rather than a supportive or structural function. This is well demonstrated by older breast reduction techniques, where skin tension used to create breast shape often resulted in poor scarring, poor long-term shape, and often times wound healing problems. Similarly, older facelift techniques involving only the skin (which are still sometimes used) result in unnatural appearance when the skin is used to try to cause a lifting effect. No doubt we can all think of a few celebrities who fall into this category. In addition, since skin has some elasticity to it, most of the lifting effect will be gone within a few months.

Unlike skin, the superficial musculoaponeurotic system (SMAS) is not elastic. It is also not visible, lying under the surface of the skin between the temporalis muscle on the side of the head, and the platysma muscle in the neck. Placing tension across the SMAS results in long-lasting, natural appearing lift. How the skin and SMAS are dealt with makes up the difference between facelift types. The following is a brief, partial list of surgical facelift techniques with some of the benefits and drawbacks of each.

  • Skin only facelift –  is an easy to perform and low risk procedure as it does not modify any deeper facial structures. The effects are shorter lasting, less effective aesthetically, and have a higher likelihood of creating an unnatural appearance.
  • Suture lift/thread lift/”Lifestyle Lift” – is heavily marketed and often advertised as having a quick recovery. However, this procedure delivers minimal aesthetic benefit and carries with it the risk of suture exposure, an unattractive “bowstring” effect of the sutures along the incision line, skin irregularities as well as retractions, as well as the risk of infection and nerve injury.
  • “Mini” facelift – is not standardized surgical technique, and you won’t find it in textbooks. Usually, this involves the perception of smaller incisions and/or smaller cost. Smaller incisions usually mean a decreased ability to remove excess skin. For this reason, mini facelifts are more appropriate for younger patients with mild facial aging. A mini facelift with the intent to address one part of the face (for example the jowls or nasolabial folds) may not improve other areas, such as the area around the eyes or the neck, which have also aged to some degree. This may result in an unnatural appearance.
  • SMAS plication or SMASectomy facelift – skin removal combined with gathering up or removing and suturing together of part of the SMAS tissue. This allows for tension to be placed across the SMAS instead of the skin as well as appropriate skin removal. Limited dissection under the SMAS decreases the likelihood of any nerve injuries and decreases the time of the operation. However, these techniques do not allow as much facial improvement as more involved techniques. These techniques are good for patients who have already had a facelift, as they allow additional improvement without increased risk because of scar tissue that is present.
  • SMAS flap facelift – this technique includes the most extensive dissection in order to obtain the most optimal improvement. Most patients benefit from this approach. In addition to removing extra skin in such a way as to optimize facial texture, wrinkles, and sagging skin, this operation also involves repositioning the soft tissues of the skin to improve cheek fullness and neck tightness. Depending on where the SMAS flap is started, this may also cause improvement in the area to the sides of the eyes and lower eyelids. Because of the extent of dissection, this technique takes longer (adding some cost) and has an increased risk of temporary nerve injury.

Each of the techniques described above has different benefits and drawbacks. It is important to identify your goals and your options so you can choose the procedure that is best for you. An individualized consultation is important, as your surgeon should be willing and able to give you all the information you need to make this choice.

Tune in next week for a discussion of the “nuts and bolts” of undergoing facelift surgery!

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