What type of Facelift is the Best? Part 1 – A Practical Review of Facelift Surgery

An editorial on the Anatomy, Techniques and Results of the Different Types of Facelifts

A facelift (Or Rhytidectomy) is one of the most common cosmetic surgical procedures performed by facial plastic surgeons. For people who have loose facial skin, aging skin, jowls, loose neck skin or fat under the chin, a facelift can have dramatic results.

However, a facelift often makes people think of Hollywood stars who look “fake,” which is not the reality of the surgery. The primary goal of a facelift is to rejuvenate the face thus making it look younger without looking “operated on.” Unfortunately, these old myths about the ‘Hollywood Face’ still run large in the world of Cosmetic Facial Plastic Surgery.  Although a facelift does result in a dramatic rejuvenation of the face and neck, using current surgical techniques and technology, results are natural and long lasting.

The goal of this article is to have a discussion about the history of facelifts, the basic anatomy of the facelift and what you can expect from the different types of facelifts. I have broken the article into two parts to ensure it’s not too long as a discussion on face-lifting can be extensive. Hopefully this will help you get a better understanding how a facelift works. I hope to answer common questions like, “what type of facelift should I get?”  “When should I get a facelift,” “What are the different types of facelifts?” or “What is the healing like after a Facelift.” I also hope to help you understand the history of the facelift and why I use certain surgical techniques. I hope this article gives you a better understanding of a facelift and what it can accomplish.

What is a Facelift?

Before we get into the details of a facelift, I’d like to discuss a few misconceptions. The first is the goal of a facelift. The primary purpose of a facelift is to rejuvenate (create a more youthful look) the lower face along the jaw (the jowls) and tighten the neck. This would be the standard facelift. As we will discuss, there are more simple procedures that just improve the neck and/or the jowls and more complex surgeries that can help the upper parts of the face as well. A facelift does not fix the ‘midface’ or the folds around the nose – this is what would be called a “midface lift” and is different than a standard facelift.

The second common misconception is that when plastic surgeons do a facelift, the skin of the face is pulled and tightened. This is a very old method that was used for a facelift, in fact there is no “pulling” the skin. Facial Plastic Surgeons pull the tissue under the skin, which will be discussed in more detail later. If you pull the skin alone and tighten just the skin, this results in the old “pulled” facelift look. Also, this can result in poor scars.

How Does the Face Age?

The key areas of an aging face are (1) the skin (2) the ligaments under the skin (3) the muscles of the Face (4) the SMAS and (5) the fat in the face and Neck.   Let’s discuss each of these:

• The Skin – As we age, the skin thins and the collagen (the material that gives skin its tightness) changes. This starts to result in the changes we see with aging. Problems like wrinkles, thinning of the skin and looseness of the skin all develop because of these changes. A Facelift can help improve the appearance of the skin, but it will not remove wrinkles or get rid of age spots – other treatments are required for these problems. If improvements in the quality of the skin is required, I often recommend additional treatments to the facelift.

• The Ligaments Under the Skin – There are areas in the face that are important to facial aging. These areas are also important to Facial Plastic Surgeons when we plan and conduct facelift surgery. A ligament is a type of tissue that connects the skin to deeper tissue in the face. They are firm and tight when youthful. They act like support structures, resisting the pull of gravity and keeping the skin and tissue in the right place. As we age these ligaments that normally keep our face nice and tight and in a good position start to loosen. This causes the skin to drop and become less tight. As this occurs, the skin falls down as a result of gravity, giving the face the ‘aged’ look we all are familiar with. A Facelift helps to reset this tightness of the ligaments and lift the tissue back to where it should be. We will discuss this in more detail later.

• The Muscles of the Face – Facial muscles are important for speaking and showing emotions. Facial muscles are all over the face and are often smaller than people may think. These muscles are located in two areas of the face, near the skin (superficial muscles) and away from the skin (deep muscles). Many of these muscles attach to the corner of our mouth and lips and thus are important for facial motion and lip movement. Think about how important your facial muscles are when demonstrating emotions. All the muscles in the face are controlled by a very important nerve, coincidentally called The Facial Nerve. This is the nerve that is affected by diseases like Bell’s Palsy. Importantly, this is the nerve than in some cases can be injured during a Facelift Surgery, thus knowledge of this nerve is important for your surgeon. Some people can have a temporary injury to this nerve, however very rarely you can have a permanent injury. Surgeons like myself who are trained in Head and Neck Surgery as well as Facial Plastic and Reconstructive Surgery have considerable experience operating near and around the facial nerve. In fact, when Head and Neck Surgeons do procedures on the parotid gland (the saliva gland) we have to carefully dissect the nerve and identify all the branches.

• The SMAS (The Superfical Musculo-Aponeurotic System) – Do not be intimidated by this. This is an easy thing to understand and is actually related to the muscles of the face. The SMAS is perhaps the most important part of a facelift. The SMAS is the part of the face that contains many of the facial muscles and the tissue that ‘falls’ as we age. The SMAS is a continuous sheet of tissue that surrounds muscles and fat. It is located under the skin. When you see jowls on a person’s face, that is actually the SMAS tissue building up around the mouth as it starts to loosen. Tightening this tissue helps reduce the jowls. As the knowledge of a facelift improved, so did our understanding of the SMAS. Perhaps the biggest improvement in facelift Surgery was when surgeons began to understand the importance of the SMAS tissue. As mentioned earlier, pulling on the skin of the face does not result in a good Facelift, the key is to treat the SMAS. There are multiple ways to treat the SMAS and we will discuss this in this editorial.

• Fat in the face and neck – When we think of fat in the face, some people think that it may be undesirable, but in fact, fat in the correct places makes the face look more youthful. In the face, there is fat above and below the SMAS tissues. There is important fat in the cheeks (think about the youthful fullness people have in their cheeks), fat around the eyes and fat within the jowls and neck. Often, fat that falls lower in the jowls and neck is less desirable and we will discuss this in more detail later.

The Evolution of the Facelift

As mentioned earlier, the science and understanding of a facelift has changed dramatically over the years. The purpose of this section is to provide information and help you understand how plastic surgeons and cosmetic surgeons have advanced the technique of a facelift.

The Early Days – The Subcutaneous Lift

The first facelift procedures were performed in the early 1900’s. The most common method of a facelift was performed by cutting and removing pieces of skin and then stitching the edges together. This looked good for a few months, however it left people with scars and eventually failed.

In 1927, surgeons realized that you needed to lift the skin off the deeper tissues in the face. Once you did this, you could then pull the face as a whole. This is what would be considered the classic “Subcutaneous Face Lift.” Similarly to the first method, this looked OK at first, but failed quickly and often appeared “over tightened.”

The Eureka Moment of the Facelift

In the 1970’s, surgeons began to realize that key to rejuvenation of the face is to re-position the deeper tissues of the face. They began to realize that the skin was only part of the problem. The fat pads and the “SMAS” that was mentioned earlier were also key parts of the aging face. The surgeons started to re-position the SMAS tissue and results were dramatic and long lasting. In fact, many of the facelift techniques used today still use methods that were described in the 1970’s.  Interestingly, many other surgeons did not use this new method as they thought it was dangerous and not needed. Research over the years have proven them wrong, tightening the SMAS is one of the keys to a good and long lasting Facelift.

The Future of the Facelift

Since the realization that the SMAS was the key to the facelift, surgeons and researchers have continued to improve upon techniques. Nowadays, we have a better understanding of where to apply tension and pull the SMAS. We have a better understanding as to what direction we need to pull for a good facelift. Some people think you just pull ‘back’ and tighten the skin, however research has shown that it is much more complicated than this. A good facelift surgeon knows that there are key directions that the SMAS needs to be pulled to get the best results.  We call the direction we pull the SMAS “vectors.” A good facelift surgeon knows the proper vectors of pull.

In addition to this, new technology like lasers and liposuction help to achieve even better results and help address some of the limitations of the facelift (see later).

As you can see, a facelift is more complicated that simply ‘pulling’ the skin. The next article will deal with the different types of facelifts and the effect you can expect from each one.