Facial rejuvenation procedures are a big part of plastic surgery in women (and some men) after middle age. Through the natural aging process, the persistent gravitation pull, and sun damage, we are seeing more facial sagging, droopy and puffy eyelids, and laxity of the neck. While a smaller deformity can be improved by non-invasive procedures, many of the above conditions can be treated best with surgery. Facelift and other adjunct surgery are very common for this age group and can result in very satisfactory outcomes. What is the process of aging of the face and what kind of results can you expect? These are some of the topics today.
Let’s first start the discussion with skin aging. As we age, the collagen in the skin decreases and the dermis (the thicker layer of skin) becomes thinner. Also the composition of the skin changes. There is less elastin (which gives the skin the elasticity) and hyuronic acid (which gives the skin soft and bouncy texture). Also coincidentally, there is less estrogen from the onset of menopause. This can change the texture of skin as well.
Compounding the natural skin aging process are the environmental factors. Two of the greatest enemies of the skin are smoking and sun damage. Not only does smoking introduce carbon monoxide and nicotine to the circulation, but the fumes directly damages the skin as well. Sun damage accelerates the skin aging process. The ultraviolet light can give rise to a leathery look; it can also cause a variety of skin cancers.
I generally consider the non-surgical options of facial rejuvenation first. They may include dermabration, chemical peels, neurotoxin, filler injection, etc. There may be many people who are good candidates for these procedures. However, it is just as important to realize the limitation of each option. Let’s now discuss the various ways facelift and eyelid surgery are performed.
As I stated before, a lot of the physical changes that give you the signs of aging are the drooping of the skin and the underlying retaining ligaments. The most relevant retaining ligaments are those under the nasolabial folds, marionette lines, and edge of jaw border which contribute to jowling. When the skin and the fat droop over the fix ligament, a deep crease forms. The filler works by filling up the indentations and the creases so that the deformity is less visible. There is obviously a limit to how much filler we can inject. We don’t want to get the “chipmunk” look. The primary way facelift works is by undermining the skin and sometimes the deeper layer, shifting these layers up, and then anchoring the structures. During the procedure, keeping the scars in an acceptable location is important. The most common facelift incisions place the incision at the crease between the front side of ears and face and around the backside of ears. There are also various amount of extension of the incision into the temporal areas and the back side of the ear. I generally keep the temporal incision within 2 inches and hug the back of the ear incision close to ears so that there are no extension of incision into the hair line. This is particularly important for men and for women who want to pull their hair up in a ponytail.
I almost exclusively do the facelift operation under conscious sedation and local anesthesia. If you ever have a colonoscopy, you would have experienced conscious sedation. Many surgeons use general anesthesia, but I prefer sedation for the following reasons:
- Sensory nerves of the face come from well delineated locations and can be anesthetized by a well placed injection.
- Sedation provides relaxation and amnesia at the time of injection and patients often do not have any memory of the event.
- The blood pressure and heart rate response is often much smoother under sedation. In particular, when the patients wake up from surgery, there is little coughing, confusion and struggle associated with general anesthesia. This can raise the hemodynamics and cause some bleeding. So sedation can minimize this at the end of facelift and eyelid surgery.
- Since I do not use deep sedation, the patients do not depend on the ventilators for breathing.
Most of the time when I do facelift, I use the the technique Minimal Access Cranial Suspension Lift (MACS) with short scars described by Patrick Tonnard and Alexis Verpaela (the Art of Aesthetic Surgery, Foad Nahai, Quality Medical Publishing, 2005). The technique provides a satisfactory lift of both the subcutaneous muscul0-aponeurotic system (SMAS) and skin layers. It also allows relatively quick recovery and minimizes swelling. In this day and age when people getting facelift are often working, it is increasingly important to avoid excessive recovery time.
The MACS technique emphasizes the vertical upward lift in the SMAS layer,which is sturdier and likely to hold the results longer. This helps smoothing out the nasolabial folds and marionette lines. In addition, because the neck platysma muscles are in continuity with SMAS layer, tightening the SMAS layer also smooth out the neck skin laxity. All of this is achieved without overtightening the skin layer to avoid the dreaded “wind-blown” look. This also allows me to use much shorter scars behind the ears since the direction of lift is upward rather than backward.
Liposuction of the neck is done as needed. Although I once used plastyma tightening, I rarely do it now. I feel with MACS the jowling is more effectively treated than platysmaplasty. Also there are advocates for sub-periosteal lift or midface lift. My impression is that they cause much more swelling and can subject the facial nerves to more injuries. I generally do not use drain tubes and remove all the facial dressing the second day after surgery. After 7 days there is not much swelling any more and in 10 days, there is generally minimal bruising.
I also perform limited facelift (mini facelift) under local anesthesia in the office. This is a skin-only procedures and is best suited for younger patients with no significant neck laxity. The recovery time is a little shorted than the regular facelift.
One of the most common question my patients ask is how long the results of facelift would last. We have to understand the fact that as soon as the facelift operation is done, you start the aging process again. Nothing we do can stop that. I prefer to think of facelift as a way to turn back the clock a certain number of years. I often use the identical twin analogy to explain this to my patients. Let’s say you had a facelift surgery and your identical twin did not. You will look a number of years younger than your twin. Of course you will continue to age, but so will your twin. Ten years later, you will still look younger than your twin! Some people are under the impression that they have to repeat surgery every so many years. This is not the case. Remember our identical twin analogy? You will likely look younger than your contemporary even if you did surgery only once. By the way, the average apparent age removed with facelift, according to a survey by American Society of Plastic Surgeons, is between 7 and 8 years.
Another common procedure of facial rejuvenation, done alone or together with facelift, is blepharoplasty, or eyelid surgery. Since the eyes are the focal point of the face, rejuvenation of the eyes can be extremely effective. Typically people state that the upper lids are drooping, the lower lids have bags under them, or they look tired. These are typical sign of excess eyelid skin or fat, or both.
Again I generally perform blepharoplasty under local anesthesia with conscious sedation. This has the benefits I outlined before. The surgery takes about 1 hour to 1.5 hours to perform. You can expect bruised eyes for about 7 to 10 days. Recovery is not too uncomfortable and most people can do routine tasks and read in about 2-3 days. Upper blepharoplasty involves removing excess skin and fat pads. There are two pads at each upper lid. I use the subciliary approach for lower blepharoplasty to remove excess skin and fat. There are three fat pads in each lower lid. I close the lower lid incision with an anchoring suture to the outside corner of the eye. With this method, we can tighten the lower eyelid while minimizing the risk of ectropion (sagging of lower lid). Overall, blepharoplasty is a very effective and rewarding operation.
Obviously facelift and blepharoplasty are not for everyone, and others may need different or additional procedures. For example, I do Z-plasty neck tightening for patients with too much laxity for standard facelift. This is done by remove the excess skin and fat directly with a zigzag excision of the neck. This procedure is more suitable for men, particular with more facial hair.
Another adjunct procedure is upper lip reduction. We often notice that with time the distance between the base of nose and the upper lip gets longer. As a result, the upper lip rolls in to become a thin line and the upper teeth are concealed. A telltale sign of this condition is presented as a horizontal crease of the upper lip when one smiles. Simple augmentation of the lips will not correct the problem. It needs excision of excess skin at the upper lip. The incision line can be hidden under the base of nose and can heal quite well. The resulting appearance is a fuller yet shorter upper lip with more mucosa showing.
Again, essentially all the adjunct procedures can be done alone or together with a facelift. For many people these adjunct procedures can really enhance the results of facial rejuvenation.
This is a detailed description of how I do facelift and several other related facial rejuvenation procedures. I hope you find it informative.