Introduction

German and French surgeons are credited with pioneering facelift surgery. In 1906, Lexer is thought to have performed surgery to treat wrinkles, but it was Hollander in 1912 who was the first to report a case. ¹ Other European physicians, including Joseph (1921) and Passot (1919), developed their own techniques for treatment of the aging face. However, these founding fathers were often guarded when it came to sharing their wisdom, and teaching was rare.

Following the Great War, the practice of reconstructive plastic surgery blossomed. Along with the explosion of new ideas and techniques came the inevitable increased interest in cosmetic surgery. Although still shrouded in secrecy, even the most prominent physicians of the time recognized its existence and demand. Many of these well-respected leaders were rumored to perform cosmetic surgery in their own private clinics or offices. Gilles in 1935 stated, “The operations for removal of eyelid wrinkles, cheek folds, and fat in the neck are justifiable if the patients are chosen with honest discrimination.” ¹

Following World War II, with the advent of newer medications and improved anesthesia methods, elective surgery became more of a reality. In addition, a progressive affluent society expressed interest in equating appearance with a youthful outlook on life. However, the occult field of cosmetic surgery, surrounded by shameful secrecy, jealousy, and greed, had not allowed for the fostering of ideas and advancement that was common to the other surgical specialties of the time. Therefore, the results achieved by facelift surgery were marginal and shortlived. Sam Fomon, a pioneer in facial cosmetic surgery and a founding father of what was to become the American Academy of Facial Plastic and Reconstructive Surgery, was instrumental in teaching cosmetic surgery to all those interested. He recognized the limits of facelift surgery when he stated, “The average duration of the beneficial effects, even with the best technical skill, cannot be expected to exceed three or four years.” ¹

At the time, facelift surgery techniques consisted of a limited subcutaneous dissection and skin elevation resulting in a tightening of the preauricular skin and, often, an obvious “operated look.” Unfortunately, these methods did not change significantly until the 1970s. The social renaissance of the 1960s and 1970s brought a new openness and acceptance regarding cosmetic surgery. This fueled scientific advances and dialogue, leading to better surgical techniques and outcomes.

The first major contribution in a half-century was provided by Skoog, who touted the benefits of dissecting in a subfascial plane. ² This allowed for a significant improvement in the lower third of the face. The validity of this new fascial plane was solidified by Mitz and Peyronnie’s landmark article in 1976, defining this fascia as the superficial musculoaponeurotic system (SMAS). ³ To achieve a more natural look, numerous modifications have since been made in the sub-SMAS rhytidectomy including plication and imbrication techniques.

Early sub-SMAS dissections mostly provided for an improved jaw line. However, surgeons have attempted to concentrate efforts on improving the midface and nasolabial fold region. Hamra, the pioneer of the deep plane and composite rhytidectomy, continues to present the beneficial effects that can be achieved in the middle third of the face. ⁴ , ⁵ Others have concurred with the improved results possible with deep plane rhytidectomy. ⁶ , ⁷ Still, there are those who have designed different methods to achieve facial balance, including venturing into a subperiosteal plane. ⁸ , ⁹ , ¹⁰ And there are even those who are revisiting the subcutaneous dissection, considering it the method of choice in select situations.

Recently, the trend has focused on “less invasive” procedures as younger patients have sought cosmetic rejuvenation surgery, often requesting procedures with minimal or smaller incisions and less downtime. The less invasive, limited form of rhytidectomy has many names, including “mini-lift,” “short-flap technique,” and the “S-lift,” just to name a few. ¹¹ , ¹² These names refer to a lift with a limited preauricular incision terminating just posterior to the lobule. Others may reference these terms for marketing purposes to attract patients. The extent of skin undermining and SMAS plication or imbrication is determined by the individual technique of the surgeon and provides more limited results than the traditional rhytidectomy.

The variety of anatomically sound rhytidectomy techniques offers the surgeon options in challenging the effects of aging. However, in addition to recent advances in surgical techniques, there is a new emphasis on recognizing the importance of patient individuality. Each surgical technique has its place. The key for the prudent surgeon is to appropriately evaluate each patient, both physically and emotionally, and then to utilize the correct treatment for the proper diagnosis.

Preoperative Evaluation and Preparation

Patients seeking aging face improvement, or in this case rhytidectomy, are treated in a standardized fashion along with all other cosmetic surgery patients in our respective practices. This includes having pleasant, knowledgeable, and courteous receptionists and office staff, and proper scheduling times to prevent undue waiting by the patient. Concise and well-organized literature is made available to the patients. On the day of the initial visit, photographs are taken by the photographer and used for preoperative photo documentation as well as video imaging. This is becoming more and more prevalent and a key part of a coherent, realistic dialogue between the surgeon and patient. Standard preoperative photographic views for facelift surgery include the fullface frontal view, as well as fullface left and right oblique views, and left and right lateral views. One may choose a close-up perioral photograph, as well as close-up detail of the submental neck tissues. A close-up view of each auricle, with hair pulled behind the ears, earrings removed, and all photographs taken in a Frankfort horizontal line, is imperative. These photographs are best taken using a single lens reflex camera with a macro 105-mm lens with appropriate lighting and background.

The initial consultation is done in a private setting to establish rapport as well as convey the surgeon’s undivided attention to understand the patient’s motivations and desires. It is imperative to understand if the patient’s main concern is truly correctable by a standard facial rhytidectomy procedure. Often, the main concern may be true rhytids of the superficial surface of the face, which would be more appropriately treated by means other than a facelift procedure. If deep nasolabial folds are the primary problem and the patient is less concerned about jowling or submental skin and fat ptosis, a rhytidectomy may not be the appropriate procedure. A full consultation including medical and surgical history, current and past medications, and drug allergies, in addition to an appropriate physical exam, is performed.

During this interaction, it is the surgeon’s responsibility to determine, with the patient’s assistance, what the patient’s true motivation for the surgery is. Being in the middle of a lifechanging situation, such as divorce, is not in itself a contraindication for proceeding with facelift surgery. However, patients who expect the cosmetic surgical procedure or procedures to solve their situational dilemma may not be proper candidates for the procedure. Patients who truly believe they are doing this for their self-esteem and not for anyone else’s benefit are more likely to have a successful psychological benefit. Patients must be realistic about what can and cannot be achieved by surgery, and it is incumbent on the surgeon to impart this information during the consultation. Video imaging greatly helps with this dialogue.

It is important to evaluate the patient’s family history to determine the likely speed at which the loss of elasticity of the tissues and the overall aging process is occurring. One must determine lifestyle and social habits, taking into account issues such as solar exposure and smoking, which accelerate aging.

Our patients complete a detailed history questionnaire. Identifying whether the patient has had previous cosmetic surgery or any other surgery is important, including what the experience was, as well as whether there were difficulties with particular medications or anesthetic techniques. Preparing the patient for an appropriate positive mental experience is crucial. If the patient is terrified of anesthesia or the idea of surgery, it is imperative for the surgeon to find a way to get past this issue and ease the patient’s mind to focus on the positive aspects of what can be achieved by surgery.

Certainly, it is important to take a complete medical history to ascertain which, if any, medical conditions exist that would preclude facelift surgery. Cardiovascular disease in itself is not a contraindication to surgery, but a complete clearance by a cardiologist is imperative prior to scheduling surgery. Certainly, an unstable cardiac history precludes any kind of anesthetic or surgical intervention. Liver and renal functions are important in determining the patient’s sensitivity to anesthetics and ability to metabolize and excrete medications or agents.

There are a few diseases that would preclude facelift surgery. The history of advanced autoimmune diseases relating to the skin of the face may be a contraindication for facial surgery. Scleroderma and systemic lupus erythematosus are not contraindications to surgery unless the disease is manifesting in the face itself. Some of the other autoimmune diseases may be looked at with suspicion, particularly depending on the type of medication the patient is taking to suppress the autoimmune response. These medicines may suppress the patient’s immune response or inhibit the healing process. Diabetes mellitus in itself is not a contraindication to surgery, nor is taking chronic steroids, particularly in the lower doses. Sjögren syndrome may be a relative contraindication, depending on the involvement of the parotid glands and stasis of salivary flow. The autoimmune diseases that relate to perivasculitis are of most concern due to the possible compromise to the vascularity of the skin.

A history of full-course radiation treatment to the preauricular regions or infra-auricular neck would preclude surgical intervention. The longterm chronic vascular compromise to the skin’s microvasculature will make skin flap elevation too risky. Use of isotretinoin (Accutane; Roche Pharmaceuticals), though unusual in the facelift age group population, is only a relative contraindication to surgical intervention. There is very little evidence of delayed healing of incisions specifically due to isotretinoin treatment. Medications that would preclude the surgeon from using epinephrine in a local anesthetic, or true allergy to any of the local anesthetic classes of medication would contraindicate the performance of facelift surgery given the importance of proper hemostasis.

Obesity is not a contraindication to facelift surgery if you and the patient take into consideration that the results of the procedure may be less than satisfactory. Certainly, a patient who is overweight and plans dramatic weight loss in the ensuing 3 to 6 months should be counseled to lose the weight prior to having the facelift surgery. Generally, a loss or gain of 10 to 15 pounds postoperatively will not affect the overall results of the procedure. However, any patient who is in the midst of dieting that may diminish their vitamin and nutritional intake should be advised against surgery. Not only should one be healthy at the time of surgery, but a proper diet is critical for proper healing as well as for electrolyte balance during the surgery. There are some significantly overweight patients who should be advised against facelift surgery due to the inherent limitations of the procedure, even if a large amount of suction-assisted lipectomy is included. The facelift itself is not a weight reduction procedure, and thinning the midfacial tissues is inappropriate and fraught with complications. As a best-case scenario, overweight patients with heavy jowls and necks often require a revision or “tuck-up” procedures more frequently than less heavy neck patients.

During the physical examination, the surgeon should be able to advise the patient as to what outcome can be expected from the rhytidectomy. A physical examination is absolutely necessary before the surgeon can show the patient on the computer imaging system what their likely neck and jaw line result will be. A good candidate for facelift surgery is a patient who has moderate thickness to the skin with minimal sun damage, and who has retained some hereditary elasticity to the skin, particularly appropriate for the chronological age. Those patients with premature loss of elasticity to their skin, despite it being smooth and non-photodamaged, may have a less than satisfactory duration of improvement ( Tables 14.1 and 14.2 ).

Thick-skinned and overweight patients should be counseled as to what to expect from the results of the rhytidectomy procedure. Not only is the initial result limited, but the length of time for which soft tissues remain firm and in an upward positioned vector may be shorter than average due to the increased weight of the tissues and gravity.

The visible presence of loss of elasticity in the jowl tissues, as well as laxity in the skin, platysma, and fat of the submental and submandibular regions, is a prima fasciae reason to entertain the idea of a facelift as an appropriate procedure for the patient. Certainly, benefits have to be of a significant degree to warrant the surgical intervention required, given the potential risks involved. There do exist patients who have a minor degree of ptosis of soft tissues or presence of signs that a facelift can correct but who should be counseled either to consider other procedures or to return at a later date when the signs of aging have progressed and the procedure may be more indicated. Today’s patient population may be slightly more anxious than they should be regarding when to begin the facelift process. It is incumbent on the surgeon not to be too eager to recommend, and on the patient not to be too eager to undergo, this procedure for marginal benefits. There are a variety of other procedures to be considered for these patients such as cheek lifts or submentoplasty.

Patients who are good candidates for facelift surgery may have a forward chin and strong bony structures such as particularly prominent cheekbones. Patients with heavy cheeks and jowls and minimum malar prominences may be disappointed in the outcome of soft-tissue lifting alone. Malar augmentation may enhance the overall angulation of the face. In addition, midfacial hypoplasia or loss of midfacial subcutaneous soft tissue due to hereditary and aging processes often necessitates submalar augmentation to achieve an appropriate rejuvenated result combined with a facelift procedure. The alternatives to these two augmentation procedures may involve a different approach to facelifting, such as midfacial lift or composite facelift. Equally, patients with class II malocclusion, hypoplasia of the mentum, or microgenia may be poor candidates for an improved neckline result. Orthognathic consultation or, at the minimum, alloplastic augmentation of the mentum at the time of the facelift is indicated to truly achieve a satisfactory aesthetic result. This is one of the values of preoperative video imaging whereby the patient can observe the results achieved by lifting soft tissues alone versus that combined with enhancing the bony architecture.

It is important for the surgeon to evaluate the cervicomental angle with respect to the underlying muscular tissues and position of the hyoid bone. Many patients are poor candidates for an improved neck angle due to a low-positioned hyoid, and this needs to be carefully shown to them, both through a mirror examination and on the video-imaging monitor ( Fig. 14.1 ). The surgeon must not overcorrect the neck angle on the computer image with respect to the true angle of the underlying tissues of the patient’s neck so as not to convey a false or unrealistic impression as to what the facelift result will be. This may determine whether the patient is satisfied postoperatively with the surgeon’s work. Repositioning of the hyoid itself or sculpting of the digastric musculature has been described but is not recommended in the routine or standard neck portion of the rhytidectomy procedure. One must understand what can be accomplished with sculpting lipectomy and platysmaplasty, which can be remarkable at times but have inherent limitations. Overaggressive work in the submental area is fraught with complications. Prior to leaving the consultation room, the surgeon must answer all of the patient’s questions including a discussion of the entire procedure and its alternatives, risks, and limitations. It is also important for the patient to be fully aware of the location of each incision and resultant scar, however well placed and camouflaged it may be ultimately. The risks of anesthesia should be covered in terms of the choices and alternatives in a general sense. It is appropriate, however, that the risks of any particular anesthetic type be covered by the administering physician.

Following this, the patient and surgeon view the morphed images on a video monitor and further issues may be pointed out and questions answered. At this point, the patient has an opportunity to view other patients’ operative results if they desire to see that the patients appear natural.

Anatomical Considerations and the Type of Facelift Performed

The fundamental decision as to what type of facelift will be required for an individual patient is primarily based on the preexisting condition of the patient as outlined and observed in the physical examination portion of the consultation. Not every patient requires the same degree of surgical aggressiveness to achieve a satisfactory result. The senior author (SWP) has described three types of rhytidectomy patients, based on the general categories of surgical intervention required to achieve a desirable surgical result. The basis of these categories focuses on the degree of skin elasticity loss, jowling, lipoptosis, and platysmal laxity ( Tables 14.3–14.5 ). The Perkins Type I to III rhytidectomy subject categorizes patients as to the degree of problems to be addressed with the rhytidectomy and the procedures required to achieve satisfactory results with longevity ( Figs. 14.2–14.5 ).

The fundamental concept of rhytidectomy is based on certain anatomical relationships of the tissues. The elasticity and condition of the overlying skin, including its degree of photodamage and rhytid formation, is important. The relationship with the underlying subcutaneous tissue, including the vector of descent as a result of gravity, true ptosis, or abnormal accumulation and distribution of fat, must be noted. Facial musculature is enveloped by continuous fascia that extends to the preparotid region. This fascia, which is contiguous with the platysma muscle of the neck, is the SMAS, first described as a dynamic contractile and fibromuscular web by Mitz and Peyronnie. ³ The fascia deep to this is the superficial layer of the deep cervical fascia that envelopes and covers the sternocleidomastoid muscle, as well as the parotid tissues and parotidomassoteric fascia. SMAS is also superficial to the superficial layer of the deep temporal fascia as well as to the periosteum of the forehead. The SMAS is contiguous with the galea of the scalp. In the neck anteriorly, the platysma muscle may or may not interdigitate to form a connected sling depending on age. Often, there is a laxity and dehiscence of the anterior borders of the platysma muscle, creating banding in the neck.

It is the very nature and the existence of this SMAS layer that allows for a deeper plane of facelifting surgery than was performed in the original rhytidectomy procedures of the past. Only skin was lifted, elevated, excised, and resutured in a more cephalic and posterior position. Skin, due to its inherent creep phenomenon and rebound stretch characteristics, often does not hold for any length of time. Therefore, the effects of the facelift surgery were brief when this was the only layer approached. To achieve longer lasting results, tighter pulls were necessary resulting in a “stretched, operated” look as well as hypertrophic scars due to the tension. Unfortunately, the skin-only rhytidectomy is still the method of choice for some surgeons.

Skin, particularly in the middle and more central portion of the face, is directly connected to the SMAS layer by firm dermal fibrous filaments. Often accompanying these dermal filaments is some penetrating vasculature from the deeper vascular systems to the superficial dermal plexus. It is easily demonstrable that lifting and pulling the SMAS layer with its integral attachment to the platysma muscle and midfacial muscles lifts and repositions the skin in the same fashion without undue tension on the skin edges ( Fig. 14.6 ). A superior and posterior vector of pull of this fascia repositions the facial tissues in a more youthful position. The visible effect of gravity on these anatomical tissues is directly countered and improved by the facelifting procedures.

It is equally important to understand the anatomical relationships of the neurosensory and neuromotor branches supplying the face and neck. The fifth cranial nerve supplies sensation to the majority of cutaneous surfaces of the face, head, and neck. Rhytidectomy requires elevation of a certain amount of preauricular and postauricular skin, interrupting the immediate innervation of this portion of the face. Typically, unless any major branch of the greater auricular nerve is interrupted, sensation returns to the skin in a relatively short time. The patient can expect return of sensation in the first 6 to 8 weeks, but occasionally 6 months to a year may be required for full return. In rare cases, the patient may report a decreased overall sensation to the skin than was there preoperatively, even beyond a year.

Sympathetic and parasympathetic reinnervation of the skin proceeds more rapidly in the postoperative period. Although the most common major nerve branch injured in rhytidectomy is the greater auricular nerve as it crosses over the sternocleidomastoid, even this rarely causes permanent loss of sensation of the auricle or the preauricular skin. As one is dissecting skin and its dermal attachments away from the superficial layer of the sternocleidomastoid muscular fascia, if one interrupts this fascia, direct injury to this very large and visible nerve branch may occur. When recognized at the time of surgery, direct suture reanastomosis is indicated and return of nerve function within a year or two is expected.

Motor branches to the facial mimetic musculature are potentially in danger during facelift surgery. Branches of the facial nerve become very superficial as they extend beyond the parotid masseteric fascia. The marginal mandibular branch is at some risk as it crosses the mandibular margin, deep both to the platysma muscle and to the superficial layer of the deep cervical fascia. Techniques requiring elevation underneath the SMAS layer into the midface endanger branches to the orbicularis, zygomatic, and buccinator muscles, although innervation to these muscles is to the undersurface of the muscles, and deep plane technique at this point would be superficial to those muscles. Direct visualization of the nerve is part of this procedure and will be discussed further in this chapter.

The branches of the facial nerve most commonly injured in rhytidectomy, with or without temporal lifting, are the marginal branch, followed by the buccal branch, and then the frontal branch. The frontal branch becomes very superficial at the level of the zygomatic arch and extends just beneath the subcutaneous tissues underlying the thin SMAS layer of the temporal region prior to its innervation of the deeper surface of the frontalis muscle. As it traverses this area, < 1.5 to 2 cm preauricular and halfway between the lateral orbital rim and the temporal tuft of hair, it is at greatest risk. It is imperative that the surgeon understands the anatomical relationships of the layers of the face and temporal region to prevent injury to the nerve. One can elevate the skin all the way to the lateral canthal region, the preauricular area overlying the zygomatic arch, up to the orbicularis muscle, as long as dissection is in the immediate subcutaneous layer. In addition, the surgeon can dissect freely under the frontalis fascia beneath the galeal layer superficial to the periosteum and the overlying superficial fascia of the temporalis muscle without injury to the frontal branch of the facial nerve, which is external to this avascular layer. However, at the level of the zygomatic arch, one needs to make the transition to beneath the periosteum or immediate transection of the facial nerve will occur as one follows the same plane overlying the zygomatic arch. Injury to the nerve in this area may or may not result in reinnervation of the frontalis muscle.