The primary purpose of the facelift is to restore the shape, volume, and contours of the youthful face. Facelift surgery has evolved over the years into multiple techniques to accomplish the same results. This article discusses the common controversies in facelift surgery and evaluates the best available evidence to guide surgical decision-making. In regard to the salient question of whether there is a “best” technique, the literature suggests that the options are generally equal in efficacy. This highlights the need for high-quality research with standardized preoperative assessment and evaluation of postoperative results to better assess outcomes.
Key points
- •
Smoking cessation should be encouraged before surgery, though smoking may not be an absolute contraindication if a deep-plane technique is used.
- •
Incision placement should be determined by patient factors and degree of skin excision to be performed. Incisions into hair-bearing scalp should be avoided if significant skin or scalp excision is anticipated.
- •
A variety of techniques are available to the aesthetic surgeon. These are classified in relation to manipulation of the superficial musculoaponeurotic system and extent of dissection.
- •
No technique has been definitively shown to be superior to others. Selection of surgical technique should be guided by the surgeon’s experience and patient factors.
- •
There are several options available for midface rejuvenation. Autologous fat grafting is a simple and reliable technique used by many aesthetic surgeons with good results.
Introduction
Numerous variations in techniques of facelift surgery have been described. Elements of the historical procedures have been adopted, molded, or abandoned, culminating in the modern techniques that exist today. A greater understanding of the process of aging, as well as facial anatomy, has advanced both the quality and duration of postoperative results.
Though advancements have been made, there is no consensus on a best facelift technique. This is abundantly evident in the literature and is hotly debated in panel discussions at aesthetic conferences. Most would agree that the ideal facelift would encompass the following: technical ease, minimal operative time, short patient convalescence, minimal risk and complications, durable efficacy, and maximal patient satisfaction. This article reviews the controversies in facelift surgery and relevant literature to provide clarity to this complex subject ( Box 1 ).
Patient Candidacy
Incisions
Plane of dissection, length of flap, vector of pull
Management of the midface and volume restoration
Management of the neck
Introduction
Numerous variations in techniques of facelift surgery have been described. Elements of the historical procedures have been adopted, molded, or abandoned, culminating in the modern techniques that exist today. A greater understanding of the process of aging, as well as facial anatomy, has advanced both the quality and duration of postoperative results.
Though advancements have been made, there is no consensus on a best facelift technique. This is abundantly evident in the literature and is hotly debated in panel discussions at aesthetic conferences. Most would agree that the ideal facelift would encompass the following: technical ease, minimal operative time, short patient convalescence, minimal risk and complications, durable efficacy, and maximal patient satisfaction. This article reviews the controversies in facelift surgery and relevant literature to provide clarity to this complex subject ( Box 1 ).
Patient Candidacy
Incisions
Plane of dissection, length of flap, vector of pull
Management of the midface and volume restoration
Management of the neck
Historical perspective
In contrast to the openness regarding aesthetic surgery in modern times, the beginnings of the rhytidectomy were secretive in nature. Publication of surgical techniques was avoided for years due to fear of ridicule. Eugen Hollander and Erich Lexer, both German surgeons, are most frequently credited with performing the first facelift. Each claimed to have completed their operations at the turn of the twentieth century, though neither admitted it until decades later.
Facelift surgery saw more prodigious growth in the wake of the First World War. Increases in surgeons, american prosperity, and quality of anesthesia cultivated a more favorable climate for aesthetic surgery. Early techniques involved small local skin excisions near the hairline in natural skin creases without undermining. In 1920, Bettman described a continuous temporal scalp, periauricular, and mastoid incision incorporating undermining of a large random skin flap. This was the predominant technique until the 1960s when surgeons began addressing the deeper tissues to compensate for the limitations of the subcutaneous lift.
In 1960, Aufrict was first to promote suturing deep to the superficial fat. Skoog is credited as the first to pioneer actual dissection of the deeper facial layers. In 1976, Mitz and Peyronie defined the superficial musculoaponeurotic system (SMAS) as a fascial layer continuous with the platysma and temporoparietal fascia, enveloping the facial mimetic musculature. Discovery of this important fascial layer, distinct from the parotidomasseteric fascia, paved the way for modern facelifting techniques. Procedures using plication or imbrication of the SMAS were the dominant techniques for decades and are still in widespread use.
In 1989, Furnas described the midfacial ligaments, which allowed greater progress in facial rejuvenation. Knowledge of the midfacial ligaments improved understanding of the facial tissue support system as it relates to the aging process. Modifications of facelifting ensued with a focus on retaining ligament release in a deep-plane of dissection. Hamra described deep-plane rhytidectomy, a ligamentous attachment release in the midface allowing for vertical suspension of the malar fat pad. Many facelift surgeons have adopted variations of this deep-plane technique and claim durable results, natural appearance, and decreased incidence of hematoma and flap compromise.
Although the evolution of facelift surgery generally involved more aggressive surgery involving deeper planes of dissection, there was a predictable counter-movement in the late 1980s towards less invasive techniques. Less invasive surgery offered less operative time, shorter convalescence, and reduced surgical risks as primary advantages. Less invasive procedures included short-scar facelifts, minilifts, the S-lift, the minimal access cranial suspension (MACS) lift, and minimally invasive threadlifting.
Facial volumization has recently become a popular adjunct to facelift surgery, particularly in the midface. Implants, alloplastic fillers, and autologous fat have evolved to address the facial deflation that occurs along with descent during aging. These techniques can have a profound impact on facial rejuvenation, especially when used in combination with rhyitidectomy.
Experts of facelift surgery have tended to be dogmatic in advocating their preferred technique. Much of the evidence supporting the available options has been anecdotal. This has led to significant controversy for decades. The interest in a best technique is substantial because aesthetic surgeons are always seeking better results by less invasive means. This would logically translate to improved patient satisfaction.
Patient candidacy
Candidacy for facelift surgery is based on multiple factors. These factors include age, smoking status, history of inflammatory conditions, goals of surgery, and anatomic factors. Surgeon factors are also an important consideration. Skill with a given technique and prior experience should guide both patient and technique selection. Ideally, preoperative assessment of the face should include a statistically validated scale. This can allow for consistent comparisons and analysis of postoperative results. This has not been widely adopted although several tools exist. Most surgeons rely on a nonstandardized general assessment of skin laxity, volume loss, and anatomic targets (midface, jowl, neck) during initial consultation.
There is no consensus regarding the optimal age for undergoing facelift and many patients tend to delay surgery until they display significant stigmata of aging. Contrary to common thought, a study by Friel and colleagues found that patients younger than 50-years-old reported increased satisfaction with their procedure at both early and later times. Another study by Liu and Owsley correlated increased self-reported patient satisfaction with improved objective results by photographic analysis in younger patient cohorts.
Patient smoking status is another important preoperative consideration. Active smoking is known to increase the risk of complications such as skin slough, tissue necrosis, and hematoma. Most surgeons advocate smoking cessation before surgery, recommending a period of abstinence ranging from 2 weeks to 6 months. A study by Parikh and Jacono advocated use of the deep-plane technique in smokers. They demonstrated no increased risk of skin slough or healing complications in smokers compared with nonsmokers in their cohort. Other surgeons have supported this concept because the deep-plane flap is more robust and better vascularized.
Incisions
The facelift incision has multiple variations in both placement and length ( Fig. 1 ). Opinions regarding optimal placement vary and consideration must be given to patient characteristics and surgical goals. Patients typically seek minimally invasive techniques with shorter and less visible scars. However, these do not always correspond with better outcomes.
The standard incision starts in the temporal region, extending preauricularly, beneath the lobule, onto the posterior concha, and postauricularly to the occipital region. Variations in placement of the temporal incision just below the temporal tuft hairline or within the hairline depend on patient factors. The amount of skin to be removed should be considered. Older patients or those with excessive skin laxity may require more excision. In this situation, incision placement below the temporal tuft prevents unnatural elevation of the temporal hairline. The potential disadvantage is more scar visibility, though meticulous tension free closure rarely leads to a suboptimal result. If minimal skin excision is expected, placement within the temporal hairline with properly oriented beveling may be a better alternative.
The preauricular incision can be pretragal or apical tragal. There is often a natural preauricular skin fold ideal for pretragal incision placement. This reduces scar visibility while preserving the pretragal notch and skin contour in this region. In men, a pretragal incision is often preferred given the adjacent hair-bearing skin that would look unnatural if extended into the external auditory canal. The apical tragal incision is advantageous because it is hidden on both frontal and lateral views. The pretragal dermis can be thinned and de-epilated to preserve natural skin contouring of the tragus and reduce unwanted hair growth. Some surgeons advocate placement of the incision on the tragal apex regardless of sex, citing scar concealment as a worthy tradeoff for the possibility of daily maintenance of displaced hair.
Usually the incision is continued around the lobule and postauricularly slightly onto the concha, allowing for scar relaxation into the natural postauricular sulcus. Extension onto the mastoid and occipital region is debated. Some surgeons extend the postauricular incision into the occipital hairline in a tricophytic fashion to allow hair growth through the scar to decrease visibility. Others make the incision just below the hairline or not following the hairline at all, with a 45° angle that veers off the overlying the mastoid to avoid an unnatural, notched appearance of the hairline.
Variations from the standard incision length described previously include the short-scar facelift described by Baker, the S-shape incision advocated by Saylan, and the incisions used in the MACS lift proposed by Tonnard and colleagues. These incisions consist of a limited preauricular incision that extends to the lobule but is not continued postauricularly. They are shorter than standard incisions and associated with only a short segment of skin undermining.
Full facelift techniques
Within the scope of a full facelift, techniques can be categorized by the plane of dissection, specifically in regards to management of the SMAS. The subcutaneous, supra-SMAS, and SMAS plication techniques do not involve incision or dissection of the SMAS, remaining superficial to this layer.
The subcutaneous technique, although a component of most facelifts, is seldom used alone in the modern era ( Fig. 2 ). In thin, elderly patients in whom the problem is excessive skin laxity, or in revision situations in which the deep tissues remain adequately positioned, a subcutaneous-only dissection may accomplish the desired results. Most currently accepted techniques involve some manipulation of the SMAS because results with the subcutaneous technique have limited durability.
The supra-SMAS technique is an extension of the subcutaneous lift over the midface. The superficial fat and skin is raised as a flap, leaving the SMAS down. Dissection extends over the malar prominences, releasing all the dermal attachments of the SMAS to the nasolabial fold. The flap is suspended posterosuperiorly, often under tension. This allows correction of ptotic cheek fat and softens the melolabial fold, though there is a large potential dead space, increasing risk of hematoma. The undissected SMAS does not allow for improvement of the jowl. There are also concerns regarding longevity because the SMAS is not manipulated.
Plication leaves the SMAS layer intact, using suture to fold the SMAS on itself. Typically, plication involves securing the mobile SMAS anterior to the parotid to the immobile preauricular SMAS, deep temporal fascia, and mastoid fascia. The result is tightening of the SMAS layer with subsequent lifting. The vector of the SMAS lift should be vertical, whereas the overlying skin flap may be redraped in an aesthetically pleasing manner (typically superolateral). The principal author uses a variation of this technique, referred to as the buccal cerclage, which involves a series of 3 separate suspension sutures to lift the neck, lower face, and improve the jaw line ( Fig. 3 ). The main concern regarding plication is the ability to maintain the lift long-term without the suture cheese wiring through the lifted tissue.
