Facial aging is a gradual process that typically begins in the fourth decade of life. The process, however, can be accelerated by excessive sun exposure, cigarette smoking, radiation therapy, or certain genetic disorders (e.g., progeria, pseudoxanthoma elasticum). Histologically, aging is characterized by multiple changes that occur primarily in the dermis and at the dermal/epidermal junction. There is loss of the dermoepidermal papillae and a gradual reduction in the melanocyte population. The thickness of the reticular dermis is substantially reduced as overall dermal organization is degraded. A decrease in total collagen content results in thinning of the skin with age; the normal ratio of type I to type III collagen is also altered. Total dermal thickness decreases with age by an average 6% per decade of life in both men and women.¹

There are alterations in both the facial skeleton and soft tissues that contribute to age-related changes in the face. With age, there is a remodeling of the facial skeleton that involves a rotation of the facial structures downward and inward with respect to the cranial base. Wrinkles, gravitational descent, and atrophy constitute the significant soft-tissue changes that occur over time. There are three causes of wrinkles in the human face: repetitive mimetic muscle action, disruption of the elastic structural network, and sun damage. Although sun damage is preventable to a certain degree and is often more limited in individuals with darker skin color, the other two noted factors contribute to the aging process in virtually all human populations. The increased melanin present in darker-skinned individuals limits actinic damage and slows the development of age-related stigmata. Darker-skinned ethnicities often do not exhibit the same degree of facial wrinkling and furrowing as their lighter-complected counterparts. If they do, it is usually at a much later age.

Early facelift procedures involved a limited elevation of the skin and subcutaneous tissues, placing the burden of tension on the skin. Innovative surgeons were eager to reduce the skin slough and scarring that was believed to be at least partly due to tension on the skin flaps and incisions. There was also a desire to improve the longevity and aesthetic results of the procedures. To improve outcomes, other methods were developed, especially following the description of the superficial musculoaponeurotic system (SMAS) in 1976 by Mitz and Peyronie.² Skoog and others developed techniques that involved dissection and suspension of the SMAS, thereby transferring tension from the skin closure to deeper tissues.^3,4,5,6,7 The literature was soon replete with various descriptions of SMAS procedures (plication, imbrication, strip SMASectomy) aimed at achieving the most aesthetically pleasing results.^8,9,10 The deep-plane facelift and composite rhytidectomy pioneered by Hamra were both extensions of the SMAS procedures, involving extensive sub-SMAS dissections and suspension.^11,12 The next landmark in the evolution of rhytidectomy surgery was the description of the subperiosteal facelift, in which the soft tissues of the face are elevated off the facial skeleton.^13,14 Over time, techniques were popularized that involved progressively deeper planes of dissection. The increased complexity of these procedures was believed to be warranted by improved and longer-lasting results.

Interestingly, in the new millennium, there has been a change of focus to minimally invasive procedures. The application of the endoscope to facial surgery has inspired facelifting procedures that limit incisions and minimize recovery times. Through exposure by the mass media and a wider acceptance of plastic surgery by the public in general, these procedures have become some of the most sought after, especially in the younger age groups. It is imperative for practitioners to describe to their patients the benefits as well as the limitations of these less invasive techniques; they certainly cannot achieve the results of a more traditional facelift and may only have applications for a specific subset of patients with more limited degrees of facial aging.

The wider acceptance of plastic surgery in the United States has led to an increased demand for facelift procedures in almost every ethnic group. Whereas surgeons previously
focused almost exclusively on issues related to Caucasian skin types, they now have to be intimately familiar with issues related to wound healing, scarring, and skin care in darker-skinned individuals. Surgeons must understand these issues for surgical planning to achieve optimal results in these patient populations.

Ethnic patients presenting for facial rejuvenation require a thorough evaluation before a surgical plan can be established. In addition to taking a full history that includes documentation of comorbidities, prior surgery, medications, family history of aging, sun exposure, and tobacco history, there must be an inquiry as to how the patient heals wounds (i.e., a history of keloids or hypertrophic scars) and whether the patient has problems related to nonuniform skin pigmentation or other medical skin conditions. Furthermore, it is necessary to ask the patient targeted questions regarding hairstyle and care, such as how they style their hair, whether they wear wigs, and if they frequently receive hair-conditioning treatments. Contraindications to surgery that could be elicited in the history include cardiovascular disease, autoimmune diseases (e.g., lupus, sarcoid, sickle cell anemia), and prior radiation therapy to the face or neck.

As with any plastic surgery patient, there must be a clear and realistic expectation of goals. It is important to allow the patient to express in their own words exactly what result he or she hopes to obtain with facial rejuvenation surgery. An invaluable part of the initial exam is providing the patient with a mirror and asking him or her to point out areas for which he or she is seeking specific improvement. This should be followed by a complete physical examination, including skin color and thickness, assessment of actinic damage, amount/location of skin laxity, assessment of facial bony skeleton, cranial nerve exam, assessment of hairline, and inspection of previous surgical or traumatic scars.

Medical photodocumentation is an integral part of the initial consultation that allows the surgeon to reanalyze the patient before surgery. It also provides a basis for postoperative comparison. The standard preoperative photographic views for facelift surgery include the full-face frontal view, full-face left and right oblique views, and left and right profiles.

The physician must process all of this information to recommend a procedure that can be performed safely and provide the results that will most closely match the expectations of the patient. For example, patients who are obese and/or have extremely thick skin must be informed that the results of rhytidectomy may be less than satisfactory. Ultimately, the best outcomes can be expected in those patients who have moderately thick skin, minimal sun damage, and some preservation of skin elasticity. In addition, patients with strong facial bony structures and a well-defined, acute cervicomental angle will exhibit more dramatic postoperative enhancements than those without such pre-existing features.