■ Rhytidectomy

The Greek word for wrinkle is rhytid and the suffix ectomy means “to remove or extract”; thus the term rhytidectomy. The layperson’s name for rhytidectomy is “facelift.”

The term facelift is often inappropriately used to reference total facial rejuvenation, which—in reality—consists of eyelid surgery facelift, and perhaps skin resurfacing. Facial surgeons know these facts, but it is often helpful to explain them to patients during the initial consultation or with printed materials.

Patients should also be informed that a facelift comprises four parts: forehead, temporal, cheek, and neck lifts. Each of these components can stand alone or be performed in conjunction with another. The exception—in my practice—is that, at least, a partial lower cheek lift is usually required to correct bunching of neck skin advanced into the region just anterior to the lobule of the ear during a neck lift.

While a facelift provides the necessary foundation for rejuvenation of the face and neck, other procedures add the “finishing touches.”

The goal of each component of the facelift operation is to reposition and remove the signs of aging caused by sagging of loose skin, muscles, and fatty tissues.

Facelift surgery does not correct aging lower eyelids. In fact, after a well-performed cheek lift, excessive skin of the lower lid is often more pronounced so that lower eyelid blepharoplasty, skin resurfacing, or both may be required. This is the best argument for performing blepharoplasty after the facelift part of a combined facial rejuvenation procedure. In the upper eyelid, less skin removal is necessary after a well-performed forehead/temporal browlift.

Still, men and women from all walks of life are seeking ways to look as good as they feel. It behooves all facial plastic surgeons to teach and perform techniques that give “natural” and “unoperated” results. The techniques I use, develop, and advocate are designed and dedicated to that end.

Facelifts may be done for one of two reasons. The first is to help prevent the advancement of aging, that is, to help relatively young individuals (around the age of 40) to maintain a youthful appearance. The second reason is to help patients with advanced signs of aging appear younger, fresher, and more rested—in short, to help one recapture the appearance enjoyed 10 to 15 years previously.

Naturally, everyone contemplating a facelift is interested in how much improvement they can expect, and for what duration. The amount of improvement depends on the condition of the skin and the degree of wrinkling and sagging present; if the visible signs of aging are excessive, the results may be dramatic—approaching the 15-year goal. If sagging is occurring prematurely and the operation is being done to attempt to keep the patient looking young, the improvement may be more subtle. People may remark that the face “looks more alive, rested, and fresher.” Some people look as though they have lost weight because the heaviness along the jawline and in the neck is improved.

■ How Long Does a Facelift Last?

The following are some of the comments I use to answer questions asked by prospective patients.

The fact is that a facelift lasts for a lifetime, in that patients will always appear younger than had they not undergone the procedure. The duration of the results noticed within the first year after surgery cannot always be accurately predicted. Results will vary depending upon the specific surgical maneuvers taken by the surgeon, for example, whether liposuction was performed to remove portions of unwanted fat, whether superficial musculoaponeurotic system (SMAS) imbrication was performed and the manner in which the SMAS was suspended, and whether incisions were extended to adequately remove redundant skin.

Liposuction can permanently remove unwanted fat cells from the neck and jawline. That it can means that the surgeon must be aware of regions of the face, neck, and subdermis that require fat to provide aesthetically pleasing volume and avoid overly aggressive removal. A thin layer of fat is necessary between the dermis and underlying musculature. Removal of buccal fat (a technique advocated in some circles in the past) is not recommended. In later years, this pad of fat is needed to avoid extreme hollowing of the midface.

When combined with tightening sagging muscles and skin in patients undergoing facial plastic surgery, liposuction can improve the results along the jawline and submental region by as much as 20 to 25%. When good skin tone is present and very little drooping is noted, the lower one-half of a face that is simply “fat” may be improved with liposuction alone.

In ideal cases, however, a more youthful appearance following a facelift can be enjoyed for 5 to 10 years. No operation can permanently prevent aging, but patients should never appear as old as they might have if the operation had not been done.

When proper attention is paid to the SMAS, sagging tissues in the brows, face, and neck noticed after a facelift are a result of the continuation of the aging process. When sagging becomes a problem again, a tuck-up procedure can be done that may provide dramatic and long-lasting improvement. I have patients for whom I have relied on “tuck” procedures to help them maintain a more youthful look for nearly 4 decades. Some would consent to surgery every year or so, if I would agree to perform it when they asked for it. It is my practice to delay additional procedures until I feel they are warranted. Because I established the doctor-patient relationship discussed in this book very early in the process, patients will concede to my recommendations.

For the best results, every patient should be evaluated within a year or two following surgery. A tuck-up may or may not be considered at this time. Aggressive lifting of facial tissues results in a “stretched” or “windblown” appearance, a condition that can—and should—be avoided.

The foundation created by the initial facelift creates the desired situation for a tuck-up. The thin layer of scar that is formed in the subcutaneous layer at the time of initial undermining and lifting provides additional strength when suspending the deeper tissues of the face during maintenance surgery.

Patients should know that it is not necessary, however, to have additional cosmetic surgery. The tuck-up is simply part of an elective alternative in a comprehensive “maintenance program.”