Miami Facelift Surgery

Introduction
The facelift operation is the surgical procedure that rejuvenates the face and neck. The operation was first developed in the late 1800's. At that time, the surgery was rather basic and only involved the removal of the excess skin.  With time the procedure has advanced, allowing a more natural and longer-lasting lift.

Facial aging occurs as a result of changes that take place in the skin and in the deeper tissues. The aging process begins in the late twenties. However, visible changes usually become apparent in the late thirties. These changes are due to alterations that occur in the skin, fat, muscle and bone of the face and neck.

Figure 1

Patient with an aging face and neck. The neck demonstrates excessive skin laxity.

The skin is one of the first components that begins to age. The amount and quality of the collagen and elastin, both important structural proteins in the skin, begins to decrease early on. The decrease in the structural proteins causes weakening and thinning of the skin (Figure 1). The skin looses elasticity and increases in laxity. You can test your skin's laxity by pinching the area under the chin; pulling it and then letting it go. The more lax the skin, the less recoil it will have.

Figure 2

Front view of a female patient. There is midface (cheek) descent and loss of fat volume in the area underneath the cheekbone.

There are changes that occur in the facial fat. The volume of fat decreases with increasing age. If you look at a person in their late seventies and compare them with a young person, one of the most distinguishing features is the loss of facial fat (Figure 2). It is fairly uniform throughout the face, but occurs more in some areas than others.

Facial fat is important because it acts to give the facial skin and soft tissues structure and support.  The loss of this additional support is another reason why the skin and overlying tissues descend.

Figure 2b

Oblique view of the same patient. Loss of fat volume can be seen in the midface (cheek). Additionally, the jowls are visualized as they descend forward.

The platysma muscle, located in the lower face and neck, descends with age. With the descent of this large facial muscle, the overlying skin and soft tissues sag inferiorly as well (Figure 2b). The last change that is seen is the loss of bone in the facial skeleton. The jawbone can loose volume, adding to the aging process. This is sometimes seen in some individuals that may develop weak or droopy chins in the later year.

The aging face: Descent, Deflation, and Radial Expansion.
There are three visible transformations that the aging face goes through as a result of the aging process. These are facial descent, deflation, and radial expansion. Descent refers to the inferior displacement of the facial soft tissues. Deflation refers to the loss of facial fat. Radial expansion is the loosening of some of the facial tissue. A properly planned and executed facelift should address these in order to fully rejuvenate the face and neck.

As a consequence of the aging process, the facial skin and underlying tissues descend. This can be first seen in the midface, where the malar fat pad (cheek) begins to descend. This descent of the cheek fat has two effects. In the area between the lower eyelid and cheek, a hollowness forms as the cheek fat descends. The other effect is the creation of the nasolabial fold.

In the lower face, the jowls begin to appear as the facial tissues begin to descend forward. The platysma muscle originates in the lower face and runs down the entire neck. This muscle descends in both the face and neck as we age. In the lower face, its descent creates the jowl. The jowl is actually the sagging front end of the muscle. In the neck, the platysma descends with aging, sometimes causing the bands that appear in the front of the neck.

The properly executed facelift procedure should elevate the midface, or cheek, to its natural position. This cheek elevation will restore the fullness to the area between the cheek and the lower eyelid. I believe that this is an area that certain types of facelifts fail to correct. It is also an area that, if corrected, can restore the youthful look to a face (Figure 3a, 3b, 4a, 4b, 5, 6). The facelift should reposition the platysma muscle back to its original position, in order to correct the jowls.

Figure 3a	Oblique view of a female. Notice the descent the of midface (cheek). Hollowness can be seen in the area between the lower eyelid and cheek.		Figure 3b	Oblique view of the same patient after having a facelift and eyelid lift by Dr. Bustillo. The midface has been elevated and a youthful contour has been re-established.
Figure 4a	Diagram demonstrating the descent of the platysma muscle in the face and the neck that occurs with facial aging.		Figure 4b	Diagram demonstrating the repositioning and elevation of the platysma muscle during the deep plane facelift as performed by Dr. Bustillo.
Figure 5	Front view of the same patient before surgery.		Figure 6	Front view of the same patient after surgery with Dr. Bustillo.

The second visible change is deflation. This describes the hollowness that is sometimes seen in some areas of the aging face. Deflation can be due to either a loss of fat volume or a descent of the facial fat. The area underneath the cheekbone can undergo deflation in some patients. The surgical rejuvenation of the face must take into account these shifts in volume and attempt to correct them. The first step is the recognition, followed by a surgical plan aimed at repositioning the facial deep tissues to replenish the volume.  This can be accomplished by either repositioning the fat during the facelift or by performing autologous fat transfer.

Radial expansion can be best described as the outward push seen in some areas of the aging face, which causes a loss of jawline definition. This is most commonly seen in the lower face in the areas of the jowls and the lower border of the jawbone. It is a consequence of the weakening the facial retaining ligaments. As they weaken, the tissues loosen and separate from the deeper tissues. The facelift technique must be able to elevate and secure the underlying deep tissues in order to recreate the definition of the jawline that is associated with youth.

The Aging Neck: Laxity, Inflation, And Muscle Descent
The aging neck is one of the most challenging areas to treat in facial rejuvenation surgery. The transformations that occur in the neck as a result of the aging process are increasing skin laxity, inflation, and muscle descent. The facelift surgeon should plan and address these to maximally improve the neck contour.

Patient with platysma banding in the neck.

The platysma muscle runs from the lower face and down into the neck. With aging, this muscle descends and may cause the neckbands that are commonly seen in the neck. In addition, the loosening of the muscle may add fullness in the neck below the jawline (Figure 7). The facelift procedure should address the muscle by tightening it centrally below the chin and laterally near the corner of the jawbone.

The submental area, just underneath the chin, is an area where the accumulation of fat can cause an inflation in the neck. Fat removal should be performed judiciously in order to sculpt the neck adequately, yet maintain a natural appearance (Figure 8, 9). Overzealous fat removal in this area can skeletonize the neck and allow the underlying neck structures to be visible through the skin. Over time, the neck skin can loose elasticity and become lax.

Patient with neck fullness, front & lateral view.

This leads to a redundancy of the skin over the neck. While the facelift procedure tightens the underlying neck muscles and removes the excess skin, it does not address the inherent laxity that the person's skin may have. The person with excessive skin laxity may have a less then ideal result in the neck as a consequence. This patient may benefit from certain skin tightening non-invasive procedures after the surgery. It is a well-known fact that facelifts may not satisfy all patients in the neck area. The reason is usually excessive skin laxity, which surgery cannot completely address.

Facelift Techniques
There are many facelift techniques that have been developed over the years. Initially, the lifts were "skin only," meaning that all of the pull was placed on the skin. The results were mostly short-lived. This lead surgeons to search for more reliable and long-lasting techniques. The next advance came in the form of the SMAS facelift.

The SMAS (abbreviation for superficial musculo-aponeurotic system) is a fibrous layer underneath the skin of the face. It envelops the facial muscles. The SMAS technique involves the removal of a strip of the SMAS and the advancement of this layer to tighten the underlying tissues. This was a major advancement and improved the facelift results over the skin-only technique. However, there where still areas of the face and neck that the SMAS lift did not address. These areas were the midface and the neck.

The facelift technique that I have been using since I began practice is the deep plane facelift. This comprehensive lift allows the correction of the facial descent, deflation, and radial expansion that occurs in the aging face. The deep plane facelift involves the elevation of the SMAS and the facial muscles. After they are elevated, they are lifted, repositioned, and secured in their new position. The malar fat pad is elevated, allowing for the correction of the deflation and descent seen in the midface. In the lower face, the platysma muscle is elevated and secured to achieve a defined jawline, thereby eliminating the jowls and decreasing the radial expansion. In the neck, the fat is carefully removed and the platysma muscle is tightened centrally (below the chin) and laterally.

The deep plane facelift has several advantages over other facelift techniques. The technique allows the repositioning of the malar fat pad (cheek) up to its youthful position. In addition, the jawline definition is greatly improved due to the muscle work that is performed in the lower face and neck. The most significant advantage, in my opinion, is the natural appearance that is attained with the deep plane facelift.

Mini-Lifts
In recent years, the mini-lift has become very popular. They have been given "brand" names by those that market them. The idea sounds promising. Mini is a term that is associated with easy and fast. However, the results are also usually "mini." My belief is that if a person demonstrates signs of an aging face and wants a surgical solution, the procedure of choice is a facelift. I often see patients in my practice that had mini-lifts and are unhappy with the result. They ultimately end up having a facelift to improve the poor result they obtained from the mini-lift.

Incisions & Scars

Patient operated by another surgeon with poor scars due to excessive skin tension.

Patient operated by another surgeon with poor scars due to excessive skin tension.

One of the biggest "tip-offs" to facelift surgery is a visible scar. Facelift scars may be visible for several reasons. The number one reason the scars are visible is due to excessive tension placement on the skin. When an incision is closed with tension, it heals poorly, and as a result, will widen (Figure 10, 11). A wide scar is always a visible scar. The surgeon should use a technique that places the pull and tension on the deep tissues. This skin closure should be meticulous and tension-free.

Incision placement used by Dr. Bustillo. All incisions are hidden inside the hair, behind the tragus (post-tragal), and in creases. A patient who wears the hair up will not have any visible scars since they will be hidden inside the hair.

The second reason the facelift scar may be visible is placement. The incisions should be placed along natural curves, folds and inside the hair. Never in the hairline. I will describe the incision that I use in my facelift. The superior portion of the incision is placed inside the temporal hair, completely hidden (Figure 12a). As it comes down, it hugs the helix and enters behind the tragus (Figure 12b, 12c). The tragus is that small round or square cartilage in front of the ear. This part of the incision is known as a "post-tragal" incision, because it is    hidden behind the tragus. This is in contrast to the "pre-tragal" incision used by some surgeons.

Patients ear before undergoing facelift surgery by Dr. Bustillo.

Patients ear after undergoing facelift surgery by Dr. Bustillo. The normal ear anatomy is maintained and all scars are imperceptible.

Patient operated by another surgeon. A pre-tragal incision was used. The scars are visible.

I believe that the post-tragal incision gives superior results, as it completely conceals this part of the incision. The incision then comes down a natural crease between the ear lobule and the facial skin. In back of the ear, it travels up in the crease behind the ear. It then crosses into the hair, where it is completely hidden. This allows my patients to wear their hair up without any scars being visible. Any incision outside this course has the potential to be visible (Figure 12d).

Post-operative view of a patient that had surgery with another surgeon. The tragus has been distorted.   Post-operative view of a patient that had surgery with another surgeon. The tragus has been distorted and there is excessive scaring.

Post-operative view of a patient that had surgery with another surgeon. There is a pixie-ear deformity. This ear lobule is stretched and blends with the face.

The natural shape and position of the ear should be maintained after the facelift procedure (Figure 13, 14, 15). The ear can change when the incisions are closed with tension or are improperly placed. For example there can be changes to the tragus. The tragus can be pulled forward or simply removed. The ear lobule, is a very delicate portion of the ear. It is fat-filled and the skin is very soft. It is therefore inherently weak and susceptible to stretching or pulling by the healing forces. The extreme case is the "pixie ear," where the ear lobule is pulled inferiorly and blends with the face. It gives a surgical appearance and   looks very unattractive. The surgeon must be meticulous in his incision placement and closure to avoid alterations in the shape of the ear.

Are You A Candidate For A Facelift
The majority of patients that undergo the facelift operation do so in their mid forties and on. Occasionally, patients with premature facial aging or weight loss will undergo the surgery at an earlier age.  People are many times confused about what exactly a facelift corrects. This uncertainty can be compounded by the advent of the different types of lifts.  The goal of a facelift procedure is to rejuvenate the neck, the lower face, and the mid-facial regions. A facelift repositions sagging facial tissues hereby achieving a more youthful appearance. A facelift does "not stop the clock, but it turns it back"; the natural aging process continues after the procedure.

The decision about having the facelift operation is a very important and personal one. You should consult with your surgeon and your family. For most people that undergo the procedure, the results are life changing. Patients describe an increase in confidence and boost in self-esteem. They feel rejuvenated and feel more comfortable in social settings and in pictures.

The ideal patient must have the proper expectation before undergoing surgery. Although with the deep plane facelift technique, results are better than they ever were, there are still limitations. It is important that the patient have a good understanding of what can be achieved. Clear communication between the patient and the surgeon is very important.

Surgeons are human and therefore are not perfect. While most facelift patients enjoy the benefits of an improved face and neck, it is important to remember that surgery, like all other human actions, is not perfect. A skilled facelift surgeon can achieve near perfection. However, one must remember that the skin and soft tissues the surgeon works with can have inherent laxity and weakness.

Consultation
The consultation begins with a discussion about the specific issues and concerns that the patient may have. It is important to discuss whether the facial aging has occurred slowly over time or recently in the last several years. Any recent weight loss or plans for weight loss are discussed so that the surgery can be planned at the appropriate time.

A thorough physical examination is performed. The midface is evaluated for descent. The lower face and jowls are then palpated and mobility of the facial skin and tissues is assessed. The neck is then examined. The amount of fat and muscle descent is determined and the amount of skin laxity is assessed. The eyes and eyebrows are evaluated to see if the patient is a candidate for a blepharoplasty or browlift.

The patient and I then have a discussion about the result that I believe can be achieved with surgery. The patient should understand exactly what the facelift procedure will achieve for them so that an informed decision can be made. The procedure is explained in detail and all questions are answered.

Preparation
All patients are required to obtain pre-operative labs and a medical clearance from their primary care physician prior to surgery. All aspirin, anti-inflammatory products (naproxen, ibuprofen), and vitamins such as A, ginkgo biloba, and St. John's wart should be discontinued ten days before surgery because they may interfere with blood clotting and cause bruising. Alcohol should also be avoided for five days before surgery to avoid swelling.  Patients are required to start high dose vitamin C two weeks before and two weeks after to help with the healing and to reduce bruising.

Anesthesia
The facelift surgery is performed on an outpatient basis in an AAASF-certified surgical facility. Because I believe that patients recover best outside of a medical environment, they are allowed to allowed to return home or to their hotel room the same day after they recover. All surgeries that require anesthesia are staffed by board certified anesthesiologists, which are part of the Baptist Hospital Anesthesiology Department.

The facelift procedure can be performed under different anesthesia modalities, depending on the patient the adjunctive procedures being performed. If the patient is having the facelift operation alone, it may be done with either local anesthesia or IV sedation anesthesia.  However, if the facelift is being performed in combination with eyelid surgery, either IV sedation or general anesthesia is used. Certain patients may require general anesthesia for safety reasons.  The facelift surgery takes about three hours to perform.

Risks
The facelift operation, like all surgery, does have risks aside from those of anesthesia. The highest risk patients are smokers. Patients who smoke should refrain from smoking for approximately two weeks before the surgery.  The nicotine patch is not a substitute for smoking cessation as far aesthetic surgery is concerned. Nicotine causes the small blood vessels to become narrower, which decreases the blood flow to the skin. The potential complication in a smoker is the death of the facial skin, resulting in a poor outcome with facial scarring and possible infection. The facelift surgery will not be performed on an active smoker.
A hematoma is a collection of blood that can accumulate under the skin. Although rare, it can occur after a facelift. The risk of hematoma is about 1%. The treatment usually entails draining it in the office. Most patients that have a hematoma after surgery recover well without any complications. Infections after facelift surgery are also rare. Patients are given antibiotics prior to surgery and after surgery to help prevent infections.

Recovery
The patient is discharged home the same day after surgery. The first night should be spent relaxed. Activity should be kept to a minimum. A liquid diet is best for the first eighteen hours after anesthesia. The head should be kept elevated using two pillows to help reduce swelling. The patient should place small zip lock bags with frozen peas on the eyes 10 minutes, for every hour spent awake for the first 48 hours.

The face will be wrapped with a bandage used to keep the skin flat. Pain should be minimal. Tylenol is usually enough to control any minor discomfort. Additional pain medication will be provided, in the event that it is needed. Any significant pain should be reported to Dr. Bustillo immediately, as this may signal bleeding under the skin. If a blepharoplasty was performed, some mild bruising may be visible around the eyes.

The patient is then seen the morning after surgery. The bandage will be removed on the first day after surgery. It is normal for some bruising to appear in the neck. A small bandage is then worn for five days while the healing occurs.  On the fifth post-operative day, the small stitches in front of the ear and under the chin are removed. Patients can usually shower and wash their hair after this second visit.

Most patients return to work and daily activities about two weeks after surgery. Seventy percent of the swelling resolves in the first three weeks. It is recommended that physical activity, such as running or lifting be resumed three weeks after the surgery. The remainder of the swelling can take up to three months to completely resolve. This remaining swelling is imperceptible.

The final results of the surgery may not be completely evident until several months after the surgery. The results of a facelift operation usually turn back the clock approximately ten years and the results last about ten years. Most patients who undergo facial rejuvenation surgery are extremely happy with the results.

What is a facelift?
Facelift surgery, also known as rhytidectomy, is a plastic surgery procedure performed to improve the neck laxity, jowls, and the midface. As a person ages, the midface begins to descend, producing the nasolabial folds. The lower face then begins to show jowling, near the chin and the neck muscles sag, producing banding and redundancy. These three areas can be improved with the facelift procedure. The facelift does not improve the skin texture or quality.

Who is the best candidate for a facelift?
Dr. Bustillo believes that the best candidate is a healthy man or woman whose face is beginning to show signs of facial aging. The typical patient may have sagging skin in the neck and jowls. He or she may also have midface descent, producing a nasolabial fold. There are many other factors that determine whether an individual is a good candidate for a facelift, such as skin type, ethnicity, and skin laxity. Dr. Bustillo does not put a strong emphasis on the age of the patient, but instead focuses on the patient's facial aging.

Are there any limitations to what a facelift can achieve?
The facelift procedure cannot stop the aging process. It, however, make the person look more refreshed and rested. It is commonly said that a facelift will make the person look ten years younger.

What happens during a consultation for a facelift?
Dr. Bustillo will personally meet with you during the consultation. He will examine and evaluate you. He will then show you before and after pictures and then explain the surgical procedure from beginning to end. This explanation will include what surgical technique he will use, where the surgery will be performed, what type of anesthesia, and a step-by-step explanation of what the recovery will be like. You will then meet with the patient care coordinator, who will explain the scheduling details and the cost.

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