10 discussing Medical Roll-CIT
The history of face-lifting dates back to the early 1900’s. A surgeon by the name of Hollander is credited with first describing the facelift operation. Early on, the operation consisted of simply removing skin and pulling it closed. In the early 1970’s, surgeons gained a better understanding of facial anatomy. It was then that more reliable methods of face-lifting were developed. Recently, face-lifting procedures have been refined to address specific anatomic areas that change with aging.
Facial aging begins in the mid thirties with the formation of dynamic wrinkles. These are wrinkles produced by the continuous action of the facial muscles. This analogous to folding a paper continuously over and over again. At one point, the paper will form a crease. In much the same way, the skin invariably becomes wrinkled at the site where the muscle acts on it. These tend to b the first signs of aging in most persons. They are typically located in the forehead, between the eyebrows (glabellar region) and around the eyes (crow’s feet).
As the years go by and the facial tissues loose elasticity and collagen begins to lose its strength, other folds and wrinkles begin develop. These are known as static folds because they are not subjected to muscular movement. Examples of these are the nasolabial folds, which run from the nose to the lateral most portion of the lip and marionette lines. Early on theses may be corrected with minimally invasive procedures to fill in the depressions. However, as they become deeper, lifting procedures are usually needed to help eliminate these.
As the aging process continues, the facial tissues continue to weaken and descent. Additionally, fat may undergo resorption in addition to downward displacement. This is particularly noticeable in the area of the midface, or the cheekbone. There, a natural mound of fat exists. The downward displacement of this fat is what actually creates the nasolabial fold. In the lower face, jowls are created as the facial tissues sag inferiorly. In the area of the neck, fat begins to collect in area underneath the chin. The skin in this area also begins to loose elasticity and hangs down. This is sometimes referred to as a turkey gobbler.
The majority of patients that undergo the facelift operation do so in their late fifties or early sixties. Occasionally, facial aging procedures such as neck lifts may be done earlier. Patients are many times confused about what exactly a facelift corrects. This uncertainty can be compounded by the advent of the different types of facial rejuvenation surgery that have been developed in the last decade.
The traditional facelift operation is aimed at improving the neck and the facial jowls. This procedure is appropriate for those patients that have a sagging neck and jowls, but do not have midface descent. In this operation, the skin is raised from the deeper tissues in the face and neck. These underlying tissues, known collectively as the SMAS are then tightened. The skin is the draped back and the excess is trimmed. The surgery involves incisions in front of the ear, underneath it, and then in back of the ear and into the hair. In men, the skin can be incised in front of the tragus, to avoid having the beard grow close to the ear once the skin is draped back done. Alternatively, the skin can be incised in a standard fashion and the hair follicles removed from the inside of the skin. Occasionally, some surgeons carry the posterior incision into the hairline, making it visible when the hair is raised. This should be avoided. The superior-most portion of the incision can be directed in two ways, according to surgeon preference. The important point is to make sure that the surgeon does not change the hairline, giving a bald look to the temporal area. This is can be a tall tail sing of a facelift. There is another incision just underneath the chin which is used to suction the fat from the neck and to tighten the neck muscles.
In the last decade, more thorough facelift operations have been developed in an attempt to correct the sagging midface in addition to the sagging neck and jowls. These are collectively known as deep plane procedures because once the skin is elevated from the underlying tissues, the surgeon lifts these underlying tissues (or SMAS) from a underneath, instead of above them. The ultimate effect is that the cheek fat pad is elevated and placed back in its anatomic position. These types of facelifts can be done through the same traditional incisions. Some surgeons approach this deep plane from a temporal incision above the ear in the hairline in addition to the traditional incisions. Patients that have significant midface descent should inquire with their surgeon regarding this concern.
The preoperative consultation usually involves a discussion with the surgeon about the specific issues that are a concern to the patient. The physician will then discuss the possible surgical and non-surgical procedures which may be used to treat the patient. This conversation should include all of the risks, benefits, indications, and alternatives to the each of the specific procedures discussed. The patient should be encouraged to ask questions and exchange thoughts and ideas with the surgeon. The best patient is a well informed patient.
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 more narrow, and decreases the blood flow to the skin. The potential complication of a smoker is the death of the facial skin, resulting in a poor outcome with facial scarring and infection. Other complications of the facelift operation include hematomas, or collections of blood under the facial skin. These are rare, but they do occur. Treatment involves draining it as soon as it is recognized. Whenever incisions are made, there is the potential for abnormal scarring. However, most unsightly scars encountered in patients having gone through a facelift are either the result of poor incision planning or excessive tension on the skin. Both are technical errors. Permanent facial weakness from nerve damage is very rare. Occasionally, the nerve may become bruised during the surgery, and a temporary weakness results. This can last up to two to three months and usually resolves. It is common, however, to feel some numbness in the area of the ear. This lasts several weeks and is the result of the incision around the bottom of the ear. Infection is rare in the face, but can happen as previously mentioned to patients who smoke. The human body is not symmetrical and there may be slight differences from on side of the face to the other. This is normal even in patients who have not had surgery and should not concern the patient unless it is highly noticeable.
The physical examination then follows. This part of the consultation focuses on the skin type ( light skin versus darker skin ) and skin texture. Patients with rough, scaly, sun exposed skin can undergo the surgery, but the skin texture will not be improved. Topical retinoic acid treatments are best for improving this skin condition. The underlying bony structure and neck anatomy also have a large influence in the final result. That is, patients with strong underlying bone structure, such as cheek bones and chin tend to have very good results. Patients with small chins may benefit greatly from a mentoplasty, or chin implant at the time of the surgery.
The examination continues with the forehead. Here, brow position is examined. The ideal woman’s brow is at the orbital rim medially and arches at its highest point laterally. The man’s brow should lie just at the level of the orbital rim. This will determine whether a brow lift is needed in conjunction with the facelift. Again, the brow lift procedure (discussed elsewhere in this book) is not meant to remove the forehead wrinkles, but instead to elevate the brows. The eyes are then examined to determine whether a blepharoplasty ( eyelift ) is needed. (This is also discussed in another chapter) Moving inferiorly, the position of the malar fat pad (cheek fat pad) is determined. A descent in this area should alert the physician that a midface lift ( either via deep plane facelift or temporal midface lift ) should be discussed. Next the jowls and neck are examined for the amount of laxity and fat to be addressed.
Attention should then be paid to the individual characteristics of each patient. For example, the way the ear attaches to a person’s face. Notes should be made so that it is placed back in the same position. If the patient does not like the way it is attached, this may be a good time to speak to the surgeon about changing it. Blemishes or moles may be addresses so that they may be easily removed during the operation.
The facelift operation can be done under local anesthesia with either a light, moderate or heavy sedation as well as with general anesthesia. This should be discussed with your surgeon so that a mutual decision that is comfortable for both is reached. Both have pros and cons, which are discussed in another chapter. The anesthesia should only be administered by a board certified anesthesiologist. Occasionally, nurse anesthetist can provide anesthesia. This should only be done under the direct supervision of a board certified anesthesiologist. Save money on your car insurance, but not on your surgery !
The procedure can be carried out in either an outpatient surgical facility based in the surgeon’s office or a free-standing one. However, the patient should make sure that the facility has passed the state surgical center codes and is certified by the appropriate ambulatory surgery credentialing board. Alternatively, it can be performed in a hospital. Healthy patients tend to be done in the outpatient facilities. Patients who are healthy, but may have a medical condition, such as controlled high blood pressure, are usually done in the hospital for safety precautions. All patients undergoing this procedure should have a medical examination and medical clearance before the surgery by their primary care physician. It is important to stop all aspirin containing and anti-inflammatory products (naproxen, ibuprofen) ten days before surgery. Acetaminophen should be the only over the counter pain medication taken ten days before surgery. Vitamins such as A, ginko biloba, and St. John’s wart should be discontinued because they may cause bleeding. All vitamins and herbal products consumed should mentioned to the surgeon, as they may have effects on the clotting mechanism. Alcohol should also be avoided for five days before surgery to avoid bleeding and bruising.
The surgery can take from two and a half hours if only the facelift is being performed to four hours if a blepharoplasty (eyelift) is being performed in conjunction. After the surgery, the patient is taken to the recovery room. The majority of patients are discharged home the same day. Occasionally, surgeons may keep the patient overnight. The patient should have a caretaker with them for about two days. This person will help with feeding, ambulating, and other chores. This person does not need to be a medical professional.
The night of the surgery should be spent relaxed, possibly watching television. Activity should be kept to a minimum. A liquid diet is best for the first eighteen hours after anesthesia. The face will be wrapped with a tight bandage used to keep the skin flat. Pain should be minimal. Any significant pain should be reported to the physician immediately, as this may signal bleeding under the skin. This is extremely rare, but possible. If a blepharoplasty was performed, some bruising will be visible on the eyes. Ice compresses should be applied to the eyes and face while the patient is awake.
The surgeon will remove the bandage on the first day after the surgery. It is normal for some bruising to appear in the neck. Occasionally some blood collects behind the ears and it is painlessly removed in the office. The surgeon will then apply an ace-type bandage with Velcro that is worn for approximately four to five days while healing occurs. On the fourth or five post-operative visit the small sutures in front of the ear and under the chin are removed. Patients can usually shower and wash their hair after this second visit. On or about the tenth post-operative visit, the tiny staples in the posterior incision ( in the hair ). The face may remain with mild swelling for approximately two weeks. After the second week, about 80 % of the swelling will have subsided. Only the patient is aware that the face is somewhat swollen. It is not noticeable to the average person. Hence, the patient can resume most of the daily activities. It is recommended that physical activity, such as running or lifting be resumed only after the fourth week. The remainder of the swelling resolves in the third week.
The final results are visible between the sixth and eight week post-operatively. 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.