Fat is injected into the plane between the skin and the SMAS, restoring cheek fullness. By releasing the SMAS and using it as a handle, the skin and the fat layer between the skin and the SMAS are elevated with it, avoiding skin tension that might otherwise create an operated look. This tissue elevation produces a temporary bump in the temple that flattens on its own. An additional incision is avoided.
What is a “Facelift”?
The facelift remains one of the most effective procedures in the cosmetic surgeon’s “toolbox,” particularly when combined with other techniques to provide true facial rejuvenation. Properly performed, a facelift can do wonders, and there is presently no substitute, regardless of advertising claims to the contrary. But it is a highly technical procedure, and there is a wide range of results from surgeon to surgeon. The technique used may be vastly different between operators, even those performing “deep plane” techniques. It is imperative that the surgeon be skilled and experienced. The facelift is the centerpiece of a cosmetic surgeon’s anti-aging capabilities. Like rhinoplasty, it is a complex procedure that is never fully mastered. The surgeon must bring his or her A-game to the operating table. There is little margin for error.
A facelift does not produce a totally different look, nor does it make a 50-year-old look 20. Fortunately, patients usually find this comforting. Rather, a facelift reverses many of the undesirable effects of time and gravity. Patients often find they look more like they did in old photographs. Friends and family may not realize they had surgery but comment simply that they look good. This is true even when a comparison of before and after photographs shows a dramatic difference. I have yet to encounter a patient who tells me, “I look too young.”
In fact, patients do not want to look 20 even if that were possible. A 2006 global survey asked women at what age they felt most attractive and desirable. The average response was age 34. Only 4% of women surveyed thought women over 50 were most attractive. The double standard for gender was confirmed, with the majority of these female respondents (58%) finding that men over 50 looked distinguished, while women over 50 appeared past their prime. Fifty is the age when women start to disappear from the pages of magazines. In the United States, women start trying to disguise the effects of aging in their mid-40s. My patients frequently tell me they think they looked their best at about age 40, and if they could recapture this appearance, they’d be happy.
In addition to a better understanding of the proper plane for elevating the facial tissues, we now recognize that other signs of aging also benefit from treatment, including skin surface changes, such as wrinkling and brown spots, and loss of volume. These important changes of aging have been largely overlooked by plastic surgeons in the past. Fortunately, we now have the technology, using laser skin resurfacing and fat injection, to simultaneously treat the skin surface and restore volume. In my own practice, it is rare for a patient to have a facelift without these other treatments.
What a Facelift Does and What It Does Not Do
When combined with a cheek lift (which is part of the deep-plane lift), the facelift really should be called a cheek, jowl and neck lift to properly describe the treatment areas.
The cheek tissue, which contains fat that gradually sags from the cheekbone, is hoisted back up to where it once was. Lifting the cheek tissue also helps de-accentuate the smile creases (“nasolabial” creases), particularly if the lift is combined with laser resurfacing and fat injection into these creases. The connective tissue under the jowls is pulled up, taking up the slack along the jawline. The muscle in the neck, called the platysma, is tightened on each side, helping to define the jawline and smooth the vertical bands that run in the neck. Liposuction is performed under the chin, and the platysma is also tightened in the midline, under the chin, using the same incision placed in the crease under the chin. This approach eliminates the double chin and further improves jawline definition. I call this combination a “triple vector” platysmaplasty (Swanson E. Evaluation of face lift skin perfusion and epinephrine effect using laser fluorescence imaging. Plast Reconstr Surg Glob Open 2015;3:e484).
Most people are unclear as to what exactly is accomplished by a facelift. This is understandable. There are dozens of published techniques, so that not all facelifts produce the same results. It is an axiom of surgery that the greater the number of techniques described to treat a problem, the less adequate the treatment.
It is common for moderators at plastic surgery meetings to comment that a skilled operator can get an excellent result using a number of different techniques. I suspect this is often a diplomatic gesture to reconcile very different treatment philosophies proposed by different surgeons. It only makes sense that technique does matter and that a superior method consistently produces better results.
The comments in this section apply to the facelift that I perform, which is a deep-plane lift, also called sub-SMAS (explained in this section).
A facelift does not treat the eyelids. The rejuvenation procedure for eyelids is called “blepharoplasty.” Often, blepharoplasties are performed at the same time as the facelift, unless they have been treated previously and do not need revision.
A facelift does not remove the fine lines around the mouth. As you might imagine, pulling up the cheeks does not affect the upper lip. Vertical lip lines are smoothed with the laser and/or fat injection.
A facelift does not restore lost volume to the face. Many techniques elevate the fallen cheek fat (“malar fat pad”), but these maneuvers provide no net increase in facial volume. To provide youthful facial fullness, fat transfer is the key, using donated fat from another area of the body (usually the tummy). The successful integration of fat injection with facelifting is an important advance in facial rejuvenation and one that cannot be overlooked by 21st-century plastic surgeons. Facial fat injection has been shown to provide lasting fullness in the cheeks (Swanson E. Malar augmentation assessed by magnetic resonance imaging in patients after facelift and fat injection. Plast Reconstr Surg. 2011;127:2057–2065).
A facelift restores tone by taking up the slack in the facial skin. Laser skin resurfacing smooths surface wrinkles. Fat injection replenishes lost fat under the skin. To use an analogy, a facelift may be compared to pulling up the bedspread, laser resurfacing irons it out, and fat injection is the blanket underneath.
In summary, the 4 R’s of facial rejuvenation are: Redrape (facelift), Relax (Botox or an endoscopic forehead lift), Resurface (laser skin resurfacing) and Refill (fat injection).
It is not unusual for a patient to assume a facelift also treats the forehead. Such an assumption is reasonable. After all, the forehead is the upper third of the face. However, by tradition, plastic surgeons consider forehead rejuvenation separately. A forehead lift, also called a brow lift or forehead-plasty is often recommended simultaneously to treat the forehead at the same time the middle and lower thirds of the face are treated with a facelift.
FEMALE PATIENTS OVER 40
Extensive Sun Damage
C.C. Age 42
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, facial fat injection (36 cc), endoscopic forehead lift, and CO2 laser resurfacing.
Before, 2 months after
J.V., Age 45
Procedure: Facelift, submental lipectomy, chin implant, upper and lower blepharoplasties, facial fat injection (45.5 cc), endoscopic forehead lift, and CO2/erbium laser resurfacing.
Before, 8 months after
Before, 2 weeks, and 1 month after
J.S., Age 46
Procedure: Facelift, submental lipectomy, chin implant, upper and lower blepharoplasties, fat injection (30.5 cc.), pulsed dye laser treatment of facial veins, and erbium laser resurfacing.
Before, 7 months after
B.W., Age 48
Procedure: Facelift, submental lipectomy, chin implant, upper and lower transconjunctival blepharoplasties, endoscopic forehead lift and CO2 laser resurfacing. Second procedure, 3 years later: fat injection (21 cc). Third procedure, 6 years later: erbium laser and fat injection of lips (4 cc).
Before, 6 weeks, 4 years, 6 years, 7 years, and 10 years after
S.G., Age 48
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, rhinoplasty, fat injection (25.5 cc), endoscopic forehead lift, and CO2 laser resurfacing.
Before, 3 months after
VB., Age 49
Procedure: Facelift, secondary lower blepharoplasties, facial fat injection, endoscopic forehead lift, and removal of bony forehead lesion. This patient had a bony lesion that was removed using the same hidden incisions that were used for the forehead lift.
Before, 2 months after
P.C., Age 49
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, replacement of old chin implant, endoscopic forehead lift, fat injection (31 cc), and CO2/erbium laser skin resurfacing.
Before, 5 months after
10 days after (with makeup)
FEMALE PATIENTS OVER 50
A.M., Age 50
Procedure: Facelift, submental lipectomy, jawline implant, upper and lower blepharoplasties, endoscopic forehead lift, and periorbital CO2 laser resurfacing.
Before, 1 year after
Improved Eyebrow Expression
S.N., Age 51
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, endoscopic forehead lift, excision of multiple skin lesions, and C02 laser resurfacing.
Before, 3 months after
Fat Injection for Wrinkles
D.B., Age 51
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, fat injection (18 cc), endoscopic forehead lift, tip rhinoplasty, and CO2 laser resurfacing.
Before, 20 months after
K.L., Age 52
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, chin implant, fat injection, setback otoplasties, full face CO2 laser resurfacing, cautery of facial spider veins, and removal of skin lesions on face and neck.
Before, 3 ½ months after
E.L., Age 52
Procedure: Facelift, upper blepharoplasties, submental lipectomy, fat injection (30 cc), CO2 laser skin resurfacing, and chin augmentation. A skin lesion was removed from the right jawline, leaving a small scar.
Before, 6 months after
L.B., Age 55
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, facial fat injection (31 cc), endoscopic forehead lift, and CO2/erbium laser resurfacing.
Before, 5 weeks after
B.M., Age 56
Procedure: Facelift, submental lipectomy, upper blepharoplasties, endoscopic forehead lift, and CO2 laser resurfacing.
Before, 2½ months after
J.O., Age 57
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, and excision of facial skin lesions.
Before, 2 months after
J.R., Age 58
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, fat injection (23.5 cc), endoscopic forehead lift, and CO2 laser resurfacing.
Before, 1 year after
B.K., Age 59
Procedure: Facelift, submental lipectomy, upper and lower transconjunctival blepharoplasties, endoscopic forehead lift, and CO2 laser resurfacing.
Before, 3 months after
FEMALE PATIENTS OVER 60
P.B., Age 60
Procedure: Facelift, submental lipectomy, upper blepharoplasties, fat injection (45 cc), CO2 laser resurfacing, cautery of nasal veins, endoscopic forehead lift, and scar revision of left forehead.
Before, 7½ months after
Loose Neck Skin
S.R., Age 60
Procedure: Facelift, submental lipectomy, and facial fat injection (21 cc).
Before, 1 month after
3 months after
B.S., Age 61
Procedure: Secondary facelift, septorhinoplasty, fat injection (40 cc), excision of facial scars and skin lesions, endoscopic forehead lift, and CO2/erbium laser resurfacing.
Before, 3½ months after
Before, 3½ months after (with makeup)
L.B., Age 62
Procedure: Secondary facelift, submental lipectomy, upper and lower blepharoplasties, fat injection (42.5 cc), endoscopic forehead lift, and CO2/erbium laser resurfacing.
Before, 10 months after
Split view, before, 2 months after (with makeup)
J.M., Age 62,
Procedure: Facelift, submental lipectomy, and fat injection (39 cc).
Before, 6 months after
J.N., Age 66
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, excision of skin lesions on temples, left upper eyelid, and forehead, and CO2 laser resurfacing.
Before, 2½ months after
FEMALE PATIENTS OVER 70
E.L., Age 74
Procedure: Facelift, submental lipectomy, and CO2 laser resurfacing.
Before, 5 months after
L.E., Age 74
Procedure: Secondary facelift, submental lipectomy, lower transconjunctival blepharoplasties, endoscopic forehead lift, and CO2 laser resurfacing.
Before, 1½ years after, and 6½ years after (with makeup)
W.A., Age 77
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, earlobe reduction, and CO2 laser resurfacing.
Before, 6 weeks after (with makeup)
Split view, before, 6 weeks after surgery (with makeup)
H.M., Age 81
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, and fat injection (22 cc)
Before, 1 year after
Removal of Sun-Related Skin Lesions
B.D., Age 82
Procedure: Facelift, submental lipectomy, biopsy of multiple facial skin lesions, and CO2 laser resurfacing.
Before, 2 months after
Premature Skin Laxity
K.B., Age 38
Procedure: Facelift, submental lipectomy, chin implant, resection of buccal fat pads, endoscopic forehead lift, tip rhinoplasty, pulsed dye laser treatment of facial veins, and fat injection of lips, jawline, and cheeks (12 cc).
Before, 3 months after
Correcting “Pixie Ear” Deformity
C.B., Age 45
Procedure: Secondary facelift, submental lipectomy, upper and lower blepharoplasties, jawline implant, revision of scar of right jawline, and pulsed dye laser treatment of neck.
Before, 4 months after
J.L., Age 52
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, chin implant, buccal fat pad resection, endoscopic forehead lift, tip rhinoplasty, fat injection (20 cc), CO2 laser
Before, 4 years after
4 years after
E.S., Age 57
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, chin implant, endoscopic forehead lift, fat injection (15 cc), and periorbital CO2 laser resurfacing.
Before, 2 months after
K.B., Age 61
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, excision of multiple skin lesions, fat injection (13 cc), endoscopic forehead lift, pulsed dye laser treatment of facial veins, and CO2/erbium laser resurfacing.
Before, 3 months after
Split view, before, 3 months after
Sun-Induced Brown Spots
J.O., Age 62
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, chin implant, endoscopic forehead lift, and CO2 laser resurfacing.
Before, 4 months after
Split view, before, 4 months after
C.F., Age 64
Procedure: Facelift, submental lipectomy, upper and lower blephs, fat injection, endoscopic forehead lift, excision of facial skin lesions, CO2 laser skin resurfacing and setback otoplasties.
Before, 10 days after
R.F., Age 64/69
Procedure: Facelift, submental lipectomy, excision of skin lesion of left lower eyelid, and fat injection (34 cc). Second procedure, 5 years later: erbium laser resurfacing of face and hands, and Botox injection of forehead and crow’s feet.
Before, 5 years after
Pain Medication Prior to Surgery
Because of its effect on platelets and the risk of increased bleeding, all products containing aspirin are avoided for 2 weeks prior to surgery and 2 weeks after. Many over-the-counter pain relievers and headache medicines contain aspirin, also called ASA, so it is worth checking to be sure. We instruct patients to avoid non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen (Motrin) or naproxen (Aleve) for 3 days before surgery. It is fine to take Tylenol right up until before surgery because it does not affect platelets. Patients with arthritic pain or headaches can take their NSAID or COX2 inhibitor up to 3 days before surgery and then take Tylenol.
Vitamins and Nutritional Supplements
High doses of vitamins, particularly vitamin E, which can prolong bleeding time, are prohibited before surgery. Also patients should avoid herbal medicines or supplements, starting 2 weeks before surgery, because of possible interactions with anesthetic medications and undesirable effects on platelets and blood pressure. Popular herbal remedies include garlic, ginkgo, ginseng, ginger, St. John’s wort, and ephedra, to name a few. Do not take any diet medications such as phentermine for at least 2 weeks before surgery. Stop taking Adderall 2 weeks before surgery and stop Vyvanse at least 1 day before surgery, if you can tolerate it and it is permitted by your prescribing physician.
*Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast. Reconstr Surg. 2011;127:823–834.
Appearance After Surgery
It is difficult to prepare for your appearance after surgery. I frankly tell patients that their appearance may startle their husbands or wives. Swelling and bruising are an expected part of the healing process. There is even more swelling when eyelid surgery or laser skin resurfacing is performed simultaneously. The eyelids may be swollen almost completely shut. The skin is red after laser resurfacing and the lips are swollen, sometimes quite dramatically. Patients look a lot worse before they start to look better. For the first few days, patients may wonder why they ever decided to have the surgery. All of this is normal.
Surprisingly, despite this appearance, patients do not usually experience much pain, although they are uncomfortable. This discomfort is to be expected, caused by the tightening of the tissue layer under the skin and superimposed swelling. Patients find they cannot open their mouth widely or turn their head easily from side to side. They notice numbness around the ears. They may find they are not moving their lips symmetrically, or closing their eyes completely. It may be difficult to articulate because of lip swelling. Frequently there is be more swelling on one side of the face than the other. Vision may be partially obscured by swelling and by the use of lubricating eye ointment. Fortunately, swelling responds to elevation and application of ice. Eyelid swelling goes down quickly, much of it within a few days.
I see patients on the morning after their facelift. Although I used a wraparound head dressing in the past, I stopped using dressings years ago. As it turns out, dressings were unnecessary and patients always felt better when they were removed. Drains are usually inserted, but not always (this determination is made during surgery).Usually the drains are taken out at this visit the day after surgery. Patients are able to start bathing right away when they get home. They can shampoo their hair and wash their face, which is soothing.
During the first 2 weeks, there is bruising of the neck, sometimes spreading down to the chest. This bruising is caused by small amounts of blood under the skin that gradually settle with gravity. Bruising is not caused by operative trauma to the neck or chest. Although bruising can be dramatic and colorful, with purple hues giving way to yellow, it is completely painless and goes away in a few weeks. Bruising may be concealed under a scarf.
Patients may notice bumps on the sides of the neck and wonder whether their “glands are swollen.” These bumps are caused by swelling. The tissue temporarily fills with fluid and becomes firm. Sometimes patients feel little nodules under the skin. These are sutures that have been used to tighten the neck muscle (platysma) on either side of the neck. They gradually absorb over 3 months.
Patients may feel irregularities of the skin behind the ear. This is normal. This wrinkling is caused by gathering of skin along the skin edge at the time of the lift. After the sutures are removed, these irregularities gradually soften, although a crease or fold may persist. Patients may feel a bump in their scalp a few inches behind the ear. This is the end of the incision, where there is puckering of the skin, (dog ear). This is also where the drain came out. No need to worry—this bump gradually smooths out.
Patients having a facelift without any other surgery usually recover quickly, and have minimal discomfort even a few days after surgery. For those patients having laser resurfacing with the facelift, the worst of it is over by the sixth day after surgery. The facial skin is usually healed in a week. Patients seem to “turn a corner” at this time and start to see the benefits. The recovery proceeds rapidly. Some areas heal faster than others. The cheeks and forehead may be healed in a few days. The skin around the mouth and eyes can take longer. Usually these areas were more wrinkled and an additional pass or two with the laser were used, accounting for the longer healing time for these areas.
Temple Rolls After Facelift
The deep plane lift pushes up a roll of skin at the level of the temple, causing a bump, like a speed bump (See photo). This roll is caused by vertical advancement of the deep tissue plane (SMAS), and it is a sign of successful tissue elevation. Patients sometimes call these temporary bumps “handlebars.” Although it is possible to remove this extra skin surgically (and many facelift techniques include such an incision), this would leave a horizontal scar in the temple, which can be a telltale sign of surgery and prevent women from wearing their hair back and up.
We’ve all seen celebrities who always seem to conceal their temples and ears with their hair. If they wear their hair short, they may choose a pageboy hairstyle. They are doing so for a reason—to conceal any scars or tragal deformity after a (nonideal) facelift. A facelift technique that allows women to show off a youthful face including the ears is very much appreciated. A youthful jawline extending all the way back to the ear is always to be preferred to hair that overly encroaches the face. The ear is an underappreciated part of the facial anatomy and a youthful-looking, attractive ear is a plus. Women should be able to confidently wear their hair back and up after a facelift and show off all of the face, not just part of it. This full-face exposure not only looks youthful, but signals confidence too.
A temple scar can be even more of a problem for men with short hair, or a receding hairline. Fortunately, a scar following the temple hairline, or continuing forward at the top of the sideburn, is unnecessary. The temple roll gradually settles down over the 4–6 weeks after surgery. It is preferable to be patient and just allow this ridge to flatten on its own. This way there is no visible scarring or elevation of the hairline or sideburn. Patients need to know about this temporary bump before surgery so that they don’t worry about it afterward. Most patients can conceal it by draping their hair over their ears during this time.
A.B., Age 47, Personal Trainer
Procedure: Facelift, upper and lower blepharoplasties, submental lipectomy, fat injection (30 cc), periorbital erbium laser resurfacing, pulsed dye laser treatment of veins of face and neck, and tip rhinoplasty.
Comments: This sequence of photos shows the temporary bulge in the temples that is often created when the deep plane lift is performed. This temple roll gradually flattens and is no longer visible 2 months after surgery.
Numbness is normal after a facelift. The skin in front of the ear, under the chin, and up behind the ear is numb after surgery. This numbness is caused by surgical division of the small sensory nerve branches that supply the skin. Gradually, these nerve branches regenerate and the area of numbness starts to recede like a puddle evaporating. The first area to regain feeling is the part of the skin farthest from the ear and the last area to regain sensation is the skin in front of the incision line itself, where the skin has been most undermined and where the nerves have the farthest to grow.
Facial Nerve Branch Weakness
Patients may be aware of temporary tearing or blurring of vision after surgery. This may be caused by weakness of the lower eyelid. The facial nerve “motor” branches to the lower eyelid have been stretched during the cheek lift, so that the eyelid at first may not close completely. Sometimes swelling interferes with the tear duct’s ability to drain tears from the eye, so that tears spill over the lower eyelid, like water going over the edge of a dam. This tearing is temporary, and goes away as the swelling diminishes and the lid function returns. Any blurriness of vision gradually resolves. It is vital to keep the eye well-lubricated with artificial tears during the day and lubricating ointment at night, to keep the cornea from drying out until eyelid function has returned to normal.
All surgical procedures carry some uncertainty and risk. Even in the best hands, complications do occur. Patients vary in their anatomy, physical reaction to surgery and anesthesia, and healing capabilities, so that the outcome is never completely predictable. That’s just the nature of surgery.
Surgeons know from experience that two operations in different patients, done almost exactly the same way, may have very different outcomes. Even operations on two sides of the same face or body can have different outcomes, particularly in terms of discomfort, bruising and swelling. Patients are often surprised at this. They think that both sides should heal at the same rate after surgery, but in reality one side always seems to take a little longer than the other, whether it’s the eyelids, face, breasts, or body.
It is best if patients anticipate having a complication, and if they don’t, that’s a bonus. There is a well-worn phrase in surgery: “The only way to avoid complications is by not operating.” Experienced surgeons (particularly toward the end of their careers) are often very candid and admit that they’ve seen just about every complication in their practice over the years. If you are seeing an experienced surgeon, you are seeing a surgeon who has seen plenty of complications, including his or her own complications, not just complications in patients treated elsewhere.
One of my colleagues says he divides complications into two groups—those he has seen in his own practice and those he has not seen yet. The reality of complications makes it vital for the patient and surgeon to have a mutual trusting relationship, so that complications may be appropriately managed when they develop. If patients are forewarned about possible risks, they are not surprised if a complication develops and are better prepared.
Patients should maintain a healthy degree of skepticism regarding complication rates quoted by surgeons. One well-known New York surgeon repeats at meetings, “Double any complication rate you see advertised, including mine.” Surgeons are human beings, after all. They don’t always remember all the complications they have encountered and few keep a real-time tally. A complication rate of 1% is commonly quoted. Such a rate seems small, only 1 in 100, and perhaps this is a rate that is comfortable from a psychological standpoint, an event that sometimes happens to other people. But such a low rate should not be too reassuring, even if it is correct. If patients encounter a complication, it’s 100% as far as they are concerned. They have to understand that it could happen to them. They should have the surgery only if they can tolerate this risk.
A hematoma is a collection of blood under the skin that is usually removed by the surgeon. This is a possible complication of all surgical procedures that involve elevation of skin flaps (“undermining”), creating a potential space for fluid accumulation. A hematoma does not typically occur after liposuction because there is no sharp dissection and no creation of large spaces for blood to accumulate. In cases where there is substantial tissue undermining, such as facelifts (and abdominoplasties), a drain is inserted at the time of surgery. The drain helps draw off blood and fluid that would otherwise pool under the skin. Drains are usually removed the morning after surgery.
A hematoma typically develops within 24 hours of surgery (the patient below was a little unusual in that the hematoma developed several days later). It can form in the recovery room, or is evident at the time of the postoperative visit the day after surgery. It is caused by bleeding from one or more blood vessels. A clot may dislodge from a vessel that has been cauterized, particularly a small artery that carries more pressure. Sometimes hematomas are precipitated by spikes in blood pressure after surgery. For example, nausea and vomiting in the recovery room can cause the blood pressure to go up, which is one reason we try to prevent nausea by avoiding anesthetic gases (using intravenous propofol instead) and routinely administering anti-nausea medications.
A short procedure is usually necessary to drain a hematoma. If it is not drained, the body will eventually absorb the blood, but this would take weeks and there would be prolonged bruising. Patients and their caretakers are told to report any significant neck swelling after surgery, usually on one side, and usually the size of a lemon or larger. A smaller amount of swelling is normal. If there is any question, it is best for the patient to call and come in right away to be assessed.
V.H., Age 47, Manager
Procedure: Facelift, submental lipectomy, upper blepharoplasties, chin implant, fat injection (30 cc), excision of skin lesion of right chin, rhinoplasty, and pulsed dye laser treatment of facial veins.
Comments: This patient developed a collection of blood under the skin after surgery—a hematoma. It was drained (“aspirated”) with a needle in the office. This treatment is not painful. The skin is still numb where the needle is introduced.
Before, 3 days after, and 8 weeks after
Infection is uncommon because of the excellent blood supply of the face. Frequent bathing (washing the face at least 3 times a day) and antibiotics are used to treat infections.
Loss of feeling is normal, especially in front of the ears. This feeling gradually returns. However, sometimes a larger nerve that supplies feeling to the lower part of the ear, called the great auricular nerve, is injured during the neck dissection, causing ear numbness that improves gradually with time but may never return completely to normal. Experienced surgeons learn to avoid this nerve by performing “hydrodissection” of the subcutaneous plane with local anesthetic solution and staying in this plane when the neck skin flap is raised.
Delayed Wound Healing and Increased Scarring
Facelift scars are usually well-hidden within the hairline or in natural creases around the ear. They fade with time and are usually barely noticeable. However, some patients are prone to forming raised, “hypertrophic” scars, which may require revision or steroid injection.
Sometimes, healing of the skin is impaired due to compromised blood supply, seen most commonly in smokers. If the skin does not receive an adequate blood supply, it does not survive. Remarkably, the skin can tolerate up to 90% interruption of its blood supply from dissection. But add the effects of smoking, and this can tip the balance. The skin may appear red and blistered, then turns black and forms an unsightly scab that surgeons call a crust or eschar. With time, the wound heals as new skin cells are created along the wound margins, which contract inward, shrinking the wound. The final scar is typically much smaller than the original wound, although it will be thicker than it would otherwise have been without the delayed healing. Fortunately, areas of delayed healing and increased scarring are usually tucked behind the ears where they are inconspicuous.
This 55-year-old smoker had a facelift. She developed an area of skin breakdown behind her ear. This gradually healed in with additional scar tissue. Fortunately, the scar remains relatively hidden behind the ear. If the scar is noticeable later, it may be revised. This complication is rarely seen in nonsmokers.
Facial Nerve Weakness
The facial nerve is responsible for making the facial muscles work. It branches out as it runs from a point just behind the ear to the facial muscles. It has 5 branches that may be stretched when a deep-plane facelift is performed. Experienced surgeons take every precaution to avoid cutting the nerves, although some branches are likely to be stretched. These nerve branches are like tiny insulated electrical leads going to the muscles they supply. Stretching them temporarily interferes with their transmission. They do have the capability of self-repair, if not completely divided, but this takes time. Patients may experience an asymmetrical smile, drooping of a corner of the mouth, or weakness on one side of the forehead.
Risk of injury to the facial nerve may be reduced by confining the dissection to a more superficial plane, as done in a skin-only lift, or a lift that relies on sutures and minimal, if any, SMAS mobilization (including all mini-lifts). However, the limitations of a superficial mini-lift are significant.
D.N., Age 51
Procedure: Facelift, submental lipectomy, upper and lower blepharoplasties, erbium laser resurfacing, and pulsed dye laser treatment of face and neck.
Comments: This patient demonstrates weakness of her left frontal nerve branch supplying the forehead. Four months after surgery she is still unable to elevate her left eyebrow. Fortunately this temporary weakness is usually not very obvious to others. She is seen 10 months after surgery with full return of frontal nerve function. Her before-and-after photos are included in the Patient Photographs section.
Corneal protection from dryness is essential. Normally, at night the cornea is protected by the closed eyelids. After surgery, however, the eyelids may not close completely, due to swelling or weakness of the orbicularis muscle. Incomplete eyelid closure places the cornea at risk of drying out from evaporation of the tear film. Patients are instructed to use lubricating ointment at night and eye drops during the day.
After surgery, the lining of the eye, called the conjunctiva, may swell. This produces a yellow-tinged bubble. It happens more commonly after combined surgery including blepharoplasties. Gradually the swelling subsides. This swelling can cause blurry vision after surgery. Treatment is simply elevation and corneal lubrication.
The pixie ear is an unnaturally tethered ear. The earlobe is pulled down by the facelift scar. Usually this results from too much skin removal around the ear, creating tension on the skin closure (See photo). Experienced plastic surgeons avoid any skin tension around the earlobe to prevent such a stigma of surgery.
This patient had a facelift performed elsewhere 2 years previously. He was unhappy with the appearance of his earlobe afterward. This deformity was corrected by revising the facelift. His other before-and-after photographs are available in the Patient Photographs section—Male Facelift.
In fair-skinned, older patients, the skin may be sun-damaged and leathery. This may be more severe on the left side of the neck because of sun exposure while driving. Removal of excess loose skin of the neck can produce vertical skin folds, like pleats in a drape. Sun-damaged inelastic skin simply does not redrape well. Usually the pleats eventually smooth out, but occasionally a revision is needed.
A lateral sweep is an unnatural, operated-on appearance that can happen after facelifts that draw back on the skin of the lateral face, while leaving the vertical descent of the cheek and jowl uncorrected. In severe cases, the skin form may form horizontal folds, like clotheslines running from the ear to the corner of the mouth (“joker’s lines”). It is not a harmonious or pleasing appearance and is best avoided by using a vertical vector to elevate the facial tissues.
Flattening of the tragus (the small bump just in front of the ear canal) may be avoided by using a pre-tragal incision, which is my preference. The tragus is a unique structure that is very difficult to re-create. I reserve a post-tragal incision for patients who had this approach at the time of a previous facelift.
Deep Venous Thrombosis
To minimize the risk of blood clots, the anesthesia does not include paralysis, so the calf muscle pump stays intact. Patients are checked with ultrasound scans to detect any small clots that may develop, so treatment can be initiated.
• A small amount of blood or drainage from your incisions is normal.
• Empty the drains when they are about a third full. You may need to do this several times. However, sometimes the drainage is so minimal you don’t have to empty them at all. The bulbs should stay collapsed. If the drain bulb is not collapsed, it is not maintaining suction and therefore is not working. It is easy to empty the drain by removing the plug and squeezing out the blood, and then replacing the plug.
• Use ice packs over the eyelids and face to help reduce swelling during the first 24 hours. Crushed ice in a Ziploc bag or a bag of frozen peas work well. Wrap the ice in a cotton towel so it’s not too cold on the skin. You can apply it intermittently for 20 minutes or so each time (20 minutes on, 20 minutes off). Don’t wake yourself up to do it and don’t feel you have to adhere strictly to this schedule. It’s not mandatory, but simply an extra measure that can provide comfort and reduce swelling.
• Sleep with your head elevated using two or three pillows, or in a recliner to help reduce swelling. Some patients use a foam wedge in bed to elevate their upper body. Avoid positioning the pillows behind your head in such a way as to cause your neck to be flexed forward. Elevation is most important for the first several days after surgery. Then it becomes more important that you sleep comfortably, so you can reduce the amount of elevation. You should not sleep on your side or on your tummy for at least a couple of weeks after surgery. This restriction can be difficult for people who are not used to sleeping on their back. Sleeping may be uncomfortable for about 2 weeks after surgery.
• You may bathe and shower the day after surgery, after your follow-up appointment. All of the incisions can get wet. Go ahead and shower, using soap and water. Shampoo your hair. Your hair was shampooed after surgery in the operating room, but there will still be some dried blood to remove.
• Bruising is usually most apparent on the neck and chest. Because of gravity, the bruising can sometimes cover much of the upper chest. This is normal. Use a scarf to cover as necessary. The bruising may take up to 1 month to dissipate.
• Makeup may be used to cover facial bruising. However, if laser skin resurfacing has been performed, you will need to wait until the skin is completely healed before applying makeup, usually a week to 10 days.
• Avoid any strenuous activities that may increase your blood pressure for 1 week. Such exercise would increase your facial swelling.
• To promote optimal healing, eat a well-balanced diet and take plenty of fluids. You should be getting up to urinate every 3 hours or so. This frequency confirms that you are adequately hydrated.
• You can take non-steroidal anti-inflammatories such as ibuprofen and naproxen as early as the day after surgery. Don’t take Arnica or anything else that is supposed to reduce bleeding or accelerate healing. They don’t work.
• Avoid smoking for 2 weeks before surgery and 2 weeks after surgery.
• The suture below the chin is usually removed 3 to 5 days after surgery. The facelift and forehead lift (if performed) sutures are removed 10 to 14 days after surgery.
• Numbness around the ears is normal.
• Take the antibiotics as prescribed—typically three doses after surgery. You don’t need to take them before surgery.
• Take the painkillers as necessary. Normally, a facelift is not a very painful procedure. Most patients report an uncomfortable tightness. Judicious use of the painkillers helps avoid side effects such as nausea, sedation, and constipation. Try to take just one painkiller at a time and don’t take them more frequently than every 4 hours.
• Apply Neosporin ointment lightly to exposed incisions or where there is any crusting. Leave the Steri-Strips on until they are removed in the office, usually 3 or 4 days after surgery. Use the ophthalmic ointment directly in your eyes at night to keep the corneas lubricated until you can fully close your eyes. Use artificial tears during the day. Tears are used during the day because they don’t blur your vision as much, but they need to be inserted more frequently than ointment. Don’t worry about dried blood along the incision lines; these crusts will come off as you wash.
• Anticipate at least 2 weeks before returning to work, and about a month before you start getting comfortable with your appearance in public. A good way to judge your time off work is to look at postoperative photographs of other patients at various times after surgery and decide what might be acceptable in your work environment.
• You can color your hair when the incisions are healed, usually 2 or 3 weeks after surgery. There’s no reason in coloring your hair at an earlier time anyway.
• After a facelift and laser resurfacing, protect the incisions and facial skin with sunblock at least until the redness has subsided. Scars heal best if they are not exposed to ultraviolet light, which may cause them to hyperpigment. Of course, sunblock also reduces future photoaging.
Q: Will I need to have another facelift?
A: This is another common question, and the answer depends on patient expectations. At a future time, the tissues may relax sufficiently to warrant another facelift. Occasionally, in a patient with marked loosening of the facial tissues, jowls may persist even after a properly-performed deep-plane facelift. It is possible to repeat a facelift using the original incisions, so there are no new scars.
Q: I’m nervous about having a facelift. What else can I do instead?
A: There is no substitute. Alternatives such as fillers, radiofrequency, nonablative laser treatments, mini-lifts, and string lifts are insufficient. The problem is fallen tissue and the only way to correct this problem is by lifting it back up.
Q: Will this fat pad go away if I lose weight?
A: The fat pad gets smaller, just as fat cells everywhere get smaller as you lose weight. However, there will still be an excess of fat cells, even at lower weights, so the problem is unlikely to go away completely. It is, after all, a genetically determined concentration of fat cells that is causing the problem. Most patients are aware that they had extra fat in this location even when they were much younger or in excellent physical condition. This fat pad makes them look pudgy, not lean and fit. Fortunately, this problem is well-treated with a submental lipectomy.
Q: Will the fat come back?
A: The fat cells that are removed are gone forever. The remaining fat cells will swell and shrink in response to your overall weight gain or loss, but whatever your weight, the contour under your chin will always be better than it would have been without the submental lipectomy. The surgery provides a permanent improvement in your profile.
Q: How long is the scar?
A: The scar is typically 2 to 3 centimeters long (about an inch). It is possible to use a shorter scar if liposuction is done without direct excision of fat tissue and tightening of the platysma muscle sling, but these maneuvers are so helpful that they justify a slightly longer incision. If the incision is correctly placed in the crease under the chin and not farther down where it might be seen on the neck, the scar is usually inconspicuous.
Q: Is it painful?
A: Usually this procedure is not painful, although there is a tight sensation in the neck afterward, as you might expect.
Q: How long do I have to wear the chin strap?
A: Just overnight. But many patients continue to wear it at home for several days to provide some gentle compression and help the swelling go down faster.
Q: Will this procedure also tighten the skin, or will it make the skin tone worse?
A: A submental lipectomy removes fat and tightens the muscle sling under the chin. It does not remove extra skin. For older patients, who have loose skin that needs to be addressed, a facelift is recommended (a facelift tightens the skin of the neck). A facelift typically includes a submental lipectomy. Sometimes patients may not be ready for a facelift and wish to do something less. Older patients may still have a submental lipectomy to improve their profile, recognizing that they can return in a few years to have the skin laxity treated with a facelift. Fortunately, a submental lipectomy does not make the skin looser, although there is likely to be negligible skin tightening, especially in older patients.
Q: Is there a laser that could be used to minimize downtime?
A: Lasers have been adapted for use with liposuction (SmartLipo). The concept is that the laser energy helps seal blood vessels and possibly provides some tightening effect. If there is less bruising, this would be expected to minimize the time off work for patients who don’t want to return to work with obvious bruising. However, it is best in almost all cases to tighten the muscle simultaneously and even remove a small amount of submuscular fat to produce a more defined neckline. Therefore, there is no real benefit in using the laser if there is going to be some postsurgical bruising from this part of the procedure. The duration of bruising is only a matter of days anyway, so bruising is not a major issue. Patients are willing to tolerate a little more bruising and swelling if the result is better.
Q: Do you do anything to the muscle?
A: Yes, I sew the edges of the muscle together in the midline of the neck, like a zipper (called plication). These muscle borders tend to be genetically separate (“decussation” of fibers) and can even let fat hang between the borders in later years causing an unsightly turkey waddle (any similarity to turkey anatomy being unattractive in humans). The benefit of the muscle repair is threefold—removal of some submuscular fat, tightening of the neckline (the effect is transmitted to the overlying skin), and a preventative measure to avoid the turkey waddle deformity from developing later on.
Q: Do you cut the muscle?
A: No. In the past, plastic surgeons often cut the platysma muscle horizontally in an effort to treat vertical bands in the neck and to improve the angle between the jaw and the neck (“cervicomental angle”). Although this maneuver was effective, there was a higher risk of bleeding during surgery and this method could sometimes produce a “popsicle neck” appearance (the head appearing like a bobblehead). It turns out that sewing the muscle edges together—the corset platysmaplasty—treats the vertical muscle folds with less risk of bleeding and without creating an unnatural look.
Q: How long do I need to take off work?
A: Swelling is not usually the limiting factor, because even with maximum swelling the day after surgery, there is usually less fullness than there was before surgery. The duration of bruising tends to set the recovery time. Bruising typically accumulates in the lower neck because of gravity, not right under the chin. It usually takes about 10 days for this bruising to fade, but it can take much longer in older patients. Fortunately, this bruising may be hidden by clothing.
Q: Will people be able to tell I had surgery?
A: The incision is typically well hidden under the chin where there is often a crease anyway. At first, the scar is a little bumpy. The scar gradually flattens with time, the redness fades, and the irregularities smooth out. After surgery, other people invariably think patients have lost weight, not that they had liposuction.
How Do You Know If You Are Ready for a Facelift?
It takes courage to see a plastic surgeon. It is impossible to miss media coverage of plastic surgery and facelifts graphically presented on prime time TV and the internet. Many of my patients ask about celebrities who had plastic surgery. They don’t want to end up looking weird. They are worried about the reactions of friends and family. They feel guilty about spending money on themselves. Yet, they still work up the nerve. That patients arrive at my office despite all of these influences speaks to the profound unhappiness that faces them (literally) every time they look in the mirror. One older patient of mine who lived alone confided that she had all the mirrors in her house taken down. I thought she was kidding at first, but she was serious.
The facelift improves the tone of the face. Hereditary factors and aging cause gradual relaxation of the facial tissues. The skin loses elasticity and gravity accentuates the sagging. Most of my patients observe this process over a period of several years. Others say it seemed to happen almost overnight. They may pull their skin back when looking in the mirror to demonstrate how much the skin has loosened.
There is no specific age for having a facelift. My youngest facelift patient was 33 and the oldest 85. A common age is around 50. Most women are noticing jowls at this age. Also, this may be a watershed time in their lives—the onset of middle age with grown-up children and perhaps finally the opportunity to do something for oneself rather than others. Sometimes patients are motivated by a marital breakup, substantial weight loss, change in job, retirement, or moving to a new city. But there is no ideal age for a facelift and likewise no reason to delay the surgery until a certain numerical age.
The decision to take action is not a hurried one. On the contrary, patients think about it for a long time. Our experience is that facelift patients consider the surgery for an average of 3 or 4 years before having it
- (Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast Reconstr Surg. 2011;127:823–834).
In considering timing for surgery, physical findings—loose skin, sagging cheeks, and jowls—are more important than chronological age itself. When these signs of aging start causing concern, a facelift may be recommended, whether the patient is 45 or 55. I have patients in my practice who were ready for a facelift at age 42 (See C.C. in Patient Photographs). Others may make it into their 50s before their skin tone has loosened enough to need a facelift. There are very few genetically-advantaged women who would not benefit from a facelift by their mid-50s. It amuses plastic surgeons to hear celebrities claim they have no interest in cosmetic surgery in their 40s; invariably, they come to another conclusion one morning while looking in the mirror in their 50s. Mothers say to their disapproving daughters, “Just you wait.”
There are advantages in not waiting once the signs of aging are apparent. Having a facelift earlier rather than later, while the skin still has greater elasticity, avoids deeper creases that can be more difficult to treat later on. With proper skin care (i.e., sun protection) and future touch-up procedures as needed, many patients can maintain an appearance much younger than their chronological age well into their later years—a “50,000 mile overhaul” followed by tune-ups, so to speak.
Patients who decide to have a facelift may say to me, “I love my mother, but I don’t like seeing her when I look in the mirror.” Or, “I’m getting that jowly, double-chinned look that runs in my family and that crease along the side of my nose.”
Often an important family event such as a wedding or a reunion, for example, provides the impetus to make changes. Patients may see their facial profile in photographs and are surprised at how they look, not knowing that “it had gotten that bad.”
Many patients tell me that their spouses are supportive, but hesitant. “He tells me he loves me just the way I am. But I’m doing this for me.” These words tell me the patient is ready and has the right motivation. She is doing it to feel better about herself, not to please others.
You might be a candidate if:
- You don’t like looking down because your jowls sag more.
- When looking in the mirror, you pull up on your face with a finger on each temple to take up the slack in the skin.
- You don’t like the appearance of loose skin or vertical bands of the neck.
- You don’t like how you’re starting to look in pictures, particularly profile views.
- You feel like you’re finally looking like your parents.
- Your aging appearance is starting to affect your mood and self-esteem.
What Causes Facial Aging?
Typically, skin laxity starts to become noticeable in one’s early 40s. Many women today have a facelift in their mid-40s. Patients in their early 50s often tell me, “You know, I was doing alright up until just last year. Then my face just seemed to fall apart.” They may make a correlation with menopause or a stressful life event such as a divorce or loss of a parent.
Genetics are most relevant. For a glimpse of what the future holds, just take a look at your parents or other close relatives. It’s usually not very reassuring.
Sun exposure matters, particularly in light-complected individuals with less ultraviolet protection from melanin, who are therefore more susceptible to “photo-aging.” Fortunately this effect is avoidable with diligent use of sunscreen and hats. Patients should not feel that the damage has already been done and there is little point in changing their habits. In fact, skin quality improves with sun protection, even in middle age. It’s time for hats to make a comeback as a fashion accessory!
Ethnicity and gender make a difference. Thin skin ages faster than thicker skin, which is why women, who have thinner skin, tend to seek treatment at an earlier age than men. People with fair skin types tend to wrinkle more and sag more than darker skin types. In my practice, Caucasians typically have facelifts earlier and more commonly than patients of color.
Does Smoking Matter?
Conventional wisdom holds that the habit of tightening the lips around a cigarette causes more wrinkles to form around the lips, commonly known as smoker’s lines. But these lines develop in plenty of nonsmokers too. Of course, smoking cannot be good for the skin, but whether it affects skin aging is unknown. One thing is certain—smoking interferes with skin circulation. Smoking is to be avoided around the time of surgery because it increases the risk of healing problems.
Reasons for Having a Facelift
Patients wonder if vanity is an acceptable reason for wanting a facelift. An appropriate response may be: “Is it reasonable to buy new clothes, repaint your house, or repair dents and scratches on your car? Why would it not be OK to spruce up your facial appearance?”
People in many parts of the world, Brazil, for example, do not find it necessary to justify having cosmetic surgery. Perhaps it is the heritage that makes Americans feel guilty about this form of self-indulgence, although you would hardly know it judging by the rest of our culture. The purist would eschew jewelry and makeup and leave her hair looking like Albert Einstein’s. But even in Einstein’s day, if you looked like that, you’d better have some good theories. Even Popes enjoy wearing Prada shoes and Gucci sunglasses (Benedict XVI).
If tabloid covers are any indication, one’s appearance is more important than jewelry, most people preferring to look like a supermodel than the Queen of England. Perhaps jewelry has been, by necessity, a substitute for cosmetic surgery, even a distraction. Is cosmetic surgery the 21st-century extension of jewelry? One of my patients called her cosmetic surgery her “everyday jewelry.” The late (and always witty) Joan Rivers justified the cost this way, “Better a new face coming out of an old car than an old face coming out of a new one.”
Having a facelift is really just an extension of one’s desire for self-improvement—to look one’s best. The psychological benefit can be profound. Fully 83% of our patients report an improvement in self-esteem afterward (Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast Reconstr Surg. 2011;127:823–834). Many of my patients are also losing weight, exercising, quitting smoking, eating better, having cosmetic dentistry, whitening their teeth, undergoing Lasik vision correction, and having their varicose veins injected.
The traditional view is that a facelift is not supposed to be undertaken in response to an external life event and there should be no expectation that a facelift will solve one’s problems. It may be more accurate to say that antiquated methods have simply not been up to the task.
In truth, many patients do experience a psychological improvement from cosmetic surgery (89% in our survey, referenced in the preceding paragraph). It is not unreasonable for them to think that surgery may have a positive effect on their quality of life. I’ve been told by many of my patients, including patients who are also psychologists, that a few hours of surgery were more helpful in boosting their self-esteem than hundreds of hours of psychotherapy.
Life events may well trigger a patient’s decision to have cosmetic surgery. The example I see regularly is the woman whose husband left her for a younger woman. That an aging appearance should be the basis for a marital breakup speaks to the power of physical appearance. A youthful appearance alone can trump all the advantages of staying together—shared life experiences, memories, and children. Plus the tremendous personal and financial upheaval that results from divorce. Obviously, there may be other considerations, but undeniably lost youth is a big one.
The good news is that expertly performed plastic surgery can help a woman “ramp up” her appearance, her self-esteem, and help her to make a new start. Nothing frivolous about it, cosmetic surgery can have huge practical implications for the direction her (or his) life takes.
I am struck by how many of my patients tell me that work pressures are part of their decision to have surgery. They say that while there is no official age policy where they work (not surprisingly), there is an unofficial one. If this were not the case, why is it that early retirement is offered and encouraged for employees over 55? A major telecommunications employer based in Kansas City settled a multimillion-dollar lawsuit brought by its older employees, including patients of mine, who were let go because of their age. Although both sexes are affected, the pressure can be greater for women.
Typically these patients are about 55 years old and feel they are on the cusp of being “over the hill.” They may very well lose their job to a younger employee. Often being older is not so much the problem as looking older. Although it is shameful to treat older, experienced employees this way, it is also a reality. Patients tell me there is no fighting it. Age discrimination is a sad commentary on our values, but a bias that is unlikely to change. My own mother told me that if she had not had a facelift at age 58 (yes, I did it), she would not have been able to stay on and eventually retire from full-time employment at a time of her own choosing, which was 67. Usually thought of as personal and discretionary, cosmetic surgery can sometimes have a very practical function—keeping people in their jobs.
How Young Will I Look After a Facelift?
Surgeons often claim that a facelift will take a certain number of years off your appearance. A number I often hear at meetings is 10 years. Similar claims may be found in advertisements for skin cosmetics and laser treatments. With no scientific basis, these estimates are purely wishful-thinking. Photographs invariably show best-case results, with lighting, makeup, jewelry, and facial expression (often all of the above) more favorable in the “after” picture. These photos may be taken shortly after surgery, when swelling is helping to smooth wrinkles. These considerations do not include “photoshopping,” a practice that has become easy and widespread (and not used on any photos on my website).
The problem in analysis of results after facial cosmetic surgery is the pervasive, but incorrect, assumption that any changes are subjective and impossible to evaluate scientifically. How is it possible to quantitate change in apparent age? How much younger can you expect to look after surgery? We have some answers (Swanson E. Objective assessment of change in apparent age after facial rejuvenation surgery. J Plast Reconstr Aesthet Surg. 2011;64:1124–1131).
In our original study, photographs of patients taken before surgery and at least 6 months after surgery, without makeup under identical photographic conditions, and with no ancillary procedures after their surgery, were shown to members of the public who attended a Women’s Exposition. The “age guessers” were asked to judge the age of the person in the photograph, not knowing anything about the individual. Two different books of photographs were used, each alternating “before” and “after” photographs so that the age guessers did not view both “before” and “after” photographs of the same patient.
This study showed that the average reduction in apparent age after a facelift alone was 4.6 years. Patients treated with blepharoplasties were compared with patients without blepharoplasties; doing eyelid surgery, on average, provided another 2 years of reduction in apparent age. The same was found to be true for forehead lifts. Laser resurfacing, on average, provided 2.5 years of apparent age reduction. An interesting finding was that smokers’ apparent age reduction averaged 8.1 years, significantly more than nonsmokers (5.6 years), perhaps because they looked older to start with.
There was no significant difference when patients were compared by gender, decade of life (40s, 50s, 60s, 70s+) or body mass index. None of the 71 patients was judged to look older. The maximum reduction in apparent age was 14 years. Twenty percent of patients appeared a decade or more younger according to the impartial age raters. This study was the first to evaluate change in apparent age after cosmetic surgery. It is the first solid evidence that cosmetic surgery is effective. It was presented at the 2011 meeting of the American Society for Aesthetic Plastic Surgery.
Remarkably, surveys completed by the patients themselves (not the age raters) showed that 97% thought they looked younger after surgery and the average subjective age reduction was 12 years (range, 0–27.5 years), double the objective findings by the age raters (Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast Reconstr Surg. 2011;127:823–834).
How Long Does a Facelift Last?
This is one of the most common questions asked by patients. Almost everything in life wears out—the car, the washing machine, other body parts —so they want to know when their facelift will finally wear out too. They would appreciate a definite answer. But the answer requires an understanding of what a facelift does (reduce apparent age) and what it does not do (stop the aging process). By lifting and restoring tone to the face, a facelift can reverse many of the effects of time and gravity. Our study found that combined facial rejuvenation reduced apparent age by an average of 6 years, so a 56-year-old now looks 50. In 10 years, she will appear to be 60 years old, not 66. The facelift “turns back the clock.”
The aging process continues, of course, but the benefit of a facelift does not wear off at some future time. Women and men will always look younger than they would have without the surgery—6 months after surgery or 10 years after surgery. The comparison is really between their future appearance and how they would have looked without the benefit of surgery. Looking at it this way, the benefits are lasting.
So, when might a patient expect to return to have another facelift? If she is unhappy with the way she looks now and can expect to have a similar appearance in 6 years, it makes sense that she might return at that time for another facelift. However, many factors (including the patient’s expectations) influence this decision, and in some areas, such as the neck, the result at 6 years may still be an improvement on their preoperative appearance (See B.W. and B.K. Patient Photographs).
Periodic maintenance procedures after surgery can reduce subsequent changes of aging. Patients may return every few years for a light laser resurfacing, fat injection, commercial fillers, and Botox. With such maintenance (and sun avoidance), patients may look better in 6 years than they did before surgery. Some of my patients in their 50s and 60s believe they look better than they did a decade ago, and some fifty-somethings (See B.W., age 52, in Patient Photographs) even say they never looked better.
Some surgical improvements may persist beyond a decade. Double chins are an example. Fat removed under the chin does not come back, although the skin gradually loosens. Patients treated simultaneously with a chin implant have a permanently enhanced profile. The results of eyelid surgery may well last beyond 10 years. It is important for the reader to maintain a healthy skepticism of surgeons’ claims, including mine. For this reason, long-term follow-up photographs are included in the Patient Photographs section.
Redoing a Facelift
Most of us know of people who have had not just one facelift, but two or three. The perception is that these people must be unbearably vain. But this may be unfair. These people do not return for more surgery because they like having surgery. Rather, they return for more because the benefits have been lost or were not very noticeable to start with. Their early facelifts may have been “skin-only” procedures. Many mini-lifts are of this type. Such skin-tightening procedures can produce a “drawn tight” or “windblown” look. There is some early benefit after a skin-only lift, but this is followed by skin sagging only a few years later. The skin is notorious for its ability to stretch. This was the impetus for the development of deep-plane techniques that pulled tight on the inelastic connective tissue layer below the skin.
In fact, I have redone many such facelifts (See L.B. in Patient Photographs), some as soon as 1½ years after the original surgery. Even on some of my own patients treated using the more-effective deep-plane lift, I have reoperated to treat persistent jowls.
Fortunately, a facelift can be redone. The original scars are included in the skin that is removed. It is often possible to improve the scars by reducing tension on the earlobe and tucking the scars in closer to the ear and hairline to make them less conspicuous. The surgery proceeds much as a primary facelift does and, perhaps surprisingly, does not pose much greater difficulty for the surgeon (unlike a redo rhinoplasty). Usually a smaller amount of excess skin is removed, sometimes just the scar. The emphasis is on the deep-plane lift, which may not have been done before or perhaps not as extensively.
Avoiding Skin Tension
When operating on the face, it is important to avoid tension on the skin because the skin stretches easily. Most people have no trouble understanding this concept, and the reason for using another tissue handle (the SMAS) for elevation. One can hardly expect the skin to hold on its own (the same is true in breast lift surgery). It stretched out before and can be expected to do so again.
Restoring Facial Volume With Simultaneous Fat Injection
We now recognize that replenishing lost facial volume, the “refill” (one of the 4 R’s of rejuvenation) is just as important as tissue repositioning—the “redrape” provided by a facelift. A facelift alone is purely a repositional procedure.
Before fat grafting became popular, many plastic surgeons tried to manipulate existing facial fat, meticulously transposing one cubic centimeter (cc) of fat from the orbit into the “tear trough” (the curved depression that runs from the inner corner of the eye down onto the cheek, just where a tear would travel). Other surgeons have tried to pull up on the egg yolk-sized buccal (cheek) fat pad, which contains a measly 4 ccs of fat (about a teaspoon), using “suspension sutures” that don’t work very well in the first place. This is a tiny volume and the fat is likely to be flattened by the suturing anyway. Not surprisingly, it is difficult to see any volume or contour differences when I view the results presented at meetings. If there is a difference, it may be due to postoperative swelling on an early postoperative photograph. Photographs of patients treated with these fat-transpositional and suspension procedures do not meet my personal minimum standard for effectiveness—I have to be able to tell the “after” photographs from the “before” photographs without labels. One well-known early proponent (Dr. William Little) has abandoned suspension sutures.
To provide youthful facial fullness, introduction of fat harvested from another area of the body (such as the abdomen) is the key. This is the only way to truly restore lost facial volume. Rather than repositioning a few grams of fat from one part of the face to another, borrowing from Peter to pay Paul, it is possible to introduce a much greater volume of new fat, in quantities of 10, 20, 30, or more ccs. Fat injection represents the biggest advance in my facial rejuvenation surgery in the last two decades.
Even counting on some resorption of injected fat, say 50%, there is still a net gain, which is better than the zero net gain of any transpositional technique. To determine changes in volume after fat injection at the time of facelift study, patients at our center were studied with MRIs before and at various times after surgery. This study demonstrated a significant and lasting improvement in cheek volume. Patients studied showed an increase in cheek thickness at 1 month, and no significant loss at subsequent times (Swanson E. Malar augmentation assessed by magnetic resonance imaging in patients after facelift and fat injection. Plast Reconstr Surg. 2011;127:2057–2065).
The successful integration of fat injection with facelifting is an important advance in facial rejuvenation. However, not all plastic surgeons have embraced it. The usual explanation is, “I find the results inconsistent.” The irony is that few plastic surgical procedures can be counted on to produce fully predictable results and fat injection of the cheeks does provide lasting and consistent improvement.
Part of the acceptance problem may be that fat injection is perceived by many plastic surgeons as a painstakingly slow and tedious procedure. A facelift is already a meticulous and time-consuming undertaking, and surgeons may be tired after spending several hours already in the operating room performing a facelift and blepharoplasties. Although fat injection was originally performed using tiny quantities injected in tiny syringes, this method adds to the time commitment. Fat may be injected in larger volumes under low pressure, using atraumatic technique, without a need for centrifugation (I use the LipiVage system) and using fewer passes to reduce tissue trauma and swelling. This method means that fat can be injected in 30 minutes or less, making the technique an ideal adjunct to facelift surgery. Fat injection gives immediate, pleasing results and, by bringing new tissue into the area, improves skin turgor (fullness) and introduces thousands of stem cells, which research suggests may be highly beneficial to the surrounding tissue.
Separating Fact From Fiction
Perhaps no other plastic surgical procedure carries as much mystique as the facelift. A facelift is popularly understood as a renovation. The word is used loosely, even to describe makeovers of inanimate structures—“shopping mall gets a facelift.” For patients, though, the word “facelift” may conjure an invasive procedure that may radically change one’s appearance and not always for the better (a favorite subject of the tabloids). The negative impact of the word “facelift” is reflected in the facial expressions and responses from many of my patients after I recommend it—“Do you really think I need a facelift, doctor?” Much of my time in consultations is spent dispelling common myths about facelifts. Patients ask me about alternative procedures they have seen advertised that promise the results of a facelift but without surgery. By promoting products that have questionable antiaging benefits, these advertisers take advantage of the public’s fear of surgery.
Alternatives to facelifts are frequently presented in the media. The interviewed doctor remarks, “My patients do not want radical surgery.” It may not be disclosed that the physician being interviewed is a non-surgeon, perhaps a dermatologist, who does not perform facelifts. It is no surprise that he or she does not recommend them. Few operators recommend procedures they don’t perform.
It is true that there are many celebrities who look altered or unnatural, and some have been outspoken about their negative plastic surgical experiences. But there are many more who have been very pleased with their results and could not imagine passing up surgical options to keep their appearance from deteriorating. Performed expertly, a facelift can have a profoundly positive effect, as evidenced by patients testimonials and survey responses (Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast Reconstr Surg. 2011;127:823–834).
Patients need to be reassured that they will not look different, drawn tight or artificial after a facelift. They need to know they won’t look like they just stepped out of a wind tunnel. If these apprehensions can be relieved, they may very well decide to go ahead with a facelift. In my experience, the only way to alleviate these concerns is by showing results, before and after photographs of other patients. Not just one or two, but dozens.
Minimally Invasive Surgery
There is simply no substitute for a facelift. There is no other procedure that can effectively and consistently tighten the loose skin of the neck, eliminate jowls, and elevate the cheeks. Such minimally invasive procedures as “string lifts,” “thread lifts,” or “feather lifts” turned out to have negligible benefits and high complication rates caused by the permanent barbed sutures. They came on to the scene with much fanfare and then quietly disappeared. Ultimately the marketplace does not tolerate failure.
Patients may ask about alternative procedures such as a “laser facelift” that avoid or minimize the incisions that come with a facelift. Laser skin resurfacing is a wonderful tool for smoothing wrinkles, fading brown spots, and even providing some skin tightening because of its “shrink-wrap” effect on collagen. But it does not lift the facial tissues or eliminate jowls, and the laser is not sufficient on its own to tighten the loose skin of the neck. These problems are squarely in the domain of a facelift.
Some operators advertise procedures that supposedly can deliver the result of a facelift, without the surgery. It is important for patients to know exactly what to expect from each procedure so that they don’t have unrealistic expectations or disappointments. Radiofrequency is being promoted as a nonsurgical alternative, but the results are modest at best.
A mini-lift sounds attractive to patients—perhaps just the right combination of at least some surgical results and a minimum of downtime and expense. It is not a new idea. The first facelifts, performed in the early 20th century, were mini-lifts. However, because this maneuver is often little more than a skin-only procedure, it is less effective and less durable than a deep-plane facelift and only marginally less expensive. It is a lesser procedure that produces lesser results. It misses out on the advantages of a deep plane lift in treating the cheeks, jowls, and neckline to achieve a harmonious result that truly rejuvenates.
Furthermore, the mini-lift scar still courses around the ear. The scar is not much shorter than a facelift scar. It makes sense that if you are going to have such a scar, it is best to make the most of it and maximize the trade-off between a scar (the cost) and rejuvenation (the benefit). An equivocal results is not worth the time and expense.
Occasionally, patients inquire about a “midface lift.” This term refers to the elevation of the cheek (malar fat pad). Some pioneering surgeons attempted to elevate the cheek using the same lower lid skin incision used to perform a lower blepharoplasty. It seemed like a good idea to try to make maximum use of this eyelid incision. But this approach did not work well in practice and, to their credit, the authors quickly alerted other plastic surgeons of its shortcomings.
Short Scar Facelift
“Short scar” procedures have an obvious marketing appeal. After all, who doesn’t want less scarring? The short scar facelift reduces the length of the scar behind the ear and may suffice in younger patients. But Dr. Daniel Baker, the author of this technique, cautions that older patients with loose neck skin are not appropriate candidates. Limiting the scar behind the ear may compromise the degree of neck skin tightening that may be achieved. Also, the abbreviated postauricular scar may cause skin puckering behind the ear (“dog ear”), a visible stigma of surgery. Further, only the portion of the scar that is normally well-hidden behind the ear is shortened. The more conspicuous portion of the facelift scar, in front of the ear, remains the same. When combined with an extended temple incision, the scar cannot be considered short.
The MACS lift (short for “Minimal Access Cranial Suspension” lift), popularized by two Belgian plastic surgeons, has been adopted by some surgeons in the U.S. Although the technique is labeled “minimal access,” the zigzag scar may be conspicuous in the temple, where it can be visible along the hairline. Recognizing its limitations in treatment of the neck, the authors added an incision behind the ear. The incision now resembles a typical facelift scar and cannot be considered minimal. The lift relies on large, permanent “purse string” sutures placed in the SMAS, which is not undermined or released, so that its movement is limited. The lift relies on the sutures alone, which tend to loosen in the tissues over time. A variation on the MACS lift is the QuickLift, which makes use of a similar suturing method.
Lengthy Temple Incisions Are Unnecessary
Ironically, the “short scar” and MACS lift include lengthy incisions in the temples, which is the portion of the facelift scar which may be abbreviated without compromising the result, and a conspicuous portion of the facelift scar. It makes more sense to shorten the scar in the temple, where it is obvious, than behind the ear where it is usually is well-concealed.
In fact, the incision I use is no longer than the short scar and (original) MACS lift incisions—it is just positioned differently—shorter in the temple and a little longer behind the ear. Patients need to be able to wear their hair up and back, exposing their ears, without worrying about scars.
Any incision in the temple (which is used in most facelift dissections, including the short scar and MACS lift) is avoided so as to eliminate a potential scar. Almost all women (and men) can wear their hair short or up without worrying about a visible temple scar. Swelling in this area gradually resolves. The “short scar” incision starts in the temple and ends in the crease behind the ear. This scar is longer in front, where it is visible and shorter behind the ear, where it is inconspicuous. Patients with loose neck skin require a longer incision behind the ear. Fortunately this portion of the scar is usually well-hidden within the hair.
Our survey showed that 98% of patients were satisfied with their facelift scars (Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane facelift. Plast Reconstr Surg. 2011;127:823-834). This high degree of scar satisfaction is reassuring, and allows the surgeon to use the procedure to maximum effect without being preoccupied by concerns about scarring.
The scar is the “cost” of this procedure and needs to be good enough so as not to outweigh the benefit. It does not take much scar deformity to negate a modest benefit in rejuvenation. Ideally, there is a substantial reduction in apparent age without a conspicuous scar. Marginal rejuvenation in the presence of a conspicuous scar deformity is obviously a net negative.
Complete Facial Rejuvenation
The 4 R’s of Facial Rejuvenation
The 4 R’s of facial rejuvenation are:
- Redrape (facelift)
- Relax (Botox or endoscopic forehead lift)
- Resurface (laser skin resurfacing)
- Refill (fat injection)
Many aging women have both saggy skin and wrinkles. They can benefit from both a facelift and laser skin resurfacing, so it makes sense to combine these procedures. Men tend to be more concerned about saggy jowls and necklines than about wrinkles, but they often elect to have other procedures such as fat injection or a forehead lift.
Most patients over 45 elect to have combined procedures. Plastic surgical procedures may be likened to paints on an artist’s palette. The more we have to choose from, the more lush the result. With many paints on the palette, we can often achieve dramatic results, providing a congruous, top-to-bottom facial rejuvenation. Once patients elect to have laser skin resurfacing and a facelift (which largely determine the length of recovery), other techniques can be added on without extending the recovery time or discomfort level, such as fat injection, eyelid surgery, and a forehead lift. Advantages of a single operation include a single recovery time and a single period of time away from work. Another advantage of combined procedures is the price. Plastic surgeons typically discount the price of additional procedures when they are done simultaneously. Of course, some patients prefer to start with one procedure. They may be nervous and need to develop a trust level with their surgeon. Or they simply need to prioritize financially and some things will just have to wait.
Safety of Multiple Procedures
There is no “safe” number of procedures. Typically, a single procedure, such as a facelift, involves more incisions, time, and tissue trauma than all of the other facial procedures combined. Combining procedures optimizes the result. However, combined procedures are not for all surgeons and not for the novice. Before undertaking combined procedures, the surgeon must be an expert in each procedure done individually and must do them regularly. Efficiency is mandatory to avoid excessively long operations. In my practice, operating times rarely exceed 6 hours. Any advantage of combined procedures is lost if the recovery is especially difficult.