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Facelifting

Facelifting was first performed in the early 1900s and for most of the 20th century involved skin undermining and skin excision. A revolution occurred in the 1970s when the public became exponentially more interested in the procedure and Skoog described dissection of the superficial fascia of the face in continuity with the platysma in the neck. Since then techniques have been described that involve every possible skin incision, plane of dissection, extent of tissue manipulation, type of instrumentation, and method of fixation. Many of these “innovations” provide little long-term benefit when compared to skin undermining, and expose the patient to more risk. The trends in facelifting at the present time are best summarized as follows:

  1. Volume versus tension—Placing tension on the skin is an ineffective way of lifting the face and is responsible for the “facelifted” look and for unsightly scars and distortion of the facial landmarks such as the hairline and ear. The current trend is toward redistributing, or augmenting, facial volume, rather than flattening it with excessive tension.
  2. Less invasive—That the more “invasive” techniques have not yielded benefits in proportion to their risk combined with the public demand for rapid recovery has led to simplified procedures.
  3. Facial harmony—The goal is to help a patient look better, not weird or operated on. Excessive tension, radical defatting, exaggerated changes, and attention to one region while ignoring another may result in disharmony. The face is best analyzed and manipulated with the entire face (and the entire body) in mind, not the individual component parts, lest the “forest be lost for the trees.”
  4. Recognition of atrophy—The process of aging involves not only sagging of the tissues and deterioration of the skin itself but atrophy of tissues, especially fat, in certain areas. Most patients are best served with limited defatting and may require addition of fat to areas of atrophy.

Facelifting addresses only ptosis and atrophy of facial tissues. It does not address, and has no effect on, the quality of the facial skin itself. Consequently, facelifting is not a treatment for wrinkles, sun damage, creases, or irregular pigmentation. Fine wrinkles and irregular pigmentation are best treated with skin care and resurfacing procedures (see Chapters 13 and 44). Deep creases, such as the labiomental creases, may be improved by facelifting. Other facial creases, however, will not be improved by facelifting (nasolabial creases), and even if improved somewhat, will still require additional treatment in the form of fillers or muscle-weakening agents (see Chapters 45 and 46).

The above disclaimer not withstanding, the facelift is the single most important and beneficial treatment for most patients older than age 40 years who wish to maximally address facial-aging changes.

Patients have individual aging patterns determined by genetics, skeletal support, and environmental influences (Fig. 49.1). Some combination of the following, however, will occur in every patient (those characteristics improved by facelifting are in bold print):

  1. Forehead and glabellar creases
  2. Ptosis of the lateral eyebrow
  3. Redundant upper eyelid skin
  4. Hollowing of the upper orbit
  5. Lower eyelid laxity and wrinkles
  6. Lower eyelid bags
  7. Deepening of the nasojugal groove and palpebral-malar groove
  8. Ptosis of the malar tissues
  9. Generalized skin laxity
  10. Deepening of the nasolabial folds
  11. Perioral wrinkles
  12. Downturn of the oral commissures
  13. Deepening of the labiomental creases
  14. Jowls
  15. Loss of neck definition and excess fat in neck
  16. Platysmal bands

A minority of aging characteristics is improved by facelifting. Those that are addressed, however, are of fundamental importance to the attractive, youthful face. The facelift confers another benefit that is more difficult to define. Aging results in jowls and a rectangular lower face. A facelift lifts the jowls back into the face, augmenting the upper face and narrowing the lower face, producing the “inverted cone of youth.” This change in overall facial shape from rectangular to heart-shaped is subtle but real, and is a benefit that no other treatment modality can provide.

History

The same compulsive medical history that is indicated before any surgical procedure is obtained when evaluating a patient for aesthetic surgery of the face. Specific inquiry is made regarding medications, allergies, medical problems, previous surgery, and smoking and drinking habits. The most common complication of facelifting is a hematoma and therefore the history focuses on factors that predispose to postoperative bleeding, specifically hypertension and medications that affect clotting. Surgery is not performed until the patient has been off of aspirin for 2 weeks. Facelifting is probably contraindicated in patients on warfarin (Coumadin) or clopidogrel (Plavix), even if they are allowed by their physicians to stop these medications. At the very least, facelifting on such patients is performed with extreme conservatism and only after every possible means of eliminating the effects of these medications has been pursued. Hypertension is probably the single factor that most closely correlates with postoperative hematomas, thus blood pressure must be under strict control.

FIGURE 49.1. Aging changes in the face. 1. Forehead and glabella creases. 2. Ptosis of the lateral brow. 3. Redundant upper eyelid skin. 4. Hollowing of the upper orbit. 5. Lower eyelid laxity and wrinkles. 6. Lower eyelid bags. 7. Deepening of the nasojugal groove. 8. Ptosis of the malar tissues. 9. Generalized skin laxity. 10. Deepening of nasolabial folds. 11. Perioral wrinkles. 12. Downturn of oral commissures. 13. Deepening of labiomental crease 14. Jowls. 15. Loss of neck definition and excess fat in neck. 16. Platysmal bands.

Cigarette Smoking

Smoking increases the risk of skin slough, the second most common complication after facelifting (1). Patients are encouraged to quit smoking permanently. Cigarette smoking, with all its deleterious effects on health, and having a facelift to feel better about oneself, are fundamentally contradictory. At the very least, patients should cease smoking 2 weeks prior to surgery. It is important that smokers know that they will never become “nonsmokers;” that is, the effects of smoking never totally disappear, and are certainly not gone in 2 weeks.

Because aesthetic surgery is elective, whenever there is a question about a preoperative medical condition, the procedure is postponed until appropriate consultations are obtained and all issues settled.

Preoperative Photographs

Photographs are essential for at least four reasons: (a) assistance in preoperative planning; (b) communication with patients preoperatively and postoperatively; (c) intraoperative decision making; and (d) medicolegal documentation.

Psychological Considerations

One of the most difficult challenges for the plastic surgeon is deciding which patients are not candidates, on an emotional or psychological basis, for elective aesthetic surgery. Studies suggest that patients frequently harbor secret or unconscious motivations for undergoing the procedure. A patient may state that he/she wants to feel better about him- or herself when the real motivation is to recapture a straying mate (unlikely to succeed).

Patients who have difficulty delineating the anatomic alterations desired or in whom the degree of the deformity does not correlate with the degree of personal misfortune ascribed to that deformity, are not candidates for aesthetic surgery. The tough, 50-year-old lawyer who states that she does not like her jowls is a far better candidate than the seemingly docile patient who cannot articulate what bothers her and defers to “whatever you think doctor.” The surgeon will regret proceeding with an operation when his or her instincts indicate that the patient is an inappropriate candidate.

Preoperative Counseling

At the time of the preoperative consultation the patient is given written information concerning the planned procedure that reinforces the verbal information provided.

In addition to describing to the patient the anticipated results of the procedure, it is necessary to point out the areas where little or no benefit is expected. As described above, the nasolabial folds that may be softened slightly by a facelift but will reappear when the swelling disappears. Ptotic submandibular glands preclude a totally clean appearance to the neck. Fine wrinkles around the mouth will require a resurfacing procedure.

Preoperative Instructions

Patients are instructed to shower and wash their hair on the night before surgery. On the morning of surgery another shower and shampoo are desirable. At a minimum the face is thoroughly washed. Although patients are not allowed to eat anything after midnight, they are instructed to brush their teeth and rinse their mouths with mouthwash.

Given that the single most important step in avoiding a hematoma is control of the blood pressure, patients with any tendency to high blood pressure are given clonidine 0.1 mg by mouth preoperatively. Some surgeons administer the drug routinely to all patients. Clonidine is long-acting, however, and may lead to hypotension in healthy patients. Consequently, I prefer to use it selectively.

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