Facelift – Is It Skin Deep?

My facelift philosophy

The facelift is the most sophisticated, delicate, refined and creative combination of procedures performed together during one operation to reverse the visible signs of aging of the whole face and neck. The most beautiful successful facelifts address all the multiple anatomic parts of the aging face and neck simultaneously.

As a Beverly Hills plastic surgeon treating facial aging, it makes me very sad to see that the effect of aggressive marketing and commercialization of cosmetic facial procedures has led to the misleading perception that face-lifting success can be often created by minimal and simple non-invasive procedures.
For example terms like “one hour facelift, “mini-facelift”, “lunchtime facelift”, “non-surgical facelift”, “laser facelift”, “liquid facelift”, “vampire facelift”, “stem cell facelift”, serve to create the illusion that these procedures are by themselves adequate or equivalent to full facelifts in restoring the true causes of facial aging. They may create a fallacy that such facial procedures of lesser magnitude and efficacy could be equally as effective as the time-tested procedures that correct the multiple of causes of facial aging at the different anatomic layers of the face and neck.

Moreover we are often made to believe that non-invasive laser and injectable treatments can be alone “as good” in reversing the signs of aging and replace the value and need of a properly performed facelift. It may be true that in some young patents minimally-invasive anti-aging procedures can be enough to accomplish a more youthful image. I perform these procedures too and in the proper candidates-young candidates- they work well.

It is also true however that there is no short cut to success in life and this also applies to cosmetic medicine and surgery. The best face-lifting outcomes are the results of detailed facial analysis and synthetic multi-procedure approaches that address all the visible signs of aging on the face and neck. Facial aging needs to be corrected at the level of the skin and also at the deeper levels of the face including soft tissues, muscles, cartilages, ligaments and even bones. Successful facial rejuvenation addresses multiple anatomic areas of the face and neck in order to create a balanced outcome. Can you imagine for instance how un-balanced a face would look if the plastic surgeon only operated on the face and did not do the wrinkly neck at the same time?

Time is also an important parameter in determining the outcome and success of a facelift. The best facelifts take away many years off someone’s face and these results last for many years thereafter. A good facelift will add 9-10 of youthfulness to the patient’s age for life. This means that when someone who is 50 gets a facelift he/she may look 40. This also means that when the same person gets to be 70 she/he will not look that age but instead about 60 years of age.

The results of “mini lifts” do not hold up for a long time. Mini-lifts last a year or two and I personally consider them a disservice to patients. They are “cheap” in every meaning of the word alternatives to a proper facelift and necklift.

How about “thread-lifts”? The most important thing to know about them is that they are not facelifts. The are not designed to be able to lift the deeper tissues of the face hat have descended with time. They are not effective anti-gravity measures. What they do is simply provide the sensation of skin tightening in certain areas of the face.

So why are they so popular for decades especially in Europe and Asia? Scientific studies have shown that their result is causing some swelling after the procedure that lasts for about 6 months after. Patients like this swelling effect because this minimal facial swelling is volumizing to the face and also makes the facial skin look younger. Furthermore in Europe and Asia they employ threads made by materials such as silicone and nylon which can offer greater pull on the skin that are permanent but they also come with a higher rate of complications such as infection, palpable knots, extrusion and asymmetry.

At my plastic surgery clinic in Beverly Hills I pay particular focus and attention to face-lifting operations. Nothing is more rewarding and empowering than a skillfully performed elegant facelift. All cosmetic plastic surgery procedures have powerful effects because they change one’s self-image. Facelifts go a big step further. If I change one’s body I change their self-image and therefore I can change what is possible and available to them in this world. However If I change someone’s face I may do more; I change their lives. Patients become more powerful. This to me is the core and the beauty of well-performed plastic surgery. It is not just about physical alterations. It is about psychology and empowerment.

Our face is our personality. The facelift therefore is not a superficial operation.

My typical approach to rejuvenating the face includes the following procedures performed during the same operation:

• Endoscopic brow lift
• Midface lift
• Eyelid tightening
• Nose reshaping
• Lip rejuvenation
• Chin lift
• Neck lift
• Earlobe repair
• Fat transfer to the face (optional)
• Chemical peel to the face, neck and chest

Facelift and Mid-face Lift

This is a minimally invasive procedure. This means that it is done utilizing only three tiny incisions, each one of which measures about 2 centimeters and they located at the hairy part of the scalp. They typically heal well, and it may be hard to notice them post-operatively. They are concealed by the hair.

The endoscopic browlift raises the brows, can make the brow position more symmetric, lifts the forehead and can remove permanently the frown lines in between the brows in the glabellar region. These actions can limit the need for future botox treatments in those areas.

The most impressive action of the endoscopic brow lift though is that it opens up the eyes.

A properly performed endoscopic brow lift will not make a patient have a “surprised” look. It will look natural. Facial rejuvenation cannot ever be ideal or complete if the peri-orbital region is not rejuvenated. The endoscopic brow lift is the most effective means for rejuvenation of the upper third of the face. The brows begin to descend at about the age of 28 in women and 30 in men. As they descend they create upper eyelid hooding. Upper eyelid excision alone or blepharoplasty is not enough or adequate to correct. Often both an endoscopic brow lift and upper eyelid surgery will be needed at the same time.

The endoscopic brow lift can also be performed to men who are bald because the incisions are small and can be hidden in natural skin creases of the forehead and scalp.There are certain patients that may need forehead reduction, which I can perform at the same time as the endoscopic brow lift and without performing the painful operation of scalp advancement. In this case the brow lift I perform is called the “Bi-planar brow lift” An endoscopic brow lift is done, and then an incision is made at the hairline in order to plicate the Frontalis muscle and create skin excess from the forehead lift that can then be excised and shorten the forehead. A shorter forehead is a more youthful or younger forehead.

Necklift

Cheek Fullness:This procedure raises the tissues that have been stretched and descended over time and gives malar prominence or cheekbone prominence and fullness. This is a very youthful sign. Children and young adults who have prominent or chubby cheeks exemplify this effect well. It is a sign of youth. Also women from Eastern European countries who have naturally prominent cheeks present evidence of the youthful and beautiful effect of the mideface lift.

Correction of prominent nasolabial folds:The nasolabial folds get elongated and deeper with advancing age. Although injectable fillers like hyaluronic acid can be effective in effacing them partly the are not enough to correct the underlying cause. The cause of deeper and prominent nasolabial folds is the descent of the Malar Fat Pad or the thick cheek soft tissues. Therefore proper, effective and long-lasting correction consists of Malar Fat Pad elevation and fixation.

Eyes:They develop laxity of the skin and supporting muscles with age that can be treated and corrected at the same time of a facelift. It may be often advantageous to perform eyelid correction together with a midface lift because the lifted cheeks add extra support to the eyelid repairs. Furthermore the aesthetic result can be superior.

The midface lift however alone will improved the lower peri-orbital aesthetics. When the Malar Fat Pad or cheek soft tissues descend then this creates a “hollow” or “tear trough hollow” at the lower eyelid-cheek junction. This tear-through area is not present in youth and it is a prominent aging sign. Malar Fat Pad elevation as I perform it improves the tear-trough deformity and furthermore yields peri-orbital rejuvenation.

Corner of the mouth:The corner of the mouth gets saggy with age and the artful facelift can lift it. A saggy or ptotic corner of the mouth is a prominent sign of aging. It exudes a sad appearance for the patient. Midface lifting with direct Malar Fat Pad elevation corrects and elevates the corners of the mouth.

Jowls: Jowls are awful and represent the main “trigger” to make people seek a consultation for a facelift. The jowls may be very hard to remove or elevate completely. However when that is accomplished the well-defined jaw line that gets created contributes to the beautiful face. To me this is one of the areas that allows the plastic surgeon to excel when performing a facelift. The jowls represent the inferior extension of the Malar Fat Pad as it descends inferiorly. Raising the Malar Fat Pad and elevating the midface will therefore also correct the jowls. Some surgeons who do not understand the relationship of the jowl fat and the malar fat pad will treat the jowl fat with direct liposuction. That works too to reduce jowls and make them less prominent. Yet this technique alone does nothing to address the he aging signs of the face and midface.

Injectable fillers, Botox, laser treatments do not remove jowls. Only Malar Fat Pad elevation with midface lift does. Adding a SMAS elevation or plication technique to the direct Malar Fat Pad elevation will also further improve the jowls and the jawline.

Nose: The nose gets longer, bigger and droopy with age. Especially the tip of the nose. A tip rhinoplasty or endoscopic performed rhinoplasty can both help improve the aging nose.

Lips: The lips get smaller with age. They can be filled and corrected with natural tissues from the face during a facelift. The upper lip can get shortened at the time of the facelift operation, as it also gets longer with age. This can be done at the same time with a procedure called upper lip lift. Furthermore many patients suffer from prominent visible “smoker’s lines” or “smokes lines” on the lips even if he never smoked. They are more prominent in the upper lip. I treat those smokers’ lines with dermabrasion at the same me of the facelift surgery, or a chemical peel like TCA (Tri-Chloroacetic-acid) peel. Additionally smokers’ lines can be treated with injectable hyaluronic acid fillers and botox.

Chin: The chin can sag with advancing age and can also be lifted by a chin lift procedure at the same time of a facelift. This in some patients can be pronounced and called “witch’s chin. I can correct “which’s chin” with a minimally invasive way through an incision on the buccal sulcus, which is inside the mouth and without external scars.

Ears: They get bigger and the earlobes longer with age. They can be shortened at the time of the facelift surgery. This is more common in ladies who have been wearing heavy earrings over the course of many years that have served to stretch the earlobe.

Buccal Fat Pad Resection: This is a procedure designed to thin the lower face immediately below the cheek. Some people have prominent and voluminous buccal fat pads. Buccal fat pad resection can be performed as an isolated procedure or in combination with a facelift procedure. The result is to offer a slimmer facial contour at a level parallel to the corner of the mouth.

Fat Transfer to the Face

The principles of neck rejuvenation include:

• Liposuction
• Tightening of the neck muscles by corset platysmaplasty
• Skin lifting and re-draping

Sub-platysma fat resection, submandibular salivary gland resection and resection of the anterior belly of the digastric muscles are additional procedures to be discussed at the time of the pre-operative facelift consultation.

When the soft tissue elevation of the midface is not enough to create sufficient cheek augmentation and projection then fat can be harvested from the body and transferred to the face. Fat can be also added to multiple areas of the face to give volume where needed including the lips, nasolabial folds and wrinkles that are hard to remove via face-lifting.

Popular areas of fat grafting to the face are: eyelids, cheeks, nasolabial folds, labiomental folds, lips, temples, forehead, glabella. Additionally fat can be added to the jaws to create stronger jawlines.

The benefit of the fat can also be improved skin texture.

Summary

The facelift is not one procedure. A facelift operation is the synthesis of multiple procedures performed by the plastic surgeon during the same operative time to improve the most visible and bothersome signs of aging of the face and neck. The main ones are listed below.

Forehead and upper third of the face:

• Brow descend and ptosis
• Forehead wrinkles
• Glabellar wrinkles (also called “11’s)
• Upper eyelid hooding
• Long forehead

Face and Midface:

• Loss of cheek projection and flatening of the face.
• Prominent nasolabial folds
• Jowls
• Tear-trough deformities
• Droopy corners of the mouth

Neck:

• Double chin
• Skin laxity
• Muscle (platysma laxity)
• Loss of youthful angle between the neck and jaw (loss of cervico mental angle)
• “Turkey neck”

When all the visible signs of an aging face and neck can be corrected at the same time the aesthetic outcome is superior and profound. Good facelifts do not only improve the face but changes lives.

This article was written by facelift plastic surgeon Dr. John Anastasatos. Dr. Anastasatos is a Beverly Hills plastic surgeon with a particular interest in face-lifting procedures and treatments.

JOHN M. ANASTASATOS , M.D., FACS
Board Certified by the American Board of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery
Member, American Society of Plastic Surgeons
Former Assistant Professor in plastic surgery at The University of Alabama at Birmingham
Expert Reviewer for the Medical Board of California