“Mini Facelift,” “Total Facelift,” “Deep-plane Facelift,” “Lower Facelift,” “Facelift with Fat,” “Necklift,” “Forehead lift,” or “Endoscopic Facelift.” These are some of the most popular terms that patients use when they inquire about facelifting and facial rejuvenation procedures. However, there is tremendous confusion about the facelift types, as well as options and indications for facial rejuvenation. At Los Angles Plastic Surgery, we offer a state-of-the-art and cutting-edge approach to holistic facial rejuvenation.

Plastic surgeons of varied skill levels use very different ways to try to rejuvenate the face and still call all these different and diverse methods “facelifts.” For example, one plastic surgeon may perform a mini facelift simply by excising and pulling facial skin. Another plastic surgeon may claim to do a facelift using fat grafting to the face only. They will both call them facelifts, but they are not the same operation. In addition, none of the two examples mentioned would qualify to be called an effective facelifting procedure.

That creates a lot of confusion to those considering a facelift procedure. Worst of all, patients think that all facelifts are the same, which is untrue and can lead to poor selections of procedures and unnatural or less desirable results.

For simplicity, here is a division of the facial areas in three (3) major sections.

• The upper third includes the forehead and eyes.
• The middle third is the midface.
• The lower third is the neck.

Each of these areas is a separate area that can be rejuvenated with a lifting procedure, but they are not all “facelift” procedures.

Upper Face: Forehead, Brows and Eyes

What are the main aging changes that occur to the upper third of the face? The brows tend to begin descending after the age of 28 in women and 30 in men. The forehead elongates and forms wrinkles. Brow descent causes upper eyelid hooding that can be mistaken by most inexperienced plastic surgeons as a problem of the upper eyelids. In reality, as the forehead and brows descend, they also drag the upper eyelid skin and give the appearance of a tired look and an aged appearance. This process also makes the eyes look smaller.

Thankfully, there is an excellent treatment for the upper third of the face. That is called the endoscopic brow lift. It differs from the classic browlift in that it is done by creating three very small incisions in the hairy part of the scalp. These incisions are 1.5cm each. They allow the passage of the endoscopic camera and fine instruments, just like laparoscopic surgeons use in the abdomen and pelvis.

The results of this operation are the following:

• Raises the brows
• Shortens the forehead
• Removes the horizontal and vertical wrinkles of the forehead and in between the eyes
• Most importantly it “opens up the eyes”
• Corrects mild and moderate cases of upper eyelid ptosis and hooding without the patient requiring upper blepharoplasty surgery

Patients acquire a fresh, youthful and engaged look after this procedure, which is one of the most advanced and recent innovations in facial plastic surgery.

All of this is done without visible scars and without the patient looking surprised or unnatural afterward. Think of this minimally-invasive procedure as a “facelift of the upper third of the face.” This operation takes about an hour, it is outpatient, entails minimal swelling and recovery is within a week.

The Midface: Middle Third of the Face

The midface is where a true facelift will occur. The five most visible signs of aging that present on the midface are the following:

• Loss of zygomatic prominence and fullness
• Lower eyelid elongation and tear-trough deformity
• Deeper and elongated naso-labial folds
• Drooping of the corner of the mouth giving off a sad look
• Jowl formation which ruins the jawline shape and widens the lower face

The cornerstone for midface rejuvenation is a structure called the malar fat pad. The malar fat pad is an anatomic facial structure consisting of dense fibrous fibers, muscle fibers and fat and it forms the most voluminous part of the midface. It is responsible for the Zygomatic prominence of youth. As it begins to sag with age, it causes deep and elongated nasolabial folds, and it makes the corner of the mouth droop, creating an expression of sadness. It causes flatness over the zygomas, or cheekbones. It increases the distance between the lower eyelid and the cheek. And worst of all, it creates the jowls, which in turn, ruin the jawline and widen the lower face.

The most common reason causing patients to come to a plastic surgeon’s office to discuss facial rejuvenation procedures is when they see the emergence of jowls. The only ethical, effective and long-term treatment for jowls is a meticulous facelift.

The treatment to correct all the aforementioned signs of aging in the middle third of the face is a proper facelift, which is done with incisions in front and behind the ears. The skin is raised, and the plastic surgeon must raise the deep facial tissues and restore the anatomy of youth. (That is why “thread lifts” are not facelift procedures and cannot be classified as such, because they act only on the skin and are unable to lift the required deeper tissues).

The main goal of the facelift is to elevate the anatomic structure described earlier, called the malar fat pad. Most surgeons will try to accomplish this by elevating, undermining and lifting a fibromuscular layer under the facial skin called the SMAS (Subcutaneous Musculo Aponeurotic System). When the undermining of this layer is deep and extensive, it is called the deep-plane facelifting technique. In general, most facelifts in the world are SMAS facelifts, and the plastic surgeons performing them can typically perform a limited undermining of the SMAS.

The effects of this technique are quite varied, however, because the SMAS can be weak and thin in many persons. A weak SMAS cannot effectively lift the midface. Other more effective techniques exist in which the important structures like the malar fat pad are lifted and repositioned directly.

Regardless of the technique used, the successful outcome is the one that can restore the five signs of midfacial aging described earlier. This operation takes about 3-4 hours because it is very delicate.

Surgeons that claim they do a facelift in an hour or so, are not doing a facelift that will address the important signs of aging. They do an operation that typically relies on pulling and removing skin and does nothing for the deeper structures. After about a year, the skin stretches again, and patients often complain that they look the same as before or worse.

Minimally-Invasive Midface Suspension

A very exciting recent innovation in facelifting is that, in certain patients who are good candidates for the procedure, their facelift can be done percutaneously. Dr. Anastasatos calls it the MIMS procedure, which stands for “Minimally Invasive Midface Suspension.” Percutaneously means that there are no classic cuts in front and around the ears. The technique utilizes special microsurgical equipment and only a single three (3) cm incision in the hairy part of the temporal scalp. Since no facial skin is cut or lifted, the recovery is very fast, usually within three days.

The ideal candidate for this procedure is a patient in his or her 40s that does not have significant skin laxity of the face and neck but has the appearance of the signs of aging discussed earlier, more importantly, jowls and midface flattening.

The Lower Third of the Face: The Neck

Neck laxity is largely due to the relaxation and stretching of a broad paired muscle (it has two halves), that extends from the undersurface of the jaws all the way down to the collar bones. When this paired muscle relaxes, it pulls the skin, which relaxes, too. This muscle is called the platysma.

The neck is often the first to reveal aging, so people are sensitive to its appearance. The treatment is the necklift. This is done by utilizing an incision behind the ear, which is not noticeable. Sometimes a small incision under the chin must be utilized as well. The best necklift procedures create a tight “corset” of the platysma muscle of the neck, which in turn will offer wonderful neck and jawline definition.

The necklift is an entire separate operation than the facelift. Often many plastic surgeons will address the face with a facelift but not do a necklift. This creates an unbalanced-looking face that does not look natural. The facelift and necklift procedures should be performed together for ideal and superior results.

Choose the Best Plastic Surgeon for Your Facelift Procedure

The best facelifting procedures to rejuvenate the face and neck can only happen when the plastic surgeon can effectively understand the underlying causes of the problems to be treated and can offer ethical, effective, safe and long-lasting solutions. A plastic surgeon’s understanding of the facial anatomy and skill are critical because the face and neck are most complex and challenging anatomically. This approach is not only ethical and long-lasting, but will offer the most harmonious and natural results.

Dr. Anastasatos at Los Angeles Plastic Surgery is a world-renowned plastic surgeon with extensive experience and expertise in advanced facelift and rejuvenation procedures. Contact our office in Beverly Hills to schedule a consultation to find out which is the best facelift procedure for you.