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Plastic Surgery
Facelift

A facelift (rhytidectomy) is a cosmetic surgical procedure to improve on the aging process that causes the face and neck to sag. It is one of the most common plastic surgical procedures. It is aimed at reversing the effects of gravity, exposure to the sun and smoking.

Anatomy

The muscles and skin of the face and neck work together to produce facial expression

  • The muscles of the face have several common characteristics
    1. The muscles are very superficial (just under the skin)
    2. Neighboring muscle fibers are frequently fused
    3. The muscles have thin delicate fibers that may insert into the skin
    4. The muscles are controlled by the facial nerve, which comes from the brainstem
  • The muscles of facial expression can be grouped into the following (Figure 1)
Figure 1 - Muscles of the face. See text. © N. Gordon
    1. Muscles that surround the eye. The orbicularis oculi muscle, protects the eye from injury by closing the eyelids. The frontalis muscle wrinkles the forehead and raises the eyebrows
    2. Muscles of the nose. These small muscles compress, widen and alter the shape of the nostrils. The procerus muscle wrinkles the nose
    3. Muscles of the mouth. These muscles alter the shape of the mouth by moving the angle of the mouth (levator anguli oris and depressor anguli oris) and lips in various directions (orbicularus oris) and controlling the tone of the cheeks (buccinator)
    4. The superficial muscle of the neck (platysma). This muscle raises the skin of the neck and shoulder
  • The skin consists of two layers, the thin superficial layer called the epidermis and the underlying thicker layer called the dermis
    1. The epidermis consists of a single layer of cells
    2. The dermis contains several different kinds of fibers, some elastic and others non-elastic. Hair follicles and sweat glands are found in the dermis
    3. The skin has a good blood supply that comes from the underlying subcutaneous tissue (fat and fibrous layer beneath the skin) and forms a plexus (network) of fine vessels

Indications

Having a facelift is a voluntary act and, therefore, there are no specific indications for the procedure, however

  • Most individuals who request this procedure are 40 to 70 years of age
  • The individual has sagging of the face and neck but the skin still has some elasticity
  • The bone structure is well-define

Contraindications

There are no specific contraindications to this surgery other than the person may have a medical condition such as severe heart disease. There are relative contraindications.

  • Several medical conditions may lead to complications during or following surgery. Very high blood pressure or a blood clotting problem may lead to bleeding. Aspirin may affect clotting and, therefore, should be reported to your surgeon
  • The individual should not smoke for at least two to four weeks prior to surgery since nicotine may cause constriction of the plexus of blood vessels in the skin · The person may be a keloid (a heavy thick scar) former
  • The individual should be realistic as to what to expect from a facelift. A facelift may make a person look younger and enhance self-confidence but it cannot create a different person or completely different look

Surgical Procedure

A facelift may be carried out either in a hospital, an outpatient or ambulatory care facility under either a general anesthetic (asleep) or with local anesthetic (awake) and a sedative.

  • After the anesthetic has been given, the surgery begins with an incision that starts behind the hairline of the temple, is carried down in front of the ear, then curves behind the earlobe to the scalp behind the ear (Figure 2A)
  • Carefully, the skin is separated off of the facial muscles and skin fat. Some of the fat may also be removed particularly about the chin and neck (Figure 2B)
Figure 2a - Surgery of facelift procedure. See the text for details. © N. GordonFigure 2b - Surgery of facelift procedure. See the text for details. © N. Gordon
  • The muscle are tightened and the skin is then pulled back towards the incision line and the excess skin trimmed (Figure 2C)
  • A small drain tube may be placed under the skin and brought out behind the ear to get rid of an blood that may collect
  • The incision is then sutured closed (Figure 4D)
  • The head is then wrapped in a loose bandage that gently helps prevent fluid collection and bruising
Figure 2c - Surgery of facelift procedure. See the text for details. © N. GordonFigure 2d - Surgery of facelift procedure. See the text for details. © N. Gordon

Complications

  • Bleeding under the skin flap causing a hematoma (collection of blood) that may have to be drained
  • Infection
  • Skin necrosis (death of an area of the skin flap). These result from interruption of the plexus of vessels in the skin flap. This occurs more often with smoker
  • Poor healing of the skin. This also occurs more often with smokers
  • Keloid (heavy scar) formation · Injury to the facial nerve with facial paralysis. This may be temporary or permanent
  • Allergic reaction to the local anesthetic

Care After Surgery

  • Swelling and bruising of the skin gradually disappears over several weeks but this may even take months
  • Pain can usually be controlled with pain medication taken by mouth, however, a sudden increase in pain should be reported to the surgeon · Drains are removed in one to two days and sutures removed in two to five days
  • The head should be elevated as much as possible since this reduces swelling
  • All patients have some numbness after surgery, which usually disappears after a variable length of time
  • There is normally some asymmetry of the face and, therefore, some asymmetry of the face after surgery is usual. Symmetry of the face should not be expected
  • The return to normal activity is gradual with no heavy work being done for two to four weeks. Follow the surgeon's instructions for returning to normal activity
  • Makeup can usually be applied in two to four weeks