There are many different techniques that come under the heading of “facelift.” This can be confusing for the consumer as they research what facelift technique is best for them. Certainly not all facelifts are created equal. I have been performing facelift surgery for over 20 years. The following composition explains how our current technique of choice, the Simplicity Lift, evolved and the key components that set it apart from more traditional facelifts.
For many years the term “facelift” conjured up images of large incisions and lengthy surgery with prolonged recovery and downtime. Over the years, the demand for less invasive methods with less downtime has increased. Patients are requesting (sometimes demanding) a simplified version of a traditional facelift, which makes for an easier recovery for the patient, in addition to less downtime and a natural, rejuvenated appearance, which does not look overdone or surgical.
What is a facelift? You can think of a facelift in terms of a cheek and neck lift as it really focuses on the lower face and neck. Many people have the misconception that a facelift includes an eyelid lift and a brow or forehead lift. This is not so. Blepharoplasty (eyelid lifts) and forehead lifts are distinctly different procedures from a facelift. Although not inherently part of a facelift, they can be performed at the same time as a facelift. A neck lift, clinically referred to as a submentoplasty, can be incorporated into a facelift to maximize improvement in the neck.
Let’s talk about the basic fundamentals that go into a facelift. First, there needs to be adequate exposure to be able to effectively complete the work. Older techniques entailed an incision extending from the temple to the front of the ear, behind the ear, and then into the scalp behind the ear. When incisions are that long, the skin flaps that result may not have enough blood supply which can lead to delayed healing or skin necrosis (a complication which results in the death of skin tissue).
Shorter incisions are less likely to have blood supply and scarring issues. However, the incisions need to be long enough to be able to perform the maneuvers that will elevate and suspend the lax, sagging tissues of the cheeks, jawline and neck. In my opinion, if the incision in front of the ear doesn’t extend to behind the ear then there isn’t enough exposure of the muscle in the neck, called the platysma muscle, to get adequate tightening of the platysma which will compromise the results seen in the neck. Extending the incision into the crease behind the ear (postauricular sulcus) also allows for better redraping of skin in the neck. I have tried to work with an incision that is in front of the ear only and the results are not as good.
The key to successful facelifting is how the surgeon deals with what is known as the SMAS (an abbreviation for superficial muscular aponeurotic system), which is a fibromuscular layer of tissue in the cheek and neck. It is important for this layer of tissue to be elevated sufficiently to obtain an adequate “release” from its underlying attachments, which will allow for more freedom of movement or mobility of the SMAS, which in turn will allow for better advancement or lifting of the SMAS. An inadequate release will limit the amount of movement of the SMAS and, therefore, will result in less lifting of the tissues.
The fixation or suspension of the SMAS is another fundamental of facelifting. Studies have shown (after evaluating five different fixation sites) that the most stable fixation point in facelifting is the tissue overlying an arch of bone in front of the ear called the zygomatic arch. That is why we use this as the suspension point for the Simplicity Lift.
The vector or direction of the lift should be vertical, not back. As we age, the tissues descend in a vertical direction, not forward. So if we want to reposition the facial and neck tissues more where they used to be, it would make sense for the lifting vector to be vertical. This, in turn, will usually provide some added support to the mid face, as well.
I have found that how the fixation is done is very important, as well. Experience with thousands of facelift cases has shown us that using a suture technique known as a “figure of eight” (which we refer to as a pulley stitch) allows for better tightening of the tissue with less tendency for the tissue to tear or give way than a single loop of suture with a knot.
For better contouring, it is very common for some degree of liposuction to be done in the areas of the jowls and/or the neck. This helps to produce a more angular jawline and better definition of the angle between the neck and chin.
If the aging of the neck is more advanced, then many patients will benefit from the simultaneous performance of a neck lift or submentoplasty. The neck lift entails the surgical removal of a fat pad below the platysma muscle and the suturing of the two muscles together known as a “plication.” This will produce a continuous muscle sling of support, which will result in a more defined angle between the neck and chin.
Finally, the skin closure should be done without tension of the suture line. This will result in a fine line scar, which will be very hard to see.
There are many nuances to facelifting that can make or break the outcome for the patient. With the Simplicity Lift, I have tried to incorporate all of the basic fundamentals of the procedure. This technique is designed to maximize the benefit to the patient while minimizing downtime and providing the patient with very natural appearing results.
(Authored by Dr. Dominic Castellano)