James J. Romano, MD
The facelift was first introduced in the early 1900s, and consisted of a small incision in front of the ear where loose excess skin was removed. Systematic advances throughout the years have improved this basic technique to the point that, in the last ten years, there has been an explosion of new methods and techniques. As a result, patients may become confused with different opinions and options. I am very clear on what I offer and why in facial rejuvenation, and I have written this document to clarify all of this.
Today, the mini-facelift is sometimes conceptualized as being the same “minimal” operation that began nearly a century ago. Although the inconspicuous incision is similar, today’s technique and results are far greater. The incision is typically from the sideburn, along the front of the ear, and stops at the earlobe or slightly behind. The mini-facelift provides more than a minimal result. It disturbs slightly less tissue as its main advantage, but risks, healing time, and results are comparable for the standard facelift. It can safely and predictably be repeated years later for touch-ups, and it doesn’t interfere with the option to have a standard or full facelift performed at a later date. The indications for a mini-facelift are patients who have heavy laugh lines, laxity, fat excess, and folds confined to above the jawline, and only minimal laxity in the neck.
So, why undergo the mini-facelift? If your expectations and anatomy are appropriate, primarily because today’s baby boomer population wants minimal surgical interventions that can make a big difference. It greatly appeals to younger or more active patients, especially those who don’t need an extensive or full facelift but still would benefit from a “refreshing” procedure. Also noteworthy is the fact that physicians have learned how to apply the principles of the larger facelift procedures to improve the benefits and longevity of the mini-facelift. Combine this with the fact that people want to return to work and active lifestyles as quickly as possible and not look as though they’ve had a facelift, and the mini-facelift is the perfect answer for many.
The Standard or Full Facelift
The second basic category of facelift is that of a standard or full facelift. The indications for offering this facelift instead of the mini-facelift lie in the fact that there is significant laxity, fat, or loose skin below the jawline, in addition to the features noted above. The standard facelift is somewhat more extensive than the mini-facelift. The incision is the same but slightly longer behind the ear and into the hairline so that tightening neck muscles and more removal of loose neck skin can be accomplished. It disturbs slightly more tissue and provides a more extensive result when needed, but risks, healing time, and results are comparable for the mini-facelift. It also can be safely and predictably repeated years later for touch-ups, and doesn’t interfere with the option to have a repeat mini or full facelift performed at a later date.
Deep Face Lift
The third basic category of facelift is what I will describe as what most doctors call the deep facelift. It can go by several names and descriptions, but they are all basically the same. As the name indicates it is performed at a level deeper than the above two procedures. It does not necessarily address the anatomy of deeper structures (like the muscle or bones); it is just that the surgery goes deeper and moves (mobilizes) deeper structures. Inherent in this surgery is a much greater degree of surgery, more swelling, and more risk. These are acceptable trade offs when the surgery is necessary, which is rare. Most patients and their anatomy are treated just fine with the mini or standard facelift. I perform this surgery and am careful to point out when you are a candidate for the deep facelift.
Anatomy of the Face
The anatomy of the face as it concerns the standard facelift and mini-facelift deserves some review. Examination of your own face can be the same as what I do in the office and should focus on skin, subcutaneous fat, muscle tone, and underlying bony foundations. Evaluate the skin not only for its texture, but also take care to note the elasticity, folds, looseness, and mobility. The subcutaneous fat is mostly localized to the areas of the face off to the side of your laugh lines, and settles over time and with gravity into the jowl and can hang over the border of the jaw and onto the neck. In addition, note the fat in the cheek pads that can descend, as well as the fatty accumulations that may be present in the cheeks in front of the ears. Muscles are most importantly evaluated in the midline of the neck (see Figure 1).
While looking in the mirror at your neck, clench your teeth and push down the corners of the mouth. This tightens the platysma muscle of the neck, which is like a sheet on each side running from the collarbone up to the jawline. The platysma muscle stops near the jawline, where it continues onto the face as a very important ligament called the superficial muscloaponeurotic system (SMAS). This ligament is used very artistically in the modern facelift surgery for internal or deep support, which will be described in the following section.
Performing this clenching maneuver will make apparent or stand out any “bands,” or double folds, in the midline neck—if they are present. These are minimally improved with the mini-facelift—all the more reason that patients without these bands get a great result. Patients with these bands are served well with the standard facelift. Finally, evaluate the jawbone and cheekbones. Sometimes, when the skin is tightened and the fat removed, underlying bony asymmetries can be uncovered, which I am always careful to identify and point out to patients before any surgical procedure. In these cases cheek or chin implants may be a worthwhile addition.
In mini or full facelifts, treatment of the localized fatty accumulations in the face and neck can be done with liposuction, with very dramatic and natural results through the same facelift incision or other tiny (2 mm) incisions. Fat also exists below the muscles in the neck (sub-platysmal fat) or in the middle of the face (buccal fat pads) that can be removed surgically during the procedure.
In general, patients who need features improved mostly above the jawline can benefit from the mini-facelift. Patients who need features improved above and below the jawline will benefit from the full facelift.
Who is a Candidate?
It is fairly straightforward determining who is a candidate for this procedure. I focus on the main areas that can be predictably improved or softened with the modern facelift in this order: excess sagging skin in the cheeks, jowls and jawline; the deep laugh line; descending cheek pads; hanging loose folds of skin; hooding, loose skin of the upper outer eyebrows and eyelids. Less common features such as drooping of the corners of the mouth, fine wrinkle lines, smoker’s lines, small chin, and small cheekbones can also be improved at the time of facelift.
I teach patients to examine themselves and make a decision with the help of the “lift and pull test,” which is easy to do. Looking straight ahead into a mirror, place the hands along the cheekbones to the jowls then gently pull straight back and lift up. If there is much laxity, and a significant and natural improvement is seen in the main features described above, then a facelift is an excellent solution. Note how much laxity and change is produced above the jawline and below. Notice how much of a fold of skin is produced in front of the ear or behind the ear. This will determine if you need a mini or full facelift and how much and where skin will need to be removed.
Bear in mind that there is great overlap in all the facelift procedures and the principles physicians have learned over the years from the deeper and more extensive facelift apply well to the mini-facelift, and vice versa. Knowing and utilizing all procedures just makes me better, no matter which facelift you receive.
Anesthesia for the any facelift has the advantage of including all options. It can be performed using straight local anesthesia only, local anesthesia with light intravenous sedation, or it can be done very safely under a very light general anesthesia, which is my preference. In each type of facelift the incision is custom-designed to best address the specific areas to be improved. It generally follows a line inside the temporal hair down to the upper ear edge, neatly along inside the ear cartilage, and down to the earlobe. From here it may extend slightly up behind the ear, or even over into the hair behind the ear if there is a lot of laxity. The length of the incision behind the ear depends on the amount of excess skin in the neck.
Working through this incision, a space is made under the fat and above the SMAS ligament (see Figure 1) for a certain distance only as far as needed—usually about two inches—until the relaxed fibers of SMAS ligament and cheek pad are identified. I tug on these with forceps to test for improvement while looking at the changes in the face until this looks natural and refreshed. Then I sew the ligament and the cheek pad up and back internally to maintain this result. This maneuver tightens the SMAS ligament, which is connected to the sagging jowl; elevates and emphasizes the cheek pad; and flattens the deep laugh line. This is the same internal or deep surgery that is routinely done on the minimal, standard, and deep facelifts, and it has shown to provide better and longer-lasting results. Any excess fat in the jowls and neck is then liposuctioned through the same incision. Since most of the tightness to the elevated tissues is distributed along the stitches that have been placed in the sturdy SMAS ligament, the skin can be laid gently up in place under no tension, and the excess is neatly trimmed and the edge carefully stitched into place. This decreases the likelihood of wide scars and promotes incisions that heal, for the most part, imperceptibly. After finishing a light dressing is used.
Recovery is comfortable and relatively rapid due to a combination of factors: a very light general anesthetic, good long-lasting local anesthetic, awakening from surgery with no pain, minimal dressings, less disturbance of facial tissues, less swelling, less bruising, and better patient preparation (diet and vitamins) and post-op care (ultrasound, skincare). Usually only mild discomfort is present and lasts for two to three days. I counsel each patient that if surgery is performed on a Thursday or Friday, the majority of the recovery happens over the weekend. This allows the patient to return to some activity and maybe even light work by the middle of the next week with minimal or no bruising and only mild swelling. The patient can shower by the second day and camouflage makeup can be applied as early as the second or third day. On a professional level, I have learned the importance of carefully supervising lifestyle, diet, and nutritional supplements both before and after surgery.
Longevity of this procedure is excellent. I have noticed that most patients are relatively younger and they seek a more active relationship with my skincare clinic in their skin health and care to help maintain and preserve the facelift results. Often, this is a procedure where having surgery earlier in life does seem to contribute to the procedure’s longevity. Most patients find that if revisions are needed, they usually only involve a minor facelift instead of a full facelift. However, a full facelift can still be done at a later date, and is usually safer and easier, can be more aggressive, and lasts longer than the previous facelift.