A facelift, technically known as a rhytidectomy (from the
Ancient Greek
Ancient Greek includes the forms of the Greek language used in ancient Greece and the ancient world from around 1500 BC to 300 BC. It is often roughly divided into the following periods: Mycenaean Greek (), Dark Ages (), the Archaic peri ...
() "wrinkle", and () "excision", the surgical removal of wrinkles), is a type of
cosmetic surgery
Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofa ...
procedure used to give a more youthful facial appearance. There are multiple surgical techniques and exercise routines. Surgery usually involves the removal of excess facial skin, with or without the tightening of underlying tissues, and the redraping of the
skin
Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation.
Other cuticle, animal coverings, such as the arthropod exoskeleton, have diffe ...
on the
patient
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health c ...
's
face
The face is the front of an animal's head that features the eyes, nose and mouth, and through which animals express many of their emotions. The face is crucial for human identity, and damage such as scarring or developmental deformities may aff ...
and
neck
The neck is the part of the body on many vertebrates that connects the head with the torso. The neck supports the weight of the head and protects the nerves that carry sensory and motor information from the brain down to the rest of the body. In ...
. Exercise routines tone underlying facial muscles without surgery. Surgical facelifts are effectively combined with eyelid surgery (
blepharoplasty
Blepharoplasty (Greek: ''blepharon'', "eyelid" + ''plassein'' "to form") is the plastic surgery operation for correcting defects, deformities, and disfigurations of the eyelids; and for aesthetically modifying the eye region of the face. With t ...
) and other facial procedures and are typically performed under general anesthesia or deep
twilight sleep
Twilight sleep (English translation of the German word ) is an amnesic state characterized by insensitivity to pain without loss of consciousness, induced by an injection of morphine and scopolamine, with the purpose of pain management during c ...
.
According to the most recent American Society for Aesthetic Plastic Surgery facelifts were the third most popular aesthetic surgery in 2019, surpassed only by
rhinoplasty
Rhinoplasty ( grc, ῥίς, rhī́s, nose + grc, πλάσσειν, plássein, to shape), commonly called nose job, medically called nasal reconstruction is a plastic surgery procedure for altering and reconstructing the nose. There are two typ ...
and
blepharoplasty
Blepharoplasty (Greek: ''blepharon'', "eyelid" + ''plassein'' "to form") is the plastic surgery operation for correcting defects, deformities, and disfigurations of the eyelids; and for aesthetically modifying the eye region of the face. With t ...
.
History
Cutaneous period (1900–1970)
In the first 70 years of the 20th century facelifts were performed by pulling on the skin on the face and cutting the loose parts off. The first facelift was reportedly performed by
Eugen Holländer in 1901 in
Berlin
Berlin ( , ) is the capital and largest city of Germany by both area and population. Its 3.7 million inhabitants make it the European Union's most populous city, according to population within city limits. One of Germany's sixteen constitue ...
. An elderly Polish female aristocrat asked him to: "lift her cheeks and corners of the mouth". After much debate, he finally proceeded to excise an elliptical piece of skin around the ears. The first textbook about facial cosmetic surgery (1907) was written by
Charles Miller (Chicago) entitled ''The Correction of Featural Imperfections''.
In the First World War (1914–1918) the Dutch surgeon
Johannes Esser
Johannes "Jan" Fredericus Samuel Esser (13 October 1877 in Leiden – 9 August 1946 in Chicago) was a Dutch plastic surgeon who pioneered innovative methods of reconstructive surgery on soldiers wounded in the First World War. He is thought to ha ...
made one of the most famous discoveries in the field of plastic surgery to date, namely the "
skin graft inlay technique," the technique was soon used on both English and German sides in the war. At the same time, the British plastic surgeon
Harold Delfs Gillies used the Esser-graft to school all those who flocked towards him who wanted to study under him. That’s how he earned the name "Father of 20th Century Plastic Surgery". In 1919 Dr Passot was known to publish one of the first papers on face-lifting, this consisted mainly of the elevating and redraping of the facial skin. After this many others began to write papers on face-lifting in the 1920s. From then the esthetic surgery was being performed on a large scale, form the basis of the reconstructive surgery. The first female plastic surgeon,
Suzanne Noël, played a large role in its development and she wrote one of the first books about esthetic surgery named ''Chirurgie Esthetique, son rôle social''.
SMAS period (1970–1980)
In 1968
Tord Skoog introduced the concept of subfacial dissection, therefore providing suspension of the stronger deeper layer rather than relying on skin tension to achieve his facelift (he publishes his technique in 1974, with subfacial dissection of the
platysma
The platysma muscle is a superficial muscle of the human neck that overlaps the sternocleidomastoid. It covers the anterior surface of the neck superficially. When it contracts, it produces a slight wrinkling of the neck, and a "bowstring" effect ...
without detaching the skin in a posterior direction). In 1976 Mitz and Peyronie described the anatomical Superficial Musculoaponeurotic System, or SMAS, a term coined by
Paul Tessier
Paul may refer to:
*Paul (given name), a given name (includes a list of people with that name)
*Paul (surname), a list of people
People
Christianity
* Paul the Apostle (AD c.5–c.64/65), also known as Saul of Tarsus or Saint Paul, early Chri ...
, Mitz and Peyronie’s tutor in
craniofacial surgery
Craniofacial surgery is a surgical subspecialty that deals with congenital disorder, congenital and acquired deformity, deformities of the human head, head, human skull, skull, face, neck, jaws and associated structures. Although craniofacial treat ...
, after he had become familiar with Skoog’s technique. After Skoog died of a heart attack, the
superficial muscular aponeurotic system
Superficial muscular aponeurotic system (SMAS) is an area of muscle, musculature of the face. The SMAS extends from the platysma to the galea aponeurotica and is continuous with temporoparietal fascia and galea. It connects to the dermis via verti ...
(SMAS) concept rapidly emerged to become the standard face-lifting technique, which was the first innovative change in facelift surgery in over 50 years.
Deep plane period (1980–1991)
Tessier, who had his background in the craniofacial surgery, made the step to a
subperiosteal
The periosteum is a membrane that covers the outer surface of all bones, except at the articular surfaces (i.e. the parts within a joint space) of long bones. Endosteum lines the inner surface of the medullary cavity of all long bones.
Structur ...
dissection
Dissection (from Latin ' "to cut to pieces"; also called anatomization) is the dismembering of the body of a deceased animal or plant to study its anatomical structure. Autopsy is used in pathology and forensic medicine to determine the cause o ...
via a coronal incision. In 1979, Tessier demonstrated that the subperiosteal undermining of the superior and lateral orbital rims allowed the elevation of the soft tissue and eyebrows with better results than the classic face-lifting. The objective was to elevate the soft tissue over the underlying skeleton to re-establish the patient's youthful appearance.
Volumetric period (since 1991)
At the start of this period in the history of the facelift there was a change in conceptual thinking, surgeons started to care more about minimizing scars, restoring the
subcutaneous volume that was lost during the ageing process and they started making use of a
cranial
Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...
direction of the "lift" instead of posterior.
The technique for performing a facelift went from simply pulling on the skin and sewing it back to aggressive SMAS and deep plane surgeries to a more refined facelift where variable options are considered to have an aesthetically good and a more long-lasting effect.
Indications
A facelift is performed to
rejuvenate
Rejuvenation is a medical discipline focused on the practical reversal of the aging process.
Rejuvenation is distinct from life extension. Life extension strategies often study the causes of aging and try to oppose those causes in order to sl ...
the appearance of the face. Aging of the face is most shown by a change in position of the deep anatomical structures, notably the
platysma muscle
The platysma muscle is a superficial muscle of the human neck that overlaps the sternocleidomastoid. It covers the anterior surface of the neck superficially. When it contracts, it produces a slight wrinkling of the neck, and a "bowstring" effect ...
, cheek fat and the
orbicularis oculi muscle
The orbicularis oculi is a muscle in the face that closes the eyelids. It arises from the nasal part of the frontal bone, from the frontal process of the maxilla in front of the lacrimal groove, and from the anterior surface and borders of a short ...
.
These lead up to three landmarks namely, an appearance of the jowl (a broken jaw line by
ptosis of the platysma muscle), increased redundancy of the
nasolabial fold
The nasolabial folds, commonly known as "smile lines" or "laugh lines", are facial features. They are the two skin folds that run from each side of the nose (human), nose to the corners of the mouth (human), mouth. They are defined by facial struct ...
(caused by a descent of cheek fat) and the increased distance from the ciliary margin to the inferior-most point of the orbicularis oculi muscle (caused by decreasing tone of the orbicularis oculi muscle).
The skin is a fourth component in the aging of the face. The ideal age for face-lifting is at age 50 or younger, as measured by patient satisfaction. Some areas, such as the nasolabial folds or
marionette lines, in some cases can be treated more suitably with
Botox
Botulinum toxin, or botulinum neurotoxin (BoNT), is a neurotoxic protein produced by the bacterium ''Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neurom ...
or
liposculpture
Liposuction, or simply lipo, is a type of fat-removal procedure used in plastic surgery. Evidence does not support an effect on weight beyond a couple of months and does not appear to affect obesity-related problems. In the United States, lipo ...
.
Contraindications
Contraindications to facelift surgery include severe
concomitant
Concomitance is the condition of accompanying or coexisting. A concomitant is something that accompanies something else.
Concomitant or concomitance may refer to:
* Concomitance (doctrine), a Christian doctrine
* Concomitant (classical algebraic ...
medical problems, both physical and psychological. While not absolute contraindications, the risk of postoperative complications is increased in cigarette smokers and patients with hypertension and diabetes.
These strong relative contraindications consist primarily of diseases predisposing to poor wound healing. Patients are typically asked to abstain from taking aspirin or other blood thinners for at least one week prior to surgery. Patients motivations and expectations are an important factor in order to determine the patient’s medical status. A psychiatric illness leading to unreasonable expectations for the surgical outcome, such as a distorted perception of reality, can be a contraindication to surgery. Some kinds of
hypersensitivity
Hypersensitivity (also called hypersensitivity reaction or intolerance) refers to undesirable reactions produced by the normal immune system, including allergies and autoimmunity. They are usually referred to as an over-reaction of the immune s ...
to
anesthesia
Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...
are a contraindication.
Surgical anatomy
*
SMAS
*
Facial musculature
*
Facial nerve
The facial nerve, also known as the seventh cranial nerve, cranial nerve VII, or simply CN VII, is a cranial nerve that emerges from the pons of the brainstem, controls the muscles of facial expression, and functions in the conveyance of tas ...
:A dissection in the deep plane can mostly be performed safely, because the facial nerve innervates the facial muscles on the deep surface of these muscles (except for the muscles which are lying deep to the facial nerve, the
mentalis
The mentalis muscle is a paired central muscle of the lower lip, situated at the tip of the chin. It originates from the mentum of the mandible, and inserts into the soft tissue of the chin. It is sometimes referred to as the "pouting muscle" due ...
, the
levator anguli oris
The levator anguli oris (caninus) is a facial muscle of the mouth arising from the canine fossa, immediately below the infraorbital foramen. It elevates angle of mouth medially. Its fibers are inserted into the angle of the mouth, intermingli ...
and the
buccinator
The buccinator () is a thin quadrilateral muscle occupying the interval between the maxilla and the mandible at the side of the face. It forms the anterior part of the cheek or the lateral wall of the oral cavity.Illustrated Anatomy of the Head ...
). The fibres of the nerve are becoming more superficially medially. Therefore, the dissection of a deep plane begins further away of the surface then it ends. This allows the undermining to be carried out towards the nasolabial fold without harming the branches of the facial nerve.
* Retaining ligaments
:The retaining ligaments in the face provide an anchorage of superficial structures to underlying bone. Four retaining ligaments exist. The platysma-cutaneous ligaments and the platysma-auricular ligament are aponeurotic condensations which connect the platysma to the dermis. The osteocutaneous ligaments, the zygomatic ligament and the mandibular ligament, are more important. They attach to the skin and bone, leading to a counteraction of gravitational forces. These ligaments should be released surgically to obtain a fully mobile facelift flap.
*
Nasolabial folds
The nasolabial folds, commonly known as "smile lines" or "laugh lines", are facial features. They are the two skin folds that run from each side of the nose to the corners of the mouth. They are defined by facial structures that support the bucca ...
* Melolabial folds (
marionette lines)
*
Greater auricular nerve
The great auricular nerve is a cutaneous nerve of the head. It originates from the cervical plexus, with branches of spinal nerves C2 and C3. It provides sensory nerve supply to the skin over the parotid gland and the mastoid process of the temp ...
:Injury to the greater auricular nerve is the most seen nerve injury after rhytidectomy.
Care should be taken in elevation over the sternocleidomastoid muscle, because of the terminal branches of the nerve that pass superficially to innervate the earlobe.
*
Vascularisation
Angiogenesis is the physiological process through which new blood vessels form from pre-existing vessels, formed in the earlier stage of vasculogenesis. Angiogenesis continues the growth of the circulatory system, vasculature by processes of spr ...
:The composite flap is vascularised by facial, angular and/or inferior orbital arteries. The
facial artery
The facial artery (external maxillary artery in older texts) is a branch of the external carotid artery that supplies structures of the superficial face.
Structure
The facial artery arises in the carotid triangle from the external carotid arte ...
supplies the platysma and goes on as the angular artery, which connects with the branches of the
arteria supratrochlearis and
arteria infraorbitalis
The infraorbital artery is an artery in the head that branches off the maxillary artery, emerging through the infraorbital foramen, just under the orbit of the eye.
Course
The infraorbital artery appears, from its direction, to be the continuatio ...
. The parts of the face elevated are in continuity in the deep-plane and the composite rhytidectomy include the SMAS layer in the lower face, subcutaneous tissue and the skin as the arteries to these parts are preserved. With this option you can create a well vascularized tissue flap, which can be used to tighten the skin without loss of vascularization, this will result in fewer complications like
skin slough and
necrosis
Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...
.
Procedures
Many different procedures are used for rhytidectomy. The differences are mostly the type of incision, the invasiveness and the area of the face that is treated. Each surgeon practices multiple different types of facelift surgery. At a consultation the procedure with the best outcome is chosen for every patient. Expectations of the patient, the age, possible recovery time and areas to improve are some of the many factors taken in consideration before choosing a technique of rhytidectomy.
In the traditional facelift, an incision is made in front of the ear extending up into the hairline. The incision curves around the bottom of the ear and then behind it, usually ending near the hairline on the back of the neck. After the skin incision is made, the skin is separated from the deeper tissues with a scalpel or scissors (also called undermining) over the cheeks and neck. At this point, the deeper tissues (SMAS, the fascial suspension system of the face) can be tightened with sutures, with or without removing some of the excess deeper tissues. The skin is then redraped, and the amount of excess skin to be removed is determined by the surgeon's judgement and experience. The excess skin is then removed, and the skin incisions are closed with
sutures and
staples.
SMAS lift
The SMAS (Superficial Musculo Aponeurotic System) layer consists of suspensory ligaments that encase the cheek fat, thereby causing them to remain in their normal position. This procedure is often performed in tandem with blepharoplasty as an ancillary procedure. Resuspension and securing the SMAS anatomical layer can lead to rejuvenation of the face, by counteracting aging and gravity caused
laxity. Modifications to this technique led to development of the "Composite Facelift" and "Deep plane Facelift."
Deep-plane facelift
In order to correct the deepening of the nasolabial fold more accurately, the deep plane facelift was developed. Differing from the SMAS lift by freeing cheek fat and some muscles from their bone implement. This technique has a higher risk at damaging the facial nerve. The SMAS lift is an effective procedure to reposition the platysma muscle; however, the nasolabial fold is according to some surgeons better addressed by a deep plane facelift or composite facelift.
Composite facelift
As well as in the deep plane facelift, in the composite facelift a deeper layer of tissue is mobilised and repositioned. The difference between these operating techniques is the extra repositioning and fixation of the orbicularis oculi muscle in the composite facelift procedure. The malar crescent caused by the orbicularis oculi ptosis can be addressed in a composite facelift.
Mid face-lift
The mid face area, the area between the cheeks, flattens and makes a woman’s face look slightly more masculine. The mid face-lift is suggested to people where these changes occur, yet without a significant degree of
jowling or sagging of the neck. In these cases a mid face-lift is sufficient to rejuvenate the face opposed to a full facelift, which is a more drastic surgery.
The ideal candidates for a mid face-lift is when a person is in his 40s, or if the cheeks appear to be sagging and the nasolabial area has laxity or skin folds.
To achieve a younger appearance the surgeon makes several small incisions along the hairline and inside the mouth, this way the fatty tissue layers can be lifted and repositioned. This way there are practically no scars. The fatty layer that lies over the cheekbones is also lifted and repositioned. This improves the nose-to-mouth lines and the roundness over the cheekbones. The recovery time is rather short and this procedure is often combined with a blepharoplasty (eyelid surgery)
Mini-facelift
The mini-facelift is the least invasive type of facelift which is similar to a full facelift, the only difference is the omission of the neck lift in the mini lift procedure. It is also called the ‘S’ lift because of the shape of the incision that is used or the ‘short-scar’ facelift. This lift is a more temporary solution to the ageing of the face which also has less downtime and is done on people who have deep nasolabial folds, sagging facial structures, yet still have a firm and well-contoured neck. The position of the incision is usually made from the hairline around the ear with scars hidden in the natural crease of the skin. The mini lift can be performed with an
endoscope
An endoscope is an inspection instrument composed of image sensor, optical lens, light source and mechanical device, which is used to look deep into the body by way of openings such as the mouth or anus. A typical endoscope applies several modern t ...
, which is used to reposition the soft tissues. After this, the skin is repositioned by the surgeon with small sutures. This type of lift is a good alternative to the full facelift to people with premature ageing.
Subperiosteal facelift
The subperiosteal facelift technique is done by vertically lifting the soft tissues of the face, completely separating it from the underlying facial bones and elevating it to a more esthetically pleasing position, correcting deep nasolabial folds and sagging cheeks. The technique is often combined with standard techniques, which provide a long-lasting rejuvenation of the face and is done in all age groups. The difference between this and other lifts is that the subperiosteal facelift has a longer period of facial swelling after the procedure.
Skin-only facelift
With the skin-only facelift only the skin of the face is lifted and not the underlying SMAS, muscles or other structures. As the elastin fibers disintegrate, the skin itself loses elasticity in older patients. A skin only face lift requires skill in understanding the extent of safe removal of skin and the Vector of pull to get an optimal result. It can be done with a simple ellipse of skin removed with minimal undermining of skin flaps or more extensively with large skin flaps. It can last 5 to 10 years but some patients may want a touch-up at 6 to 12 months after the procedure. The reason that this option is considered is that it has fewer complications and quicker recovery. One of the father's of plastic surgery Sir Harold Gilles described a simple ellipse of skin excision in a socialite who was pleased with her quick recovery and outcome. Can be done for a simple jowl lift in a 35 to 45 year old patient.
Thread lift
A technique called thread lift or non-surgical face lift simplifies the operation. Silicone threads with barbs are used to pull the face and neck skin upwards without the need of skin excision. These are non-absorbable threads and combination of these threads with other methods of facial rejuvenation reveals even better results. One such procedure is thread-lift with anti-
ptosis (APTOS) sutures.
[
In the UK aesthetic practitioners—who administer thread lifts and other treatments—are not required to have any mandatory qualifications, although some treatments can cause serious complications. In ]Liverpool
Liverpool is a city and metropolitan borough in Merseyside, England. With a population of in 2019, it is the 10th largest English district by population and its metropolitan area is the fifth largest in the United Kingdom, with a popul ...
the BBC #REDIRECT BBC #REDIRECT BBC
Here i going to introduce about the best teacher of my life b BALAJI sir. He is the precious gift that I got befor 2yrs . How has helped and thought all the concept and made my success in the 10th board exam. ...
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found 26 cosmetic training academies offering courses ranging in price from £150 to £5,000 in 2021, lasting from a couple of hours
to a couple of days of face-to-face training. A professionally trained cosmetic doctor, Vincent Wong, said that a thread lift is the most dangerous procedure an aesthetic practitioner can do. A great many things can go wrong, more so than any injectable treatment, because threads stay in the skin and cannot be pulled out; while the results can be very good, the procedure can also cause irreversible damage. The professional training of Wong—already a physician with a degree in surgery—in this procedure involved four courses over three months.