There are different methods of facelift to tighten the sagging parts of the face for a long time. Classic facelift can be divided into treatment of different layers, but today’s trend is towards the minimally invasive method with short recovery time and low surgical risk. Postoperative complications are rare, but clinically relevant.
100 years of tradition
Facelift (synonym “facelift” or “rhytidectomy”) means surgical removal of facial wrinkles and tightening to give a younger facial appearance. Facelift surgery can look back on a tradition of over 100 years, but has become increasingly important in recent decades.
In addition to the formation of wrinkles, skin irregularities such as pigmentation spots, loss of volume and sun-damaged skin should also be taken into account. Further analysis includes the patient’s skin type and skin thickness.
This article provides an overview of the various techniques, indications, advantages and disadvantages of facelift surgery, modifications using combined methods and possible complications.
Basic principles of facelift
As early as 1900, Hollander introduced the basic principles of facelift, removing excess skin along the hairline. In 1920, surgeons developed the technique of subcutaneous mobilization of the skin. The method improved skin laxity but did not take into account underlying ptosis. Skoog made a breakthrough in 1974, tightening the skin together with the underlying platysma on the neck as a so-called “composite” flap.
In 1976, the so-called “superficial musculoaponeurotic system” (SMAS) was described by Mitz and Peyronie. In the late 1980s and early 1990s, Hamra described deep layer facelift or “composite” facelift along with SMAS to improve the periorbital and nasolabial regions. Ramirez described the subperiosteal technique for the cheek area, forehead, lateral canthus and eyebrows in 1992.
There were several comparisons between the different techniques, which are described below. The more invasive methods showed a tendency towards better long-term results. Recently, however, techniques have tended toward less complex operations with little downtime for patients.
Patient selection and preoperative preparation
Patient selection and evaluation are crucial for the further treatment plan. In particular, care should be taken not to treat a SIMON (“single, immature, male, overly expectant, narcissistic”) patient.
The operation and the associated risks as well as the possible prospects of success must be clearly demonstrated to the patient. Certain medications such as isotretinoin or vitamin E must be paused two weeks before surgery. In addition, the patient must pause nicotine for two months before and after surgery.
Mini-facelift or SMAS technique, with preauricular or postauricular incision.
Facelift techniques
The subcutaneous face lift
According to the initial concept of facelift, the preparation is performed in the subcutaneous fat tissue. This technique involves skin resection alone and has been popular for a very long time. Subcutaneous facelift may be ideal when excess skin is the primary concern or when a previous facelift with SMAS plication has been performed.
Long-lasting results are limited by this technique, especially since the deeper, pendulous structures such as the SMAS are not addressed. In addition, there is a risk for flap ischemia with extensive subcutaneous mobilization, especially in smokers. However, the procedure is ideal for beginners and is very safe because the underlying structures and facial nerves are spared. In addition, the recovery time is very short.
The SMAS Plication
The SMAS plication technique primarily treats the deeper, hanging structures. The preparation technique is above the SMAS. After the SMAS is exposed, the mobile portion of the SMAS is fixed to the posterior immobile SMAS portion by multiple sutures. The excess SMAS can subsequently be trimmed. The procedure is relatively easy to perform and poses little risk to the patient. The operation time and recovery time are short.
The "Minimal Access Cranial Suspension"(MACS) lift
Compared to the traditional facelift, the MACS lift tightens the skin vertically to avoid a “dog-ear”. MACS procedures can be divided into a simple and an extended version. In the simple version, two tobacco pouch sutures are used to address the regions of the neck and the lower half of the face. In the extended MACS lift, a third tabac pouch suture is placed in the temporal hairline to fix the malar fat pad to tighten the midface and eye area.
The dissection technique is above the SMAS and the dissection is continued to two transverse fingers below the mandible. The excess skin is resected vertically. Advantages include a small incision line, minimal subcutaneous undermining, and low risk of facial nerve injury. Recovery time and results are reported to be good. This technique is less suitable for a simultaneous neck lift, skin irregularities are possible due to the tobacco pouch sutures, and long-term results may be negatively affected by the so-called “cheese-wiring” effect.
"Deep Plane Facelift" (DPFL)
The so-called “Deep Plane Facelift” was described to treat especially the midface and the nasolabial fold. This technique was first described by Hamra. In principle, the preparation technique is under the SMAS and the reference points are the orbicularis oris muscle and the zygomaticus major and minor muscles.
The zygomatic ligament is cut. This technique is particularly suitable for older patients with changes in the midface and mento-nasolabial fold. Results are longer lasting than with preparation techniques above SMAS. However, there is a potential risk for nerve injury.
The extended SMAS facelift
The sub-SMAS preparation technique is the basic principle for achieving long-lasting tightening of the overlying skin structures. The technique was first described by Stuzin in 1995. The basic principle is the separate preparation of the skin and the SMAS flap. The SMAS flap has a different vector than the skin flap. The direction of traction is more vertical than the skin flap.
A portion of the SMAS flap can also be retroauricularly transposed to tighten the neck and cheek region. This technique is efficient and the effect is long lasting, in that the malar fat pad as well as the facial bands can be addressed separately. A disadvantage is the long operative time, the technique has a shallow learning curve, and there is a potential risk for nerve injury. There is also a risk for flap necrosis with extensive skin mobilization.
The lateral SMASectomy
Lateral SMASEctomy was popularized by Daniel Baker in 1997. In this very safe technique, only the lateral portion of the SMAS between the mobile and immobile SMAS is resected. The SMAS is fixed supero-posteriorly to the immobile SMAS, and the vector is usually perpendicular to the nasolabial fold, but may vary depending on the shape of the face.
This technique is easier than DPFL or composite facelifts, and the results are highly predictable. However, the facial ligaments cannot be treated and the surgical time is slightly longer than with MACS lifting. Several prospectively conducted studies failed to demonstrate a difference between lateral SMASectomy and conventional SMAS facelift at 6 and 12 months.
The subperiosteal facelift
The subperiosteal facelift was first described by Paul Tessier. The endoscopic approach is intraoral and temporal. After subperiosteal detachment, fixation of the midface to the deep temporalis fascia is performed. It is postulated that this approach minimizes the risk of nerve injury.
The technique is more minimally invasive than conventional techniques, and the malar and buccal fat tissue can be treated as well. The results are long lasting and flap perfusion is not problematic. The technique is advantageous especially for smokers. Longer operation time and recovery time are the disadvantages of this operation.
Complications with facelift
Possible complications include postoperative bleeding, and blood pressure should remain within the normal range in the postoperative period. Other possible complications include scar hypertrophy, skin necrosis, nerve injury (cave auricular nerve), temporal alopecia, seroma, wound dehiscence, contour irregularity, and infection.
The complication rate is 1-15% for hematoma formation, 0.05-0.18% for infection, 0.07-2.5% for nerve injury, 1-1.85% for skin circulatory disorders, and 0.1% for venous thrombosis.19-21. Increased BMI above 25 kg/m2 is also described as having an increased complication rate of 9.5% (versus 4.7% in normal weight patients).
The most common possible complication of facelift is postoperative bleeding. The most important risk factors are male gender, high blood pressure, preoperative use of blood thinners, nicotine abuse, increased BMI, preoperative and postoperative blood pressure peaks, nausea and vomitus. Hematoma can cause circulatory disturbances, swelling, as well as hyperpigmentation.
Combined treatments for facelift
In recent years, several non-invasive facial treatments have become increasingly popular, which can be performed in addition to and simultaneously or sequentially to a facelift.
Possible treatment methods include radiofrequency treatments and ultrasound therapy, liposuction, lipolytic injections, fractional laser treatments, “platelet-rich plasma” injections and chemical peels. Neuromodulators or various types of fillers (e.g. autologous fat grafting, “lift-and-fill face lift”) are ideal complementary methods.