A number of intrinsic changes occur in aging skin. The ratio of collagen subtypes alters with an increase in the ratio of type III to type I while the diameter of collagen fibers decreases. Other changes include dermal and epidermal thinning with a less well-organized stratum corneum. Cell turnover decreases; so, there are also fewer fibroblasts, mast cells, and blood vessels, as well as a reduction in the total number of collagen and elastin fibers.1 Dermal thickness decreases approximately 6% per decade and is accelerated by sun exposure, fluctuations in weight, and smoking. Subdermal adipose tissue also decreases. These skin and soft-tissue changes are further compounded by gravitational forces that cause deep wrinkles as facial fat descends and the dynamic forces from mimetic muscles that cause rhytids in the overlying skin. Approaches to improve skin quality include actinic damage prevention by using sun block and daily skin care, while reducing sun exposure and smoking. Techniques to address changes once they have developed include laser resurfacing and chemical peels.
There are a number of changes within the bone and facial soft tissues during aging. These include retrusion of the anterior maxilla and inferior orbital rim, downward rotation of the facial skeleton with respect to the cranial base, and expansion of the orbital socket volume which leads to a sunken eye appearance and contributes to the tear-trough deformity. The adult facial skeleton continues to grow in dentate patients. In edentulous patients, however, there is a reduction in facial height because of loss of alveolar bone in the mandible and maxilla. Soft-tissue changes with advancing age include deflation and volume loss in the upper two-thirds of the face, while there is accumulation of fat in the lower face and neck. The appearance of these volume changes is exacerbated by descent of the remaining upper soft tissues from gravity and a combination of attenuation and tethering of retaining ligaments. There may be an appearance of ptosis along the inferior orbital rim, but this is really a pseudoptosis due to the effects of soft-tissue volume loss.1–4
3. Lambros V. Models of facial aging and implications for treatment. Clin Plast Surg 2008;35(3):319–327, discussion 317
4. Warren RJ, Aston SJ, Mendelson BC. Face lift. Plast Reconstr Surg 2011;128(6):747e–764e THE AGING PROCESS 3. Where on the aging face are the effects of “radial expansion” most apparent? The four main mechanisms of soft-tissue aging in the face are the effects of gravity, upper and midface volume loss, lower face and neck volume gain, and radial expansion. Radial expansion refers to a process where repeated animation stretches the retaining ligaments of the face and allows the soft tissues to expand away from the face. This is most apparent at the nasolabial fold during smiling, because the skin of the lip is forced under the subcutaneous fat of the cheek, allowing the soft tissues to prolapse outward from the skeleton.1 The nasolabial folds represent one of the key areas patients request attention to as part of facial rejuvenation. Deep nasolabial folds have been treated by various techniques including surgical and nonsurgical options. Nonsurgical approaches generally involve facial fillers placed directly in the fold or in the midface to increase cheek fullness and secondarily elevated and reduce the fold appearance. Hyaluronic acid is the most popular filler choice as it is reliable and reversible with low rates of complication. Surgical approaches include face lift, midface lift, and, in some cases, direct excision or dermal graft/fat graft surgery.
During face lifts with manipulation of the SMAS, the key elements are to elevate and resuspend the SMAS in a largely vertical direction. In some cases, a vertical oblique direction will also work well. In contrast, most techniques use a more posterior or lateral vector in combination with some vertical lift for the skin. The fact that the two vectors are often different highlights one of the benefits of having two separately dissected layers, i.e., SMAS and a skin flap for independent manipulation rather than a composite flap with skin and SMAS moving as a single unit. The vertical vector on the SMAS is critical and improves the jawline and perioral areas, and the high SMAS can help restore the midface. The vertical/diagonal vector on the platysma improves the neck and submental areas. Once elevated, it is normal to then resuspend and support the SMAS with a permanent suture depending on surgeon’s preference and technique used. Use of a long-acting absorbable suture would not be first choice for most surgeons, as it may not provide sufficient long-term support. Some surgeons may prefer to incorporate an absorbable mesh (such as Vicryl) to suspend the SMAS.1–3
Skin-only face lifts have generally fallen out of favor to be superseded by techniques that manipulate the SMAS layer as well as the overlying skin. The thinking behind using the SMAS is to lift and suspend the deeper tissues of the face and then redrape the skin over the top without tension. This is thought to provide the most stable and natural long-term result. By avoiding tension on the skin, the scars are less likely to stretch or be of poor quality. There is less likely to be over-resection of skin in order to achieve an adequate lift and the classic overdone windswept look of early face lifts can be avoided. Perhaps if there is an indication for a skin-only approach, it would be for thin patients without much deep tissue ptosis yet with significant skin excess. In an overweight patient with ptotic deep soft tissues, a skin-only approach would be unlikely to provide a satisfactory result. Theoretical advantages of a skin-only lift are that it is safe (with low risk of motor nerve injury), relatively easy to perform, and the downtime is short. Potential disadvantages are that even where early results are pleasing, longevity of the effects may be reduced. There is no strong evidence to direct surgeons in their specific choice of face-lift technique because there is no robust evidence to prove one technique is better than another. Most surgeons choose one that works well in their hands, based on their training and personal experiences. Some senior surgeons have described their results over a career of plastic surgery and have reflected on the fact that a skin-only approach can provide results comparable to other techniques and that the additional risks of more complex procedures are not justified. The skin is a powerful tool to manipulate in a number of ptotic structures and forms part of direct brow lift, neck lift, mastopexy, abdominoplasty, brachioplasty, and thigh lift, so it must not be underestimated. It just should be remembered that ideally deeper soft-tissue bony layers should be repositioned and the skin used as a secondary rather than a primary elevator of the aged face.1–3
The MACS-lift is a popular supra-SMAS plication technique that uses continuous purse-string sutures placed within the SMAS to elevate the face and neck in a vertical vector. Plication techniques in general are used to tighten the SMAS layer and avoid reliance on skin to hold the required lift. A perceived advantage of SMAS plication compared with other SMAS manipulation techniques is that sub-SMAS dissection is avoided and therefore the risk of facial nerve damage is decreased. However, risk of facial nerve damage is still present because the SMAS is not elevated, and therefore the sutures passed to tighten the SMAS are done so blindly in relation to facial nerve branches. Consequently, branches of the facial nerve may be inadvertently caught within the suture. Intraoperatively, it is therefore important to ensure sutures are placed superficially through the SMAS and recognize any mimetic muscle twitches during passing of this suture. If there is any doubt that the suture may have contacted or compressed a facial nerve branch, it should be removed and replaced.1 MACS stands for “minimal access cranial suspension” because it uses a short scar (not an endoscopic) approach and elevates soft tissues vertically/cranially. A lateral SMASectomy elevates facial tissues parallel to the nasolabial fold and involves excision of a small patch of SMAS over the parotid. Techniques that involve elevation and resection of the SMAS are termed deep plane techniques and include low and high SMAS approaches, where both subcutaneous and sub-SMAS planes are elevated and SMAS is secured in a posterior and vertical direction.2,3
The MACS-lift is a vertical vector face lift with short scars and SMAS suspension without SMAS elevation or resection. It involves raising subcutaneous skin flaps around a preauricular incision passing from the lobule to the temporal hairline. Dissection proceeds anteriorly and inferiorly in the subcutaneous plane to allow access to the underlying SMAS in the face and neck. The original technique described placement of two continuous purse-string sutures placed within the SMAS, both anchored to the deep temporal fascia (DTF) just above the zygomatic arch. The first of the two sutures is placed in a U-shaped loop commencing at the DTF passing in front of the ear vertically down into the neck ensuring bites of platysma are incorporated. A U-turn is then made and the continuous suture passed vertically upward approximately 1 cm in front of the descending line to be completed and tied at the level of DTF. A second suture is passed toward the nasolabial fold from the same DTF location, but this time with a more oval rather than U-shaped purse-string shape loop. For many patients, this combination of sutures will be sufficient to achieve a nice shape to the neck and jowls. If as in this case, the patient wishes to address the midface, a third optional suture may be indicated. This would be passed in a small loop just posterior to the orbital rim in order to lift the midface soft tissues and support them onto periosteum of the zygomatic arch. Suture selection for this procedure is personal choice but most would advocate a permanent suture to maintain the lift. There is debate between monofilament and braided alternatives. The benefit of a monofilament is reduced risk of infection but increased risk of loosening. In contrast a braided suture (such as Ethibond) will be less likely to loosen but carries a greater risk of infection or extrusion. When performing this surgery, it is possible to vary the vectors of the SMAS and skin relative to one another. Overall modifications of this technique remain very popular with many surgeons, as the results are reliable and reproducible, the risks are relatively low, and the technique is straightforward to master. Many surgeons will use this SMAS suspension with varied skin incision lengths based on the skin extent required for removal.1–3
Skoog described a technique for face lifting in 19741 that involved elevation of the skin and SMAS as a single unit, advancing the entire skin-SMAS unit posteriorly onto the cheek and neck. The main limitation of this technique was that it failed to address the nasolabial folds and anterior neck. Hamra2 later modified this approach to better treat the nasolabial folds. His “composite” technique incorporates the lower lid orbicularis muscle into the single dissected soft-tissue unit. Each of these techniques has a robust blood supply to the skin because it is elevated in conjunction with the SMAS, rather than as a separate layer independent of it. Results are long lasting as the SMAS is able to support the elevated soft tissues. Skin excess can be managed as required with these techniques.2
Face-lift procedures can be categorized by the plane of dissection. Common dissection planes for face lifts are subcutaneous and sub-SMAS. Less commonly, subperiosteal and supraperiosteal planes are used. The term “deep plane” refers to a sub-SMAS dissection and this is performed so that the SMAS can be elevated and resuspended to provide support for redraped soft tissues such as skin, fat, and muscle. The intended benefit is to obtain long-term support for the face lift without reliance on skin fixation alone. Many, but not all, deep plane techniques also involve separate subcutaneous dissection, so that skin and SMAS layers can be moved with different vectors. This means that SMAS can be elevated and fixed in a more vertical or diagonally vertical direction, while skin can be elevated and fixed in a more posterior and vertical direction. Deep plane face lifts can be either low SMAS or high SMAS. This relates to the craniocaudal dissection in relation to the zygomatic arch, respectively. A low SMAS technique will, in theory, treat the lower face but not affect the midface, perioral, or infraorbital tissues. A high SMAS technique should be able to do both areas as the malar fat pad can be elevated.1–4
The subperiosteal approach to face lifting involves elevation of the midface periosteum as a single unit and then redraping of the composite face to achieve tissue repositioning. The main perceived advantage is that the facial nerve and its branches are protected because dissection is deep to them. A further advantage is that visible scarring can be minimized by using temporal and intraoral approaches. There are, however, a number of disadvantages to this technique. First, it is technically difficult and may need to be performed using endoscopic techniques. This can make for a steep learning curve, particularly for surgeons not used to working on the bony facial skeleton nor using the endoscope regularly. Second, it does not allow for skin and fat excesses to be treated; so, it is less effective at managing skin redundancy of the nasolabial folds, jawline, and neck compared with other techniques.1,2
The upper lip becomes longer and less full with increasing age; so, there is decreased dental show. Because a long upper lip is characteristic of aging, techniques have been developed to address this. The appearance of a long upper lip can be improved using a vermillion advancement technique. However, this does leave a visible scar on the lip margin. Alternatively, the lip height can be shortened by using a skin incision at the base of the nose which effectively hides the scar at the lip–nose interface. Lip volume can be enhanced using fillers such as hyaluronic acid and autologous fat grafting. This also addresses the decreased (not increased) vermillion exposure characteristic of the aging lip. The oral commissure does not specificity alter with age.1
Fat injection is a popular technique used predominantly in the head, neck, and breast regions following reconstruction or as part of a rejuvenation procedure. It can help restore age-associated volume loss and improve skin appearance. Advantages of fat over other injectable materials are that it is autologous and relatively permanent. In this scenario, fat is being harvested from the neck anyway, so it would be reasonable to recycle and redistribute this soft-tissue volume by reinjection at the sites requested by the patient. Disadvantages are that fat does resorb over time so the injection process may need to be repeated. It is safe to combine this with a face lift, bearing in mind that fat requires a well-vascularized recipient site. Fat can be placed in the lips, nasolabial folds, chin, jawline, tear trough, malar region, and periorbicular areas. When injecting with fat, it is standard practice to overcorrect the defect on the understanding that once swelling has gone and some of the fat has resorbed, the result will still be satisfactory. The resorption following fat injection can be unpredictable, but most surgeons anticipate up to 50% loss. Deep nasolabial folds and midface volume loss have been treated by various techniques and there is no single best technique for either of them. A sub-SMAS face lift that goes through the SMAS medially to the subcutaneous plane at the level of the belly of the zygomaticus major muscle can stretch the nasolabial fold if sufficient tension is placed on the anterior cheek skin. Alternatively, dermal attachments of the fold can be released and filled with fat or dermal fat grafts. Malar augmentation can be provided by implants, fillers (fat, hydroxyapatite, hyaluronic acid), or autologous tissues (e.g., SMAS). Improved malar fullness and nasolabial contour can be achieved with a midface lift via a transblepharoplasty approach and suspension of deep structures to the lateral orbital periosteum.1–3
Smoking is a contraindication to a face lift, and the incidence of skin slough is much higher than 5% among smokers with a sub-SMAS technique. Their risk is estimated to be 12 times greater than non-smokers.1 Therefore, patients should be advised to stop smoking before face-lift surgery. Because this woman has recently separated from her partner, there is a risk that this is the trigger for her desire to have a face lift, and it may be a poor time for her to proceed with this surgery. Recent major life changes and social instability are red flags to proceeding with some plastic surgical procedures. Patients need to be fully supported in the preoperative meetings to ensure they are undergoing the right procedure for them at the right time in their life. In this case, she is also relatively young to need or want her first face lift. As with any cosmetic procedure, unrealistic expectations must be assessed, and if that is determined to be the case, surgery should be avoided. A consult with a clinical psychologist preoperatively is strongly advised given the above. The risk of bleeding during and immediately after a face lift should be minimized, and many herbal medications can increase bleeding or negatively affect wound healing. Her regular analgesics may include nonsteroidal anti-inflammatory drugs that can also increase bleeding risk.
A hematoma is a common early complication following a face lift, occurring in 2 to 3% of female patients and 8% of male patients. Although it may be prudent to release the suture line if there is an area of vascularly compromised skin, it would be better to promptly return to the operating room to ensure formal evacuation of the hematoma and hemostasis. The patient in this scenario has maintained a stable and appropriate blood pressure, so no action for this needs to be taken. In rebound hypertension, intravenous chlorpromazine at 1 and 3 hours after surgery can be very effective. Other options include clonidine or labetalol. Discussion with the anesthesiologist is advised in such circumstances. In this case, they are not warranted, as blood pressure is satisfactory and the hematoma has already occurred. Small hematomas may be left to resolve spontaneously or drained a few days after surgery, once they have liquefied.1–5
The most common complication during or after a face lift is hematoma. It is most likely to occur within the first 24 hours. The risk can be minimized by meticulous intraoperative hemostasis and careful perioperative blood pressure control. The reported rate is about 2 or 3% in women and 8% in men. Other avenues to reduce this risk are commonsense and include patient selection, systemic factors, and intraoperative techniques. The first step to minimizing hematoma is patient selection. Patients with uncontrolled hypertension should not be booked for face lifting surgery. It is reasonable to discuss face lifts and a patient’s suitability for this, but surgery should be deferred until blood pressure is well controlled. Patients who require anticoagulants such as Plavix, Rivaroxaban, or Coumadin are likely to have additional health risks anyway and stopping their medications may be unwise. These patients should generally be discouraged from undergoing face lifting surgery, as their risks of bleeding or other postoperative complications maybe high. Herbal supplements which can affect bleeding should also be stopped. Once you and your patient have committed to surgery, intraoperative steps to minimize bleeding include stable, normotensive blood pressure throughout and meticulous hemostasis. Avoiding rebound hypertension postoperatively needs to be achieved. Postoperative management is also important and the patient should be nursed with the head elevated and the patient must be advised to avoid stooping or straining for the first 48 to 72 hours. Neck drains are used by many, but not by all surgeons and these can be helpful at removing fluid from the neck but won’t themselves be a substitute for adequate hemostasis. Other surgeons use fibrin sealants at wound closure, but these again are unlikely to stop a hematoma while they may reduce bruising and overall drainage. Use of epinephrine should be with caution as rebound bleeding can occur. However, the benefits of a clear surgical field by using the outweigh the risk on most cases. The other complications listed are common but less than that of hematomas. Altered sensation to the lobule represents injury to the greater auricular nerve and is the most common nerve injury in face lifting (approximately 7%). Facial nerve weakness is much less common (<1%) and tends to be transient. Infection and skin slough tend to be associated with patients who have other comorbidities such as smoking or diabetes and specific techniques.1–3
Jones and Grover1 reported that tumescent infiltration of around 200 mL per side without epinephrine reduced the rate of postoperative hematomas without significantly increasing wound bleeding or facial edema. The use of drains will not lower the risk of hematoma formation but can reduce postoperative bruising. Many surgeons use fibrin glue under the skin flaps, but there is no evidence to show that this action actually reduces hematoma occurrence either. Preoperative injection of epinephrine may limit early intraoperative bleeding but could lead to a rebound effect part way through the case. Prophylactic administration of low-molecular-weight heparin may increase postoperative bleeding without decreasing the risk of venous thrombosis.
Face lifting can lead to unnatural appearances if the lift is performed with incorrect or inappropriate vectors and preexisting deformities may be amplified. For example, Joker’s lines were described by Lambros and Stuzin1 and refer to the appearance of the oral commissure extending onto the cheek following a face lift. This is a potential sequela of performing a face lift in a patient who has submalar hollowing preoperatively. Prevention of this deformity requires careful patient selection and for those with submalar hollowing, a more limited SMAS and skin release in combination with a more subtle vertical lift should be performed. Established Joker’s lines are difficult to treat but may be improved by fat-transfer procedures. Hamra introduced the term “lateral sweep” caused by an excess of lateral pull in the lower face without treatment of the midface.2 This allows natural descent from aging over time to sag over the lateral pleat in the lower face. It can be avoided by using vectors that provide a more vertical lift and avoid excessive lateral tightening, while ensuring that the midface is adequately supported. Smile blocks have been described as hypodynamic cheek mounds that do not move appropriately with animation and these may be improved with fat transfer. A pixie-ear deformity may arise from distortion of the lobule because of excessive tension on the skin flap. It can be minimized by securing SMAS to the postauricular region (mastoid) in order to minimize caudal pull on the lobule. Hairline distortion can generally be avoided by thoughtful incision placement and then ensuring that skin is not excessively removed and that tension during closure is minimized.
It is not uncommon for patients to present requesting their second or third face lift procedure. The timing of this can vary and the average duration between the primary and secondary face lift in one large series was 9 years.1 In most cases, it probably is around the 10-year mark and this is something to discuss with patients preoperatively when considering their first procedure. Patients may seek secondary face lifts not only to treat the natural aging process but also deal with an unfavorable result or a combination of the two. Preexisting deficits in sensation and facial animation must be identified and documented thoroughly. Though it is prudent to obtain the surgical report from the patient’s previous operation, it often is not available, and this should not preclude surgery. From a technical perspective, some things need to be considered when undertaking secondary face lift. As with all secondary procedures, the natural tissue planes will have been disrupted and the presence of scarring can complicate the procedure. Because of this, sub-SMAS dissection may increase the risk of facial nerve damage and patients must be advised of this. The SMAS is generally thinner in secondary face lifts and some of this may have been excised or imbricated. The skin flaps are probably more robust, if anything, having been elevated before. Secondary face lift may be an ideal opportunity to correct some of the stigmata of face lifts if these are present, e.g., pixie ears, smile blocks, or poor scars.1,2