Facelift There is a multitude of approaches for rejuvenation of the ageing face. The surgical facelift however remains the mainstay and is increasingly popular. In carefully selected candidates it can produce a dramatic effect, shedding some 15 or even 20 years. In most instances expect the clock to be reversed by some 10 years or so, but also recognise that the clock cannot actually be stopped. That 10 year advantage will be carried on through life. A facelift carried out in someone with say, heavy features and a thick neck is unlikely to give such dramatic improvement. Conversely those with very thin skin and little fat are more prone to show lumps and other irregularities. The general aim is to remove surplus skin, reducing folds and wrinkles and restore the volume which has sunk to the jowls, back to the cheek area. Extending the facelift into the neck i.e. face and necklift is aimed at improving the profile of the jaw line and neck. This may be combined with a platysmaplasty, which involves tightening the neck muscles reducing the banding effect, and liposuction of fatty pads. Furthermore, facelifts are frequently combined with an endo browlift to correct sagging eyebrows and forehead, blepharoplasties to remove surplus wrinkled skin from the upper and/or lower eyelids together with fat deposits, fat filling of heavy folds or contour defects of the face, lip augmentation, or indeed rhinoplasty (nose job) or correction of prominent ears. In suitable individuals it may be combined with more widespread surgery such as breast augmentation, breast uplift, abdominoplasty etc. A facelift operation normally takes around 3 hours to complete. It is carried out under a general anaesthetic and although there is usually minimal discomfort in the immediate postoperative period, some patients, unsurprisingly, feel a sense of tightness around the neck area. Commonly, fine tubes (drains) are used, emerging from the hairline behind each ear and these can be expected to be removed the morning after surgery. A hospital stay of one or two days is usual, but expect to feel tired for two or so weeks. Most surgical approaches require a skin incision from the lower temple across the sideburn area into the crease laying in front of the ear. As it descends it passes either behind or in front of the tragus (the little cartilage prominence in front of the ear), back into the earlobe crease and on behind the ear, rising back up towards the top of the ear and sweeping back into the hair. (see diagram) The skin is undermined to a variable degree towards the nasolabial fold, the facial line that extends from the side of the nose to the angle of the mouth and on down into the neck. With the skin flap raised up the next layer underneath is seen. This is the SMAS (superficial muscular aponeurotic system) which usually comprises a tough sheet of tissue, although occasionally it can be very delicate indeed and difficult to work with. The tightening of this tissue sheet using stitches is the basis of the facelift. The direction of tightening is dictated by the desired result. Stitches placed vertically will reduce the jowls and supplement fullness of the cheeks; those placed horizontally tighten the neck
skin and sharpen the jawline. Next the surplus skin is trimmed, the area checked for bleeding and the fine tube drains are placed. The skin is then stitched closed using absorbable stitches under the skin, so there are none to be removed later beyond a single stitch holding each drain tube. No dressings are applied. You will be moved from theatre to the recovery department where the general anaesthetic will rapidly wear off and the recovery nurses will keep a close watch over you, particularly noting any inappropriate swelling of the cheek (see later). From there you will be returned to your bedroom, probably for a late lunch! There are many features you should consider before proceeding with facelifting surgery: 1. Expect significant bruising and swelling after the operation. This is unpredictable. It may be minimal or occasionally dramatic and may not be symmetrical. Its affect can be significantly reduced by sleeping a little propped in bed for some ten days following the operation. It is vital to avoid stooping, i.e. if you drop something on the floor bend your knees to reach it rather than putting your head down. The purple bruising will steadily change to yellow, track towards the neck and fade over some three weeks. Rarely heavily bruised areas can leave a patch of brown pigmentation within the skin. This is from hemosiderin deposition, a breakdown product of blood, and can be permanent. 2. Frank bleeding tends to occur as you wake up from general anaesthetic. During your anaesthetic your blood pressure is low and your blood pools in your relaxed distended veins. As you wake up your blood pressure returns to normal and any small blood vessels which have ceased bleeding under the low blood pressure may open and bleed. This is usually noticed an hour or so following surgery as a swelling under the skin of the cheek or persistent drainage into the drain bottle. It often requires a prompt return to the operating theatre where stitches will be removed, the source of bleeding found and stopped and the wounds closed again. It occurs in some 5% of patients, but potential blood loss is quite small and the chance of a blood transfusion being required is remote indeed. 3. Swelling, like bruising, tends to settle fairly speedily over some three weeks or so. again helped by being propped up a little. 4. The sensation of the skin will remain numb for some months. This is because when it was undermined the little sensory nerves are cut and it takes that time for them to grow back. Rarely, patients experience odd sensations or even discomfort, but this is most unlikely to be a permanent concern. 5. All surgical cuts result in scars. The position of the scars is chosen to make them the least conspicuous. The very best mature to fine, white lines, barely visible at
normal conversational distance i.e. a metre. Although the skin heals rapidly the final appearance of scars may take many months or even years to develop. Some will heal less well, becoming stretched or red and lumpy, maturing more slowly. Rarely a keloid can develop - a red lumpy scar which worsens with time and is difficult to treat effectively. Occasionally scars develop increased pigmentation rather than becoming pale. 6. Blood supply is the key to survival of body tissue such as skin, and the healing process. The blood supply to the area of skin laying in front of the ear has a tendency to be reduced because that skin has been undermined. If the blood supply is compromised to some degree blistering of the skin may occur. Mild blistering, much like sun burn, will crust and heal leaving little if any marking. However, depending on the degree of reduction in blood supply more severe blistering may lead to loss of skin colour or even patchy loss of skin resulting in a long healing time over some weeks and definite scarring. Such scarring can improve dramatically with time and may benefit from later revision. 7. The stitches used are dissolving and placed under the skin and usually are trouble free. However, occasionally they can cause lumps or suture ends may emerge through the skin, which in turn can leave marks. 8. Infections are uncommon in facial surgery. A spreading area of reddening of the skin suggests an area of cellulitis developing and required anti biotic treatment. Abscesses can form and like boils (which are abscesses) generally requires drainage. 9. Seroma. A collection of yellowish plasma fluid may develop causing lumpiness of the skin. This fluid collection is usually reabsorbed by the body or may drain through the stitch line. Sometimes it is worthwhile to empty the area using a needle and syringe. 10. Thinning of the hair particularly near the scalp suture lines can occur rarely. 11. Because of the disparity in the length of skin edges to be stitched together a fold or dogear may form at the extreme end of the stitch line behind the ear. This small bump may settle spontaneously over three or so months, but occasionally needs removal, which can readily be done under local anaesthetic on an outpatient basis, taking some ten minutes or so. 12. A small sensory nerve laying vertically in the neck supplies the sensation to the skin of the inner surrounding cheek skin (but not hearing). This great auricular nerve can be damaged inadvertently leaving a patch of numbness. Sometimes the nerve end may form an uncomfortable bud called a neuroma. 13. The facial nerve is a large nerve passing forwards from deep below the ear, spreading forward forming multiple, increasingly superficial branches. This nerve supplies power to the muscles of facial expression on each side (i.e. smiling, frowning but not chewing and eating). Any branch may be damaged. The two main
branches at risk are a) the frontal branch, which supplies power to the forehead and if damaged will leave a sagging brow on that side with a smooth forehead. The brow asymmetry can be corrected by a browlift, although movement would not be possible. b) The marginal mandibular branch which if damaged would lead to drooping of that side of the mouth. This is a facial or Bell s Palsy. Although reconstruction to some degree is feasible, the result is generally poor compared to normal function. If the nerve is affected through surgery most usually spontaneous recovery occurs over a few weeks. The risk of a permanent deficit is about 1 in a 1000 facelifts. 14. Although skin wounds seal rapidly and swelling and bruising resolve soon thereafter, softening of the skin with resolution of any lumps and return of skin sensitivity, a process known as maturation, takes some six months. Makeup can generally be used at two weeks after the operation and can help to disguise any residual bruising. 15. Asymmetry may be due to unequal swelling and bruising, or sometimes due to an underlaying asymmetry of the structure of the face. Uncommonly a facelift procedure requires revision to achieve better symmetry. 16. Revision can be useful occasionally to improve the placement of scars etc, but of course will entail the associated risks and healing time. 17. Tobacco smoking has several adverse effects of facelift procedures. Every bodily function requires oxygen which is carried round the body in the arterial blood. Poisonous substances within inhaled smoke tend to reduce blood flow by constricting the blood vessels. Furthermore, the carbon monoxide in smoke displaces oxygen from the haemoglobin thus reducing oxygen delivery to the body further. 18. Coughing tends to raise blood pressure which in turn leads to more risk of bleeding, more bruising and a possible unplanned return to the operating theatre. It is strongly recommended smokers give up smoking completely six weeks in advance of surgery and until they are successfully healed. 19. In addition to facelift specific risks there are general ones such as chest infection, deep vein thrombosis and those associated with a general anaesthetic. However, all these are very uncommon. 20. It may be a relief to know that despite this protracted list the large majority of patients are delighted with the result of their facial rejuvenation procedures. For most the operation recovery proceeds smoothly and satisfactorily. If concerns arise contact the hospital or my office promptly it is always better to nip problems in the bud. Bear in mind in you live far from the hospital an urgent return may be required. Although emailed photographs can be helpful, direct examination in person is almost always safer.
Before leaving the hospital following the operation pain killers are supplied and a follow up clinic appointment arranged usually for two weeks time. You will be able to shower freely and wash your hair the day following the operation as all the stitches are dissolvable and under the skin.