Facelift
Facelift
History
Facial Surgery from the Beginnings till Today
It is hard to say when the first aesthetic anti-ageing operations of the face were performed. According to Richard B. Stark the death of Queen Victoria in 1901 brought about the change of a liberated way of thinking of the human body. The hypocrite attitude of the Victorian age was followed by an optimistic approach towards life, when the quality of life was highly appreciated. Of course the process of change was a slow one. In the beginnings aesthetic surgery operations were made in secret, because surgeons feared their colleagues’ criticism and that they may lose their professional esteem because they operated healthy patients. Publications were also neglected for the same reasons.
The method of excision without undermining was shortly followed by the technique of stretching the skin, i.e underminig, stretching and excising the skin in front of and behind the ear and on the neck. Lexer (1910) and Passot (1919) have to be mentioned as one of the first authors to describe face lifting. We owe a lot to Noel, Bames, Joseph, Bourguet, Burian, Gonzalez-Uloa, Spira, Regnault, Backer, Gordon, Hinderer for the development of the classic form of face lifting.
In 1997 Little developed a new concept of face lifting, the main point of which is the release of the praemaxillar fat pad and its imbrication on the topmost point of the yoke. The procedure is based on the classic method of underminig, supplemented by yoke lift, which increases the rounding of the face by lifting the fat pad.
The methods and tools of face surgery have gone through great progress in the past decades. Earlier the aim of these procedures was overstretched skin and the immediate perception of face lifting, whereas today operations resulting in natural, young-looking and fresh appearance, highlighting the personal characteristic features. Patients expect fast recovery, minimal hospital care, durable results and the least possible scars from the surgeons.
Age and its Reflection on the Face
With age the tight skin of the face starts to get loose, and as a result of the sun and the wind skin gets dry and spotted. The first crows feet appear around the eye and the horizontal wrinkles on the forehead, the vertical ones between the eyebrows and the nasolabial fold get prominent. The skin below the lower mandibule is sagged, a double-chin is acqired and the skin on the neck is getting to be more and more wrinkled. The lip becomes narrower, the nose seems to be longer, all the wrinkles on the face get prominent and vertical wrinkles appear around the upper lip.
When we talk about ageing, it is worth remembering Shakespeare’s fantastic description of the seven stages of human life in “As You Like It”:
Unfortunately the ageing of the body and the face strikes not only ourselves, but it affects our social relations. Often we have to notice the discrimination that goes with age from deeply humiliating signals. However, the ageing of the face is not parallel to the decline of mental activity. The acceptance of their ageing face does not mean a problem for people who lead a dynamic and mentally intensive life, but many people cannot acquiesce in the discrimination caused by the sgeing face. The signs of ageing mean discrimination even in the case of top mental productivity in the competition for social or professional positions.
Recently anti ageing operations are carried out more and more frequently. The operation improving life standard ensures not just a more favourable and young-looking appearance, but also joy, satisfaction and self-confidence.
The Anatomical Bases of Face Lifting
Anatomical Designations and Shortenings
The nomenclature of the various classic anatomical and plastic surgery books is different and often gives way to misunderstandings. In the following table you can find the widely used shortenings of face lifting.
The Innervation of the Face
It is the 5th brain nerve, the nervus trigeminus, and the strands of the plexus cervicalis that are responsible for the nervous system of the face:
- • the supraorbital nerve
- • the infraorbital nerve
- • the mental nerve
- • the big auricular nerve
The Important Anatomical Layers of Face Lifting, the Fascia of the Face
The architecture of the fascia is the basis of the reconstruction of the face. The fascia is well-defined, it covers the blood vessels and the nerves in the temporal, praeauricular and especially in the parotis area. The superficial and subcutaneous fascia fibrosus is strongly adhered to the deep fascia in these areas. This close anatomical contact comes to an end at the frontal part of the m. masseter. A fine areoloar space develops in front of the parotis, above the m. buccinator and under the subcutaneous fascia, which reaches till the nasolabial furrow. The skin and the subcutaneous fat pad together with the soft fascia layer covering it are easy to mobilise in one block above the Bichat fat node.
The size of the Bichat fat node is varying, but it is a constant lobular formula to be found even in skiny people. The fat pad covers the parotid duct, the strands of the facial nerve, the blood vessels and the outer part of the m. buccinator. The ageing of the structure of the fascia, its loosening and lengthening result in the change of the position of the subcutaneous fat pad, and also in the deepening of the nasolabial furrow because of the superfluous skin above it. The stretching of the superficial fascia (fascia buccalis) in the lateral direction reduces the wrinkles around the mouth corner effectively and soothes the prominence of the nasolabial furrow.
The superficial cervical fascia
The superficial cervical fascia runs from the outer part of the collar-bone upwards to the base of the mandibule and goes over to the fascia parotideomassetericaba at the edge of the mandibule.
The SMAS
It was Mitz and Peyrone, who described the anatomy of the SMAS in 1976, and Jost and Levet stated that the SMAS constitutes the fascia of the parotis, it is not separable from it and is in fact the remains of the platysma.
The SMAS is the continuation of the temporo-parietal fascia and the aponeurotic galea and adheres to the arcus zygomaticus, extends to the fascia of the parotis and continues to the platysma. It constitutes the frontal upper part of the sternocleidomastoideus. The SMAS is in strong fibrosal connection with the skin, so when it is pulled, the skin moves together with it. According to Skoog and Owsley the underminig and plication of the SMAS means the stretching of the skin at the same time.
The platysma
It lies between the skin and the superficial cervical fascia and reaches from the upper part of the chest through the collar-bone and the basis of the mandibule to the face. The muscle fibers spread in the lower part of the face to the line of the labial slit. Its medial fibers cross those of the opposite side on the chin. The lower part of the platysma is not fixed to the deep structures. The skin and the superficial layers together with the platysma move above the deep structures. This movement ensures the stretching of the superficial tissues of the neck. The contraction of the muscle tenses the skin of the neck.
Making the Incisions
An omega shaped incision in order to cover the scar in the occipital region
The incision of classic face lifting runs forward from the temporo-parietal region in front of the ear down towards the uppermost point of the auricle in the shape of a concave. The incision starts
Alternative incisions
- • The horizontal auriculo-temporal incision is applied to make the furrow in front of the ear disappear. We incise in the line of the side whiskers from the region in front of the ear to the corner of the eye after the lifting of the face and the supero-posterior rotation of the undermined flap. The furrow is excised in a triangular shape in the direction of the corner of the eye and we make a non-stretching suture.
- • The incision between the ear and the hairline can be visible, and also the the healing of the incision with a hypertrophic scar at the occipital region, the hairline from the occiput to the neck may be broken. In order to avoid this we lengthen the retro-auricular incision upwards and include an omega shaped incision in the temporo-parietal area, which stops visible cicatrisation.
- • The incisions of face lifting can be supplemented by a coronal incision to open up the forehead totally.
The Excision and Fixation of Superfluous Skin
After undermining the skin, excising and fixing the SMAS we have to carefully arrest bleeding. The treatment of the superficial temporal artery is easy because of the superficial veins. We apply a bipolar coagulator for the bleedings above the yoke, at the frontal part of the parotis, in the submandibular and occipital areas. We can avoid bleeding, if we undermine the other side after having undermined and arrested the bleeding on one side already. We check the bleedings on both sides before finishing the operation.
In order to avoid post-operative haematoma, we put a drain into the submandibular area, which is the deepest point of the undermining. The drain comes out in a separate opening in the occipital area. In the case of the extensive undermining of the skin we can place a drain from the temporo.parietal area to the frontal part of the face, which diverts the blood and the serum collected around the yoke.
We stretch the undermined skin by applying a hook to the tip of the skin behind the retroauricular furrow and to the tip of the undermined skin of the temporoparietal area, and pull it according to the previously marked vectors at right angle to the nasolabial furrow. We apply two fixing stitches, the first one in front of the ear at the topmost point of it, and the second one at the topmost point of the retroauricular furrow.
We excise the triangular hairy scalp in the temporal region and by pulling the skin segment behind the ear continuously in the direction of the occiput, we mark and then remove the superfluous skin. If a crease develops at the distal end of the incision, we can get rid of it by excising the triangular shaped superfluous skin. If the superfluous skin does not exceed 10 mm, we distribute the surplus subcutaneous stitches and sutures between the topmost point of the retro-auricular furrow and the end of the incision.
We excise the skin in front of and behind the ear according to the curves at thes area. The skin must not be too tight in front of the ear, therefore we fix the skin with subcutaneous stitches at the topmost and the lowest point of the tragus when incising above the tragus. The subcutaneous fat pad has to be thinned above the tragus, but the subdermal plexus should not be injured. We fix the skin behind the ear with suspending subcutaneous stitches in the retro-auricular furrow (we use 4 – 0 absorptive thread).
The curve of the incision should remain in the retro-auricular furrow after the operation as well (in the case of excessive excision or too tight skin, the scar of the retro-auricular excision will move in the distal direction and will be visible behind the ear). For the sutures we apply 4 – 0 monofil plastic thread in the hairy scalp, 5 – 0 at the tragus and in front of the ear and 4 – 0 in the retro-auricular area.
After having applied the sutures, we wash the hairy scalp and the face with disinfectants. We apply antibiotic creme on the sutures and a loose bandage on the face and the neck for 24 hours. The use of compression may damage the blood circulation.
The Post-operative Period
The patient has to lie on the back at a 45 angle position of the back and the head in the post-operative period. The cooling of the operative area reduces the edema in the direct post-operative period, but the use of intravenous drugs containing steroid did not provide the expected result in all cases.
We recommend to use a peri-operative antibiotic prophylaxe because of the extensive undermining of the skin and the closeness of the nose and the mouth. The patient should avoid any physical activity causing high blood – pressure and the consumption of carbonated drinks, spicy food and must not smoke or drink alcohol in the post-operative period. The post-operative tumescence of the face varies individually and lasts normally 5 – 7 days, but it can drag on for more than 4 weeks. The sutures are removed after 7 – 12 days. (The pictures in the colour appendix demonstrate the results.)
The Complications and their Treatment
The most frequent complication is haematoma (2 – 5%). It can occur anywhere in the undermined subdermal area, but most often in the prae-auricular and the submandibular regions. The stretching haematoma is very painful and needs to be removed imediately and the bleeding has to be arrested. Organised or liquid haematomas can be removed on the 5th or 7th day.
The injury of the strands of the facial nerve is rather rare. It is the n. facialis r. temporalis and the marginalis mandibulae that are injured most often. The nerves can be injured due to incisions or traction. In the case of incision, we have to carry out the suture of the nerve immediately.
The partial injury of the big auricular n. triggers a pain in the direction of the path of the nerve. In the case of tomplete incision the neuroma on the proximal stump hurts. We have to make the suture of the nerve after realizing the injury. Taking vitamin B and the use of selective electric stimulus helps regeneration.
Inflammative complications after face lifting are rare, the most typical symptoms are: the warmth and blush of the face, pain and high temperature. In such cases the dose of wide-spectrum antibiotica, the cooling of the inflammated area and the bacteriological draining of the canules or the mucus is indispensable. The stretching sutures have to be removed. In the case of purulent processes the whole operative area has to beopened and cleaned. If skin necrosis appears, we have to excise the affected tissues. The regeneration of the skin and the subdermal tissue has to be promoted in cases of superficial injuries. If there is extensive skin necrosis, free skin transplantation is justified. The prevention, the early realization and the immediate treatment of complications is essential.
"professioklinika" Phone: +36 1 212 7006 or +36 1 202 3683