ARTE FACIAL
by Abraham Gómez, M.D.
At some point in our lives, we all begin to recognize certain aging patterns in our faces. These signs become evident in our 30s and 40s, determined by the influence of genes and hastened by environmental factors such as sun exposure, smoking, and alcohol consumption. Stress, health conditions, and poor diet also play a significant role. Visible signs of aging progress slowly over time and, to some degree, involve all areas and features of our face.
Facial aging occurs mainly due to skeletal bone resorption, loss of volume in the fat compartments, and decreased skin elasticity. The manifestation of aging in the lower face is seen by the sagging of cheek tissues – deepening the nasolabial fold and marionette lines – and the accumulation of fat in the jawline and neck in the form of jowls and neck banding.
Facelift surgery, known as rhytidectomy, reverses many aging changes to restore a youthful facial contour. When appropriately done, this surgery will not change a person’s fundamental appearance but will reverse aging patterns in the lower face to create a natural, younger look.
The procedure
A facelift is designed primarily to improve the sagging of the tissues of the lower portion of the face. It is a customized procedure that treats cheek descent, jowls, and laxity of the neck muscles. Therefore, it is meant to restore a defined jawline contour and a tight neck.
A facelift operation varies from extremely conservative (weekend facelift) to a more invasive surgery (deep plane facelift). When deciding how aggressive to be with the lift, surgeons must consider the patient’s bony features, general health, and amount of aging, among other factors.
Facelift surgery does not simply remove excess skin from the aging face but deliberately manipulates the deeper layers of tissue below the skin envelope. These deeper layers are called the SMAS. Sagging of the ligaments and muscles within this layer is responsible for the effacement of the jawline, deepening of the folds between the nose and the mouth, and unattractive neck bands. Therefore, the facelift surgeon must focus on the SMAS to effectively treat the aging of the cheeks and jowls.
A facelift requires an incision that starts inside the sideburn and travels just in front of the ear down to the earlobe. The incision is carried around the back outline of the ear to end up in the hair-barring skin of the lower scalp. In most cases, a small incision is also required below the chin to address neck bands.
The next step consists of addressing the SMAS layer. Treating this layer is vital in facelift surgery. Several techniques have been described to elevate and reposition sagging tissues in the SMAS. A plication technique is one of the most commonly used, in which the tissue layer is folded over itself with sutures. To correct more severe aging, a SMASectomy may be preferable. This approach consists of removing a vertical strip of SMAS and using sutures to approximate the borders of the remaining tissue. This option means a more effective operation but carries a higher risk of nerve damage. Deep plane facelift techniques provide the most dramatic improvement of the jawline and cheeks, although they are aggressive and have a higher probability of complications. They also require a longer recovery, meaning more time off work, something many patients cannot afford.
The final step involves skin excision and suturing of the incisions. These are crucial steps that must be performed with finesse and accuracy because they will affect the appearance of the scars. Poor suturing techniques are responsible for the tell-tale signs of a bad facelift: unsightly scarring in front of the ear, effacement of the sideburn, and pixy ear deformities. On the contrary, attention to this step will create elegant and natural facelift results with inconspicuous scars.
Limitations of Rhytidectomy
What a facelift can’t do
Having realistic expectations about the clinical result of a facelift is the first step to guaranteeing that patients will be happy with the operation. Everyone embarking on this journey must understand its limitations and clearly understand what a facelift can and can’t do.
Achieving the best outcomes in facelift surgery
The best facelift is the one that meets the patient’s aesthetic concerns and produces natural results with minimum complications. It is possible to achieve excellent outcomes in facelift surgery if the correct technique is selected for each patient and standard surgical principles are followed.
Facelift surgery is not a one-size-fits-all operation. On the contrary, every facelift must be customized to treat specific aging patterns in a given patient according to their health status, individual expectations, and time available for recovery.
Identifying the three major components of facial aging is vital to achieving natural and consistent facelift results. A facelift is designed to tighten the lower face and neck, but this procedure does not address many other components of facial aging.
A facelift does not treat skin breakdown, a significant component of aging characterized by deep wrinkles and pigment changes. This component of aging should be addressed if one desires to achieve natural outcomes in facelift surgery. Chemical peels, laser resurfacing, and dermabrasion are the main options for restoring skin tone and suppleness.
Facial hollowing due to loss of fat volume has also been recognized as a major factor contributing to a flat and haggard appearance. Facial fat grafting has been one of the most noteworthy innovations in facial plastic surgery in the last four decades, as it improves facial deflation. Using techniques similar to liposuction, fat is harvested from the patient’s body and injected into the face to provide added volume. In most cases, this procedure should be performed simultaneously with a facelift.
Recovery after facelift surgery
Modern-day facelift surgery carries very little pain in the postoperative period due to refinements in surgical technique and effectiveness in anesthetic interventions. Some discomfort is expected after the operation, but patients experiencing significant pain associated with an area of swelling should contact their surgeon immediately. Swelling and bruising will progress over 24-72 hours and will begin to improve after the first week. However, some swelling may last up to 3 months, depending on the type of facelift and whether additional facial cosmetic procedures were performed in conjunction with the facelift. Patients must consider this point if planning their facelift before a public engagement such as a wedding.
The surgeon will remove sutures between days 8 and 10 after surgery, although some may remain in place for longer. Most patients can use their computer the first week and return to work in weeks two or three, depending on their required tasks. Postoperative downtime may be lengthened if ancillary operations like blepharoplasty and fat grafting were also performed. Female patients may wear makeup to conceal black and blue areas after the first week unless they also underwent a skin resurfacing procedure.
Patients should refrain from all forms of exercise for at least three weeks and cannot resume strenuous physical activity for two months. Clinical results can begin to be appreciated after 6 to 8 weeks. Incision scars will take up to 8 months or more to fade, depending on the patient’s skin quality.
We can think of a facelift as an operation that turns back the clock of aging. For some patients, it may be five years, and for others, ten, but the clock will resume ticking as soon as the patient leaves the operating suite. To continue to age gracefully after a facelift, patients should adopt a healthy lifestyle, including a regular exercise routine, a wholesome diet, and refraining from tobacco and alcohol. Additionally, avoiding sun exposure will go a long way to prolong the results of a facelift. Finally, maintenance treatment with skin products and botulinum toxin will ensure a youthful look for many years.
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