Facelift surgery, what anatomy changes with age?

Written by Dr. Julian De Silva

Facelift surgery is a facial plastic procedure that requires a comprehensive understanding of the underlying anatomy and an artistic approach to incorporate an individual’s facial characteristics to give a natural-looking result. The key for a natural-looking result is refinement surgery that is conservative and avoids an unnatural stretched, puffy or fake appearance. The principal steps in facelift surgery are as follows however, the surgical technique is tailored to the individual. Dr De Silva utilises his own signature deep plane facelift to enhance recovery and ensure a natural rejuvenation, although each person needs artistry for their unique characteristics and features.

Watch Video: Facelift surgery, what anatomy changes with age?
Facelift surgery, what anatomy changes with age?

What are the different types of a facelift?

Generally, facelift procedures can be classified into three main types:

  1. Minimally invasive or non-invasive procedures.
  2. Mini-Facelift procedures
  3. Classical facelift and neck lift procedures.
Watch Video: What happens in a facelift? An animation of a facelift procedure
What happens in a facelift? An animation of a facelift procedure

Mini-facelift procedures

The second category includes smaller facelift procedures including small-incision facelifts which will have used in some early signs of facial ageing: Mini-facelift, MACS lift (Minimal Access Cranial Suspension), neck liposuction, fat augmentation facelifts. These techniques have a role in younger patients in their forties who have some signs of facial ageing without the need for enhanced lifting techniques. Dr De Silva completes a customised mini-facelift procedure for patients with early facial ageing. If a patient has more substantial ageing including loose bands in the neck and heavy jowls softening the jawline, a facelift and neck lift may be indicated to give you the result you are looking to achieve.

Signature deep plane face & neck lift

Dr De Silva has developed a signature deep plane facelift surgery that restores the natural curvature of the neck, to give a sharp and youthful neck angle requires elevation of the soft tissues and SMAS layer beneath the skin. This advanced technique minimises surgery, thus improving the speed of recovery and giving a natural rejuvenation. The standard facelift techniques are given different names and including SMAS lift surgery (Superficial musculoaponeurotic system including SMASplication, SMAS imbrication, SMAS excision), subperiosteal lift and endoscopic facelift techniques. Dr De Silva has customised his approach to face and neck lift surgery, with the focus of giving a natural-looking result and fast recovery. In addition, additional techniques are used to redistribute areas of lost volume, restore the natural contours around the eyes and skin resurfacing to make the face look more beautiful than before.

Facelift surgery (surgery areas on the head)

How is facelift surgery completed?

The goal of facelift surgery is to rejuvenate the face by lifting the neck that has descended and dropped as a consequence of facial ageing. Dr De Silva’s facelift technique is focused on a natural rejuvenation, no two people age identically, and unique factors include genetic and environmental influence. Frequent changes include decent of the cheeks with age that can result in deepened lines in the face (nasolabial lines) as well as an irregular jawline with jowls (soft tissue hanging below the jawline). The key for natural-looking surgery is to avoid pulling of the skin alone and to lift the deeper tissues of the face, including the SMAS layer (Superficial Muscular Aponeurotic System). The elevation of the surface alone with tension gives rise to the sequelae of an unnatural “done” appearance; this appearance is avoidable with proper surgical technique and experience. In addition, care is required to tailor the treatment to the person, including attention to volume loss and skin changes that are also common with facial ageing.

The markings of the face are an essential aspect of facelift surgery as they can lead to scars, Dr De Silva hides incisions on the face wherever possible. The markings are tailored to the individual person, millimetres make a difference in the face, and meticulous care is required to ensure the markings are accurate to enable a natural rejuvenation and to avoid scars in the skin. Dr De Silva hides the facelift incision in the natural creases of the face, in the hairline, behind the tragus cartilage of the ear. The incisions Dr De Silva uses can be seen in the figures above; the incision is tailored to each individual depending on the surgery required and their natural creases. Key to sound healing and minimal scarring is skin closure without tension, Dr De Silva utilises three layers of skin closure with facelift surgery to ensure the finest possible scarring. Some individuals are more prone to scarring; a good example is keloid scarring in certain ethnicities if you know that you have scarring tendencies always let your surgeon know.

Facelift surgery (areas on the head, around ears)
Facelift surgery (surgery areas on the head, around ears)

After the incision in the skin is completed, a subcutaneous flap is developed that enables the lax skin to be taken up and the face to be lifted. The flap is continued from the incision anteriorly towards the cheek and lips as shown by the dotted blue line above, anatomical landmarks include the zygomatic arch, parotid gland, lateral canthus and lateral commissure and the mandible. At this time it is key to release deep facial ligaments that tether the skin to the bone that has the potential to reduce lifting, care is required to preserve the functioning of the delicate underlying structures including the facial nerves and muscles. Dr De Silva takes meticulous attention is paid to the creation of the flap and haemostasis to reduce both bruising and swelling. Speedy lifts that take only an hour may only lift the skin; this does not give a natural-looking result as it results in a wind-swept appearance.

The flap is continued behind the ear in the hairline, and care is required to preserve superficial nerves that supply sensation to this area. Dr De Silva is cautious in this area to elevate the skin in a natural arc, so a person can wear their hair up after surgery if they so choose.

Dr De Silva’s facelift technique is a technique was devised from the cosmetic centres of New York and Los Angeles that involves a deep plane lift that moves from the subcutaneous tissue, from the SMAS to a deeper facial layer. This reduces both bruising and swelling and lifts the face at a deeper layer resulting in a more extended period of effectiveness. Technically deep plane lifting is more challenging as it requires a detailed understanding of the underlying anatomy and facial nerve branching. Alternatively, the SMAS (Superficial Muscular Aponeurotic System) layer can be elevated, stitched or part of the SMAS removed (SMASectomy), this technique avoids a deep plane lift. The SMAS is lifted, and the orientation or vector of lift is assessed to give a natural-looking elevation that varies in different people and faces (The vector of lift is shown in the figures above with arrows). The lift is then supported with deep stitches, Dr De Silva uses long-lasting stitches that help the face during healing for several months. Below and inferior to the ear is a sheet of muscle termed the platysma, Dr De Silva creates a flap from this muscle and lifts the soft tissue to enhance the youthful angle of the neck at the same time as the facelift surgery. In some cases, Dr De Silva uses 3D telescope to enable a more profound lift while preserving the natural anatomy and preserving essential anatomy in the face.

Facelift surgery (surgery areas around ears)
Facelift surgery (surgery areas around ears after surgery)

The images above are taken from Dr Julian De Silva's book on Facial Cosmetic & Plastic Surgery, the sequence of figures show the principles of facelift and neck lift surgery, the figures show an overview of the procedure as all surgery required tailoring to the individual for a natural-looking result.

At this time, there is excess skin as a consequence of facial ageing and loss of natural skin elasticity. The excess skin can be seen in the figure above as covering part of the hair and ear. Closure of the skin is essential as meticulous attention is required to avoid scarring and some of the sequelae of facelift surgery, that result from tension during skin closure such as pixie ear. Dr De Silva closes the skin with meticulous detail, using interrupted stitches at three different levels, and a combination of interrupted and continuous non-dissolving fine stitches. Non-dissolving stitches are preferred as these avoid scarring and stitch lines. Closure of one side of the face can take up to 45 minutes in a person with marked skin laxity. By closing in multiple layers, when the superficial stitches are removed from the skin after one-two weeks, there are deep stitches that remain under the skin that support the soft tissues during healing, this results in a fine linear scar that is difficult to see. This meticulous technique avoids closure under tension that results in a wide scar that is unsightly and difficult to correct.

Dr De Silva uses specialised equipment including CO2 laser and electrocautery, to aid removal of skin and to minimise bleeding. Reduced bleeding during the surgery results in less bruising and speed-up recovery. Dr De Silva’s techniques avoid the use of drains that are used with older surgical procedures.

Dr De Silva also has pioneered the use of regenerative medicine with facial plastic surgery. This innovation enhances recovery by utilising your own body’s healing growth factors to aid recovery. Dr De Silva prefers to use a combination of interrupted and continuous non-dissolving fine stitches in these cases to allow for scarring and changes in the natural anatomy.

All of Dr De Silva’s patients have a customised soft bandage placed around the head after the procedure to reduce swelling, patients stay overnight in London, and Dr De Silva personally removes the dressing the following day.

Facelift surgery. Before and After Treatment photos

Can other procedures be helpful with facelift surgery?

Facial ageing results in changes in all layers of the face, including the skin, the soft tissues and the underlying bone. A facelift restores soft tissue drooping and laxity of the face, neck and jowls. To give a patient a natural rejuvenation, Dr De Silva often combines facelift surgery with other procedures to provide a fully rejuvenated natural-looking result.

Eyelid changes with facial ageing are frequent and include drooping of the skin in the upper eyelid (termed dermatochalasis), dark circles and bulging bags of fat in the upper and lower eyelids. These eyelid changes are best treated with blepharoplasty at the same time as a facelift.

Volume loss around the cheeks, mouth and temples are common signs of facial ageing and can be effectively treated with volume augmentation. Dr De Silva prefers the use of a natural volume to restore the face using a patients’ soft tissues. Fat transfer is the term given to describe transferring fat from one part of the body (commonly around the belly-button area), which are then transferred into areas of deficiency in the face. Dr De Silva utilises state-of-the-art fine cannulas to apply the fat to areas where the fat has been lost, giving a longer-lasting natural result. Fat transfer to faces that have had a substantial loss of volume can be very useful in restoring the curvature of the cheeks giving a natural and youthful look.

Can other procedures be helpful with facelift surgery?

Ageing of the skin from damage by the sun and environmental elements results in lines and dark spots that may be effectively rejuvenated and smoothened with a combined facelift and Laser Resurfacing procedure. Dr De Silva will often combine facelift surgery with CO2 laser resurfacing to rejuvenate the skin surface. Dr De Silva takes precautions with the use of laser on the skin to ensure a high-quality result. Laser treatment of the face does result in some discomfort on day-one after surgery; oral analgesia is adequate to relieve any discomfort. After one-week, the face has healed mainly although a minority of people may have residual redness that can be covered with conformer. Dr De Silva only uses the very latest in laser technology and combined deep and superficial skin resurfacing.

Facial imbalance secondary to the underlying bone structure cannot be addressed by a facelift alone. Dr De Silva analyses the face as a whole, common shortcomings are in the chin and cheek areas; in some patients, these are addressed with volumetric addition with facial implants, Chin Implant and Cheek Implants. Dr De Silva prefers the use of silicone implants; these are very safe and have been used in the body for many decades and are undetectable once inserted.

Enlarged ear lobes can occur as a consequence of ageing and natural growth of the ears or as a consequence of prolonged use of earrings over a period of years.

Facelift surgery. Wrinkles area on the face

How can a small chin make your neck look tired?

A small chin can give the appearance of a more tired beck by increasing the fullness and skin laxity under the chin. In a person with ideal facial proportions, the chin is positioned 1-2mm behind the lower lip. With a normal chin compared to a small chin, the jawline is strengthened, and that improves the shape of the neck and reduces loose skin. There are variations in facial harmony and balance based on genetics, gender and ethnicity.

The position of a recessed chin is characterised by a chin position (>5mm) behind a vertical profile line drawn through the lips. By augmenting the chin at the same time as rhinoplasty, this can improve the final result. With chin augmentation, the chin is moved forward, and the relative distance from the lips to the chin is reduced. Dr De Silva uses reference points on the face to evaluate proportions, and the artistry of chin augmentation also includes taking into account gender, ethnicity and chin shape into account with chin shaping.

Particular importance is shaping the implant to soften the appearance of the chin and ensure a natural jawline (shown with hatching in the figure below). Dr De Silva is known for natural-looking work and customisation of techniques that are in harmony with a person’s facial characteristics.

For more information on chin implants, please click here.

Watch Video: Chin Implant Animation Video - How is a chin implant inserted?
Chin Implant Animation Video - How is a chin implant inserted?

What happens on the day of surgery?

On the day of surgery, all patients can feel nervous. However, this is only short-lived as once we start the sedation anaesthesia; all patients are relaxed and calm. Patients are asked to change to a hospital gown and special socks. Dr De Silva sees all his patients before surgery, to check his patient and to put specific markings that are unique for each patient. We take 3D facial images as a guide to facelift surgery for every patient. Dr De Silva works every week with three specialist anaesthetists who are very experienced in sedation anaesthesia having completed 1000’s of cases. Dr De Silva has streamlined the sedation anaesthesia commonly used in the US for his. Once in the theatre, all patients are monitored by an anaesthetist for their entire procedure and recovery period. Only when you are sleeping does Dr De Silva use a customised water-based anaesthetic solution (termed tumescent) to gently numb the whole face and neck. As you have sedation anaesthesia, you will sleep through this part; the anaesthetic solution will last many hours longer than the surgery. The facelift procedure is then started, Dr De Silva takes special care with the incisions as this is key to hiding the scars from facelift surgery. The droopy soft tissues of the face are repositioned to a more youthful position, and associated techniques completed, such as fat transfer and skin resurfacing to improve the final result.

Once the surgery is complete, the sedation is switched off, and as you have only been sleeping the recovery is usually 30 minutes or less. All patients can walk out of the operating theatre, and this is unlike traditional surgery with general anaesthetic where your recovery make take six hours or more. Dr De Silva continually looks to innovate and refine each patient experience to give you a natural-looking result, fast recovery and smooth experience.

What happens on the day of surgery?

Minimally invasive or non-invasive procedures

Minimally invasive or non-invasive facelift procedures include the use of facial fillers, platelet-rich plasma (Vampire facelift), Radiofrequency, Ultrasound (Ulthera), lasers (Carbon dioxide), skin resurfacing (Co2 Laser), thread lift sutures and others. The principal benefit of these techniques is they avoid surgery, the non-surgical treatments have short-term effectiveness and are best suited for patients with early facial ageing. Patients with more marked facial drooping, skin laxity and bands in the neck are better suited and have more effective longer-lasting results from surgical facelift and neck lift options. Dr De Silva advises his patients on the most appropriate treatments to rejuvenate your face after an assessment of your face and discussion about your goals.

There are patients with early facial ageing who benefit from non-invasive treatments. However, this does depend on the degree of facial ageing and is not suitable for patients with more than premature facial ageing. Dr De Silva had developed a signature non-surgical facelift that utilises gold-standard fillers (FDA-approved) to augment natural “Phi golden ratio” lines on your face. More recently, there has been increased marketing of thread lift techniques (barbed or coned stitches) that offer to lift without surgery. Unfortunately, many patients who come to see me have been left disappointed by these techniques as their effects can be compromised with bruising and swelling, with a low impact of a few months and the stitches can give rise to lines and marks in patients with thinner skin.

Minimally invasive or non-invasive procedures - female face, before and after treatment

Revision Facelift surgery

Over 30% of Dr De Silva’s patients have undergone previous surgery, termed revision facelift or neck lift surgery. Click here to learn more.

More information on Facelift:

More information on Facelift: Facelift (Rhytidectomy); Face & Neck Lift Frequently Asked Questions; Facelift Types; Facelift Surgery Step-By-Step; Facial Ageing; Recovery After Facelift

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