Facelift Surgery Step-By-Step
Written by Dr. Julian De Silva
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 factors including genetic and environmental factors influence facial changes with time. Common changes include decent of the cheeks with age that can result in deepened lines in the face (nasolabial lines) as well as an irregular jaw line with jowls (soft tissue hanging below the jaw line). 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), elevation of the skin alone with tension gives rise to the sequelae of an unnatural “done” appearance, this appearance is avoidable with good surgical technique and experience. In addition care is require to tailor the treatment to the person including attention to volume loss and skin changes that are also common with facial ageing.
The images below are taken from Dr. Julian De Silva’s forthcoming 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
The markings of the face are an important 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, millimeters 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 and behind 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 good 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.
After the incision in the skin is completed, a subcutaneous flap is developed that enable 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 zymgomatic 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 have 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. Very quick 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 is able to 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 longer 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 support 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 deeper lift while preserving the natural anatomy and preserving important anatomy in the face.
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 important 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 1-2 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. Julian 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 techniques.
Dr. De Silva also has pioneered the use of fibrin glue with blepharoplasty. This surgical innovation is preferred by his patients, as it enables the surgery to be completed with reduced bruising and swelling, and avoids the need for drains. In addition the tissue adhesive works on the triggering the patient’s natural clotting, as a result the technique reduces both bruising and swelling, speeding up the recovery. The glue is not suitable for all patients, where there is greater potential for tension on the soft tissues, such as revision surgery. 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 dressing placed around the head after the procedure is completed, patients stay overnight in London, and Dr. De Silva personally removes the dressing the following day.
Other procedures 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 in order to give a fully rejuvenated natural looking result.
- Eyelid changes with facial ageing are common 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.
- 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 high quality result. Laser treatment of the face does result in some discomfort on day-1 after surgery, oral analgesia is adequate to relieve any discomfort. After1-week, the face has largely healed 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 boney 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.
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