Face lifting: the procedure

Since their introduction in the early 1900s, facelifts have come a long way. Here is a brief overview of the modern facelift.

The face, more than any other part of the body, defines an individual to the outside world. With age, the effects of gravity, sun damage and the stresses of everyday life become apparent and can alter the appearance of a person's face. As such, these age-related changes can make people feel as if their identity has changed over time. As people are living longer and more active lives, many seek facial cosmetic surgery to help them look as young as they feel.

Changes can occur in the upper, mid and lower portions of the face due to the downward descent of facial fat and skin, resulting in deep lines around the eyes and mouth, sagging skin in the cheeks, jaw line and neck, as well as banding around the neck. Facial tissues weaken over time, losing their resiliency and ability to maintain a firm, youthful position. Additionally, facial muscles weaken and stretch, and fat deposits which normally give the face a soft, rounded appearance deplete and descend to create hollow areas A facelift, or rhytidectomy, is designed to address these age-related changes and can restore a firmer, more youthful appearance.

The modern facelift

By repositioning both the skin and the SMAS, the modern approach to face lifting restores the facial structures to a more desirable position to create a younger looking appearance while avoiding the telltale signs of surgery. While a modern facelift predominantly address volume replacement and vectors (directions) of lift, the procedure also helps smooth wrinkles and folds.

A typical facelift today begins with incisions that are concealed within the hairline. From these incisions, the skin is separated from the muscles and tissue beneath. The SMAS layer is then tightened in the lower face, mid-face and neck, after which the skin is pulled back to reduce lines and wrinkles. Excess skin and fat is removed and the incisions are closed.

Recovery from modern facelifts is typically much less extensive and lengthy compared with facelifts of the past, with less swelling, bruising, pain and recovery time. There are also different procedures, such as mini-lifts that use smaller and fewer incisions, offering less recovery and down time.

There are different types of face lifting surgery, with each tailored to correct different regions of the face. For example, a lower facelift is usually performed to rejuvenate the lower portion of the face, while a brow lift or mid-facelift can typically correct age-related changes in the upper and mid-face, respectively. In addition, sagging and puffy eyelids can be addressed with eyelid surgery, or blepharoplasty.

It is important to note that facelifts do not address overall skin texture, skin thickness, or wrinkling and creases around the nose and mouth. Instead, modern face lifting techniques are designed to correct sagging, loose skin and reposition fat and tissues to add volume back to the face.

Lower facelift

A lower facelift can be performed using different types of incisions, depending on the patient's individual needs and wishes. A single incision is commonly made within the hairline that extends downward around the perimeter of the ear and into the hairline on the backside of the head.

Through these hairline incisions, the skin is lifted from the underlying tissue of the lower face, jaw line and neck to expose the SMAS, a layer of tissue composed of muscle and fibrous connective tissue.

The SMAS is then repositioned to elevate and tighten the underlying facial structures to a more youthful position. There are a variety of methods that can be used to lift the SMAS, such as plication or excision in which the tissue is augmented and suspended in a higher position with sutures.

After the necessary adjustments, the skin is then repositioned over the face and any excess skin is removed. In some cases, the surgeon may place a surgical drain beneath the skin to prevent fluid build-up during healing, although this is not usually necessary. The incision is then closed with sutures. A lower facelift procedure typically takes around three hours, depending on the extent of treatment.

Mid-facelift

During a mid-facelift, the underlying tissues are tightened, and fat pads that give the face shape and volume are lifted to restore a firmer, younger looking appearance. A mid-facelift cannot correct loose skin in the neck or along the jaw line, nor can it address fine lines or uneven skin tone and texture.

A mid-facelift can be performed using a variety of different incisions and surgical techniques. For example, when combined with eyelid surgery (blepharoplasty), the surgeon may choose to make incisions in the lower eyelid. When performed in conjunction with a lower facelift, the physician may make additional incisions inside the mouth along the gum line to help release the mid-face tissues.

Another approach is the endoscopic technique, whereby small incisions are usually made just above the hairline, above the ear or by the temple. Additional incisions are made inside the mouth over the cheekbone. With the aid of an endoscope, a thin tube-like instrument with a tiny camera on the end, the surgeon can gently manipulate the facial tissues and lift them to a more youthful position.

The tissues are typically suspended by use of sutures or absorbable medical-grade material that dissolves over the course of a few months.
Once the underlying tissues are tightened and the fat pads are lifted, the incisions are closed using sutures.

A mid-facelift procedure takes around one and a half hours, depending on the extent of treatment.

Face lifting techniques

Advances in surgical procedures and technology mean there are several different face lifting techniques available today. They are designed to address each patient's individual needs more specifically, helping to ensure optimal and natural-looking results.

SMAS lift

The SMAS (Superficial Musculoaponeurotic System) technique concentrates on the thin underlying connective tissue land muscle layer called the superficial musculoaponeurotic system, as well as repositioning and removing excess skin. Tightening this foundational tissue gives a smoother and improved shape without noticeable tension in the skin. This type of facelift is generally considered to be the gold standard in facelift surgery today.

Extended SMAS lift

An extended SMAS lift separates the SMAS from the underlying facial structures more extensively towards the nose and upper lip compared with the SMAS lift. This can address age-related changes in the nasolabial area (around the nose and mouth) more than the traditional SMAS lift, however increasing the amount of SMAS lifted also increases the risks of complications, such as skin necrosis.

Deep plane lift

A deep plane facelift is designed to reshape the entire face, including the upper and lower eyelids, the brow and the neck, by lifting facial tissues, fat, muscle and skin in one continuous section. Because the dissection is deep, the flap is thicker than in the SMAS method. This procedure is more invasive than other methods and may require a longer recovery period.

Subperiosteal lift

Commonly performed with the aid of an endoscope, the subperiosteal lift is designed to reposition skin, fat and muscle simultaneously since the tissues tend to sag together, not individually. This type of facelift releases tissues off the bony layer, separating the bone from all of the tissues covering it. There is more swelling with the subperiosteal lift than with more superficial lifts due to the depth of the dissection. It also usually causes more swelling and takes longer to recover.

Composite lift

The composite facelift is similar to a deep plane lift, with the addition of an extra step to include the muscle around the lower eyelid. The orbicularis oculi muscle (around the eye) is separated from its attachment to the cheekbone through an incision in the lower eyelid and then lifted and sutured into place. The composite facelift essentially involves elevation and resection of the SMAS layer, orbicularis muscle and cheek fat pad. There is typically more swelling with the composite lift than with more superficial lifts.

S-Lift

The S-Lift is a type of SMAS lift, named after the s-shaped incision made in the hairline at the temple and in front of the ear. The best candidates for an S-Lift are those who do not have significant skin laxity of the neck and jowls. It is most suited to patients beginning to show signs of facial ageing and want some tightening of the lower face without longer incisions.

Mini-lift

This type of facelift typically refers to any limited-incision facelift, usually with a quicker recovery time compared with other more invasive techniques. Also referred to as a MACS Lift (Minimal Access Cranial Suspension) and the short-scar facelift, it is typically suited for patients with early signs of ageing, usually aged in their 30s and 40s, to achieve a natural-looking facial rejuvenation. During a mini-lift, the surgeon makes a short incision on the front side of the ear. Via this incision, deep plicating sutures lift the deep tissues and the extra skin is then removed. Due to its less invasive approach, this type of facelift typically offers less recovery time and a lower risk of complications.

Thread lift

Thread lifting is a minimally invasive technique that elevates the soft tissues of the face using specially designed internal sutures and can deliver subtle yet effective results. The procedure involves the use of multiple, fine biocompatible threads to lift and support sagging skin on the face and neck. Tiny ‘nicks' are made to the skin, which are hidden in the sideburn area. Threads are then looped to the sagging soft tissues that support the face and neck, lifting and anchoring the facial tissue in an elevated, more youthful position. Excess skin is then removed through a fine incision along the ear.

Once in position, the body generates new collagen that surrounds each thread to maintain the lifting effect. The procedure is typically performed under local anesthetic and usually takes around one hour to perform. In most cases there is minimal, discomfort, bruising and swelling and patients can usually return to normal activities in a few days. This procedure does not replace a conventional facelift; rather it offers patients a minimally invasive approach to address the early signs of facial ageing. Results tend to last around two to four years.