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Facelifting
Over the last decade,
new facelifting techniques have been developed to give a longer
lasting more natural, less pulled appearance
The number of people
undergoing facial rejuvenation surgery is increasing worldwide as
the baby boom post World War II generation reach middle age and,
with the personal pressures imposed by a youth-oriented society,
seek to maintain a competitive and youthful edge.
Facelifts have little
to do with wrinkling but are most concerned with re-establishing
facial muscular tone, and reducing or redistributing facial, neck
and jowl lipoaccumulation of middle age.
As we age, the neck and
jowls fill out as fat accumulates; this is often associated with
a laxity of the facial musculature. Most noticeable in the neck
are the platysma bands, referred to as 'chook neck' by Australian
patients and 'turkey neck' by their American counterparts. Australian
women seem to age more rapidly than American women, probably due
to their, overexposure to the sun, the ozone depletion problem,
and possibly due to a high proportion of women with a Celtic background,
type 1 and 2 skin.
Over the last decade
'deep plane' facelifting techniques and the subperiosteal approach
have been developed to give a longer-lasting, more natural, less
pulled or 'operated on' appearance.1
Hopefully gone are the
days of the overtight, drawn appearance feared by so many patients.
Such a result was often accompanied by hairline abnormalities, heavy
scarring, and an unsightly and obvious 'operated on' appearance.
Current techniques avoid
tension on the skin closures, thereby minimising scars. Attention
to the hairline and to the location of incisions has led to a more
natural result which can be touched up secondarily as needed, perhaps
in up to eight to 10 years.
In the early part of
the century, European and American surgeons carried out facelifts
using skin resection alone. These basic tenets remained until the
late 1970s when French anatomists defined the SMAS (superficial
musculoaponeurotic system). Later, it was found that correction
of laxity of the SMAS and of the platysma muscle resulted in a redefinition
of the jaw and neck, thus restoring a youthful appearance.
Appreciation of the role
of muscle laxity and fatty accumulation in ageing of the face (Figure
1) resulted in the development of a variety of procedures aimed
less at skin resection and more on the repair of lax facial musculature
and on the resection of fat which accumulates in the neck, jowl
and periorbital region.
The modem facelift referred
to as composite facelifting' involves elevation and plication or
resection of the SMAS (Figure 2) platysma complex, orbicularis muscle
and cheek fat pad. Numerous SMAS flap designs (Figure 3) have been
devised; the choice depends on which portion of the face has sagged
the most. The neck alone may sag with prominent platysma bands,
or the mid-face may degenerate and the cheeks flatten, resulting
in heavy nasolabial folds and a downturning of the mouth.
These SMAS flaps are
raised from the underlying deep cervical fascia and parotid gland
(Figure 4). The facial nerve runs in this plane and must be avoided.
Figure 5 shows the course of the nerve. The branches, especially
the temporal and submandibular, are vulnerable, and if damaged could
lead to permanent facial palsy.
Fatty accumulation in
the neck and jowls may be dealt with by fat resection, or open or
closed liposuction. Over-resection of fat may lead to a gaunt appearance
or a skeletonised neck. Careful aesthetic surgical technique and
development of a plan for the re-establishment of a more youthful
face should enable these deformities to be avoided. The resulting
appearance must be soft, not tight.
Trends in facelifting
The emphasis is less
on skin resection and more on repair of lax facial musculature and
resection of accumulated fat.
Two major trends have
occurred over the last decade. Younger females (Figure 6) and males
are more likely to seek surgery. Chemical peels using the newer
agents, alpha hydroxy acids, to reverse the photoageing of the skin
present in so many Australians are becoming more useful as an adjunct
to, but not a replacement for, facelifting. These peels are an improvement
on the previously used phenol peels, which were liable to damage
the skin by causing hypopigmentation or scarring. Their use for
actinically damaged skin is well documented.2
Younger patients are
becoming motivated to seek aesthetic facial rejuvenation as they
note prominence of the jowls, loss of the jawline and thickening
of the neck - the early signs of ageing. In this group of patients,
tone must be re-established in the face and fat resected, all without
distortion of the hairline or excessive scar formation. The results
are often subtle but can be striking (Figure 7). Because most of
the surgery is concentrated on the deeper layers of the face, including
the fascia muscles and periosteum, little tension is placed on the
suture lines, which tend to heal with a minimum of scarring (Figure
8).
More men are seeking
facial rejuvenation, especially those who work in competitive white
collar industries in management, sales and marketing. For these
men, image is very important. Hair restorative surgery is well-established
and an integral part of rejuvenation. In males, facelifting must
concentrate on restoration of the neck contour and reduction of
heavy nasolabial folds and jowls (Figure 9). Techniques are similar
to those used for females but incisions vary due to the beard and
should be concealed within the hairline. Cheek implants may be combined
with facelifting to give more strength and angularity to the mid-face.
Medical aspects of facelifting
The emotional stability
of the patient must be ascertained and the motivation for surgery
determined.
Many patients do not
seek advice from their general practitioner about facelifting due
to embarrassment or fear of rejection. However, a workup is important
for patients undergoing facelifting. If hypertension is present,
it must be under control. A bleeding diathesis should be ruled out.
The emotional stability of the patient must be ascertained and the
motivation for surgery determined.
The surgical procedure
is carried out under local anaesthesia with intravenous sedation,
or under general anaesthesia. It usually involves three to four
hours of surgery and may be carried out as an outpatient procedure
or involve one to two day's stay in a private hospital. Recuperation
takes one to two weeks and patients can expect to return to their
usual occupation in two to three weeks.
Chemical peeling
Chemical peels are
not a replacement for facelifting when jowl and neck laxity predominate.
Ageing of the skin is
accompanied by wrinkling and pigmentary changes which cannot be
corrected by facelifting. For this reason, chemical face peels have
been used to reduce perioral and periorbital wrinkling, and to give
the facial skin a more uniform complexion by reducing age-related
pigmentary changes.
Phenol in Baker's formula
was used for the past two decades and satisfactorily reduced the
deep perioral rhytides (vertical wrinkles); however, it often bleached
the skin, caused unpredictable scarring and had potentially toxic
cardiac side effects. Peels using alpha hydroxy acids, such as trichloroacetic
acid and glycolic acid, have become popular over the last three
to four years as dermatologists shared their experience and results.
Improvement of fine lines and complexion is well documented.3 Figure
10 shows a patient before, one year and four years after facelift.
The patient has received annual 30% trichloroacetic acid peels since
the celi . ese peels are not a replacement or facelifting when jowl
and neck laxity predominate; however, they are an invaluable adjunct
to facial rejuvenation, improving the quality and texture of the
facial skin. Pharmaco-cosmetics which combine these alpha hydroxy
acids are available to continue the peeling process; this has a
long term positive effect on photodamaged skin.
Blepharoplasty
Eyelid surgery is sought
by patients who are concerned about excessive skin in the upper
eyelid, wrinkled eyelid skin or herniation of periorbital fat pads
which gives them a tired, bedraggled appearance. Excessive eyelid
skin, blepharochalasis, may cascade over the eyelashes and obstruct
the lateral visual field. Herniate t pads give the patient a tired,
worn out, self abused appearance and the removal of these pads greatly
improves the overall appearance of the patient. The removal of fat
should not be excessive and skin removal should be especially conservative,
as a hollowed out appearance from over-resection is unattractive,
making the patient look gaunt. If too much skin is resected, the
upper lid assumes a flattened appearance and lag ophthalmia can
result.
Trends in blepharoplasty
Laser blepharoplasty
utilises laser scalpels to excise skin and remove fat, possibly
offering a more rapid recuperation due to less morbidity.
These days much less
attention is directed to resection of skin (Figure 11). Newer techniques
popularised by Flowers in the 1980s concentrated on re-establishing
the cutaneous insertion of the levator muscle to the upper eyelid
skin to re-establish a well defined supratarsal fold (Figure 12).4
Trans conjunctival blepharoplasty achieves removal of the fat pads
without removal of skin or an excision on the outside of the eyelid.
Oriental patients seek
blepharoplasty to establish a defined supratarsal fold (double eyelid
operation). About 25% of Asians have a poorly defined or absent
supratarsal fold. A hooded appearance and accompanying epicanthal
fold is usual. Numerous procedures have been developed to reduce
this fold, but all have the same principle of establishing a permanent
connection between the dermis of the supratarsal fold and the underlying
levator aponeurosis. A natural, attractive oriental eye, not a Westernised
one, is the desired outcome of the surgery.
Laser blepharoplasty
utilises laser scalpels to excise skin and remove fat. It has been
suggested that there is a reduction in morbidity with this technique
compared with the more traditional blepharoplasty procedures.
Medical aspects of blepharoplasty
The patient's visual
acuity must be tested. Dry eye should be evaluated by a Schirmer's
test. A visual field study may confirm visual obstruction secondary
to eyelid blepharochalasis. Eyelid ptosis may be present as well
as brow ptosis and should be evaluated and corrected. Lower lid
laxity needs to be evaluated, as ectropion must be prevented by
canthoplasty. The patient should be normotensive or, if hypertensive,
controlled on medication. Any bleeding diathesis should be ruled
out.
Browlifting
Replacing the brows
in their original position above the orbital rims is an important
step in rejuvenation of the upper face.
Brow ptosis is often
an early sign of ageing and is accompanied by crow's feet in the
periorbital region, heavy glabella lines and deep transverse forehead
wrinkling. Patients appear permanently concerned or angry. Collagen
injections temporarily improve the wrinkles but do not correct the
underlying problem of muscle hypertrophy and eyebrow descent.
Replacement of the brows
in their original position above the orbital rims and sculpturing
of hypertrophied muscles is an important step in rejuvenation of
the upper face. The surgical incision extends across the skull,
usually behind the hairline. and the scalp galeal complex is dissected
down to and over the supraorbital ridges (Figure 13). Care is taken
not to damage the supraorbital sensory nerves or the frontal branch
of the facial nerve. The hypertrophied glabella musculature is resected,
the frontalis muscle is scored and, after scalp replacement, the
excess scalp is trimmed. The procedure may be carried out under
local anaesthesia with sedation, or under general anaesthesia on
an outpatient basis or with a short hospital stay.
Trends in browlifting
Browlifting is often
indicated when on first examination it appears that the patient
has excess skin in the upper eyelids. Replacement of the brow above
the supraorbital ridges will determine if an excess truly exists.
Figure 14 shows a patient before and after browlifting, which takes
away the concerned, serious appearance of brow ptosis.
Medical aspects of
browlifting
Brow ptosis may contribute
to visual field disturbance. Facial nerve function should be assessed.
The scalp incision may raise the hairline, the position of which
should be assessed and preserved. Any scalp disease may preclude
incisions within the hairline, as Koebrier's phenomena may lead
to alopecia within the scalp incision.
Rhinoplasty
Nasal deformity causes
psychological distress in many patients. As young teenagers they
often feel stigmatised from being taunted by peers. Patients often
present for rhinoplasty in the middle or late teenage years.
Nasal trauma, if inadequately
treated, can lead to deformity and result in accompanying nasal
obstructions and septal deviation.
Two rhinoplasty techniques
are popular: the closed and the open. The open technique (Figure
15) involves an incision in the columella and reflection of the
nasal skin from the underlying cartilages and bones. This exposure
allows for a precise remodelling of the nasal structures, the insertion
of grafts, and fixation with a more predictable outcome. However,
the majority of cases can be managed by the closed technique, in
which there are no external incisions. These procedures may be carried
out under local anaesthesia with sedation, or under general anaesthesia
on an outpatient basis or with a short inpatient stay.
Trends in rhinoplasty
Nasal shape and size
should be individualised to balance the overall facial structure
(Figure 16). The conventional procedures involve resection and reduction,
which often resulted in a small, scooped out appearance to the nose.
Careful measurement of
the facial aesthetic landmarks can guide the surgeon to an anticipated
ideal in shape and tip projection, dorsal height and length of nose.
To achieve this ideal may require cartilage grafting of the nasal
tip or dorsum, with autogenous septal or chondral cartilage or,
occasionally, bone.
Communication with patients
and an understanding of their expectations is most important. I
have the patients bring photographs from glossy popular magazines
and discuss with them which noses they like and which noses they
think would suit their face. This 'reality test' helps determine
if the patients' expectations are realistic. Videoimaging is another
tool which may be useful in discussing the anticipated final result
with patients, and determining whether or not it will satisfy their
aesthetic goals.
The diversity of ethnic
groups seeking nasal aesthetic surgery presents a challenge to the
nasal surgeon who can hardly have a standard procedure to suit all.
Patients of Mediterranean extraction often have generous noses and
commonly seek aesthetic rhinoplasty (Figure 17). Importantly, the
results must be attractive to the patient's own ethnic subgroup;
the nose must not appear obviously operated on, too small, sculpted
or be disharmonious within the family or peer group.
Medical aspects of rhinoplasty
Nasal obstruction should
be assessed by internal examination of the airway. Bleeding disorders
and hypertension should be evaluated and treated prior to elective
rhinoplasty. The psychological stability of the patient should be
evaluated. If the patient's motivation or expectations are questionable,
counselling by the patient's general practitioner, or a psychological
or psychiatric assessment might be considered. Sometimes numerous
interviews are necessary to delineate clearly the patient's desires
and expectations.
Facial implants
To improve deficient
facial contour, shape or volume, alloplastic implants have become
popular.
The beauty of a face
is in part defined by the skeletal anatomy. Occasionally, major
orthognatic or craniofacial surgery is indicated to achieve ideal
skeletal anatomy; however, alloplastic implants may be used to improve
deficient facial contour, shape or volume, and have become popular.
Nasal augmentation using
silicone implants has been practised successfully for many years,
especially for the nasal dorsum in oriental patients. Solid silicone
implants can also be used successfully to augment the cheek bone,
chin and mandible. Figure 18 shows a patient after rhinoplasty and
chin implant.
These silicone implants
come in various sizes and shapes, and can be contoured and inserted
in the subperiosteal pockets to enhance the facial skeleton. Improving
shape and volume of the skeleton augments the soft tissue by displacement
and can achieve beautification of the face in profile and anterior
projection. The variety of implants available allows precise facial
skeletal augmentation, offering a tool to enhance the facial shape.
There have been no reports of adverse reactions to solid silicone
implants, unlike liquid silicone implants, which once were used
commonly for breast augmentation.
Trends in facial implants
Bold, defined, dramatic
facial features are the hallmarks of many fashion models and cinema
or television idols. Aesthetic ideals change dynamically, constantly
varying for the cosmetic surgeon. Newer shaped implants which significantly
refine the facial skeleton are now available for the malar region,
chin and premandible, and assist the cosmetic surgeon to achieve
the goals of beautification and accentuation of the features of
the face.
Medical aspects of facial
implants
Dental occlusion should
be assessed, and referral to an oral surgeon is appropriate if orthognatic
surgery is anticipated. Cephalometric x-ray or CT scan can aid in
diagnosis of skeletal disharmony. This workup is similar to that
outlined above for rhinoplasty.
Otoplasty
A major trend in cosmetic
surgery is to operate earlier on children with a deformity such
as bat ears.
Bat ears (prominent ears)
are unappealing features which attract scorn and ridicule from childhood
peers. Although hairstyles can camouflage bat ears, stigmatisation
will cause anxiety in children. These children are often brought
for consultation five or six years prior to the period at which
taunting might be expected to commence. Figure 19 shows the result
of repair of bat ears.
The corrective procedure
can be carried out safely in the infant years provided the child
is co-operative. Other groups of patients present as teenagers or
mature adults. Two problems usually coexist: there is a conchal
excess and absence of formation of the normal curved concho-scaphoid
angle.
Trends in otoplasty
A major trend in cosmetic
surgery is to operate earlier on children with deformity. Appearance-impaired
children can be socially stigmatised; in order to prevent this,
consideration should be given to earlier surgical repair of bat
ears or obvious scars or nasal deformities. Children are becoming
more socialised earlier and accepting more responsible roles, and
thus may request physical change at a younger age. Medical professionals
often have trivialised the importance of appearance. However, appearance-impaired
children may suffer embarrassment, depression or shame, which can
be averted or prevented by judicious, early surgical procedures.5
Otoplasty is carried
out on an outpatient basis or with an overnight stay. Incisions
are kept behind the ear; the concha and scaphoid fossa are contoured
to improve shape and the ear is positioned closer against the side
of the scalp.
Medical workup
Ear deformities may be
associated with first and second branchial cleft deformities. Occlusion
and mandibular growth may be affected and any indication of facial
asymmetry should be referred to our dental colleagues for assessment.
Many children take a week out of vacation for otoplasty and return
to school with more self confidence.
Part 2 of this article
will appear in the April 1993 issue of Modern Medicine and will
discuss body contour surgery, and breast surgery and reconstruction.
References
1. Hamra S.
Composite rhytidectomy. Plastic and Reconstructive Surgery 1992;
90(l): 1-14 .
2. Brodland DG, et al. Trichloroacetic acid chemoexfoliation (chemical
peel for extensive premalignant actinic damage in the face and scalp).
Mayo Clinic Proceedings 1988; 63: 887-896.
3. Collins PS. Trichloroacetic acid peels revisited. Journal of
Dermatological Surgery and Oncology 1989; 15: 933-940.
4. Flowers RS. The art of eyelid and orbital multiracial surgical
considerations. Clinics in Plastic Surgery 1987; 14(4): 703.
5. Hill BA. Beauty is the beast. Pennsylvania: University of Pennsylvania
Press, 1990. res 19a and b. A child with prominent ears (left).
Correction involves changing the shape and position of the ear (right).
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