Procedures | Facelift
It is important to understand that a facelift is not a canned operation but a selection from a menu of surgical maneuvers meant to correct specific aesthetic problems. Furthermore, the techniques that different surgeons employ vary greatly and should be understood by the patient. The general method that I use, the "composite" facelift, will be discussed in some detail later on. For now, it is important to remember that specific problems demand specific solutions and a "facelift" is tailored to those needs.
- When is the best time in life to have a facelift?
- What does a facelift fix?
- Are there different types of facelifts?
- What are the risks of facelift surgery?
- What is Dr. Zubowicz's complication rate?
- How often does a facelift need to be redone?
- Is there a lot of pain with a facelift?
- When can I go back in public after a facelift?
- Will I look "pulled" or "too tight"?
- What is Dr. Zubowicz personal philosophy about his patients and their surgery?
- How do I find out what I need to know about a facelift?
- Will Dr. Zubowicz give me anything to calm my nerves before my facelift?
- What exactly is a "composite facelift"?
- Management of the Deeper Plane
- Conservation of Useful Tissue
- Repositioning Fat-Not Removal
- What are the side effects of a facelift operation?
- What is an "endoscopic facelift"?
- Will anyone besides Dr. Zubowicz be taking care of me
Not every patient ages the same way or at the same rate. Various outside influences can accelerate aging (smoking, sun damage, major weight changes) but genetics exerts most of the control. Usually aging of the face is relatively synchronous, meaning the eyes, brow, face, and neck deteriorate at about the same time. Occasionally one area may lead the way and can be addressed by a limited procedure. The appearance of aging is, in many ways, subjective and the only important opinion is that of the patient.
I have performed facelifts on patients in their early 40'a to late 70's. That is to say, the best time to do the operation is when you feel you need it. It is the responsibility of the surgeon to explain everything involved to achieve a particular result-risks, convalescence, biologic and financial costs. The patient must decide whether the costs are worth the benefits. Younger patients do get better results because their skin tends to be in better condition and the aging issues not as exaggerated. But there is no prophylactic role for cosmetic surgery. Don't have a facelift that you're not ready for to "head something off at the pass".
A full facelift fixes everthing from the lower lids to the the collarbone. This includes the repositioning the cheeks, fixing the jowls, tightening the neck, and any other adjustments necessary.
There are probably as many different types of facelifts as there are surgeons that perform them. The technique that I use will be discussed below. However, occasionally a full facelift is not required, and only a part of the face or neck will be surgically addressed. An upper facelift ("minilift", "lunchtime lift", etc.) deal with the cheeks and not the neck. A lower facelift (cervicoplasty) addresses a saggy neck and chin.
A full facelift is an extensive procedure that, as I mentioned above, is performed differently by each surgeon. The safety of this operation is very much related to the skill and judgment of the surgeon. The patient should be very particular in selecting someone who knows this operation and performs it often.
Fortunately, major complications almost never occur with a facelift when a qualified plastic surgeon performs the operation. Minor complications do occur on occasion but generally have no lasting effect.
In April of 1994, I presented a paper at the Aesthetic Society meeting in Dallas, Texas on complications in deep plane rhytidectomy (the technique I employ) vs. conventional facelift techniques as reported in the plastic surgery literature. That is, I was comparing the complication rate of the composite facelift in my hands alone versus the complication rate of other facelifts performed collectively by a host of other surgeons. The incidence of major complications in my series of 60 consecutive facelifts was lower than reports of the more conventional subcutaneous methods. As a matter of fact, only one patient returned to the operating room (to have a small collection of blood removed called a "hematoma"). There was no nerve damage, loss of skin, or significant scarring.
Since then, I certainly have had more hematomas. They occur in about 1 in 20 cases and are easily correctible. I also have to occasionally revise a scar, usually behing the ear. Major complications are rare.
One major complication reported in conventional facelifts is skin loss. This is particularly a concern in patients who are smokers. In our series, which included 4 heavy smokers, there was not one case of skin loss. This is undoubtedly due to the preservation of blood flow to the skin afforded by the technique. This is not to say that the complication cannot occur. However, the risk for this significant problem must be low.
About 10 % of patients have minor complications ranging from small collections of fluid under the skin (which are aspirated in the office) to nerve temporary weakness resulting in asymmetrical facial expressions for several weeks. Minor complications are self-limited and resolve over time without any operative intervention.
Most patients have only one facelift in a lifetime? This does not mean that a facelift freezes the aging process, but a return to the condition that prompted the facelift in the first place usually does not occur. In addition, there is a law of diminishing return with subsequent operations. Too many operations, and the patients can look weird.
No, facelift patients are surprised at how little pain there is (with exceptions, of course). As a patient of mine you will be permitted to interview former patients that I have operated upon and get first hand reports on pain and convalescence.
Physically, patients can go about their business the next day. As a matter of fact, I want my patients active (with restrictions) after surgery. Unfortunately, most of us would be a little embarrassed by the way we would look one day after a facelift. Patients are advised that after two weeks most of the swelling and bruising has subsided to the point that it will not be obvious that an operation had been done.
There is, however, changes that go on for months after any operation. It takes that long for all the swelling to completely subside. With a facelift, sensation returns to the face over weeks. Softening of the skin, and flattening of the incision are part of this longer window of convalescence.
No. Refer to the photo gallery.
The overall health of the patient and previous medical history are important. Safety is the premiere consideration in dealing with elective cosmetic surgery patients. A working knowledge of their medical condition, both in general as well as specific to facial surgery, must be ascertained.
After the patients voice their opinions about the desired changes that have brought them to the office, it is the responsibility of the plastic surgeon to organize that picture and relate the observations to specific anatomic circumstances that can be addressed to effect the proposed changes. Patients may ask the surgeon's opinion of the situation, in which case a broad range of surgical possibilities will be discussed. Other patients know exactly what they want, and planning is direct. In any event, it is the responsibility of the surgeon to explain the possibilities, not sell an operation.
Several tools are available to assess the wishes of the patient, as well as demonstrate the capabilities of certain operations. Video imaging utilizes computer technology to manipulate the appearance of an individual on screen, establishing a desired outcome and allowing comparison with appearance of the patient before and after computer manipulation. Much can be done on a computer that cannot be reproduced in the operating room. It is the responsibility of the surgeon to point out the idealized conclusion and distinguish this from what is surgically achievable. Computer imaging is an excellent way for the patient to understand what the surgeon is visualizing as the obtainable result.
Photography galleries catalogue the pre-operative and post-operative pictures of patients who have had facial aesthetic surgery. Our patients are presented with a large number of clinical examples to provide a view of the quality of work. Most patients have specific problems that can be demonstrated on one or a number of gallery patients. Close scrutiny will allow the patient to decide if the results fall within their realm of expectations.
Patient-patient interviews are available in most cases for those patients anticipating surgery and wishing to speak with someone who has already undergone a similar operation. Much can be learned by candid discussions with those who have already experienced a particular procedure. Not all of our patients are willing to discuss their operations and their privacy is, of course, guaranteed. However, many have agreed to field questions as a service to our new patients explaining the good and the bad.
Written information about the operations including the magnitude of the procedure, the convalescence, the risks, and the costs are supplied to the patient for the purpose of thorough education. Much of the material available has been assembled by the office for the specific use of our patients. Other more generic information is also available.
By far and away, the most important part of the evaluation process is the patient-physician interview. This is a very thorough discussion with the surgeon regarding clinical information and establishes a rapport between the doctor and patient. It is critical that the interview provides the details and opinions that the patient is seeking. In general, most significant areas are covered by Dr. Zubowicz' review. However, the patients must ask questions if there is something that they do not understand or has not been explained.
The patients are expected to do certain things before an operation, many of which are specific to the procedure. These are explained during the pre-operative visit. All patients are to avoid consuming anything after midnight on the night before. Smoking should be stopped 3 weeks before surgery, and alcohol should be consumed only in moderation.
Vitamins are not recommended routinely. On occasion, because of unusual metabolic circumstances or dietary problems, vitamin therapy may be instituted. In general, however, a balanced diet is all that is required of the patient.
Patients may, on occasion, be given sedatives prior to the operation for anxiety. Some anxiety is completely normal. When nervousness interferes with proper rest, a minor sedative may be indicated. Many facelift patients will be prescribed a regimen of pre-operative skin care. This depends on skin type and condition. On occasion, this will be supervised by a clinical cosmetologist.
Dr. Zubowicz uses a particular technique, called the "composite rhytidectomy" for face-lifting. "Rhytidectomy" is the clinical term for facelift. "Composite" refers to a specific technique which will now be discussed. The evolution of the technique began in the mid-1980's and is now a well defined operation with predictable results.
Conventional techniques for face-lifting begin by lifting the skin off the cheek and neck. The deeper layers are accessed by this dissection and are available for manipulation. However, much of the blood supply to the skin is supplied by networks of blood vessels within these deeper layers that nourish the skin by small perforating vessels. Lifting the skin requires division of these "perforators" thus compromising the blood supply.
The "composite" technique lifts both the skin and the deeper layers (which will be discussed later) as a unit, preserving both the network of blood vessels in the deeper tissue as well as the perforators. The resulting flap of tissue is maneuvered to reposition sagging areas of fat, muscle, and skin to their more natural youthful position. The skin remains well nourished by attention to the blood supply anatomy.
Many conventional techniques rely on pulling the skin to effect changes in the neck, jowl, and cheek. Remember that the pulling is directed behind and above the ear, a significant distance from the center of the neck and the medial cheek. To sharpen the neck angle and flatten the jowl, a significant amount of tension needs to be generated at the level of support around the ear. This commonly will leave the patient with the appearance of being "pulled too tight." The patients have an "operated upon" look.
The composite rhytidectomy bases all support for the facelift on a deeper inelastic layer. As stated, the skin remains attached to the deeper connective tissue and muscular layers during dissection. As the flaps of tissue are redraped, the sutures of support are placed through the deeper inelastic layers of connective tissue. The attached skin accompanies these deeper layers in redraping and are not required to support the lift. The skin is closed almost tension free with the most delicate of sutures. As a result, the patients look more natural, the incisions heal better, there is little risk for hair loss, and the lift probably lasts longer.
The deeper layers of tissue that we have been discussing above include three distinct structures. The first of the three is the platysma. The platysma is actually two very flat muscles that originate over the collarbone and ascend to insert upon the edge of the lower jaw. Anchoring about half way up the neck creates the angle that distinguishes the neck from the jaw. As one ages, the playsma will fall away from these attachments and blunt the angle creating, in severe cases, the "turkey neck." Re-suspending and tightening this muscle recreates a sharp neck angle and helps smooth the jowls along the jaw.
The second of the deep structures is the SMAS, an acronym for Superficial Musculo-Aponeurotic System. This is a matrix of connective tissue and fat in continuity with the platysma. (Indeed, it commonly will have extensions of the platysma muscle well into it.) As one ages, gathering of the anchored SMAS along the nasolabial line creates the deep furrow in the cheek along the side of the nose and the corner of the mouth. Repositioning of this fatty-connective tissue layer over the cheekbone allows the fullness of the cheek to be redistributed to the more youthful location.
The third deep structure is the orbicularis oculi. This a large flat disc of muscle that closes the eye and also is continuous with the SMAS. It is anchored along the cheekbone. As one ages, the muscle drops slightly and creates an unsightly bag called a "festoon." Redraping and tightening the muscle helps eliminate festoons. Furthermore, expression lines around the eye can be significantly improved by tightening of the orbicularis oculi.
The deep plane facelift generates a surplus of SMAS-blocks of fibrofatty tissue. This provides the surgeon with a useful reservoir of native material for contour embellishment. It is used commonly for augmentation of the cheek, lips, and chin. The SMAS grafts are permanent and originate from the patient, there is no foreign material implanted. The results are natural in appearance and touch.
Because it is so simple, there is a tendency by inexperienced surgeons to treat certain features of aging by removing fat through liposuction. In conditions where there is surplus fat, this makes surgical sense. However, in the jowls and cheeks of most patients, there is not too much fat but rather abnormally positioned fat and skin. Treating the aging feature by liposuction in these cases makes no sense and can be harmful. Re-positioning of the fat and skin is the proper management of the problem.
As one ages, there is a loss of subcutaneous fat. Picture the 80 year old grandmother with skin as thin as crepe paper. This is due to a gradual loss of subcutaneous fat and is a normal product of aging. Because this happens in time to everyone, it is unwise to suction out this fat if it is not in surplus. Patients will look old and skeletonized much earlier if they allow ill-advised suction of layers of fat that are normal in volume. The proper solution is to preserve the fat and reposition it to a more youthful position. Facial features will remain smooth and natural, not overly defined and harsh.
There are certain unpleasant experiences for facelift patients that are not really complications but expected consequences of the operation. The most common is bruising and swelling. All patients have bruising and swelling to some degree which takes several weeks to resolve. As a very general rule, with proper make-up, most patients can return to work and active social lives in about 2 weeks. However, patients generally look their best at about 6 months.
Most patients experience some post-operative emotional depression. This is the normal consequence of a major operation and is transient, lasting for about 2 weeks after the procedure. Usually, no medication is required particularly if the patient understands that the depression is a normal physiologic response. Commonly, when the patients emerge from this melancholy, there is some emotional overshoot and a period of euphoria.
Numbness in portions of the cheek and scalp are annoying but generally resolve over several months. Commonly as the nerves repopulate the anesthetic areas, itching or other peculiar sensations are experienced. Most of the time this is of no problem for the patient but the occasional individual will find some of these sensations extremely annoying. Medication may be required.
The resulting scars from the operation should become inconspicuous in time. However, all scars go through a maturation process before they settle down to become flat, narrow, and white. The incision sites are carefully selected for facelifts so that they can be easily hidden until their presence is no longer an embarrassment. Occasionally, a scar can eventuate that is too thick or too wide. A revision is then necessary.
Hair loss along the incisions in the scalp has been reported. It has not been a problem with the composite technique. This is probably due to the good blood supply to the hair follicles and because of the lack of tension on the scalp closures.
We've heard other complaints that are quite varied. Our patients have invested much in their operation and should expect that questions, no matter how trivial, be answered thoroughly. Most of the time simple reassurance is all that is necessary. We encourage our patients to call the office or stop by for any concerns.
Not all patients need to have the full complement of incisions for facial rejuvenation. Select problems may be addressed using endoscopic technique. With the endoscope, small incisions are made to allow access to areas for correction. By employing computer/video technology, operations can be performed through very limited incisions.
Generally this technique applies to conditions where little if any skin needs to be removed. Where sizable redraping and pruning of skin is required, endoscopy offers no advantage. It can, however, be used as a technical adjunct to more formal operations to achieve a better result or to decrease incision length.
We have found endoscopy particularly useful in aging of the brow. Access to furrows and folds is fairly easy where significant elevation of the brow is not required. The incisions are short and discontinuous, eliminating much of the numbness browlift patients experience.
Endoscopy is a no longer a new technique. With year of experience behind us now, we know which patients stand to benefit from this technology and those who will not.
Our operating rooms are fully certified and furnished with the best and most modern equipment. The recovery rooms are similarly designed and constructed. Recently we have remodelled our extended care suite for patients not wishing to return home the day of surgery. This room is appointed luxuriously for a comfortable and safe stay. Nursing personnel staff the room to attend to the comfort and needs of our patients.
It has probably been noticed that "we" is used commonly in this manuscript to describe persons or points of service. This is intentional in that management of patients is considered a team endeavor. To that end, the finest team of medical, anesthetic, nursing, and office personnel has been assembled to assist and service our patients. We are extremely proud of our staff and their record.
Our facelift patients are referred to carefully selected aesthetician for help with make-up and convalescent care. This includes pre-operative skin care. These professionals are an integral part of the team whose services are essential. Visits to the aesthetician are financially covered as part of the facelift. Additionally, the aestheticians participate in patient evaluation and in our educational seminars.
We encourage all patients to visit our facility, ask questions freely, and access our literature. There is no question that well-informed patients do better because they know what to expect. We have former patients that are willing to share their personal experiences and represent a valuable reservoir of advice.
We feel that the welfare of our patients is our responsibility exclusively. Critical medical, anesthetic, and nursing staff have beepers so service can be provided 24 hours a day. Patient's problems and concerns are dealt within our facility by our staff. Specialty care in areas outside plastic surgery are provided by a network of physicians that represent the finest in the Atlanta area.