The earlier face lifts were done by simply working on the skin alone. The skin was lifted from the underlying tissues along the cheeks, excising some of it along the area in front of the ear to allow pulling the cheek skin tighter. This technique resulted in an improvement in the patients’ looks but the results were not long lasting. As our understanding of anatomy and surgical principles developed, the modern techniques of face-lifting were advanced.
What we now understand is that there is a layer of connective tissue and muscle just beneath the skins surface that is actually what loosens and sags over time. This structure is called the SMAS.
These initials stand for the Superficial Musculo Aponeurotic System (SMAS).
Superficial – defines the layer just beneath the skin surface.
Musculo - refers to the muscle layer named the platysma muscle in the neck that extends up over the jaw line into the cheeks as a connective tissue layer called the Aponeurosis.
This entire structure forms a system that allows the facial muscles to transmit their expression to the skin. When the muscles contract deeper in the face the muscle fibers pull on the SMAS and that in turn pulls on the skin. The skin itself is a very elastic structure and will simply contour to whatever it is attached.
Over the years as we continually express ourselves, the SMAS stretches and loosens and eventually sags causing the skin which is attached to it to sag as well.
Modern face-lifting involves tightening the SMAS layer beneath the surface of the skin and that in turn tightens the skin. By placing most or all of the tension on the SMAS layer, we avoid a stretched and mask-like appearance on the surface of the skin. This results in a much more natural appearing surgical result and also prevents the tension on the incision lines which can lead to poor scarring.
There are three basic ways to tighten the SMAS.
The easiest and least risky is to tighten the SMAS on its surface by sewing parts of it together.
The second way is to surgically cut a wedge out of the SMAS and tighten the SMAS by sewing the two edges together.
The third technique is an extension of the second, and is technically more demanding. It involves surgically cutting into the SMAS, releasing and lifting it from the underlying structures, pulling it up to tighten it and sewing it in its new position. Of the three techniques, this technique carries the greatest risks as the facial nerve runs under the SMAS. Elevation of the SMAS makes various branches of the facial nerve vulnerable.
The specific technique used depends on what the patient and surgeon are trying to accomplish, the type of tissue the patient has, and the surgical skill and comfort of the surgeon.
In addition to tightening the SMAS and overlying skin, completion of the facelift requires addressing the neck either with liposuction alone or liposuction in conjunction with tightening of the neck muscles to improve the neck contour.
After tightening the SMAS beneath the skin the excess skin that is elevated and moved both upward and backward is trimmed and sewn with very fine sutures.
Where are the incisions placed?
This is another important aspect of the final results of a face lift. The placement of the incision must preserve the tuft of hair in front of and just above the attachment of the ear. If this hair happens to move up or be reduced it can give a very obvious surgical appearance to the patient and also makes hair styling very difficult. The placement of the incision must also preserve the hairline behind the ear, as shifting this may also have similar consequences.
The incision starts either in the natural skin crease where the ear meets the face, or just inside the ear. Many surgeons prefer to place the incision inside the ear whenever possible as this minimizes its visibility. Superiorly, the incision is then carried into the hair-bearing scalp toward the temple, and inferiorly it curves around the earlobe, extends behind the ear and into the hair-bearing part of the scalp. There is often one small incision beneath the chin, either for the neck liposuction or the combination of liposuction and muscle tightening.
What is the recovery time for a face lift?
The recovery time is approximately two weeks. Most of the bruising and swelling can be covered up with makeup after seven to ten days. However, it is wise for patients to give themselves a period of two weeks for recovery.
Are there any scars?
There are scars but these run in the natural creases of the skin, inside the ear, and in the hairline.
Usually after they have healed, these scars cannot be easily seen. During the initial period after surgery, they are red and those behind the ear may be slightly raised. They fade over a 6 to 12 months period.