Background
As the baby boomer generation ages, the popularity of cosmetic plastic surgery continues to rise. Facelift surgery, or rhytidectomy, is one of the more commonly performed aesthetic facial procedures. [1] Given the right patient, and with proper technique and planning, an excellent result that takes years off of the patient's appearance usually is obtained. Although a wide variety of more extensive dissection planes have been proposed, the subcutaneous (skin-only) facelift is discussed in this article. However, much of the information included within is applicable to other techniques as well. For detailed information on other facelift procedures, please see the Rhytidectomy section of the Medscape Reference Plastic Surgery journal.
History of the Procedure
The history of facelift surgery spans the last century. Hollander is credited with originally describing a surgical "lift" of the face in 1901. [2] Throughout the early 1900s, others such as Miller, Kolle, and Lexer made variations and refinements of this original description. [3, 4, 5] Lexer is credited with suggesting that the skin flaps be dissected in a subcutaneous plane, as earlier facelifts consisted mainly of skin excision with primary closure.
For the next 60 years, until the early 1970s, the subcutaneous facelift was the most popular method. Improvements during this time mostly concerned the incision and not the surgical concept. However, in 1974, Skoog described elevating the platysma of the neck and lower face without detaching the skin. [6] This deep layer method, along with the description of the superficial musculoaponeurotic system (SMAS) by Mitz and Peyronie, changed the way many surgeons viewed surgical rhytidectomy. [7] Although now not performed as commonly as some other methods, the skin-only facelift still may have a role in selected patients. It also remains the basis for how most plastic surgeons perform a facelift.
Indications
Every patient presenting for a facial rejuvenation procedure needs to be evaluated thoroughly to assess specific problems and personal desires. For a patient to be a candidate for a skin-only facelift, the anatomic problem should be limited mainly to skin excess. A patient who previously has undergone a facelift with SMAS tightening and now desires a touch-up may fit into this category.
The skin lift alone also produces good results for thin women with good skin tone and a good underlying bony structure. In the patient with a heavier face and not as ideal a bony framework, obtaining a natural-appearing result with a skin-only lift is more difficult because of the greater amount of pull that usually needs to be placed on the skin flaps.
If the need to correct significant jowling or an obtuse cervical-mental angle is required, then a different approach that incorporates deep suture suspensory techniques may be more applicable. Patients also must be made aware of the inherent limitations in performing a skin-only facelift, since other facial structures that have aged are not addressed. With the recent resurgence in SMAS plication sutures and purse-string suturing of the underlying facial musculature, the skin-only approach will likely be less commonly used.
Relevant Anatomy
A complete understanding and knowledge of the anatomy in the facial region are required to obtain the best results with a minimum of complications. Although many variations exist, a common approach includes a temporal incision continuing down inferiorly to a preauricular incision that then becomes postauricular as it curves around the ear and down the edge of the hairline. An alternative approach to the temporal portion of the incision is to carry the incision horitzontally along the sideburn/cheek junction and then vertically along or just posterior to the anterior hairline. This avoids the temporal dissection along the deep temporal fascia and spares the superficial temporal vessels. Most surgeons prefer a posttragal incision in front of the ear, while others use a pretragal approach in males or patients who smoke. With a skin-only facelift, a subcutaneous dissection is all that is required, leaving the underlying SMAS layer undisturbed.
Manchot described the vascular supply to the face in 1889. [8] Whetzel and Mathes refined the study and further described the vascular territories of the face and scalp. [9] The facelift flap is supplied mainly by musculocutaneous perforators as they emerge from 3 main arterial trunks: the facial, superficial temporal, and ophthalmic arteries. Most blood flow originates in the central facial area, and rich anastomotic networks exist. This allows for skin-flap survival after undermining. As more extensive dissection is carried out medially, the risk of ischemia in the flaps increases. With other deeper plane techniques such as composite facelift, the blood supply is preserved to a greater degree, making ischemia less likely even with extraordinary tension that a subcutaneous facelift would not allow. [10, 11]
The underlying facial musculature is beneath the plane of dissection and covered by the SMAS.
Contraindications
Patients who are not medically stable should not be considered for cosmetic surgery. In addition, patients on aspirin-containing products or blood thinners are at a higher risk for postoperative complications. Therefore, these patients should have stopped using those products or the surgery is postponed. Heavy smokers are also at increased risk of skin-flap ischemia and have a relative contraindication to an aggressive skin undermining procedure. Studies have shown the adverse effects that smoking can have on wound healing. Patients with unrealistic expectations or with ongoing psychiatric issues should also be very carefully evaluated before surgery is agreed upon. Elderly age is not necessarily a contraindication for surgery. [12]
A skin-only facelift is also relatively contraindicated in someone who has more significant facial aging or an obvious sagging of the underlying facial muscles. In these individuals, a more extensive facelift approach with treatment of the SMAS layer may produce a better result.
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Facelift, skin only. Preoperative frontal view of a 48-year-old woman.
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Frontal view 11 months after a subcutaneous skin-only facelift.
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Facelift, skin only. Preoperative side profile of a 47-year-old woman.
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Side profile 9 months after a subcutaneous skin-only facelift.
