facelift Surgery – Rhytidectomy

Serving New York City, Manhattan

 

The theories of facial aging have changed over the years, and the original face lifting descriptions in New York were performed as simple skin lifts or excisions. As our understanding of the anatomy has improved, it was recognized that repositioning the deeper connective tissue layers became important.  This led to a myriad of procedures that will be described below. More recently, it has been recognized that there is not only changes to the connective tissue causing laxity of the skin and underlying soft tissues, but there is also facial deflation or atrophy of the fatty soft tissue layers as well, leading to sagging. The goal of face lifting procedures for Dr. Wallach’s Manhattan New York patients, is to create a more youthful appearance by lifting the sagging tissues and elevating them, but they may need to be re-inflated due to facial fat and soft tissue atrophy. Describing how a roller coaster track is shifted is an analogy that can be used to describe what a facelift does. A face lift can reposition the soft tissues just like the tracks of the roller coaster can be moved to change where the highs and lows are. Face lifting procedures can accomplish this, but further rejuvenation is required to treat the fine lines and wrinkles that a face lift will not treat. Just like removing the rust from the roller coaster’s tracks, this can be accomplished with lasers, chemical peels, and skin care products.

No one New York patient undergoes the same exact face lift. It is very important when performing the surgery to avoid creating “telltale” signs, or unfavorable looking results that make the face appear “unnatural.” This would include distortion of the ear shape, hairline and/or sideburn. Dr. Wallach, a New York City Plastic Surgeon, usually works on the deeper layers of the face to provide the so-called “lift” and to create a “natural” result. The deeper tissues of the face are mobilized to recreate the soft tissue appearance of a youthful face. Most importantly, he does not “pull’ on the skin, which can result in a distortion of the face. He uses the analogy of a bed to describe this. The deeper tissue of the face is like the mattress of a bed and the skin is like a sheet covering the mattress. In order to smooth out the bumps in the mattress, or improve the contour of the face, you have to work on the mattress, or the deeper tissues of the face. Dr. Wallach always tries to provide the maximum result with the minimum amount of incisions. Therefore, some patients may undergo a short- scar facelift (mini-facelift) to improve their neck and jowls while others may require a more involved procedure that improves the neck, jowls, and cheeks. The surgical procedure usually takes between two and four hours to perform. The recuperation is from one to two weeks. Dr. Wallach has presented at national meetings and published articles on this subject in peer-reviewed journals.

Contents

Techniques:

Non-Invasive Approaches

Fat Injection

Facial rejuvenation techniques have evolved. In the past, skin and soft tissue laxity were treated solely with face lifting techniques. As the understanding of facial aging has improved, it is apparent that not only does the skin lose elasticity and sag, but facial atrophy, more specifically facial fat loss, is also a key component to facial aging. This is a reason why facial fillers have become so popular. However, most of these available filler products dissolve overtime and last an average of six months to a year. They are great products and Dr. Wallach uses them frequently. Fat injection techniques have improved significantly as the understanding of how to harvest and inject the fat has been refined. With this in mind, many plastic surgeons have been incorporating facial fat injection into their armamentarium of facial rejuvenation solutions. It has revolutionized some of the facial rejuvenation work that can be accomplished, especially in a very thin, hollow looking face. Sometimes this is used as the sole means of rejuvenation but many times it is performed in conjunction with face lifting procedures. The fat injected has to incorporate a blood supply from the local tissue. If it does not, then some will resorb and repeat treatment may be necessary.

Liquid Face Lift

The liquid face lift is a marketing phrase that refers to a non-surgical procedure incorporating both facial filler material such as Restylane™, Restylane Lyft, Juvederm, Radiesse, and Sculptra along with using the neuromodulators, Botox™ or Dysport. As our knowledge of facial aging has evolved, these products have become more important. The filler materials can be used to fill the depressed cheeks that as a side benefit may improve the nasolabial folds (creases along the sides of the nose and mouth) indirectly. The nasolabial folds can be injected directly as well. Facial wasting along the sides of the mouth can also be treated by filler injections to treat the marionette lines. Jowling can be camouflaged to some extent with filler injections, and jaw line deformities can be improved as well. Areas around the eyes such as the tear trough can be filled to soften the “double-bubble” deformity of the lower lid -cheek attachments that appear with increasing age. In addition, cheek hollows and lines of the upper face can be filled. Temporal hollowing can also be treated in a similar manner. Even brow elevation can be accomplished with fillers. In addition, the neuromodulators such as Botox and Dysport can treat overactive frontalis muscle that causes transverse forehead lines, overactive corrugators that lead to “11” lines, and lateral crow’s feet lines that are caused by the overactive orbicularis muscle. Treating the lateral brow with neuromodulators can create lateral brow elevation. In addition, the neuromodulators can treat some neck bands due to overactive platysma muscles.  Lip lines, chin puckering, and overactive depressor angulioris muscles of the lower lip region can also be treated. The key in using these products for facial rejuvenation is to not over do it.  Some patients are over treated by their injector, possibly because the injector has not been trained properly in aesthetic rejuvenation or the injector does not offer other procedures such as face lifting, brow lifting, or eyelid lifting procedures. Inevitably, some patients look “puffy” or like marshmallows. Too much product can make someone look as unnatural as someone who has had too much surgery!

Chemical Peels, Lasers, and Skin Care Products

As stated previously, using the roller coaster analogy, the fine wrinkles and sun damaged skin, like the rust on the roller coaster tracks, can be treated with chemical peels, lasers, and skin care products (see the section on Non-Invasive Procedures).  This is not treated with a face lift but is an important ancillary procedure to make the face lift or filler procedure results look that much better. There are numerous laser and light based regimens that can improve the skin quality. For instance, Erbium laser peels either performing microlaser peels or deeper peels can be of benefit for some to improve fine lines, skin color, and tone. Thermascan laser treatments can help with pore size and skin tightening. Intense Pulsed Light (IPL or Sciton laser system BBL) can help with tightening the skin, treat sun spots, and general dyschromia.  BBL-ST is also a light based system that can tighten the skin.  Skin care products are also a great ancillary product to be used as well.


“I always wanted to be a physician because I wanted to help people. Plastic surgery gives me the ability to help people in very positive ways.”


Surgical Incisions

Limited Incision

Otherwise known as a “short scar” approach. This is an incision usually confined to the region from the base of the earlobe to the sideburn region. This is most commonly used for short scar face lift techniques in which a SMASectomy, SMAS plication, or a MACS face lift (see below) is performed. This incision does not permit adequate re-draping of loose neck skin, and so it is not a good incision to use for patients that require extensive neck work. It is a good choice for those patients in New York that need some jowl and cheek elevation with minimal need for neck work. In addition, it is a quicker procedure, so it may be better for patients who are not candidates for longer procedures.

Full Face Lift Incision

The traditional face lift incision extends from the temporal hairline, then goes in a pretragal incision, (in a skin crease in front of the ear notch) and then follows around the earlobe along the ear sulcus behind the ear and then extends transversely into the hairline. If patients have very loose neck skin or upper cheek and face skin, then these incisions may leave the patient with a “wind-blown” look with loss of hair behind the ear and along the temple. Not uncommonly, female patients will lose their side-burn in this situation. Dr. Wallach often uses modifications of these traditional approaches to camouflage the incision and preserve the hairline so patients look more natural. This often includes a side-burn type of incision, an incision hidden behind the tragus or ear notch called a retrotragal incision, and then in patients with loose neck skin he will place the posterior incision along the hairline.  Dr. Wallach, a Manhattan NY Cosmetic Surgeon, applies these same techniques in men and is able to preserve their natural hairline.

Face Lift Techniques

Composite Face Lift

Is a face lift procedure in which the tissues are dissected below the Superficial Musculo-Aponeurotic System (SMAS), the connective tissue layer over the muscles. This is a deeper dissection plane than a SMAS face lift or skin face lift. This procedure moves the cheek fat superiorly as one unit with the overlying skin. This procedure is probably safer in smokers than more traditional techniques.

Deep Plane Face Lift

Is a subperiosteal (just above the bone) lift that is performed at a deeper plane than more traditional face lift techniques (SMAS or composite lift). This form of face lift treats mainly the upper two-thirds of the face and is commonly performed in conjunction with a brow lift, often using an endoscopic approach. This provides correction of facial aging mainly in the brow and the mid-face region.

Extended High SMAS Face Lift

The SMAS refers to the Superficial Musculo-Aponeurotic System, a connective tissue layer below the skin and above the facial muscles. This procedure is a variation of the SMAS facelift (see below) but the incision into the SMAS is made higher in the cheek, usually at or above the level of the cheek bone. This higher incision allows for better elevation of the cheek soft tissues than the lower incision SMAS.  It can be used to also accomplish a mid face lift.  The SMAS itself can be used to augment the cheeks as well and improve the neck contour. It can provide for a fuller cheek appearance, but because the incision is higher on the cheek there is a slightly higher potential for a  facial nerve injury.

MACS Face Lift

Refers to a Minimal Access Cranial Suspension lift. This is a limited incision face lift procedure. An incision is made in the area hidden in the front of the ear. Limited undermining is performed and then sutures are placed  to 1) suspend the soft tissue and elevate the cheek and 2) improve the jaw line by using suspension sutures to improve the jaw line and elevate the cheek region.

Mid-Face Lift

The mid-face lift is a procedure that focuses on the cheek and lower lid junction. The goal is to elevate the cheek fat pad and treat the lower lid region as well. This can be done as an isolated procedure using only a lower lid incision. The soft tissue around the cheek is freed and secured to the temporal fascia of the face. A canthopexy or a support procedure for the lower lid is also performed at the same time. Commonly, mid-face treatment is performed during other face lift procedures using the access during the face lift procedure such as in a deep plane face lift, a composite face lift, and a SMAS face lift.

Neck Lift

A neck lift refers to the treatment specifically of the neck itself. Access to the neck as an isolated procedure can be performed through incisions behind the ear, and in the submental (under the chin) crease. Neck lifts are commonly treated in conjunction with a face lift. There are multiple structures in the neck that may warrant treatment.

Digastric Muscles

They are muscles that can impact the contour of the submental region and may require partial excision.

Neck Fat Removal

There may be fat above and below the platysma muscle (muscle found just under the neck skin). Fat above the muscle can be removed either directly or by suction assisted lipectomy (SAL). If liposuction is the only procedure, this can be performed  through small incisions behind the ear and under the chin.  Removing fat under the platysma muscle will require the exposure obtained during a neck lift procedure.

Neck Skin

Commonly patients complain of a “turkey gobbler” neck as they age. This is often due to loose neck skin. Removal of the excess skin can be performed after neck skin undermining, and the incisions can be hidden within or along the hairline.

Platysma Bands

They form  the vertical bands of muscle that originate from the lower neck and extend to the chin region. These can cause dynamic bands (seen with motion) or static (seen when at rest). They can be treated by imbrication or plication of the muscles in the midline or by partial or complete transection to allow the muscles to re-drape.

Submandibular Glands

They can be prominent in the area under the mandible (jaw). Some surgeons will partially excise them to improve the neck contour. However, some risks of removing the glands  include bleeding and dry mouth.

Skin Only Facelift

A skin excision only face lift is sometimes performed. This will only treat skin laxity. It is best for patients with loose skin, and for patients whose health limits the amount of surgery that they can have. It is a fairly quick operation with less downtime than some other procedures, and with a lower risk of complications. A major disadvantage is that it is not good for patients with significant soft tissue atrophy or facial soft tissue descent.

SMASectomy

This is another variation of the SMAS procedure but instead of incising the SMAS and lifting it, an ellipse of SMAS is excised (cut-out) along the line perpendicular to the pull vector. This is usually an oblique ellipse. The risk of injury to the facial nerve is lower than with some of the other techniques described, but it may not give the same elevation as those procedures that use an elevation of the SMAS. This is also a shorter surgical time as compared to that during the elevation techniques.

SMAS Facelift

The SMAS refers to the Superficial Musculo-Aponeurotic System, a connective tissue layer below the skin and above the facial muscles. After the skin is elevated, the SMAS is appreciated. Treatment of this layer can be done in several different ways. Commonly it is incised, elevated, and pulled back in a superomedial direction. Depending upon the level at which it is cut will determine what area will be best treated. A low incision will primarily treat the lower face and jowl region. It can also be used to improve the neck contour. This low incision is usually made close to the inferior border of the cheekbone or just above the superior border of the parotid gland. The underlying facial nerve, which activates the facial muscles, is protected in this region by the parotid capsule.

SMAS Plication

SMAS plication refers to the technique used when the SMAS is not elevated or incised, and is just imbricated (or overlapped). This is performed more commonly in patients who do not have a well-defined, thick SMAS. This procedure like the SMASectomy shortens the surgical time and is sometimes reserved for patients with higher medical risks, or in patients whose facial aging is not as severe as others.

Stem Cell Face Lift

This is a marketing ploy phrase. There is actually no such thing as a stem cell face lift, but some surgeons market this phrase as fat grafting to the face either separately or in conjunction with a face lift. Stem cells are found within fat graft harvest specimens. So technically there are stem cells, but there is no scientific evidence that stem cells offer any benefit.

If you would like more information about Dr. Wallach and his success with New York City Facelift procedures, we invite you to contact our Manhattan office at (212) 257-3263 or by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028; or using our contact form to request additional details.  For more information regarding facelifts or other procedures, visit our blog.

Questions and Answers about Facelift Surgery

What is the recovery time for a facelift?

Answer:

The recovery can vary from patient to patient. This also depends upon the type of operation performed. In general, most facelifts are done in my accredited ambulatory surgery center and therefore go home the same day. I prefer that my patients go home with a nurse who can take care of them for a day or two if possible. Many of my patients have one or two drains that drain fluid from the face and neck region. These are often removed after a few days. Sutures are taken out over the first one to two weeks. Most patients will have some bruising and generalized swelling. The facial bruising usually goes away within a week to ten days but can last a bit longer for some. The facial swelling can last three to six weeks, but may persist to a small extent for several months after that. If patients have had fat injection, the swelling may persist a bit longer. Most patients can go back to light desk work within seven to ten days. Many can start light aerobic activity within about three to four weeks and then advance to more strenuous activity within about six to eight weeks.

What are the risks of getting a facelift?

Answer:

In general, facelift surgery is safe. The most common issues that develop are prolonged skin numbness which often improves as the swelling goes down, and bruising which can last one to two weeks for most patients. Other less common risks include skin necrosis, fat necrosis, hematomas, fluid collections like seromas, infections, and contour irregularities as well as unfavorable scarring. While quite rare, there have been some reports of facial nerve injuries which can result in facial animation weakness. Many of these go on to heal without any sequelae or any need for further surgical intervention, and fortunately they are quite rare. Most of these procedures are performed under local anesthesia with sedation or general anesthesia, and of course there are some risks. Thanks to modern technology and advancements of anesthesia techniques, the risks of anesthesia are extremely low.

How do I know if I need a facelift?

Answer:

Facelifts are commonly performed on patients from their 40’s all the way into their 80’s! Some patients who prematurely age due to weight loss, extensive sun exposure, and genetic variability have come in for facelifting in their mid-40’s, while, there are many that come in much later. It really varies in terms of age. Initially, people present with facial soft tissue sagging in their cheeks, jowl area, and necks. They notice loose skin as well. Some of these patients show early signs of aging and quite often can benefit from facial fillers to stave off surgical intervention. Eventually, facial rejuvenation surgery is warranted. I see many patients that have seen doctors that can not perform surgery that have overcompensated by overfilling patients’ faces, and these same patients can look a bit “puffy.” I always tell my patients that I have a “full tool belt” of potential treatments that I can offer. While I do not think that everyone needs surgery, I think many require a delicate balance of filler products, neuromodulators like Botox, and facial surgical rejuvenation procedures. Over the past several years, I have added facial fat grafting to many procedures because I think that facial aging is a combination of both deflation and sagging. I do not think that one specific procedure or non-surgical intervention is right for every patient. Many times it is a mix of both to get a very natural, long lasting result.

What is a limited scar facelift?

Answer:

A limited scar facelift is one in which the incision used courses from the top of the ear or sideburn region superiorly, and extends to the base of the earlobe or just behind it. It is best in patients that do not have a lot of redundant skin who undergo a SMASectomy or a SMAS plication. SMAS stands for the superficial muscular aponeurotic system.

Is the skin pulled in a facelift?

Answer:

Usually the deeper tissues of the face are repositioned as opposed to pulled.  The skin should not be used to lift the tissues. The skin should be draped in a more perpendicular orientation to the incision so it does not potentially lead to telltale signs of a facelift, such as lateral swoops of skin.

Is the neck lifted at the same time as a facelift?

Answer:

Quite often the neck is treated at the same time as the face.  The two are strongly interconnected and to just treat the face would create an imbalance with the neck and it would look out of place.

Do you inject fat with a facelift?

Answer:

Facial aging usually consists of two main problems. One is deflation or soft tissue atrophy, and the second is skin laxity or poor elasticity.  For many patients, fat injection is a nice adjunct to provide volume to the face while elevating, draping the skin and removing the excess. However, too much of either one (skin excision or fat injection) may lead to unnatural results.

What is the recovery like from a facelift?

Answer:

The recovery for a facelift is relatively easy for most patients.  I like patients to go home with a light dressing and to keep their chin to neck angle about 90 degrees for the first week or so to avoid tension on the incision closures. Often if drains are used, they will be removed within a few days. I usually remove about half of the sutures within a week and the remainder by 10-14 days after surgery.  Many patients can go back to work within a week to ten days but residual bruising might be present.

When can I go back to work after my facelift?

Answer:

Many patients can return to work within about one to two weeks. There may still be some bruising after this time, but for women, make-up can be applied to camouflage any bruising.

Where are the incisions for a facelift?

Answer:

The type of facelift performed and who is doing the procedure will determine where the incisions will be placed. Traditionally the incision starts in the temporal hairline and extends in front of the ear tragus and then goes behind the ear and back into the occipital hairline. I have found that these incisions are not always best in patients with severe skin laxity. This results in loss of good quality hair along the neck and the side-burn. Additionally, the pre-tragal incision can leave a very noticeable scar.  I prefer in many cases, to place the upper portion in front of the hairline or sideburn to preserve the hair in this region. Typically, I will also place the incision behind the ear tragus, which is called a retrotragal position. In turn, this will better camouflage the incision in this area. When the incision goes behind the ear, I often like to keep it along the hairline as well to avoid loss of hair in this region. If performing a limited incision facelift, then the incision starts near the side-burn and ends at the base of the earlobe, or slightly behind it.  My goal is to use the least amount of incisions and maintain a natural ear appearance and hairline to avoid telltale signs of a facelift.

Will I lose my hair by my sideburn or behind my ear after the facelift?

Answer:

It was fairly common during a traditionally designed facelift that the hairline along the sideburn and behind the ear would sometimes be distorted.  Patients would sometimes get the “windswept” appearance. In my opinion, the goal is to preserve the hairline and maintain a very natural look. Often I will set the incision along the border of the hairline so that the hairline is not distorted.

Why do some people look funny after a facelift?

Answer:

Poor quality work is often related to unfortunate designed incisions, poor execution, and a lack of understanding the various techniques to improve the facial appearance.  I think a good quality facelift is one that does not look strange or weird.  The goal is to provide high quality work that maintains a very natural appearance while improving the facial aging.

Why are sweep lines caused by some facelifts?

Answer:

Lateral sweep lines occur along the side of the face in some individuals after a facelift. This can be due to improper re positioning of the skin during a facelift.  In my opinion, it happens more commonly in those patients when the surgeon pivots the skin in a superior fashion to “lift” the face. In general, I believe that the deeper tissues should be used to reposition the soft tissue, and the skin should be draped perpendicular to the incision in most cases. This should minimize the risk of sweep lines.

Why do some patients have their ears pulled after a facelift?

Answer:

When ears are pulled down after a facelift onto the cheek, this is sometimes referred to as a “pixie” ear because of the pointed nature along the attachment of the earlobe to the face. This happens when there is too much tension on the face skin or when the earlobe is detached from its normal position.  Patients have come to me with this problem from prior work done by others. I have fixed this by hitching up the skin underneath the ear and detaching the lobe from the cheek to allow it to properly “dangle.”

Will my nasolabial creases be improved with a facelift?

Answer:

The nasolabial creases run alongside the mouth up to the nose, and often are accentuated with smiling. As a person ages, the soft tissues deflate and sag and the nasolabial folds often become deeper. Sometimes facial fillers like the hyaluronic acid products can help improve this area. Fat grafting can do the same, and may be a more permanent solution. Facelift techniques can be performed that will lift tissues around the cheek and will help soften the nasolabial folds. Effacing or completely flattening the folds can be performed but is not recommended. Nasolabial folds are part of the normal facial anatomy and should be present to some extent. Removing them completely causes patients to look a bit “robotic.”

Will the lines around my mouth be improved by a facelift?

Answer:

Perioral rhytids or lip lines are not treated by a facelift per se. They can be treated at the same time as an ancillary procedure. Often laser procedures using Erbium, CO2, or Fraxel can help improve the quality of the lip lines. Dermabrasion is another method to soften the lines. Sometimes I will use a neuromodulator such as Botox/Dysport/Xeomin to weaken the muscle a bit. Fillers can be used to fill the lines as well.

How tight will my face be after the facelift?

Answer:

A face after a lift should not feel too tight. Certainly the deeper tissues will be repositioned and so some internal tightness may be felt, but the patient should be able to turn their head back and forth and lift their chin upward. Over the ensuing few weeks post-op, as the swelling subsides, the tissues become softer and more mobile.

What is a composite facelift?

Answer:

A composite facelift is a type of facelift that entails elevating the SMAS (the superficial muscular aponeurotic system) with the skin as one unit. This also includes repositioning the orbicularis oculi (the muscle around the eye in the same flap). It is different from the subperiosteal facelift.

What is a superiosteal facelift?

Answer:

A subperiosteal facelift is a technique that works mainly on the upper two-thirds of the face. This procedure elevates the soft tissues of the cheeks and forehead below the level of the soft tissue just above the bone. Commonly this is performed with an endoscope, a small camera, to assist with the dissection. It does not treat the neck directly.

What is a MAC’s lift?

Answer:

MAC’s lift refers to Minimal Access Cranial Suspension. A short scar facelift approach is performed, and looped sutures are used in the upper neck and cheek region to vertically raise the tissues. The advantage is a shorter operation using shorter incisions. However, it does not really treat the neck to any degree, and in someone who has severe laxity of the soft tissues, may be a better candidate for a more traditional approach.

What is a High extended SMAS lift?

Answer:

SMAS refers to the superficial muscular aponeurotic system. This is a connective tissue layer superficial to the muscles but deep to the subcutaneous fat layer. When a high SMAS extended facelift is performed, the SMAS is released at or above the malar eminence and extended across the cheek region just past the region of the zygomaticus major muscle. This allows for elevation of the malar fat pad and enhancement of the cheek region. The soft tissue can be suspended in a superolateral vector and even imbricated to augment the cheek region. This is a very versatile procedure and I use it quite often on my patients.

What is a short scar facelift?

Answer:

A short scar facelift is any one of a number of operations that refers in general to the length of the incision used to perform the facelift. It often runs from the side-burn extending downward by the ear and stopping just at the earlobe or slightly behind it. Various techniques to treat the deep tissue can be offered with this approach. It may not be appropriate for someone with severe skin laxity.

How do I avoid that “pulled look” from a facelift?

Answer:

The “pulled look” is commonly the result of actually pulling on the skin to give the lift and pulling it too tightly. Some surgeons use the skin to “lift” the face in a supero-lateral vector. The skin is pulled tightly to try to elevate the deeper soft tissues and as a result, distorts the face. I usually mobilize the deeper layers of the face to obtain the proper contour and then only remove the redundant skin as necessary.

If I have a facelift, do I need to have my eyes and brow surgery as well?

Answer:

In the analysis of all new patients, I always examine the entire face and discuss treatment options as indicated. The surgery is individualized for each patient and is not necessary in everyone. If the patient could benefit from eye surgery and/or brow surgery, it can be staged at a later time or not done at all. This really depends on the individual patient’s desires. Of course, if only the facelift is performed than a youthful lower two-thirds of the face will be out of “sync” with a tired looking upper one-third of the face. Nevertheless, the choices are always up to the patient.

How do I avoid “elf” ears from a facelift?

Answer:

One way to avoid the removal of the sideburn and temporal hair is to properly design the incisions for a facelift. In addition, the ear can sometimes be distorted looking like an elf or “pixie” as well. I spend a lot of time designing and properly closing the incisions so that the risk of these deformities is minimized. This also adds a lot of time to the overall surgical procedure, but it is well worth the result!

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