Current concepts of facelifting

There are various methods of facelifting to tighten sagging areas of the face in the long term. The classic facelift can be divided into the treatment of different layers, but the current trend is towards minimally invasive methods with a short recovery time and low surgical risk. Postoperative complications are rare, but clinically relevant.

100 years of tradition

Facelifting (synonym “facelift” or “rhytidectomy”) means the surgical removal of facial wrinkles and tightening of the skin to achieve a younger appearance. Facelift surgery can look back on a tradition of over 100 years, but has become increasingly important in recent decades.

In addition to the formation of wrinkles, skin irregularities such as pigmentation, loss of volume and sun-damaged skin should also be taken into account. Further analysis includes the patient’s skin type and thickness.

This article provides an overview of the various techniques, indications, advantages and disadvantages of facelift surgery, modifications using combined methods and possible complications.

Basic principles of the facelift

As early as 1900, Hollander introduced the basic principles of the facelift, in which excess skin is removed along the hairline. In 1920, surgeons developed the technique of subcutaneous mobilization of the skin. The method improved the sagging of the skin, but did not take into account the underlying ptosis. Skoog achieved a breakthrough in 1974 by tightening the skin together with the underlying platysma on the neck as a so-called “composite flap”.

In 1976, the so-called “superficial musculoaponeurotic system” (SMAS) was described by Mitz and Peyronie. In the late 1980s and early 1990s, Hamra described the deep-layer facelift or “composite” facelift together with SMAS to improve the periorbital and nasolabial regions. In 1992, Ramirez described the subperiosteal technique for the cheek area, forehead, lateral corner of the eye and eyebrows.

There were several comparisons between the different techniques, which are described below. The more invasive methods tended to show better long-term results. Recently, however, the techniques have tended towards less complex operations with less downtime for patients.

Patient selection and preoperative preparation

Patient selection and assessment are crucial for the further treatment plan. In particular, care should be taken not to treat SIMON patients (“single, immature, male, overly expectant, narcissistic”).

The operation and the associated risks as well as the possible prospects of success must be clearly explained to the patient. Certain medications such as isotretinoin or vitamin E must be discontinued two weeks before the operation. In addition, the patient must refrain from smoking for two months before and after the operation.

Facelift techniques

The subcutaneous facelift

According to the original concept of the facelift, the preparation takes place in the subcutaneous fatty tissue. This technique involves only a skin resection and has been popular for a long time. A subcutaneous facelift can be ideal if excess skin is the main problem or if a facelift with SMAS plication has already been performed.

However, the results of this technique are limited in duration, particularly as deeper, hanging structures such as the SMAS are not treated. In addition, extensive subcutaneous mobilization carries the risk of flap ischemia, especially in smokers. However, the procedure is ideal for beginners and very safe as the underlying structures and facial nerves are spared. In addition, the recovery time is very short.

The SMAS application

The SMAS plication technique primarily treats the deeper, hanging structures. The preparation technique is performed above the SMAS. After the SMAS has been exposed, the mobile part of the SMAS is fixed to the posterior, immobile part of the SMAS with several sutures. The excess SMAS can then be removed. The procedure is relatively easy to perform and carries only a low risk for the patient. The operation and recovery time is short.

Minimal Access Cranial Suspension (MACS) lifting

Compared to the traditional facelift, the MACS lift tightens the skin vertically to avoid “dog ears”. MACS procedures can be divided into a simple and an advanced version. In the simple version, two tobacco pouch sutures are used to treat the areas of the neck and the lower half of the face. In the extended MACS lift, a third tobacco pouch suture is placed in the temple hairline to fix the zygomatic fat pad and tighten the center of the face and eye area.

The dissection technique is performed above the SMAS and is continued to two finger widths below the lower jaw. The excess skin is removed vertically. Advantages include a small incision line, minimal subcutaneous undermining and a low risk of facial nerve injury. Recovery time and results are described as good. This technique is less suitable for a simultaneous neck lift, skin irregularities are possible due to the tobacco pouch sutures, and long-term results can be negatively affected by the so-called “cheese-wiring” effect.

Deep Plane Facelift (DPFL)

The so-called “deep plane facelift” was described specifically for treating the midface and the nasolabial fold. This technique was first described by Hamra. Basically, the preparation is carried out below the SMAS, with the orbicularis oris muscle and the zygomaticus major and minor muscles serving as reference points.

The zygomatic ligament is severed. This technique is particularly suitable for older patients with changes in the midface and nasolabial fold. The results are longer lasting than with dissection techniques above the SMAS. However, there is a potential risk of nerve injury.

Advanced SMAS facelift

The sub-SMAS preparation technique is the basic principle for long-lasting tightening of the overlying skin structures. The technique was first described by Stuzin in 1995. The basic principle is the separate preparation of the skin and the SMAS flap. The SMAS flap has a different vector than the skin flap. The direction of traction is more vertical than that of the skin flap.

Part of the SMAS flap can also be transposed retroauricularly to tighten the neck and cheek area. This technique is efficient and the effect is long-lasting, as both the malar fat pad and the facial bands can be treated separately. One disadvantage is the long operation time, the technique has a shallow learning curve and there is a potential risk of nerve injury. There is also a risk of flap necrosis with extensive skin mobilization.

Lateral SMAS ectomy

The lateral SMAS ectomy was popularized by Daniel Baker in 1997. In this very safe technique, only the lateral part of the SMAS between the mobile and immobile SMAS is resected. The SMAS is fixed superoposterior to the immobile SMAS and the vector is usually perpendicular to the nasolabial fold, but can vary depending on the shape of the face.

This technique is simpler than DPFL or composite facelifts and the results are very predictable. However, the facial bands cannot be treated and the operation time is slightly longer than with the MACS lift. Several prospective studies have shown no difference between lateral SMAS ectomy and conventional SMAS facelift at 6 and 12 months.

Subperiosteal facelift

The subperiosteal facelift was first described by Paul Tessier. The endoscopic approach is performed intraorally and temporally. After the subperiosteal detachment, the medial septum is fixed to the deep fascia of the temporalis muscle. It is assumed that this approach minimizes the risk of nerve injury.

The technique is more minimally invasive than conventional techniques, and the malar and buccal fat tissue can also be treated. The results are long-lasting and the blood supply to the flap is unproblematic. The technique is particularly beneficial for smokers. The disadvantages of this operation are the longer operation time and the longer recovery time.

Complications of a facelift

Possible complications include postoperative bleeding, whereby the blood pressure should remain within the normal range in the postoperative phase. Other possible complications include scar hypertrophy, skin necrosis, nerve injuries (cavus auricularis nerve), temporal alopecia, seroma, wound dehiscence, contour irregularities and infections.

The complication rate is 1-15 % for hematoma formation, 0.05-0.18 % for infections, 0.07-2.5 % for nerve injuries, 1-1.85 % for skin circulatory disorders and 0.1 % for venous thrombosis.19-21. An increased complication rate of 9.5 % is also described for an increased BMI over 25 kg/m² (compared to 4.7 % for normal-weight patients).

The most common possible complication of a facelift is post-operative bleeding. The most important risk factors are male gender, high blood pressure, preoperative use of blood thinners, nicotine abuse, increased BMI, preoperative and postoperative blood pressure spikes, nausea and vomiting. Hematomas can cause circulatory disorders, swelling and hyperpigmentation.

Combined treatments for the facelift

In recent years, several non-invasive facial treatments have become increasingly popular, which can be performed in addition to a facelift and at the same time or one after the other.

Possible treatment methods include radiofrequency treatments and ultrasound therapy, liposuction, lipolytic injections, fractionated laser treatments, “platelet-rich plasma” injections and chemical peels. Neuromodulators or various types of fillers (e.g. autologous fat grafting, “lift-and-fill facelift”) are ideal complementary methods.