A facelift, technically known as a rhytidectomy (from the Ancient Greek () 'wrinkle', and () 'excision', the surgical removal of wrinkles), is a type of cosmetic surgery procedure intended to give a more youthful facial appearance. There are multiple surgical techniques. Surgery usually involves the removal of excess facial skin, with or without the tightening of underlying tissues, and the redraping of the skin on the patient's face and neck. Surgical facelifts are effectively combined with eyelid surgery (blepharoplasty) and other facial procedures and are typically performed under general anesthesia or deep twilight sleep.
According to the most recent American Society for Aesthetic Plastic Surgery facelifts were the third most popular aesthetic surgery in 2019, surpassed only by rhinoplasty and blepharoplasty.
Cost varies by country where surgery is performed. Prices were quoted ranging from US$2,500 (India and Panama) to US$15,000 (United States and Canada) . Costs in Europe mostly ranged £4,000–£9,000 .
History
Cutaneous period (1900–1970) In the first 70 years of the 20th century, facelifts were performed by pulling on the skin on the face and cutting the loose parts off. The first facelift was reportedly performed by Eugen Holländer in 1901 in Berlin. An elderly Polish female aristocrat asked him to: "lift her cheeks and corners of the mouth". After much debate, he finally proceeded to excise an elliptical piece of skin around the ears. The first textbook about facial cosmetic surgery (1907) was written by Charles Miller (Chicago) entitled The Correction of Featural Imperfections.
In the First World War (1914–1918), the Dutch surgeon Johannes Esser made one of the most famous discoveries in the field of plastic surgery to date, namely the "skin graft inlay technique," the technique was soon used on both English and German sides in the war. At the same time, the British plastic surgeon Harold Delfs Gillies used the Esser-graft to school all those who flocked towards him who wanted to study under him. That's how he earned the name "Father of 20th Century Plastic Surgery". In 1919, Dr Passot was known to publish one of the first papers on face-lifting, this consisted mainly of the elevating and redraping of the facial skin. After this, many others began to write papers on face-lifting in the 1920s. From then, the aesthetic surgery was being performed on a large scale, form the basis of the reconstructive surgery. The first female plastic surgeon, Suzanne Noël, played a large role in its development and she wrote one of the first books about aesthetic surgery named Chirurgie Esthetique, son rôle social.
SMAS period (1970–1980) In 1968, Tord Skoog introduced the concept of subfacial dissection, therefore providing suspension of the stronger deeper layer rather than relying on skin tension to achieve his facelift (he publishes his technique in 1974, with subfacial dissection of the platysma without detaching the skin in a posterior direction). In 1976, Mitz and Peyronie described the anatomical Superficial Musculoaponeurotic System, or SMAS, a term coined by Paul Tessier, Mitz and Peyronie's tutor in craniofacial surgery, after he had become familiar with Skoog's technique. After Skoog died of a heart attack, the superficial muscular aponeurotic system (SMAS) concept rapidly emerged to become the standard face-lifting technique, which was the first innovative change in facelift surgery in over 50 years.
Deep plane period (1980–1991) Tessier, who had his background in the craniofacial surgery, made the step to a subperiosteal dissection via a coronal incision. In 1979, Tessier demonstrated that the subperiosteal undermining of the superior and lateral orbital rims allowed the elevation of the soft tissue and eyebrows with better results than the classic face-lifting. The objective was to elevate the soft tissue over the underlying skeleton to re-establish the patient's youthful appearance.
Volumetric period (since 1991) At the start of this period in the history of the facelift, there was a change in conceptual thinking, surgeons started to care more about minimizing scars, restoring the subcutaneous volume that was lost during the ageing process and they started making use of a cranial direction of the "lift" instead of posterior.
The technique for performing a facelift went from simply pulling on the skin and sewing it back to aggressive SMAS and deep plane surgeries to a more refined facelift where variable options are considered to have an aesthetically good and a more long-lasting effect.
Indications
A facelift is performed to rejuvenate the appearance of the face. Aging of the face is most shown by a change in position of the deep anatomical structures, notably the platysma muscle, cheek fat and the orbicularis oculi muscle. These lead up to three landmarks namely, an appearance of the jowl (a broken jaw line by ptosis of the platysma muscle), increased redundancy of the nasolabial fold (caused by a descent of cheek fat) and the increased distance from the ciliary margin to the inferior-most point of the orbicularis oculi muscle (caused by decreasing tone of the orbicularis oculi muscle). The skin is a fourth component in the aging of the face. The ideal age for face-lifting is at age 50 or younger, as measured by patient satisfaction. Some areas, such as the nasolabial folds or marionette lines, in some cases can be treated more suitably with Botox or liposculpture.
Contraindications Contraindications to facelift surgery include severe concomitant medical problems, both physical and psychological. While not absolute contraindications, the risk of postoperative complications is increased in cigarette smokers and patients with hypertension and diabetes. These strong relative contraindications consist primarily of diseases predisposing to poor wound healing. Patients are typically asked to abstain from taking aspirin or other blood thinners for at least one week prior to surgery. Patients motivations and expectations are an important factor in order to determine the patient's medical status. A psychiatric illness leading to unreasonable expectations for the surgical outcome, such as a distorted perception of reality, can be a contraindication to surgery. Some kinds of hypersensitivity to anesthesia are a contraindication.
Surgical anatomy
SMAS Facial musculature Facial nerve A dissection in the deep plane can mostly be performed safely, because the facial nerve innervates the facial muscles on the deep surface of these muscles (except for the muscles which are lying deep to the facial nerve, the mentalis, the levator anguli oris and the buccinator). The fibres of the nerve are becoming more superficially medially. Therefore, the dissection of a deep plane begins further away of the surface then it ends. This allows the undermining to be carried out towards the nasolabial fold without harming the branches of the facial nerve. Retaining ligaments The retaining ligaments in the face provide an anchorage of superficial structures to underlying bone. Four retaining ligaments exist. The platysma-cutaneous ligaments and the platysma-auricular ligament are aponeurotic condensations which connect the platysma to the dermis. The osteocutaneous ligaments, the zygomatic ligament and the mandibular ligament, are more important. They attach to the skin and bone, leading to a counteraction of gravitational forces. These ligaments should be released surgically to obtain a fully mobile facelift flap. Nasolabial folds Melolabial folds (marionette lines) Greater auricular nerve Injury to the greater auricular nerve is the most seen nerve injury after rhytidectomy. Care should be taken in elevation over the sternocleidomastoid muscle, because of the terminal branches of the nerve that pass superficially to innervate the earlobe. Vascularisation The composite flap is vascularised by facial, angular and/or inferior orbital arteries. The facial artery supplies the platysma and goes on as the angular artery, which connects with the branches of the arteria supratrochlearis and arteria infraorbitalis. The parts of the face elevated are in continuity in the deep-plane and the composite rhytidectomy include the SMAS layer in the lower face, subcutaneous tissue and the skin as the arteries to these parts are preserved. With this option you can create a well vascularized tissue flap, which can be used to tighten the skin without loss of vascularization, this will result in fewer complications like skin slough and necrosis.
Procedures Many different procedures are used for rhytidectomy. The differences are mostly the type of incision, the invasiveness and the area of the face that is treated. Each surgeon practices multiple different types of facelift surgery. At a consultation the procedure with the best outcome is chosen for every patient. Expectations of the patient, the age, possible recovery time and areas to improve are some of the many factors taken in consideration before choosing a technique of rhytidectomy.
In the traditional facelift, an incision is made in front of the ear extending up into the hairline. The incision curves around the bottom of the ear and then behind it, usually ending near the hairline on the back of the neck. After the skin incision is made, the skin is separated from the deeper tissues with a scalpel or scissors (also called undermining) over the cheeks and neck. At this point, the deeper tissues (SMAS, the fascial suspension system of the face) can be tightened with sutures, with or without removing some of the excess deeper tissues. The skin is then redraped, and the amount of excess skin to be removed is determined by the surgeon's judgement and experience. The excess skin is then removed, and the skin incisions are closed with sutures and staples.
SMAS facelift The SMAS (Superficial Musculoaponeurotic System) is a fibromuscular layer that envelops the muscles of facial expression and is continuous with the platysma in the neck. It functions in conjunction with retaining ligaments and facial fat compartments to support and transmit movement to the overlying skin. In facelift surgery, manipulation of the SMAS allows for repositioning of deeper facial structures to restore contour and address age-related soft tissue laxity.
Resuspension and stabilization of the SMAS can contribute to facial rejuvenation by counteracting gravitational descent and structural changes associated with aging. These procedures are often performed in conjunction with other facial rejuvenation techniques, such as blepharoplasty, depending on the patient's anatomy and aesthetic goals.
SMAS Plication
SMAS plication involves folding and suturing the SMAS without extensive dissection. This technique provides moderate tightening of the underlying structures and is generally considered less invasive than flap-based approaches, though it may offer more limited tissue mobilization.
SMAS Flap (Imbrication)
SMAS flap techniques involve elevation and repositioning of the SMAS as a distinct layer. By mobilizing the SMAS, surgeons can achieve more substantial lifting and redraping of facial tissues compared with plication methods.
Extended SMAS Techniques
More advanced approaches extend beyond superficial SMAS manipulation to address deeper structural components. These include composite facelift and deep-plane facelift techniques, which involve dissection beneath the SMAS and release of retaining ligaments to allow repositioning of the midface and related structures.
Deep-Plane facelift The deep-plane facelift is a rhytidectomy technique in which dissection is performed beneath the superficial musculoaponeurotic system (SMAS), allowing the skin and underlying soft tissues to be elevated as a single unit. This approach permits mobilization of the midface, including the malar fat pad and release of selected retaining ligaments that contribute to facial aging.