Introduction

“Welcome to Plain Talk About Plastic Surgery. I’m your host, Dr. Elizabeth Kerner, and we’re here today to talk about facelifts.

If you’ve listened to any of the other podcasts, I’ve already done brief segments on the forehead lift, and your eyelids, and then the neck. So today we’re going to put it all together with the facelift.

Facelifts have been done pretty routinely since the early 1960s, with the first facelifts being what we would call now mini-facelifts or skin only. Plastic surgeons back then were quite pioneering in attempting to do this with the surgical techniques, equipment, and sutures that they had back then.

So it just tells you that both women and men, but predominantly women, have been desperate to alter the ravages of facial aging for a very long time.

What is a Facelift?

It’s really just pulling the skin and the underlying tissues of the face tighter, and depending on the direction, giving a more lifted, less tired, less saggy, less depressed look by removing extra skin and altering positions of fat so that if you have big fat jowls, or what’s called a buccal fat pad, that can be removed, or if your face is quite gaunt, putting fat in to give a fresher, healthier look.

What causes facial aging?

As I always say, our old friend gravity, along with your genes. Some people really do have not such great luck in the gene category for facial aging. You may have a very loose, less elastic skin that then has sun damage on it, so that your skin is really thin and crepey and doesn’t give you a nice firm look.

You might have gone through cycles of weight gain and weight loss; could have had major illnesses; maybe your bone structure isn’t quite so great, like you have fairly flat cheeks, or a very small retrusive chin, or a poor jawline. As we talked about in the neck episode, maybe your hyoid is very low, so your neck has always been oblique.

All of these things contribute to how we age. But gravity, of course, is the biggie. I would put in weight loss and gain as two secondary ones.

Some people have won the genetic lottery. They look like Lena Horne or Audrey Hepburn, they have these great swan necks, and they have Angelina Jolie’s cheekbones and a good strong jawline, and they don’t ever seem to age. But for the most of the rest of us, that’s not the case.

So I’m not going to talk really about forehead, lids, or neck, because I’ve already discussed all of that in the other podcasts. I’m just going to really focus on what we call the mid face, which would be the cheek from right below the eyes, along the cheekbone, down to the jawline.

The Mini Facelift Versus a Full Facelift

There are two things that can be done for facelift:

Mini Facelift

A Mini Facelift, which is essentially an incision for some length (sometimes a mini facelift doesn’t mean that you have a little bitty scar) but it goes along the front of the ear. We usually, in almost all instances, try and hide the scar back behind the bump of the ear, which is called the tragus.

In a mini facelift it is pretty simple; just go in underneath the skin, pull the skin back and tighten it up. And that works really well, typically, if you’re younger and you’ve had a weight loss and there’s some familial predisposition to having a saggier mid face.

But if your internal tissues, those tissues over the cheek, have really started to sag, all this is going to do is give you kind of a flattened look.

Most mini facelifts are really only done on women and men in their younger ages. As you get older, there’s just no way that a mini can give you the results that a full facelift can.

Of course, a mini is going to come with the front part of the scar. Typically in a mini facelift, we’re not going to do anything to the lower lids, and the neck is not going to be altered at all.

The Lifestyle Lift, which was quite popular years ago, is mostly a mini facelift. In the right person it works really great, and you can see a nice result with no abnormalities of how somebody looks. They don’t look weird and can gain years and years before they might need a real facelift.

Full Facelift (SMAS Flap or Plication)

A real facelift is making the incision, and this goes from up in the temporal hair usually or under the sideburn – kind of depends on what your hair pattern is – swoops long in front of the ear, behind the bump, around the lobule, and then into the crease behind the ear.

A full facelift can be done several different ways. I like to do what is not called a deep facelift, but would be called a SMAS flap or plication.

The SMAS tissue is the superficial muscular aponeurotic system, and that is a fibrous layer that is on top of the parotid gland, and it extends down over the jawline into the neck, becoming the platysma muscle. This is the tissue that we use to reposition all the rest of the tissues in your mid face.

So we would go underneath of the skin for a variable distance to loosen it up, and then look at that layer and say, “gosh, can I just pull and tug on it, and suture it and get it to do what I want? Or do I need to detach it from the underlying tissues?”

Underneath of this is the parotid gland. And then as you go further towards the nose, you start to get into the muscles that go around the eyes, up along the side of the nose, and those are where the facial nerve branches are. And that’s why this operation is technically a challenging one and I think is really why it costs more money, because there is significant potential for problems.

The Importance of Proper Suturing

I use permanent stitches. I think pretty much everybody does to tighten the SMAS, either from elevating and moving it to a different vector of pull; we’re usually trying to pull upwards towards the top of the ear, the outer part of the eye, what’s called the lateral canthus.

It would be great if you could do a straight vertical pull, but that doesn’t happen because it really bunches up along the lower part of the eyelid. And also I think it kind of gives you a snarl to your upper lid.

When we suture this tissue we have to be very careful not to create widening of the nose or widening of the mouth or what’s called a lateral sweep, where there’s just too much tension and it looks like you’re in a wind tunnel. That also goes with removing the skin.

Once all that tissue has been tacked up, then fat modification can be done; either liposuction in the jowl area, taking out some of the buccal fat pad if that’s the culprit; or conversely, if your face is too gaunt, putting fat in to help plump it up. I think fat injections into the face have significantly made facelifts look better and last longer.

And then the skin is removed and cut off along our incision and sutured in place, again with care taken to try and not give you this lateral sweep look where you look like you’re in a wind tunnel, and also to make the ear lobule look normal. I think doing the suturing of the facelift is just as important as the internal work.

Anesthesia During Facelift Surgery

I like to do my facelifts with my patient asleep. I don’t particularly want you to move. It would seem to me the time you’re going to move is always when I’m close to nerve, and I really don’t want you to move. We don’t paralyze our patients because as the dissection goes and we get close to all those little branches of the facial nerve which make the muscles work, there’ll be twitches. That’s what tells you you’re in a danger zone, or you need to be careful and look for that nerve.

The operation takes hours. I don’t have a nurse or a PA that works with me, so I do all my own suturing. So it is a fairly slow and long operation for me. And I do prefer that my patients spend the night with a nurse at the surgery center. I don’t typically drain in the mid face, although we’ll put a drain in the neck that comes out the next day.

Post-Op Recovery and Final Results

Sutures are in for about twelve to 14 days and depending on your hair pattern, may or may not be too visible. By three weeks, you’re usually looking reasonably good to be out in public without eliciting any stares. By four to six weeks you can probably be out with friends and hopefully nobody’s going to particularly notice that you’re just freshly post-op.

Some surgeons do a very tight, highly pulled facelift. That is not what I like. So if that’s what you’re thinking you want, probably you should look elsewhere. I like to do facelifts where the patients look themselves, but relaxed, less tired, and you kind of turn the clock back about ten to 15 years.

Good facelift patients don’t have too fat of a face, nor do they have too thin of a face. They would have a good bone structure and they have reasonable elasticity of their skin.

Once you start getting lots and lots of sun damage with all those corrugated lines on the skin, that skin is not going to hold up very well after it’s been pulled. It’s going to relax and you’re going to see looseness again, especially along the jawline. If you are losing weight, trying to get down close to your goal weight is certainly the best because weight loss after a facelift will make your face not look as good as when it was fuller.

Conclusion

So this is just a very brief overview of facelift. The discussion in the office, if you’re interested, will usually take me about 45 minutes.

I like to see when you pull your face back what you’re kind of hoping to look like.

I also like to look at pictures from previous decades. So let’s say you’re 60. I’d like you to bring in a picture when you’re 30, 40 and 50 just so I can see how your face has aged. There’s some things that if you had really deep creases along the side of your mouth, that’s probably not going to change if it’s been there since you were 20 years old. And we’ll look at those pictures at your second discussion.

I realize this is a relatively brief overview of a very complicated topic. It’s hard to get into too much detail because everybody’s face is different. So what would be done to make one person’s face look better is not what I would recommend for another person. So I’m just giving you kind of the glossy overview of facelifts.

Some surgeons do a facelift where they go in through the mouth, an endoscopic facelift. Others do it by elevating the muscle off of the bone. And some do it by taking the SMAS layer and the skin and the fat all in one layer.

I don’t think that there’s a particularly right or wrong way. It’s just how the surgeon gets the best results. And I’m pretty confident that all surgeons modify what they do based on the anatomy that the patient brings to the operating table and also what their expectations are.

I hope this has given you a little bit of insight into facelifts and the way we do them today.

If you would like more information, please visit my website, www.drkerner.com. That’s drkerner.com. I do have some facelift pictures, but as I said with cervicoplasty, it’s very difficult to get patients to agree to having their before and after pictures on the internet when they’ve had a facelift.

So I think all of us, when you look around, there’s not just a huge number of post-op pictures available to show you. I do have patients’ pictures on my computer and if I have someone whose face I think is very much like yours, I may pull up a before and after, with no names of course, just so that you can get a better idea.

Thank you very much for listening to this podcast and have a good day.

Introduction

“Welcome to Plain Talk About Plastic Surgery. I’m Dr. Elizabeth Kerner, your host for this podcast. If this is the first podcast you’ve tuned into, I’m here to give you practical and down to earth honest information about various plastic surgery operations and procedures.

I’ve been in practice for 32 years, and I’m hoping that this will be an informative discussion, almost as if I were your sister saying, “oh, you should do this or don’t do that.”

Today, our podcast is Why Can’t I Just Have My Neck Fixed?

This is such a common question I’m asked when women and men come in and what really bothers them is the neck. So, that is the portion below the jaw line. And I’m here to tell you why most people aren’t going to do well with just an isolated neck lift.

How the Anatomy of Your Neck Affects Whether a Neck Lift is For You (or Not)

As I always like to do, I’ll start with some anatomy. So the neck is considered the area underneath your jawline or your mandible, and it extends down to your collarbones, the clavicles. And what bothers most people is the central portion of the neck, what’s called the submental area, the mentum being your chin.

This area is created by – going from the outside to the inside – skin, and then a layer of fat, which can be substantial or in some people very little, and then below that are the platysma muscles.

Platysma muscles are little thin rhomboidal shaped muscles that go from the collarbone up to the jaw line and in most people extend into about the mid cheek. When they hit the cheek, they kind of peter out and become part of what we call this SMAS or superficial musculo aponeurotic system. And the SMAS is what is sutured, lifted, moved, vectored, in facelifts.

So if you think about it, for most people, the platysma is intimately involved with the SMAS, which means what’s happening in your cheek is also affecting what’s happening in your neck.

Well, to get back to anatomy, so when we’re young, normally the platysma muscles meet in the mid part of our neck underneath of the chin, and they cross over each other. So they form a nice little hammock there.

Underneath of the platysma muscles, there’s usually a little fat pad, the subplatysmal fat. And adjacent to the subplatysma fat will be your sub mandibular glands, which are the little round bally glands sitting about a third of the way along your jaw line.

And deep to that are the muscles that support your throat. The mylohyoid is the floor and the deep sides are the digastrics. The digastrics help for internal throat support and movement. They hook onto a little wishbone piece of cartilage called the hyoid.

So in the anatomy lottery, if your hyoid sits pretty high up towards your mandible, that means the digastrics are going to go from, let’s just say, bottom part of the mouth into the hyoid, and you’re going to have a very acute angle or a nice, sharp, crisp angle underneath of your chin. Think Audrey Hepburn. That would be a good person to think of.

If you have a low hyoid, meaning the hyoid is situated farther down along the neck, the digastrics when they join into that are going to create a more oblique angle.

So underlying all of what can be done to your neck is really your anatomy. If you have a low hyoid and you have bulky digastrics and you’ve always had an oblique angle, and then you couple that with maybe you have a bit of a weak chin, so you don’t have a very prominent chin, because that also adds to the appearance of fullness if you don’t have a chin that juts out.

Jay Leno with his big old chin will never have a problem with looking fat and full under his neck because the chin just comes out so far he’s always going to have more of an acute angle.

So that’s all the anatomy. A low hyoid, thick digastrics, a platysma muscle that never quite met in the middle or has gotten quite weak and also extends up into the cheek area; all of those are going to be factors for how you’re neck’s going to look.

The Mirror Test: What You See Isn’t Always What You Get

So if you’re like most everybody and you stand in front of the mirror and you pull the skin of your neck backwards and you say, “look, I just need my neck.”

But what I find is most people are subconsciously putting their finger along the jaw line because when you pull along the jaw and upwards a little bit, it makes the neck look a whole lot better.

That’s when we get into facelift territory.

Now, if you go to the mirror and you pull your neck skin from the center back and you really stay underneath of the mandible, so you’re not encroaching in the skin in the jaw area, sometimes what will happen is it will pull that jaw towards the ear. So you get a really unpleasant looking furrow from the corner of your mouth down towards your mandible.

Other times it will cause a lot of bunching of skin in front of the ear lobe, which you can’t leave that there. So that has to be taken out. So now essentially you’re doing a facelift.

If you pull up in your cheek area, like along your cheek bone and you pull that skin and fat up and it’s like, “wow, half of my neck just miraculously got better.” That means that your platysma muscle goes up into the SMAS and the lengthening and the falling of that tissue is really part and parcel of what’s happening in your neck.

And for most patients that’s what I find; I can’t just do the neck because it’s really the cheek fall – the mid face fall – that’s exacerbating it. And if we don’t pull the cheek back up then number one: the operation isn’t going to last very long because you haven’t attacked what the problem is of facial aging.

The second is, if you are able to just do a neck, then we run into problems again with how do we support the tissue.

The Three Operations That Can Be Done On The Neck

So for the neck, real quickly, there’s three operations that can be done.

One is just to liposuction the fat under the chin.

So if between the skin and the muscle, all you have is a little wad of fat there, that can be liposuction and that does very well.

That’s usually a late 20s to 40 kind of operation because someone has just kind of a fatty face right there. We’re not tightening the muscles. We’re not doing anything else. We’re just getting rid of that little fat blob.

The second would be an anterior cervicoplasty, cervicoplasty being the name for tightening up the neck.

In this operation a small cut is made under the chin. You take the fat out and then you just tighten the front part of the muscle where it separates. But if your platysma muscle is weak all the way along and it’s really falling from the cheek area, that’s not going to help very much.

I find that doing just an anterior cervicoplasty probably lasts about 18 months and then people will start to see that they’re getting banding back.

A full cervicoplasty is a half of a facelift.

So that’s the incision behind the ear, and then under the chin. We do all the regular stuff under the chin, take the fat out and then go underneath the skin, across the neck, and then you’re pulling that platysma muscle and suturing it in behind the ear into the mastoid.

The problem with all of this is a platysma muscle is relatively thin. It’s not a great big bulky muscle. It’s not like your tummy where we can put big stitches into the rectus muscles and they’ll stay. There’s really no fascia to speak of there.

So the biggest issue we have with necks, even with a facelift, is that oftentimes the sutures that we put into the platysma muscle just don’t hold, because if you think of it, you’re just sort of stitching up meat. And if there’s nothing to really get a good firm handle on, that muscle will pull through.

That’s why if you’ve now thought, “well, I’ll just do a thread lift or do some barb suture lift,” well, that really doesn’t last at all.

Again, you’re putting a barbed material into the meat of the muscle and it just pulls through. So unless you create a good amount of scarring, that’s not going to hold either.

In a full cervicoplasty, the correction is really from below the jaw line, so below the mandible, down towards collarbone. Again, if you have a lot of mid-cheek fullness or laxity in jowling then it’s not going to fix that. So sometimes it makes you look really weird if the lower part looks good and then your face itself has kind of a weird bagginess to it.

But those are the things that can be done for patients to know if they could potentially have just a cervicoplasty.

Am I A Candidate for a Cervicoplasty (Neck Lift)?

The only way for me to be able to tell you that is to come into the office and just basically play with your face. I can pull on the tissues and tell you pretty quickly if you’re a potential candidate for just a neck or if you just really are going to have to bite the bullet and do a facelift.

And nobody likes to hear that, but we don’t want you to have an operation that is not going to last long or is not appropriate for your condition and isn’t going to hit your expectations, or you’ll always be moderately disappointed with your results.

Because any time you have an operation, you have the risk of surgery and anesthesia, not to mention the money. We need to be really sure that what I can do, what can be done with your anatomy, is going to hit your expectations pretty solidly.

Conclusion

So that is all I have today on why can’t I just do my neck?

I hope this has cleared up a little bit of the confusion of why cervicoplasties are not normally done as an isolated procedure.

Feel free to visit our website, www.DrKerner.com. That’s D-R-K-E-R-N-E-R.com.

We do have more information on my web site, and before and after photographs. I have a few cervicoplasty pictures but not many because I don’t do very many in isolation. And I think you’ll find if you look across all plastic surgeons web sites, we don’t have that many facelift pre and post pictures because patients are very reluctant to let us put their faces up on the Internet. Although they tend to say before surgery, “absolutely, put my pictures up” and then afterwards they’re like, “noooo, don’t really think I want to be up there.” So it’s hard to find a lot of good facelift pictures to show you. But we do have some up there.

We also have a newsletter that you can subscribe to just by calling and giving us your email. This keeps you up to date on specials that are being offered in the office.

Thank you very much for listening. Have a great day. And don’t forget to use your sunblock.