How Facelift Surgery Works and What to Expect

Doctor’s Note

Welcome to Plain Talk About Plastic Surgery, a podcast that educates you about all things relating to plastic surgery procedures and operations, with down-to earth and honest information.

I’m your host, Dr. Elizabeth Kerner.  While you listen, I hope you’ll think of me as your sister, the plastic surgeon, who will tell you like it really is.

I have been in practice in Plano TX, a northern suburb of Dallas, for over 30 years.  I am an American Board of Plastic Surgery certified plastic surgeon, and have been a member of both the American Society of Plastic Surgeons and the The Aesthetic Society.

My practice is predominantly cosmetic surgery, doing about 80% cosmetic surgery and 20% reconstructive surgery.

I am a past president of the Texas Society of Plastic Surgeons.  I was also the first female president of the hospital medical staff at Texas Health Presbyterian Hospital Plano, where we have 1,400 doctors.

I am a member of the Texas Medical Association, and the Dallas County Medical Society. I have been on many leadership committees and boards over the years.

Each episode of Plain Talk About Plastic Surgery will focus on one area of plastic surgery in depth, discussing the anatomy, the operative technique, risks, potential complications, and most importantly, who would be a good candidate and who would not be a good candidate.

Useful Links

If you enjoyed this episode, you might also like:

• Learn about Brow / Forehead Lift
• Learn about Face / Neck Lift
• Learn more about Eyelid Lift
• Learn about Ear Reshaping
• Lear about Earlobe Repair
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Episode Transcript

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.

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