Facelift Anatomy

This chapter marks the third major writing I have done for Elsevier over the past decade on facelift surgery. Although there is some overlap with previous writings (especially the inclusion of excellent drawings or images), I have continually enriched the content of the chapters with new discussion, pictures, and innovations to remain contemporary.

My own journey with facelift surgery has changed over the past decade as I continually research different techniques, approaches, and treatments for safe surgery with predictable outcomes. Because of this, there is always new content. For instance, in previous chapters I did not advocate the use of post-facelift drains, but having done almost a hundred cases using them, I feel they definitely expedited healing and reduced complications. My point is that dogma should be avoided and progress reported.

At the time of writing, I have performed 1000+ facelifts, with the following statistics:

• 97.5% female

• 2.5% male

• 8.5% smokers

• 29% had simultaneous full-face CO ₂ laser skin resurfacing

I am proud of this number and I have charts, operation reports, and before-and-after pictures for every single patient to back up this statement. Of these 1000+ facelifts, 98% were traditional comprehensive facelifts with midline platysmaplasty and preauricular and postauricular flaps averaging 7 to 8 cm of circumferential dissection. In other words, large facelifts; 2% were short scar lifts. I have done every inch and every stich by myself. I have attempted to analyze and reanalyze every step. In a single chapter, it is impossible to cover all areas of facelift surgery, and that single topic could easily fill this entire text. My goal with this chapter is to convey the techniques that have proven to be safe and effective in the 1000+ facelifts. This does not mean that “my way” is the only way to do it or that it cannot be done better. My goal with this chapter lies in my slogan: Always be a teacher, always be a student .

Facelift Anatomy

Facelift surgery and anatomy are inseparable and great surgeons are great anatomists. Facial anatomic expertise is imperative to performing competent facelift surgery and avoiding complications. The best way to discuss anatomy is to consider the progressive layers encountered during the procedure from skin to bone ( Fig. 5.1 ).

Layers of the face:

• Layer 1: Skin

• Layer 2: Subcutaneous

• Layer 3: Musculoaponeurotic

• Layer 4: Areolar plane

• Layer 5: Deep fascia and periosteum

Layer 1

The first layer concerned in facelift anatomy is the skin. Facial skin varies in thickness, being thinnest in the eyelids and thickest on the nasal tip and forehead. The dermal plexus of blood vessels nourishes the skin (and facelift flap) and must at all times be respected. The handling of lipocutaneous flaps in cosmetic facial surgery should be as gentle as other procedures in which the vascularity of the flap is essential to its survival. During facelift dissection, several millimeters of fat is left adherent to the dermal undersurface to protect this area and enhance flap viability. A general rule is that there should be fat on both sides of the facelift flap.

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