Face lift - Clinical Tree

Introduction

Much has been written about the aging face. The face lift procedure (rhytidectomy) is a critical component in addressing the issues of volume loss, sagging tissues, deep rhytids, jowling, and skin stretching. There are numerous trademarked names and even more nontrademarked names including “Vampire Lift,” “Weekend Face lift,” “Advanced Lift,” “Quick Face lift,” mid face lift, deep plane face lift, “Swift Lift,” “Liquid Face lift,” and composite lift.

While many of these are promoted for marketing in a highly competitive environment, the now defunct “LifeStyle Lift” with its multimillion dollar national marketing campaign brought face lift procedures to the attention of the general public and demonstrated the popularity and demand for rejuvenation procedures.

The public, in its thirst for noninvasive facial rejuvenation procedures, has embraced nonsurgical radiofrequency devices such as the Venus Legacy, Vanquish, and minimally invasive Thermi Lift as well as cryotherapy devices such as Cool Sculpting. Brief one time or repetitive nonsurgical treatments have caught the public’s fancy.

The “Liquid” Face lifts in which hyaluronic acids such as Juvaderm, Voluma, Perlane or hydroxyapatite, (Radiesse) or poly- l -lactic acid (Sculptra) are used to fill out the volume loss with aging and heredity are increasingly popular. These products can “lift” the soft tissue and restore a more youthful appearance. Adipose tissue transfer has also gained in popularity to fill out the tear trough and add facial cheek volume. The “Vampire Lift” capitalizes on the public enchantment with vampires and uses platelet-rich plasma obtained from the patient’s blood. This technique, when added with soft tissue fillers, supposedly improves facial rejuvenation by adding volume with healing blood factors.

Minimally invasive face lifts using barbed sutures have also been used, but many of these techniques have been removed by the Food and Drug Administration (FDA). However, the Silhouette Lift has recently gained popularity with an absorbable suture that suspends the sagging facial tissues.

Fortunately, there will always be demand for a well-performed face lift procedure. The key to obtaining a good result and avoiding complications requires knowledge, critical assessment, and surgical expertise.

Key Operative Learning Points

In-depth knowledge of facial and neck anatomy is essential for the successful rhytidectomy.
Placement of incisions is critical to preserve the natural hairline in the temple and posterior neck.
Careful planning is required to preserve the sideburn tuft of hair in a natural nonraised position.
Preservation of the facial nerve is based on understanding the three key danger points. Injuring the temporal branch of the facial nerve can occur halfway between the lateral orbit and the temple hairline where the nerve is fairly superficial as it courses in the superficial temporalis fascia.
The superficial muscle aponeurotic system (SMAS) was named by Mitz and Peyronie to describe the fascia system that is just deep to the facial skin and subcutaneous tissue. The SMAS is contiguous with the platysma in the neck.
Erb’s point is located along the posterior border of the sternocleidomastoid muscle, midway between the mastoid and the clavicle. The greater auricular nerve emerges anteriorly to supply sensation to the ear and posterior cheek. The spinal accessory nerve courses along the posterior edge of the sternocleidomastoid muscle to supply motor function to the trapezius muscle. ( Fig. 158.1 )
With deep plane face lift techniques, Stensen’s duct must be preserved, as it courses parallel to the buccal branch of the facial nerve. The duct travels in a line from the tragus to the corner of the mouth. What is deep plane? It is defined as the cleavage plane separating the SMAS from the deep cervical fascia.

Preoperative Period

History

Consultation: As with all cosmetic surgeries, the consultation is critical for examining the patient and the patient’s motivation, medical history, and performing a physical examination. A questionnaire can be helpful for determining the patient’s area of interests, prior procedures, and a brief psychologic profile to determine whether any of the patient types to avoid are evident.

1.
Areas of interest: Circle all that apply: sagging neck, face jowling, brow position, wrinkles, skin discolorations, wrinkles, smoker’s lines.
2.
Prior cosmetic procedures
3.
Past medical history—medical history especially diabetes mellitus, coagulation defects, use of anticoagulants, herbal products, reactions to anesthesia, scarring
4.
Past surgical history—cosmetic and noncosmetic
5.
Social history—married, divorced, separated/work history
6.
Psychologic history—psychologic counseling, life changes, holding grudges, suicide ideation, reasons for seeking face lift, sleep and eating habits to evaluate for depression
7.
Smoking history—Some surgeons insist on a 2- to 3-week period of cessation of smoking prior to the face lift and 3 weeks after the surgery. Others refuse to operate on smokers with concern for skin flap viability. Some surgeons perform a urine nicotine test the morning of surgery and cancel the face lift if the test is positive. Others may have their patients sign a waiver that they have been informed that smoking may jeopardize their healing.
8.
Computer imaging—There are 2D and 3D systems available. The photos can be used in the consultation to demonstrate the surgeon’s anticipated but not promised goals of surgery. Incisions can also be demonstrated to the patient. The computer imaging enhances communication between the patient’s goals and what the surgeon believes is an obtainable result.

Physical Examination

Assessing the degree of platysma banding, jawline jowling, submental fullness, nasolabial jowling, brow ptosis, masseter hypertrophy, ptosis of submandibular glands, tear trough prominence, mid-cheek hallows, skin laxity, and Fitzpatrick skin type

Imaging

Photographs aid in evaluating the patient and recording for the medical record.

Frontal view, lateral views, oblique views, animated views to evaluate the function of the facial nerve preoperatively. Consistent positioning of the patient for pre- and postoperative analysis is important. Using a solid blue or black background also aids by eliminating background distraction.

Indications

Determining the patient’s motivation for a face lift procedure is as important as knowledge and skill in performing a face lift. Patients who have realistic goals and genuine interest in looking better but not perfect and understand the importance that guarantees cannot be provided are excellent candidates for the face lift.

Contraindications

Proper patient selection is critical to having a patient who is satisfied with his or her result and avoiding a malpractice suit. An excellent review of patient types shows to avoid the following :

1.
The overly narcissistic patient
2.
The single immature male who is obsessive neurotic (SIMON) patient
3.
The body dysmorphic patient
4.
The unstable patient undergoing major lifestyle changes—for example, loss of job, divorce
5.
The culturally estranged patient—desires major change to alter natural culture features
6.
The exceptionalism patient—the patient who refuses to talk to staff, fill out paperwork, refuses to follow medical instructions, overly demanding
7.
The unrealistic patient—brings photos of his or her youth—wedding photo, graduation photo—and expects to have the surgeon recreate
8.
The multiply operated patient—lavishes praise on you and denigrates prior surgeons

Preoperative Preparation

Cessation of smoking at least 3 weeks prior to surgery is advocated by some physicians. Discontinuing aspirin, vitamin E, fish oil, and other platelet-inhibiting herbal products or medications is recommended 2 weeks prior to surgery. Arranging for transportation and an overnight caretaker following surgery is essential for procedures performed with Intravenous (IV) sedation or general anesthesia.

Operative Period

Anesthesia

The selection of the anesthesia technique is determined by the surgeon’s preference, patient’s preference, and the face lift technique selected. Some surgeons prefer general anesthesia, especially, for the more extensive face lift procedures.
Other surgeons prefer IV sedation and an oral airway with oxygen cannula and carbon dioxide monitor.
Sequential compression is recommended to prevent deep vein thrombosis.
Public attention has been piqued with the ability to perform face lifts under local anesthesia. Surgeons often use oral anxiolytics or hypnotic medications. It is still important to monitor the patient’s vital signs.
Most surgeons use 1% xylocaine with 1,100,000 epinephrine along the incision line and in a field block.

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