A guide from consultation to recovery
With the almost daily arrival of new “no-downtime” procedures, there was a time when the plastic surgery community felt that the demand for rhytidectomy (facelift surgery) would decline. However, quite the opposite has occurred. Because these procedures have increased the number of choices that patients have for facial rejuvenation, many patients feel more comfortable visiting a plastic surgeon’s office. This in turn has alleviated some of the fears that patients once had when discussing facelift surgery.
Traditional facelift surgery initially focused on skin-tightening alone. The skin was undermined and advanced superiorly and posteriorly to recreate a youthful appearance. The problem with skin-flap surgery alone was the duration of the results. Advances in rhytidectomy led to varying degrees of repositioning of the tissues of the face. The concept of SMAS elevation and suspension allows the surgeon to redrape the deeper tissues of the face, followed by the skin. To more adequately address the cheek areas, midface elevation may be used with or without rhytidectomy, depending on the patient’s concerns.
One of the mainstays of the aging face has been the concept that, due to gravity, the face falls over time and requires resuspension. An additional concept about aging has been that not only does the aging face experience sagging of the tissues, but also that it experiences a loss of actual volume. A myriad of facial implants is available to address these concerns. With so many options available, and an increased public awareness of these options, a thorough consultation continues to be imperative in laying the foundation for a gratifying experience for the patient.
In the past, consultations were consultations. The surgeon met with the patient, and the goals of surgery were discussed and agreed upon. However, a growing number of our consultations are now being conducted via email and telephone. The typical long-distance consultation usually includes a photograph that is sent via email; a computer-generated representation of the expected postoperative results; and an explanation of the procedure, the expected limitations, and the postoperative care. It is mandatory that the surgeon meet the patient personally at least once before surgery, however, to review all of these in a face-to-face encounter. I have found that even with improvements in computer-generated pictures, I can most accurately show patients their expected results in a three-way mirror.
The most common question during a consultation is, “How much younger will I look?” The second most common is usually, “How long is my recovery?” It is at this time that we extensively review the measures that we take to decrease downtime. All patients are started on a combination of herbals and vitamins to minimize bruising, and are taught a lymphatic massage technique to decrease swelling. Also, they are seen preoperatively by an aesthetician so that skin care becomes part of their daily routine following surgery. Once patients realize that the facelift is not a “one-time” procedure, but instead is a process that includes general maintenance of their overall health as well as skin care, the recovery experience and follow-up care is made more predictable.
Anesthesia is often overlooked in the facelift process, even though it is a source of anxiety for many patients. I perform all of my surgery under twilight anesthesia with the assistance of an anesthesiologist. Because so many patients are as afraid of receiving an intravenous (IV) injection as they are of the anesthesia itself, the whole experience is designed so that the patient does not see any needles. Patients are given an oral sedative combination while a topical anesthetic is placed on the expected IV site. Within 30 minutes, most patients are so drowsy that they don’t remember the needle stick for IV access. Patients are then kept comfortable during the remainder of the operation. In my experience, this process allows for an easier recovery from the anesthesia experience. The preoperative period is therefore more time-consuming, but it is well worth the time to create a more comfortable situation for the patient.
I seldom perform the rhytidectomy procedure by itself. A rhytidectomy is usually performed in conjunction with a midface augmentation or elevation, a brow lift, a periorbital rejuvenation, and either a submental liposuction or a neck lift.
The incision for cheek rhytidectomy is a traditional posttragal incision that is carried superiorly to the junction of the ear and the face. At this point, it makes a 90-degree turn and is brought horizontally under the temporal tuft of hair to preserve the hairline. The incision is intentionally beveled to allow for hair growth through the scar.
Wide undermining of the skin over the cheek and jowl areas is then performed. Then the SMAS is elevated to the anterior border of the parotid gland and advanced in a two-directional manner. The lower border of the SMAS is advanced posteriorly behind the ear, and the superior portion of the SMAS is elevated superiorly. The SMAS is then secured using Vicryl suture, and the skin flap is redraped over the newly elevated SMAS flap. The skin flap is not trimmed or sutured until the midface lift is performed.
The midface lift that I am currently performing is the one described by Keller, in which an intraoral incision is made in the gingivobuccal sulcus, and elevation of the subperiosteum is performed over the entire midface. A Prolene suture is then tunneled from the temporal region down through the midface tissues and advanced back up superiorly to the point of its original insertion. The Prolene suture is then tied over either a dental roll or a button to prevent necrosis of the skin as well as alopecia at the anchor site. It has been my experience that even with a midface lift, most patients can use additional augmentation in the cheek area to give them a more youthful look. During consultation, I usually compare two images with the patient: one with the midface lift alone, and one with the combination of midface lift and cheek augmentation. The majority of my patients like the idea of this additional fullness in the cheek area. The small malar implant is used most often, with the only variation being the site of placement. Some patients need more fullness anteriorly, especially if they have had an aggressive lower-lid blepharoplasty in the past that has left them with a hollow appearance. If a patient wants more of a chiseled appearance, then the cheek implant is positioned more laterally on the cheek. The cheek implant is then secured in place using the Prolene suture that is also used to suspend the midface. It is then removed in 2 weeks so that no permanent sutures are left in place. Once the midface lift and cheek augmentation are complete, the skin flap is redraped, trimmed, and sutured in place with chromic suture (Figures 1, 2, 3, and 4).
Because of the elevation of the cheek and the resultant gathering of skin at the lateral aspect of the zygoma, I perform some form of forehead lift or lateral temporal lift on patients to elevate this redundant skin and to position the brows. In the past, I have used a pretrichial incision across the entire forehead, as described by McCollough. The advantages of this incision are the full exposure of the corrugators as well as the ability to maintain (and, in some cases, lower) the hairline. The resultant scar is typically cosmetically pleasing and can be further camouflaged if the initial incision is beveled so that hair grows through the scar. However, the disadvantage of the incision is the prolonged period of numbness (up to 1 year) that patients experience during the recovery stage.
When I began looking at what I was actually trying to achieve by brow elevation, I found that, with most of my patients, I was trying to get more lateral brow elevation as opposed to an entire brow elevation. The lift needed to include as much of a brow-shaping component as a brow-lifting component. Instead of a full-forehead pretrichophytic incision, I limited my incision to approximately 2 inches in length directly over the lateral aspect of the brow—still in a pretrichophytic manner. The incision is located in the pretrichial area of the junction of the anterior hairline and the lateral temporal tuft of hair—specifically where the majority of females begin to experience hairline recession. In this technique, I am still able to lower this portion of the hairline back to a more youthful position.
Initially, a diamond is diagrammed over the incision site (Figure 5, page 34). The diamond of skin is excised, and the entire forehead subperiosteum is elevated. The frontal, supraorbital, and temporal areas are then released using an elevator as if doing an endoscopic brow lift. The gathering of skin that has accumulated from the previously performed midface lift is advanced superiorly with the brow tissues. If corrugator or procerus work is to be done, an endoscope is required for better visualization of the medial forehead area. Once the brow area is freely mobile, the forehead tissues are elevated and approximated to the trichophytic side of the diamond incision. I have not found it necessary to use any type of anchoring device. If there is overlap between the skin edges, then additional skin is excised. Prior to closure, I bevel the anterior and posterior incisions to allow for hair growth through the resultant scar. The incision is closed in two layers: first using a deep Vicryl suture, then using a skin-edge closure with an absorbable suture.
When I am diagramming my diamond in preparation for brow elevation, I must first decide which part of the brow truly needs elevation. Most commonly, the lateral aspect of the brow is to be elevated. The diamond is then drawn so that its lateral sides are much longer than its medial sides. If the brow needs to be uniformly elevated, then the diamond is drawn with four equal sides. If the patient needs elevation of the medial heads of the brow, the medial sides of the diamond are much longer than the lateral sides. This allows for a significant brow-shaping component to the brow lift. When I limit the size of the incision, patients experience fewer areas of numbness over the scalp. Most patients recover full sensation of the scalp within 1 month following their surgery. Because it is still a pretrichial incision—as opposed to an endoscopic incision within the hair—I can preserve (and in some cases lower) the hairline in a youthful position.
With completion of surgery, patients are wrapped in a compression dressing that is removed within 24 hours. During this initial 24 hours, patients are kept comfortable with oral analgesics. Once the dressing is removed, patients immediately begin the process of lymphatic massage to decrease swelling.
Skin sutures are removed at 7 days, and the midface lift-suspension suture is removed in 2 weeks.
Adair Blackledge, MD, is a fellowship-trained facial plastic surgeon practicing strictly facial cosmetic surgery in Jackson, Miss. He can be reached at (601) 981-3033 or by email at [email protected]