Gravity causes drooping of the soft tissues in the face and neck, leading to ptosis (drooping) of the brow and cheek and also the formation of jowls and loose folds of skin. In addition to this the full fat pads of youth shrink causing a hollowed appearance in some patients. Browlift, facelift and necklift are three procedures which may be performed individually or in harmony with one another to produce an aesthetic rejuvenation of the face. These ‘lifting’ operations are without doubt the most operator dependent procedures in plastic surgery. In other words the success of these operations are the most dependent on the skill of the surgeon. There are a variety of options available for facelifting which have evolved over the last century. These range from a simple skin only facelift (also known as a subcutaneous facelift or mini-lift), which provides a tightening of the jawline and superficial rhytids (wrinkles), through to subperiosteal procedures and SMAS (Superficial Musculo Aponeurotic System) lifts which provide a greater degree of longevity and tightening.
Face and Neck Procedures
The Subcutaneous Facelift
This is performed under general anaesthetic or twilight sedation. An incision is made in the crease in front of the ear, descending from the hairline to the earlobe, and then up the back of the ear and into the hairline behind the ear. The skin is lifted from the underlying SMAS layer and tightened as necessary. Redundant skin is trimmed off and the incisions are carefully sutured over fine suction drains. Soft dressings are applied and after one night in hospital the drains are removed and it is usually possible to be discharged. This procedure is rarely performed in Mr McDiarmid’s practice as it does not confer the same degree of effectiveness and longevity as the SMAS based procedure – see below.
The SMAS Lift
This is performed under general anaesthetic. An incision is made in the crease in front of the ear, descending from the hairline to the earlobe, and then up the back of the ear and into the hairline behind the ear. The skin is lifted from the underlying SMAS layer and tightened as necessary. The SMAS layer, which is a tough fibrous layer under the skin, is then also lifted up and tightened as necessary. It is anchored with permanent sutures which confer longevity to this type of facelift and then the redundant skin is trimmed off. The incisions are then carefully sutured over fine suction drains. Soft dressings are applied and after two nights in hospital the drains are removed and it is usually possible to be discharged.
The High Lamellar SMAS Lift – The Super-Evolved Facelift
In Mr McDiarmid’s opinion the results of this specialised type of facelift surgery are unparalleled in aesthetic facial rejuvenation. There are several reasons for this (see animation for more):
Firstly the SMAS layer is incised at a higher level (closer to the top of the head). This guarantees that the mid-face tissues will be effectively elevated in harmony with the neck and cheek tissues – an imperative if excellent aesthetic relationships are to be maintained. The high level of SMAS incision also guarantees that the SMAS will reach the deep temporal fascia – the anchorage point of choice for a definitive SMAS fixation (see point five).
Secondly – no tissue is removed from the face during this procedure. Many facelift procedures remove a certain amount of SMAS so that the incised edges of the SMAS can be sutured back together again. Fundamentally this reduces mid-facial volume and goes against the principle of maximising volume (a concept which artists and sculptors have known for centuries is an essential component of the youthful face).
Thirdly, the SMAS retaining ligaments are extensively released during this procedure. This enables the SMAS to move upwards far more than if the ligaments were left intact. An extensive sub-SMAS dissection is vital if significant permanent elevation of the facial tissues is to be achieved.
Fourthly, the skin is the ‘cover’ of the face; the SMAS layer is the handle we pull on to elevate it. This principle sums up the premise of effective facelifting. The high lamellar SMAS lift is an excellent demonstration of this succinct principle. It achieves its results by reshaping the face rather than just pulling hard on the skin – as previously stated, pulling hard on the skin (as in a mini facelift) simply results in the tissues drooping and the scars being of lower quality than they would be if the tension is placed on the deeper layer.
Fifthly, the anchorage point for the SMAS flap needs to be a solid fixed point. Simply anchoring SMAS up to more SMAS results in the upper attachment stretching downwards as the SMAS has some elasticity. In a high lamellar SMAS lift the upper free edge of the SMAS layer is anchored to the deep temporal fascia. This layer is a far better point of fixation and permits very little sagging compared to the SMAS alone.
The high lamellar SMAS lift takes longer to perform than many other facelift techniques. At present Mr McDiarmid does not offer SMASectomy facelifts, MACS lifts or minilifts. The reasons for this are stated above but boil down to the fact that, in his opinion, they offer limited benefit and transgress many of the principles that define effective harmonious rejuvenation. Neither does he see any reason for patients to have threads inserted into the face for temporary benefit as the benefits of these are extremely temporary. In Mr McDiarmid’s opinion, if it is worth doing a surgical facelift then it is worth doing comprehensively in order to make the effect as natural, long-lived and effective as possible; the high lamellar SMAS lift is unbeatable in terms of delivering these benefits.
This is a procedure which involves reshaping the platysma muscle in the neck, which can sometimes become slack and hang in folds, and also removing excessive fat from under the chin. A necklift is usually performed simultaneously with a facelift to give more harmony to the simultaneous cheek, neck and jawline definition and help to frame the rejuvenated face. There are different degrees of intervention for the neck and it is essential to tailor this to the patient’s requirements – not every patient undergoing facelift surgery benefits from work on the platysma muscle. Instead some patients benefit massively from extensive liposuction of the neck, platysmaplasty, total transaction of the platysma muscle and insertion of a chin implant. The ideal procedure choice must be tailored to the individual patient taking both anatomy and degree of motivation into account.
What are the scars like?
Usually minimal. This is another procedure in which stopping smoking is an absolute necessity. Smokers run the risk of losing areas of skin as cigarette smoke dramatically reduces the skin’s blood supply.
How painful is it?
Patients usually suffer minimal discomfort following this surgery and the main feeling is one of tightness which is due to facial swelling. This can be kept to a minimum by sleeping propped up on three pillows for the first two weeks following surgery.
What happens after surgery?
The stay in hospital is one or two nights only and most patients can be discharged with a short course of painkillers. The cheek skin is often numb immediately after surgery and it takes several months for sensation to return. The ears may also be temporarily numb as the greater auricular nerve which provides their sensory supply can be stretched or traumatised during surgery. This sensation usually recovers in the first week after surgery. Wounds should be kept dry for five to seven days until the sutures in front of the ears (and under the chin if a necklift has been performed) are ready to be removed. Surgical clips used behind the ear are removed on day seven when all wounds should be settling and normal washing can be resumed. The neck fat often gets quite firm for a few weeks after the surgery and it requires massage and time to become soft again. Three months after surgery a further appointment is made to check that everything is settling nicely and that the desired result has been achieved.
What could go wrong?
Every operation has the risk of bleeding and infection. In facelifting, surgery bleeding or haematoma may occasionally necessitate a return to the operating theatre to remove a blood clot. Pressure from a large clot can sometime compromise the circulation to the skin leading to healing problems.
The face will feel numb for a few weeks following surgery due to all the skin undermining which has taken place – this largely resolves and is rarely a problem. There is a tiny chance that, during a SMAS lift, branches of the facial nerve (the nerve which controls voluntary expression of the facial muscles), which run in the same plane as the SMAS layer, may be stretched or cut during facelift surgery. If the nerve is stretched (a so-called neurapraxia) it fully recovers in a matter of weeks or months.
The incidence of a branch of the facial nerve being permanently divided is estimated at 0.5% (1 in 200 patients). If the nerve is cut then motion or part of the face may be lost.