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FACE
WHAT IS NORMAL?
- Smooth skin without wrinkles or folds, ideally. A crease between the nose and the corners of the mouth is normal. A crease underneath the bottom of the eye is normal.
- No jowls or hanging skin.
- A well-defined jaw line.
- No turkey-gobbler.
COMMENT: Wrinkles and folds are signs of age. The dependent areas like the jaw line and the areas of greatest motion like the line between the nose and mouth show the first signs. We have separated this problem of heavy skin treated by a facelift from the finer wrinkles that will be addressed in the next section under skin. SELF-EVALUATION:
- Pull up on the side of your cheeks.
NOTE: Patients should understand that the center of pull from surgery is different from the center of pull when you do it by yourself. When you place your finger next to any wrinkle and pull, of course it will go away. Unfortunately with surgery, the location of the pull is not the same. The area of tension is greatest where the surgeon makes his cuts and places his sutures.
SO: I tell patients to pull as hard as you can. Then, relax 50%. That's what you can expect.
- Grasp the excess skin in your neck and imagine that gone. Only grasp what is held easily.
HOW MUCH CAN BE IMPROVED?
- Everyone is different with a facelift. The older the patient, the more dramatic is the result. It is easier to keep a young patient looking young than make an old patient look younger.
- Revision results are often less exciting.
- The improvement usually lasts years, at least ten or twenty. If most people have a lift at forty or fifty, they may have a second one at sixty or seventy. Some people can't stand the smallest wrinkle and come back sooner.
- Again, things never end up as tight as you can make them and after six months and a year they relax quite a bit. That's why they may look too taunt at the beginning.
- A fold between the nose and mouth is normal. Don't be surprise if it recurs.
- With an incision under the chin, excess skin and fat can be tucked very well.
- Liposuction may serve well enough in young patients with just some excess fat.
- Scars are usually easy to hide.
THE OPTIONS: FACELIFTS
As the skin of the face sags from gravity, many people consider the possibility of having a facelift. Tremendous improvement can be achieved by returning a youthful appearance through a well-done procedure.
DEEP FOLDS VERSUS SUPERFICIAL WRINKLES
There are two aspects to wrinkling of the face. One are the heavy deep folds that tend to create a down hanging appearance, particularly in the jowl region along the jaw line and the neck. These are the result of gravity dragging the face downward.
Second are the more superficial wrinkles in the surface of the skin and these are often addressed separately. They are the consequence of sun-damage and aging.
The deep folds and heavy skin can be corrected with the face lift. Fine wrinkles and skin irregularities may need separate treatment by peeling, dermabrasion, or some other means.
We will discuss skin treatments in the next section. Some skin procedures that tighten the skin may support the deep tissue for a while. In some patients, the problems with the jowls and hanging chin can be treated well with liposuction or some other simple fat removal procedure. It is usually a question of whether the problem is primarily hanging skin and loose muscle or whether it is also excess fat. Each person is different.
HOW MUCH YOUNGER CAN I LOOK WITH A FACE LIFT?
The older you are the younger you'll look, so that if we do a facelift on someone who is seventy years old who has never had a face lift, the change is much more dramatic than if someone is fifty, if for no other reason than their face has been sagging for that much longer.
I try not to number the years that a person may improve after a facelift. Patients may bring a picture from a certain age and ask if they can look like that again. I try to convince them not to think of it that way. You will look different after a facelift and younger, of course. Because of the re-draping of the skin, you will never look like you did before at one particular age.
HOW OLD SHOULD I BE WHEN I GET A FACE LIFT?
The answer to this is different for everyone and depends on the amount of loose skin that is hanging and also on how much it bothers you. Some people want to reverse the earliest signs of aging and some people are less concerned. There is an axiom that "It is easier to keep a young person looking young than it is to make an old person look young".
Generally speaking, if a person has a facelift at age forty or forty-five, they might request a second somewhere around sixty or sixty-five and usually that is about it. Just like other procedures in plastic surgery, when you ask how long will this procedure last, it is relative. The first signs of the tissues relaxing may occur in only a few years. Before you would return to your original condition, easily ten or twenty years could go by. You would never truly return to that original appearance in any case.
WHERE TO LIFT?
There have been almost a limitless array or variations on the standard facelifts described and a complete discussion is truly beyond the scope of this manual and probably not important to you as a patient.
If the problems are primarily in the face alone or in the neck alone, you may suffice with either the upper portion of the facelift or a NECK LIFT alone. In this case, you can approach the surgeon with a lesser charge for a lesser procedure. For instance, if you are simply addressing the neck, and if that surgeon won't accommodate you, there are many surgeons who would perform simply a neck lift and so on.
Likewise, the neck lift is made from an incision that goes around the posterior portion of the ear and the posterior hair line. The center of pull is in the upper neck and combined with the chin tuck can produce essentially the full results of the facelift in the neck area.
The full facelift has an incision that extends from up in the hairline, curves around the edge of the ear, and back behind the ear, and the central pull is in the jowl line.
WHERE TO MAKE THE INCISIONS?
The most common variation that people are acquainted with is IN-THE-EAR versus IN-FRONT-OF-THE-EAR. This is a very small difference in the facelift incision that only involves approximately less than an inch of the incision that curves around the small portion of the ear.
If a patient has a nice natural crease at the edge of the ear, many surgeons put the incision there, in-front-of-the-ear. If they specifically request it, I will put it in-the-ear. When it is put in front of the ear, there can be some blunting of the ear cartilage that likewise looks unattractive.
Frankly, the incision in-front-of-the-ear is rarely a problem for most patients, and they can wear their hair up once this is healed.
Another variation has to do with the incision at the hair line. We put the incision high in the hair if the patient is only planning on one or two facelifts and has a low hairline. If someone anticipates four or five facelifts, then it would be important to put the incision at the edge of the hairline, so that hair-bearing skin is not lost.
If the incision is properly designed, the patient can still wear their hair up. Likewise with the incision behind the ear, we generally put this at the hairline to keep it closer to the center of pull and avoid removing hair-bearing skin. Patients who wear their hair short or up should still be able to do so.
IS IT NECESSARY TO LIFT THE DEEP TISSUE?
From a surgeon's point of view there are a few technical touches that different surgeons add and may or may not consider important.
Besides the removal of excess skin, many surgeons do something to pull the deep muscles and connective tissue tighter. I personally believe that a thorough job in this area is worth the effort to a patient. While all surgeons will say that they do something in this area, some simply put in a few stitches, and others truly trim and remove the excess tissue and perform almost a second facelift to the deep tissue.
There is more risk to the nerves of the face when this is done.
The other new facelift variation is the extra deep facelift, known as the subperiosteal facelift, in which the tissue is raised from the bone up. This is very controversial and the jury is still out. There is some concern that the supporting elements that are cut during surgery may permit more drooping rather than less.
Some of the latest approaches are difficult to evaluate since rarely is one side of the facelift done in one way and the other done a second way to allow a real visual comparison. As a patient, you are often left with nothing more than the surgeon's very biased opinion.
LASER FACELIFT
Recently there is the laser facelift in which the identical operation as a standard facelift is performed, only using the laser. This procedure takes longer, and although there may be less bruising in the immediate week or two after surgery, the amount of excess skin removed and the tightening of the tissues is exactly the same. In fact, with the laser, it may be difficult to access some areas at odd angles. The procedure also takes longer for the surgeon.
CHIN TUCK?
Some surgeons, depending on the size of the turkey gobble underneath the skin, may elect to do a chin tuck procedure in addition to the facelift. The incision in this area usually heals well and it should not worry you if the surgeon suggests this.
The ability to tighten the tissues is best when you can pull them as close to the area of loose skin as possible. From way up by the ears and hairline, it may be difficult to get good long-term pull way down in the front by the chin. The extra incision by the chin allows helpful access.
Instead of a facelift, the chin tuck may be a nice alternative for many patients who want a faster recovery and a simpler procedure. This serves the area under the chin very well, but does not address the sides of the face and jowl line when upward pull is required.
FACELIFT AFTERCARE
This only includes items that are different from the NOSE AFTERCARE. READ THAT before going on to this material. Most items are the same.
- Remove the entire dressing the next morning or the doctor will do it for you.
- Cold packs may be applied to the face for 48 hours. After that, they won't have much effect.
- Expect some tightness and pressure, especially when chewing.
- Sutures remain in about five days, clips about two weeks.
- Do not sunbathe after surgery, especially for the first few months.
- Keep the incision lines clean. Use hydrogen peroxide to clean off adherent blood. Use ointment to keep the incision line moist.
- You may wash your hair gently the day after surgery. Soap it lightly and use a brief spray of water. Don't run the water through your hair.
- NOTIFY YOUR DOCTOR of any areas of special PAIN OR SWELLING. If there is fluid draining from an area of a wound INFORM YOUR DOCTOR.If one area is especially RED and TENDER, let the doctor know.
- DON'T PANIC. Most problems are easily treated and managed.
- If you were given antibiotics or other medicines, take them as prescribed.
FACELIFT COMPLICATIONS
- ASYMMETRY
Small differences are common. The face will tend to even out as you move it once again.
- NUMBNESS
Usually from damage to a skin nerve just below the ear. Usually it resolves but may take a long time.
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MUSCLE PARALYSIS
The nerves that move muscles are different from those that control sensation.
There are two branches of the nerve to the face that are at risk of being damaged. One is the nerve to the forehead. If this occurs and produces a noticeable problem, the treatment is to cut the same nerve on the other side of the face. The forehead will lay flat.
The second nerve is the one that goes to the corner of the mouth. It travels along the jaw line. If it is damaged, the corner of the mouth may tend to drag downward as the person talks. Again, function may return to this nerve with time, so it is advisable to wait six months to a year for some sign of recovery. Some secondary procedures may help restore the defect, but it may never return to perfect.
- PERSISTENT FOLDS AND WRINKLES
- HEMATOMA
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LOSS OF HAIR/ALTERED HAIRLINE
Discuss these with your surgeon. Make sure everything will end up where you expect it to be. Women are often sorry to lose the tuft of hair just above their ear, so ask your surgeon about that.
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SCARRING
Usually the patients consider the scarring a response to the surgeon's technique but more often the healing characteristics of their skin are responsible. After the tissues have softened again and stretched, a revision of the scar might be worthwhile. Usually, we would wait about a years.
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