Introduction - Advice for patients
Ageing inflicts it’s own stigmata on the face, and it does this in two distinct but related ways. It may change the texture and surface of the skin of the face, producing wrinkles and fine lines (or rhytids) particularly in the upper lip or around the eyes. Secondly it may result in structural changes in the tissues of the face, especially slackness of the skin and muscles, or drooping of pockets of fat to form jowls and folds; these changes may also be reflected in the skin of the neck and the eyes.
New techniques in the last ten years have improved the treatment of both of these effects of ageing. Laser treatment can be very effective in resurfacing the skin of the face and at least temporarily improving the appearance of wrinkles. Similar effects are claimed for chemical peels and for dermabrasion, although the latter has fallen out of fashion. Some benefit in treating creases can be had from selective weakening of muscles in the face or brow, especially by the use of botulinum toxin injections, or by brow lift, and notably endoscopic brow lift. These will be discussed in future information pages on this site.
The term Facelift covers a number of different operations, all of which have in common the aim of reducing sag or droopiness in the patients face. This may be particularly apparent in the area of the jaw line, where excess slackness of skin may produce jowls, and give the face a square outline when seen from the front in contrast to the more youthful triangular shape. In addition there may be deep furrows passing from the outer part of the nostrils down and outward to the outer aspect of the mouth: these lines are called nasolabial folds. Ageing and sagging of the face as a whole is often of course associated with ageing changes in other parts such as the eyelids and the mouth. The eyelid changes are dealt with in another part of plastic-surg.co.uk, but in the region of the mouth the changes may be manifest by fine (often called "smokers") lines that radiate out from the lip margin across the upper lip. In addition, with age the upper lip gets longer in distance from the nose to the lip margin, and as this happens the fullness of the red part of the lip (called the "vermilion") is lost and the lip appears thinner.
Face-lifting is a very satisfying procedure in the correct patient and can produce a very pleasing improvement in a patient’s appearance and sense of well being. It is however a complex and delicate operation, and like all operations has the potential for complications that can be minor or not so minor. I believe that all potential patients should be aware of these problems before they can make a sensible and informed decision about surgery. It should be stressed that in the vast majority of patients no significant complication occurs, but in any surgeon’s practice problems can arise, and before embarking on surgery you should ask yourself whether you feel you could cope with that eventuality.
Face-lifting aims to reduce the extent of skin sag and restore some of the youthful appearance. This is accomplished by using a scar that passes vertically down within the hair-bearing scalp to reach the very front of the ear. Here it may wind its way around the front of the ear, hugging the natural skin creases before abruptly turning back beneath the ear lobe and passing up and across the bare patch of skin behind the ear to finally turn downward again along the edge of the hair margin behind the ear. The only visible part of this scar should be that which runs in front of the ear, and every effort is made to make this as fine and unobtrusive as possible. No surgeon can guarantee the quality of a scar, since much depends on healing that can vary enormously from part of the body to part of the body, and from age to age in the same patient. However the scar in front of the ear in face-lift patients is usually of very good quality. the scar in the hair bearing scalp is of course hidden (although the effect of the lift in this region will be to slightly raise the hairline level in the region of the temples). The scar behind the ear however is frequently of poor quality, and the reason for this is that it is here that much of the tension and force of the facelift is concentrated. It is my practice therefore to warn all patients that this scar may be hard to disguise and may prevent patients from wearing their hair up in future.
Through the incision described above, the skin (and sometimes the muscle of the face) is gently and precisely separated from the underlying structures to allow it to eventually be lifted posteriorly, and the slack or excess skin then removed. During this process of separating the skin (and sometimes muscle layer) the nerve that wrinkles the forehead and the nerve that lowers the angle of the mouth are at risk. Very rarely these may be damaged by stretching and the relevant function lost temporarily, recovery taking some weeks. They may even be damaged beyond the point of recovery but this is extremely rare and few surgeons ever encounter this complication. More common is some numbness in the skin of the face and ears. This usually recovers (and in any case is not the cause of any visible change) but in the case of the ears complete recovery of feeling may (rarely) not occur.
Like all operations face-lifting may cause bleeding and very occasionally it is necessary for the patient to return to the operating theatre briefly in order to stop unwanted postoperative bleeding or to release blood that has collected beneath the skin. Sometimes very small collections of blood beneath the skin may cause small bumps that can be felt rather than seen and which disappear in a matter of weeks. The bruising associated with face-lifting similarly clears in one or two weeks, although in very pale skinned patients some redness or discolouration may persist for some time requiring cover with make-up. This is unusual.
Finally, because of the tension placed on a face lift some delay in healing of the skin can occur. Although far from common, this can be troublesome, and usually is confined to the skin behind or below the ear, but usually heals in time with very little difference in the scarring. This delay in healing is far commoner in patients that smoke and it for this reason that I am most reluctant to operate if patients are still smoking at the time of surgery. I recommend a period of at least 2 weeks non-smoking both before and after surgery.
Specific questions some patients ask include anxiety about the possibility of too tight a lift, causing a strained immobile appearance to the face. In my experience this never occurs in a first face lift, and the few cases shown on the media over the years have either had many repeat facelifts or other procedures done. In fact more commonly patients wish that the lift had been tighter, although in this respect I point out that it is a sensible to lift the face as far as is reasonable with due regard to avoiding any of the problems listed above.
Other patients enquire about mini-lifts. I do not often recommend this procedure since it has a very short-lived effect.
It is possible to lift the neck at the same time, and during this procedure the muscles that form unsightly cords in the necks of some patients may be divided. Similarly small local deposits of fat in the neck or jaw line may be treated with liposuction at the time of face-lifting.
The length of the upper lip may be reduced with a small incision hidden beneath the nose in some patients, although this is rarely necessary. The fine smokers lines around the mouth are difficult to eradicate, although some techniques may help and will be discussed with you.
The brow may also be droopy, and this can be improved in a number of ways, including open or endoscopic brow lift. In this latter procedure the brow is elevated away from its drooped position over the eyes through small incisions in the hairline by the use of a minimally invasive technique. You may wish to discuss this option in greater detail with your surgeon.
Eyelid surgery is frequently done in conjunction with face-lifting and is described elsewhere on plastic-surg.co.uk
Surgery is undertaken with the patient asleep, and following surgery the face may be bandaged for a day, and we like you to rest quietly in bed for the first 24 hours with your head back to prevent creasing of the neck. There may be one or two drainage tubes emerging from the scar behind the ears, and these are removed at about 24 hours. Usually patients are fit to go home at 48 hours, and it is imperative they avoid even passive smoking.
Sutures are removed at a week and at 2 weeks, and during this time the bruising is gradually improving.
Scarring pattern after facelifting
The illustrations show the possible disposition of scars after facelifting. It should be remembered that there are over 20 variations on face and neck lifting and that the exact extent of scars may vary from patient to patient, and will be discussed at the time of consultation. In particular the scars behind the ears may be omitted in some facelifts and the scars in front of the ears have a variable nature (see dotted lines) depending on whether there is a risk of changing the hairline significantly.
Face-lifting is a very rewarding operation in the right patient, but no one should proceed without being fully informed, and in that respect I hope this information has been of value: it is not meant to replace your consultation with your surgeon or primary care physician, but I recognise how difficult it can be to take everything in at the first visit, and I hope that if you have questions regarding this information you will write them down and consult your carer further for clarification.
Simon Kay, Consultant Plastic Surgeon