Early face lifting procedures date back to the early 1900's when Hollander in 1912 reported the first case to treat wrinkles. Early face lifting techniques consisted of a limited subcutaneous dissection with just elevation of the skin and minimal subcutaneous fat. It became obvious that with the best technical skills the beneficial effect would not last more that 3 or 4 years. Unfortunately these techniques did not change until the 1970's, when Skoog defined the deeper plane of dissection as the SMAS, superficial musculo-aponeurotic system. This and its modifications have brought lasting results of 10 to 12 years to these procedures for the past 20 years. If you have the stomach, these procedures can be viewed and are repeated on the Discovery Health channel on a regular basis.

Face lifts can be thought of as three separate procedures today, in this order of increasing difficulty. The lower face, chin and neck lift, the upper face or brow lift, and the most difficult the mid-face or cheek lift. Originally the face lift was termed a meloplasty or "reshaping the cheek or apple", but that has been replaced by the term rhytidectomy or "removal of wrinkles". The combination of the advancement of anesthesia and the fact that patients can expect to look more natural and youthful has resulted in an explosion in the number of procedures performed. Patients generally present with their areas of concern and a desire to set the clock back to a more youthful version of themselves. It is important for the patient to understand that gravitational effects working in concert with the loss of skin elasticity and the changes in fat and bony structures are responsible for the aging face and will continue. Can we defy gravity? To some extent, if the patient gives up smoking, tanning and starts HRT to improve skin texture.

Patients commonly present with concerns of a double chin or neck banding with increased fat and sagging of the lower chin, then a heavy nose to mouth fold with increased jowls and the "marionette line" from the end of the lips to the chin. In the middle face the cheeks are not prominent and the eyes may be hollow and finally the forehead may be wrinkled and the eyebrows descended from all that frowning and stress. All of these situations can be addressed separately or at once depending on the surgeon's preference and the amount of anesthesia time and downtime the patient wants considering possible morbidity.

In most cases the face lift will begin with incisions around each ear in front and back. The skin, subcutaneous fact and aponeurotic layer will be elevated from the facial muscles staying away from the facial nerves which could lead to temporary or rare facial paralysis. It is not uncommon for sensory loss to occur around and in front of the ears. but this usually recovers in six months. These large facial skin flaps are then moved in a superior - lateral direction, upwards and out in 3 vectors to reduce the amount of skin which will be reattached with removable staples to a hairline incision at the top of the forehead. These scars will be fine and undetectable with time but it is better to wear a hair design which covers the forehead and sideburns. Now don't you just love your wig. That tightened post operative look may appear unnatural for the first 2-3 weeks, but will relax after a month and continue to improve. Most patients return to work or social activities after 2 weeks, but full physical activity is restricted for 6 - 8 weeks. Additions to the face lift can include liposuction of the neck as described in earlier columns and relaxation of neck muscle bands and surrounding eye muscles to flatten the skin. Operating time averages about 3 hours depending on what has to be done and almost never exceeds 5 hours. The skin flaps are fixed at certain points to the muscles and some surgeons are using a fine fibrin glue to decrease hematomas and swelling. Hematomas are reported in 2 - 15% of face lifts. Some just use neck drains to be removed on Day 1 or 2 to obviate the problem. The vast majority are using pre and post op antibiotics to reduce infection and about 50 - 70% are using perioperative steroids to reduce swelling.

The most innovative surgery has been the endoscopic brow lift developed in the early nineties with small incisions positioned in the hairline. What's new is that these procedures involve incisions of the thin forehead muscles which produce the furrows. And now involve release of muscles surrounding the eye orbit to relax the brow in its corners. Of most interest to the balding and hair transplant population is a new procedure developed in 1996, which is called the Transblepharoplasty Subperiosteal Brow Lift and the limited -incision forehead lift as seen in the pictures. This can easily be combined with upper eyelid surgery as it is the same incision. These procedures when combined with carbon dioxide laser resurfacing of the forehead give the best long term brow lift results.

Best Wishes in Your New Future,
Cerise Richards, M.D.