Who is a candidate?
Your face is typically the first thing people see, and first impressions are very powerful in creating one’s image. With age, the face undergoes some characteristic changes. The face typically loses volume with age (hollowness under the eyes, less fullness to the cheeks, hollow temples), and what volume is left tends to droop lower on the face (bag under the eyes, jowls on the lower face). The skin also shows signs of aging, with loss of elasticity and discoloration from sun damage. The neck skin also tends to become loose and droopy, with a loss of the youthful jawline and angle of the neck. These types of changes occur in men and women, and can really affect one’s self-esteem and confidence. Patients also report this in turn affects their job performance, and relationships. The reason facelift and necklift are described together is they are typically addressed at the same time. For example, even if only the neck is bothering you enough to have surgery, if the neck skin is tightened without touching the face, the result can look artificial and strange. Others may not know why you look strange, but they subconsciously pick up on the fact that your neck and face do not match. The same is true the other way around. If you lift and tighten the face without addressing the neck, the result again seems patchwork like. The face and neck must remain in harmony. Another critical thing to understand about facelifts and necklifts is that the surgery itself repositions the tissues to achieve a more youthful look, but does not take the place of excellent skin care. The skin care can consist of high-quality products, laser treatments, Botox or Dysport, and fillers. If you think of getting a pair of pants tailored to fit, the shape and contour of the pants fit better and are way more flattering, but the tailoring will not change the texture of wool or leather to feeling like silk. If you start with good skin care and non-surgical treatments early on, you may postpone the need for surgery, but doing one does not take the place of needing the other. Also, a good facelift or necklift can turn back the clock so-to-speak, but it does not stop the clock. Aging will resume, but the effects may be lesser since the tissues have been repositioned.
Common reasons for having a facelift and/or necklift include:
- Restoring a more youthful contour to the face and neck
- Tightening of face and neck skin
- Repositioning the volume of the face
- Restore fullness to cheeks
- Get rid of jowls
- Get rid of “turkey neck”
How to Find the Best Facelift Surgeon for You
This is a critical decision, and finding the best facelift surgeon really means finding someone you trust your face with altogether. Your facelift surgeon should be thought of as your all around go-to person for your face. The options available to rejuvenate a face are so variable, including both surgical and nonsurgical options, and your facelift surgeon needs to be a pro in all of these. Dr. Patel is a big believer in keeping the face looking as natural as possible, and feels the least you can do with the most impact, the better. For example, if you are the right candidate and can get just an effective lift of your neck with ultherapy as you can a necklift, Dr. Patel would recommend the noninvasive ultherapy first, and reserve the necklift for if and when you really need it. Also, if Botox and fillers give you the result you are after, that will be utilized first. Often with a good combination of excellent skin care, periodic laser treatments, and skilled use of Botox and fillers, one can postpone the need for surgery and look younger longer. The different treatments also complement one another, so even if you are an excellent candidate for a facelift and necklift, Dr. Patel may want to begin with getting your skin in good condition before surgery so that you achieve the best possible result you can. For certain patients, they will simply be better off with a facelift/necklift, because surgery will be the most effective in terms of results, downtime, and even cost (compared to adding up the non-surgical treatments that would have to be used to get to a level even close to that of the facelift). Your face is what you are judged on first and foremost, so be careful when choosing your surgeon. A good way to find your facelift surgeon often starts with finding someone you trust with your Botox/Dysport and fillers, so that you have the opportunity to get to know your surgeon, and learn what your surgeon thinks is attractive with non-permanent treatments. Know that it is possible to achieve a natural looking facelift, and it is very technique dependant.
Different Types of Facelifts
There are different types of facelifts, and they vary based on the length of scars, and the type of lifting involved. The incisions can basically be described as short-scar or full-scar. After the incision is created, the difference lies in the way the tissues are lifted. Below the skin there is a fibrofatty layer above the facial muscles called the SMAS, or superficial musculoaponeurotic system. There are a large number of different types of facelifts. The simplest kind done in the past was a skin-only facelift, or a skin/SMAS together (superficial Skoog type facelift), and these are not typically as popular these days due to the often unnatural or pulled appearance. Other types of facelifts recognize the benefit of treating the skin and SMAS layers differently, lifting the SMAS in a more vertical manner, and the skin in an oblique posterior fashion. These types of facelifts are known generally as SMAS plication or SMAS flap techniques. Another type of facelift is the deep-plane or subperiosteal facelift, where the tissues of the midface are elevated as a single unit, and the skin and SMAS are not separately dissected. This type of facelift has a theoretically higher risk of nerve injury than the others. Dr. Patel feels the most natural result is achieved when lifting the skin and SMAS separately in different directions, and utilizes either a SMAS plication or SMAS flap technique.
There are also various “named” facelifts, and these often confuse patients because it makes it difficult to compare and contrast between surgeons and techniques. Certain ones are simply variations on the above, or utilize some but not all of the techniques available. There are also more limited facelifts that have gained popularity due to lower cost, shorter surgery, and not having to be under general anesthesia. The thing to know about mini-facelifts are that the results are likewise mini, and either don’t realize the potential of a full facelift or last only a short time. This may be worth it to you if you have a small budget and are happy with a small result that lasts 6 months to a year. However, if you want a full lift and long-lasting results, a real facelift is typically your best option.
Location of incisions
The incisions used for facelifts and necklifts come in a number of different variations. In general they start in (or in front of) the hair above the ear, down in front of the ear, down along the tragus (in front of the tragus, along the edge of the tragus, or even behind the tragus), around the base of the earlobe, hidden in or just above the crease behind the ear, and into the hairline (or along the border of the hairline). The reason for the variations is to use the least noticeable incision in any given patient. Ideally the incisions are not noticed at all once you are healed, even in men with short hair or women wearing their hair up.
The length of incisions needed really depends on the degree of lift needed. Some patients are candidates for short scars, and others need the full extent of the scars to get rid of the excess skin. The length and location of scars will be discussed at your consultation, and the reasons behind those decisions will be discussed. Typically incisions are created in a way to avoid tell-tale signs of a facelift, such as a distorted hairline, pulling on the tragus in front of the ear, “pixie” or attached earlobe, or widened and visible locations of scarring.
Other procedures that can be done at time of facelift/necklift
Procedures that can be done at the time of a facelift and necklift include: browlift, upper eyelid blepharoplasty, lower eyelid blepharoplasty, fat transfer to the face, chin implant, and laser resurfacing. In general, if rhinoplasty is being considered, Dr. Patel prefers to perform the rhinoplasty at a separate time than the facelift.
Risks of facelift/necklift
The standard surgical risks include pain; bleeding; infection; scarring; painful or hypertrophic scarring; wide or visible scars; injury to vessels, nerves, surrounding structures; asymmetry; poor cosmetic result; prolonged edema, numbness, parasthesias; temporary or permanent nerve damage; contour irregularity; recurrent or residual skin laxity; hair loss around incisions; loss of skin; dehiscence of skin incisions; open wounds; need for further procedure and out of pocket costs; and risks of anesthesia. It is very important to avoid smoking before and after surgery, and have normal blood pressure.
Postoperative follow-up visits
Visits following surgery typically occur the day after surgery (for dressing change and making sure there was no bleeding, fluid collection, or blood supply issues overnight), the week after surgery (for removal of stitches), 1 week after that (removal of any staples if present), 2 weeks after that, and then spread out less frequently thereafter. The schedule is adjusted based on doctor/patient preferences and needs.
Walking the day of surgery is recommended. You may wash the head and neck 24 hours after the drains (if any are placed) have been removed. No baths, soaking in tubs, hot tubs, or swimming pools until incisions are fully healed. Gentle soap (non-perfumed, non-irritating soap preferred) and water over the incisions is okay. Bacitracin ointment may be applied along the incision lines until stitches and staples are removed. Scar gel may be used starting 2 weeks after surgery or once incisions have no open areas, crusting, or scabs. Sun protection along scars is very important, and should be used routinely for the face and neck in general. Regarding activity, Dr. Patel recommends avoiding exercise for 6 weeks following surgery, at which time you can ease back into your workouts. Light activity that does not involve the upper body may be okay around 3 weeks after surgery. You may return to work 1-2 weeks after surgery, depending on your pain level, stamina, and activities required in your occupation. You may drive once you are no longer taking pain medications or muscle relaxers, and allow a 24 hour minimum window between your last pain medication or muscle relaxant dose and driving. All recovery processes and recommendations vary patient to patient, so these general guidelines may not apply to every patient. You will want to avoid photographs or events requiring photo or video for at least 3 weeks.