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The Face Lift-understanding the Various Procedures

If you are considering a face lift or any facial rejuvenation procedure it is important to understand what a face lift can and cannot achieve and the many variations of the face lift technique that are designed to correct individual variations in facial aging that appear on different faces. Your face is unique and your face lift or facial rejuvenation procedure needs to be customized to create a pleasing result on your face.

Excellent results and beautiful rejuvenation can be achieved safely with modern face lift techniques:

Most important for you is the skill and experience of your doctor. Honest expert evaluation of your face and a clear explanation of the procedure that is best for you are essential. I have written a book called Save Your Face and in chapter 10 you will find an important guide on how to choose a plastic surgeon, questions you should ask, and warnings about potential situations that I think you should avoid.

What a face lift can achieve

· Restoration of a full youthful cheek

· A smooth tight jaw line

· A youthful smooth neckline

· Some elevation of the lateral brow

· Removal of jowls

· Correction of loose skin around the mouth

· Improvement in Marionette lines and Nasal labial fold lines

What a face lift cannot achieve

· Wrinkle removal

· Eyelid rejuvenation

· Removal of crow’s feet

· Removal of eye bags

· Removal of eyelid hooding

The different Types of Face lift Procedures

There are so many different names used to describe the face lift that it can be very confusing for you the patient. Terms like week end lift, mini lift, S lift, non-surgical face lift, thread lift, lifestyle lift are often used and it is hard for you the patient to know what these terms mean. Below I will try to describe the variations of the face lift procedure hopefully shed some light on this subject for you.

The Standard Face lift

The standard face lift involves an incision around the ear and undermining or freeing the loose facial skin from the deeper facial attachments. Once the skin is free to move it is drawn tight back to a more youthful and normal position on the face and the excess skin is removed from the area around the ear and the incision is closed. This relatively straightforward operation can produce excellent results and has “stood the test of time”. Elements of the standard facelift are used in virtually all of the facelift variations listed below. The main difference is that the underlying “musculo-aponeaurotic” tissues are not always tightened.

One common variation of the standard face lift is the SMAS Plication which involves tightening the deep layers with a stitch rather than actually excising or removing some of the deep tissue layer. The standard face lift with “SMAS Plication” is the most common face lift I perform. Published reports document the superiority and effectiveness of this technoique.

The SMAS Face lift

The SMAS face lift involves dissecting, and tightening the deeper tissue called the SMAS layer in addition to the standard facelift dissection of the skin. This is done to provide additional tightening of the face and presumably provide a longer lasting result. Studies have cast doubt on whether SMAS lifting provides a longer result, but most face lifts today include some modification of the SMAS.

The SMAS stands for “superficial muscular aponeurotic system” and describes a firm fibrous tissue layer beneath the facial skin that attaches the facial skin to the underlying facial muscles. When this tissue is tightened during a face lift additional facial tightening is achieved.

The classic SMAS face lift involves dissecting beneath and elevating the SMAS layer, excising some of the excess and suturing the SMAS layer to tighten it.

I achieve the same effect by “plicating “the SMAS layer which means I do not dissect beneath the layer but fold the layer on itself with a suture to tighten the SMAS.

I do not dissect beneath the SMAS because the facial nerves run below the SMAS and I fear damage to the facial nerve. In my experience the placation provides the same result and is safer

The Extended SMAS Face lift

The extended SMAS face lift involves a more extensive dissection beneath the SMAS layer in an attempt to get a more extensive tightening of the facial skin especially down around the mouth. In my experience I am able to get this correction by undermining skin only and plicating the SMAS.

I avoid the extended SMAS face lift because in my opinion the facial nerves are more exposed to injury by this technique

The Deep Plane Face lift

The deep plane face lift involves a more extensive dissection beneath the SMAS layer and some of the facial muscles such as the orbicularis occuli. Proponents argue a more effective correction of cheek laxity and lower and mid face correction especially around the mouth. Longer lasting results are reported and this technique is purported to be safer for people who have smoked in the past.

Beautiful results have been achieved by the originator of this procedure, Dr Sam Hamra of Texas. Others have experienced an increased incidence of nerve injury. My own experience is that while excellent results are possible, some patients find an objectionable change in the appearance of their mouth.

Some studies have shown that the SMAS Plication technique mentioned above provides superior cosmetic results.

Subperiosteal Face lift

The subperiosteal face lift involves undermining beneath the deepest facial layer adjacent to the bone. This technique is designed to elevate and tighten all of the lax soft tissue on the face. Theory holds that undermining in the area next to the bone, deep to the nerves, also helps avoid nerve injury. Nerves still can be injured by this blind deep dissection. The subperiosteal face lift is an extensive operation and in my experience offers no advantage over the standard face lift with SMAS placation

The Lateral Brow Lift

The lateral brow lift is a modification of the face lift to treat laxity and sagging of the upper third of the face, the outside portion of the eyebrow and the upper cheek. An incision is made in or on the hairline on the side of the forehead, the skin is undermined, pulled tight and the excess removed.

This technique can be effective when only the side or lateral potion of the eyebrow and the upper cheek are lax. However care must be taken to avoid displacement of the hairline and injury to the frontal branch of the facial nerve, which if injured can cause the brow to droop.

The Forehead Lift

The forehead lift is a procedure I rarely do since the advent of Botox. Proper use of Botox can correct most forehead laxity caused by contraction of the frown muscles and the standard face lift corrects most lateral brow laxity of the outside portion of the eyebrow.

A forehead lift requires and incision within or at the hairline all the way across the forehead. The results can be excellent if you are willing to accept the scar. One problem however is that for a long lasting result the frown muscles must be removed and this can result in a permanent depression or contour deformity in the mid forehead in the frown area. In the past the frown muscles could be neutralized through an upper blepharoplasty eyelid incision, but again Botox has made this operation unnecessary for most people who want to correct laxity of the middle portion of the forehead.

The Mid face or Cheek Lift

The mid face lift or cheek lift is designed to tighten the cheeks and help improve the nasal labial fold lines. This is a modification of the face lift which involves an incision along the crease in front of the top part of the ear extending up onto the hairline.

The cheek lift or mid face lift is effective for people who have laxity in the cheek and nasal labial fold lines but have no laxity along the jaw line and neck.

The cheek lift or mid face lift is becoming very popular among younger patients who have early facial laxity in the midface. Cheek sagging is often the first facial aging change to occur, and younger patients are choosing to have a cheek lift or midface lift before further facial sagging extending to the neck and jaw line occur.

The Neck Lift

The neck lift is designed to tighten sagging neck skin below the jaw line and chin. The neck lift is a good choice for younger patients who only have loose skin beneath the chin and jaw line.

In some cases the neck lift can be accomplished through a small incision beneath the chin which is well hidden. This procedure is also called a platysmaplasty or corset platysmaplasty. In some cases with more extensive neck laxity an incision behind the ear is also required.

The Short Scar Face lift

The short scar face lift describes a face lift performed through an incision which runs only in front of the ear in the skin crease. The incision behind the ear and above the ear in the hairline is avoided.

Some authors show very impressive results showing improvement in face and neck laxity with this technique. This procedure is effective for younger patients with mid face laxity and less extensive neck and forehead laxity. The smaller incision is advantageous cosmetically and should require less healing and down time.

The Mini Lift

The mini lift or mini face lift means many things to many people. Most commonly the mini lift term is used by patients who want a face lift but don’t want to call it a face lift!

To me a mini face lift is a smaller procedure than the standard face lift and is useful in patients who have early facial laxity in the cheek and jaw line who do not have extensive neck laxity.

Usually I can use a short scar or an upper scar along the upper portion of the ear crease into the hairline.

The mini lift or mini face lift is a less extensive procedure and works well for younger patients and older patients with minimal facial laxity.

The Lifestyle Lift

I include the lifestyle lift here because so many people ask me about it. I only know what I read. I have not trained in nor have I ever done or seen a lifestyle lift performed. I have seen patients who claim they have had a lifestyle lift. As advertised the lifestyle lift is done without general anesthesia or IV sedation and claims are made that recovery is less than a traditional face lift.

The Non-surgical Facelift

When most people use the term non-surgical face lift they are talking about skin tightening with the various new skin tightening machines. Some misuse this term by applying it to extensive soft tissue filler injections

The newer skin tightening technology uses radiofrequency energy or infrared energy to heat the deep layers of the skin to cause contraction and tightening but first cools the skin before the energy is applied to prevent injury and ablation of the superficial skin by the heat energy. Thus the skin is tightened but the surface is not ablated, thus non-ablative skin tightening. There is no down time following non-ablative skin tightening unlike the older CO2 laser resurfacing skin tightening.

Several new skin tightening machines are available. The LuxIR by Palomar, and the Titan by Cutera utilize infrared energy for skin tightening. The Aluma by Lumenis and Thermage utilize infrared energy for skin tightening. Refirme by Syneron uses a combination of light energies with radiofrequency for skin tightening.

All of the machines achieve about similar results when used properly. Generally there is less discomfort with the Infrared skin tightening machines. Complications have been minimal although some serious complications occurred with Thermage skin tightening early on.

In my practice I find that non-ablative skin tightening is most helpful for younger patients who do not have severe aging changes and significant sun damage, people in their 30’s and 40’s who want to correct or tighten early skin sagging along the jaw line or jowl area, neck and cheeks. I use the LuxIR on these larger areas. For skin tightening around the eyelids I use the Aluma which has a smaller treatment head and a suction device that will pull the delicate peri ocular skin into the treatment chamber for skin tightening.

The field of non-ablative skin tightening is in its infancy and will definitely become more effective in the years ahead. The companies are improving their products frequently. For now however the people who benefit most from the skin tightening machines today are younger people who still have thick healthy skin with early aging changes.

The use of the term non-surgical face lift to describe non-ablative skin tightening is an overstatement with technology available for skin tightening today. At best a 30% result is possible when compared to a traditional face lift.

Result Oriented Face lift

A face lift can create a truly beautiful and refreshed look to your face:

The important components of a beautiful Face lift result are:

* A smooth, firm neck and jaw line
* A full elevated cheek high on the cheek bone
* A normal appearing ear lobe
* Hidden scars
* A normal “unoperated” appearance
* Looking “like you” just younger

The Face lift is one of the most enjoyable surgeries that I do. After 25 years in practice I usually achieve the result you want and it is a joy for me to share your happiness and enthusiasm for your new refreshed look.

The Face lift requires experience and skill and is a complex procedure which requires both artistry and a clear understanding and shared image of the final look you hope to achieve.

Your Consultation

When we meet I will talk with you and ask you to explain to me the specific facial rejuvenation goals you hope to achieve. I will examine you and tell you my findings and describe the areas where I think improvement can be made. I will demonstrate on your face the appearance that I believe the face lift will create on your face.

I will then recommend the procedure I feel is best for you. I will discuss the procedure, your recovery, and expectations and answer your questions. Photos of your face will be taken. You will be given an estimate or quote of the cost of the procedure. Financing plans are available.

The Face lift procedure

I perform different types of Face lifts designed to meet your specific needs for your unique face.

A Full face lift elevates and firms the entire face and neck, including the lateral brow, the cheek, the jaw line and the neck. A neck lift just tightens the neck and lower jaw. A midface lift or cheek lift tightens the cheeks and nasal labial folds. An upper face lift or brow lift elevates the outside of the eyebrow and the upper face.

A mini face lift is a less extensive full face lift which is appropriate for people who have minimal facial laxity and need only minor facial tightening or tuck. The mini lift is usually appropriate for younger people in their 30’s and 40’s, or those lucky people in their 50’s and up who have very little facial laxity.

A good face lift result requires tightening of both the skin and the deeper facial tissues which also sag with age. I tighten the deep layers of the face; the SMAS face lift, which tightens the deeper muscle like layer of the face. This is necessary to achieve a good result that lasts. Minor lifts that are advertised as being quick, easy and with no down time usually only involve skin removal and they do not last, often only a few months. A well done SMAS lift should last years.

Face lift Vectors

A very important concept in face lifting is the Vector. The vector is the direction of pull required to lift the face to a younger more attractive look. The appropriate face lift vector is unique to your face and the face lift must tighten your face along the appropriate vector if you are going to achieve the result you want.

When you see a person who has had a face lift and has the surprised look, or looks too tight, unnatural or like a “weasel”, it usually means that their surgeon did not tighten the face along the appropriate vector.

I always examine your face, determine the best most natural vector for your face and draw the vectors on your face before I make my lines to mark my planned face lift procedure. This helps to assure a natural looking face lift result.

Scars

No one wants scars on their face and everyone is concerned about face lift scars.

Usually face lift scars are not visible to those around you. 75% of the face lift scars are behind the ear or in the hairline and people do not see them unless they closely inspect you and look for them. Yes your hairdresser will know, but he/she is likely the only one other than your partner.

The 25 % of the scar that is in a visible location is also hidden. This scar is placed into the fold in front of your ear. It is usually not visible and is easily covered by your make up.

Your Ears

In my opinion, the worst sign of a bad face lift by an inexperienced surgeon is the “Spock ear” or “elf ear” deformity. This occurs when the ear lobe is fused to the cheek and pulled down to where it looks like the ear is attached to the angle of the jaw.

I have developed a very specific technique for creating a normal looking ear lobe following a face lift-check my photos; you will not see the “Spock ear”.

Pre OP

The pre operative visit is the time when we will sit down and clearly define your face lift goals. We will discuss what you hope to achieve and what I believe I can achieve with your face lift. I will try to give you an honest image of what you can expect for a result.

You will also undergo a history and physical exam to make certain that you are healthy and have no medication allergies or contraindications to surgery. An EKG (electrocardiogram) may be done if you have a history of heart problems or have reached a certain age. You will also be given prescriptions for post operative medications. You also will be asked to read and sign surgical consent forms which outline the risks, potential complications, limitations and expectations of face lift surgery.

The Operation

A full SMAS face and neck lift usually takes me about 90 minutes to 2 hours. If I am doing eyelid rejuvenation or 4 lid blepharoplasty at the same operation, as is often the case, then the surgery can take 3 hours. Mini lifts, neck lifts and cheek lifts usually take only an hour.

You are asleep during the surgery. I have very experienced superb anesthesiologists who will be taking care of you. Safety is our first concern. We use modern, very safe anesthesiology techniques, and take precautions to avoid nausea after surgery.

Following your surgery you will go to the recovery room where a nurse will take care of you and make sure you are comfortable.

Some patients prefer the comfort of an overnight stay in the hospital. In this case I will examine you the next morning, remove two tiny drains from behind your ear, remove your bandage, and have you shower and comb out your hair, and then discharge you. When you go home a small scarf placed over your head and a pair of sunglasses will usually hide the fact that you have had surgery.

For those of you who want to go home the same day after surgery, you will spend about 2 hours in the recovery room with a nurse taking care of you. As soon as you are comfortable, able to drink and eat a bland food such as crackers or cookies, and able to go to the bathroom, you will be discharged. The nurse will escort you by wheel chair to your car.

We require that someone bring you to the surgery center and take you home, and that you have someone staying with you the first night after your surgery.

Post op- What to expect

My patients do not always complain of pain following a face lift. Your face and neck will feel tight, which means that I have done my job correctly. After a few days the tight sensation will go away as the facial tissues relax. If you have had a blepharoplasty for eyelid rejuvenation you will have ice packs on your eyes to reduce swelling and bruising.

I place a bandage around your face which comes off the next day and you may shower and wash your hair on the first day after surgery. I usually place a tiny drain behind each ear which is removed the first day after surgery.

Bruising on the face is unusual; bruising when it does occur is usually on the neck and upper chest and is usually minimal and easily covered with make up.

Usually after 1 to 2 weeks you will be comfortable being seen in public and will be back to most normal activity. I ask you to wait 3 weeks before heavy weight lifting or aggressive work outs.

I have you take an herbal supplement called Arnica Montana before and after surgery which helps reduce bruising. I also have excellent mineral cover up make up to cover any visible bruising.

Consultation with Dr Seckel

I can tell you a great deal more about face lift and how it would work for you if I see you in person. Call me 978-844-3116 or contact me by email at drseckel@saveyourface.com. If you would like to email me your photos I can email you my thoughts about how I think a Face lift would work for you. For more information on face lift read my blogs on face lift.

I look forward to meeting you.

About the Author

Dr. Brooke R. Seckel is a nationally and internationally recognized authority on Plastic Surgery and the treatment of facial aging. He performs all types of cosmetic, facial and breast plastic surgery, but his special interest lies in the field of non-invasive and non-surgical therapies to correct and prevent facial aging.
Dr. Seckel was founder and Director of the Lahey Center for Cosmetic and Laser Surgery in Lexington, Massachusetts. He was also the founder and first chairman of the Department of Plastic Surgery at The Lahey Clinic in Burlington, Massachusetts, a large multi-specialty group practice hospital in the Boston area. At Lahey Clinic he founded the Lahey Clinic Residency Program in Plastic Surgery and the Plastic Surgery Research Laboratory where he conducted basic science research in nerve regeneration, spinal cord regeneration and laser tissue interactions.
He is certified by the American Board of Plastic Surgery, The American Board of Neurology, and the American Board of Emergency Medicine. He is a member of the American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, American Association of Plastic Surgeons, is an Assistant Professor of Surgery at Harvard Medical School, and was recently voted one of the "Best Doctors in America" by Best Doctors® Inc. Boston Magazine has also recognized Dr. Brooke Seckel as one of the "Top Doctors in Boston" in 2006.
Dr. Seckel has published over 100 scientific articles in the field of plastic surgery and authored the first book on cosmetic laser surgery in 1995 entitled "Aesthetic Laser Surgery". He also published, Facial Danger Zones, a book devoted to teaching surgeons how to perform facial surgery safely without injuring the facial nerves.
More recently, Dr. Seckel published Save Your Face - The Revolutionary 6-step Non-surgical Facial Rejuvenation Program which discusses, in easy to understand language, the causes and prevention of facial aging, and the revolutionary new non-surgical methods for facial rejuvenation.
Dr Seckel maintains an active plastic surgery practice in the Boston area. He is on the staff at the Lahey Clinic and Emerson Hospital and maintains an office at Emerson Hospital in Concord, Massachusetts. He resides in Concord and is the father of two children. In his spare time he enjoys sailing at Cape Cod, woodworking, building furniture, restoring his antique home and jogging with his German Shepherd, Griffin.

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