Facial aging is an inevitability. As we reach our 30s and 40s, we start noticing changes in our face and neck which can be displeasing. The gradual deepening of skin folds, flattening of cheeks and heaviness in the lower face gives us a more aged, tired look.
Early signs of facial aging or volume deficiency can often be managed with the appropriate combination of preventative measures, good skin care, botulinum toxin injections and selective placement of injectable fillers. However, as deeper elements of our facial tissue weaken and start to descend, volume shifts to our lower face. At this point, a surgical facelift is an excellent option for someone to truly look and feel the way they want. The goal of a facelift is to restore beauty and youth to the face, without creating permanent signs of surgery or changing a person’s identity. The well-executed facelift results in a younger appearing and more rejuvenated version of the patient.
At Sharma Facial Plastic Surgery, our goal is to help you match your radiant, inner energy with an elegant, more youthful version of yourself. We pride ourselves in delivering the most advanced facelift solutions to produce exceptional and natural results.
WHICH TECHNIQUE IS BEST FOR ME?
There are several different approaches to the facelift. In present day, many plastic surgeons have gone as far as to trademark names for their facelifts. The different terminology and techniques can be confusing for individuals who are simply seeking the best possible and most natural appearing result for their face. Ultimately, every patient’s goal is to have a rejuvenated, long-lasting appearance which enhances their confidence and beauty.
Before understanding the different types of facelift, it is important to understand the different soft tissue layers of the face and how they age.
SUPERFICIAL LAYER – The outermost layer of the face is the skin (epidermis and dermis). As we age, our skin loses key proteins such as collagen and elastin. This leads to a loss of thickness, strength and elasticity, and the eventual development of wrinkles. Over time, sun exposure (UV radiation) leads to hyperpigmentation.
MIDDLE LAYER – The middle soft tissue layer of the face is the SMAS-platysma complex. The SMAS (superficial musculo-aponeurotic system) is a fibrous layer which divides the superficial and deep fat compartments of the face and connects the facial muscles (deep) to the overlying dermis (superficial). The platysma is a muscle which drapes across the neck and lower face and connects with the SMAS in the cheek region.
The lateral SMAS (closer to the ear) is fixed to underlying deeper structures and does not descend with age, while the more medial SMAS (over the cheek and closer to the mouth) is mobile and descends along with the deeper structures.
DEEP LAYER – Beneath the SMAS-platysma complex is the “deep plane” which consists of the muscles which control facial expression and deep fat compartments of the face. As we age, these deeper tissue structures descend and contribute to volume loss in the cheek, deepening of the nasolabial fold or “smile lines”, and loss of definition over the jawline.
Traditional Facelift – The earliest approaches to the facelift employed lifting the skin (superficial layer only) and pulling it back towards the ear. This often resulted in an overly tight and windswept appearance which was unnatural and clearly indicative of surgery. This technique only addressed skin wrinkles, had a high incidence of post-operative scarring and deformities around the ear, and had a short-lasting effect.
SMAS Facelift – As facelift techniques evolved, surgeons began to address the middle tissue layer, or the SMAS-platysma complex. In present day, the majority of plastic surgeons currently perform a variation of a SMAS-lifting or a SMAS plication facelift. With this technique, the skin (superficial layer) is lifted off and peeled away from the middle layer (SMAS-platysma). Suspension sutures are placed through the lateral, “fixed” SMAS to pull it back horizontally towards the ear. The SMAS plication technique is often combined with a neck lift, where the loose platysma muscle of the neck is tightened across the middle (platysmaplasty).
The combination of a SMAS plication facelift and neck lift can produce good results in the hands of a skilled surgeon. However, a limitation of the SMAS technique is that the deeper structures (fat and muscle) of the cheek and midface are not repositioned to their youthful state. Only the “fixed” SMAS, which does not descend with age, and the platysma muscle are pulled back. The primary effect is on the jawline and neck, with minimal correction to the descended cheek. Meanwhile, the cheek skin overlying the “mobile” descended SMAS is separated off from the SMAS and pulled as a single layer, without providing any lift to the middle or deep layers it was previously attached to. While this approach may produce a good cosmetic result and improved jawline for the first one to two years after surgery, it does not directly treat the cheek and nasolabial folds and has a shorter lasting effect than a Deep Plane Facelift. Often times, these patients feel dissatisfied with their result after a few years and may seek injectable filler treatment to volumize their cheeks or even revision facelift surgery.
DEEP PLANE FACELIFT
Dr. Sharma believes in the principles and longevity of the Deep Plane Facelift and Neck Lift. The deep plane facelift, and its variations, is the most advanced facelift technique which is performed exclusively by plastic surgeons who are highly specialized in facelift surgery.
With the extended deep plane technique, the skin is left attached to the “mobile” SMAS over the cheek, so the superficial and deep tissue layers are lifted together as one unit. A dissection is performed beneath the SMAS-platysma layer, into the “deep plane”. Key retaining ligaments which tether the skin and muscle are identified and released, to allow for a tension-free lift of the descended muscles and deep fat pads of the face. These ligaments are not addressed with the traditional or SMAS-lifting facelift approaches.
The extended deep plane facelift restores the cheek volume to a natural, youthful position through release of the zygomatic cutaneous ligament and vertical repositioning of the descended midfacial tissues. This maneuver also results in improvement of the deep “smile lines” or nasolabial folds which develop between your nose and corner of the mouth. By repositioning volume back to the cheek, the deep plane facelift precludes the need for cheek filler or cheek implants after surgery.
Similarly, the masseteric and mandibular retaining ligaments which tether the lower face and jowl are released in order to create a smooth and youthful jawline. The extended deep plane facelift is the only facelift technique which involves release of these critical retaining ligaments and true volume redistribution.
LONGEVITY OF THE DEEP PLANE FACELIFT
The longevity of a facelift depends primarily on the selected technique of surgery and its proper execution. Factors such as patient age, genetics, general health and overall maintenance of the skin can also contribute to how long a facelift will maintain a pleasing result. For the average patient, a deep plane facelift should have lasting results for at least 10 years.
Two key surgical factors which favor the deep plane facelift in terms of longevity are: (1) vertical repositioning of the muscle and deep fat in the deep plane lift, and (2) the specific tissue layer which bears tension after the lift is performed. In the deep plane technique, the skin is left attached over the mobile SMAS-platysma complex. Following release of the retaining ligaments in the deep plane, the skin and SMAS are lifted vertically as one contiguous unit. As such, the cheek and lower eyelid region are effectively revolumized. While excess skin is removed at the end, virtually no tension is placed on the skin, as the lift and tension are maintained by the deeper layers .
As a contrast, if the skin is fully released all through the face and neck and plication sutures are used to pull the fixed SMAS back, the skin bears more tension as a single layer. Deeper retaining ligaments are not released and the descended muscle and deep fat of the cheek are not adequately repositioned. As the skin continues to age, the face often returns to an aged appearance more rapidly.
HOW TO CHOOSE YOUR SURGEON
When choosing a facelift surgeon, it is important to find a surgeon whose aesthetic ideals match with your own. There are a wide variety of facelift results that we see around us and in the public eye. Some patients have a drastic change with a pulled back face, while others may receive a good, subtle result which unfortunately is not long-lasting. It is important to find a surgeon who understands and produces the ideal balance – a substantial result which still appears natural and has a lasting effect for many years.
Equally as important is selecting a surgeon who specializes only in cosmetic surgery of the face. This ensures your face is in the best hands, and that you get comprehensive care for your facial rejuvenation. The face should be treated as a whole. In some cases, if a heavy brow (brow lift) and aging eyes (blepharoplasty) are not addressed at the same time as a facelift and neck lift, the patient can be left with an imbalanced, unnatural appearance. As a facial plastic surgeon, Dr. Sharma will perform a global assessment of your face and discuss all appropriate surgical and non-surgical options to best rejuvenate your face and skin.
FREQUENTLY ASKED QUESTIONS
What is the right age to get a facelift?
Everyone’s face ages in a unique way, and at different rates. Subjective facial aging is also not always a linear process. Some individuals maintain a consistent, youthful appearance throughout their 30s and 40s where they appear around the same age, then undergo more rapid, noticeable aging which dramatically changes their appearance.
Traditionally, patients seek facelift surgery when they start to see signs of facial aging which are bothersome. This is most commonly in the 50s and 60s. As facelift techniques have advanced to produce increasingly natural results, more and more patients are undergoing facelift at earlier ages, some as early as their late 30s. The optimum timing for a facelift depends on a person’s general health, skin quality and sun damage, face and neck anatomy, and their individual goals.
Generally speaking, the older the patient and the more skin and facial aging that has occurred, the more extensive a facelift surgery is required. If you are considering a facelift or think you may want one in the future, it is never too early to consult with a facial plastic surgeon to discuss your goals and options. With expertise in a full range of surgical and non-surgical facial rejuvenation treatments, Dr. Sharma will recommend the best possible options which fit your comfort level and goals.
What level of anesthesia is required for a facelift?
A deep plane facelift can be performed safely under IV sedation (without general anesthesia or a breathing tube) or, if necessary, general anesthesia. There are multiple considerations and factors which determine which level of anesthesia is best for a particular surgery . These include patient comfort and safety, the number and type of procedures being performed (e.g. combining facelift with a neck lift, browlift or other facial surgeries), risks of surgery, duration of surgery, patient age and overall health to name a few.
For all of Dr. Sharma’s facelift surgeries, whether you are going under IV sedation or general anesthesia, there will be an Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) present in the operating room. This ensures there is always a certified medical professional monitoring your health and safety while your plastic surgeon operates. Some surgeons perform facelift surgery in private surgery centers or clinics under twilight sedation without an Anesthesiologist or CRNA present. In these scenarios, the surgeon monitors and manages the patient’s pain levels, blood pressure, heart rate, and oxygenation levels themselves while operating. While these parameters are generally manageable under twilight anesthesia, different patients have different tolerances to sedative and pain medications. This can potentially create a distraction for the surgeon and OR nurses, and most importantly jeopardize patient safety.
IV sedation or general anesthesia administered by an Anesthesiologist or CRNA are proven to be very safe and associated with very low complication rates. Most patients are awake within 20 to 30 minutes after their surgery and ready to be discharged home. You should talk to your surgeon about anesthesia for facelift if you have any questions!
How much swelling and bruising can I expect after a facelift?
All facelift patients will experience some degree of swelling after surgery. Swelling can be minimized with meticulous surgical technique and good post-operative care. Swelling generally peaks on days 2 and 3 after surgery and the majority subsides over the first week. The remainder of swelling generally takes 4 to 6 months to fully subside. Supplementary medications such as arnica and bromelain can help reduce the amount of post-operative swelling.
How much pain can I expect after a facelift?
For the majority of Dr. Sharma’s facelift patients, there is no significant pain after surgery. Common symptoms in the first week after facelift surgery are tightness in the neck and pressure from facial swelling. The majority of our patients use over-the-counter pain medications such as extra-strength Tylenol (acetaminophen) for the first 1 to 2 days after surgery. Although prescription-strength pain medication is provided to our surgical patients, it is very rare for patients to have significant or persistent pain which requires opioid or narcotic pain medications in addition to Tylenol.
When will I feel comfortable being out in public and when will I get my final result?
At approximately 3 to 4 weeks after surgery, most facelift patients start to feel comfortable being around friends and family members. By this time, the early swelling and any bruising will have resolved and the surgical incisions are starting to conceal well behind the hairline and ear. Swelling will continue to reduce over the next several months. By months 4 to 5 after surgery, the majority of swelling has resolved and most patients will appreciate their desired, final results. These timeframes can vary between patients depending on their anatomy, overall health and surgical procedure(s) performed.
How long should I plan to take off work?
Dr. Sharma advises his facelift patients to take at least 3 weeks off of work. This allows adequate time for post-operative swelling and bruising to heal (one week). Sutures are removed within the first 7-10 days after surgery. Dr. Sharma recommends no exercise for the first 2 weeks after surgery and only light physical activity for the remainder of the first month . Lastly, your overall energy level should return to normal around 1 to 2 weeks after surgery.
If you are not sure how long you may need for recovery, feel free to discuss this with your surgeon. It is always best to open the lines of communication and come up with a personalized plan for a comfortable recovery after your surgery.
Can I have a facelift if I have had filler in my face before?
For most patients, Yes. As always, candidacy for facelift is made on a case-by-case basis, depending on your history, facial anatomy, overall health, surgical goals and Dr. Sharma’s recommendations. However, in most cases, a facelift can be performed even if you have had hyaluronic acid (HA; e.g. Voluma) or calcium hydroxyapatite (e.g. Radiesse) filler before. While the majority of HA filler naturally resorbs within 1 to 2 years, there is always some leftover filler which does not resorb. In some cases, Dr. Sharma may recommend dissolving hyaluronic acid filler prior to surgery.
Case 1: 59 year old female who underwent Total Facial Rejuvenation surgery. 6 week result. She had a heavy brow and eyelids, midfacial volume loss, jowls and severe laxity of her neck skin and deep neck structures. She underwent an endoscopic brow lift, upper and lower blepharoplasty, facial fat grafting, extended deep plane facelift and deep plane neck lift.