eMedicine Specialties > Plastic Surgery > Rhytidectomy

Facelift, Skin Only

Author: Jonathan L Kaplan, MD, MPH, Fellow in Plastic Surgery, Cleveland Clinic
Coauthor(s): Dean Fardo, MD, Associate Staff, Department of Plastic Surgery, Cleveland Clinic Foundation; Gregory A Buford, MD, FACS, Medical Director, Body by Buford; Randall Yetman, MD, Head, Section of Plastic Surgery of the Breast, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation; James E Zins, MD, Chairman, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation
Contributor Information and Disclosures

Updated: Feb 19, 2008

Introduction

As the baby boomer generation ages, the popularity of cosmetic plastic surgery continues to rise. Facelift surgery, or rhytidectomy, is one of the more commonly performed aesthetic facial procedures. Given the right patient, and with proper technique and planning, an excellent result that takes years off of the patient's appearance usually is obtained. Although a wide variety of more extensive dissection planes have been proposed, the subcutaneous (skin-only) facelift is discussed in this article. However, much of the information included within is applicable to other techniques as well. For detailed information on other facelift procedures, please see the Rhytidectomy section of eMedicine's Plastic Surgery journal.

History of the Procedure

The history of facelift surgery spans the last century. Hollander is credited with originally describing a surgical "lift" of the face in 1901.1 Throughout the early 1900s, others such as Miller, Kolle, and Lexer made variations and refinements of this original description.2,3,4 Lexer is credited with suggesting that the skin flaps be dissected in a subcutaneous plane, as earlier facelifts consisted mainly of skin excision with primary closure.

For the next 60 years, until the early 1970s, the subcutaneous facelift was the most popular method. Improvements during this time mostly concerned the incision and not the surgical concept. However, in 1974, Skoog described elevating the platysma of the neck and lower face without detaching the skin.5 This deep layer method, along with the description of the superficial musculoaponeurotic system (SMAS) by Mitz and Peyronie, changed the way many surgeons viewed surgical rhytidectomy.6 Although now not performed as commonly as some other methods, the skin-only facelift still may have a role in selected patients. It also remains the basis for how most plastic surgeons perform a facelift.

Indications

Every patient presenting for a facial rejuvenation procedure needs to be evaluated thoroughly to assess specific problems and personal desires. For a patient to be a candidate for a skin-only facelift, the anatomic problem should be limited mainly to skin excess. A patient who previously has undergone a facelift with SMAS tightening and now desires a touch-up may fit into this category.

The skin lift alone also produces good results for thin women with good skin tone and a good underlying bony structure. In the patient with a heavier face and not as ideal a bony framework, obtaining a natural-appearing result with a skin-only lift is more difficult because of the greater amount of pull that usually needs to be placed on the skin flaps.

If the need to correct significant jowling or an obtuse cervical-mental angle is required, then a different approach that incorporates deep suture suspensory techniques may be more applicable. Patients also must be made aware of the inherent limitations in performing a skin-only facelift, since other facial structures that have aged are not addressed. With the recent resurgence in SMAS plication sutures and purse-string suturing of the underlying facial musculature, the skin-only approach will likely be less commonly used.

Relevant Anatomy

A complete understanding and knowledge of the anatomy in the facial region are required to obtain the best results with a minimum of complications. Although many variations exist, a common approach includes a temporal incision continuing down inferiorly to a preauricular incision that then becomes postauricular as it curves around the ear and down the edge of the hairline. Most surgeons prefer a posttragal incision in front of the ear, while others use a pretragal approach in males or patients who smoke. With a skin-only facelift, a subcutaneous dissection is all that is required, leaving the underlying SMAS layer undisturbed.

Manchot described the vascular supply to the face in 1889.7 Whetzel and Mathes refined the study and further described the vascular territories of the face and scalp.8 The facelift flap is supplied mainly by musculocutaneous perforators as they emerge from 3 main arterial trunks: the facial, superficial temporal, and ophthalmic arteries. Most blood flow originates in the central facial area, and rich anastomotic networks exist. This allows for skin-flap survival after undermining. As more extensive dissection is carried out medially, the risk of ischemia in the flaps increases. With other deeper plane techniques such as composite facelift, the blood supply is preserved to a greater degree, making ischemia less likely even with extraordinary tension that a subcutaneous facelift would not allow.9

The underlying facial musculature is beneath the plane of dissection and covered by the SMAS.

Contraindications

Patients who are not medically stable should not be considered for cosmetic surgery. In addition, patients on aspirin-containing products or blood thinners are at a higher risk for postoperative complications. Therefore, these patients should have stopped using those products or the surgery is postponed. Heavy smokers are also at increased risk of skin-flap ischemia and have a relative contraindication to an aggressive skin undermining procedure. Studies have shown the adverse effects that smoking can have on wound healing. Patients with unrealistic expectations or with ongoing psychiatric issues should also be very carefully evaluated before surgery is agreed upon.

A skin-only facelift is also relatively contraindicated in someone who has more significant facial aging or an obvious sagging of the underlying facial muscles. In these individuals, a more extensive facelift approach with treatment of the SMAS layer may produce a better result.

More on Facelift, Skin Only

Overview: Facelift, Skin Only
Workup: Facelift, Skin Only
Treatment: Facelift, Skin Only
Follow-up: Facelift, Skin Only
Multimedia: Facelift, Skin Only
References
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References

  1. Hollander E. Cosmetic surgery. In: Joseph M, ed. Handbuch der Kosmetik. Leipzig: Verlag von Veit;1912.

  2. Miller CC. The excision of bag-like folds of skin from the region about the eye. Med Brief. 1906;34:648.

  3. Kolle FS. Plastic and Cosmetic Surgery. New York: Appleton; 1911.

  4. Lexer E. Zur Geischtsplastik. Arch Klin Chir. 1910;92:749.

  5. Skoog T. Plastic Surgery: New Methods. Philadelphia, Pa: WB Saunders Co; 1974.

  6. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. Jul 1976;58(1):80-8. [Medline].

  7. Manchot C. Die Hautarterien des Menschlichen Korpes. Leipzig: Vogel;1889.

  8. Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous vessels. Plast Reconstr Surg. Apr 1992;89(4):591-603; discussion 604-5. [Medline].

  9. Hamra ST. Composite Rhytidectomy. Plas Reconstr Surg. 1992;90:1-13.

  10. Pribitkin ED, Boger G. Herbal therapy: what every facial plastic surgeon must know. Arch Facial Plast Surg. Apr-Jun 2001;3(2):127-32. [Medline].

  11. Zins JE, Moreira-Gonzalez A. Cosmetic Procedures for the Aging Face. Clinics in Geriatric Medicine. 2006;22:1-20.

  12. Thorn C, Aston SJ. Aesthetic surgery of the aging face. In: Grabb and Smith's Plastic Surgery. 1997:633-49.

  13. Friedland JA. The cutaneous rhytidectomy. In: Bernard RW, ed. Surgical Restoration of the Aging Face. 1996:127-43.

  14. Connell BF, Miller SR, Gonzalez-Miramontes H. Skin and SMAS flaps for facial rejuvenation. In: Guyuron B, ed. Plastic Surgery: Indications, Operations, and Outcomes. Vol 5. 2000:2583-2607.

  15. Barton, FE. Esthetic surgery of the face. Selected Readings in Plastic Surgery. 1997;8(19):1-43.

  16. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidectomy. Plast Reconstr Surg. Nov 1980;66(5):675-9. [Medline].

  17. Rees TD, Barone CM, Valauri FA. Hematomas requiring surgical evacuation following face lift surgery. Plast Reconstr Surg. May 1994;93(6):1185-90. [Medline].

  18. Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a personal 8-year quest. Reviewing 910 patients. Plast Reconstr Surg. Jan 2004;113(1):381-7; discussion 388-90. [Medline].

  19. Kaufman T, Eichenlaub EH, Levin M, et al. Tobacco smoking: impairment of experimental flap survival. Ann Plast Surg. Dec 1984;13(6):468-72. [Medline].

  20. Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg. Jun 1984;73(6):911-5. [Medline].

  21. Webster RC, Kazda G, Hamdan US, et al. Cigarette smoking and face lift: conservative versus wide undermining. Plast Reconstr Surg. Apr 1986;77(4):596-604. [Medline].

  22. Nolan J, Jenkins RA, Kurihara K, Schultz RC. The acute effects of cigarette smoke exposure on experimental skin flaps. Plast Reconstr Surg. Apr 1985;75(4):544-51. [Medline].

  23. Mosely LH, Finseth F. Cigarette smoking: impairment of digital blood flow and wound healing in the hand. Hand. Jun 1977;9(2):97-101. [Medline].

  24. Riefkohl R, Wolfe JA, Cox EB, McCarty KS Jr. Association between cutaneous occlusive vascular disease, cigarette smoking, and skin slough after rhytidectomy. Plast Reconstr Surg. Apr 1986;77(4):592-5. [Medline].

  25. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS plication for the treatment of prominent nasomandibular folds and restoration of normal cheek contour. Plast Reconstr Surg. Nov 1995;96(6):1279-87; discussion 1288. [Medline].

  26. Duffy MJ, Friedland JA. The superficial-plane rhytidectomy revisited. Plast Reconstr Surg. Jun 1994;93(7):1392-403; discussion 1404-5. [Medline].

  27. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg. Dec 1979;64(6):781-95. [Medline].

  28. Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg. Jul 1983;10(3):543-62. [Medline].

  29. Gamble WB, Manson PN, Smith GE, Hamra ST. Comparison of skin-tissue tensions using the composite and the subcutaneous rhytidectomy techniques. Ann Plast Surg. Nov 1995;35(5):447-53; discussion 453-4. [Medline].

  30. Tonnard P, Verpaele A, Monstrey S. Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg. May 2002;109(6):2074-86. [Medline].

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Further Reading

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Keywords

rhytidectomy, skin-only facelift, face lift, subcutaneous facelift

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Contributor Information and Disclosures

Author

Jonathan L Kaplan, MD, MPH, Fellow in Plastic Surgery, Cleveland Clinic
Jonathan L Kaplan, MD, MPH is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Dean Fardo, MD, Associate Staff, Department of Plastic Surgery, Cleveland Clinic Foundation
Dean Fardo, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Gregory A Buford, MD, FACS, Medical Director, Body by Buford
Gregory A Buford, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Student Association/Foundation, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Dermik Aesthetics Honoraria Speaker/National Trainer; Allergan Honoraria Speaker/National Trainer; Medicis Honoraria Speaker/National Trainer; Sound Surgical Technologies Honoraria Speaker/National Trainer; Kinetic Concepts International Honoraria Speaker/National Trainer

Randall Yetman, MD, Head, Section of Plastic Surgery of the Breast, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation
Disclosure: Nothing to disclose.

James E Zins, MD, Chairman, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation
James E Zins, MD is a member of the following medical societies: American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American Medical Association, American Society of Maxillofacial Surgeons, Ohio State Medical Association, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

David W Furnas, MD, Clinical Professor Emeritus, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California at Irvine
David W Furnas, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Head and Neck Society, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Surgery of the Hand, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society of Transplantation, California Medical Association, Phi Beta Kappa, Plastic Surgery Research Council, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center
Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

 
 
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