Skin-Only Facelift

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.[1] 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 the Medscape Reference Plastic Surgery journal.

The history of facelift surgery spans the last century. Hollander is credited with originally describing a surgical "lift" of the face in 1901.[2] Throughout the early 1900s, others such as Miller, Kolle, and Lexer made variations and refinements of this original description.[3, 4, 5] 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.[6] 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.[7] 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.

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.

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. An alternative approach to the temporal portion of the incision is to carry the incision horitzontally along the sideburn/cheek junction and then vertically along or just posterior to the anterior hairline. This avoids the temporal dissection along the deep temporal fascia and spares the superficial temporal vessels. 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.[8] Whetzel and Mathes refined the study and further described the vascular territories of the face and scalp.[9] 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.[10, 11]

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

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. Elderly age is not necessarily a contraindication for surgery.[12]

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.

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• Standard preoperative laboratory tests should be ordered based the patient's age and medical history.

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• While no diagnostic imaging studies need to be performed specifically for the facelift procedure, high-quality preoperative photographic documentation must be obtained prior to the procedure.

As in most procedures, a complete history and physical examination are the initial steps in the preoperative evaluation of the cosmetic plastic surgery patient. Patients for elective surgery ideally should be medically healthy or cleared for surgery by their internists or other specialists as required. Of great importance, hypertension must be controlled prior to surgery to minimize the possibility of untoward bleeding.

Preoperative medications, including vitamins and herbal supplements, need to be reviewed. Those that have a negative effect on bleeding or healing need to be discontinued prior to surgery. Patients often are unaware that herbal supplements may cause unwanted bleeding, thus a specific inquiry into their use should be elicited.[13] Aspirin products must be stopped 2 weeks before surgery since aspirin irreversibly inhibits cyclooxygenase, thus affects the platelets for their entire lifespan (approximately 10-14 d). Nonsteroidal anti-inflammatory drugs (NSAIDs) are also best avoided for at least a week prior to the procedure. While the medications listed above should be stopped preoperatively, others should be started. Because of the relatively decreased vascular supply to the subcutaneous skin flap, the health of the flap should be optimized preoperatively. Also, fine lines associated with aging in the perioral region may not be treated with a facelift. For these reasons, hydroquinone and retin A creamcan be applied to improve skin quality and treat fine wrinkles in areas of skin that are not undermined.[14]

Informed consent also is required so that the patient understands the risks of surgery as well as the improvement that can be obtained. Other patients' preoperative and postoperative photographs may be helpful in that regard. However, care must be taken to avoid giving the patient an implied guarantee of results.

The technical details of the procedure may vary depending on the surgeon but certain steps are consistent among many surgeons.[15, 16, 17, 18, 19, 20]

• A skin-only facelift can be performed either as an outpatient procedure or with an overnight stay. Similarly, either intravenous (IV) sedation or general anesthesia can be used.

• After a sterile preparation and drape, mark the proposed skin incisions. A solution containing lidocaine with epinephrine is infiltrated into the proposed skin incisions and into the area that will be undermined during dissection. One way to avoid using dangerous amounts of either lidocaine or epinephrine is to use 0.5% lidocaine with 1:200,000 epinephrine at the incision sites and then use 0.25% lidocaine with 1:400,000 epinephrine for injection into the cheek and postauricular regions. The dose for lidocaine ranges from 3.5mg/kg of body weight(without epinephrine) to 7mg/kg of body weight with epinephrine. It is important to remember that in an elderly population ,epinephrine is is not without its risks. The total dose of epinephrine injected should be also be carefully monitored and tailored appropriately to the patients condition. Waiting at least 10 minutes for the hemostatic effects of the epinephrine is advised.

• Make the incisions with a scalpel and then initiate flap dissection with either the scalpel or dissecting scissors. In the postauricular region, take care to avoid injury to the great auricular nerve, which usually crosses the sternocleidomastoid muscle approximately 6.5 cm below the external auditory canal.[21]

• Dissection in the posterior neck continues anterior and superficial to the platysma muscle. A submental incision often is used to undermine the neck skin and treat platysmal banding if present. Carry out subcutaneous dissection in the cheek only to the extent of where the excess laxity is present. The recent trend has been for a more aggressive undermining of skin; however, use a less aggressive approach in patients who smoke. As one dissects further medially, the chance that insufficient blood flow may lead to skin slough or poor healing is increased.

• When the skin undermining is complete, meticulous hemostasis must be assured. At this point, having the patient's blood pressure at the normal preoperative level is helpful. Otherwise, a factitiously low intraoperative blood pressure may fool the surgeon into thinking that hemostasis has been obtained. In this situation, a return of the patient's normal blood pressure may lead to hematoma formation in the postoperative period.

• The direction of vector pull for the undermined skin then must be decided. Typically, the cheek skin is pulled laterally and superiorly in a direction parallel to the nasolabial fold so that the skin originally over the tragus is elevated to the superior helical rim. A purely vertical vector is to be avoided to prevent a "lateral sweep" deformity. In the postauricular region, a more vertical upward vector is used. Tacking sutures at two points holds the flaps in correct position so that the excess skin then can be excised carefully. Removing more skin produces a tighter pull but this is at the expense of increased tension on the closure. Minimize tension at the closure site to help prevent excessive or widened scars. Also, earlobe deformities are more common when tension is applied at the inferior lobe.

• Drains, if used, may decrease postoperative swelling or seroma formation. Carefully undertake closure of the skin in layers. If a posttragal incision was used, also perform defatting of the new tragal skin and tragal reformation. In males, individually cauterizing hair follicles of the new tragal skin may be required. This helps prevent beard growth that was previously on the cheek from growing in an unnatural location over the tragus. Even with this maneuver, other depilatory techniques may be required later.

• Apply Xeroform strips or ointment to the incision site and apply a very loose dressing. Do not use a pressure dressing in an attempt to prevent hematoma, since pressure on the skin flaps may have undesirable consequences.

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• Patients who have undergone facelifts require close observation in the postoperative period. Before leaving the operating room, inspect the dressing to ensure that no undue compression is placed on the skin flaps. An overly tight dressing should not take the place of meticulous hemostasis. The patient's blood pressure also is maintained within that patient's normal range.

• The patient's head is elevated to minimize edema but no ice is used on the skin flaps. Appropriate pain control can minimize the chance of a hypertensive episode that is related to patient discomfort. Nausea and emesis also must be avoided since this can cause an increase in bleeding or swelling.

• Preferably, a nurse monitors the patient overnight but the patient also can be monitored at home by a responsible adult.

• Checking on the patient in the early postoperative period can detect early hematoma or skin ischemia problems.[22] Furthermore, early evacuation of a hematoma may prevent secondary skin flap ischemia or infection. If flap ischemia is detected early, then releasing a few of the skin sutures may limit the skin slough. Allowing a small portion of the wound to heal by secondary intention is usually preferable to a large skin slough.

• On postoperative day 1, the dressing and drains, if present, usually are removed. Instruct the patient on basic wound care and limiting activity for the next few days. Early follow-up care is optimal for ensuring that no complications are developing.

• Sutures usually can be removed in 4-6 days in non–hair-bearing regions and in 7-10 days elsewhere. Also give patients reassurance that the swelling and bruising may take several weeks to fully subside.

Follow-up protocols vary, depending on the patient and amount of surgery performed. Generally, follow-up visits are scheduled at 1 day, 1 week, 3 weeks, 3 months, and then yearly. However, that schedule is adjusted according to the patient's needs. Patients who experienced complications should be seen more frequently.

Although usually a complication-free procedure, as in any surgery, problems can arise. Numerous studies have examined the complication rate after facelift surgery. As expected, the complication rate varies with the surgeon involved and the type of facelift performed.

In 1994, Rees et al examined 50 surgeons' experiences with 1236 consecutive facelifts.[23] The hematoma rate varied from 0-3.83%. All occurred within the first 48 hours after surgery. In this study, preoperative hypertension was associated with a higher hematoma rate, as was a below-normal intraoperative blood pressure that later rebounded to normal after the surgery.

Men generally have twice the incidence of hematomas after facelift surgery as women (8% vs 4%).[24] This is believed to be due partly to the increased blood supply to the beard area in men. In 2004, Jones and Grover examined 910 patients in an attempt to see what factors may contribute to an increased risk of hematoma.[25]

Those considering a facelift procedure should have stable and controlled blood pressure preoperatively. A long list of prescription and over-the-counter drugs, herbal medicines, and food supplements may adversely affect the coagulation cascade. These substances must be avoided, usually for 10-14 days prior to surgery. Having a patient's blood pressure at near-normal levels prior to the skin closure may limit this problem.

Skin slough, or partial flap loss, is another possible complication. It most often occurs in the postauricular region and often is associated with hematoma, infection, or excessive tension on the closure. In 1994, Duffy and Friedland examined 750 patients who had undergone subcutaneous facelift procedures and found a 0.5% incidence of skin slough. However, approximately 1% seems to be average.

Flap loss in patients who smoke is likely higher due to the negative effects nicotine has on platelets and the microcirculation.[26, 27, 28, 29, 30] Riefkohl in 1986 also correlated cigarette smoking with a greater incidence of skin slough in patients undergoing rhytidectomy.[31] Patients ideally should refrain from smoking 3 weeks before surgery and 2 weeks after the operation. In those who smoke, the amount of undermining of the skin is usually less aggressive to help minimize the possibility of skin healing problems.

Another possible risk factor for skin slough is prior acne scarring. The subdermal scar associated with acne may compromise blood flow to portions of the flap. Good judgment by the surgeon is required in these situations to determine the amount of undermining that can be performed safely.

Facial nerve injury is a dreaded but possible complication. Fortunately, it is rare. A subcutaneous facelift that does not violate the SMAS or platysma poses less of a chance for this complication. Robbins found 0 palsies in 226 subcutaneous facelifts,[32] while Duffy and Friedland found 0.5% in 750 patients.[33] The buccal branch is the most commonly injured facial nerve branch but it may not always be recognized or clinically significant given the considerable overlap it shares from other branches. In contrast, the marginal mandibular and temporal branches may have little or no cross innervation, and injury to these branches is much more noticeable and problematic. Certainly, a meticulous dissection and a thorough knowledge of anatomy can greatly minimize the possibility of a facial nerve injury in a patient who has undergone subcutaneous facelift.

Overall, the most commonly injured nerve after a facelift is the great auricular nerve.[34] This can produce sensory disturbances in the ear or posterior auricular region and can be quite a nuisance to patients. Again, knowledge of where the nerve is in danger should be able to minimize this complication.

Although very rare, two of the most dreaded complications are deep venous thrombosis and/or pulmonary embolism. Both have occurred after facelifts and they have the potential to be very serious or even fatal. Patients undergoing facelifts are at modest risk of blood clots given their usually older age (>40 y) and the length of the procedure. General anesthesia also can increase the risk. Therefore, appropriate precautions are recommended to minimize risk. These include the use of pneumatic compression devices or low-dose subcutaneous heparin treatment before surgery.

Minor problems after facelift occur but fortunately are rare, and each should have an occurrence of less than 1-3%.[35] These include infection, alopecia, hypertrophic scars, earlobe deformities, prolonged edema, and hairline contour irregularities. Careful preoperative planning, attention to detail, and minimal skin closure tension should minimize the possibility of each occurrence. These are considered finesse issues and the surgeon's experience and careful preoperative planning and technique can minimize these problems.

The preoperative and postoperative images below show outcomes of skin-only facelift.

A cadaveric study by Rao et al comparing skin-only, SMAS plication, and extended SMAS facelifts reported that lifting along the horizontal and vertical vectors was significantly greater for the SMAS operations than for the skin-only surgery. Indeed, no appreciable vertical elevation was seen with the skin-only procedures. For all three methods, the greatest horizontal lift was achieved in the lower face, the aggregate lifts for this region being 0.72 cm, 1.27 cm, and 1.28 cm for the skin-only, SMAS plication, and extended SMAS lifts, respectively.[36]

The subcutaneous (skin-only) facelift still may produce good results in selected individuals but most surgeons agree that paying attention to the deeper SMAS layer (ie, through plication, SMAS-ectomy, or a composite facelift) usually produces a better result. Most also believe that a surgery involving SMAS support usually produces a longer-lasting improvement in the patient's appearance. However, no objective data of this assumption have been obtained. In 1995, Gamble et al compared composite facelifts to subcutaneous techniques and found that the composite flap resisted stretch more than the subcutaneous flap.[37] This meant that less skin excision was possible for a given tension in the composite flap. However, they felt that this resistance could be overcome by placement of deep support sutures.

A skin-only facelift can be combined with anterior platysmaplasty. This allows resection of the supraplatysmal and subplatysmal fat, digastric modifications, and even submaxillary gland excision directly through a submental incision. This adds both time and potential morbidity to the procedure.

Summary

The last 25 years have seen many advancements in rhytidectomy techniques over the standard skin-only facelift. Most of these techniques address the sagging muscular layers under the subcutaneous tissue. However, in selected patients, a skin-only facelift still may produce safe and pleasing results to both the patient and surgeon. Attention to detail and careful planning should help ensure optimal results.