Face Lift (Meloplasty or Rhytidectomy)

How is Facelift Surgery performed?

Facelift surgery does not simply involve pulling back and tightening the skin. This is what has been originally described, but as techniques have evolved, there has been a better understanding of what produces good long lasting results. As one might already know, the skin’s ability to keep its tone reduces with age. Hence we can not rely on the skin alone to keep things tight. Whilst simulating the results of surgery by pulling on the skin, can provide an idea of the anticipated results, what is actually being done in this manouvre, is traction force that is being applied on the underlying structures, namely the facial fat pads and SMAS layer. SMAS refers to the superficial muscular aponeurotic system. This is the key structure involved in facelift surgery. The SMAS is a muscular layer that is modified in facelift surgery. It does not “give “ like skin, and so a tightening of the SMAS layer is often what is undertaken to achieve elevation and correction of the jowls. This has the effect of producing a defined jawline.

The SMAS layer lies deep to the skin. Once the skin is elevated via the predetermined incisions, the SMAS layer is exposed. The SMAS is modified either by way of a SMASectomy or SMAS plication procedure. Some surgeons stick to one or the other, without consideration of the potential benefits of adopting a certain approach to the patients’ specific requirements. The surgeon should have a good understanding of when to use a SMASectomy or SMAS plication, rather than adopt a ‘one size fits all’ approach. There are various factors to consider and Dr Reddy adopts the approach that bests fits your facial shape.

Once the SMAS muscle is tightened and the desired contour achieved, the excess amount of overlying skin becomes evident and addressed. This is in effect a tailoring procedure. Experience and technique is important in this aspect of the surgery. Poor technique can result in skin bunching, undesired puckering and poor scar outcomes.

Where are Facelift incisions placed?

There are two relatively common approaches to incision placement in facelift surgery. Having said that, experience and an appreciation of hair distribution are important factors in choosing the preferred site of the incisions in each individual case. The length of the incision can also vary depending on the amount of skin tailoring that is required. Dr Reddy will be able to accurately advise you on this prior to surgery.

Incisions can be placed along the hairline or with in the hair. Again, at face value, one might feel that incisions hidden in the hair will be less visible. This is not necessarily the case, and Dr Reddy will be able to advise on the advantages and disadvantages of each approach and what might be best suited for your specific facelift procedure.

Another concept to consider is incision (scar) length. ‘Shor scar’ techniques or smaller incisions are often popularised through media and marketing, obviously because of the concept of minimal scarring. Whilst Dr Reddy does employ short scar techniques where indicated, such approaches may not necessarily be the best approach in certain patients. Dr Reddy will be able to clearly advise on what might be best suited to your needs. The decision is often dictated not by the surgeons ability to do everything though a small scar, but rather how much skin needs to be tailored. To put it in simple terms, a well planned and executed facelift with appropriate incision length can look far more favourable and natural than a poorly executed facelift with short scars. The latter, despite having short scars will likely lead to skin bunching and puckering with suboptimal contour. Dr Reddy will be able to clearly advise on the anticipated length of your incisions following the consultation process.

Deep plane facelift vs SMAS facelift – Which is better?

This a question that I not uncommonly get asked. I have put together the following information to help serve as useful guide in answering this question.

In simple terms, the answer is that one is not better than the other. Both techniques have advantage and disadvantages, and what is more important is that the technique chosen should be the one that will best serve the interest of the patient and achieve the desired endpoint.

In recent years, there has certainly been a trend towards the ‘promotion’ of the Deep plane facelift techniques. This may reflect more of a move towards this approach in the training of certain specialty groups or popularisation of this technique by certain individuals, rather than a reflection of its ability to create superior results. Much of the commentary surrounding deep plane facelifts suggesting that it is a better technique, appear to be opinion based rather than based on rigorous supporting data. This is not to say that it is not a good technique, but rather it is important to take into consideration all the facts when researching on this topic. The reality is that there is very little data to suggest that one technique is better than the other, but there is data to indicate that both deep plane facelifts and SMAS facelifts can provide excellent outcomes.

So who should I choose and which approach should I choose?

This boils down to several factors and relies on an understanding which approach will best achieve the desired changes. Assessment and discussion during the consultation process will allow a decision to be made, as this will take into consideration your particular facial shape, age related changes, and type of correction required. Many surgeons will offer a single approach or technique during facelift surgery, whether it be a Deep Plane facelift or SMAS facelift. This is not necessarily a negative consideration, as it can mean that the surgeon has developed a vast degree of experience in that particular technique. I think, what is important however is that the treating surgeon should understand the pros and cons of each approach and derive a surgical plan that is aimed at producing the optimal result for your particular facial shape and presenting age related changes. When this is undertaken, then the original question about ‘which technique is better ‘becomes less of a consideration.

The premise of Deep plane facelift is that the skin and SMAS musculature is raised as one unit. Proponents of this technique would advise that this ensures better circulation to the overlying skin during the healing process. This may translate to less risk fo skin necrosis, less visible bruising and potently less downtime. The difference in down time may amount to 1 week. By undertaking the surgical dissection at a deeper level, more correction of the nasolabial and upper cheek is thought to also be achieved. The downside however is that some surgeons would argue that this combined elevation can lead to a ‘windswept’ or stretched look. Another consideration with deep plane facelift surgery is that because the dissection is at a deeper level, there has been a concern that the facial nerve is at greater risk. A metanalysis in 2019 revealed that there was no elevated risk for permeant nerve injury, although temporary nerve injury was noted to be higher with deep plane facelift when compared to traditional SMAS facelift surgery approaches. The overall rates of nerve injury remain low, and are usually reported as under 1%.

The premise of SMAS techniques is that the skin and SMAS musculature are treated as two sperate units. The principal advantage of this over Deep plane techniques is that it allows for a more customizable facelift ie the underlying SMAS elevation can be undertaken in a different direction to the skin correction. This is particularly useful for individuals with concomitant lower face and neck redundancy. The SMAS can also be treated differently, either by way of SMAS plication or SMASectomy. This again allows facial volume to be adjusted in a more tailored manner. Whilst the upper cheek is not amenable to improvement with traditional SMAS techniques, this can be overcome by fat grafting (which is also commonly undertaken with deep plane techniques) and or High SMAS facelift.

Ultimately, irrespective of the technique employed, a well-trained surgeon who is competent in a chosen technique and who can tailor the overall surgical plan to specific needs, should be able to achieve the desired results. In achieving the desired result, just as much as the surgical approach is important, post-operative attention to detail, rigorous follow up and an overall engaged experience all contribute to reaching a highly satisfied result.

What is the recovery like after a facelift?

As per recommended NSW health guidelines, facelift surgery is undertaken in hospital. Patients are typically in hospital overnight and are able to go home the next day. Pain is usually minimal and patients receive appropriate pain killers and antibiotics prior to discharge. You will go home wearing a facelift compression garment. It is important to rest for the first two weeks after surgery to optimise the healing and recovery process. Generally allow for 2-3 weeks before you can return to work. Swelling and bruising are the common visible sequela after surgery. Bruising typically resolves in a 2 week time frame. Swelling can take longer to resolve, although the vast majority of swelling subsides in the first one to two weeks. Residual swelling will continue to subside over the subsequent two months. If concurrent fat grafting is undertaken, then a greater degree of swelling can result. It is important to follow the prescribed post-operative regime to facilitate the recovery process and avoid any unexpected sequelae that might delay your recovery period.