Lidlift Keneth D. Steinsapir, M.D.
Cosmetic, Facial & Eye Plastic Surgery

There has been a recent proliferation of so-called mini-facelifts including small incision proprietary facelifts with a confusing array of names. Adding to the confusion are so-called minimally invasive procedures including cable lifts, laser resurfacing and other procedures that are sometimes positioned with clever marketing names to sound like they provide a facelift, but in no way provide the longevity or degree of improvement of an actual facelift. In some cases having an actual facelift would have involved less downtime and expense than some of these so-called minimally invasive alternatives. Unfortunately, some of these proprietary procedures allow doctors to unbundle what is customarily performed in the facelift and instead present an ala-carte menu of services (profit centers for the doctor). It should not be your job to figure out what components of a facelift you should or should not have. It is the job of your surgeon to educate you on what is right for your face and present a plan that addresses your facial needs.

It is first helpful to understand when a facelift is appropriate and how underlying facial anatomy contributes to these issues. This will provide a basis for understanding the facelift and when variations on the facelift make sense. When looking at the face, we are looking at a three dimensional structure composed of several separate layers. The deepest layer is the facial skeleton. The bone structure is the base for everything else. While bone structure is relatively stable, it does change over our lifetime. The big aging changes that occur in the face leading to cosmetic concerns include: skin quality, a fall in the eyebrow, under eye circles and lower eyelid fullness, a fall in the cheek fat, deepening of the nasolabial fold, jowling along the jaw line, and neck cords and loose skin under the chin (turkey neck), and loss and gain of facial volume.

The fall in the eyebrow is discussed under the pages in the site directed at eyelid surgery and the forehead lift. The under eye circle and fullness in the lower eyelids is also discussed in the sections on under-eye Restylane® and eyelid surgery. The descent of the cheek fat is also discussed in the section on midface surgery.

In time there are subtle changes in our facial skeleton from the effect of gravity pulling at the facial tissues. Ligaments that support the cheek soft-tissue and, in particular, facial fat, slowly give away in time aided by gravity and facial movement. The nasolabial fold deepens due to the descent of these soft-tissues but also as a result of changes in the bone structure. Vertically descending cheek fat contributes to the development of jowls along the jaw line. In the face, muscles of facial expression are in layers from deep, intermediate, and superficial. It was once thought that aging changes in the face was due to lengthening of the muscles of facial expression. Elaborate, high-risk surgeries were developed to shorten these facial muscles in the hope of developing a more natural facelift. It was found that these techniques did not produce a facelift that was any better than standard techniques and were associated with prolonged swelling and occasional nerve damage. MRI studies established that in fact the facial muscles do not stretch out over time but rather maintain a constant length. However, the fat that surrounds the muscles of facial expression fall and need to be addressed with surgical procedures. One exception to this rule is the platysma muscle that is very superficial in the lower face. This muscle does not elongate but it does insert on the facial skin and superficial facial fat. Laxity in these insertions causes the platysma muscle to sag contributing to cords in the neck below the chin. Laxity in the skin of the lower face also contributed to the neck cords. Addressing the neck cords and skin laxity is one of the most important aspects of a lower facelift. So if you are consulting a surgeon and you are told that a neck lift is not a routine part of a lower facelift, a little skepticism is appropriate. This type of unbundling is used to justify a higher surgical fee for “additional procedures.”

Let's consider how facelift techniques vary. The first type of variation is related to how extensive an incision is made. Access to the deeper structures and removal of unwanted facial skin is done by a contoured incision along the edge of the face in front of and behind the ears. Access to the central neck is carried out through a small incision made under the chin. The second variation in facelifts is based on how the deeper tissues are mobilized prior to being supported. The depth of the facelift is further classified relative to a plane of fibrous tissues in the face known as the subcutaneous musculo-aponeurotic system (SMAS). This is a fancy term for a plane of collagen that occurs in the subcutaneous fat of the face and connects with the platysma muscle in the lower half of the face. This system seems to peter out in the cheek just below the lower eyelids. The variations include so-called skin only facelifts where no support is performed for the deeper tissues, SMAS plication, SMAS flaps with imbrication, deep plane, and subperiosteal facelifts. A SMAS plication facelift uses multiple sutures to overlap the SMAS layers at the side of the face, which effectively firms and tightens the deeper facial structures. The skin is then trimmed and sutured around the ears to complete the facelift. A SMAS imbrication facelift essentially works in a similar fashion except the SMAS is cut at the lateral edge of the face to create a flap that is elevated. Imbrication means overlap like the overlap of tiles on a roof. Once an SMAS imbrication flap is developed, its anterior edge is sutured to the edge of the face creating the imbrication. In terms of results and permanency there appears to be little difference between imbrication and plication techniques. There is a slightly greater risk of injuring the facial nerve with the dissection needed to develop the SMAS flap but the incidence of facial nerve injury, while not zero, is small. The so-called composite facelift is performed by leaving the skin attached to the SMAS layer and dissecting a skin/SMAS flap. Proponents of this technique argue that the increase risk of injuring the facial nerve is outweighed by the more profound results that can be obtained. This conclusion is debatable. First if you happen to be the person that ends up with the facial nerve injury and the corner of your mouth does not move or look the way it did before surgery, it is very likely that you will not feel that the risk was worth the reward. The other criticism of this procedure is aesthetic. Many patients need different degrees and vectors of pull on the SMAS layer and the skin layer. I think it is better when people ask you if just got back from vacation or if you have lost weight. I think it is less comforting to hear from your plastic surgeon’s office the patronizing reassurance that you look “maaaarvolous.”

In evaluating the results of patients who have undergone a deep plane facelift, there is something unnatural about their results: they often look too pulled. This happens because it is necessary to over-pull the skin in the composite facelift in order to obtain a sufficiently dramatic result along the jaw line and cheeks. The other factors that account for this is the mistaken belief by some surgeons that the composite facelift has the power to flatten the nasolabial fold. The face ends up with a wind swept look in the process of trying to achieve an improvement in the nasolabial fold. It is Dr. Steinsapir’s opinion that the wind swept look should be avoided at all costs and if this mean that fillers such as Restylane® must be used to address the nasolabial fold after surgery, this is a much better option than a freakish look that simply does not belong on the face. The goal should be the best natural look for a given face, not the tightest face at the expense of aesthetics. Speaking of freakish looks, Dr. Steinsapir is also not a fan of the subperiosteal facelift. There is a role for subperiosteal lifting in the midface and in the forehead. However, elevating an extensively degloved face, which is the goal of the subperiosteal facelift, does not make for an aesthetically desirable result. Remember, the goal is cosmetic improvement. A difference has to make a difference, and a surgical, unaesthetic result is not a desirable difference.

Let's talk about some of the method facelifts such as the S-lift, and the MACS lift. There are several variations on these facelifts that are heavily marketed. The trademarked name of one type emphasizes the rapidity of recovery and the marketing focuses on how comfortable it is to have the procedure itself. Unfortunately, these limited scope procedures generally do not address the central neck. Also the support for the deeper facial structures follows a formula that either does not work for everyone or does not work in the hands of many surgeons. Dr. Steinsapir believes these procedures are appealing because they promise results of a facelift without significant down time. However, there is a happy middle road between the overly complex high-risk facelifts and the limited scope miniface lifts that under deliver. In assessing your face at your consultation, Dr. Steinsapir will design a customized facelift that minimizes incisions yet addresses what is needed to achieve the optimal result. Instead of a cookie cutter approach, you get a customized facelift with a fast recovery. These facelifts can be performed in the office awake under local anesthesia for younger individuals in good health. However, many individuals benefit from deeper anesthesia. So Dr. Steinsapir may recommend that your surgery be performed at the UCLA Medical Center where he is on staff.

Not everyone needs a facelift. If there is no neck cord present, lower face and neck liposuction occasionally combined with a full face chemical peel or filler services provides a powerful alternative to the facelift. Down time for a lower face and neck liposuction is just a few days. Many people have this service in the office procedure suite under local anesthetic on a Thursday and by Monday return to work with essentially no bruising. A full-face chemical peel is a fantastic alternative procedure especially when fine lines and sun damage contribute to facial changes. Dr. Steinsapir believes that procedures should be tailored to your aesthetic needs, therefore he will discuss a range of options with you and help you find the most appropriate combination of services that achieve your goals with the least risk and minimum of downtime. Call now to schedule your personal consultation with Dr. Steinsapir.