The face is generally the first to reveal signs of aging. Rejuvenating the aging face has gained tremendous popularity over the last 2 decades. In the past, incisional face-lifting was the main strategy for facial rejuvenation, but during the past decade cosmetic surgeons have revolutionized facial rejuvenation with adjunctive procedures such as alloplastic facial implants, chemodenervation, injectable fillers, and skin resurfacing via laser or chemical exfoliation. Although we now have several weapons to reverse the signs of facial aging, the “modern” face-lift is still the “gold standard” for correcting generalized facial cutis laxa (rhytidosis), jowling, cervicomental redundant skin, and platysmal banding. Facial dyschromia, changes in pigmentation, acne scarring, and deep wrinkles can all be treated with the adjunctive procedures described later in this chapter and in other dedicated chapters in this textbook.

The face-lifts described in the early literature involved skin excision only. Even though the benefit is usually temporary and a rather poor natural appearance results, some surgeons still use this technique for certain patients with unique anatomy or for revision surgery. The current face-lifting techniques are numerous, although most involve manipulation of the superficial musculoaponeurotic system (SMAS). SMAS involvement in face-lifting was first introduced by Mitz and Peyronie in 1976 when their landmark article was published.

Historical details regarding face-lifting are evident from publications in the literature, such as those by Hollander (1912), Lexter (1931), Joseph (1921), Passant (1919), Bourget (1921), and Madam Noel (1926). At that time surgeons and patients were reluctant to make their cosmetic surgical interest public. Hence, technical advances were slow to flourish and propagate ( Box 107-1 ). Even with extensive undermining of skin flaps during face-lifts decades ago, the results were only partially beneficial and did not emphasize pathology of the neck and the platysma. A better understanding of facial anatomy was described by Skoog in 1974, and his manipulation of facial tissue led to the future advancements in face-lifting surgery. Webster and colleagues later added that extensive subcutaneous dissection leads to greater exposure of raw surfaces with an increased risk for complications. Richard Webster was one of the first to recommend a “short flap” with basic SMAS plication and suggested that the skin would advance adequately from its attachment to the elevated deep tissue.

Etiopathogenesis

Indications for face-lifting cosmetic surgery are numerous and involve the changes that accompany facial aging. First, the patient is identified as seeking facial rejuvenation because of age-related complaints. Upper face-lifting is described in a separate chapter, and our focus here is to target the lower part of the face and neck. Cutis laxa of the jowls and cervical area, deepened nasolabial fissures, and platysmal banding are the main complaints that are targeted by current face-lifting strategies. Genetics, age, and smoking are the key determinants of the cause of signs of facial aging ( Fig. 107-1 ). In general, the average age when patients first seek lower face-lifting and neck lifting can vary widely from 45 to 65 years.

The facial features of a youthful, 25-year-old woman ( A ) are contrasted with those of a somewhat aged, 55-year-old woman ( B ). Their lower facial and mid-face regions are vastly different because of the aging process. The malar fat pad and jowls descend secondary to gravity and loss of tissue integrity. The prejowl sulcus deepens, and bone resorption taking place along the mandibular border accentuates the cutis laxa that occurs with age. The aged eyebrow shows both: medial and lateral descent with loss of volume and hooding over the lateral orbital rim.

Clinical Anatomy

Surgeons have multiple techniques at their disposal to perform face-lifts, although detailed knowledge of surgical facial anatomy is the key to any cosmetic surgery, regardless of the techniques used ( Figs. 107-2 and 107-3 ). Determining who is best suited for liposuction versus submentoplasty with or without a face-lift is at least half the battle for ultimately producing pleasing esthetic results ( Figs. 107-4 to 107-6 ). Basic neck liposuction for an ideal patient can be dramatic despite being a relatively simple procedure when performed well ( Fig. 107-7 ).

Multiple techniques can be used to perform face-lifts. Detailed knowledge of surgical facial anatomy is the key to any cosmetic surgery regardless of the techniques used. Selection of the most ideal technique or techniques is based on a correct working diagnosis along with realistic expectations and desires of the patient.

Patient assessment should look at skin tone/laxity, platysmal banding, amount of fat and location, jowling, jaw bone structure, submandibular gland ptosis, and hyoid position. A, A good candidate for liposuction. B, A good candidate for submentoplasty and face-lift. C, A bad candidate.

Preoperative photographs showing ideal neck anatomy for basic submental liposuction only.

A, Ideal neck anatomy for a basic face-lift includes loose skin, thin/average frame, minor banding, normal hyoid, no gland ptosis, good bone structure, and normal digastrics. Preoperative photographs show ideal neck anatomy for a basic face-lift. Frequently, submentoplasty may not be required with this type of patient. B, Postoperative view.

Ideal neck criteria include good skin elasticity, adequate excess superficial fat, minimal muscle laxity and no banding, good bone structure, and a patient who understands the limitations of the procedure. Side ( A ) and facial ( B ) preoperative views of the “ideal” neck. Side ( C ) and facial ( D ) views 6 months following basic neck liposuction only.

“Ideal” neck in a 41-year-old woman. A, Preoperatively. B, Four months following basic neck liposuction and a small chin implant.

Detailed knowledge of the anatomy in conjunction with the pathology to be corrected is necessary for correct surgical planning and preoperative markings ( Fig. 107-8 ). Marking the skin over the known danger zones can reduce the risk for complications and neurovascular injury ( Fig. 107-9 ). These areas are often obscured when the patient is in the supine position and distorted with local anesthetic.

A, Small (2 to 3 mm) microcannulas are ideal for a basic liposuction technique in the neck. Larger, flat cannulas may be used safely with an “open” technique, such as submentoplasty. B, Cervical liposuction from the retroauricular area. C, Submental liposuction from the submental crease.

Liposuction of the cervical and jowl regions. Caution must be used in the jowl region to avoid injury to the marginal mandibular nerve. Tumescent local anesthesia provides anesthesia, as well as vasoconstriction and hydrodissection, when injected properly. The tumescent solution consists of 500 mL of normal saline, 1.5 mg of epinephrine, and 30 mL of 2% lidocaine (600 mg). A 0.12% lidocaine solution with 1 : 333,333 epinephrine is injected with a 22-gauge spinal needle.

A surgeon must be mindful of three main danger zones: the mid-zygomatic temporal region, the malar eminence region, and the area at the inferior border of the mandible near the angle. The mid-zygomatic arch area contains the temporal or frontal branch of the facial nerve ( Fig. 107-10 ). The nerve crosses over the arch approximately 2 cm from the external auditory meatus. It can be easily injured in the area over the bony prominence where there is less soft tissue.

A,

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