There is no such thing as a “one size fits all” face-lift. Surgical techniques should address specific problems, and the same procedure is not applicable to every problem and every person. A forty-nine year-old woman does not have the same aging issues as a sixty-seven year old, so why should she be offered the same operation? Men want to tidy up their necks and have their skin fit. Women are concerned with wrinkles, folds and blemishes. Why would I offer them the same single option? It doesn’t make sense. Different people in different stages of life have different requirements.
It has always been clear to me that if we are to provide a full range of maintenance and correction options, something must fill the void between simple, noninvasive skin treatments and a full face-lift. Loss of elasticity and signs of aging begin early and even if a road map of facial wrinkles has not yet appeared, relief is often welcome. Our goal is to stop the progress before the changes have pushed from youthful to matronly. Clean up the jawline, return the cheekbone prominence to what it used to be and undo those nasolabial folds along the cheeks and lines beside the mouth. While these changes are not terrible they are beyond the scope of injections, lasers and peels.
In the past, the most common advice was “Wait and do a full face-lift when you are ready.” Few plastic surgeons, myself included, thought very much of doing less. We were taught that anything less than a full face-lift wasn’t worth the trouble. We were wrong. Even as the nuances of the surgery and the sophistication of the profession advanced, we held to preconceived notions. But I was searching for a better solution. One that could be applied earlier, produce a natural result and make the early middle-aged patient look appealingly young again.
It was at that point, in the mid-1980s, that I first encountered the rudiments of the S-lift, so named for its lazy S incision. A few years later, I reduced the incision further, eliminating the component in the scalp and increasing effectiveness. The result was even more natural. It corrected the loss of elasticity and drooping from the eyes, to the Adam’s apple, and dramatically reduced the nasolabial fold. This was the limited incision facelift technique, or short scar face-lift. it seemed to be exactly what surgeons and patients were looking for and became enormously popular. As with everything in medicine, many people have simultaneous inspiration, and one cannot lay claim to “inventing” a procedure. “Success has many authors; failure is an orphan.”
This modern mini-lift has been adopted, renamed, and publicized by many surgeons. The June 4, 2009, New York Times published a long article about the marketing of specialized face-lifts, making reference to the seminal importance of my original S-lift and the procedures it had spawned. But be warned: A new name doesn’t make a new procedure. After the journal Aesthetic Surgery published the scientific paper on the first 1,000 limited incision facelifts I had performed, I smiled at advertisements for surgeons claiming credit for the new operation. I am happy to have had something to do with devising and popularizing an excellent procedure, but the real beneficiaries are my patients, who understood that the new procedure would help them achieve and maintain a natural, youthful appearance.
In order to understand how all this works, let’s consider the anatomy of the face, what we are trying to achieve, and the difference between face-lift procedures. The skin of the face lies on a bed of subcutaneous fat and wispy connective tissue. Only in areas of facial expression is it bound directly to the underlying muscles. That means that there are muscle-skin connections around the eyes, lips, mouth, nose and chin, but the entire cheek and neck area, from the ears to the nasolabial fold, is free of these attachments and not closely bound to the underlying tissues. Therefore, it is easily separated and lifted. It is because of this lack of firm anchors that these areas are liable to become lax and droop as soon as the skin begins to lose elasticity. Correcting that laxity, along with the tightening of the underlying tough muscle fascia, lends itself to successful repair, or lifting. This tough layer, called the subcutaneous muscular aponeurosis, or SMAS, is where much of the real pulling takes place. This tightening helps alleviate jowls and deep nasolabial folds and adds longevity to the result. The thin, flat platysma muscle, a continuation of the SMAS, which underlies the skin of the neck, is also tightened to correct the two loose bands under the chin.
The limited incision facelift incision, or short-scar face-lift incision, begins in the bottom of the sideburn and follows a into the ear, behind the tragus, the little piece of cartilage that sticks out from the ear, and ends just behind the ear lobe. Incisions are hidden, and signs of surgery disappear quickly. One can confidently appear in public ten days after surgery. There is no scar in the hair or behind the ears or on the neck, and women can wear their hair up without worrying about the noticeable signs of traditional face-lifts. Because the top of the incision is in the sideburn there is no unsightly, telltale distortion of the hairline. The procedure reverses the loss of elasticity which has caused facial sagging, and results in a firm, straight jawline. Ancillary procedures include microsuction of the double-chin area and corners of the mouth and fat transfers to lip lines, lips, cheekbones and chin. Eyelid surgery is done at the same time, when indicated.
The procedure takes less than two hours to perform, usually under sedation and local anesthesia. It corrects loose jowls, reduces nasolabial folds, loose neck skin and reconstitutes the angularity of the cheekbone area. It does not correct the very lowest portion of the neck or the forehead. For these problems other variations of the face-lift may be employed.