The face is the landscape of the self. It is the “ground zero” of one’s identity, the one piece of real estate that everyone must, by default, own. Unbeknownst to most people, this topography is continuously recontoured by the constant, subtle, and cumulative effects of time, gravity, and life experiences. As such, the facelift—the most iconic of all facial plastic surgery procedures—has a long and storied history. For many years, the cultural perception of a facelift was a very visible and overt “fix” that typically involved the pulling and tautening of skin to counter the years of laxity and volume loss. Like most procedures performed with heavy hands in the past, facelifts resulted in a new set of cosmetic clues (rubber bands, pinched eyebrows) that were just as obvious, if not worse, than the natural lines and folds that had been there to begin with. This caricature of the facelift has thankfully been relegated to the dustbin of history. The modern facelift has undergone a revolutionary change in philosophy. It is no longer simply a two-dimensional tightening of the skin but a three-dimensional surgical repositioning of facial structures. The most successful facelifts are now less about fighting the aging process and more about reclaiming the precept of structural integrity: a thoughtful, artful, and scientifically grounded dialogue between surgeon and patient to restore the light, shade, and balance of the face through the rebuilding of its foundational framework.
The critical shift in technique and thinking is a result of an evolving understanding of exactly what is happening in the aging process. Skin wrinkles, folds, and laxity are merely the superficial “end stage” manifestations of a more complex process of structural collapse that is occurring at every layer of the face. In its youth, the face is a study in anatomical form and function. The volume of fat that resides in each of the cheeks and temples is held in place with a sturdy scaffolding of dense and elastic ligaments. These soft-tissue structures, in turn, rest on the immovable scaffold of the facial skeleton. The aging process, in its relentless methodical way, leads to a stepwise breakdown of this complex architecture. As the elastic ligaments lose their “snap” like a loosened rubber band, they stretch and lengthen, allowing the fat pads to gradually migrate downwards into the lower third of the face (causing jowling), and downwards into the nasolabial folds. At the same time (and perhaps most importantly), the bony support of the face is undergoing a process of resorption that begins around the orbital margins (eye sockets) and extends all the way down to the jawline (chin), thereby “shrinking” the support framework and making the overlying soft tissues fall even faster into this resorbing “sinkhole.” The skin, as the final layer of this stack of tissues, now has to drape over this deflated balloon-like structure. Thinned out and losing its own structural integrity in the process, the skin writhes and wrinkles because of, in large part, a lack of anything to rest upon. A traditional facelift (simply a tightening of the skin) was therefore, in many ways, like a carpenter attempting to fix a leaning table by simply straightening the tablecloth.
In a modern facelift, by contrast, the entire framework of the mid and lower face is repositioned. The key technical breakthrough was the identification and utilization of the SMAS (Superficial Musculo-Aponeurotic System). This fibrous layer that overlies and invests the superficial facial musculature and fat pads of the mid and lower face is now considered the target layer (the “substance” or “structural framework” of the face). The modern SMAS facelift is the process by which the surgeon can separate, “hoist,” and anchor this layer back to its youthful higher level, thereby “lifting” the overlying skin. Once the SMAS is properly elevated and secured, the patient’s own skin can then be redraped over this new buttressed infrastructure. The surgeon can literally reestablish the mid-face volume, tighten the jawline, and reduce the heaviness in the jowls and neck. The skin, no longer hanging in free-fall and now requiring far less trimming, is redraped in a less constricted fashion and is therefore far less likely to look “tight” or “pulled” as it did in the past. The net result is not a “tight, drawn” look but a restoration of pre-existing facial topography: the patient’s own youthful facial features once again revealed through this restorative rebuilding of a three-dimensional facial “architecture.”
Out of this basic concept have now emerged a whole host of specialized facelifts—many of which are often specifically tailored to the unique “blueprint” of an individual’s particular aging pattern. A deep-plane facelift, for example, involves an even more deep-seated dissection (through the SMAS) in which the surgeon can raise the entire mid-face “sandwich” of muscles, fat, and skin as a single block, thereby potentially providing an even more robust and natural elevation of the mid-face, and with the added benefit of improved blood supply to the skin with potential for better healing. Mini-facelifts (and S-Lifts) are a more limited form of facelift, primarily focused on the jawline and neck, with smaller incisions and a more abbreviated recovery period. Another important development is the understanding that lifting is only one part of the solution, as a face that has merely been lifted can still look hollow and gaunt if the atrophy of fat and loss of bony support are not addressed. Herein lies the critical importance of regenerative fat grafting, more popularly known as lipofilling. A patient’s own fat can be harvested from their abdomen or thighs and, once carefully purified, be re-injected in very small droplets to restore volume to areas of the face (temples, cheeks, infraorbital area, etc.) that have been ravaged by atrophy and resorption. This is not simply filling in lines, but rather an artful sculpting of one’s own living tissue to restore the natural, plump fullness of youth. The grafted fat also brings stem cells with it that may benefit the skin as well as enhance the production of collagen, and is therefore regenerative in nature, not just volumizing.
The transformation process itself is an exercise in careful planning and collaboration between surgeon and patient. A consultation (diagnostic, educational session) is performed in which the surgeon (both architect and artist) analyzes the various structural issues (i.e., weakened “framework”/volume “deflation”) and determines, together with the patient, the personalized plan of attack to best help achieve the individual’s goals. In some cases, “trial imaging” may also be performed to help a patient “visualize” some of the potential results. The surgery itself, performed under general anesthesia, is a very precise and time-consuming process that requires the surgeon to balance the skill of a surgeon with the eye of an artist. Recovery, while not insignificant, is much easier than in the past, and most people can be fully social after 2 weeks, although final, set results may take months to fully appreciate as the subtle swelling resolves and the new structures settle. In a word, the new face is the new old you: a face that is imbued with balance, light, and harmony. In reimagining its purpose as an exercise in the “restoration” of one’s own youthful precepts (rather than a battle against aging itself), the modern facelift has found a way to not simply defy time but to meaningfully reclaim one’s own youthful self.
