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About Face

Chapter Six The Face-lift Lower Face-lift Liposuction The Chin

Liposuction

Another complementary procedure to the face-lift operation is liposuction along the jaw-line. This is because patients who need a face-lift often show a tendency toward being “jowly”. Jowls are created when the SMAS fascia and the skin sag, and the problem is made worse with local deposits of fat along the jaw-line. It’s a kind of hangdog look, and both men and women suffer from it. (Younger patients can often be treated with a liposuction alone; they don’t yet have the problems of sagging to correct.)

For those who need it, liposuction and a face-lift can be done as a continuous procedure. I start by making three incisions for the liposuction. No incision is more than about one-and-a-half centimeters long, which minimizes scarring afterward. The first incision is made one centimeter under the chin. The next two are made behind each earlobe. (You might have noticed that the ears are terrific hiding places for most of the scarring associated with face-lifts.) Operating from three incisions facilitates the removal of fat from the jowls and prevents taking too much fat from under the chin area; it gives a more balanced contour to the neck and jaw.

Through these incisions, I insert a hollow metal tube called a cannula, which is connected to plastic tubing and a motor-driven vacuum. In a kind of fanlike motion, I work the cannula just under the skin to suck out the fatty deposits. People are always surprised at how vigorous an action this is, but the short, sharp, smooth strokes are needed to break up tissue, and it’s a smoother technique than it appears to be. During the procedure, patients are awake but sedated in most cases; some prefer a general anesthetic. Either way, patients feel no pain, though they might react to the curious, sucking sound that the vacuum makes. The cannula is designed to extract only fat, which travels in globules down the tubing to a receptacle. Once I’ve got all the fat out, we can see the true extent of sagging to be repaired by face-lift. (If the patient is younger, the skin will contract or shrink on its own, making face-lift unnecessary.)

Maintaining the natural hairline behind the ear is an important element of any face-lift operation, whether the patient is male or female. Years ago, we used to bring the incision behind the ear down along the hairline, and the resultant scar became visible with a short haircut, or with long hair pulled back into a ponytail. Now, as I described above, we take the incision straight back into the hair, and this has pretty well eliminated the problem.

Man can be a bit of a challenge in a face-lift operation because of some of their hair-growth patterns. A surgeon has to be careful not to draw back the sideburn hair so far that it looks unnaturally thinned. The skin behind men’s ears is non-hair bearing, but when the skin is pulled back and upward during a face-lift, the hair-bearing skin just below the ear moves behind the earlobe. This area must be shaved.

The progress we’ve made by treating both the SMAS fascia and the skin with a face-lift has lessened the likelihood of postoperative complications. There is less surface area of surgery and therefore less chance of bleeding or “hematoma formation” when pools of blood collect under the skin. There have been rare cases, however, where a surgeon has damaged one of the branches of facial nerves that provide movement to the face.

Facial cosmetic surgeons will continue to offer the “two-layer” face-lift with liposuction because of the enormous improvement over the previous method when only the skin was treated. This approach results in a longer-lasting lift, and our ability to reduce the depth of the lip-cheek groove is much improved. The SMAS fascia can be tightened in a different direction than the skin layer, which enhances the effect of the lift and makes the skin more flexible. But it also seems to result in less swelling over a shorter period of time - in fact, the entire healing process is faster and better after this operation - again, because there is less surgery involved.

During recovery from a face-lift operation, patients are likely to experience some “hypoesthesia.” This is a temporary loss of sensation, or a numb feeling, and there are a couple of reasons for it. The natural swelling following the operation might contribute to hypoesthesia - much the same way your face feels numb for a while after someone has slapped it. If the feeling of numbness is localized around the lower part of the ear and the earlobe, it could be that the nerves to these parts of the ear were separated in order to do the lift. Either way, hypoesthesia often disappears after six weeks and rarely lasts as long as six months.

Patients recovering from a face-lift must wear a firmly wrapped tensor bandage continuously - night and day - for two weeks following surgery. The extensive wrapping resembles a football helmet with a chin “sling”. The purpose of the bandage is to counter the effects of the swelling that naturally occurs after surgery; without it, the swelling may stretch the skin and cause renewed sagging.

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