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About Face

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

As it ages, the SMAS fascia loses its elasticity and begins to sag. Until this phenomenon was properly understood, surgeons were treating only the skin for its sag without addressing the SMAS fascia. As a result, no matter how tightly the skin was pulled, the SMAS fascia would counteract the face-lift and begin to reveal sag again within a couple of years. (In fairness to those who had the procedure done in the 1960s, this might be where they got the idea that they had to have repeated face-lifts to maintain their appearance.)

The SMAS fascia is directly attached to the platysma, which is the broad, thin muscle on either side of the neck. It extends from the top part of each shoulder all the way up over either side of the jawline. When the platysma is in an advanced state of sagging, toward the middle of the fifties in most people, but, surprisingly, occurring much earlier in others, you’ll see two “cords” begin to appear at the front of the neck. These cords are actually the leading front edges of the platysma muscle, which has fallen forward with the fascia. A face-lift operation takes into account both the cheek and neck areas, so that, again, the SMAS fascia and its effect on the platysma is an important factor.

Because of our advanced understanding of the SMAS fascia, we almost always perform what is known as the “two-layer” face-lift when the operation is called for. There are several ways of dealing with the two layers of skin and SMAS fascia, and new techniques are continually being introduced as we get to better understand these remarkable body organs. For example, different procedures are employed for patients who smoke: their micro-circulation is reduced as a result of smoking, and the skin will not tolerate much pull.

Generally speaking, the most common approach is to loosen and lift both the skin and the SMAS fascia underneath before snipping off the excess in both layers and suturing up afterward. In my experience, this is a safe and effective technique, and the face-lift lasts a good long time. The interesting thing is that the two-layer approach requires less surgery for better results. No more “shaking hands” under the chin skin!

The incisions we make for a face-lift vary slightly from surgeon to surgeon. Many surgeons actually draw lines with felt-tip pen indicating where we plan to cut on the patient’s face. This is done when the patient is sitting upright on the operating table so that we can trace the areas of sag. (As soon as the patient lies down, these areas disappear or fall away to the sides of the face.) Some surgeons simply prefer one type of cut over another, so the lines are not always exactly the same. And the lines will vary depending on what the patient has to offer in terms of hairline, fatty deposits and other factors.

The incision starts with a continuous cut around the ear that starts in front of and above the ear (in the hairline), traveling down in front of the ear underneath the lobe, then up behind the ear, tracing the ridge of cartilage to the mastoid bone, just above and back of the ear. At a point level with the top of the ear canal, the incision travels straight back horizontally into the hair.

When this cut has been completed, I loosen the skin and the SMAS fascia separately, then pull them up. By pulling up, the extra tissue that sags becomes apparent when it overlaps the cut lines. This is the tissue that we excise, or snip off. The resulting wound is then sutured, using the method I described earlier in the chapter on linear scar revision. (This is a three-layer approach to closing a wound, with a deep dermal stitch, surface stitching or Histoacryl glue, then temporary taping to hold everything in place.)

The incision behind the ear allows access so that a surgeon can correct sag in the neck and lower chin area. If the patient has trouble with “cording” in the neck - meaning the SMAS fascia has sagged and brought forward the leading edges of the platysmal muscles as I explained above - I will use this incision to reach down and pull up the muscles, anchoring them with sutures as close to the mastoid as possible.

The incision in front of the ear deals with sag that is above the chin, but still within the lower half of the face. This is the kind of sag that often revels itself in a deep lip-cheek groove where the cheek mound has sagged forward and down. The cut continues at the bottom of the ear, behind the lobe, where the posterior cut ended. The scalpel traces a line that travels up the front of the ear, as close as possible to the base of the tragus (the cartilage shutter at the front of the ear that you can push in to block out loud sounds), then disappears vertically into the hairline.

If you look carefully, you’ll see a slight natural angle between the cheek and the tragus, and by cutting along the base, the resulting scar, when it heals, will contract to maintain this angle. Occasionally, I will make an incision behind the tragus, then add a deep suture to give the area a natural-looking cheek-tragal angle after surgery.

When both the skin and the SMAS fascia are pulled up toward the hairline, the extra tissue is revealed at the cut by the way it overlaps the ear. The extra tissue is excised and the wound sutured, as I described above. This procedure can result in the lip-cheek groove being diminished by up to fifty percent; a dramatic result. Any remaining groove can be filled in with collagen or Gore-Tex.

Some surgeons extend the incision above the area of the temples in the hairline. They’ll pull up from this area to correct sag in the upper third of the face, especially around the eyes and the lateral eyebrow area. I rarely perform this temporal lift only because I find sagging in this area is more effectively treated with a forehead-lift. The face-lift and the forehead-lift are two different operations, and each one creates a different effect; often, I’ll perform both as a combined procedure. (For more information on the forehead-lift, see Chapter Three: The Eye Region.)

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