Facelift is the major part of facial rejuvenation. It is a procedure performed to correct the jowls, jawline, neck and cheek wrinkles. I almost always combine it with lower face and neck liposuction and fat grafting. Eyelid correction and/or browlift can be done at the time of facial rejuvenation surgery, as can Botox, filler, resurfacing. I usually do some form of short scar or mini lift – more on this below.
The procedure is performed in my clinic as day case surgery (discharge on the same day as surgery), under sedation and local anaesthetia. When doing a facial rejuvenation with facelift, I allow a whole morning for surgery. You usually arrive at the clinic at 7.30 when you will be admitted to the ward. I will chat to you before surgery and draw my markings on your face. We will give you a pre-med consisting of tablets for pain and Dormicum, a short acting Valium like drug which will calm and sedate you. I also usually apply anaesthetic cream to your face to numb the areas where injections will be done.
In theatre, I will put up an IV drip for more sedation and pain control during the procedure. I will slowly inject your face with local anaesthetic. Once numb I will usually start with some liposuction of the lower face and neck and then go on to do the facelift. Usually I finish with fat grafting which I regard as the cherry on top.
The incision starts under the sideburn. The normal sideburn position is therefore maintained and the incision created in such a way that the sideburn hair can grow through it to disguise it. From the sideburn, the incision travels back towards the ear and then follows the curves of the ear down to the earlobe. The incision continues around the earlobe and then up in the groove behind the ear. A short cut is then made backwards towards the scalp. The length of this cut depends on how much work your neck requires. The more lifting needed in the neck, the longer that incision will be, although it is rarely longer than a few cm. I avoid the traditional facelift incision into the hairline above the ear as this causes the sideburn to displace upwards, a stigma of surgery. The incision that I use is depicted below. It is a short scar facelift incision.
Day 5 after surgery showing the typical scar of facelift.
Once the incision is made, the skin is elevated as required to expose the SMAS layer, the superficial musculo-aponeuritic system, a fibro-muscular layer. For longevity of the procedure it is important to elevate the SMAS layer. There are a number of ways of doing this including SMAS flaps, SMASectomy (cutting out a piece) and SMAS plication. Studies in our peer review scientific literature (patients get one technique on one side and another on the other, or different procedures are done in identical twins) show no difference between methods. I therefore opt for the simplest and safest method which is SMAS plication. The SMAS is elevated and sutured to itself. This avoids exposure of the facial nerve (facial nerve damage can lead to stroke like paralysis of the face) and creates volume in the cheekbone area which is desirable. SMAS plication allows me to vary the vectors of pull to suit individual patient requirements. I have tried many other techniques in the past including the MACS lift, but what I do seems most logical to me and has given me the best results. It is a well-described technique.
Following the SMAS plication, the skin is elevated and redraped, the excess removed and the incisions sutured with dissolving sutures.
Dressings will be applied in the theatre. These consist of small pieces of micropore tape where incisions will have been made for liposuction and fat grafting. These incisions will be practically healed by the time the tape falls off. Micropore tape will also be applied to the facelift cut and a light absorbent dressing applied around your head. You will be transferred to the ward where you will recover under the care of my nurses. These are the same nurses who have been with you in theatre so they understand what has been done and how to care for you. You will be given medication for pain although there is not much pain from facial rejuvenation surgery. Once we are satisfied with your recovery you can be discharged from the clinic, usually mid to later afternoon.
At home you should rest. You should not move about too much and when you do move you should move slowly. From bed, gently sit up and it is best to have assistance if you walk around. Avoid bending, lifting and exercise. Voice rest is a good idea – don’t talk too much – and eat soft food rather than food which requires a lot of chewing.
The first follow up will be done 1-3 days after surgery. The bandage will be removed, but the tapes left on. At this point you will be bruised and swollen, although the degree of bruising and swelling varies considerably between patients. A facial support band will be given to you for you to wear most of the time for the next week. You can remove the band when lying down. After this follow up visit and removal of the dressing, you can wash your hair. Along with the bruising and swelling, your face will feel tight and mouth opening may be difficult. You will want to be eating soft foods for the initial period after surgery. I will see you every few days initially for check ups.
The bruising and swelling will peak at between 3-6 days and mostly resolve by about 2-3 weeks. I will recommend manual lymphatic drainage (MLD) to help recovery. There is a salon near my practice where this is done (patients love this and Danielli who does it). Around 10 days to 2 weeks after surgery you will be presentable although your face will still be a little swollen. Out of town patients should plan about a two and half to three week stay in Cape Town so that they can recover under my care.
Gentle exercise can be started 4-6 weeks after surgery and can be increased in intensity as you feel better. You should be able to drive a week after surgery. You can see the hairdresser, if you want, from about 2-3 weeks post-op. The recovery from facial rejuvenation is likely to take longer than you expect it will. It takes about a month for the nerves to start growing and then they grow slowly at about 1 mm per day (an inch a month). Full recovery of sensation can take 4-6 months and can be preceeded by odd facial sensations (insects under the skin, pricking, pins and needles, numbness). Little lumps or bumps, contour irregularities, grooves and so on will settle over time and this can also take several months. Gentle massage is useful to help lumps settle. For a clean incision, at the time of surgery, a small amount of hair is shaved away in the sideburn area. This will regrow.
Having a facial rejuvenation can also affect you more than you expect emotionally. Be prepared for this and expect it. It is normal to experience doubts and to find fault with how things look afterwards. Minor imperfections will seem major, but these will settle over the next few months.
Risks and Complications
All surgery carries the potential for risks and the possibility of complications. Risks, however are low and complications are rare. Minor complications are more common than major complications. If a complication occurs then my policy is to aggressively manage it. This may not need surgery, but certainly I will want to see you more frequently to ensure that your recovery goes as smoothly as possible.
Complications of facelift:
- Anaesthetic related problems. All surgery and anaesthesia carry a risk. The risk is probably equivalent to flying in an aeroplane.
- Bleeding. The risk of bleeding is around 1-2%. A bleed into your face may require surgery to drain it and to stop the bleeding source. This would require an additional operation (possible additional expense).
- Infection. Not a common problem due to the good vascularity of the face, but, nevertheless infection can occur. Infection can set you on the path to wound healing problems. Minor infections can be treated with antibiotics. More major infections may require surgical intervention.
- Wound healing problems: either impairment or delay. Slow or deficient wound healing (made worse by smoking) can result in skin or tissue loss and require dressings for a prolonged period of time to allow healing.
- Skin loss or other tissue loss. This can present as an area mottled redness or a purple discolouration, usually situated near the scar. It can form a scab or even go black. Most skin loss will heal over time with dressings.
- Suture abscesses. The skin is closed with dissolving sutures. The inflammation necessary to cause the sutures to dissolve can result in the formation of small pustules. If the pustule is opened a suture may be seen or felt and removal of this suture usually ends the problem.
- Nerve damage. The nerves are of two types: sensory nerves convey information about touch, pressure, pain, temperature to your brain; motor nerves convey messages from your brain to your muscles and injury to motor nerves results in weakness or paralysis, in other words like a stroke. Sensory nerves to the cheek are invariably injured during facelift. It will feel as if you are being touched through plastic or similar. Over a period of months, this is likely to improve. The commonest nerve injured in facelift is the nerve which supplies sensation to the earlobe. Injury to this nerve will cause your earlobe to be numb. The two commonest motor nerves injured are the branches to the eyebrows and forehead and the branches to the mouth. Injury here is likely to be temporary, usually not lasting longer than a few days or weeks, although rarely it can be permanent.
- Scars. How well you scar is largely a function of your skin type. I will suture you up as best I can, but some people do form bad scars. In the early part of the healing process, the scars will be red and raised, but after a few weeks this will settle down. Scars with too much tension on them can stretch.
- Cosmetic result. Perfection is rarely achieved. It is likely that there will be some residual neck sagging or jowling, especially over time. The neck tends to be the primary point of failure in time with recurrence of platysmal bands.
- Asymmetry is almost a guarantee. Almost everyone has an asymmetrical face with one seed being longer and thinner while the other side is shorter and squater. Most people have a good side. When operating on two sides of the body, as with facelift, it is normal for one side to heal faster, one side to be more bruised and swollen and it is normal for the two sides to be slightly different.
- Hardness, lumpiness, contour irregularities. These can occur probably due to small bleeds under the skin or depressions created by the deep sutures in the SMAS layer under the skin. Hardness and lumpiness will soften in time, facilitated by gentle massage in an upwards direction. Lumpiness and asymmetry from fat grafting can occur due to unequal take and resorption of fat. Correction may be achievable through a repeat fat graft or other procedure.
- Tightness. A feeling of tightness is not uncommon following facelift. This can make eating, smiling, talking, etc. difficult. Tightness will pass over days and weeks.
- Prior to surgery you are healthy, but surgery induces the sick state – you will be sore, bruised, swollen and not look like yourself. You may not be able to go out for a week or two. These changes can affect some patient’s moods and they can become depressed post-operatively. This is not usually long lasting.
The results from facial rejuvenation can be very satisfactory. On average the clock can be taken back 5 to 20 years, but the aging process is not halted. Maintenance with botulinum toxin, fillers and revision fat grafting is useful to maintain a more youthful look.
Facial rejuvenation is one of my favourite procedures. I like the creativity that goes with it and I like the results that I see when I find the beauty revealed again in a patient’s face.
“I had my consultation. I was made to feel very comfortable and everything was described to me with great detail. I was very impressed and will be having a facelift in March done by Dr Lazarus.”
13 December 2016.
Actually underwent surgery, January 2017
Just wanted to drop a quick line to say thank you so much for all your help and your patience with me!
Back home in a not so warm England, missing the warmth already. Was very impressed with the service provided by yourself and Dr Lazarus and not only will visit again but will recommend to my colleagues and friends.
I know from my own industry people are quick to complain but not so much to compliment so thought I would just say how happy I am and once again thank you!
Dear Dr Lazarus,
I wanted to say that you are amazing! My face is beginning to settle down nicely.
The best thing is the comments I have received from some of my colleagues. One said, ‘Your face is unbelievable. The surgery must have been very advanced.’ Another person said, ‘Oh My ***, you look so YOUNG … I am shocked!
I will send you a photo but it is not a close up just a normal one to give you an idea. I am wearing a little concealer. I will send you close ups soon.
I wanted to email you to say thank you for giving me back, perhaps more than 15 years.