Is There A Best Time To Have A Facelift
The Importance of Knowing the Correct Timing
Most women these days are aware that having facial rejuvenation surgery can significantly help their appearance. Most often, surgery is deferred due to the natural reluctance to go through surgery for understandable reasons, at least until a significant loss of freshness of appearance makes it become a pressing issue. Having the correct answer to this key question about timing is important. Otherwise it is likely to result in an, all too common, mistake.
Almost half the women who come to me for help with their tired facial appearance have missed the ideal time to benefit the most from their facelift surgery. They are usually disappointed on hearing this, as they had thought they had been virtuous in waiting so long! They had assumed they were doing the correct thing by ‘waiting’ at least until they were in their mid fifties before consulting a plastic surgeon. Their usual response is ‘if only someone had told me’.
The ideal time to be considering a facelift is when you are becoming aware of early laxity of your face. This early laxity is first noticed only when the head is tilted down or when you press the skin along the jawline or inner cheek, and it moves more than it used to! At this stage the laxity is still not so obvious as to be noticed by others, especially in normal head position ie, with the chin up. This is what I term, Latent laxity.
Ideally this laxity should be corrected before it has progressed to become obvious laxity, from which there is no escaping. The typical comment heard from a patient in the plastic surgeon’s office is a woman of between 45 and 50 years (in men it is typically older) who expresses their concern: ‘I can’t believe how rapidly my face is aging. This jowl has only appeared in the last 6 months’.
Some others are even more distressed, ‘I have always been fortunate to be one of those people who look young for my age, but now over the last 6 months age has caught up with me as I have aged by several years “. They are quite frightened to see their identity slipping away.
This is the typical experience, of appearing to age suddenly after several years of latent laxity. Ideally, this unpleasant experience can be avoided, by having a corrective facelift at the right time, which is, before the latent laxity becomes apparent. The experience of aging almost overnight, is like the appearance of your first grey hair, there is no going back.
The transition from latent to obvious laxity tends to be accelerated by illness and long term stress, often to do with a family member or relationship difficulty, and particularly by weight loss. The worsening laxity is extremely disappointing for those people who are doing the correct thing to regain control of their figure only to find they are paying for it on their face. Losing 5 kg adds a couple of years to a persons facial age when they are in the latent laxity phase.
With the quality of facelifts available, they should be taken advantage of, but in a well considered prospective manner, using a correct strategy.
The correction of latent laxity is undetectable, with a quality facelift.
This is for two reasons,
1).Correct timing, ie. before it is obvious.
2).Correct surgery. Quality facelifts avoid the obvious facelift look as they do not pull the skin directly, instead they tighten the internal support structure of the face. This also slows the rate of future aging, by delaying the onset of obvious laxity for a further decade.
Look out for these related blogs.
- The advantages of a quality facelift.
- How does a proper facelift slow facial aging?
- How you can recover from a late facelift.
- The downside of using fillers on your face.
- The upside of permanent fillers.
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/12000694
Article in Plastic & Reconstructive Surgery · June 2001
Centre for Facial Plastic Surgery 111 PUBLICATIONS 2,987 CITATIONS
Some of the authors of this publication are also working on these related projects:
complete project on Breast Reconstruction View project
All content following this page was uploaded by Bryan C Mendelson on 11 July 2018.
The user has requested enhancement of the downloaded file.
Surgery of the Superficial Musculoaponeurotic
System: Principles of Release, Vectors, and
Bryan C. Mendelson, F.R.C.S.E., F.R.A.C.S., F.A.C.S.
The SMAS was described more than 25 years ago, yet its full potential in
ªIf you understand something in only one way, then you do not really understand it at all.º
ÐMarvin Minsky, Society of the Mind, 1987
The essence of most rejuvenation surgery of the face and brow is to mobilize the lax and ptotic tissue (skin based flap with a varying depth of the underlying tissue) and then ad- vance that flap to a somewhat higher position relative to the facial skeleton. The question of ªpreferred direction of liftº is still discussed, although current teaching favors a strong ver- tical lift for best correction. Of necessity, with limited access surgery, vertical traction is all that is possible.
The inclusion of the superficial musculoapo- neurotic system (SMAS) has been the most fundamental change in technique since the beginning of
problems that have only gradually become understood.
Chief among these was that, although the basic anatomy of the SMAS (the deeper layer of the superficial fascia of the face) was well described at the outset, other most relevant anatomy was not. Particularly significant is the anatomy of the ligamentous attachments be- tween the SMAS and the facial skeleton.3±5 The
In the 25 years since the introduction of the superficial fascia into
Received for publication September 19, 2000; revised November 6, 2000.
Presented in part at the 4th Annual Dallas Aesthetic Surgery Symposium, in Dallas, Texas, on March 6, 2000, and at the Annual Scientific Conference of the Australasian Society of Aesthetic Plastic Surgery, Sanctuary Cove, Australia, on July 10, 2000.
The discussion that follows is a synthesis of empiric observation and established fact. It covers the related topics of extent of release required, vectors of lift, and principles of fixation.
The matter of ªthe extent of surgical release requiredº continues to engage the mind of aesthetic plastic surgeons. When face lifts are performed at the subcutaneous and subperios- teal levels, this is a relatively simple matter, as these
The effect of complete surgical release of the deep ligamentous fixation of the SMAS in the vicinity of the area requiring correction is to
PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001
reduce the resistance of the tissues so that when traction is applied to this area the flap readily moves. Movement ceases when a new equilibrium is reached, i.e., when the laxity has been taken up and the resistance of the tissues again increases to equal the tension force ap- plied (Fig. 1, left and second from left).
Accordingly, the extent of undermining re- quired in SMAS flap surgery is the minimal amount necessary to enable a
In some situations, the application of a trac- tion force to an incompletely released SMAS flap may cause a distortion. If there is a resis- tance to movement that is greater in one direc- tion than another, the magnitude of displace-
FIG. 1. (Left) Force diagram showing that an equilibrium exists when the force of traction applied to the force point (white circle) is not greater than the force of resistance provided by the tissues. (Second from left) Reduction of tissue resistance by release of the immediate retaining ligaments allows displacement of the force point in the direction of the traction force. Displacement continues until a new equilibrium is reached between the traction force and the increasing tissue resistance. (Second from right) Traction force applied in the presence of resistance
Vol. 107, No. 6 / SURGERY OF THE SMAS
ment no longer relates just to the applied force and the angle of traction as an additional fac- tor comes into play, i.e., rotation of the flap around the point of remaining fixation. The flap does not advance in the direction of the applied force and to the extent expected. Rather, there is an angular displacement such that there may be excessive movement of the flap in the ªwrongº direction relative to the limited movement in the intended direction (Fig. 1, right). A classic example of this distor- tion is the lateral sweep of the cheek.10 This undesirable sequela of face lifts can result from SMAS flap surgery when the anterior masseteric- cutaneous ligaments remain intact and block the intended vertical displacement of the mid- cheek. Instead, the more mobile lower part of the flap along the jaw line rotates around the lowest of these ligaments and is displaced pos- teriorly (Fig. 2).
A similar situation is prone to occur around the lateral canthus when vertical traction is applied to the suborbicularis oculi fascia in this area. If the resistance inferolateral to the force point has been released but the medial restric- tion persists (due to the orbicularis retaining ligament remaining intact), an oblique fold of the flap may result. The outer part of the lower lid remains uncorrected until the restriction to mobility imposed by the resistance of that lig- ament has been released. These examples illus- trate a key principle of SMAS flap surgery that where there is a block between the force point and the area requiring correction, it is not possible for SMAS flap surgery to improve that area.
When SMAS flap surgery was introduced, it was not appreciated that there is a key func- tional differentiation of the cheek into two parts. The outer or lateral cheek (preauricu- lar) is separated from the medial cheek by an internal vertical ligamentous boundary. This boundary is located along the line formed by the angulation of the underlying facial skele- ton at the superior temporal line, the lateral orbital rim, and at the lateral border of the body of the zygoma. The key ligamentous at- tachments of the superficial fascia to the un- derlying skeleton occur along this line. The important muscles of facial expression are lo- cated medial to this line, and it is here where most of the facial aging occurs.5,11,12
As surgery of the SMAS was originally de- scribed, the release was restricted to the outer part of the face. Specifically, it did not release
FIG. 2. (Above) The lateral sweep deformity of the cheek that can occur in SMAS flap surgery, despite vertical traction. This outcome occurs from the failure to properly release the anterior
the vertical ligamentous boundary to allow an effect on the medial part of the cheek. The extended SMAS technique, which was a key evolution of SMAS surgery, continues the re- lease beyond this ligamentous line, i.e., it takes
up the release at the level at which it was dis- continued when performing the traditional SMAS release.13
VECTORS: BASIC PRINCIPLES
According to Oxford, vector is defined as a quantity having direction as well as magnitude, denoted by a line drawn from its original to its final position.
²When a force is applied in a particular di- rection (e.g., vertical) the result is maximal in that direction, but there is also an effect at an angle to the primary force (Fig. 3, left).
²If the force is applied at an angle to the vertical, the resultant effect has both a ver- tical and horizontal component (Fig. 3). This effect can be demonstrated by use of
PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001
FIG. 3. Classic
Vol. 107, No. 6 / SURGERY OF THE SMAS
The dermis of the face is attached to the facial skeleton by a multilink fibrous support system that comprises the retaining ligaments and the superficial fascia, which includes the SMAS and the retinacula cutis.11 A taut and intact retinacula cutis faithfully transmits the shape and movement of the superficial fascia to the skin. The function of the face imposes unique and conflicting requirements on its su- perficial fascia, namely the need for both fixa- tion and movement. The functions of facial expression demand precisely controlled move- ment such as occurs with lip control in articu- lation. To restrict the amount of movement to the degree intended and to the area of the face intended, stability of the tissues is required, which takes the form of the deeper fixation of the superficial fascia. An example of the local- ization of movement is the prevention of trac- tion on the lower lid when the muscles around the mouth contract. Strong fixation is also re- quired to resist the external forces of gravity and of traction, such as occurs in sleeping with the cheek buried in a pillow.
The anatomic pattern of ligamentous fixa- tion of the superficial fascia to the facial skel- eton defines boundaries that compartmental- ize the face into several regions (Fig. 4). Three of these are component parts of what is exter- nally visualized as the cheek, i.e., the lateral cheek and the prezygomatic and infrazygo- matic parts of the medial cheek, in addition to the other regions, the lower lid, lower temple,
FIG. 4. Regions of the face. Compartmentalization occurs from the pattern of ligamentous fixation of the superficial fascia to the periosteum and deep fascia. The boundary of each region is formed by a ligament.
upper lid, and forehead. The stabilizing effect that occurs at these ligamentous boundaries quarantines the movement resulting from mus- cle contraction within each region so that, at least in youth, movement does not transmit into the superficial fascia of adjacent areas. The ligamentous fixation has a shock absorber- like effect, which modulates the degree of tis- sue displacement upon muscle contraction.
The laxity that develops in the multilink fi- brous support system of the face is due to a progressive weakening of the supporting con- nective tissue. This presumably arises from the combination of intrinsic,
These events would account for the acceler- ation of the rate of aging changes commonly seen in a woman in about her
The direction of the weakening and of dis- placement of the connective tissues from repet-
FIG. 5. The displacement of soft tissue that occurs under the influence of gravity is conditional on laxity being present. The correction of laxity in the vector of displacement (seen here as taking the slack out of the chain) nullifies the apparent effect of gravity.
itive muscle shortening and stretching differs according to the configuration of each muscle (Fig. 6). For linear muscles, e.g., zygomaticus major and corrugator supercilii, the laxity tends to be parallel to the direction of short- ening of the muscle fibers. Whereas, for those muscles in which the fibers follow a curve, e.g., orbicularis oculi pars orbitalis and medial platysma, contraction of the muscle fibers causes a radial, or centripetal displacement force on the supporting connective tissue. Over time, medial platysma contraction even- tually pulls the supporting tissue away from the depth of the neck concavity. It is not the mus- cle contraction that changes over time but the laxity of the fascial support that allows the platysma banding. Similarly, the part of orbic- ularis oculi that courses over the temple even- tually becomes displaced toward the lateral canthus as a result of a weakening of its fibrous support, as does the part of orbicularis oculi that directly overlies the body of the zygoma. The action of orbicularis oris, the most power- ful muscle of facial expression, is the major
PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001
factor contributing to laxity of the medial cheek, which is the most mobile and least sup- ported part of the face. The tissue displace- ment is directed medially, but when laxity de- velops, it is held up at the nasolabial furrow.
There are multiple vectors of displacement in the aging face. This is because each of the muscles of facial expression has its own direc- tion of connective tissue laxity. The correction of each vector of displacement requires its own vector of fixation. Fortunately, use of the SMAS provides increased opportunities for control- ling the directions of lift. This situation is quite different from that in subcutaneous and sub- periosteal flap surgery in which a single, mostly vertical, vector is used. Once the retaining lig- aments have been fully released, several ana- tomic regions have been entered into and have become as one. With the original, limited re- lease SMAS surgery, it was considered to be an advantage to have two vectors; one direction for the SMAS, and a different vector for the skin flap.15 When a properly released SMAS flap is used, multiple vectors are possible.16,17 The use of multiple vectors enables the appro- priate vectors of correction for each region of the face.
If strong, nonabsorbable sutures are used for the surgical fixation, what is effectively being performed is a replication of the original type of ligamentous fixation akin to that in joint surgery.17 These sutures can hold a substantial,
The sutures into the SMAS flap need not be restricted to the cut edge of the flap. With the