The Facelift Dilemma: I know Why You Regret Last Facelifting! 

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As the demand for anti-aging procedures increases, people are becoming more familiar with various facial rejuvenation options such as InMode^®, Ultherapy^®, mini lift, and traditional facelift surgery. However, there are many misconceptions due to exaggerated advertising claims, making it difficult for patients to understand what is needed for a successful outcome. In this article, we will compare conventional facelift, mini facelift, and thread lift to provide valuable insight into choosing the right rejuvenation procedure.

FAQ

1. The Goal of Facelift in Aesthetic Surgery

Face lift surgery aims to improve the central and lower portions of the face, including the jawline, jowl, and nasolabial folds.

This surgery has a long history, dating back over 100 years, and has evolved into three main types nowadays in Korea.

2. Current Facial Rejuvenation Surgery: Conventional Facelift, Thread lift, and Mini facelift

1) Conventional Facelift (Extended or High SMAS facelift)

The procedure involves a long U-shaped incision from the front to the back of the ear. Although the operation is time-consuming, it is one of the few that can effectively treat multiple areas of the face when performed correctly. However, from a practitioner’s perspective, the steep learning curve makes it challenging to achieve the desired outcome. The Conventional Facelift can also improve the appearance of the neck, as detailed in the document Plastic Surgery for Neck Wrinkles. The detailed signs of a bad facelift will be discussed here.

2) Thread lifting

Using thread in lifting procedure is a less invasive procedure with a quicker recovery time. It became popular in recent years due to advancements in thread manufacturing technology.
The advantage of this procedure is that it requires minimal to no incisions, and patients can return to work after just three days of rest. However, the effects are temporary compared to the traditional facelift, and ongoing research is being conducted to improve the outcome.

3) Mini facelift (Short scar facelift)

Short-scar facelifts have gained popularity due to the promise of a shorter incision and reduced operation time. However, this technique has met with skepticism from experienced rejuvenation surgeons for several reasons.

• Firstly, the scars associated with the short-scar facelift are not much shorter than those seen with traditional techniques.
• Secondly, the short-scar techniques are less effective at providing optimal rejuvenation, with short-lived results.
• Lastly, it can be problematic in many cases. The short incision can lead to tissue gathering, puckering, and skin bunching along the incision site, especially in the temple and post-ear regions. This bunching can be concealed to some extent by women with longer hairstyles but is a source of embarrassment for men.

As a result, more research is needed to determine the reliability of this technique. Some surgeons offer a modified approach, combining mini-lift and thread lifting, but the specific procedure may vary.

3. Key Factor for Effective Anti-Aging Treatment

As discussed in my other article, signs of aging show in all areas of the face, including skin, fat, muscles, and bones. To improve the signs of aging, the following steps are crucial:

• Fill the depressed area (fat grafting)
• Lift sagging tissue upward (dissect and lift attached tissue)
• Remove excess skin (redundant tissue resection)

We will delve further into the second step, dissecting and lifting, in this article.

4. Reason why minimally invasive procedures last short: Facial Retaining Ligaments

Facial retaining ligaments play a crucial role in maintaining the shape of our face. These ligaments, which appear white in the upper photo, help prevent skin and muscle tissue from sagging due to gravity and aging. However, not all areas of the face have the same amount of these ligaments. As we age, weak areas are more susceptible to droop, leading to jowls or nasolabial folds.
To lift the droopy area, the ligament needs to be cut to move the tissue upwards. Unfortunately, a thread lift can’t sever these ligaments, leading to a temporary result.

Pulling the tissue without cutting these ligaments will not effectively lift the sagging tissue.

5. The 4 pitfall of Mini-Face lifts: A Critical Assessment

The idea of the mini facelift, which promises to lift a large area through a small incision, sounds appealing. But, in reality, the results often fall short of expectations. Think of it like this: if you had a bag of coins and a needle and needed to get 67 cents out, would you rather open the bag wide and find the coins or try to find them through a small hole by feeling around? Just like finding coins through a small hole is harder, mini face lifts also face several challenges:

1) Small incision makes a limited surgical view, resulting less tissue movement

Patients looking for surgical rejuvenation are mostly concerned with improving the central part of their face. But the small incision of a mini facelift restricts the view, making it difficult to cut the medial retaining ligament properly and causing less tissue movement in the midface. It also increases the risk of nerve damage and limits the procedure’s ability to improve midface ptosis.

2) Making SMAS effects in doubt

The limited view makes it challenging to use a SMAS flap effectively. The less visual field can make SMAS flap a higher risk of tearing or injury to the structures beneath the SMAS.

3) Inappropriate lifting direction

The mini facelift’s direction of lax skin pull can’t treat sagging skin appropriately. The small incision tends to shift the skin in a vertical direction, which can cause deep cervical wrinkles to move from the neck to the lower face. This problem doesn’t occur when a posterior ear incision is used and the skin is shifted in a more backward direction.

4) Puckering and pleating along incision line

If the incision is long enough, there’s room for proper tailoring. However, if it’s too short and there’s a gap between the upper and lower incisions, the skin will bunch and pucker along the incision line. This can be concealed to some extent by women with longer hairstyles but can be a source of embarrassment for men.

6. Who is a Good Candidate for Mini Face lift or Thread Lifting?

Short-scar face lifts or thread lift can benefit patients with minimal aging signs. Age mid 30’s to 40’s might be a proper candidate. This age has more options for the minimally-invasive procedure like Ulthera®, Thermage®, and InMode®. And doctors must continue to study and refine these procedures to deliver better outcomes.

7. Where Should the Incision for a Face lift be Made?

The facelift incision can be divided into three parts: the temple, front of the ear, and back of the ear to the hairline.

1) Temple area: Within the hairline vs. Along the hairline

A) Within the hairline

Traditionally, the temple area incision for facelift has been within the hairline, to hide the scar in the hair. This option is suitable for young patients with minimal skin laxity. However, this incision can lead to the loss of sideburns for patients with significant skin laxity. Besides, the distance from the side of one’s eye to the temple hairline will be increased. These changes will appear strange, unattractive, and a telltale sign of a poorly designed face lift with an operated appearance.

B) Along the hairline

On the other hand, an incision along the hairline can accommodate the necessary skin shifts for optimum correction of the upper and lateral face, without distorting the hairline or sideburns. This incision is recommended for moderate to severe aging patients and men with sideburns. The downside of this technique is noticeable scarring if the doctor is less skilled. Detailed surgeons can minimize these risks by beveling the surgical blade and using half-buried mattress sutures.

Unfortunately, errors in incision placement and objectionable shifting of the hair will last longer than any improvement achieved by the face lift, and great care must be taken in incision placement and planning of the face lift to prevent these untoward results.

Quote from: Longevity of SMAS facial rejuvenation and support. by Bruce Connell

2) Front of the ear: Pretragus vs. Marginal(retro-tragal)

The pre-auricular region is a noticeable indication for a facelifted face. Therefore, there had been disagreement about where the incision should be placed near the ear during facelift surgery. The most common problems associated with facelifts include three:

• Visible scars in front of the ear,
• deformities in the tragus (rectangular cartilage that sits just anterior to the external auditory meatus), and
• deformities in the earlobe.

But nowadays, facelift specialists have no doubt that retro-tragal (more accurately, marginal) incisions are a far more better option. So, a world-renowned facelift master says,

“Invisible scars in front of the ear are the hallmark of how well a surgeon can perform a face lift.”

Timothy Marten

A) The pre-tragal incision

• pros : easy to perform and maintains tragus shape,
• cons : scars are more noticeable.

B) The marginal incision

• pros : The advantage of hidden scars, so a mismatch of color, texture, or surface irregularities between the tragus and cheek skin will not be a problem. With careful observation, the scar will seem to be a light reflex of the ear cartilage margin.
• cons : There is a risk of tragus deformation if the incision placement and skin tension are improper. The basic concept of Z-plasty should be applied to preserve tragal shape.

3) Back of the ear: Along the hairline

For the posterior side of the ear, the incision can either be within the hairline or along the hairline. In the past, incisions within the hairline were common among surgeons. However, incisions along the hairline are now preferred for better tissue movement. The height of the incision should be raised to the helix-hairline touch point named by Dr. Feldman.

8. What is SMAS? 

If you are thinking about a facelift, you may have heard the word ‘SMAS.’ SMAS stands for Superficial Musculoaponeurotic System and was first introduced by French doctors Vladimir Mitz and Martine Peyronie in 1976. It is the central concept for modern facelift surgery. The SMAS flap is a layer of tissue that is created by the surgeon during a facelift procedure. It consists of muscle, fat, and fibrous tissues. According to Dr. Mendelson, this structure is located in the third layer of the face, which consists of five layers from the superficial surface.

9. Why SMAS Facelifting? 

There are various types of facelift procedures. SMAS facelift involves lifting the deep tissue (SMAS) underneath the skin. This deep layer is a better option than only lifting the skin layer, as it has a longer-lasting effect and reduces the risk of scarring. The tension during skin suturing can be reduced, resulting in less visible scars. However, creating a successful SMAS flap requires expertise. If you are considering SMAS facelift, check the following during the consultation: thickness, size, direction, and fixation.

10. Checklist for SMAS Facelift

1) Skin Flap Thickness: Must be Thin

Lifting is an operation that lifts saggy tissue against gravity. And SMAS must be thick and robust to support the structure for long-lasting good results. The skin flap must be dissected as thin as possible for optimal results.
SMAS flap facelift by unskillful surgeons share some common thoughts: They find SMAS to be thin and not substantial enough to have any structural or lifting value. The problem they have encountered is that they have raised the SMAS while elevating the skin flap. The separation of the face into multi-layer is critical to the SMAS facelift because the skin and SMAS must be repositioned in different directions. Therefore, while seemingly simple, elevating the skin flap is one of the most critical steps in the whole procedure. Raising the skin flap should be done deliberately and under direct vision; in mini-lift, it is done blindly.

However, the thickness may vary based on the patient’s medical history, such as hypertension, diabetes, smoking, and previous procedures like Ulthera® or Thermage®. In some cases, an effective SMAS flap may not be possible in revision surgery, so it’s important to carefully assess the patient before deciding on the surgery method and timing.

2) Endpoint of sub-SMAS dissection: until the retaining ligaments are released

The retaining ligaments that hold the SMAS in place must be released during the surgery. However, caution must be exercised as underneath the SMAS layer contains vital structures such as facial nerves and salivary glands. Facial expressions are modulated by this motor nerve, which runs from deep to superficial when it passes medial to the masseter muscle.

As the dissection goes more medial;

• SMAS can be torn as it usually gets thinner as it goes forward,
• The risk of nerve damage increases,
• The dissection procedure gets more complicated as the face is not flat.

Therefore, the extent of the SMAS dissection must be decided considering the patient’s needs and facial features to achieve meaningful results while avoiding nerve damage.

3) Direction of Pull

A bi-lamellar facelift, which dissects the face in two planes, is a technique that lifts the skin layer thinly and elevates the SMAS flap. The reason for bi-lamellar dissection instead of lifting them as an en bloc has two advantages: the pulling vector’s diversity and the pulling amount. Therefore, the direction and amounts should be discussed with doctors based on the patient’s goals.

4) Fixing point

One can imagine the lifting results better if you pulled the SMAS flap more from the medial side. But scientific evidence shows that the SMAS on the lateral side is more robust: the creep appears lower, and bursting strength is higher than on the medial. (Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System). Therefore, the flap should be designed where the SMAS has the best strength.

11. Conclusion

Facelift surgery is a procedure with a long history and various methods. Each doctor may have different techniques that impact the results. The #1 most growing plastic surgery in Korea for recent 10 years are facial rejuvenation procedures like facelift, thread lift, and mini facelift.
In a field saturated with heavily marketed “light lifts” and “lunchtime facelifts,” it’s essential to have thoughtful and quality information about facelift surgery; these largely advertised quick procedures often produce poor results with subpar scarring and short-lived outcomes. Patients should be educated to make informed decisions and achieve satisfactory results. I hope this article will help.