The Evolution From Traditional to Contemporary Techniques

The history of facelifts is greater than one hundred years. Many facelift techniques have been developed. Some techniques have become widely adopted. Other techniques have fallen out of favor and been forgotten. Those procedures that have endured reflect improvements in our understanding of facial anatomy.

History of Facelift Surgery: Overall Trends

The overall trend has been:

• An increase in the depth of the lift, i.e., deep plane facelift surgery
• An expansion of the area lifted from the face to the lateral neck, i.e., extended deep plane facelift

The Earliest Techniques Involved the Excision of Ellipses of Skin

Some of the earliest facial surgery techniques involved removing ellipses of skin from the hairline and pulling the remaining skin, thereby hiding the incisions in the hairline. These techniques were quick to perform and were often performed under local anesthesia only. The problems with them were significant, however. The problems were related to the significant tension placed on the skin closure, including:

• Distortions of the facial anatomy, including, but not limited to, the mouth
• Increased risk of abnormal scarring
• Increased risk of infection

Skin is more likely to heal poorly when placed under a lot of tension. Results are more likely to appear unnatural as well.

The Peri-Auricular Incision Revolutionized Facelifting

The area where the skin was lifted gradually expanded across the face and neck. By the mid-twentieth century, a long incision hidden around the ears gave surgeons greater access to lift the skin off the face and neck. In fact, this peri-auricular incision is very similar to the most common incision performed for these procedures today. Sutures were often placed through the deep tissue around the jowls to lift them. There was little understanding of the makeup of this deep tissue. The skin was pulled tight, secured to the peri-auricular incision, and skin was removed. This approach risked not only poor healing at the incision sites (e.g., infection, abnormal scarring, ischemia, and necrosis of the skin) but also stretching the skin too much in an abnormal direction. This can lead to a pulled or windswept look. Furthermore, when skin is placed under significant tension, it risks stretching out worse than prior to surgery due to a feature called biological creep.

The Discovery and Characterization of the SMAS Layer Improved Results

Surgeons then began to understand the importance of the deeper tissues in the face, specifically the platysmal muscle and the Superficial Musculoaponeurotic System (SMAS), and how their weakening and sagging contribute to age-related changes in the face. This led to the development of a broad category of facelift surgery called the SMASectomy. Skin is still lifted widely and pulled tight like older approaches. However, now an incision is made through the SMAS, and stitches are used to pull on this layer to lift the jowls. This improved the effectiveness and longevity of the procedure. However, important problems with this approach remained:

• The skin is still treated the same way as the previously described procedures, with all of its potential problems and limitations
• Because there is no SMAS layer in the upper cheeks, a mid-face cheek lift cannot be accomplished with this technique.
• It is because the SMASectomy approach cannot lift cheek fat that one sometimes sees individuals who are over-filled with facial fat grafting procedures to make up for this limitation.

Deep Plane Surgery Helps Address Many of the Problems with the Above Traditional Approaches to Facelifts

The above realizations lead to the development of deep plane facelift surgery, with the differences as discussed in a previous blog post. Deep plane facelift surgery and its improvements have, over its approximately 35-year history in the medical literature, become the gold-standard approach to facelift surgery (for a technical overview, see this peer-reviewed review of the evolution of rhytidectomy).

Conclusion

To learn more about contemporary techniques or whether an extended deep plane approach is appropriate for your goals, please contact our office.