Radical Face Lift Surgery: A Plea for Caution

Abstract

The goal of any face lift technique should be to produce predictable and consistent results with limited morbidity. Patients should be able to return to society within 5 days and return to most occupations and activities within 2 weeks, provided that these do not involve strenuous face and neck muscle activity or depend on head and neck position.

The vast majority of articles in the current literature describe radical face lift procedures. Yet there is no evidence to date that radical procedures produce a superior or a more lasting improvement compared with standard methods. What is known is that radical procedures, such as mid-face lifts and deep-plane or composite face lifts, increase the potential for complications and increase morbidity.

Midface lifts

• Increase the rate and severity of ectropion

• Produce lateral canthal distortion

• Risk the integrity of the middle division of the facial nerve

• May produce lateral cheek gathering and distortion

• May result in midface widening

• May result in deep cheek-fat necrosis leading to secondary depressions or dimpling

Simon Fredricks, MD, Houston, TX, is a board-certified plastic surgeon and an ASAPS member.

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Deep-plane or composite face lifts

• Increase the incidence of facial nerve injury and paralysis

• Produce prolonged morbidity with edema for up to 6 months

• Prolong postoperative recovery

For all these reasons, most plastic surgeons have avoided these radical procedures. They prefer to perform conservative, safe procedures with low morbidity.

The advocates of radical face lift procedures have acknowledged that a steep learning curve exists in performing these procedures properly. How does one select those patients on whom to perform surgery during the high-risk “learning curve” period? What is our ethical responsibility to those patients? There is no magical superior skill that permits one well-trained surgeon to perform these techniques better than another. Clearly, advocates of these radical approaches have gone past the dangerous learning curve and still acknowledge the increased risk involved in every such procedure. How do they justify this increased risk? Do the radical face lift techniques produce a consistently superior result, and do the results last longer?

Most standard face lift techniques will restore the appearance that the patient had 7 to 10 years earlier (Figures 1 and 2). In addition, no further surgical procedure should be necessary for most patients for the following 7 to 10 years except for surface skin enhancement.

Figure 1.

A, C, Preoperative views of a 40-year-old woman demonstrate the surgical challenges presented by a “moon” face. B, D, Postoperative views 3 months after standard face lift procedure, chin implant, bicoronal brow lift, and 4-lid blepharoplasty.

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Figure 2.

A, C, Preoperative views of a 63-year-old woman with severe skin redundancy and solar damage. B, D, Postoperative views 6 months after standard face lift, bicoronal brow lift, 4-lid blepharoplasty, and a staged phenol peel.

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The following techniques should accomplish a gratifying result while meeting the criteria of predictability, consistency, and low morbidity:

• Undermining should reach the anterior border of the parotid in the cheek. Furthermore, undermining in the neck should extend completely across the midline to facilitate satisfactory redraping.

• Fat must be excised to resculpture the facial and neck contour. Repositioning by mobilization and reefing may be required. Repositioning is mandatory in the cheek and jowl area to define the jaw line, increase the malar prominence, and eradicate the submalar hollowing caused by descent of the cheek fat. Precise defatting of the neck under direct vision and fiberoptic illumination results in the best possible neck contouring.

• Once the platysma has been cleanly exposed, tightening of the muscle is mandatory. This is accomplished by suturing the 2 anterior borders in the midline. If one border is significantly thicker than the other, it should be excised before suturing. I also prefer to incise the anterior platysmal borders, perpendicular to the border at the level of the hyoid, to lengthen them. Once the midline repair is accomplished, lateral platys-mal suturing recreates the sling of the neck. This lateral platysmal suturing to the mastoid fascia will improve the protrusion of the ptotic submaxillary gland. Chin augmentation should be considered preoperatively. Implantation is easily accomplished via the submental defatting incision.

• If the SMAS is of sufficient strength and quality, it should be undermined no further than the anterior border of the parotid and elevated in a posterosuperior direction by suturing. Alternatively, a limited lateral excision of the SMAS followed by posterosuperior repositioning may be done. In men the repositioning of the SMAS is best accomplished in a vertical rather than oblique direction. If not, a bizarre, effeminate appearance will result. Malar augmentation without implants can be accomplished by folding over the fat and SMAS, mobilized from below back upon itself, and then suturing.

Radical face lift procedures certainly have a place in the armamentarium of surgery for the aging face. Patients with deep tear troughs and a sad look will be most improved by a midface lift. A patient with recognized small vessel disease, in whom circulation compromise is a concern, is best handled by a deep-plane or composite lift. However, for most patients, I consider the standard face lift to be the procedure of choice. It provides a predictable and consistent 7- to 10-year improvement with the lowest risk and least morbidity.

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