To understand the present-day rhytidectomy procedure, the surgeon must have full knowledge not only of the underlying surgical anatomy but also of the aging physiology of the face, which leads patients to seek rejuvenation surgery. In general, the aging face presents five landmarks that are points of interest to patients and surgeons alike. These areas include (a) the jowl, (b) the deepened nasolabial folds and lateral perioral jowling, (c) the platysma banding and submental fullness in the neck region, (d) the orbicularis oculi and malar fat pad ptosis, and (e) the aging skin itself (Fig. 188.1A).

In youth, the facial skin is maintained in normal anatomic position by retaining “ligaments” that run from deep facial structures to the dermis itself (4). With aging, attenuation of these “ligamentous” supports then results in malar soft tissue descent. The result of this descent is not only deepening of the melolabial folds but also jowling of the platysma and soft tissue between the masseteric and mandibular ligaments at the jawline. Moreover, this descent of the malar fat pad along with ptosis of the orbicularis oculi also results in hollowing in the infraorbital region. Finally, loss of platysma muscle tone results in anterior banding and the classically pictured “turkey gobbler” neck (5) (Fig. 188.1B).

Separate from the described underlying soft tissue changes, the surgeon must note the cumulative effects of the inherent aging process coupled with the effects of environmental exposure on the skin itself. While a comprehensive review of the changes associated with aging skin is beyond the scope of this chapter, it is important for the surgeon to have a fundamental understanding of
these changes. In this regard, it is convenient to think of skin aging in terms of extrinsic and intrinsic factors, affecting both the epidermis and the dermis (6). Extrinsic factors refer to environmental insults such as sun-induced damage (photodamage). Intrinsic aging refers to the natural effects of time and is generally characterized by tissue atrophy and descent and reduction in skin cellular and protein components. In fact, chronologically aged skin has reduced epidermal thickness, flattening of the dermal-epidermal junction, atrophy of the dermis, and a general decline in a variety of cell populations including melanocytes and Langerhans cells (7). This epidermal thinning then makes the skin more susceptible to damage from shearing-type forces (6). Moreover, Yousif and Mendelson (8) showed how habitual facial expressions lead to coarse skin wrinkling and deep folds. However, Kligman et al. (9) noted that in point of fact, there are no histologic features that distinguish the various types of wrinkles from the surrounding skin. He noted that instead there is a configurational change that results from mechanical stress acting on lax, excessive skin, especially in actinically damaged regions.

On the other hand, photoaged epidermis is characterized by striking variability: in its thickness, with alternating areas of atrophy and hyperplasia; in pigmentation, with alternating lentigines and depigmented areas; in the degree of nuclear atypia; and in orderliness of keratinocytes maturation (10). In the past, sun-damaged epidermis was thought to be characterized by a reduction in structural elements, leading to skin wrinkling. In fact, the most striking feature of photodamaged skin is the presence of large quantities of thickened, poorly organized degraded elastic fibers, which degenerate into an amorphous mass, better known as elastosis. This loss of elastin decreases skin elasticity, defined as the loss of the ability of the skin to recoil and redrape once pulled away from the deep tissues (11). The result is aged skin, which does not retain moisture and which loosens and hangs. The ground substance component of the dermal connective tissue matrix is greatly increased. In the dermal cell population, photodamaged skin shows numerous, hyperplastic fibroblasts and abundant, partially degranulated mast cells, which result in a chronic low-grade inflammation termed heliodermatitis. Finally, photodamaged skin shows extensive changes in the microcirculation, which can affect flap viability. Along with skin changes, atrophy of underlying soft tissue and fat have also been described. Skeletal changes pertaining to both bone loss and bone remodeling also occur with aging.

Overall the aging face can be viewed as a coupling of redistributed ptotic underlying soft tissue with overlying skin changes. Together, these changes combine to contribute to the overall impression of the aging face. For most aging face patients, this means that facial rejuvenation will necessitate the surgeon concentrating on five points of interest: (a) the jowl, (b) the deepened melolabial and nasolabial folds, (c) the neck, (d) the malar region, and (e) the skin itself.

The last 20 years have brought about numerous improvements in the face-lift surgery. These new advances have largely come about through better anatomical understanding as well as an understanding of how the aging process alters these anatomical components throughout the face and neck. Certain salient points of the facial anatomy for rhytidectomy, including vascular supply, details of the SMAS and its relation to the facial nerve, as well as the presence of retaining “ligaments,” are described here.

The facial skin is supplied by branches of the external carotid artery. Specifically, the superficial temporal artery, facial artery, transverse facial artery, and infraorbital artery anastomose with one another in the subdermal plexus. The internal carotid artery also contributes to the facial skin centered around the radix and the glabella through branches of the ophthalmic artery. However, this area is not routinely addressed during face-lifting. The elevated subcutaneous flap is based solely on the subdermal plexus, which is supplied by muscular cutaneous arteries arising from branches of the facial and infraorbital arteries. Unfortunately, the standard subcutaneous and SMAS two-layered face-lift effectively divides the skin from its underlying perforating branches. A recent study comparing the vascular anatomy of basic skin flaps in the subcutaneous and SMAS rhytidectomy, the composite rhytidectomy, and the subperiosteal rhytidectomy found, not surprisingly, that the best blood supply was found in subperiosteal dissection while the most tenuous supply was in the subcutaneous flap (12). However, outside of smokers and those patients with small vessel disease, one must consider that each of these techniques has been used for many years with minimal low flap perfusion rate complications (5).

Perhaps the first, and most important, development in the evolution toward the present-day rhytidectomy was the description of the SMAS. In fact, while the precise boundaries of the SMAS continue to be a source of debate, the significance of this fascial layer in relation to present-day rhytidectomy is unquestionable. The SMAS, which is a fibromuscular fascial layer, invests and interlinks the muscles of facial expression. Moreover, in this function it maintains consistent relationships with the facial nerve and major vessels within the facial region. For the operating surgeon, mastery of these relationships and planes of dissection are therefore critical (13).

The regional variations that are found in the relationship between the SMAS and the neurovascular structures are most profound when examining the SMAS and the facial nerve above the zygoma versus below the zygoma (14). Specifically, in the temporal region above the zygoma, the superficial temporal artery and frontal branch course through the SMAS (also called temporoparietal fascia). Below the zygoma, the SMAS fans out over the parotid gland and then above the masseter muscle before it surrounds the facial mimetic muscles. Therefore, in the lower face, the facial nerve branches are always deep to the SMAS and innervate the facial mimetic muscles on their undersurface (Fig. 188.2).
However, there are three exceptions to that rule. The levator anguli oris, buccinator, and mentalis muscles lie in a somewhat deeper plane making their innervation from the facial nerve from their superficial surface, rather than their undersurface. It should be noted that even in the deep plane and composite lifts, the dissection medial to the zygomaticus major and minor is actually above the SMAS because the SMAS thins out over this region. Moreover, it should be noted that a significant, distinct myofascial layer superficial to the parotid fascia is not always clinically apparent. In fact, Jost and Levet (15) have suggested that the SMAS overlying the parotid includes what the authors have otherwise distinguished as the parotid fascia.

Finally, as previously alluded to, the SMAS has been noted to have a number of “ligamentous” supports, which make it adherent at specific points to the overlying dermis and underlying muscular/osseous attachments. Specifically, four ligaments support the soft tissues of the cheek: (a) the parotidomasseteric ligament, (b) the platysmal auricular ligament, (c) the zygomatic ligament (McGregor patch), and (d) the mandibular ligament (Fig. 188.3). Although not true ligaments, these fascial condensations are especially important in the deep plane and composite rhytidectomy (16). Release of these ligaments is important and will allow the surgeon to achieve a better pull to redrape the tissue. However, this task must be undertaken with extreme caution as branches of the facial nerve are in close proximity.

A steady evolution of anatomically derived technical advances has occurred in the rhytidectomy procedure since the early days of simple skin flap advancement. Reports of face-lifting attempts date back to the very first years of the 20th century and consisted primarily of skin excision and direct closure. This technique was utilized for over 50 years before the first major contribution to advance face-lifting was provided by Skoog. Sometime in the mid-1960s, Skoog began to elevate a “complex morphologic unit” in the cervical region and advance it posteriorly (17). It was observed that this “two-layered shift” of the cervical fascia corrected the anterior banding of the neck and the redundant skin of the cervical region. Skoog subsequently followed this with his description in 1974 of his technique of superficial rhytidectomy of the face and neck based on a subfascial dissection. The new era in face-lift surgery had begun (18,19,20).

It would take until 1976 before Mitz and Peyronie (21) defined the “complex morphologic unit” referred to by Skoog as the SMAS. The SMAS lift approach, which then became vogue, was a significant step in the evolution of the
present-day rhytidectomy. However, some surgeons, in pursuit of the ideal lift, still found the results of the SMAS lift to be short-lived and complicated by perioperative problems. For some surgeons, the SMAS lift did not appear to sufficiently address the ptotic midface and melolabial fold region. In an effort to enhance midface tissue, Faivre (22) described in 1988 the deep temporal face-lift in the sub-SMAS plane. That same year, Psillakis et al. (23) described the subperiosteal midface lift to correct ptotic malar fat pad. In 1990 and 1992, Hamra (24) published his techniques on deep plane face-lift and composite face-lift, respectively (25). In the deep plane face-lift, Hamra innovates on the Skoog technique by adding a superolateral elevation of the malar fat pad. The composite lift added dissection and resuspension of the orbicularis oculi muscle superomedially, thus effacing what the author has termed as the malar crescent, in an effort to rejuvenate the periocular complex and better create harmony with the lower parts of the face.

Recently, many “newly named” face-lift techniques have been heavily marketed: the mini-lift, weekend lift, short flap lift, S lift, and lunchtime lift. Most of these lifts rely on a short skin flap and sometimes a minimal SMAS suspension. These less invasive procedures have the advantages of decreasing associated complications and substantially minimizing patient recovery time. However, in most cases their indications are limited to patients with limited signs of aging, and results from such techniques may be shortlived or less than ideal. Webster had explored short flap face-lifting in 1983, which many later abandoned (26).

To date, it is uncertain what percentage of surgeons are performing the extended sub-SMAS lifts versus the traditional SMAS plication/imbrication techniques. Moreover, questions remain as to the superiority of the results that are achieved in the deep plane versus plication techniques. In fact, while anecdotal reports abound to this effect, it will be very difficult to accomplish the study that can definitively answer this and a whole host of other questions. Proponents of deep plane rhytidectomy claim an improved nasolabial fold in comparison to the traditional SMAS suspension techniques (27). Adamson et al. (28) found a twofold improvement with deep plane measured by the degree of increased volume at the malar eminence and by the amount of effacement of the fold. Becker and Bassichis (29) concluded that results from a deep plane face-lift were not superior to those from SMAS plication in patients that are younger than 70 years old. Baker (30) and Kamer (31) maintain reservations regarding the superiority of the results from the deep plane lifts, especially when these “implied benefits” are weighed in relation to the added risks to the facial nerve. Baker and Conley (32) notes that a review of the world literature in 1979 found an incidence of 0.01% permanent facial nerve injury in deep plane cases. He notes in a later paper (30) that the published articles on the new deep dissection techniques conjure concern as they report a relatively high incidence of facial weakness in the hands of extremely qualified surgeons. He questions what happens when these procedures are attempted by less experienced surgeons. Time and experience are still needed before the authors will know if the added work and increased potential risk for complication is worth the improved aesthetic results. In a recent systematic review of 39 articles comparing the efficacy and complication rate of different face-lift techniques, Chang concluded there was a lack of quality data to be objectively compared (33). It is also important to note that results will always vary from surgeon to surgeon due to skills and expertise.

With an understanding of the physiologic and anatomical changes that present with facial aging, the surgeon is ready to determine whether the patient is a candidate for facial rejuvenation surgery in general and rhytidectomy in particular. This evaluation includes surgical, medical, and psychological components.

The surgical criterion to be addressed is whether rhytidectomy will create physical changes in the patient’s face that will contribute meaningfully to a more youthful appearance. In making this determination, it is helpful to divide the stigmata of facial aging into two categories: those that are improved by repositioning of facial tissues and those that require changes in the structure of the tissues themselves. In the first category, one would include ptosis in the jowl, submentum, and anterior neck leading to a disruption of the ideal youthful contours of the jawline, cervicomental angle, and neck, respectively. These are the primary areas improved by rhytidectomy. Malar ptosis will experience modest improvement as well.

On the other hand, intrinsic changes in the tissues themselves are not well addressed by rhytidectomy. As noted earlier, concomitant with the ptosis described above, aging brings about many changes in the skin itself. Fine lines and deeply etched wrinkles in the skin are the grossly visible correlates of crevices in the dermis and subcutaneous tissues formed over time as a result of actinic damage, senescence of connective tissues, and habitual facial expressions. These cosmetic defects will be minimally improved, at best, by rhytidectomy. Instead, they can be addressed more directly by resurfacing techniques, including both chemical and laser exfoliation. In the situation in which such intrinsic properties of the skin comprise a significant portion of the aesthetic problem, the patient should be encouraged to consider skin resurfacing as an adjunct or, in some cases, an alternative to rhytidectomy.

Once the surgeon has determined that a rhytidectomy will address the patient’s aesthetic concerns appropriately, it is imperative to assess medical candidacy for the procedure. Most patients who seek cosmetic surgery are in good health, so medical contraindications to the proposed procedure are rarely seen. Vigilance is essential for avoiding disaster. Facelift candidates—people who feel young inside and want their outward appearance to mirror that vitality—are exactly the same people who tend to minimize medical complaints and even may forget to relate serious medical problems
unless questioned directly. Significant bleeding diatheses and American Society of Anesthesiologists (ASA) class IV or V, in which a patient has a dangerously compromising medical condition, should he considered absolute medical contraindications to rhytidectomy. A patient in ASA class III, in which a medical condition impairs the patient’s activities to some degree, should be approached with great caution. The severity of the condition and its potential impact on the safe conduct of the operation should be explored in detail. Conditions that may adversely affect healing including uncontrolled diabetes, diseases requiring chronic steroid therapy, or connective tissue abnormalities like the Ehlers-Danlos syndrome should be considered strong relative contraindications to face-lift surgery. Consultation with the primary care physician may be necessary to coordinate prescription medication regimens and facilitate the management of relevant medical conditions.

On the other hand, there are no age limitations for facelift surgery, and age should not be a reason to deny surgery if the patient is in otherwise good health. A healthy patient in his or her late 70s or early 80s may have 15 or 20 more years of quality life ahead, and the desire to have an improved appearance is indeed valid.

Finally, but not least important, an accurate assessment of the patient’s psychological status is central to determining patient candidacy. The surgeon should determine patient motivation and attempt to ascertain whether the patient might fail to view a successful surgical outcome favorably or might react inappropriately to any aspect of the surgery. A thorough discussion of the patient’s goals and objectives should provide important clues to his or her psychological profile (34). Although many patients are unaware of exactly what surgery can and cannot accomplish, others have clearly unreasonable expectations, which can include looking exactly as they did 10 or 20 years ago, having surgery without scars, requesting an unnaturally tight lift, or attempting to obtain promises and guarantees. Patients who are excessively occupied with minute flaws also may be poor surgical candidates. Moreover, patients who have recently undergone a major change in their personal status, such as the death of a loved one or divorce, may be subject to depression or psychological unevenness and may require special care.

Full-disclosure informed consent for surgery and photographs are obtained. The patient is given a packet that includes preoperative and postoperative instructions and a
description of what to expect during recovery. Having the patient fill all prescriptions in advance serves two purposes: It removes the distraction of a rushed visit to the pharmacy for the patient and caretakers in the early postoperative period when even simple things can be difficult. Also, it allows the patient to take antibiotics the night before surgery to assist in preventing infection and provides the patient with sedatives should sleep be difficult the night before surgery.

The patient is urged to stop smoking 1 month prior to surgery. All medications containing aspirin, steroids, nonsteroidal anti-inflammatory agents, and vitamin E, as well as all herbal medications, should be discontinued at least 2 weeks before surgery. If there is a history consistent with a bleeding diathesis, however tenuous, preoperative bleeding time, platelet count, prothrombin time, and partial thromboplastin time or other coagulation studies should be ordered. The goal is avoidance of hematoma, the most common complication of rhytidectomy.

Successful face-lift surgery is achieved through thoughtful planning and execution of every aspect of the procedure (38). The amount of actual skin excised, the tightness and completeness of the lift in the cheeks, the ability to contour and resuspend the neck, the smoothness of the submental region, and the degree to which the incisions can be camouflaged all are important considerations in achieving a natural, nonoperated appearance. Rhytidectomy is an operation of compromises.