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Facelift surgery or rhytidectomy, browlifts, and midface lifts are performed in an effort to redrape and suspend facial soft tissues to gain a more youthful appearance to the face. Facial aging has traditionally been attributed to the force of gravity causing soft tissue ptosis of the face as patient ages. The actual causes of facial aging are incompletely understood at this time, but the pathogenesis of the aging face continues to be a fascinating, hotly debated topic among physicians. In general, facial aging tends to occur in three dimensions and involves all tissue components of the face: skin, muscle and soft tissue, facial fat pads, and the bony facial skeleton.

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Facial aging can be thought of occurring from superficial to deep, and tends to begin in the late twenties and thirties in the skin. Photodamage is defined as the functional and structural damage that occurs to skin after chronic exposure to ultraviolet radiation from the sun. The structural changes involve gradual thinning of the epidermis, flattening of the epidermal-dermal border, loss of collagen and thickness in the dermis, decrease in collagen Type I to Type III ratio, and reduction in the skin cellular and protein components. Lax skin with decreased collagen manifests through sagging and increased propensity to be wrinkled and furrowed.

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Deeper into the facial soft tissues, muscle laxity and atrophy, as well as bony remodeling and resorption can potentiate the loss of facial, mandibular, and neck definition. These anatomic changes manifest clinically as brow ptosis, deepening of the nasolabial fold, jowling, blunting of the cervicomental angle, and platysmal banding (Figure 73–1). These features of the aging face are particularly amenable to correction with a rhytidectomy, platysmaplasty, midface lift, and/or browlift.

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Figure 73–1.
Graphic Jump Location

Characteristics features of facial aging: (a)—brow ptosis, (b)—descent of the midface, (c)—nasolabial fold, (d)—excessive jowling, (e)—Marionette line, (f)—prejowl sulcus, and (g)—platysmal banding

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However, there are limitations to these surgical procedures. The surgeon must know that there are options to deal with aspects of the aging face for which a facelift or a browlift is not as effective. Although photodamage from the sun or tanning beds can increase the process of skin thinning, it causes fine skin wrinkling which may be more amenable to a skin treatment such as laser resurfacing or a chemical peel. Also, there is a gradual volume loss in the face which occurs over the time from change in facial fat pads and bony remodeling of the facial skeleton. Fat pads in the temporal and malar area lose volume, and the malar fat pad descends. Although a facelift may elevate the malar fat pad, additional augmentation of facial volume may be necessary with injections of autologous fat, fillers, or even implants.

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SMAS

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The key to understanding facelift surgery is understanding ...

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