Anatomy of a facelift
Here I try to break down the facelift, and discuss the different aspects of it. I hope that this makes you feel empowered to make informed decisions about your facelift journey.
Having a facelift is a significant decision, and most patients will invest huge amounts of time investigating the subject and potential surgeons. There are many resources available including websites, online forums and social media that aim to provide information, but it can be very overwhelming.
Even to expert surgeons, the information can appear to be confusing and conflicting. Here I try to break down the facelift, and discuss the different aspects of it. I hope that this makes you feel empowered to make informed decisions about your facelift journey.
Anaesthesia
The primary purpose of anaesthesia is to ensure your safety and comfort during the operation. All decisions on what type of anaesthetic to use are based on these 2 factors. It is possible to perform short scar facelifts under local anaesthetic and this is both safe and comfortable.
A typical deep plane face and neck lift takes 5 hours and is an invasive procedure. It is my belief that general anaesthesia is the safest, and most comfortable option for both the patient and surgeon. There are certain circumstances where deep sedation may be a safe and effective alternative.
I work with a small group of select anaesthetists, all of whom offer the most advanced anaesthetic techniques. They have developed protocols to ensure that all patients wake up quickly, safely and comfortably meaning that many patients are discharged home on the day of surgery.
Anaesthesia
The primary purpose of anaesthesia is to ensure your safety and comfort during the operation. All decisions on what type of anaesthetic to use are based on these 2 factors. It is possible to perform short scar facelifts under local anaesthetic and this is both safe and comfortable.
A typical deep plane face and neck lift takes 5 hours and is an invasive procedure. It is my belief that general anaesthesia is the safest, and most comfortable option for both the patient and surgeon. There are certain circumstances where deep sedation may be a safe and effective alternative.
I work with a small group of select anaesthetists, all of whom offer the most advanced anaesthetic techniques. They have developed protocols to ensure that all patients wake up quickly, safely and comfortably meaning that many patients are discharged home on the day of surgery.
Scars
One of the most common questions relating to facelifts is about the scars and will they be visible. Any cut in the skin will result in a scar, however when placed correctly and once they have matured the scars from facelift surgery should not be visible at conversational distance. To achieve this, scars must be meticulously placed, closed precisely and without tension, and cared for after surgery.
I typically use 2 types of scars. A short scar (Vr) facelift, and a full (deep plane) face and neck lift. The scars for the short scar facelift are all in front of the ear. They curve through the hairline in from of the ear and then through the natural creases of the ear to the bottom of the ear lobe. This allow access to the face and is ideal for those with early signs of aging limited to the face.
In a full face and neck lift, the scars are the same as a short scar facelift, but they then continue up the back of the ear, and into the hairline behind the ear. This allows access to the area below the jaw in addition to the face, and is more suited to those with concerns in both the face and neck.
As part of a face and neck lift, an additional short submental scar is placed under the chin. Through this incision fat can be reduced, and it also allows access to the submandibular glands. These glands sit under the jawbone and can drop in to the neck. For those patients who have prominent submandibular glands, the part of the gland dropping below the jaw will be removed to enhance the definition and contour. At the same time, the digastric muscles are trimmed and sculpted to give the optimum shape.
Scars
One of the most common questions relating to facelifts is about the scars and will they be visible. Any cut in the skin will result in a scar, however when placed correctly and once they have matured the scars from facelift surgery should not be visible at conversational distance. To achieve this, scars must be meticulously placed, closed precisely and without tension, and cared for after surgery.
I typically use 2 types of scars. A short scar (Vr) facelift, and a full (deep plane) face and neck lift. The scars for the short scar facelift are all in front of the ear. They curve through the hairline in from of the ear and then through the natural creases of the ear to the bottom of the ear lobe. This allow access to the face and is ideal for those with early signs of aging limited to the face.
In a full face and neck lift, the scars are the same as a short scar facelift, but they then continue up the back of the ear, and into the hairline behind the ear. This allows access to the area below the jaw in addition to the face, and is more suited to those with concerns in both the face and neck.
As part of a face and neck lift, an additional short submental scar is placed under the chin. Through this incision fat can be reduced, and it also allows access to the submandibular glands. These glands sit under the jawbone and can drop in to the neck. For those patients who have prominent submandibular glands, the part of the gland dropping below the jaw will be removed to enhance the definition and contour. At the same time, the digastric muscles are trimmed and sculpted to give the optimum shape.
The Skin
The skin is the outermost layer of the face. The aging process has significant effects on this layer with a reduction of collagen and elastin. However, the effects of aging on the face are more profound on the deeper layers and more often the skin reflects those deeper changes. For this reason, treatments and operations that focus only on the skin will only have a limited effect in terms of outcome and duration. However, the importance of healthy skin on the outcome of facial rejuvenation and facial surgery should not be underestimated. Skin health is a fundamental part of a multi-faceted approach to facial rejuvenation.
Subcutaneous
Subcutaneous mean ‘under skin’ and refers to the layer immediately below the skin. This layer has 2 main components; fat which provides volume and mobility, and tough fibres (retinacular cutis) that connect the skin to the underlying SMAS. Traditional facelift techniques such as SMAS plication separate layer 2 from layer 3 and release the tough fibrous connections, before placing stitches in the SMAS (Layer 3) to lift and tighten it.
Musculo-aponeurotic
The Superficial Musculo Aponeurotic System (SMAS) is the 3rd layer in the face and neck and is fundamental to our understanding of how the face ages. All successful facelifts will address the SMAS later. It contains the muscles of facial movement that are encased within a layer of fascia. Layer 3 is the layer above the ‘Deep Plane’ and must be divided to perform a deep plane face and neck lift.
Retaining ligaments and spaces
Layer 4 is the layer that is entered during a deep plane lift. It is made up of a series of natural mobile spaces that provide a gliding plane to allow tissue to ove over each other. Each space has a tough immobile boundary which are reinforced by the facial retaining ligaments. The principle of deep plane face lift surgery is to release the facial retaining ligaments in layer 4 that anchor layers 1,2 and 3 to the bones. This allows the entire face, jowl and neck to be lifted without tension and repositioned. Layer 4 also contains the branches of the facial nerve that travel forwards in layer 4 to supply the muscles of facial movement in the roof of this layer.
Periosteum
The deepest layer of the face is the periosteum which is the layer that covers the bones. In certain parts of the face it has a specific name such as in the temple where it is referred to as the deep temporal fascia. The periosteum is a tough immobile layer and it is what the facial retaining ligaments are anchored to.
The layers of the face
The soft tissues of the face can be divided in to 5 distinct anatomical layers that are continuous with each other from the scalp, through the face and in to the neck. Understanding these layers, and what is contained within them is critical to a safe and successful facelift.
Managing the SMAS during a facelift
The Superficial Musculo Aponeurotic System (SMAS) is a layer of fascia that wraps around the muscles in the face and continues as the platysma muscle in the neck. It is our understanding of this layer, how it changes with age, and how me manage it that is critical to a successful facelift. Most facelift methods use a variety of techniques to lift and tighten the SMAS.
Plication
The SMAS is lifted and folded over on itself and secured with sutures. This is the most common type of technique performed.
Imbrication
Loops of sutures are passed through the SMAS and tightened like a purse string. This technique was made popular by the MACS lift.
SMASectomy
A section of SMAS is removed and the edges sutures together. Usually there is no release of deeper ligaments.
Deep Plane
The dissection goes underneath the SMAS layer to free all the deep ligaments and attachments. This allows for a tension free lift of the face and neck together, giving the best natural results.
Managing the SMAS during a facelift
The Superficial Musculo Aponeurotic System (SMAS) is a layer of fascia that wraps around the muscles in the face and continues as the platysma muscle in the neck. It is our understanding of this layer, how it changes with age, and how me manage it that is critical to a successful facelift. Most facelift methods use a variety of techniques to lift and tighten the SMAS.
Plication
The SMAS is lifted and folded over on itself and secured with sutures. This is the most common type of technique performed.
Imbrication
Loops of sutures are passed through the SMAS and tightened like a purse string. This technique was made popular by the MACS lift.
SMASectomy
A section of SMAS is removed and the edges sutures together. Usually there is no release of deeper ligaments.
Deep Plane
The dissection goes underneath the SMAS layer to free all the deep ligaments and attachments. This allows for a tension free lift of the face and neck together, giving the best natural results.
Zygomatic
These are the ligaments over the cheek bone.
Masseteric
These are the ligaments in the cheek / midface.
Mandibular
These are the ligaments next to the jowl.
Cervical
These are the ligaments below the ear.
The ligaments
Deep to the SMAS is . These spaces are bounded by tough fibrous attachments that contain the facial retaining ligaments. The facial retaining ligaments are anchored to the bone via their attachment to the periosteum (the layer that covers the bone). From there they pass up and spread out like a tree attaching to every layer of the face including the SMAS and skin. These attachments limit the movement of the soft tissues of the face, and the principle behind deep plane face and neck lifts is the release of these ligaments to allow tension free movement and lift of the face and neck.
The 4 key ligaments that need to be divided to achieve a successful tension free lift are shown left.
The neck
For many people, the lower face, jawline and neck is their main area of concern. For the best results, neck lift surgery needs to address multiple different structures and layers including skin, fat, muscle, and glands.
Liposuction, and non surgical methods to reduce fat will have very little affect on the shape of the neck as the majority of fat in the neck is underneath the platysma muscle and not reachable by liposuction. The only way to reach and reduce this fat is through a direct approach with a scar under the chin. Through this incision fat can be reduced, and it also allows access to the submandibular glands. These glands sit under the jawbone and can drop in to the neck. For those patients who have prominent submandibular glands, the part of the gland dropping below the jaw will be removed to enhance the definition and contour. At the same time, the digastric muscles are trimmed and sculpted to give the optimum shape.
The neck
For many people, the lower face, jawline and neck is their main area of concern. For the best results, neck lift surgery needs to address multiple different structures and layers including skin, fat, muscle, and glands.
Liposuction, and non surgical methods to reduce fat will have very little affect on the shape of the neck as the majority of fat in the neck is underneath the platysma muscle and not reachable by liposuction. The only way to reach and reduce this fat is through a direct approach with a scar under the chin. Through this incision fat can be reduced, and it also allows access to the submandibular glands. These glands sit under the jawbone and can drop in to the neck. For those patients who have prominent submandibular glands, the part of the gland dropping below the jaw will be removed to enhance the definition and contour. At the same time, the digastric muscles are trimmed and sculpted to give the optimum shape.
Mr West’s facelift technique
am trained in all aspects of cosmetic surgery, however my main focus and interest is in facial rejuvenation and facelift surgery. I am fellowship trained in facelift surgery, and have spent lots of time with surgeons in Europe and USA developing my techniques to ensure I consistently deliver the best, natural results to my patients. It is my belief, built on years of personal and shared experience, that deep plane facelift surgery offers the gold standard in facial rejuvenation, and this is what my own technique is based upon.
Full deep plane face and neck lift
The majority of facelifts that I perform are full deep plane face and neck lifts. This is the most comprehensive approach to facial rejuvenation and is widely accepted as being the gold standard in modern facelift techniques. It allows full release and repositioning of the midface, jaw, jowl and neck giving optimum, natural results.
The full deep plane face and neck lift is performed under general anaesthesia or deep sedation. The decision on which type is made by the consultant anaesthetist after discussion with the patient. Incisions are placed in the hairline in front of the ear, down through the natural folds and creases of the ear, up the back of the ear and in the hairline behind the ear. An additional incision is made under the chin. Through these incisions the skin is lifted off the SMAS in the face and the platysma muscle in the neck.
Through the incision under the chin, excess fat is removed from under the platysma muscle. Prominent submandibular glands can be reduced, and the digastric muscle trimmed to enhance the shape and contour of the neck. The platysma muscle is repaired and small cuts are made to prevent any bands from forming.
Full deep plane face and neck lift
The majority of facelifts that I perform are full deep plane face and neck lifts. This is the most comprehensive approach to facial rejuvenation and is widely accepted as being the gold standard in modern facelift techniques. It allows full release and repositioning of the midface, jaw, jowl and neck giving optimum, natural results.
The full deep plane face and neck lift is performed under general anaesthesia or deep sedation. The decision on which type is made by the consultant anaesthetist after discussion with the patient. Incisions are placed in the hairline in front of the ear, down through the natural folds and creases of the ear, up the back of the ear and in the hairline behind the ear. An additional incision is made under the chin. Through these incisions the skin is lifted off the SMAS in the face and the platysma muscle in the neck.
Through the incision under the chin, excess fat is removed from under the platysma muscle. Prominent submandibular glands can be reduced, and the digastric muscle trimmed to enhance the shape and contour of the neck. The platysma muscle is repaired and small cuts are made to prevent any bands from forming.
To access the deep plane in the face and perform a full release of the ligaments, enters the SMAS is entered via a ‘High SMAS’ incision. This is my preferred technique as it provides simultaneous lift of the face, neck and mid face. The ‘High SMAS’ flap can be secured to the deep temporal fascia giving a very secure fixation point for the SMAS. Furthermore, the incisions made in the SMAS are close to the skin incisions therefore there are no suture lines or seems in the central face and cheeks.
Fat grafting is performed as part of almost all face and neck lifts to restore natural volume and youthful appearance. Typical areas for fat grafting include temples, jaw, cheeks, and nasolabial folds.
Deep plane face and neck lift is frequently combined with additional procedures such as upper blepharoplasty, lower blepharoplasty, lip lift, brow lift, and laser resurfacing.
Short scar / Vr facelift
For patients with moderate signs of aging, where their concerns are only with the face, a short scar facelift that is performed under local aneasthetic may be an alternative. These patients are typically younger with moderate facial descent and jowls. The short scar / Vr facelift does not address sagging in the neck, and is therefore not suitable for people wishing to address concerns in the neck.
Short scar / Vr facelift
For patients with moderate signs of aging, where their concerns are only with the face, a short scar facelift that is performed under local aneasthetic may be an alternative. These patients are typically younger with moderate facial descent and jowls. The short scar / Vr facelift does not address sagging in the neck, and is therefore not suitable for people wishing to address concerns in the neck.
