Before Surgery

The nurse will discuss the pre- and postoperative instructions with you. A simple blood test is performed, and a cardiogram is obtained for those patients over fifty or with any history of cardiac problems. Sometimes additional tests are performed.

For Smokers

Smokers are at an increased risk for wound healing problems after surgery, so that we instruct smokers to refrain from smoking for two weeks prior to and two weeks after surgery. Patients often ask about using nicotine patches or gum. Unfortunately, these cannot be used because they also contain nicotine and it is the nicotine that causes the small blood vessels to constrict and interfere with healing.

Most surgeons understand that smoking is a tough addiction and patients are very unlikely to stop smoking during this period regardless of what we tell them. However, they need to know that they are at increased risk of delayed wound healing and they will do themselves a favor by quitting or at the very least minimizing their smoking. Smokers may take longer to heal and may have more scarring, particularly behind the ears. Eventually, these areas tend to heal with an acceptable result. Also, the deep-plane approach maintains more blood supply to the skin, because there is less skin undermining, offsetting the risk.

Pain Medication Prior to Surgery

Because of its effect on platelets and the risk of increased bleeding, all products containing aspirin are avoided for two weeks prior to surgery and two weeks after. Many over-the-counter pain-relievers and headache medicines contain aspirin, also called ASA, so it is worth checking to be sure. We tell patients to avoid non-steroidal anti-inflammatory medications (NSAIDs), such as Ibuprofen for three days before surgery and three days after. Tylenol^® is okay right up until before surgery because it does not affect platelets. Patients with arthritic pain or headaches can take their NSAID or COX2 inhibitor up to three days before surgery and then take Tylenol^®.

Vitamins and Nutritional Supplements

Healing and Bruising Medications

Don't take any product that is supposed to "speed healing" or reduce bruising, such as Arnica montana. A good rule of thumb is that, despite claims to the contrary, there are no medications known to accelerate healing or make you scar better. There are plenty of advertising claims for such products as Mederma^® and StriVectin^® but little scientific support. Bruises go away and scars improve with time regardless, which is great for those who market products that purport to do these things.

Support Before and After Surgery

The surgery is usually performed as an outpatient. You will need a ride to the Surgery Center on the day of surgery and a ride home afterward. It is a good idea to have someone with you for the first few days after surgery. Do not eat or drink for at least six hours prior to surgery.

The Incisions

The incision starts within the hairline, above the ear, and continues down along the crease in front of the ear. It then passes within the groove under the earlobe and up the crease behind the ear, turning at a right angle and continuing straight back into the hair a few inches. The incision behind the ear is placed so that it eventually will lie in the crease behind the ear, not on the exposed skin of the back of the neck.

One popular variation is to make this incision obliquely, following the hairline rather than disappearing straight back into the hair. Often patients who have had previous facelifts have this type of scar that follows the hairline. An advantage of making the incision within the hairline instead is that it is well concealed. This is the ideal placement in men or women who would like to be able to wear their hair short, up or bathe without a conspicuous scar behind the ear - a telltale sign of a facelift. The scar in front of the ear is kept close, often along the line of an existing crease, and a running stitch is used under the skin so that it is not visible and leaves no suture tracks. Patients are always concerned about this scar before surgery, but it is almost always inconspicuous. I do not shave the hair so that patients do not have to wait for it to grow out and the incisions tend to be well concealed. Men need to be aware that the procedure will move some of the hair-bearing skin up behind the earlobe so that they will need to include this area when they shave.

Sutures are used rather than staples, for comfort and ease of removal. They also do a better job of lining up the edges. Staples are fast, but that's their only advantage and a matter of five extra minutes to sew is inconsequential. I don't even have any staples in my operating room.

It is important to place minimal tension on the skin. Tension may cause a scar to spread. If there is minimal tension, the scar will usually be thin and inconspicuous. Another telltale sign of a facelift is tension on the ear so that the earlobe becomes stuck down. This is known as a pixie ear (See Patient C.B. in Patient Photographs), a sign of an inexperienced operator. The scar may move down with time, making it more visible. To avoid this operative stigma, minimal tension is placed on the incision as it courses under the ear lobe.

One approach is to make an incision behind the tragus, which is the bump in front of the ear canal. Patients often ask about this hidden incision. The problem is that deformities of the tragus occur with regularity afterward. The tragus may end up flattened so that there is unnatural exposure of the ear canal. This is a stigma of surgery and difficult to correct (See Complications). I prefer the anterior tragal approach, hugging the tragus. By staying close to the tragus, even a little on it, this scar tends to blend in nicely, and the unique beauty of the tragus is not at risk. This incision should hug the tragus. If it is made even a little too far forward, it will migrate and be visible, which you sometimes see in actors on close-up shots. Fortunately, this problem may be corrected at the time of a redo facelift.

Surgery is all about fine points of technique. Although each one individually seems insignificant, taken together they may make the difference between a mediocre result and a superb one.

Another incision is placed below the chin. This is used to access the fat deposit under the chin. Most patients have extra fat here which is removed by liposuction. The muscles of the front of the neck (platysma) are sutured together like a zipper to further improve the neckline and reduce vertical bands. These vertical neck bands are a concern to most patients. These bands are treated by suturing the muscle edges together. The same muscle is also tightened at the side of the neck through the facelift incision. This also helps to define the neckline. A well-defined neckline is a very desirable feature and gives a youthful appearance. It is also very achievable, and is a vital part of every facelift, which might be more accurately called a "face and neck lift."

I am judicious in the use of liposuction and avoid its use in the face. It is youthful and therefore desirable to have fullness of the cheeks. As we age, we lose fat in the face, so it would not be advisable to perform liposuction in the face. However, liposuction is very commonly performed in the neck, where it is needed to achieve the desired flat contour under the chin.

Perhaps wishing to avoid a facelift, patients sometimes ask if their jowls (the fold sagging over the jawline) can be treated with liposuction. However, it is better to elevate the jowls rather than treat them with liposuction because liposuction can cause excessive tissue thinning over the bony jawline which looks unnatural and is not youthful. It makes more sense to lift this tissue back up where it came from which also serves to restore youthful fullness to the cheeks.

Cheek lift

Over the last few years, advances have been made in lifting the cheek tissue. Traditionally, the mid-face (the area between the lower eyelid and the upper lip) has been a source of dissatisfaction among patients and surgeons because of the gradual sagging of this tissue producing an aging appearance. The nasolabial crease often persists, even when surgeons perform a deep plane lift. To correct this, surgeons have developed ways to lift and reposition this cheek (malar fat pad) tissue. Some surgeons tried using an incision at the corner of the eye to approach and lift the cheek pad, but this had a high complication rate. The eyelid was often pulled down. Instead, I use the facelift incision to approach and elevate the cheek pad, avoiding any downward pull on the lower lid.

The retaining ligaments holding the SMAS (the superficial musculoaponeurotic system) are released and the cheek is elevated as one continuous tissue layer containing skin, the cheek fat and the connective tissue layer that forms the SMAS. This is held with long-lasting sutures at a stable anchoring point on the temple. The handle is the SMAS, which is a strong, inelastic material just right for stability. The relatively elastic and distensible skin layer comes along for the ride. The fat comes up too, sandwiched between the skin on the top and the SMAS underneath.