FACELIFT

Our faces age from the bottom up. As the supportive structures of youth stretch and weaken, gravity acts to bring down the loosened skin and inner fat to the bottom of the pile. The mid face sags onto the corners of the mouth, and these corners themselves drop downward. The lower cheeks appear to droop over the angles of the jaw causing bilateral jowls, which end by squaring off the heart shape of the jawline. The length and depth of our necks are gradually lost to a piling up of skin and fat beneath the jaw. The once proud line of the neck becomes an accordion folding on itself and may be overhung by a small wattle; or worse a large turkey gobbler from beneath the chin. A thinner face will drape more skin whereas fuller fatter faces fill up below the chin, appearing broader with eventual loss of all neck definition.

The most effective surgical measures to restore a youthful appearance are those which redrape the lower face, sharpening the jawline by deepening and lengthening the line of the neck. Without such improvement little is accomplished. Improving the neckline and reducing the jowls enhances the projection of the chin giving the lower face a more youthful firmness.

The face above the cheekbones ages slowly as it is more firmly attached to the temples and frontal areas with underlying muscles of facial expression. It does not sag significantly until very late in life (if at all). In my experience, surgical procedures on the upper face or forehead produce an unnatural loss of normal expression. They are intended to avulse or paralyze the forehead and brow muscles pulling the brow upwards. This produces a frozen startled expression and elevates the hairline. It gives one a "deer in the headlights" look that makes a face seem strangely different. Seeing such a result we often feel the person does not look like herself.

No two facelifts should look the same. Each person's unique bone structure, skin tone, complexion, fat content, healing process and age, will influence the outcome. A meticulous surgeon doing two patients on the same day with equal care cannot assure such patients that they will have a similar outcome. The surgeon should not do the exact same steps in two different faces. There is no standard or control for facelift results as there is none for the ageing process itself. Patients cannot expect to look five, ten or any specific years younger, but may anticipate looking better than their starting appearance. Attempts to remove every millimeter of excess skin will produce a stretched mid face and may cause linear bands or furrows across the mid cheeks, a telltale sign of facelift. A ninety percent improvement is far better than overdoing a hundred and ten percent. Patients should accept a few remaining wrinkles to avoid a masklike face. Yet the inner layers of the facial structure are appropriately repositioned to counteract the drooping which has taken place. This two layer approach known as a SMAS lift corrects the inside first, eliminating a need to pull the outside skin excessively. Loose skin is then simply redraped to eliminate excess overlap.

The age at which one seeks a facelift will vary with the degree of fastidiousness and personal awareness of changes of ageing. Here too there is no standard. I have had fine results in patients as young as 38 and as old as 83. Younger patients will have more subtle results but will see a fresher look. The older patient whose face has aged significantly will see a more dramatic change but should always retain her own natural expression. The surgeon cannot promise patients that a result will last for five, or any years, but a person will always look better for having had the surgery as life and the ageing process continue. I know this from comparison experiences in my own practice. I have operated on the older of two sisters only to have the younger seek surgery after several years to catch up with her older sister's more youthful appearance.