Overview of Rhytidectomy
Rhytidectomy, usually known as a facelift, is a type of surgery that rearranges the soft tissue of the face to make the person look younger and their features more balanced. Although now quite common, this procedure wasn’t well known in the early 1900s because people tended to be against cosmetic surgery and because surgeons didn’t share their methods.
The first facelift was recorded in 1901 by a surgeon called Eugene von Holländer. He simply cut away excess skin and then stitched it back together with minimal disruptions to the underlying tissue. After World War I, people began to get more used to the idea of plastic surgery, and the demand for it increased. And after World War II, with the development of antibiotics and anesthesia, surgeons started to take a more ambitious approach to facelifts.
In 1969, Tord Skoog, a plastic surgeon from Sweden, changed the way facelifts were done by creating a dissection along the superficial fascia, the connective tissue just under the skin of the face. This technique provided longer-lasting results. This tissue was later given the name superficial musculoaponeurotic system (SMAS) in a 1976 study. From this research, a new surgery method, called the “SMAS rhytidectomy”, was developed. This technique involves manipulating the SMAS tissue, either by folding it and suspending it in place or by cutting away the excess and stitching the remainder together.
In 1983, a surgeon called Hamra introduced a new method called the “tri-plane rhytidectomy”, which included lifting the skin in the neck area to improve the shape of the neck. However, this still did not address saggy skin or lax tissues in the middle of the face. So, in 1990, Hamra introduced the “deep-plane rhytidectomy,” a new procedure that involved rearranging the muscles and supportive tissues in the cheek area to lift the fat pad in the cheeks and smooth out the folds between the nose and mouth (melolabial folds). In 1991, Hamra added the lifting of the muscles around the eyes (orbicularis oculi) to improve the look of the cheek and eyelid area, and reposition fat around the lower eyelid (suborbicularis oculi fat) to correct prior facelifts which caused a hollow look around the eyes.
Nowadays, there are many types of facelift techniques that focus on individual patient concerns, whether that’s saggy skin around the jaw (jowls), folds between the nose and mouth (melolabial folds), loose neck muscles (platysmal banding), or reducing scars.
Anatomy and Physiology of Rhytidectomy
Facial aging is a result of various factors such as gravity’s pull on our skin and soft tissues, weakening of the ligaments holding our skin, looser skin, fat loss, shrinkage of bones, amongst others. These changes in our skin and bones result in a hollow appearance in the areas around the temples, lower cheeks, and chin. Dropped facial fat and sagging ligaments deepen the folds and lines in our face. Alterations in the bones around the upper jaw and eyes can lead to saggy lower eyelid tissues. Jowls, which form due to sinking of the fat of the cheeks, distort the jawline and is a common reason people choose facelifts. Facelifts or a deep-plane facelift may be necessary if there are wrinkles or folds that require treatment.
An understanding of our anatomy is crucial to a successful surgery and to avoid complications. This is particularly true when it comes to our face, where important structures are very close to each other. Any damage can lead to noticeable changes in our appearance that are tough to hide or reverse. A vital layer known as the Superficial Muscular Aponeurotic System (SMAS) that covers the large salivary glands in our face plays a huge role in facelifts. Understanding its function has led to a better knowledge of how our face ages. The SMAS continues into the muscles on the side of our neck, the area of our skull above our cheekbones, and our sternocleidomastoid muscle, which helps us turn and tilt our head.
Our facial nerve is of prime importance when performing facial surgery. This nerve exits the base of the skull, travels through a salivary gland and divides into many branches, which resemble the foot of a goose. These nerves are divided into five major sections and run deep to the SMAS and stimulate muscles from their deeper surfaces. These nerves enable us to make different facial expressions. During a facelift, these are the nerves most commonly affected, with ones going to the ear being most frequently injured.
A neck lift, or Cervicoplasty, is often performed alongside a facelift to maintain a balanced and renewed look. This procedure aims to restore a youthful shape with the ideal angle between the neck and the chin, reduce excess fat under the chin, and/or lessen the appearance of bands on our neck muscles.
From a surgical perspective, there are a few critical points to keep in mind. For instance, the ‘Pitanguy’s line’ approximates the path of the frontal branch of the facial nerve that travels deep to a layer called Temporoparietal Fascia (TPF) and another point on the nerve called the ‘McKinney’s point,’ identifies the location of the great auricular nerve. The facial nerve goes through several critical points that may be injured during surgery, but usually, injuries do not warrant nerve exploration or repair. The marginal mandibular nerve’s location is superficial to facial vessels and often associated with wrapping around a vein, known as the facial vein. The cervical branch of the facial nerve located below the midpoint of a line running between the chin and the tip of the mastoid process innervates certain muscles. An injury to this nerve can cause lower lip asymmetry.
Why do People Need Rhytidectomy
The process of getting a facelift, also called a rhytidectomy, is one of the many options you have to enhance your appearance as you age. This procedure involves lifting and re-positioning sagging skin and reducing excess skin. The type of facelift you get will take into account your unique features and particular concerns about your looks.
Before the surgery, your doctor will conduct a thorough examination of your skin’s condition, wrinkles, scars, and whether there’s been any loss or shifting of fatty tissue or bone loss. This is to set realistic expectations for the results. Your doctor will also take pictures of your face from different angles to properly document things like unevenness in your face or irregular contours, as well as your hairline. This is all done to ensure you and your surgeon understand and agree on the outcome you desire.
If you’re mainly worried about jowls or a sagging neck, with or without visible neck muscle bands, you might be recommended a specific type of facelift called SMAS rhytidectomy and cervicoplasty. If you have significant sagging in your cheek fat or deep lines running from your nose to the corners of your mouth, then a deep-plane rhytidectomy or an additional mid-face lift might be suggested. The composite rhytidectomy, which is a type of deep-plane facelift that also includes adjustment of the fatty layer under the eyes, can be used to further improve the transition between your lower eyelid and cheek.
The facelift can also be accompanied by other types of procedures to address ageing, such as a brow lift, eyelid surgery (blepharoplasty), cervicoplasty, fillers or fat transfers, and laser resurfacing. These all contribute towards a comprehensive treatment approach to handle signs of aging on your face.
When a Person Should Avoid Rhytidectomy
Several major health conditions such as diabetes, weakened immune system, need for steroids, blood clotting problems, and disorders of the body’s connective tissues can make it harder for wounds to heal. Smoking is a significant risk, as it negatively affects blood flow, and can increase the risk of skin flap damage. Similarly, radiation therapy can also have a negative impact. For individuals with these risk factors, aggressive surgeries should generally be avoided.
Doctors suggest that someone should stop smoking at least 2 to 4 weeks before surgery and maintain that break for a month after surgery. This helps wounds to heal better.
In some instances, a history of serious sunburns can also make it harder for wounds to heal. Conditions such as blood clotting disorders, the need for blood thinners, and high blood pressure that isn’t well-controlled can be particularly problematic. These conditions can increase the risk of developing a hematoma (a swollen area filled with blood) which is a common complication after a rhytidectomy (also known as a facelift).
Medications and herbal supplements that can affect blood clotting should be stopped, if possible, two weeks before surgery. It’s also very important for your doctor to understand any mental health conditions you may have before deciding on surgery. This helps your doctor understand your motivations behind wanting surgery. People with a condition called body dysmorphic disorder, who perceive flaws in their appearance that aren’t observable to others, should be assessed by mental health professionals before having surgery.
Moreover, any significant health conditions that can be addressed before starting cosmetic procedures should be properly managed. This will help to make the surgery safer for you. In general, it’s not recommended to have a facelift if you aren’t in good overall health.
Equipment used for Rhytidectomy
In layman’s terms, a basic facelift surgery tool set should contain:
Certain types of facelift and suture scissors – These are used to cut skin and stitches. Some specific types include Gorney-Freeman, Kaye, Goldman-Fox, Castanares, Mayo, and Iris or Tenotomy scissors.
Needle drivers, like the Halsey or Webster models – Needle drivers are tools used to hold and guide the needle during suturing. Some surgeons may prefer the Haney needle drivers for tightening the neck muscles (platysmaplasty), and the Castroviejo needle drivers for delicate stitching.
Various types of forceps, such as the models Adson-Brown, DeBakey, Gerald, or the fine Castroviejo – These tools are used to hold or pick up tissues during the surgery.
#15 blade scalpel and #3 handle – This is the cutting tool used during the surgery.
Ferreira facelift or breast retractor – These tools are used to hold back the skin or tissue to improve the surgeon’s view of the surgical area. This could come with or without a light source attached.
Headlight – This is used if there’s no light source attached to the retractor, to illuminate the surgical area.
Joseph or Freeman skin hooks – These are used to lift and hold the skin during surgery.
A suction device – This helps to remove blood or other fluids during surgery.
Bipolar and/or monopolar electrocautery – These devices use electricity to cut tissue or stop bleeding.
The stitches might include:
2-0 polydioxanone, braided polyester, or polyglactin – These are strong stitches used to lift muscles under the skin and the neck.
4-0 or 5-0 polyglactin or poliglecaprone – These are used for the closure of deep layers of the skin.
5-0 or 6-0 polypropylene, nylon, or gut – These are used to stitch up the skin surface.
Staples – These are used for the incision within the hairline behind the ear.
Some doctors might place drains and a bandage with cold packs to reduce swelling and bleeding. Others may avoid this and consider using a tissue glue to minimize the space under the facial skin.
If there are additional procedures needed, such as eyelid surgery, brow lift, fat transfer, or laser skin resurfacing, extra tools will be required.
Who is needed to perform Rhytidectomy?
Most surgery needs a special kind of nurse called a surgical technologist and another nurse who moves around the room (a circulating nurse). For most people getting a rhytidectomy, which is a type of cosmetic surgery, they are put to sleep with general anesthesia by a professional who specializes in that. There is also usually an assistant who helps the surgeon to make the surgery go smoothly and quickly.
Preparing for Rhytidectomy
The patient is made to lie flat on their back on the operating table during the procedure. If the patient has a tube inserted into their throat to assist with breathing, it might be tied to one of their upper teeth. This helps to keep the patient’s airways open while allowing the doctor to work on both sides of the face and neck.
Before the operation, the skin is cleaned with povidone iodine or isopropyl alcohol. This is a common step to avoid any chances of infection during the surgery. Often, a good amount of a local anesthetic or a “tumescent solution” is injected into the area. This solution usually contains medicines to numb the area and slow bleeding. This step helps to use fewer anesthetic drugs during surgery and reduces the chances of postoperative bruising.
In addition, intravenous antibiotics are given to ward off any potential infections, steroids to manage inflammation, and tranexamic acid to minimize bleeding. All these pre-procedure steps are taken to ensure a safe and effective operation.
How is Rhytidectomy performed
The process of preparing for this surgery includes marking points on the skin where the surgeon will make cuts, as well as identifying key areas necessary for the operation. The exact pattern for the cuts will depend on the surgeon, but usually involves making an incision that starts either within or along the edge of the hairline and proceeds around the ear. The surgeon might choose to make the cut slightly behind or in front of the ear. It’s important to note that the placement of this incision can affect how visible the scar is after the surgery and how the ear looks.
Additionally, the surgeon might mark points on the skin to show where underlying nerves and muscles are. They’ll also make note of the angle of the jaw, and might highlight lines on the neck if part of the procedure includes tightening the neck muscles.
Then, the surgery begins. If necessary, the surgeon might remove excess fat from the neck and face using a suction technique. Next, they make an incision and create a flap of skin. Using special tools, the surgeon lifts this flap of skin so they can work on the tissues underneath.
During the surgery, the surgeon may manipulate the layers of tissue underneath the skin to create a more youthful appearance. There are different methods for reducing excess tissue – in one approach, this tissue is folded and sewn into place. Alternatively, the surgeon may cut away the excess tissue and sew the remaining tissue into a more flattering position. Another technique involves making a similar skin flap, but then going deeper to adjust the muscle and fat in the face.
A newer, less invasive method called Minimal Access Cranial Suspension (MACS) lift, involves lifting the tissues with special sutures. The stitches are used to lift and tighten the tissues in a more natural-looking way, resulting in a less invasive procedure with more natural results.
Throughout the surgery, it’s critical to manage bleeding carefully – too much use of a tool that stops bleeding can cause injury, while not enough can lead to complications. Once the underlying work is done, the skin is then laid back into place. The excess is removed, and the skin is sewn together with stitches or staples. Finally, if part of the procedure included tightening the neck muscles, this is done either before or after the main part of the face lift surgery.
Possible Complications of Rhytidectomy
Just like any medical procedure, facelifts can sometimes have complications despite the careful preparation and precision used during the surgery. Most often, people just might not be happy with the result of the facelift, due to issues like scarring, a change in balance or symmetry, changes in the shape or smoothness of their skin, or a result that looks like too much or too little was done. Building a good relationship between the doctor and patient before surgery can help handle these challenges afterwards, leading to better satisfaction and fewer chances of legal problems if the result isn’t as expected.
A hematoma, or an area of the skin that’s bruised or filled with blood, is the most common complication after a facelift. It happens to about 0.2% to 8% of people who have the surgery. Hematomas can either be major or minor. Major ones usually happen within 24 hours of the surgery. Symptoms include a mass under the skin, pain, and a skin discoloration that looks like a bruise; these require a follow-up procedure to stop the bleeding. If this happens in the neck, it can affect your airway, and the wound needs to be immediately opened. Minor bleeding, on the other hand, can be delayed and may come from the blood vessels right under the skin. These minor bleeds can be managed with careful observation or draining where the bleeding happened.
Certain factors can increase the risk of hematomas. These include high blood pressure, being male, having blood clotting disorders or taking medications that thin the blood, experiencing post-operation nausea, vomiting, and pain. Men’s skin is more likely to bleed than women’s because it has hair follicles. People should also avoid medications and supplements that can increase bleeding, like aspirin, NSAIDs and some herbs or high doses of certain vitamins, for two weeks before the surgery.
High blood pressure specifically is the most significant risk of causing hematomas. The goal is to keep blood pressure below 150/90 mmHg. Before the surgery, medications that can relax or calm you, like valium or clonidine, may be given. During the surgery, efforts should be made to stop any bleeding before closing the wound. And after the surgery, things that can upset patients, like nausea or pain, should be addressed right away. Although it’s not clear if placing drains affects the formation of hematoma, they may help in reducing seroma, or the accumulation of watery fluid in the body.
Skin death or necrosis can sometimes happen due to small blood vessels being compromised from fluid or hematoma formation, and due to conditions such as diabetes and smoking. Procedures that enhance the skin’s look done on the cheeks at the same time as the facelift can also increase the risk of skin necrosis. This can involve either the top layer or the deeper layers of the skin. Patients suffering from top layer necrosis may notice their skin changing color and peeling. This usually gets better with simple wound care and heals well without leaving a scar. Medicines like Nitropaste or dimethylsulfoxide (DMSO) might be used to improve blood flow. Full-thickness necrosis takes a longer time to heal, and can leave the skin discolored or scarred, and sometimes need further interventions. Doctors should wait for the wound to clearly show symptoms, and early cleaning should be avoided to prevent more harm.
The biggest risk factor for skin necrosis among rhytidectomy patients is smoking. Cigarette smoke contains harmful substances that can affect the flow of oxygen in small blood vessels and hinder wound healing. Research has shown a higher rate of skin death among smokers compared to non-smokers who underwent rhytidectomy. Giving up smoking two to four weeks before and after surgery is strongly advised to prevent skin necrosis. Certain medications that can affect wound healing, like chemotherapy and steroids, should also be considered before a rhytidectomy.
Finally, the skin should be closed without tension to avoid blood flow shortage at the wound edges. The skin areas in front of the ears and just above the back of the ears are the most prone to ischemic injury, a kind of damage caused by lack of blood supply, and thus more likely to undergo necrosis.
Damaging the nerves is another complication but is not seen often, and can be prevented by proper knowledge of the relevant anatomy and careful surgical techniques. If a nerve is cut and the injury is identified during the surgery, immediate repair by microsurgeries is recommended. Damage to the nerves that move muscles may take a year to recover or may not fully recover at all, but they can be managed in the meantime with injections to the opposite facial muscles to improve symmetry.
The nerve that feels the sensations of the lower ear and mastoid skin, or the area of the bone behind the ear, is the most common one to be injured during a rhytidectomy, mainly when the back part of the skin flap is raised. This can cause numbness, with patients reporting difficulty in placing earrings, using telephones or combing their hair. The nerves that drive the movement of the front and the lower edges of the face are the most common ones to be injured. Raising the thin layer of fat over the arch of the cheek bone and the thinner muscle layer around the lower jaw’s angle can help prevent injury to these nerves.
A rare complication is surgical site infection, owing to the plenty of blood supply to the face that protects it. Wound infections are most commonly caused by bacteria like Staphylococcus or Streptococcus, and typically go away with antibiotics targeting skin bacteria.
Scarring and changes in the skin’s shape and texture are issues that might happen after a facelift, which is why the incisions are carefully placed in the hairline or natural skin folds to hide them. Post-operative hematomas can stretch the skin, leading to wider scars.
What Else Should I Know About Rhytidectomy?
Rhytidectomy, also known as a facelift, is one of the top five most common cosmetic surgeries, with over 120,000 carried out in 2019, according to The American Society of Plastic Surgeons. This makes it crucial for surgeons performing these procedures to have a deep understanding of their craft, including the history, anatomy involved, and the minute details of the technique. They also need to be excellent at building relationships with patients to achieve the best results.
No two facelifts are the same; each one is customized to the individual. The success of the procedure relies heavily on choosing the right patients, the surgical method used, and how patients are looked after once the operation is complete. Health professionals need to know about any medical conditions a patient has like diabetes or high blood pressure, as well as lifestyle habits like smoking or using herbal supplements as these can increase risks. It’s also essential to build good relationships and manage patients’ expectations realistically.
The best approach to a facelift depends on several factors: what the patient wants to achieve, how their face has been impacted by aging, and the surgeon’s expertise. There are several types of facelifts, such as SMAS rhytidectomy, deep-plane rhytidectomy, and MACS lift, which focus on different parts of the face. It’s also worth noting that facelifts are just one way to rejuvenate the face. Other treatments like blepharoplasty (eyelid surgery), cervicoplasty (neck lift), liposuction, injectable treatments, and skin resurfacing could also be considered to improve the overall results.
Finally, looking after the patient once the surgery is over is vital. Patients need to follow the care instructions provided and should have easy access to their surgeon or a nurse in case complications arise. Quick intervention can help prevent any negative effects and improve the outcome.
