The Minimal Incision Facelift
James J. Romano, MD, practices plastic surgery in San Francisco, specializing in cosmetic and restorative surgery of the face and body, including laser surgery. A graduate of The College of William and Mary in Williamsburg and the Eastern Virginia Medical School, he completed training in general surgery at Bellevue Hospital and Georgetown University, and had plastic surgery training at The Johns Hopkins Hospital. Dr. Romano has been in practice since 1988.
The facelift was first introduced in the early 1900s, and consisted of a small incision in front of the ear where loose excess skin was removed. Systematic advances throughout the years have improved this basic technique; in the last 10 years, there has been an explosion of additional techniques. As a result, clients are more confused than ever, and are asking more questions and demanding detailed information. How can the esthetician help shed some light on surgical procedures? Skin care specialists play an increasingly significant role in guiding their clients and providing some of the answers in the arena of facelift surgery. It is for this reason that the not-so-new-procedure—but one that is becoming increasingly popular and worthy of review—is being highlighted: the mini-facelift.
Today, the mini-facelift sometimes is criticized as being the same "minimal" operation that began nearly a century ago. Although the inconspicuous incision is similar, today's results are far greater. The mini-facelift provides more than a minimal result—it also disturbs less tissue, is less risky, heals faster, has less swelling, and provides a faster return to work than a standard facelift. It can safely and predictably be repeated years later for touch-ups, and doesn't interfere with the option to have a standard or full facelift performed at a later date. The role of the esthetician in patient preparation has a significant impact in this procedure, where even a little bit of aggressive skin care seems to go a long way. Inventions such as deep cleansing, glycolic peels, masks, lymphatic massage, and topicals all play a role pre- and post-operatively. So, why the sudden interest in the mini-facelift? Primarily because today's baby boomer population wants minimal surgical interventions that can make a big difference. It greatly appeals to younger or more active patients, especially those who don't need an extensive or full facelift but still would benefit from a "refreshing" procedure. Also noteworthy is the fact that physicians have learned how to apply the principles of the larger facelift procedures to improve the benefits and longevity of the mini-facelift. Combine this with the fact that people want to return to work and active lifestyles as quickly as possible and not look as though they've had a facelift, and the mini-facelift is the perfect answer for many.
Anatomy of the face
The anatomy of the face as it concerns the standard facelift and mini-facelift deserves some review. Examination of your clients for pre-surgical purposes should focus on skin, subcutaneous fat, muscle tone, and underlying bony foundations. Evaluate the skin not only for its texture, but also take care to note the elasticity, folds, looseness and mobility. The subcutaneous fat is mostly localized to the areas of the face lateral to the nasolabial furrow (laugh line), and settles over time and with gravity into the jowl and can hang over the border of the jaw and onto the neck. In addition, note the fat in the cheek pads that can descend, as well as the fatty accumulations that may be present in the lateral cheeks. Muscles are most importantly evaluated in the midline of the neck (see Figure 1). Ask your clients to lift their neck, clench the teeth, and push down the corners of the mouth. This tightens the platysma muscle of the neck, which is like a sheet on each side running from the collar bone up to the jaw line. The platysma muscle stops near the jaw line, where it continues onto the face as a very important ligament called the superficial musclo aponeurotic system (SMAS). This ligament is used in facelift surgery for internal or deep support, which will be described in the following section. Asking clients to do this maneuver will make apparent any "bands," or double folds in the midline neck—if they are present. These are not improved with the mini-facelift—all the more reason why clients without these bands get a great result. Finally, evaluate the jawbone and cheekbones. Sometimes, when the skin is tightened and fat removed, underlying bony asymmetries can be uncovered, which the physician always should be careful to identify and point out to patients before any surgical procedure.
In addition, localized fatty accumulations in the neck in patients without muscle bands and good skin tone can be liposuctioned with very dramatic and natural results through the same facelift incision or other tiny (2 mm) incisions. In general, clients who need features improved mostly above the jaw line can benefit from the mini-facelift. Clients who need features improved above and below the jaw line will benefit from the full facelift.
Who is a candidate?
It is fairly straightforward determining who is a candidate for this procedure. I focus on the four main areas that predictably can be improved or softened with the mini-facelift in this order: excess sagging skin confined to the cheeks, jowls, and jaw line; the deep nasolabial furrow; descending cheek pads; and hanging skin, or hooding, of the upper lateral eyelids. Remember that the drooping corners of the mouth as well as the extreme excess skin, folds, and loose muscles of the neck cannot be predictably improved with the mini-facelift. However, in many clients with good skin tone and elasticity, but with fat excess in the jowls and neck, I combine the mini-facelift with facial and neck liposuction. Estheticians should teach clients to examine themselves and make a decision with the help of the "lift and pull test," which is easy to do. Looking straight ahead into a mirror, place the hands along the cheekbones to the jowls then gently pull straight back and lift up. If there is much laxity and a significant and natural improvement is seen in the four features described above, then a mini-facelift is a good solution. Notice that this causes just a little tightening of the neck in the center, which should be pointed out to the client only as a possible bonus, should it occur. But remember, the best treatment for a difficult neck remains a full facelift. To make this even clearer, consider the specific technique of the mini-facelift and how this differs from a full or standard facelift. Bear in mind that the principles physicians have learned over the years from the deeper and more extensive facelift apply well to the mini-facelift and help improve the procedure.
Anesthesia for the mini-facelift has the advantage of encompassing all options. It can be performed using straight local anesthesia only, local anesthesia with light intravenous sedation, or can be done very safely under general anesthesia if the client prefers. The incision is custom-designed to best address the specific areas to be improved, but generally follows a line inside the temporal hair down to the upper ear edge, neatly along inside the ear cartilage, and down only to the earlobe. It does not extend behind the ear or down onto the neck, a major advantage of this over the full facelift incision. Working through this incision, a space is made under the fat and above the SMAS ligament (see Figure 1) for a short distance only as far as needed—usually about two inches—until the relaxed fibers of SMAS ligament and cheek pad are identified. I tug on these with forceps to test for improvement while looking at the face, and then sew the ligament and the cheek pad up and back onto itself. This maneuver tightens the SMAS ligament, which is connected to the sagging jowl, elevates and emphasizes the cheek pad, and softens the nasolabial furrow. This is the same internal or deep surgery that routinely is done on the standard and more extensive facelifts that has shown to provide better and longer-lasting results. Any excess fat in the jowls and neck is then liposuctioned through the same incision. Since most of the tightness to the elevated tissues is distributed along the stitches that have been placed in the sturdy SMAS ligament, the skin can be laid gently up in place under no tension, and the excess is neatly trimmed and the edge carefully stitched into place. This decreases the likelihood of wide scars and promotes incisions that heal, for the most part, imperceptibly. No drains are needed, and a light dressing is used. Recovery is comfortable and relatively rapid due to a combination of factors: minimal dressings, less disturbance of facial tissues, less swelling, less bruising, and better patient preparation and post-op care. Usually only mild discomfort is present and lasts for two to three days. I counsel each client that if surgery is performed on a Thursday or Friday, the majority of the recovery happens over the weekend. This allows the client to return to some activity and maybe even light work by the middle of the next week with minimal or no bruising and only mild swelling. The client can shower by the second day and camouflage makeup can be applied as early as the second or third day. On a professional level, I have learned the importance of carefully supervising lifestyle, diet, and nutritional supplements both before and after surgery. Longevity of this procedure is excellent. I have noticed that since many clients are relatively younger, they take a more active role with their estheticians in their skin health and care to maintain and preserve the mini-facelift results. Therefore, this is a procedure where having surgery earlier in life does seem to contribute to the procedure's longevity. Most patients find that if revisions are needed, they usually only involve a repeat mini-facelift instead of a full facelift. However, a full facelift can still be done at a later date, and is usually safer, easier, can be more aggressive and lasts longer than the previous facelift.
Know the options
The mini-facelift is not only a procedure your clients will be curious about, but keep in mind that it can be an excellent option or even a better alternative to the standard facelift, especially for the baby boomer clients. Don't underestimate your role in educating clients about this procedure, and the importance of the pre- and post-operative care you will render. Not only do you see and deal with the face and skin everyday, but you also see many clients who have had facelifts. This makes you a particularly good judge and counselor since you are aware of their pre-operative condition, the completeness of their results, and what is being done to maintain them. The mini-facelift is a procedure that can be tailored to the clients' needs and expectations. Be the first person to educate them about this procedure.