Rhytidectomy

Rhytidectomy commonly known as face-lift, is a cosmetic surgical procedure to create a younger appearance in your face. Rhytidectomy tightens and lifts loose, sagging skin in the face. Rhytidectomy also helps reduce lines and wrinkles in the face. Rhytidectomy procedure can reduce the sagging or folds of skin on your cheeks and jawline and other changes in the shape of your face that occur with age. During a rhytidectomy, a flap of skin on each side of the face is pulled back, and tissues below the skin are surgically altered to return the contour of the face to a more youthful shape. Before the flap is sutured closed, excess skin is removed. You may choose to have the rhytidectomy surgery to improve your appearance. Discuss your treatment goals with your board certified plastic surgeon. He or she can tell you more about what to expect.

The ideal rhytidectomy candidate is a middle-aged woman with a fair or medium complexion and a minimal amount of adipose tissue and moderate skin laxity in the jowl and cervicomental regions ¹. An individual with a strong, attractive underlying osseous framework, including prominent zygomatic arches, obtains even further enhancement. Conversely, an individual who is overweight with hyperpigmented thick skin does not obtain optimal results. Individuals with ptotic submandibular glands and an inferiorly positioned hyoid have a more obtuse cervicomental angle and obtain less-than-optimal results.

In 2014, according to the American Society of Plastic Surgeons, 128,266 facelifts were performed in the United States, making it one of the top five cosmetic surgical procedures performed (along with breast augmentation, blepharoplasty, liposuction, and rhinoplasty). Female patients accounted for the majority of facelifts (116,415) ².

Rhytidectomy risks and complications

The decision to have rhytidectomy surgery is extremely personal and you will have to weigh the potential benefits in achieving your goals with the risks and potential complications of facelift surgery. Only you can make that decision for yourself.

Rhytidectomy risks and possible complications include:

• Bleeding
• Infection occurs in less than 1% of cases
• Facial nerve injury, causing partial paralysis of the face (usually temporary) occurs in less than 1% of cases
• Great auricular nervy injury occurs in up to 7% of cases (most commonly injured nerve); causes lobule numbness
• Blood clots (hematoma formation) occurs in less than 2% of cases; must be addressed promptly to prevent flap necrosis.
• Poor wound healing and skin loss
• Hair loss (alopecia) near the incision sites may be prevented with beveled hairline incisions and avoidance of cautery near the hairline
• Changes in sensation, such as numbness or pain
• Persistent pain
• Unfavorable scarring
• Prolonged swelling
• Skin irregularities and discoloration
• Death of skin tissue, or of fatty tissue in the skin. Skin slough occurs in less than 3% of cases; most commonly in the post-auricular location.
• Abnormal collection of fluid under the skin
• Pixie-ear deformity caused by excessive tension on the lobule during skin inset
• Sutures may spontaneously surface through the skin, become visible or produce irritation that require removal
• Not happy with cosmetic results. Unsatisfactory results may include asymmetry, unsatisfactory surgical scar location and unacceptable visible deformities at the ends of the incisions. It may be necessary to perform an additional surgery to improve your results.
• Deep vein thrombosis, cardiac and pulmonary complications.
• Risks of anesthesia (the anesthesiologist will discuss these with you)

Past history of Bell palsy is significant. If positive, the patient should be informed that recurrence is possible postoperatively.

Increased risk of hematoma ³:

• Patients taking anticoagulants, antiplatelet agents, and nonsteroidal anti-inflammatory drugs
• Patients taking herbal medications and supplements such as chondroitin, ephedra, echinacea, glucosamine, ginkgo biloba, goldenseal, milk thistle, ginseng, kava, and garlic
• Men (relative contraindication): twice as likely to experience hematoma (up to 8%)
• Poorly controlled hypertension, both pre-operatively and intra-operatively.

Rhytidectomy contraindications

Absolute contraindications include bleeding diatheses and American Society of Anesthesiologists (ASA) classes IV and V. Strong relative contraindications include patients with diseases predisposing to poor wound healing, ie, those with diabetes mellitus, those on long-term steroid therapy, or those with connective-tissue disorders such as Ehlers-Danlos syndrome.

Active smokers: Skin flap necrosis is 12 times more common in smokers who undergo any type of facelift. Rees and Aston noted that people who smoke have 12 times more risk of skin slough than people who do not smoke do. Patients who smoke also have a higher risk of hematoma formation. These effects are believed to be due to increased vasoconstriction and coughing in smokers, respectively. If the patient stops smoking for 1 month before and after surgery, these complications can be limited. Note: may not hold true for the deep plane technique ⁴.

Body Dysmorphic Disorder: a psychiatric condition classified as an obsessive-compulsive–related disorder, where patients exhibit an obsessive preoccupation with perceived defects in their appearance that are either minute or absent. Moreover, patients with body dysmorphic disorder tend to have poor satisfaction following surgery and show a higher rate of aggression and litigation toward surgeons. The prevalence of body dysmorphic disorder may be as high as 13% in patients who present for a facial plastic surgery consultation ⁵.

Preparing for rhytidectomy surgery

During your facelift consultation be prepared to discuss:

• Your surgical goals
• Medical conditions, drug allergies and medical treatments
• Current medications, vitamins, herbal supplements, alcohol, tobacco and drug use
• Previous surgeries

Your surgeon will also:

• Evaluate your general health status and any pre-existing health conditions or risk factors
• Discuss your facelift options
• Examine and measure your face
• Take photographs
• Recommend a course of treatment
• Discuss likely outcomes of a facelift and any risks or potential complications
• Discuss the type of anesthesia that will be used

Prepare for the rhytidectomy surgery as you have been told. In addition:

• Tell your doctor about all medications you take. This includes herbs and other supplements. It also includes any blood thinners, such as warfarin, clopidogrel, or daily aspirin. You may need to stop taking some or all of them before surgery.
• Tell your doctor if you smoke. Smoking can affect healing after the surgery. For better results, your doctor may ask you to stop smoking in the weeks before and after the surgery.
• Do not eat or drink during the 8 hours before your surgery, or as directed by your surgeon. This includes coffee, water, gum, and mints. (If you have been instructed to take medications, take them with a small sip of water.)

A history of anticoagulant use (including warfarin [Coumadin] and nonsteroidal anti-inflammatory medications such as aspirin and ibuprofen) is critical. Use of these medications must be discontinued at least 1 week prior to surgery to prevent excessive bleeding and hematoma formation. Vitamin E intake in excess of 400 IU per day should also be discouraged. Other herbal therapies, including Ginkgo Biloba, should be avoided.

The day of rhytidectomy surgery

The surgery takes about 2 to 6 hours. You may go home the same day. Or you may stay overnight.

Before surgery begins:

An IV line is put into a vein in your arm or hand. This line supplies fluids and medications.

You’ll be given medication to keep you free of pain during the surgery. You may have general anesthesia, which puts you into a state like deep sleep during the surgery. (A tube may be inserted into your throat to help you breathe.) Or you may have sedation, which makes you relaxed and sleepy. With sedation, local anesthesia will be injected to numb the areas being worked on. The anesthesiologist will discuss your options with you.

During the rhytidectomy surgery

Step 1 – Anesthesia

Medications are administered for your comfort during the surgical procedure. The choices include intravenous sedation and general anesthesia. Your doctor will recommend the best choice for you.

A variety of other procedures can further enhance the outcome of a facelift. They include:

• Facial implants or fat transfer to improve contour
• Resurfacing techniques to improve the tone and texture of facial skin
• Wrinkle reduction by injection of fat or fillers

Step 2 – The incision

Depending on the degree of change you’d like to see, your facelift choices include a traditional facelift, limited incision facelift or a neck lift.

A traditional facelift incision often begins on one side of the face in the hairline at the temples. It travels along the front of the ear, and then behind it. It ends in the lower scalp. The same incision is made on the other side of the face. Shorter incisions, or incisions in different locations may also be used.

The skin is lifted to expose the fat and muscle layers beneath.

Excess fat may be removed or repositioned for smoother contouring and underlying tissue is repositioned, commonly the deeper layers of the face and the muscles are also lifted. The deeper muscle and tissue layers may be tightened and lifted with stitches (sutures).

The skin is pulled back down. Any excess skin is then removed.

The incisions are closed with stitches, staples, or surgical glue. Some surgeons use skin glues to seal the incisions. Once healed, the incision lines from a facelift are well concealed within the hairline and in the natural contours of the face and ear.

A small tube (drain) may be placed near the incision. This removes fluid that can build up after the surgery.

Additional procedures may be done at the same time for fat filling, recontouring, or soft tissue augmentation if you choose.

• An alternative to a traditional facelift uses shorter incisions at the temples, continuing around the ear. “Mini-lifts” are usually reserved for patients with less skin relaxation, as the results are less rejuvenating than a full facelift.
• A necklift addresses the sagging jowls, loose neck skin and fat accumulation under the chin. The neck lift incision often begins in front of the ear lobe and wraps around behind the ear, and ends in the posterior hair behind the ear.

After the rhytidectomy surgery

You’re taken to a recovery room to wake up from the anesthesia. You may feel sleepy and nauseated. If a breathing tube was used, your throat may be sore at first. If needed, you’ll be given pain medication to relieve any discomfort. Your face may be bandaged to minimize swelling and bruising. And you may need to wear a compression garment around your head. An ice pack or cold compress may also be applied to your face. These steps help reduce bruising and swelling.You may go home the same day. Or, you may be moved to a room to stay overnight. When it’s time to go home, have an adult family member or friend ready to drive you.

Recovering at home

For the next few weeks, expect to have some pain, bruising, and swelling. Your doctor will tell you when you can return to your normal routine. Once at home, follow all the instructions you’ve been given. Be sure to:

• Take all prescribed medications exactly as directed.
• Apply an ice pack or cold compress to your face as directed.
• Care for your incisions as instructed. This includes keeping your bandages and incisions dry when bathing or showering.
• Wear your compression garment as directed.
• For 10 days after surgery, always keep your head higher than your heart. For example, don’t stoop down to tie your shoes.
• Walk at least a few times a day, but don’t push yourself too hard.
• Avoid heavy lifting and strenuous activities as directed.
• Avoid driving until your doctor says it’s okay. Do not drive while taking medications that make you drowsy or sleepy.

Follow-up

You’ll have follow-up visits with your doctor. These are needed to check how well you’re healing. These also allow your doctor to monitor the results of your procedure. If you have a drain, it may be removed about 2 days after surgery. If your stitches need to be removed, this is done about 5 to 7 days after surgery. Staples at the hairline are often removed 7 to 10 days after surgery.

What results should I expect after a facial rhytidectomy?

While most people are presentable to the public within 10-14 days, it will take 2-3 months for the face to feel “back to normal” in terms of texture, sensibility and loss of tightness.

Continuing daily sun protection and a healthy lifestyle will help extend the results of your facelift.

As swelling and bruising subside, the visible improvements of a facelift appear. Your final result should not only provide a more youthful and rested appearance, but also help you feel more confident about yourself.

Although good results are expected, there can be no guarantee. In some situations, it may not be possible to achieve optimal results with a single surgical procedure and another surgery may be necessary.

Follow your physician’s instructions to ensure the success of your surgery.

1. SMAS Facelift Rhytidectomy. https://emedicine.medscape.com/article/841892-overview
2. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. 2014 Plastic Surgery Statistics Report. American Society of Plastic Surgeons.
3. Derby BM, Codner MA. Evidence-Based Medicine: Face Lift. Plast. Reconstr. Surg. 2017 Jan;139(1):151e-167e.
4. Parikh SS, Jacono AA. Deep-plane face-lift as an alternative in the smoking patient. Arch Facial Plast Surg. 2011 Jul-Aug;13(4):283-5.
5. Joseph AW, Ishii L, Joseph SS, Smith JI, Su P, Bater K, Byrne P, Boahene K, Papel I, Kontis T, Douglas R, Nelson CC, Ishii M. Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics. JAMA Facial Plast Surg. 2017 Jul 01;19(4):269-274.