What Is The Best Type Of Facelift To Have Done?

Q: Dr. Eppley, I have a lot of  facelift questions for you. Which ‘full facelift’ technique do you offer? Do you offer the deep plane composite facelift technique with a 80% vertical pull and 20% lateral pull? I see on your website that most of your pulling is towards the ear. Doesn’t this result in a ‘wind pull’ ‘done’ appearance? The vertical pull seems to be more natural. And using the deep plane technique to offer a longer lasting result by accessing the the premasseter space, to lessen the jowl, and the labiomandibular fold?

A: Facelift surgery comprises a large number of techniques that can principally be broken down into incisional locations, skin flap undermining, SMAS management, platysmal muscle manipulation, method of fat removal and/or fat volume replacement. Any facelift procedure and its results and longevity is really a symphony of how these parts are put together that can really be different for each patient. Rarely do two facelifts have exactly the same anatomic components. I would submit that each and everyone of these parts have a role to play in the outcome and no one component alone is responsible for how a facelift result will look or how long it will last. There is also the other important variable which is the patient themselves…how extensive a procedure do they want, how much recovery and swelling can they tolerate and what is their budget.

But since you have ask about the SMAS component of a facelift I will address that issue in detail only as it relates to results and longevity. Manipulation of the SMAS layer in a facelift can be done by numerous methods including suture plication with no undermining to extensive undermining with a SMASectomy and plication. (what you are partially referring to with the term deep plane) While some manipulation of the SMAS has proven benefits over none at all (a simple subcutaneous facelift) it is has never been conclusively proven that deeper methods of SMAS undermining produce a more natural result or last longer than lesser degrees of SMAS undermining.  It would theoretically seem like it would, and it may well be, but proving it (other than some surgeon’s touting it as so) is another matter. Its proof would be difficult as it would require one type of facelift being done on one side of the face and another on the other side in a series of patients.

It is also important to understand the movement of the SMAS layer and the overlying skin may and often are different. Since the skin and SMAS are commonly separated, their tissue movements are usually in slightly different vectors. The SMAS layer can be done in a completely vertical direction (when it is plicated) or in a more superolateral direction when it is undermined and repositioned. Likewise the skin layer can be similarly moved  in these directions. Both the SMAS and skin layers are moved in varying degrees of superolateral movements. There is no such true lateral repositioning in either the SMAS or the skin layers. This is probably where you have gotten the phrase ’80% vertical and 20% lateral’, demonstrating that tissue relocation in a facelift is a combined superolateral translocation of tissue that is directed primarily towards the ear and the lower temporal region.

When it comes to what makes a facelift look natural, it is not an issue that is caused by one facelift technique being better in that regard than another. All facelift techniques, big or small, can make for an unnatural result. It is most significantly influenced by the ‘artistry’ of the plastic surgeon…not overlifting or overpulling any tissue layer and in how the incisions and hairline are managed around the ears and the temporal hair-bearing region. (e.g., more vertical directions of skin movement will move the hairline up higher unless that is factored into the incision design.

The deep plane composite facelift is unique amongst facial rejuvenation techniques because it basically does not separate the skin and the SMAS layer once beyond the anterior border of the parotid gland. Once the tissue plane is elevated, the entire composite of tissues is then lifted and secured. This composite tissue unit will always have a more vertical direction of relation, because if it does not, the amount of change would be minimized because the skin is attached to the SMAS layer throughout the flap. The deep composite facelift takes the longest to perform, has the greatest risk to injury of the buccal facial nerve branches, and will have a longer recovery due to prolonged swelling. Its best benefit, in my experience, is that it is the ‘safest’ facelift technique in smokers and others that may have compromised healing as the blood supply to the overlying skin is not disrupted by making a completely separate tissue layer from the SMAS.

Facelifting in men offers several unique considerations. The vector of tissue lifting in men has to be as vertical as possible since any significant lateral movement will result in having to workout tissue excesses behind the ear, risking a longer and more visible scar into the occipital hairline. Moving the sideburn higher is overcome by merely growing out the beard skin to drop the hair level back down. (which is why it is advised that men grow longer sideburns before the procedure) Too much of a lateral movement will also risk placing the beard skin closer to or on the tragus of the ear which is obviously undesirable. (although this can be prevented regardless of tissue movement by the location of the incision) Men are also unique facelift patients as their tolerance for a lot of swelling and prolonged recovery is not typically very high.

As you can see, facelift surgery is a myriad of assembled parts. While it is understandably convenient to label them as certain types, each facelift technique has varying influences on the outcomes, recovery and risk of complications.  One facelift type is neither completely superior nor applicable to every patients’s facial aging needs and concerns.

Dr. Barry Eppley

Indianapolis, Indiana