Combining the strength of deep plane facelift with the softness of autologous fat grafting.
When seeing me for a facelift consultation, almost universally, my patients share the same fears and apprehensions.
Certainly, they want to see significant improvements in their neck and jawline, to reduce hollowness and loss of volume of their cheek region, to soften deep folds around the eye and mouth—all in order to present a more youthful and healthy appearance.
But what they dread is the risk of looking overly pulled and stretched. Everyone has an image of a poorly done facelift producing distortion of the mouth, a windswept appearance to the cheeks, and an unnatural transition and balance of the lower face. Combine that with broad and visible scars, facial nerve disruptions, pulled earlobes, and hairline irregularities--improperly performed facelift surgery can cause serious deformity.
While these are the common factors that come to mind when thinking of poorly performed facelift surgery, I see another series of disappointments when patients come to see me for revision facelift surgery. Often times, a previous inadequate surgery has produced substandard correction and minimal improvement. Furthermore, these patients often describe a very short-lived result, returning to their baseline in a few short years.
It is with the goals of producing the most effective and natural appearing result while avoiding any distortion, that I am a strong believer in deep-plane facelift surgery. The procedure should be envisioned as a repositioning and volumizing procedure rather than a pulling or stretching. Sometimes our patients may envision the term “deep-plane” as being a more invasive procedure, however, this is certainly not true. Rather, in experienced hands, elevating the delicate facial tissues in a slightly deeper layer allows us to produce a more effective, long-lasting result without any difference in downtime or recovery.
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Recently, we have developed a much more sophisticated understanding of the facial aging process. Over time, three primary elements undergo significant change: the quality of the skin envelope, the composition of subcutaneous fat and muscle, and the support of the facial bones.
We can all appreciate that over time and with exposure to our environment, facial skin loses elasticity and develops both coarse and fine wrinkles. Deep to the surface, the facial fat compartments not only descend in position, but they undergo atrophy and loss of volume. These positional and volumetric changes result in the transition from elevated and defined upper cheeks to a more aged, heavy redistribution of soft-tissue along the jowls and upper neck. Furthermore, the facial skeleton itself undergoes significant involution over the years. The bony support of the eyes, cheeks, and jaw actually starts to recede. This loss of framework compounds the hollowing and lack of projection seen in the older face.
In our approach to patients undergoing facelift surgery, we must also expand our focus beyond simply the jowls and submental regions. The interplay between the lower face the lower eyelids, temples, and forehead should be assessed carefully. While additional procedures such as eyelid surgery and forehead lifting may contribute significantly to a comprehensive result, an effectively performed facelift should have the power to enhance the midfacial and lower orbital regions by itself.
In my practice, facelift surgery is an out-patient, day-surgery procedure. I generally favour deep intravenous sedation for anesthesia as it reduces the post-operative recovery period after surgery. The incision is precisely marked out prior to surgery so that it may hide in the most favourable locations, thereby minimizing visibility. Placed within the first few rows of hairs along the temporal tuft, it is almost completely camouflaged in this region. As it courses along the junction of the ear and cheek, it is concealed within the natural crease. A millimeter cuff is left along the ear lobe to avoid distortion in this region, and then the incision is brought into the post-auricular sulcus and along the margin of the posterior hairline. I prefer this placement as opposed to extension into the posterior hair as it avoids any step-deformity in the hairline. Once healed, the incision is almost invisible when it is closed without any tension. I tell my patients that they will not have to hide their incision lines at all, and they will be able to wear their hair back or in a pony-tail without hesitation. Producing a perfectly natural hairline, with near-invisible scars should be an achievable goal for all our patients undergoing facelifts.
The skin is elevated in a subcutaneous plane, just above the SMAS and platysmal layer of the face. This layer is a fine, but sturdy layer upon which all the lifting is performed. Elevation and mobility of the SMAS is where all of the power of facelift surgery lies. The SMAS is incised along a line that extends from the angle of mandible to the malar eminence (or lateral-most projection of the cheek). The platsyma is then freed along its posterior border, inferiorly for five to six centimeters. The SMAS and platysma are elevated anteriorly in the deep-plane over the zygomaticus and masseter muscles as a continuous layer. Importantly, the zygomatic and masseteric-cutaneous ligaments are deliberately divided which allows for maximally mobility of the overlying soft-tissues. Following this maneuver, the SMAS and platysma are repositioned posteriorly and superiorly to allow for an incredible tightening of not only the neck and jowls, but also the malar cheek mound of the midface. This method is what produces a superior lift, but also an incredibly natural facial contour which is free from the appearance of any stretching or tension.
When there is significant laxity of the platysma or fat deposition in the central neck, platysmaplasty (central tightening) and liposuction will be used in conjunction with the facelift.
With this facelift technique, all of the tension is placed on the deeper layers and there is no pulling on the skin itself. After the repositioning, the skin is simply redraped, excess skin is tailored and then closed meticulously. No staples are used. Rather the incisions are closed with a combination of extremely fine 5-0 and 6-0 sutures which are removed on post-operative days 5 and 8.
* Figure 1: Blue line corresponds to the facelift incision line. Blue shaded area shows region of sub-SMAS elevation. Blue dots indicate location of zygomatic and masseteric-cutaneous ligaments.
As a highly trained head and neck surgeon with extensive education in facial plastic and reconstructive surgery, Dr. Asaria is among the most qualified facelift specialists in Toronto and all of Canada to perform your facial surgery.
When selecting a facial cosmetic surgeon it is of the utmost importance that you choose a surgeon who truly understands the anatomy of the human face. Dr. Asaria is properly qualified to address the face both inside and out, ensuring his patients end up with beautiful, functional and lasting results.