The Ageing Face

The passing of time leads to multiple changes in our facial features. Whilst ‘ aging gracefully’ is often a term used to assuage this natural process, it often leads to a tired, dull appearance, which can be undesirable to many.

Features of the aging face happen in all layers, from the skin to the bone. Starting from the outside in, our skin loses its suppleness, begins to sag, and develops patchy pigmentation, both as a result of aging as well as cumulative damage from environmental factors such as UV rays. Beneath the skin, the fat compartments of the face shrink, leading to a hollowed appearance in areas such as the temples, upper eyelids and cheeks. Deeper down, the ligaments, otherwise known as the support structures of the face, start to relax, leading to the drooping of the overlying fat and skin layers. Finally, the bony support structure recedes at the forehead, cheeks and jaw, leading to a flattened upper face, cheek retrusion and squaring of the jaw.

Much of modern plastic surgery is focused on slowing or reversing the ageing process of the face. Minimally invasive methods can help with parts of this and include skin care, laser therapy and other energy devices, fillers, botulinum toxin and implantable threads. However,surgical methods such as facelift surgery need to be employed.

Facial Anatomy

To understand a facelift, one must first understand the basic layers of the face, some of which are the target of pulling and lifting during the surgical procedure. Again from the outside in, you have 1) the skin, 2) the connective tissue and fat compartments, 3) the muscle and its fascia (otherwise known as the SMAS or superficial Musculo-aponeurotic system), 4) the loose connective layer or ‘spaces’ of the face, and 5) the fibrous covering of the facial bone, also known as the periosteum. Within these layers lies the complex vascular and nerve supply of the face, which through study and dissection, have been clearly and consistently elucidated.

Furthermore, the face can be divided into the upper, middle, lower face, and neck regions, each or all of which can be targeted during a facelift procedure. The upper face consists of the temples and the area from the hairline to the brow, the middle face consists of the area from the brow to the bottom of the nose, and the lower face consists of the area from the bottom of the nose to the chin. The neck can be subdivided into the area under the chin (the submentum), and the lower neck.

How does a Facelift work?

In a facelift, the previously described layers of the face are tightened in various ways to help to reverse the sagging caused by ageing, and to lift the landmarks of the face to their original youthful position, thus restoring volume where it should be.
The layers of the face that are commonly tightened or ‘pulled’ are the skin, the SMAS, and the periosteum.
In the past, skin only facelifts were employed to help to reduce the wrinkles of the face caused by loose skin. However, these resulted in an unnatural and ‘wind-swept’ appearance as it did not address the ageing of the other crucial layers.
Through research by pioneers such as Mitz and Peyronie, it was found that there existed a definitive, firm fibrous covering of the musculature of the face, called the SMAS. Through the tightening of this layer, volume descent of the face could be reversed along with lifting of the musculature. Many modern facelifts are based on SMAS tightening, with subsequent tension free removal of excess skin, which results in better scarring and a more natural appearance.
Periosteal lifts involve the deeper dissection of the covering over the bony skeleton and tightening of this layer through sutures or devices such as endotine hooks. This sort of lifting is usually reserved for the upper face, and occasionally the midface.

What types of Facelift are there?

Lifting options for the upper face include open as well as endoscopic techniques. Open techniques involve making a partial or full incision at the hairline and allow for rejuvenation of the forehead with the removal of excess skin. Care must be taken to minimize the scar, which can usually be hidden at or in the hairline. Endoscopic techniques utilize small incisions within the hair-bearing area and a telescopic camera to dissect and lift the brow. This technique does not leave any visible scars, but no skin is removed and is not suitable for individuals with higher foreheads. A good compromise is the temporal browlift, which involves a limited incision at the temporal part of the brow, allowing for a lasting lift of the brow peak.

The middle part of the face can be approached through incisions at the lower eyelash margin. Through this approach, prominent lower eyebags can also be addressed. The periosteal or the SMAS layer can be lifted to help bring the volume descent of the midface back to the natural position at the upper cheekbone.

The lower face and neck can be lifted through incisions just in front of the ear, extending around the ear to the posterior hairline. In cases where the lower neck does not need rejuvenation, the incision can be finished in a ‘short-scar’ fashion, whereby no incisions at the back of the ear are required. Once the SMAS layer is exposed, there are various descriptions of how it can be tightened, including plication, minimal-access cranial suspension (MACS), SMASectomy, and sub-SMAS procedures. Whichever technique is used, care must be taken to avoid injury to the facial nerve which can result in temporary or even permanent paralysis of the face. Once SMAS tightening is done, the excess skin is removed to enable tension free closure for more invisible scarring.

For Asians in particular, more powerful techniques have to be utilized to lift as Asian skin and soft tissue tends to be heavier and more difficult to lift. The most significant lift can be derived from the deep-plane facelift, which directly lifts the anterior part of the face and mobilizes the SMAS layer over the spaces by releasing and repositioning the ligaments of the face through strong sutures. This brings the tissues of the face back to the original position of youth, and restores the natural contours of the face.

 The neck is approached via incisions extending to the hairline behind the ear, sometimes requiring a small incision at the area under the chin. Adjunctive procedures such as liposuction, buccal fat removal or fat grafting may be performed along with the facelift.

 
For all forms of facelift surgery, the performing plastic surgeon has to be familiar with the underlying facial anatomy to minimize complications including bleeding, loss of sensation as well as nerve and muscle paralysis. For more assurance, you should approach a fully-certified plastic surgeon in Singapore who performs facelifts regularly. Performed well, a good facelift can last at least 10 years.

The Facelift Consult 

During the consult with the plastic surgeon, a thorough history and physical examination will be taken. Your goals, motivations and desires for the procedure will be discussed, to enable a wholistic decision is made to ensure lasting satisfaction. A past medical and surgical history is also important to elucidate risk factors for the procedure. The physical examination is paramount to determine the areas of the face requiring rejuvenation, the existence of any pre-existing asymmetry, as well as the techniques required. Often, a lift for other parts of the face besides the region is question may be recommended to achieve a balanced outcome to the facelift. Benefits and risks of the different methods of facelifting should be discussed. Though uncommon, risks of facelifts include pain, bleeding, infection, nerve injury, wound breakdown and scarring. 

Preparing for a Facelift

Facelifts are commonly performed under sedation or general anaesthesia (GA). Occasionally, a patient may opt to have the procedure under pure local anaesthesia. However, this is not advisable as a full facelift can last up to 5-6 hours. Any medications or supplements that can increase bleeding and decrease wound healing such as aspirin, garlic and smoking should be stopped at least 1-2 weeks prior to the procedure. If sedation or GA is chosen, you will need to fast for at least 6 hours prior to the procedure.

What to expect during the procedure

The facelift procedure itself can be performed as a day surgery procedure, and there is usually no need to stay in a hospital overnight. You will be kept very comfortable during the surgery, and almost always no shaving of hair is required. After the facelift surgery, there may be small drains left which help to reduce post-surgical fluid or blood collections. These are removed within the first 1-2 days after surgery. After sedation, you will be observed for a few hours for recovery, and you can be discharged once you are walking and drinking water. It is advisable to have someone to accompany you home after any surgical procedure.

In recent years, fat grafting has become a popular adjunct, allowing for the natural restoration of volume loss in the face in addition to the facelift. Your plastic surgeon may recommend this in addition to the facelift surgery.

In recent years, fat grafting has become a popular adjunct, allowing for the natural restoration of volume loss in the face in addition to the facelift. Your plastic surgeon may recommend this in addition to the facelift surgery.

What should I expect during Facelift recovery?

After the procedure, you may be put into a facial pressure garment which helps to reduce swelling and bruising for the first 1-2 weeks. Placing cold compresses on the face also help with this. The stitches are usually removed at 1 week post-operatively, and almost all the bruising will be gone by the end of the 2nd week after the procedure. Swelling due to the procedure usually peaks in the first week, and by 2-4 weeks 80-90% of the swelling is gone.

Performed well, a good facelift can last at least 10 years. If patients desire further lifting after this period and are still in good health, repeat facelifts can be performed if required.

How much does a facelift cost?

Costs for facelift surgery in Singapore depend on the type and extent of facelift performed, and can begin from $6000  upwards. It is best to have an open discussion with your plastic surgeon about which procedure suits you best.