Apart from maybe breast augmentation there is hardly a procedure in the minds of people they think of sooner when “cosmetic surgery” is mentioned other than facelift. No other procedure than facelift better reflects all the good and bad about cosmetic surgery, its errors and evolutions and the whole gamuth of misconceptions in the eye of the public.
In our opinion, any discussion about the facelift procedure needs to begin by delineating what a face lift is not. On the top of the list comes the fact that it is not really a facelift, but a lower one third of the face and neck lift. Its most powerful effects take place over the lower jaw and neck. In these areas an actual lift can be achieved, which most people intuitively would associate with an upward movement. The higher up one moves on the face the more a facelift becomes a “face pull back”, which is basically an undesirable effect, resulting in the stigmata of the “overdone look”. Next, a facelift has only a modest effect on rhytids, which in plain English are wrinkles. It has neither the capability to remove a lot of the wrinkled skin (rhytidectomy) nor can it transform the wrinkles (rhytidoplasty). Hollaender, Lexer, Noel, Passot and several other pioneers of cosmetic surgery between the two World Wars depicted the operation in their sketches as if it were removing wrinkled skin and “tightening” the remaining skin, coined various “rhytid” oriented terms and thought of it as a skin only procedure. As an irony of history, the subsequent two or three generations of cosmetic surgeons did try to outperform their teachers and predecessors in an effort to tighten and remove wrinkles (rhytidectomy, rhytidoplasty), putting more and more tension on the skin with more and more complications at the closure sites and a more and more “overdone look” going from a cosmetic to a comic procedure. The fact that the skin dogma persisted for decades tells a lot about the firm and definitive teaching methods practiced by the heads of department of most European training programs.
So, what then is a facelift ? At Trinidad Institute of Plastic Surgery we follow the paradigm that structure is beauty. Skin is just draped over structure. We want to recreate the structure to approximate the youthful state. The youthful “ideal, beautiful, normal” changes with age. The structural change comprises descent and loss of volume. These two issues are addressed in the neck and lower one third of the face by facelift surgery in as far as the sagged, descended soft tissues in these areas are concerned (e. g. jowls, blunted neck line). With advancing age there is a strong component of loss of volume of the facial skeleton contributing to an aged facial appearance. Facelift surgery as a soft tissue only technique does not address changes in the skeleton. Intrinsic aging of the skin contributes much to wrinkles, but these changes are in our philosophy better addressed by supplemental techniques and not surgical skin tightening. Descent is counteracted by lifting the deeper connective tissue and muscular layers, which once were firmly anchored to the underlying skeleton but descended over the years when the anchors became loose. The skin is just in for a ride on the way up, as it was on the way down. Volume on the other hand has to be added and our main tools are implants and transferring the patient’s own fat to areas in the face.
At Trinidad Institute of Plastic Surgery we also believe in using procedures for their effect and avoid getting an effect a certain procedure can not provide very well. Thus, eyelids, midface, nasolabial folds and forehead/eyebrows are addressed by separate procedures exerting their strongest effects in these areas should rejuvenation beyond the neck and lower one third of the face be desired by the client.
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