During the aging process a number of structural changes in the soft tissues and bones of the face and neck take place. The basic feature of all these processes is the loss of tissue strength, which results in lowering of the soft tissues of the face and neck down, in gravity direction. The skin loses elasticity because the elastic fibers decay, and also stiffness due to the collapse of the collagen fibers. Below the skin and subcutaneous tissue there is the surface connective muscle layer of the face and neck (SMAS – “Superfitial musculoaponeurotic system”), which also experiences degenerative changes which ultimately result in the loss of tension or tonus of the soft tissues of the face and neck and in typical changes which take place due to the aging process. It is important to mention that not all elderly people age in the same way and at the same speed; it mostly depends on genetic factors, exposure to the sun and wind during lifetime, the diet, lifestyle, abundance of cigarettes, alcohol and drugs. The earliest changes are visible at the lateral parts of the eyebrows and the upper eyelids. The lateral eyebrow parts are starting to lower (“lateral hooding”) with the formation of the fold above the eyelids which, like a curtain, leans above the lateral parts of the eyelashes. The adipose tissue from the orbit penetrates forward and presses the impaired supporting structure of the lower eyelids, resulting in the creation of the typical “eyebags” which contribute to the exhausted or tired facial appearance. Then the adipose tissue in the cheeks lowers down from its normal position at the level of the cheek bones and deepens the folds which combine the nasal wings and the corners of the lips (the nasolabial folds or sulci), and the middle third of the face becomes flat or concave, which makes people look tired and exhausted. The skin and SMAS in the lower third of the face also lose elasticity and form typical wrinkles (the labiomandibular folds, “jowling”), which go down over the edge of the lower jaw to the front upper part of the neck. Such face takes on a typical square shape. Below the corners of the lips the folds of redundant skin are formed, which can be called the “marionette lines” or the mentolabial folds. The corners of the lips lower down. The lips are becoming increasingly thin, and this especially relates to the upper lip which inverts towards the oral cavity and becomes extremely thin. Similar changes can be noticed on the neck. First, the loose skin of the front upper part of the neck is formed in the central line, which is manifested in the vertical skin folds, and this is a sign of weakness of medial edges of the superfitial neck muscle platysma. In addition, the subcutaneous adipose tissue below the chin is also lowered down and completely erases the angle between the chin and the neck (the cervicomental angle). Such people often look as if they have a “double chin.” In addition to the above major changes on the face and neck, numerous small wrinkles appear: the horizontal forehead lines, the vertical glabellar lines (the “frown lines”), the lateral lines around the eyes or the periorbital lines (the “crow’s feet”), the vertical lines around the lips or the perioral lines, the horizontal neck lines which appear due to the weakened platysma muscle and the neck skin. It is evident that the correction of the above mentioned changes on the face and neck during the aging process should try to recover these tissues back to their youthful position, pulling them up, in antigravity direction. This is the basic characteristic of the modern methods of facelift among which especially important is the short-cuts facelift (“Short Scar Rhytidectomy” – the authors are Belgian surgeons Tonnard and Verpaelle). Pulling up the lowered and loose soft tissues of the face and neck up, in superior or antigravity direction, is one of the fundamental differences between the modern and classical facelift.
„Short Scar“ facelift
Short Scar facelift (“Short Scar Rhytidectomy or MACS – minimal access cranial suspension lift”) was introduced into the medical practice in Gent, Belgium, a few years ago, and the authors of the method are the excellent aesthetic surgeons Patrick Tonnard and Alexis Verpaelle. The reasons for finding a newer and more modern method of facelift lie in the fact that the classical facelift is an operation which lasts four to five hours, the incision extends from the hair line in the temporal area, in the front of and behind the ear, and ends far in the hair line of the occipital area. Recovery takes a long time, bruises and swelling last four to five weeks. The complications such as facial nerve injury and decay (necrosis) of the part of the skin flap are relatively common, especially with the chronic smokers. The classical facelift is a big operation, followed by certain risks, and requires a long postoperative rehabilitation, and the majority of the patients are business people and other employees who can not disengage so much time for the whole procedure. This is the basic difference between the classical and modern facelifts. Short scar facelift is made through the twice shorter incision, the surgery lasts twice as short (about 2.5 hours), the postoperative rehabilitation is twice shorter (about 2 weeks), postoperative complications are significantly less, frequently the result of the operation is equally lasting and good, very often a lot better than in the classical facelifts. Instead of the surgical raising of the neck skin and complete separation from the platysma muscle as in the classical facelifts, the hydroliposuction of the neck is applied as the essential part of the short scar facelift, in order to achieve full mobilization of the neck skin, after which the skin and platysma muscle may be pulled up in antigravity direction and keep in this position by using permanent, purse-string sutures which are fixated to the deep fascia of the temporal muscle.
Facelift in the “Polyclinic Ostojić”
After the long experience in applying the standard facelifts, we were among the first clinics in Croatia to accept a new method of the modern facelifts wholeheartedly. We have perfected the method directly where it was created, in Gent, Belgium. There we have attended several educational seminars and a surgical procedure performed by the authors of the mentioned surgical techniques. We believe that this method fully meets the aspirations of the physicians and patients in the 21st century. In the last several years we only apply short scar facelift. Specifically, we at the “Polyclinic Ostojić” in the first place take care of the patient’s satisfaction with the outcome of the aesthetic procedures, and we devote most attention to the health of the patients. This method combines all the mentioned aspirations, achieves the excellent and long-lasting aesthetic result with a reasonable duration of postoperative recovery, the minimal rate of postoperative complications, which all together contributes to preserve the overall health of the patient. The method is characterized by its extremely well-hidden scar, raising the minimum of the skin flap of the cheek (up to 6 cm from the front part of the ear), which allows precise setting of two or three permanent, purse-string sutures in the shape of a loop which are fixated to the deep fascia of the temporal muscle, ensuring durability of the results achieved. Our patients are very satisfied with the quick recovery because even after 10-14 days the majority of the patients return to their normal life activities. In the “Polyclinic Ostojić” facelift is performed very often, and with regard to our long practice and application of the most modern methods of facelift we can say with satisfaction that our patients are very pleased with the aesthetic results of facelift. In the “Polyclinic Ostojić” special attention is devoted to the further improvement of the professional problems of facelifts and other aesthetic corrections through attending medical congresses in the country and abroad regularly, and using the professional literature in the most reputable medical journals.
Procedure
The first step is preoperative examination of a patient. The approach to every patient is extremely individual. A thorough family and personal history has to be taken (smoking, chronic tendency towards using alcohol, chronic use of aspirin, chronic diseases of the coronary arteries and other organic systems of the organism and other data). Patient’s wishes and expectations from the procedure are carefully observed. After the consultation a medical examination takes place, and a significant part of the examination is a psychological evaluation of each patient. During the examination a plan of operational procedures is determined in relation to the visibility of the labiomandibular folds, nasolabial and mentolabial folds, loose skin of the front upper neck, appearance of the eyelids, and combining of additional or adjuvant surgical techniques in addition to facelift is being considered (Aquamid applications into the lips, nasolabial or mentolabial folds, applications of Botox A or hyaluronic acid fillers, the use of chemical “peel” with 35% TCA to remove small wrinkles around the lips or eyes). It is important to ascertain any possible asymmetry of the face and neck, which is relatively common, and present them to the patient in front of the mirror. During the examination the type and texture of the face and neck skin have to be carefully determined, which is crucial for the outcome of the operating procedures. After the examination, the patient is being photographed in 7-9 standard projections. Routine preoperative tests (blood tests, ECG, USD of the heart, X-rays of heart and lungs, internist examination) have to be completed before the procedure and should not be older than one month.
Surgical procedure
Our surgeon, Dr Duje Ostojić, is preparing for a facelift, while the anesthetist is preparing a patient for the surgery mentioned. The specified surgery can be done under reinforced local or general anesthesia. The general anesthesia provides greater comfort for both the patient and the operator because this is a procedure that takes about 3 hours and requires the precise surgical technique and calm hand of the operator.
The preoperative “marking”, which marks the area of the neck where hydroliposuction of the neck will be made and where it is planned to raise the skin flap of the cheek in the subcutaneous plane. The black marker is used to mark the position of two permanent, purse-string sutures in the shape of a loop within the cheek flap, which will pull the lowered soft tissue of the face and neck in antigravity direction and “clasp” them to the fixed point (“anchor point”), deep temporal fascia.
The surgical technique of the short scar facelift (“Short Scar Rhytidectomy or MACS lift – minimal access cranial suspension”), which we adopted among the first clinics in Croatia, is shown. The first surgical maneuvre of the given technique consists necessarily and inevitably of hydroliposuction of the neck. Through two minimal incisions, using the thinnest liposuction cannula of 3 mm in diameter (in order to minimize the tissue trauma), the neck skin is fully mobilized, and at the same time the deposits of the adipose subcutaneous tissue in the area of the front upper neck (submental area) are being removed. The full mobilization of the neck skin is a condition that would allow a maximal reposition of the skin and the superfitial platysma muscle (part of SMAS) in antigravity or superior direction.
In the first picture the scope of raising the skin flap of the cheek in the subcutaneous plane is shown. The skin incision is located in front of the ear and in the hair line of the temporal area. This is a big advantage of short scar facelift because the surgical incision is twice shorter than in the classical facelift. Correspondingly, the postoperative scar and recovery are twice shorter. The incision consists of the vertical and horizontal limbs. The vertical limb of the incision begins around the ear lobe and goes up, in the fold in front of the ear, precisely calibrated so that the scar is almost invisible. In the third picture the transition from the vertical to the horizontal limb of the incision is shown. The horizontal part of the incision is located in the hair line of the temporal area, 2-3 mm away from the hair line, and has a “zig-zag pattern”. A scalpel is directed at the angle of 30 degrees towards the skin, so to cut the hair follicle which will later grow over the scar and hide it completely.
The picture shows a radiowave knife with which a surgeon performed the surgery. By using a precise radiowave knife the bloodless operations can be done, which ensures a minimal duration of the postoperative course.
After raising the skin flap of the cheek, two permanent, purse-string sutures are set in the subcutaneous plane (Prolene 2-0) in the form of a loop by which the skin and superfitial aponeurotic muscle layer of the face and neck (SMAS) are being pulled up in antigravity direction, which is logical, given that the soft tissue of the face and neck are lowering down during the aging process. After the maximum anchoring of the subcutaneous tissue of the face and neck follows the removal of the redundant skin, which is clearly shown in the pictures above. A piece of skin is removed together with the subcutaneous tissue and it is about 4 cm wide.
Sewing the horizontal limb of the incision in facelift must be made in two layers of sutures. Placing of inverse, resorptive sutures (Monocryl 4-0 and 2-0) is finished, and setting of the skin running suture (Prolene 5-0) follows. The suture of the horizontal limb of the incision in facelift is being sewn under mild tension. The minimal skin wrinkles of the horizontal limb of the incision in facelift will disappear in 3-4 weeks. In the “Polyclinic Ostojić” special attention is devoted to the precise sewing of the incisions with the aim of obtaining almost invisible scar. In the case shown sewing lasted about 45 minutes.
The additional redundant skin in front of the ear is being removed using the scissors, and the careful control is necessary, not to remove too large piece of skin. The suture of the vertical limb of the incision in facelift is being sewn without any tension on the skin edges, to avoid postoperative changes in the natural position of the ear.
Sewing of the horizontal and vertical limbs of the incision in short scar facelift is done. The vertical limb is sewn with non resorptive suture (Prolene 5-0). The position of the ear or ear lobe is the same as before the operation. The disadvantage of the classical methods of facelift is a very common dislocation of the ear lobe forward and down, which is not common in short scar facelift.
On completion of the surgical procedures a special bandage is set up, tightened by the elastic bend, which will be removed the next day. After that a patient can use children’s baths to wash the hair and locally apply antibiotic spray on the incisions of the facelift.
Postoperative period
The basic feature and advantage of the short scar facelift is a twice faster recovery of the patients than with the classical facelift. The patient stays under medical observation for 24 hours. The early postoperative course is almost completely painless because of the application of intramuscular injections of painkillers. The patient goes to postoperative care the second day with completely uncovered incisions, because the hygiene of the hair, face and neck is the best sustainable that way. Possible mild pain in the area of the face and neck in the next few days can be successfully resolved by taking analgetics perorally. The bruises (hematomas) and swelling (edemas) of the face and neck usually last for about ten days, and the absorption or disappearance of hematomas and swelling can be accelerated by taking antiedematosis therapies on the basis of pineapple regularly (eg Traumanase tablets, 4×1 tablets a day) during four weeks, with the recommendation for the beginning of the therapy a week before the planned procedure. The sutures of the vertical limb of the incision in facelift can be removed after 7 days, and the sutures of the horizontal limb of the incision after 2 weeks. The patients should sleep on their back with a slightly hightened position of a pillow for at least two weeks. The patients must avoid trauma or physical manipulation (such as friction of the skin and subcutaneous tissue) of the face and neck for at least four weeks. The application of anti-bruise ointment may also speed up the recovery. The patients can return to their normal life activities in about 2 weeks, which is an indivudual process. Hypoesthesia of the skin flap of the cheek is almost always present and persists for a few months, and then sensitivity returns completely.
Complications
The complications of the short scar facelift are very rare and significantly less than in the classical facelifts. Possible complications include:
- infection (the infection prevention is perioperative, intravenous and peroral application of antibiotics in the first few postoperative days)
- bleeding or hematoma
- facial nerve injury (very rarely, and almost exclusively this is a brief mild disorder of the normal face mimic)
- hypertrophic scars and keloids (very rare, but they can occur only with people who are prone to creating hypertrophic scars and keloids)
What is a face lift?
Face lift is among the more demanding procedures for aesthetic surgery. The patient needs to have patience in the recovery phase, and the aesthetic surgeon needs to have great experience and skill. With this procedure the relaxed skin of the face is tightened as well as the excess skin of the neck (which is why it is also called a full face lift).
What’s the difference between “Short Scar” and the classic face lift?
The classic face lift operation lasts for about four to five hours. The cut extends from the scalp region of the temporal region, in front of and behind the ear, and ends far in the scalp region. Recovery is relatively long, swelling and bruises usually last four to five weeks. Relatively frequent complications such as a face nerve injury are known, and in chronic smokers, there is often a collapse of the part of the occipital lobe. Given the modern lifestyle, patients can no longer separate as much time for surgery and recovery. The procedure is complicated, it is accompanied by certain risks and a long postoperative recovery is required.
On the other hand, short-cut face lift or “Short Scar” face lift is done through a double shorter cut, the surgical procedure is significantly shorter compared to the classic (approximately two and a half hours), and the postoperative procedure lasts for about two weeks. What is extremely important is that post-operative complications in the short-cut face lift are considerably less frequent, while the very result of the operation is as durable as in classical, and often is significantly better.
What method of the face lift is used in the Ostojić Practice?
After many years of practice with the classic face lift, we bowed to the modern method and among the first practices in Croatia we started applying a short-cut face lift. We improved this method in the institution where it was founded, in Ghent, Belgium, where several educational seminars were held. We were in fact attending the surgical procedure performed by the mentioned authors of surgical technique, top cosmetic surgeons Patrick Tonnard and Alexis Verpaelle.
In the last few years we have been using only short-cut face lift. Our goal is the patient’s satisfaction with the outcome of the aesthetic procedure, while extreme attention is paid to the health of the patient. Due to the short duration of the procedure itself, as well as the short postoperative recovery period, the minimal risk of postoperative complications, and an excellent and lasting aesthetic impression – our patients are extremely satisfied with the short cut method.In the ” Ostojić Practice” face lifting is performed very often, and special attention is paid to further professional improvement of the facial and other aesthetic corrections by regular attendance at medical conferences in the country and abroad, and by carefully monitoring the professional literature in the most eminent medical journals.
What is relevant to the preoperative review?
In a preoperative examination, the approach to each patient is individual. A thorough personal and family anamnesis is taken into account. Patients talk about their wishes and expectations followed by an overview, in which an important part is the psychological evaluation. During the examination, an operational procedure plan is established in relation to the expression of labiomandibular folds, nasolabial and mentolabial fissures, the flabbiness of the front upper neck and the appearance of the eyelids. Options are also considered for combining additional or adjuvant surgical techniques as a facial elevator supplement, for example, the use of Botox A or the use of Aquamide in the lips, nasolabial or mentolabal furrows, etc.
When examining, it is important to determine the texture and type of skin of the face and neck, and to identify possible facial and neck asymmetries and present them to the patient in front of the mirror. After the examination, a patient is photographed in 7-9 standard projections. Routine preoperative tests must be performed before the procedure and should not be older than a month, and include ECG, heart ultrasound, heart and lung x-rays, blood tests and an internist examination. After the preoperative phase a surgical procedure is carried out.
What to expect from the postoperative period of the face lift?
A great advantage of the short-cut face lift is a quick recovery (twice as fast than a classic face lift). Since intramuscular pain injections are used, an early postoperative course is painless. After surgery, the patient is kept for 24 hours under medical supervision, after which the patient is left in postoperative care. For easier maintenance of hygiene of the face, neck and scalp, the cuts remain uncovered.
Mild pains in the area of the face and neck are possible for several days, and are successfully solved by oral administration of analgesics. The bruising and swelling of the face and neck usually last about ten days, and the resorption or disappearance of hematoma and swelling can be accelerated by regular administration of antiedemateous pineapple based therapy for four weeks with a recommendation on the start of therapy a week before the planned procedure.
Patients should be careful to sleep on their backs with a slightly raised head for at least two weeks, and for at least four weeks they must avoid skin friction and similar trauma and physical manipulation of the face and neck. The numbness or hypoesthesia of the skin facial lobe is almost always present and persists for several months, and then the sensory sensation returns completely.
Patients can return to most of their normal activities in about 2 weeks, but this is an individual process. The seams of the vertical arm of the facelift are removed after 7 days, and the seams of the horizontal arm after 2 weeks.
What are the possible complications of the face lift?
In the face lift of the short cut, the complications are extremely rare, as opposed to the classic face lift. Possible complications include infection, bleeding or hematoma, eye nerve injury, hypertrophic scars, and keloids (appearing only in people who are otherwise prone to it). Prevention of infection can be preoperative, intravenous, and oral administration of antibiotics in the first few days after surgery are suggested. The face nerve injury is very rare, it is about short, mild disturbances of normal facial movements.
