You may look younger with facelift.
You may look even younger with associated fat grafting.

History of facelift

The history of facial plastic surgery has become somewhat obscure due to the culture of the time. Many face surgeries were performed for the purpose of facial reconstruction, even before thinking about performing surgery to improve the aesthetic aspect of the face. When the facelift for a purely aesthetic purpose had its first impulse, the doctors of the time considered it as the "surgery of vanity" and little esteemed it, as it was seen as trivial, for creating unnecessary risks and trying to avoid the forces of nature, like the weather. The first cosmetic plastic surgery of the face was performed in Berlin by Eugen Holländer in 1901. It was a time of great changes, but the plastic surgeons who mastered the technique did not want to divulge it and kept it under lock and key. The ancient technique of facelift consisted of elliptical excisions of excess skin, made at the hairline. In addition, the lack of antibiotics, which was not yet present in people's lives, made the procedure very difficult, which often ended with some complication, such as infections.

The old technique was improved in the early 1950s by WA Swanker, currently known as classic rhytidectomy, which basically consisted of a large rotating and advancing skin flap, that is, it involved only the relocation of the subcutaneous layer and of the skin of the face. In 1974, Dr. Tord Skoog decided to dare even more, advancing the technique with the description and development of subfascial dissection. Two years later, in 1976, Dr. Mitz and Dr. Peyronie identified and described the SMAS (Superficial Muscular Aponeurotic System) which is the fascial layer that connects the frontal muscle with the platysma muscle, then publishing it to the world, something revolutionary. Dr. Owsley, in 1977, made one of the first publications showing the benefits of SMAS treatment in the facelift. All this has allowed the standards of face surgery to rise more and more, with the SMAS as the main target for correction during the procedure. Between 1970 and 1980, there were great discussions about the use of the long flap or the short flap and about which one would be the most beneficial technique, not reaching an exact and concrete conclusion. Around 1990, with a lot of research and studies, we see the facelift being performed in deeper planes with great success, like the S-Lift - for less complex cases – and how Dr. Sam T. Hamra, who developed the facelift with compound detachment. Currently, with all the technology in their favour, plastic surgeons are increasingly performing facelift, which has become a very safe and effective surgical procedure. Although this surgery has its procedure developed over a century ago, it was only recently, around 25 years ago, that it gained strength and had its techniques improved. Currently, the facelift is one of the most performed plastic surgeries in Brazil.

Patients with a good profile for face surgery

The ideal candidate for the facelift does not smoke, aims for realistic results, has good demarcations and bone structure, has the hyoid bone well positioned, good elasticity in the skin and little subcutaneous fat. Obviously not all patients fit this expected profile, but that is what, amongst other things, the different techniques to be used are for. Patients who smoke will have recommendations to stop the addiction fifteen days before and fifteen days after surgery and must receive special care during the facelift. If the patient has significant asymmetry, Dr. Zamarian will explain the possible treatments, which will require different techniques for each case.

Indication

Surgery is performed on both women and men who feel some discomfort in relation to their face due to sagging, deep furrows, wrinkles, etc. Often, premature aging can lead to a tired look that does not match the patient's actual age. The facelift is the most important, beneficial and effective individualised treatment for patients over 35 years of age who wish to improve facial changes due to aging. In addition, patients who have sagging and sagging cheeks, as well as those who have lost beautiful facial contours, such as the cheekbone, jaw demarcation and who have lost the contour of the cervicomental angle, who have fine wrinkles around the lips, eyes and chin, which have excess skin in the eyes and large pockets, drooping eyebrows, amongst other possible signs of aging, are excellent candidates for a facelift. Not only for aging, but the faceliift also offers the correction of important sagging resulting from massive weight loss. When losing a lot of weight, the patient starts to have excess skin all over the body, consequently, also on the face, which looks droopy and tired. So, overall, Dr. Zamarian recommends a facelift in cases of significant facial aging signs (sagging, wrinkles, deep furrows, etc.) of skin.

Patients who require special care

There are some cases where patients who want to have face surgery are somewhat limited by some factors. Dr. Zamarian explains that some patients, because they are carriers of certain diseases, or because they are in an unfavourable health condition, require special care. Patients with uncontrolled diabetes, with CVD, who use steroids, who have uncontrolled high blood pressure, psychiatric history or are addicted to cigarettes (smoking), should be observed very carefully. These factors do not prevent the patient from undergoing the facelifting, however, requires both the patient and the plastic surgeon to be aware. In these cases, before performing the surgery, Dr. Zamarian makes some recommendations, like:

• control the disease through examinations, food, etc.;
• stop steroid use for 20 days prior to surgery;
• stop smoking for 15 days before surgery, as well as 15 days after.

Highlights of the facelift performed by Dr. Walter Zamarian Jr.

Facial matching with fat

Fat has the ability to restore the volume lost to the face during the natural aging process. In addition, this wonder manages to improve the quality of the skin under which it is grafted, rejuvenating the face as a whole. It is a modern and indispensable complement to obtain the best possible result in a facelift, whose skin is wrinkled and lacking service. A complete understanding of how aging occurs is necessary to understand that this fat graft is the icing on the cake that was missing for the old technique of facelift with SMAS treatment. "Fat is gold!" - sums up Dr. Zamarian.

Volume and Tension

The trend of facelift is to provide increasingly natural results. Moderate use of volume and tension is essential for good results. Dr. Zamarian, always valuing the patient's naturalness and satisfaction, redistributes and gives volume to the face, in addition to performing delicate plications (small folds), providing slight tension in the muscles. When the plastic surgeon uses only tension in the skin, he ends up using it in excess, leaving the face looking very “stretched”, resulting in an artificial face without expressions. In addition, the lack of common sense can lead to great distortions and unsightly scars.

Minimally Invasive

Dr. Zamarian does not use the deep plane facelift or with detachment, as they are very invasive techniques, which prolong recovery time and can pose high risks to the patient, such as nerve damage. facial. Therefore, Dr. Zamarian uses the plication of the SMAS and platysma, minimally invasive techniques that provide excellent results and do not require a long recovery time.

Experience and skill of the plastic surgeon

The purpose of facelift is to improve the patient's appearance and not leave him looking disharmonious or stigmatized from having undergone surgery. Excessive use of tension, excessive removal of fat, too radical changes and highlighting only one area of the face, leaving the others aside, can result in a result far from natural. Dr. Zamarian explains that the face must be analyzed and manipulated together with all its elements, along with the body as well, because starting from an individual analysis of each element can make the results not look harmonic and natural.

Atrophy and sagging

The aging process not only involves sagging of tissues and skin, but also involves atrophy of tissues, especially adipose tissue, in some areas. The surgeon's refined aesthetic sense counts a lot when evaluating the patient. When detecting the problems and defects to be corrected, there are patients who were very well served by the correction by the subtle removal of fat, while other cases may require increasing the volume of certain regions with fat, when it is atrophied. Dr. Zamarian meticulously evaluates the patient during the consultation so that he can accurately detect the patient's defect. From there, with his refined aesthetic sense and deep knowledge of anatomy, he starts to decide which maneuvers and techniques he will have to use.

The surgery

Fat collection, preparation and grafting

The routine of a facelift performed by Dr. Zamarian has changed. Today, he begins the surgery by performing a small liposuction - most often performed on the inner thighs -, preparing the fat by washing and centrifuging it, and separating the fat into three sizes: nanofat, microfat and milligram. Each one will have a specific function and will be grafted in certain regions of the face, according to the needs of each patient. This step precedes the facelift itself, and greatly enhances the results of the facelift.

During face surgery, Dr. Zamarian makes incisions inside the hair and in natural folds of the face. Then the skin is separated from the underlying fat and muscle tissue. Liposuction of the submentum is performed to improve the contour of the neck. Then, the deep tissues are repositioned and, finally, only the excess skin is removed, leaving a natural and lasting result.

Pitanguy's round lift

Professor Ivo Pitanguy, renowned plastic surgeon and author of the famous technique called round lift, describes his technique with details, emphasising the need for a sense of traction from the tragus to Darwin's tubercle and posterior rotation of the flap to improve the neck and its anterior advancement to decrease the step at the hairline. Dr. Zamarian uses the technique that learned with Professor Ivo Pitanguy, with the plication of SMAS, obtaining excellent results in Londrina, Paraná, Brazil.

The incision

In face plastic surgery, the incision can be divided into three segments:

• inside the hair, in the temporal region, is used to treat wrinkles at the corners of the eyes and raise the eyebrow tail;
• the part anterior to the pinna is performed to approach the middle third of the face and lift the deep tissues, with the plication of the SMAS;
• the posterior region of the incision is made in the posterior fold of the pinna and is continued inside the hair, backwards, to treat the flaccidity of the neck with plication of the SMAS at that level.

It is important to remember that the entire incision of the face is positioned in such a way as to maintain the naturalness of the result, while at the same time making it inconspicuous and concealed. Thus, it is not the scar from this surgery that bothers patients in the postoperative period.

The plication of the SMAS

In most cases, Dr. Walter Zamarian Jr uses the plication technique of the SMAS. It is one of the most performed approaches and with the highest satisfaction rate amongst patients who underwent facelift. In addition, it is much more effective than a simple facelift performed only in the subcutaneous part and less invasive than a rhytidectomy with compound detachment, which exposes the patient to high risks of damage to the facial nerve. The facelift with plication of the SMAS is one of the most efficient techniques to correct ptosis (drooping) of the deep plane of the middle third of the face and the nasolabial fold, promoting good elevation of the corner of the mouth, which was previously drooping, and improving the definition of the contour and facial angles, especially of the jaw and neck. This is all due to the fact that it consists of traction of the SMAS, and this, in turn, promotes longer-lasting support of the face. Attraction of the SMAS reduces the need for excessive tension on the facial skin, thus avoiding results with an artificial appearance, with stretched skin. One of the best advantages that this technique provides is the minimal tissue ischemia, that is, it barely restricts the blood supply to the tissues and, consequently, reduces the chances of incidence of epidermolysis and gangrene of the detached skin flap almost to zero. In summary, the facelift with plication of the SMAS is a safe technique that allows the suspension of the deep structures of the face, providing a good postoperative recovery, with a low incidence of complications and lasting results.

Neck

Many patients have significant sagging of both the skin and the neck muscles. In addition to the lateral traction of the platysma muscle, which covers the neck internally together with the SMAS, Dr. Zamarian often chooses to make a complementary incision in the submentum (below the chin) to medially approximate the platysmal bands, sectioning (cutting) the muscle bands, and even removing a triangle from each band, to avoid recurrence. This results in an improvement in the neck angle and an elevation of the submental floor, allowing a more refined result of this surgery. In addition, neck liposuction reduces the fat accumulated over the years and improves the contour of the jaw.

Forehead

The forehead, or frontal region, can be addressed together with the facelift, in order to handle the following structures:

• frontal wrinkles
• glabellar wrinkles
• drooping eyebrows

Front wrinkles can be caused by too strong a frontal muscle, resulting in deep frown lines over the years. This muscle can be weakened with facelift surgery, resulting in attenuated wrinkles and preventing them from increasing. If the wrinkles are already very deep, they can be softened, but not completely eliminated.

Glabellar wrinkles can be vertical, denoting an appearance of fierceness and seriousness, caused by the corrugator muscles, or horizontal at the root of the nose, caused by the procerus muscle. In both cases, the treatment consists of weakening the referred muscles, aiming to attenuate the signs of the exaggerated action of these muscles.

Elevation of the eyebrows can be achieved by deeply releasing the lateral tissues and ligament that hold the eyebrows in position or pull them down. With this release, they are free to obtain a lift in the tail of the eyebrows, resulting in a less sad and less tired expression on the part of the patient.

The forehead approach in facelift is only performed when necessary, and when the patient's forehead is not too long.

Eyelids

As a complementary procedure to the facelift, eyelid surgery (blepharoplasty) can be performed and is an important factor for a complete result, since the eyelids represent about 60 % of the result of this surgery.

Only the upper, lower or both can be treated, and excess skin or fat pockets can be removed, when necessary, resulting in a more rested and youthful look.

Wrinkles on lips

Lip wrinkles are more common on the upper lips, and can be improved in three ways: fat grafting, dermabrasion, or filling with hyaluronic acid. Dermabrasion treatment consists of sanding and definitively improves wrinkles, as long as they are not too deep, but it can result in dyschromia (whiter skin than the rest of the face). Filling with hyaluronic acid does not have the inconvenience of dyschromias, but it has to be reapplied approximately every 18 months.

Neck lift

When the face still doesn't show the signs of time, but the neck has excess skin or fat, you can perform a procedure just to treat the neck, the neck lift, which restores the contour of the neck, corrects sagging and restores its youthful appearance. Plastic surgeon Dr. Zamarian, performs neck lift surgery to minimise the effects of time on the neck, restoring its contour, giving greater tension to the platysma muscle that composes it.

Assessment of a patient with sagging neck

During the medical consultation with the plastic surgeon in Londrina, Paraná, Brazil, Dr. Walter Zamarian Jr., he will assess if there is:

• sagging skin (and its excess) on the neck;
• excessive neck fat;
• presence of platysma bands, forming two vertical folds below the chin;
• presence or not of sagging face;
• presence of scars from previous surgeries;
• lobe-to-ear position and whether it is attached or naturally loosened;
• presence or not of hypomentonism (small or retracted chin).

The plastic surgery of neck lift

It is started with the patient under general anesthesia. Then, incisions are made behind the ears, continuing forward just close to the earlobes, so that they are not directed backwards at the end of the surgery. The detachment of the skin begins behind the ears and then in the front, on the neck. Liposuction of the submentum (double chin) is associated in the neck with a very thin cannula to avoid trauma and mental paresis. Soon after, the submentum is incised (incision below the chin), with detachment also in this region. Sutures with absorbable 4-0 Vicryl threads are performed on the submentum to bring the bands of the platysma muscle together (closing the famous folds in the double chin) and also sutures laterally, below the ears, pulling the platysma muscle laterally, giving a new tension to the neck muscles, restoring its contour. Then the excess skin behind the ears is removed. The result is a young neck, with its contour restored, without visible scars, with the platysmal bands close together.

What is the difference between the full facelift and the neck lift?

Basically, the neck lift is one third of the facelift. What does that mean? The full facelift is composed of a scar that starts in the temporal region (to treat the corner of the eyes), extends in front of the ears (to treat the middle third of the face) and continues behind the ears (for neck treatment). Thus, the cervical neck lift is composed only of the component behind the ears, for the treatment of the neck, leaving the middle third of the face and the region of the corners of the eyes and eyebrows untreated. It has, therefore, its main indication in patients who have flaccidity or wrinkles in the neck, or platysma bands (vertical folds in the neck), with the face with little or no flaccidity.

The candidate for neck lift

As mentioned above, the neck lift is for patients who have a firm face but a disproportionately sagging neck. This surgery aims to remove excess skin from the neck, give more firmness to the neck with the treatment of the cervical muscles, soften or eliminate the visible bands of the platysma muscle, soften neck wrinkles (but rarely eliminate them completely), restore the contour of the jaw and elevate the tissues of the neck to restore the cervical angle, present in youth. It is worth remembering that this surgery does not promote results above the mandible, and for that, a full facelift, would be necessary.

Postoperative neck lift

The surgery is performed by Dr. Zamarian in the operating room under general anaesthesia, and the patient could be discharged the next day, after the drain was removed. The period that follows after the surgery is quite peaceful, painless and with a little swelling, and some signs of ecchymosis (purple) may appear, especially on the fifth day. The dressing used in the operating room is removed the next day, when the patient is allowed to shower. It is recommended to sleep a month on your back, without physical exertion and gym. The food should be pasty for about four days, so as not to force the worked muscles. You can eat fish, minced meat, well-cooked meat, puree, rice, beans, but nothing hard to chew.

The importance of treating platysma muscle bands

With age, the neck loses its definition. The part of the mandible where the tissues fall off (Bulldog) is treated with liposuction with a thin cannula to restore the contour of the mandible. The neck itself presents an increase in muscle flaccidity (platysma) that must be treated during cervical neck lift to optimise results.

The platysma is a flat muscle that covers the deep structures of the neck and that normally has a hiatus in the midline, that is, a space between the right and left platysma in the central part of the neck. The sagging of the platysma muscle causes there to be two vertical folds (one on the right and one on the left) in the neck of some people. During the neck lift, through an incision in the submentum (below the chin), the central region of the neck is detached and the bands are brought together medially with Vicryl 4-0 . This makes the folds disappear, in addition to elevating the entire submentum, making the "chap" rise and have a more youthful appearance.

Similarly, during lateral detachment in the neck lift to remove excess skin behind the ears, another lateral platysma plication is performed (one on each side) to give more firmness to the neck and better show the result of the median plication.

Without the treatment of the platysma muscle, the result would be inferior, leaving the remaining vertical folds and not elevating the submentum sufficiently. Lateral plication also helps with skin removal, as it allows for greater removal of excess skin.

Some patients report improvement in snoring, most likely because they had a very significant neck flaccidity that interfered with the floor of the mouth. Despite this, this surgery is not intended to treat snoring or nocturnal apnoea, which is only an occasional benefit.

Lymphatic Drainage

Dr. Zamarian recommends a team of physiotherapists who perform lymphatic drainage and endermologie which, in the case of neck lift fifth day.

Other types of lifts

Temporal lift

The temporal lift is a part of the full facelift, being the one that performs the traction and consequent elevation of the tissues on the lateral part of the eyebrows. Thus, a temporal lift, with removal of skin inside the hair, causing a resting effect on the side of the eyes. The question to the technique is that the further away from the area where the result is desired the skin is removed, the lower the result in the target region, that is, a surgery with incisions far from the eyebrow tends to have less result than Minicastañares, for example.

Forehead lift

During face plastic surgery, you can join the incisions in the frontal region, three fingers inside the hair and perform the frontal lift. In this technique, the complete result is obtained, treating the frontal muscles, procerus, corrugators, the entire eyebrow is raised and not only the caudal or lateral region, in short, it is an important complement to facelift that effectively treats the upper third of the face, in indicated patients. As it is a larger surgery than Minicastañares, it is performed in a surgical centre. The only possible downside is possible itching (pruritus) from the coronal incision at the top of the scalp, which occurs in 10 % of Dr. Zamarian, but that improves in up to six months. The results are excellent, like the Minicastañares, and the best technique indicated for each patient is chosen by Dr. Zamarian together with the patient in their consultation at the Zamarian Clinic in Londrina, Paraná, Brazil.