Facelift Surgery or Rhytidectomy

Introduction of Facelift Surgery

Facelift surgery (rhytidectomy) is a popular surgical procedure that reduces visible signs of facial ageing, such as wrinkles and sagging skin. By the 30s to 40s, eyebrow drooping begins; fat loss and bone resorption happen later, especially in the 60s–70s. Therefore, understanding facelift surgery is crucial for MBBS and ENT PG students preparing for exams. This chapter simplifies the history, biology, techniques, and complications of facelift surgery, ensuring you grasp key concepts for NEET PG MCQs and viva.

Biology of Facial Ageing

Facial ageing results from intrinsic (natural) and extrinsic (environmental) factors. Consequently, understanding these changes is vital for surgical planning.

• Intrinsic Ageing:
  • Skin: Loses keratinocytes and collagen, causing thinning, wrinkles and decreased elasticity of the skin.
  • Subcutaneous Fat: Atrophy of fat and weak fascial attachments causes sagging (e.g., jowls). The facial fat compartments (superficial and deep) shift downward with age.
  • Facial Skeleton: Looses volume, reducing support for soft tissues.
• Extrinsic Ageing:
  • Photoaging: UV radiation thickens skin and causes elastosis (disorganised elastic fibres), forming fine wrinkles. Smoking and pollution accelerate these changes.

Table 1: Key Causes and Manifestations of Facial Ageing

Factor	Type of Aging	Affected Structures	Key Manifestations
Atrophy	Intrinsic	Epidermis & Dermis	Thinning skin, abnormal pigmentation, decreased collagen & elastin, increased wrinkles, dryness.
		Subcutaneous Fat	Volume loss, weakening fascial attachments, ptosis of fat pads (malar, jowl), tired appearance.
		Facial Skeleton	Volume loss, bone remodeling (e.g., maxilla height ↓, orbital width ↑), disproportionate soft tissue coverage.
Solar Exposure	Extrinsic	Skin (epidermis & dermis)	Photoaging, actinic damage, skin thickening (hyperkeratosis), elastosis, fine/coarse wrinkles.

Clinical Evaluation

Proper patient selection ensures successful outcomes. Therefore, surgeons assess:

• Psychological Motivation: Patients with a stable self-image achieve better satisfaction. However, those with unrealistic expectations may be dissatisfied.
• Health Status: Good health is essential. For instance, diabetes or smoking increases complications like skin sloughing.
• Skin and Skeleton: Fair, elastic skin and strong facial bones yield better results. Conversely, thick or inelastic skin limits improvement.
• Submental Region: Assess for excess fat or platysmal banding, which may require liposuction or platysmaplasty.

 

Table 2: Clinical Evaluation: Patient Selection Criteria

Category	Favorable Candidate	Less Favorable / Contraindication
Psychology	Stable self-image, internal desire for youth, realistic expectations.	Unrealistic expectations (e.g., seeking remedy for social dilemmas).
Indications	Redundant lower face/neck skin, jowling, lost mandibular contour, deep rhytids.	Superficial rhytids (photoaging), acne scarring, minor depressions.
General Health	Overall good health, stable weight, appropriate medical clearance (if comorbidities).	Bleeding diathesis (absolute), uncontrolled hypertension/cardiac/pulmonary disease, active smoking, chronic steroid use, diabetes.
Age	Mild to moderate visible aging (chronological age is secondary).	Extreme skin sagging, very advanced aging (limits dramatic improvement).
Skin Quality	Fair, medium-thickness skin, moderate elasticity, modest subcutaneous fullness.	Darker, thicker skin (less dramatic improvement, more relaxation); poor elasticity; extreme thinness.
Skeletal Support	Strong facial skeleton (well-defined bony contours).	Mid-facial hypoplasia, microgenia, low-positioned hyoid bone (limits submental improvement).

Indications for Rhytidectomy

Rhytidectomy primarily corrects visible signs of ageing in the lower two-thirds of the face and upper neck. This includes:

1. Sagging facial skin and deep rhytids (wrinkles).
2. Jowling or poor mandibular contour.
3. Modest improvement of prominent nasolabial folds.

Important Considerations: Patients should be meticulously counselled that rhytidectomy is not effective for superficial rhytids resulting from solar damage (e.g., fine perioral lines) or minor depressions secondary to acne scarring. These abnormalities are more appropriately treated with adjunctive techniques, such as laser resurfacing or dermabrasion.

Preoperative Photography and Digital Imaging

Preoperative photographs are taken with standardised 1:8 full-face frontal, lateral, and oblique views. Digital imaging can be a useful tool for demonstrating realistic expected changes to the patient following surgery, helping manage expectations.

 

Surgical Techniques: A Multi-Modal Approach

Facelift surgery typically involves a combination of techniques to achieve comprehensive facial rejuvenation.

1. SMAS Rhytidectomy: The Foundation

SMAS (Superficial Musculoaponeurotic System) rhytidectomy is the most common and effective facelift technique, addressing both skin and deeper facial tissues.  The SMAS is a strong, thin layer just under the fat of the skin. It lies over the facial muscles and helps maintain the facial shape.

Connections of SMAS:

• Below: joins the platysma (neck muscle).
• Behind: merges with the parotid fascia near the ear.
• Above: connects with temporalis fascia in the temple area.

Understanding facial anatomy is crucial to avoid nerve injury. The facial nerve has five main branches: frontal, zygomatic, buccal, marginal mandibular, and cervical. Each controls specific facial muscles. The facial nerve, lies deep to the SMAS. That means it is safely under this layer, but if the surgeon cuts too deep during a facelift, they may damage these important nerves. This is why understanding the SMAS is very important for safe and successful facelift surgery.

Techniques of SMAS Rhytidectomy. There are two main ways to handle the SMAS during facelift:

• Plication: The SMAS is folded and stitched to tighten loose skin. This is best for thin patients with mild-to-moderate sagging.
• Imbrication: A part of SMAS is cut and overlapped to lift the tissues, used for more severe sagging.

Indications: Facial laxity, jowling, facial asymmetry, neck bands (platysmal banding).
Contraindications: Unrealistic expectations, psychiatric issues, severe sagging, obesity, diabetes, hypertension, poor healing, and smoking.

Surgical Steps of SMAS Rhytidectomy

1. Preoperative Marking. Start by marking important landmarks on the patient’s face and neck. Draw the genio-mandibular groove (line from chin to jawline), mandibular border (jawline outline) and submental triangle (area under the chin). These markings guide both the incision design and the tissue repositioning.
2. Anaesthesia and Infiltration. Administer general anaesthesia for patient comfort and safety. Alternatively, use local anaesthesia combined with IV sedation for select cases. Inject anaesthetic mixed with adrenaline (epinephrine 1:100,000) along planned incision lines. Infiltrate beneath the facial and neck skin in a fan-shaped pattern. The adrenaline minimizes bleeding by constricting blood vessels.
3. Incision Design. Proper incision planning is crucial for a natural appearance and hidden scars.

• Temporal Incision: Begin within the temporal hair tuft. For a low hairline, place an incision inside the tuft to allow hairline lift. For high or normal hairlines, place the incision right at the hairline to avoid further elevation. Curve gently backwards 2–3 cm into the hair-bearing scalp, then turn downward toward the ear.
• Preauricular Incision: In females, make a post-tragal incision (behind the tragus) to hide the scar. In males, use a preauricular incision (in front of the tragus) to avoid pulling hair-bearing skin onto the ear. Adjust incision based on the patient’s ear anatomy.
• Lobule Incision: Place the incision 1–2 mm below the lobule attachment for a natural appearance. Extend incision behind the ear, staying 3–5 mm away from the postauricular sulcus. In men, place the incision within the sulcus to prevent hair from being pulled onto the ear.
• Postauricular Incision: Continue incision behind the ear toward the fossa triangularis. Add a small V-shaped dart (cut) in the sulcus to prevent skin webbing during healing. Extend incision into hair-bearing skin along the occipital hairline.

4. Skin Flap Elevation. Begin elevating the skin flap gently in an avascular plane (plane without major blood vessels). Use a snipping (scissors) or spreading (blunt) technique to avoid damaging small vessels. Preserve a thin layer of fat attached to the skin’s underside to maintain blood supply. Extend dissection into the neck, staying above the platysma (supraplatysmal plane). Limit dissection near the zygomatic arch to the back one-third to avoid injuring the frontal branch of the facial nerve. Elevate a full-thickness skin flap off the tragal cartilage for smooth redraping.
   Dissection Extent: Anterior dissection extends ~9 cm forward toward the cheek. Extend dissection over the jawline and into the upper neck for complete mobilisation.
5. SMAS Dissection and Modification. Identify the SMAS layer beneath the fat but above the parotid fascia. SMAS is thicker near the ear and becomes thinner across the cheek.
   • SMAS Incisions: Make a horizontal incision in SMAS, parallel to the zygomatic arch, but only in the back one-third (posterior third). Add a vertical limb ~2 cm in front of the tragus. Do not extend cuts beyond the mandible’s angle to avoid damaging the marginal mandibular nerve.
   • SMAS Elevation: Elevate the SMAS flap about 3–5 cm. Include the platysma muscle when possible for better lifting, as the platysma connects with SMAS.
   • SMAS Plication or Imbrication: Pull SMAS flap upward (superior vector) and slightly backwards (posterior vector). Avoid over-tightening on one side to prevent asymmetry. Remove excess SMAS tissue. Anchor the SMAS flap securely:

• • • Fix the upper edge to the zygomatic arch fascia.
    • Fix the lower edge to strong preauricular SMAS tissues.
    • Use strong, permanent or long-lasting dissolvable sutures (e.g., PDS, nylon).

• In select cases, dissect additional SMAS posteriorly and secure it to the mastoid periosteum behind the ear.

6. Skin Redraping and Trimming. Gently drape the elevated skin back into place without tension. Pull skin behind the ear upward and slightly forward. Pull skin in front of the ear upward and slightly backwards. Trim extra skin with careful measurements for even tension.
7. Special care at the tragus and lobule: Thin skin flap over tragus to match natural contour. Carefully release skin around the lobule to allow free movement (“hammock effect”), preventing satyr ear deformity. Reshape the lobule contour before final closure.
8. Closure and Drainage. Insert a suction or Penrose drain beneath the skin flap to prevent fluid accumulation. Close deep layers with absorbable sutures (e.g., 5-0 polydioxanone). Close skin with fine non-absorbable sutures (e.g., 6-0 nylon for hairline, 5-0 fast-absorbing gut for postauricular skin). Apply antibiotic ointment over the incision. Place a firm gauze pressure dressing over the surgical site.
9. Postoperative Care. Monitor the patient overnight. Remove the drain the next morning and reapply a fresh pressure dressing. Prescribe antibiotics for 10 days. Instruct the patient to sleep with the head elevated for one week to reduce swelling. Apply a neck support dressing for 1–2 weeks. Remove skin sutures after 7–10 days. Swelling usually resolves over 4–6 weeks. The facial contour settles, and scars continue to fade over months.

2. Submental Liposuction and Platysmaplasty: Neck Contouring

When indicated, submental liposuction and platysmaplasty are performed before rhytidectomy to address neck laxity and fullness.

• Incisions: A midline incision is made within the first well-developed submental crease posterior to the mandible. For liposuction alone, a 5mm stab incision suffices; for subsequent platysmaplasty, this can be widened.
• Liposuction Technique: It is useful when the fat is superficial to the platysma.
  • A variety of cannulas exist; smaller cannulas minimise surface irregularities. Pre-tunnelling with a 2 mm cannula is followed by low suction.
  • The cannula is inserted into the subcutaneous space between the dermis and the platysma. The dominant hand controls cannula movement, while the contralateral hand guides tip position.
  • Liposuction involves radial dissection away from the incision. One atmosphere (760 mmHg) of negative pressure is usually sufficient. The suction port must always be directed away from the skin to minimise dermal trauma and dimpling.
  • Uniform suctioning is performed across the submental triangle down to the hyoid bone. Liposuction is limited near the inferior border of the mandible to avoid injuring the marginal mandibular branch of the facial nerve.
  • The “pinch and roll” technique helps determine the extent of liposuction, ensuring sufficient fat remains for natural skin cushioning.
• Platysmaplasty: It is useful for patients with platysmal bands. 
  • Requires a slightly wider submental incision. Blunt scissor dissection exposes the medial border of the platysma muscles. Residual fat between the muscles is removed under direct vision.
  • For minor platysmal banding, plication (simple suturing) of the exposed muscle borders is sufficient.
  • For severe platysmal banding, both muscles are horizontally incised at the level of the hyoid bone, then plicated anterior to this incision to recreate a well-defined cervicomental angle.
  • Subplatysmal structures (digastric muscles, submandibular glands) are addressed if necessary.
  • The submental incision is closed in a layered fashion.

3. Autologous Fat Transfer: Volume Restoration

Autologous fat grafting has seen a resurgence in interest for restoring lost facial volume, complementing facelift surgery.

• Patient Marking & Donor Sites: Volume-deficient areas are marked preoperatively (e.g., nasojugal, submalar, malar, nasolabial, geniobuccal regions, marionette lines, prejowl sulci). Common donor sites, not requiring significant patient repositioning, include the abdomen, flanks, and lateral thighs. The medial thigh is robust but requires a frog-leg position. Fat grafting is often a complementary procedure.
• Harvesting Technique:
  • A tumescent liposuction technique is used. Tumescent solution (lidocaine and epinephrine in isotonic saline) is infiltrated into the subcutaneous fat plane via a blunt-tip cannula, allowed to stand for vasoconstriction.
  • Fat is harvested using a liposuction technique similar to that for the neck, preferring a 2–3mm blunt multihole “cheese grater” type cannula.
  • Careful attention is paid to the plane of harvest to avoid irregular scarring or entry into the abdominal cavity. The non-dominant hand continuously palpates cannula depth. The volume needed for facial injections is typically small, reducing donor site morbidity.
• Fat Processing: Harvested fat is transferred to syringes, capped, centrifuged (e.g., 3000rpm for 3 minutes) to separate purified fat, and then the infranatant (fluid) is drained. The fat is transferred to 1mL tuberculin syringes for injection.
• Injection Technique:
  • Small 3 mm stab incisions are made for the injection cannula. A typical injection can be accomplished through three such incisions per side (submalar, nasolabial base, geniobuccal sulcus).
  • Fat is carefully injected using a blunt 20G injection cannula. Constant, controlled motion and attention to injection depth prevent irregularities.
  • Microaliquots of fat are deposited in multiple tissue planes to ensure smooth integration and survival. Volume depends on deficiency and patient goals.
  • Special attention is paid to injection depth in areas with thin skin (e.g., nasojugal region, orbital rim) to avoid irregularities. The non-dominant hand protects the orbit during upper midface injections.
  • Incisions are typically closed with a single fast-absorbing gut suture.

Complications of Facelift Surgery include:

1. Hematoma, the most common complication, usually occurs within 48 hours and ranges from minor collections to life-threatening expanding hematomas needing urgent surgical evacuation.
2. Nerve damage is rare; the great auricular nerve (sensory) and facial nerve branches (motor) are most vulnerable, with most motor nerve injuries recovering spontaneously.
3. Skin necrosis often results from untreated hematomas, excess tension, or smoking; superficial sloughs heal well, while full-thickness necrosis may lead to scarring.
4. Alopecia, particularly at the temple, can be transient or permanent; hair restoration may be needed if no regrowth occurs.
5. Satyr ear deformity stems from poor incision placement and over-excision.
6. Fat injection complications include contour irregularities, donor site morbidity, and rare but serious intravascular embolism causing tissue loss or blindness, preventable with meticulous technique and anatomical knowledge.

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High-Yield Points for Quick Revision

• Facelift Goal: Achieve natural rejuvenation of the lower two-thirds of the face and upper neck.
• Ageing Biology: Intrinsic (atrophy of skin, fat, bone) vs. Extrinsic (photoaging, elastosis).
• Key Indication: Jowling, loss of mandibular contour, redundant neck skin.
• Contraindications: Bleeding diathesis (absolute), poorly controlled systemic diseases, unrealistic expectations, active smoking (relative).
• Smoking Risk: 12x increased risk of skin slough; cessation for >2 months pre-op reduces risk.
• Skin Type: Fair, medium-thickness skin with moderate elasticity is ideal.
• Skeletal Support: Strong facial skeleton leads to better results; hypoplasia requires augmentation.
• SMAS: Superficial Musculoaponeurotic System, targeted for deeper tissue tightening.
• Nerve at Risk (SMAS near zygoma): Frontal nerve (most superficial over middle 1/3 of arch).
• Nerve at Risk (SMAS near angle of mandible/platysma): Marginal Mandibular nerve.
• Most Common Complication: Hematoma (most within 48h, often 6-8h). Expanding hematoma is a surgical emergency.
• Most Commonly Injured Sensory Nerve: Great Auricular nerve.
• Skin Slough Predisposing Factors: Hematoma, excess tension, smoking.
• Satyr Ear Deformity: Inferior displacement of lobule due to improper lobule incision/excess skin excision.
• Fat Grafting Complication: Contour irregularities (most common); Intravascular injection (most serious – blindness, stroke).
• Intravascular Injection Prevention: Blunt cannulas, aspiration, low pressure, small volumes, knowledge of anatomy.

NEET PG Style MCQs

Q1. The most common nerve injured during facelift is:

• A) Marginal mandibular nerve
• B) Great auricular nerve
• C) Temporal branch
• D) Buccal branch

Answer: B) Great auricular nerve

• Explanation: It supplies sensory innervation to ear; injury causes numbness over ear lobe.

Q2. SMAS stands for:

• A) Superficial Myofascial Anatomical System
• B) Superficial Musculoaponeurotic System
• C) Superficial Muscle Attachment System
• D) Submandibular Aponeurotic System

Answer: B) Superficial Musculoaponeurotic System

• Explanation: It includes fascia investing superficial mimetic muscles.

Q3. Which incision is preferred in males to avoid hair displacement?

• A) Post-tragal
• B) Pre-tragal
• C) Supra-auricular
• D) Retroauricular

Answer: B) Pre-tragal

• Explanation: Prevents hair-bearing skin from moving onto ear.

Q4. Subplatysmal fat is addressed during:

• A) Simple liposuction
• B) SMAS tightening
• C) Open neck platysmaplasty
• D) Fat transfer

Answer: C) Open neck platysmaplasty

• Explanation: Requires open approach for deep fat removal.

Q5. The zone where frontal nerve is at maximum risk is:

• A) 1 cm anterior to tragus
• B) 2.5 cm anterior to external auditory canal
• C) 5 cm above zygoma
• D) 1 cm below mandible

Answer: B) 2.5 cm anterior to external auditory canal

• Explanation: Classic danger zone for frontal nerve.

Q6. Alopecia post-facelift occurs mostly in:

• A) Postauricular area
• B) Temporal scalp
• C) Occipital region
• D) Submental region

Answer: B) Temporal scalp

• Explanation: Tension or devascularization leads to hair loss.

Q7. Platysma originates from:

• A) Sternocleidomastoid fascia
• B) Pectoralis major fascia
• C) Mandibular periosteum
• D) Trapezius fascia

Answer: B) Pectoralis major fascia

• Explanation: It inserts into lower mandible and submental skin.

Q8. Nanofat is used for:

• A) Volume augmentation
• B) Skin texture improvement
• C) Wrinkle correction
• D) Glandular hypertrophy

Answer: B) Skin texture improvement

• Explanation: Nanofat improves skin quality; no live fat cells.

Q9. Which condition is absolute contraindication for facelift?

• A) Controlled hypertension
• B) Smoking cessation 1 month before surgery
• C) Ehlers-Danlos syndrome
• D) Controlled diabetes

Answer: C) Ehlers-Danlos syndrome

• Explanation: Fragile connective tissue contraindicates elective surgery.

Q10. The primary plane of skin elevation during facelift is:

• A) Subcutaneous
• B) Submuscular
• C) Subperiosteal
• D) Subplatysmal

Answer: A) Subcutaneous

• Explanation: Dissection proceeds in the avascular subcutaneous plane.

1. • 1. Viva Table: Quick Reference for Exams

Question	Key Answer
Define SMAS	Superficial Musculoaponeurotic System
Most common complication	Hematoma
Commonest nerve injured	Great auricular nerve
Zone of danger	2.5 cm anterior to external ear (frontal branch)
Platysma origin	Pectoralis major fascia
Nanofat use	Skin texture improvement
Fitzpatrick types for resurfacing	Type I-III ideal for dermabrasion

FAQ in Viva

• Q: What is a facelift (rhytidectomy)? A: Facelift surgery, or rhytidectomy, is a cosmetic procedure that lifts and tightens sagging skin and tissues of the lower face and neck to create a more youthful appearance.

• Q: What are the main causes of facial aging? A: Facial aging is caused by intrinsic factors like atrophy of skin, fat, and bone, and extrinsic factors primarily from environmental damage such as sun exposure (photoaging) leading to elastosis.

• Q: What is the most common complication of facelift surgery? A: Hematoma formation is the most common complication following facelift surgery, often occurring within the first 48 hours.

• Q: Why is smoking a significant risk factor for facelift complications? A: Smoking significantly increases the risk of skin slough (necrosis) and hematoma due to its vasoconstrictive effects and impairment of wound healing.

• Q: What is the purpose of SMAS manipulation in a facelift? A: SMAS (Superficial Musculoaponeurotic System) manipulation lifts and repositions the deeper facial tissues, providing more natural and long-lasting results than skin-only facelifts.

• Q: What is the most serious complication of autologous fat grafting to the face? A: The most serious complication of autologous fat grafting is intravascular injection, which can lead to severe adverse events such as blindness or stroke due to embolism.

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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