Facelifting: Evolution of the Facelift
For over a century now, women and even men have fervently pursued the goal of looking younger through Facelifts. In fact, the first Facelift was performed in Germany, at the very start of the 20th Century when an elderly, Polish aristocrat asked her doctor to give her a “little lift” in her cheeks and mouth. By the 1920s, aesthetics had already become a burgeoning specialization for Facelift Surgeons. Today, Facelifts are commonplace. They enable modern day, men and women alike to knock ten years off of their appearance, enhance their feelings of confidence and increase their quality of life.
When Plastic Surgery was first introduced into the surgical specialties, it was primarily founded from a necessity of reconstructing soft tissue injuries from traumatic insults which soldiers sustained during wartime. The surgery restored tissue that had been lost due to bullet wounds, fragments or explosions. As Plastic Surgery techniques continued to evolve, eventually it was noted that some of the sagging or wrinkled facial skin was being corrected by elevating the skin tissue, pulling it back, excising the excess and re-sewing it. At that time there was also very little knowledge of the basic embryology, development and facial anatomy. As more and more research was performed on the anatomy and embryology of the face, knowledge of the tissue planes within the face, the enervation and vascular supply increased. This knowledge helped Facelift Surgeons continue to develop techniques that would correct jowling and neck sagging, as well as other wrinkling or aging characteristics of the face, eyes, forehead and lower face and neck. In addition to the basic scientific research in surgery taking place, advancements in anesthetics and Anesthesia were being developed.
The earliest form of Anesthesia was ether inhalation, which then led to the development of respirators and paralyzing agents. These allow a patient breathing on a ventilator while vital signs are monitored vital signs and IV fluids and drugs are administered in order to control cardio pulmonary physiology during surgery. As anesthetic and Anesthesia techniques continued to advance, Facelift Surgeons observed that patients could tolerate a light form of sedation with Local Anesthetic infiltration.
Anesthetics and Anesthesia
These anesthetics were primarily drugs such as Versed, Fentanyl, Morphine and Propofol. Versed is listed in a category known as Benzodiazepine. It is typically the first drug administered with any surgery, as it is an anxiolytic which reduces any anxiety patients may have prior to Facial Cosmetic Surgery. In turn, this will help eliminate or decrease cardio pulmonary response that a patient may experience, due to anxiety, such as increased heart rate and blood pressure. Decreasing the heart rate and blood pressure helps to reduce intraoperative bleeding and swelling, thereby reducing the chance of bruising. In addition to Versed, typically a narcotic is given, such as Fentanyl, which is an extremely potent form of intravenous narcotic. This reduces the pain response the patient may experience when Local Anesthetic is injected into the operative area. Once the patient is sedated with both, at that point, Propfol is administered. This essentially puts the patient asleep to the depth where the patient is unaware yet can breathe on his or her own and still maintain a gag reflex. The gag reflects protects the airway in such cases as Rhinoplasty Surgery or other procedures where there may be secretions or blood that pass through the oral cavity or nasal pharynx. In these cases, the patient will be able to swallow the contents, versus have those secretions aspirate into the lung, which could potentially lead to respiratory issues. Additionally, in nasal or oral procedures, typically a protective packing is placed to reduce the amount of secretion that could potentially be dripping into the post-nasal pharynx.
Once the patient has been adequately sedated, injection of the Local Anesthetic, typically Lidocaine at one percent with 1 to 100,000 Epinephrine is used to anesthetize the area of the face being operated on. Lidocaine with Epinephrine serves two functions: Lidocaine inhibits the nerve response to physical stimuli therefore eliminating pain sensation; Epinephrine constricts the blood vessels in the area to further reduce bleeding and swelling. Injection with Lidocaine and Epinephrine as performed by Dr. Slupchynskyj is a proprietary technique decreasing the amount of swelling and bruising in the intra- operative and postoperative periods. This specialized local infiltration technique minimizes penetration of blood vessels and swelling. It is micro-targeted towards the operative areas in order to reduce intraoperative and postoperative swelling and bruising, thus speeding recovery after surgery.
Facial Anatomy and Surgical Technique
As the embryology of facial anatomy were better defined through research, Facelift Surgeons discovered particular surgical planes within the face and body that can be entered allowing an almost avascular or bloodless dissection to be performed. The face does have certain avascular or less vascular tissue plane spaces that can be entered to reduce intraoperative and postoperative bleeding and swelling thus decreasing recovery time after Facelift Surgery; however, the Facelift Surgeon must have knowledge of this anatomy and understand those avascular surgical planes in order to dissect into them.
Facelift procedures became more popular in the late 1970s and 1980s. At this time, they were being performed under General Anesthesia within hospital settings where the patients typically stayed several days after the procedure, primarily due to the fact that patients had a considerable amount of bleeding and swelling postoperatively. Facelift Surgeons were concerned about the risk of postoperative hematoma formation, which is blood under the skin that can compromise the viability of the skin and the airway. They were also concerned about periorbital swelling around the eye, which could impair vision. The patient needed several days of very close care in order to monitor these particular and potential complications.
Additionally, and because of the fact that most Facelift Surgeons took longer to perform the procedure, operative time was prolonged under General Anesthesia, so the patient’s physical and mental recovery took longer and, consequently required more monitoring. General Anesthesia as compared to Sedative Anesthesia requires anesthetic agents that change the cardiovascular and pulmonary physiology to the point where typically more intravenous fluids are required an/or additional medications to control blood pressure and heart rate. With General Anesthetics, paralyzing agents such as Acetylcholine are given at the induction of Anesthesia in order to be able to intubate the patient and place them on a respirator. Furthermore, having a patient on a respirator with a tube in his/her trachea requires a deeper form of Anesthesia so the patient can tolerate the endotracheal tube.
Again, as the surgical techniques and Anesthesia continued to advance, the realization that a patient can undergo a “Full Facelift” which would include Neck Lift, Jowl Lift, Upper and Lower Eyelids, and Forehead Lift; these types of procedures could be performed over a 4 hour period without General Anesthesia and once the surgery was finished, and the Propofol was turned off, the patient was able to be discharged immediately home and would not require in hospital postoperative care. Patients that have combined facial cosmetic procedures like this in my practice and undergo approximately 4 hours of surgery are more comfortable having someone to be with them for the first 24 to 48 hours, in order to provide them with emotional support and postoperative care such as application of ice packs, preparing food and administering any medications. These responsibilities can be performed in a home setting with either a friend or non-medical personnel. NYS law does require that any patient that undergoes Anesthesia has a responsible adult stay with the patient for 24 hours after sedation. In my practice, we require of all patients that undergo Sedative Anesthesia have a responsible adult sign that they will accompany the patient for a 24 hour period after surgery.
The other aspect of Facial Cosmetic Surgery or Facelift Surgery that has evolved over the years is that the popularity has increased for a variety of reasons. One is that newer technology and innovations within Facial Cosmetic procedures have encouraged patients to pursue Cosmetic Surgery and as well as the minimally invasive procedures that reduce recovery time and downtime away from work, school and social lives. One example of this is Botox®, which after being administered, the patient can go back to work immediately. In addition, over the past 25 to 30 years, patients have been and are more informed about cosmetic procedures due to the availability of information on Internet. They can research Facelift Surgeons and procedures. Although all the information there is not all factually based, patients can get a relatively good idea about what type of result and procedure they desire.
In the past, patients who sought cosmetic procedures, would consult with a Facelift Surgeon and ask, “What do you recommend I do to look better or younger?” The Facelift Surgeon would then suggest surgical or non-surgical procedures to address the aging aspects of the patient; however, it should be noted that the aesthetic results and expectations of the patient and that of the Facelift Surgeon are both somewhat subjective. Over the past 25 years, Facelift Surgeons have standardized what facial features and structures look good and does not look good. Regardless, patients still carry the primary decision as to what the result or outcome should be and what is aesthetically pleasing to them. This paradigm shift weighs heavily on that of the patient, versus that solely of the Facelift Surgeon, with the recognition that the patient is well informed of the procedure they desire and of their aesthetic goals. In turn, the patients will now typically request specific procedures, versus ask the Facelift Surgeon what they should have done. It is then up to the Facelift Surgeon to determine whether he or she can perform this procedure and whether the procedure is within the realm of an aesthetically acceptable result.
The other change in Facial Cosmetic Procedures over the past 25 years is that patients have realized that having less invasive procedures earlier in their life will preserve their and maintain their youth for a longer period of time. Previously, it would be a patient waiting until their 60s or 70s There are several disadvantages of having procedures when a patient has aged significantly. One is that if the patient has extensive aging characteristics who then undergoes a Facelift, there would be an obvious change in appearance and this will be noticed by those who know this person. Rejuvenating someone from 65 to who now looks 45 can appear obvious. Another is the additional risk factors, (i.e., medical issues that may have been developed over the years). Elderly patients tend to have more bleeding, swelling and a longer recovery. So the trend over the past 5 to 10 years has been that younger patients are now seeking cosmetic procedures which are minimally invasive or non-invasive. Between ages of 40 and 50 they start to notice minor aging characteristics such as: mild jowling, minor neck tissue redundancy or Turkey Neck, or Crow’s Feet and heavy eyelids, or puffy lids, or eye bags. These patients that tend to come in earlier to retard the progression of a particular jowling effect either resulting either from gravity or aging. This approach has the advantage of having less aggressive procedures done at a younger age where the results are less obvious and retard the aging or delay it.