THE NATURAL FACELIFT-LESS IS MORE

INTRODUCTION

The most common request I see in my practice in a patient requesting facial rejuvenation from the patient is ”I want to look natural and well rested.” They also usually mention a bad facelift they have seen and usually will say I don’t want to look pulled like this person. The other most common patient concern is the speed of recovery. We sought to evaluate two surgeon’s experience with the use of the natural lift. Both surgeons use the same facelift technique. This retrospective review evaluates 625 patients who underwent the natural lift with other concomitant procedures. In particular, patient satisfaction and speed of recovery were most important variables reviewed. A minimum follow-up of 12 months was used and patients underwent surgery from 2000-2004. Demographic data was collected, and patient satisfaction was determined from postoperative interviews conducted at postoperative follow-up visits. The type of facelift described is a variation of the deep plane facelift which produces a very natural result with a rapid recovery. The natural lift is a variation of the deep plane facelift. Tissel tissue glue was used in 65% of patients and none of the patients had a drain.

PATIENTS AND METHODS:

1. Incision placement: Goal is to camouflage scars and preserve temporal and posterior hairline. The hairline incision should be placed at the temporal hair tuft or a few millimeters inside the temporal hairline rather than higher in the temporal region. This results in a natural hairline by preserving the temporal hair tuft and avoiding the "wind blown" look. The preauricular incision is placed in the post-tragal region. The posttragal incision achieves the least noticeable scar. First, during closure the area of the tragal skin is left long and trimmed later after establishing closure above and below it without tension. The tragal skin is then trimmed and then defatted down to dermis to recreate the thin skin normally covering the tragus. Defatting it avoids blunting the tragus and closing without tension avoids pulling the tragus forward.
Postauricularly the incision is placed onto the concha so that when closure occurs and pulls down with gravity the incision lies in the postauricular crease. The hairline entrance from the postauricular incision should be in the region where the ear meets the hairline so the scar is covered by the ear. The hairline incision is then placed in the hairline and is perpendicular to the neck vector of elevation.
2. Minimal lifting in the upper face and lateral orbital region and more lifting in the deep plane along the jowl and in the neck. In lateral orbit region, there is less distortion of the eye and less bunching of skin in the lower eye. The subcutaneous flap is raised in the face towards an imaginary line drawn from the zygomatic arch to angle of mandible and then the deep plane is entered anterior to this imaginary line overlying the masseterric fascia and zygomaticus muscles. By lifting less in the upper cheek region, there is less skin excision in the temporal hair incision and more skin excision in the lower preauricular region. In the neck, subcutaneous flaps are dissected anteriorly towards the midline. Liposuction is performed below the mandible from the postauricular incision conservatively. The posterior platysmal border in the neck is lifted towards mastoid periostium.
3. Adjunctive treatments: In a natural lift, patient understands that the nasolabial fold will not completely disappear but injection of restylane during the facelift in the nasolabial folds can improve the result here. Occasionally a patient has a very skeleton-like thin face and may require further injections of restylane in the area below the zygomatic arch or in the pre-jowl sulcus if it is really deep.
4. Preoperative counseling is imperative: Education regarding preoperative and postoperative medications to avoid including all NSAID's and herbal medicines which can result in bleeding. Addition of Arnica Montana and pineapple extracts has shown improved healing postoperatively, particularly a decrease in edema and ecchymoses. Preoperative anxiety-reducing medications are prescribed.
5. Intraoperative measures: Intraoperatively, in addition to meticulous hemostasis, at the conclusion of the procedure and prior to flap closure, Tissel tissue glue is sprayed under the flap and has decreased hematomas, seromas, bruising and swelling significantly and avoids the use of a drain (Rizk SS, Matarasso A: Use of Fibrin Sealant in Short Scar Facelift. In Saltz, Toriumi: Tissue Glues in Cosmetic Surgery, 2004). By not having a drain, it decreases recovery time and eliminates an extra incision on both sides of the face with the potential for further scarring. Prior to spraying the tissue glue, irrigation under the flap is performed to see if there are any small oozing vessels and they then are cauterized as needed.
6. Postoperative measures: A private duty plastic surgery nurse is essential for the first 24 hours for monitoring and application of ice compresses. In addition, it takes the burden of postoperative care away from the family and results in a more relaxed patient. Decreased postoperative patient anxiety through the use of a controlled environment and post-operative anxiety-reducing medications results in a more expedient recovery. Patients usually will be advised to stay in a hotel very close to the hospital rather than go home again to produce a more controlled, secure environment for the patient with proximity to the hospital in case the patient requires admission for any reason such as blood pressure control, nausea or pain control.
7. Other medications: Addition of stool softeners and production of normal bowel movements results in a happier patient postoperatively, especially with the constipating effects of pain medicines. Vitamin C 2000mg is recommended for 2 weeks preoperatively and 2 weeks postoperatively. Vitamin k 5mg is given also for 1 week preoperatively and 1 week postoperatively.