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Face Lift By Villar

What constitutes a quality face lift and how to identify one?

 

Surgeons argue endlessly about how best to perform a face lift and ancillary procedures.  There is no definitive technique, because we still do not know all the details of the aging process.    Val  Lambros  in  California  has  been  photographing patients  in  3D  and compositing  them  in  a  computer.    The  computer  then  creates  a  3D  image and  can morph  back  and  forth  through  the  years  for  each  patient.  The computer  can  then average hundreds of patients and we can watch the aging process on a screen.  As the database  increases,  we  learn  more  and   more  about  aging  and much  of  it  was unexpected.  Before we can fix a problem, we must understand it.

 

The  science  and  the  surgery  are  evolving. There  are  common  denominators,  but  each patient  is  unique  and  surgery  should  be  customized.    It  is  easier  to  appreciate  poor surgery than to recognize good surgery.

 

How to identify a face lift By Villar

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There  are  some  basic  objectives  that  have  stood  the  test  of  time.  A clean  jawline,  a smooth neck with restoration of the angle, cheek fullness without distortion, and a clean natural hairline.

 

Choosing the optimal incisions

The  first  sign  of  a  poorly  executed  face  lift  is  loss  of  hair  in  the  temple  area  and/or behind the ear.

This  resulted  from  a  variation  of  the  traditional  incision  in  which  the  novice  surgeon attempted  to  hide  the  posterior  incision  in  the  hairline  by  cutting  straight  back.    The traditional  incision  up  from  the  ear  results  in  loss  of  the  sideburn  hair  in  patients  with lots  of  excess  skin.  Gutting  straight  back  violating  the  natural  hairline  results  in  a  bald area when the skin is pulled, hairless skin is pulled into previously hair bearing areas.

The  ideal  incision  would  preserve  the  natural  hairline  in  front  and in back of the ear.

At  4  weeks  after  lower  facelift,  there  is  no  distortion  of  the  hairline  front  or  back.    The patient can wear her hair up in a pony tale.

 

Restoring the Jawline and Angle of the Neck

The  modern  face  lift  relies  on  various  techniques  of  tightening  and  adjustment  of  the muscles  and  fascia  of  the  face  and  neck.  Platysma  and  SMAS  plasty or  plication  are common  terms  related  to  the  concept  of  tightening  the  muscular  structures  instead  of just pulling on the skin which re-stretches rapidly has not stood the test of time.

 

As  we  understand  the  aging  process  better,  we  are  modifying and  improving  our techniques.    The  important  thing  to  remember  is  that  one  size  does  not  fit  all.    Each patient  is  unique.    The  initial  plan  is  customized  and  findings  at  surgery  require  the training  and  ability  to  think  on  your  feet  and  adjust  as  necessary.    That  is  what  makes these surgeries so challenging and fun.

This  lower  face  and  neck  is  difficult  in  that  there  is  no  angle  to  the  neck  right  from  the chin.  There is a lot of sub-mental fat and significant subcutaneous fat.  The jowls extend over the jawline onto the neck, obscuring the jawline. Some would insert a chin implant to obtain an improved neck angle, but this chin pleasing to my eye.  There is a crease at the base of the neck.

 

The Plan

The  plan  is  to  design  an  incision  that  will  not  distort  the  hairline  in  front  or  behind  the ear.    We  will  perform  a  sharp  scissor  dissection  of  the  subcutaneous  tissue  leaving  the thickness we want on the skin and the excess will be left on the platysma to be removed with a flat wide cannula with the suction hole face down to avoid irregularities and dents in the skin..  This is left until  after the SMAS  and  platysma have been tightened to  give us  some  leeway  to  sculpture  the  jawline.  If  there  is  a  prominent  hyoid,  we  have  a  chin implant available, if we need it.

The Execution

The skin was sharply scissor dissected leaving  enough subcutaneous fat to preserve  the  venous  plexus  to  the  mid  face  and  across  the  midline  in  the neck.    The  SMAS  (Superficial  Musculo-Aponeurotic  System)  was  rotated upward  and  plicated  over  the  zygoma  to  restore  fullness  in  the  cheeks.

 

Then  the  platysma  muscle  was  plicated  down  the  midline  to  restore  the angle to the neck.  The hyoid was not prominent, so a chin implant was notnecessary.  The sub mandibular glands, hidden preoperatively by the jowls, required  some  tightening  of  the  platysma  to  better  hide  them.    After  the sub-structures  were  customized  to  this  patient,  the  skin  was  pulled  back without tension.  The fat remaining on the muscle was then sculptured with sharp scissor dissection to define the jawline.  The crease at the base of the neck  was  dissected  free  of  its  attachments  to  the  muscle.    The  skin  was pulled  tight  behind  the  neck,  trimmed  and  sutured.    No  staples  on  my patients.  The skin in front of the ear is gently laid, not pulled under tension, marked and cut, then sutured meticulously.  No nurse or technician places a single  suture  because  the  final  closure  has  to  be  adjusted  meticulously  to the  patients  needs.    We  consider  this  a  work  of  art,  not  assembly  line surgery.

At 5 days, sutures are removed in the front of the ear and under chin

At   10   days   all   sutures   are   out,   good   angle,   smooth   jawline,   crease diminished,  no  dog-ears  behind  ear.    Chin  implant  was  unnecessary.   Unrestricted activity allowed at three weeks.

 

Attention to Detail

   Dr. Luis F. Villar, M.D., F.A.C.S.   |   Villar Plastic Surgery    |   309 SE Osceola Street, Suite #201, Stuart, Florida 34994   |   (772) 678-0932