Facelifting Surgery

Facelifting procedures will be discussed purely from a practical angle, including the particular techniques which the author finds more straight forward, sharp, less complicated and invasive.
The features and signs of an aging face result mainly from the following major factors:
1. Atrophy of the cutaneous fat.
2. Loss of elasticity of the skin.
3. Facial skeleton bone absorption including periodental.
4. Overactive facial and neck muscles.

Common features of an aging face are:
– Skin wrinkles, rhytids, creases, furrows, fissures, folds and deep lines of facial expressions.
– Eyes sagging, eyebags, bulging, fullness, redundant eyelid skin and fat herniation and prolapse.
– Fat deposits in submandibular and submentum.
– Redundant skin and ptosis of the lateral neck, anterior neck, cheek, submandibular, submentum and       postcervical neck.
– Ptosis of the nose and chin.
– Vertical platisma muscle folds and binding submentum.
– ‘Gaunt’ appearance due to fat atrophy.
– Acquired pigmentation and skin lesions.
– Loss of hair pigmentation, sparse and coarse hair.

The goals of lower facelifting are to achieve the following:
– Natural, satisfactory and safe results.
– Avoiding unwanted postoperative problems.
– Short hospital stay and early mobilization (day case).
– Early return to work.
The technique of lower facelifting that the author has been using for the last seven years is based on a combination of:
– Suspension rhytidectomy (superficial musculoaponeurotic system plication).
– Superficial musculoaponeurotic system management: limited superficial musculoaponeurotic system       flap, elevation and advancement, trimming, rotation and suture imbrication.

The main advantages of combined suspension rhytidectomy and superficial musculoaponeurotic system flap techniques are:
– Limited dissection that reduces bruises, echymosis, tension cones and dog ear formation.
– Reduction of subcutaneous dead space that limits and reduces the haematoma, infection, abscess
formation and leads for rapid wound healing.
– The branches of the facial nerves are usually safe.
– Procedure is easily performed under local anaesthesia and sedation as a day case.
– Preserve the hair pattern.
– Good healing resulting in invisible scars.
– Return to work usually in five days time.


Fig. 18 – 9. A 65-year-old patient was presented with redundant skin of the lateral neck, anterior neck and submandibular regions with skin wrinkles, rhytids, creases and eyes sagging.

Postoperative photos showed the results of facelifting, forehead lifting with upper and lower blepharoplasty.


The following steps for lower facelifting are recommended:

  1. Patient in an upright position. The planned skin incision is marked, the anterior, inferior and posterior limits of the dissection are noted. The regions of fat deposition or atrophy are pointed out.
  2. Local anaesthesia Xylocaine 1%, 1:200,000 adrenaline is infiltrated.
  3. Skin incision: the following incision is the author’s preference, because it preserves the normal anatomy and avoid changes in hair pattern or hair loss.
    A double taft of hair in the temporal and preauricular area should be preserved. The incision starts on the anterior hairline of the sideburns at the level of the eyebrow, then follows the hairline of the sideburns down, then around, then up along the posterior hairline of the sideburn to the junction of the antihelix with temporal skin, then, the skin incision runs inferiorly in a preauricular crease two mm anterior to the tragus in the males to prevent beard growth in the ear, but in females the incision passes just within the ear behind the tragus. Next the incision runs around the ear lobule one mm below its crease, after that, it is angled up and runs superiorly on the medial surface of the concha five mm above the postauricular sulcus and continues up the level of junction of the inferior crus with the helix rim. Then the incision is angled at 900 and extends horizontally in the occipital skin just anterior to the posterior proturberance, finally angled at 450 downwards for about two cm.
  4. Dissection and undermining of skin is carried out forwards, downwards, backwards in all directions up to the noted dissection limits. The dissection is carried out by a straight blunt scissors just deeper than the hair follicles between skin and platisma.
  5. Undermining should be superficial to the platisma muscle to avoid injury to the mandibular branch of facial nerve. As well as the cheek flap, the temple flap should be undermined superficially and stopped halfway between the ear and lateral canthus, in order to protect the frontal branch of the facial nerve at the transition between the temple and cheek flap. Dissection below the ear should be done with care superficially to avoid injury to the greater auricular nerve. (Fig. 18 – 25)
  6. Superficial musculoaponeurotic system management: The preparotid fat is removed and superficial musculoaponeurotic system fascia identified. A vertical incision 1.5cm anterior to the preauricular incision is made through the SMAS, it extends from xygomatic arch and inferiorly three cm below the mandibular border. The vertical incisions made in continuity with three cm horizontal incision just below the xygomatic arch. The superficial musculoaponeurotic system plane is entered with a blunt scissors superficial to the parotid capsule. The SMAS flap is elevated anteriorly for only two to three cm along the vertical incision, then advanced and rotated superiorly, the excessive overlapped tissue is trimmed, then edge to edge suture repair is completed with appropriate advancement and rotation using 2/0 Ethibond. The superficial musculoaponeurotic system flap is split horizontally at the mandible border with the lower segment sutured to the mastoid fascia.
  7. Suspension rhytidectomy:
    SMAS plication in addition to the above SMAS management is recommended. We add six to eight sutures 2/0 Ethibond which are positioned anteroposteriorly, from the anterior limit of the dissection at the junction between the skin and platisma then posteriorly just one cm anterior to the skin incision.
  8. The above manoeuvre will definitely achieve excellent SMAS lifting, resulting in skin closure with no tension and significant reduction of subcutaneous tissue space leading for rapid healing and decreases the risk of haematoma and infection.



Fig. 18 – 11. (A)Standard incisions for male. (B) Incisions for male with thinning hair.

  1. Skin flap redistribution:
    Flap redistribution and skin closure should be under no tension, whatsoever. The redistribution of the flap made perpendicular to facial folds by drapping a right angle to prevent tension cones or dog ear formation. The face is observed for smoothness. The flap is secured initially by a stapler at two key points: first, postauricular at the junction between scalp hairline and non hair bearing of postauricular skin. The second, just above the helix. The excess skin is tailored and trimmed in an appropriate way without any tension to avoid skin necrosis, later wound dehesance, and unwanted scars. A stapler is used in hair bearing skin. Subcutaneous 4/0 Dexon or interrupted 4/0 nylon is used on non hair bearing skin in the preauricular area. Small drains are applied. (Fig. 18 – 25)
  2. Steri-strips, Sofratulle and gentle pressure dressings are applied. Appropriate medication for nausea, vomiting and coughing are given. Pain may indicate haematoma. Drains removed and dressing are changed next morning. Patient discharged home on antibiotics and mild pressure dressing and reviewed in five days. Sutures are removed in eight days, and staples in twelve days. Antibiotics and steroid ointment on the wound are recommended for two weeks. Gentle hair shampooing from day five postoperative. (Fig. 18 – 10)

Summary of complications

  1. Early haematoma, bruises, echymosis, wound dehesance, infection and abscess formation.
  2. Facial nerve weakness which may be transcient due to the local anaesthesia injection which usually recover in a few hours. Permanent weakness is due to iatrogenic nerve injury.
  3. Late unwanted scar, tension cones, dog ears, change in pattern of the hair.
  4. Patient dissatisfaction due to undercorrection or overcorrection.

The main indications of endoscopic forehead lifting are:

  1. Forehead wrinkles/frontalis hyperactivity.
  2. Glabellar vertical wrinkles _ Scowl appearance.
  3. Root nose horizontal wrinkles.
  4. Frontal bossing/prominent orbital rims (ancillary procedures).
  5. Brow ptosis.
  6. Pseudoptosis.

Goals of endoscopic forehead lifting are: (Keller GS)

  1. Reduce forehead rhytids.
  2. Elevate the brows.
  3. Diminish lateral hooding.
  4. Diminish infrabrow skin overhang.
  5. Reduce forehead scarring.
  6. Reduce or eliminate hair loss.
  7. Diminish forehead elevation.
  8. Reduce degree of morbidity.
  9. Reduce postoperative recovery time.
  10. Reduce incidence of parasthesias.



Fig. 18 – 12. (A)Incisions for a bald male. (B) Anatomy and general principles of endoscope forehead lift

Advantages of endoscopic forehead lifting are:

  1. Decreased scarring (scalp).
  2. Reduce numbness (scalp).
  3. More acceptable to the patient.
  4. Good for patients with thin hair or baldness.
  5. Less bleeding.
  6. Less eodema.

Disadvantages of endoscopic forehead lifting are:

  1. Technique may be difficult and needs instructed cadaver workshop.
  2. Undercorrection.

Technique: the author recommends the Anthony Geroulis method.

  1. The incisions are marked while the patient is in a sitting position. Five incisions may be made for the dissection: one along the midline of the forehead as a semi-circle, one above each iris and one in each of the temporal areas (Fig. 18 – 9A). For male patients, the iris incision is usually placed in the scalp directly above the midline of the iris. In most female patients, the scalp incision is made at the lateral border of the iris. The position of the temporal incisions are determined by the use of a straight line from the nasal ala across the lateral canthus of the eye to the temporal area. In men, attention is also paid to the placement of the incisions according to the patient’s hair line. There are three general types of incisions in male patients: standard incisions for male (Figs. 18 – 11A,12B), incisions for male with thinning hair (Fig. 18 – 11B) and incisions for a bald male (Fig. 18 – 10A). The latter simply eliminates the central incision of the other two techniques, which avoids a possibly obvious scar.
  2. Local anaesthesia with sedation: 1% Xylocaine with 1:200,000 adrenaline. This is injected at the incision sites and subgaleal across the entire top of the skull and forehead. When the patient is adequately sedated and anaesthetized, the incisions are made. The dissection begins in the lateral temporal area. The deep temporalis fascia is identified and several small pinpoint marks with the electrocautery on the temporalis fascia. This marks the original position of the scalp and allows for assessment of the degree of the skin retraction on the forehead. This becomes important in the analysis of correction for fascia symmetry.
  3. A drill-hole mark is made in the skull at the anterior aspect of both the right and left iris incisions with a hand-held drill system. The surgeon will use this mark at the end of the procedure to measure the distance of the skin retraction of the brows. This is particularly important in the correction for an asymmetry of the brows.
  4. The dissection continues through the midline incision and through the right and left iris incisions with a periosteal elevator or a mastoid elevator. This dissection is in the subgaleal plane anterior over the forehead. The extent of the dissection in this plane is determined by the extent of the male patient’s rhytids. For severe forehead rhytids, the subgaleal dissection extends to just above the brow. Posteriorly, the dissection is subgaleal to the occipital area to the occipitalis muscle (Fig. 18 – 12B). The periosteal flap is then elevated to about two finger-breadths above the eyebrows. At this point, the two flaps have been established; the galeal flap and the periosteal flap, and the scalp is fully mobile. Once this is completed, dissection continues endoscopically with the subperiosteal elevation.
  5. Now, an endoscope is inserted into the temporal incision. A five mm, 300 endoscope is preferred, with light source and an auto-exposure video camera. The dissection continues with an elevator on the deep temporalis fascia toward the zygomatic


Fig. 18 – 13. Results of bilateral facelifting, in a white skinned patient which achieved excellent results. The scar is hardly visible after two months.
arch. The plane is extended downward until the superficial temporal fat pad is first visualized. The inferior dissection stops at this landmark so that structures in this area, such as the frontal branch of the facial nerve and the middle temporal artery, are not damaged. These structures lie just superior to the temporalis fascia or galea.
  1. Elevation of the periosteum continues around the ocular rim to the position where the conjoint tendon is found, i.e., the area where the temporalis fascia attaches to the frontal bone. Along the way, the sentinal vein is encountered on the lateral side of the ocular rim. Identification and avoidance of this structure will keep the dissection from extending too far medially and prevents postoperative hemorrhage and haematoma.
  2. The next major landmark to be identified is the supraorbital nerve, which should be avoided. The corrigator muscles are more medial. The extent of the dissection of this region will vary among patients and with the degree of a scowl appearance which they portray.
  3. The corrigator muscles are cut high so that one can identify and easily control any bleeding in the area. If heamostasis is required, a foot-pedal-operated tonsillectomy suction and bovie device provides a simple means for controlling bleeding while maintaining adequate visualization of the surgical field. A laser may also be used, if available, for cutting the muscles in this area.
  4. Slightly deeper, the supercilious muscles are identified and may be cut (Fig. 18 – 12B). At this point the dissection extends through the periosteum, and the procerus muscle is identified, which may also be cut.
  5. The supraorbital nerve on the opposite side may be identified at this time. The same steps are performed on the opposite side for the complete release of the periosteal flap around both orbital trims. The composite flaps of the periosteum and galea are now established.
    The rhytids in the male are surgically approached from the subgaleal plane. These are corrected by scoring the tissues of the forehead parallel to the rhytids. Depending upon the exposure, this is performed with either the endoscope or direct vision.
  6. Next, a similar mark is made at the anterior edge of the iris incision, which is in a changed position because of the retraction of the frontalis and occipitalis muscles. These two marks are used for an accurate measurement of the extent of the skin retraction, which is usually about ten to fifteen mm. This measurement may be performed with a protractor which measures in millimeters. Measurements are made from both sides and recorded. Frequently, the contraction of the frontalis and the occipitalis muscles will `self-correct’ brow asymmetry.
  7. Once symmetry has been determined, the last drill holes are made and used for placement of a twelve mm screw into the skull to secure the periosteal flap in place.
  8. With the periosteal flap elevated and retracted posteriorly, the brows are raised. The degree of brow elevation is determined by the posterior relocation of the periosteal flap. This flap is secured in position by suturing both the flaps together anteriorly to the screws on each side using the 4-0 Gortex suture. This establishes and maintains the level of brow elevation and symmetry during the initial healing phase.
  9. A drain (Hemovac #6) maybe inserted to the right temporal region behind the hairline, and placed across the entire forehead just above the brow. The drain is placed on a bulb suction and may be removed the next day. Many times the drain is unnecessary and is used only in those cases where fluid collection is anticipated. The right and left iris incisions are closed with staples. Staples are also used for closure of the remaining incisions. A pressure dressing bandage is applied around the head. The dressing is replaced the next day and removed after three days.
  1. A head band is worn for added pressure and protection during the healing process, for the next nine days. The two screws remain in place for twelve days to give adequate time for the fascia to reattach to the skull and maintain the set relationship of the brows to the orbital rim.
    The general principle of the endoscopic forehead and brow lift is that, once the scalp is fully mobilized, the natural contraction of the frontalis muscle will draw the forehead skin brow back towards the occipital area. This will provide the lift automatically, without extensive incisions and without tissue removal.

Possible complications are:

  • Undercorrection: unsatisfied patient.
  • Asymmetry of correction of eyebrow and forehead rhytids.
  • Frontal branch of VII nerve injury.
  • Numbness due to supraorbital or supratrocheal nerve injury.
  • Early bleeding, haematoma, bruises.
  • Loss of hair at site of incisions.



Patients who have submental fatty deposits and relatively tight skin that has maintained its elasticity.

Patients who have submental redundant skin or skin that has lost its elasticity because it is impossible for the redundant skin to shrink and favourably conform.


  • A horizontal one cm submental incision is made through the skin.
  • A 100cc of Klien solution (100 ml normal saline + 10cc Xylocaine 10% in 1:200,000 Adrenaline + 2cc NaHBC02) is injected using cannula and Klien pump. It is injected to the submental and neck area which is marked for liposuction. (Fig. 18 – 26)
  • Then wait for twenty minutes.
  • Now, using a fine liposuction cannula, the fatty deposits are extracted. The cannula is directed toward the muscle in order to extract the fatty tissue on the muscular layer while preserving a uniformly thick skin cover.
  • The wound is closed with one suture 4/0 Nylon.
  • Pressure bandage is applied for five days.