PLASTIC SURGERY OF THE FACE – RITIDOPLASTY

Indications - An individual’s identity is often primarily determined by the face—its structure, overall appearance, and expressions. The face and its expressions often give initial impressions, sending messages regarding emotion, health, vitality, and age. Over time, the face and its features undergo age-related changes that make people feel as if they look tired, angry, sad, or older than they feel. As such, age-related changes that can alter the appearance of the face may make an individual feel as if their identity has changed over time. Mostly, facial changes are related to changes in body weight, genetics, and gravity (as with the age-related changes) leading to a reduction of the skin thickness (atrophy) and elasticity (laxity), creating deep wrinkles in the cheeks and around the mouth, loose, excess skin in the cheeks, jaw line, and neck, and banding around the neck. Moreover, the facial muscle tone diminishes and the facial muscles weaken and stretch. Fat deposits, which normally give the face a soft, rounded appearance, migrate downward and are depleted, creating hollow areas. After the age 30 an excess of superior eyelids is observed, as well as the development of wrinkles around the eyes and creases between the nostrils and the lateral region of the mouth (nasolabial folds). Around, 40 frontal wrinkles can be seen. After 50 starts the cervical bandaging, drooping of the nasal tip and jaw line, and so forth. Changes can occur in the upper, mid, and lower portions of the face; however, changes to the lower third of the face are often the most readily apparent. Most often performed on individuals ranging from 45 to 55 years of age, a lower facelift can help to reduce the appearance of deep facial wrinkles, sagging jowls, and sagging and banding in the neck, restoring a firmer, more youthful appearance. The surgery is indicated after the age 18 when facial structure completes its development.

Preoperative period (before surgery) – Some exams are previously requested. The use of medications containing salicylic acid or vitamin E should be avoided 10 days before surgery. Smokers should quit smoking 15 days before surgery. It is necessary to stop any oral intake (not even water) 8 hours before surgery.
 
Surgical Technique – the surgery is usually performed as an outpatient procedure in a hospital. The length of a facial plastic surgery can vary depending on the extent of tissue removal, or the necessity for an additional procedure such as liposuction. However, the majority of the surgeries last approximately 2 to 6 hours. Prior to the start of the procedure, incision guidelines are drawn. For complex procedures, which involve the removal of a large amount of tissue, or are performed in conjunction with another procedure, general anesthesia will likely be administered. Conversely, a local anesthetic and sedative may be administered for less complex procedures, which will help the patient to stay comfortable and relaxed. There are several different types of facelift—each specialized to treat different regions of the face. For example, the lower facelift is usually performed to rejuvenate the lower portion of the face. Age-related changes in the upper and middle region of the face are usually corrected with a forehead lift and mid facelift, respectively. During a lower facelift, the underlying connective and muscle tissues known as the SMAS are lifted, facial skin is tightened, and excess skin is removed. It is important to realize that a lower facelift cannot correct signs of aging in the forehead or around your eyes, nor can it address fine lines or uneven skin tone and texture. Sometimes an additional procedure such as eyelid surgery or skin resurfacing is necessary to produce more global facial rejuvenation. Prior to making the incisions, the hair along the incision area is parted and an antibiotic ointment is applied, which will help to hold it in place. Once the incision area is exposed, the incision lines are drawn so that the resulting scars will be as inconspicuous as possible. A lower facelift can be performed using different types of incisions. Commonly, a single incision is made within the hairline that extends downward around the perimeter of the ear and into the hairline on the backside of the head. Working through the incision along the hairline, the skin is elevated away from the underlying tissues of the lower portion of the face, jaw line, and neck. In doing so,   the SMAS is exposed, which may be repositioned to achieve a more youthful appearance. The SMAS is a layer of tissue composed of muscle and fibrous connective tissue. There are a variety of methods that can be used to lift the SMAS, in which the tissue is augmented and suspended in a higher position with sutures. Although the techniques may differ, they all work to lift and tighten the underlying structures of the face. If a neck lift is being performed in conjunction with a facelift, a small incision is made on the underside of the chin. In some cases, the muscles in the neck are manipulated, which are known as the platysma muscles. Similar to the SMAS, the neck muscles can be lifted or a portion of them can be removed in order to reduce the appearance of skin laxity and banding around the neck. In other instances, fat is removed to further sculpt the area. The skin flap is stretched in order to determine how much excess skin should be removed. Pilot cuts and sutures are placed at different points along the incision to establish the proper amount of tension. The excess skin around the natural contours of the face is removed, and the remainder of the incision is closed with additional sutures. A forehead lift, or brow lift, can help to lift the brow line to a higher position and reduce the appearance of lines and wrinkles, restoring a firmer, more youthful appearance to the upper portion of the face. When layers of muscle weaken and fat deposits, which normally act as a cushion between skin and underlying bone, are depleted, lines and wrinkles in the brow region become increasingly apparent. A forehead lift can reduce their appearance as well as lift the brow, often achieving results that make people look as much as ten years younger. While there are several different techniques that can be used to alter the appearance of the brow, one of the most common is known as a coronal lift. This type of forehead lift involves making an incision that extends from ear to ear around the coronal region of the head. The procedure usually involves removing loose, excess skin, as well as disrupting muscle activity and function. It is important to understand that those individuals who are bald, have receding or high hair lines, or have had upper eyelid surgery may not be optimal candidates for this procedure. Before surgery, the hair may be parted along the incision area by combing it back and fastening it with small aluminum foil wraps or rubber bands. In addition, an antibiotic ointment is applied to the hair to help hold it in place. An incision is made that extends from ear to ear, over the coronal region of the head which lies approximately six to eight centimeters behind the natural hairline. The skin and muscle are dissected away from the frontal bone. In order to fully elevate the tissue, the dissection will also extend outward into the temple regions. Some of the muscles will then be removed to reduce the appearance of lines and wrinkles in the forehead. In general, there are three different muscles in the upper face that may be addressed, including the frontalis, corrugator, and procerus muscle. Repetitive muscle movement creates different wrinkles in the various muscles. Using a variety of different techniques, these signs of aging are corrected by carefully removing small areas of the different muscles. Depending on the extent of treatment necessary, there is a choice to augment all of the different muscles or only a subset of them. By modifying the muscles in the region, the normal muscle activity is disrupted without compromising proper muscle function. As a result, lines and wrinkles will diminish and the muscles will still function to create facial expressions. After addressing the different muscles, it will be determined how much skin must be removed. Small sutures will be placed along the incision to determine the correct amount of tension. Once the proper amount of tension has been applied, the excess skin will be removed. The incision will then be completely closed with sutures to obtain a smoother, more youthful appearance. The incisions are sutured with stitches hidden into the dermis or intra dermal absorbable sutures, with no need to be removed, and sometimes non absorbable stitches, which are removed in 5 to 7 days. Compressive dressings and bandages are applied.

Postoperative period (after surgery) – after the surgery a vocal rest is indicated during a short period in order to avoid traction on the operated area. Swelling around the eyes can be alleviated with cold compresses. It is also recommended to keep the head elevated during recovery, in order to reduce bruising and swelling in the area. The patient goes home around 6 hours after surgery, with a dressing that need to be kept dry, oriented to rest until the removal of the first dressing 2 to 3 days after surgery. At this time another dressing is done and the patient is free to take a full shower. After that the patient can resume most of his normal activity, including driving vehicles. Most patients are able to return to work in 7 days time. However, it may take 30 days to be able to return to full normal activity including heavy lifting and strenuous exercise. The use of a compression garment is indicated. A compression garment is tight-fitting, and will help to reduce swelling by preventing fluid build up, as well as provide comfort and support. Some bruising and swelling can occur, most of which will subside within a few days. The results are typically noticed very soon after the procedure. They will become even more evident in two to three weeks, as the bruising and swelling continue to fade. As all individuals heal at different rates, the final results may continue to evolve for several months. It is important to realize that there will be permanent scars; however they are typically well hidden within the hairline. Although a facelift will not stop the aging process, it can significantly reduce the appearance of loose, sagging skin in the face and neck, restoring a youthful appearance for many years to come.