"surgical removal of wrinkles") might imply. Wrinkles around the mouth and eyes, for example, may benefit little from face lift surgery. Other procedures, such as blepharoplasty, chemical peel, or dermabrasion, also may be necessary.

Precautions
Patients with other medical conditions should consult with their primary physician before undergoing face lift surgery. Lung problems, heart disease, and certain other conditions can lead to a higher risk of complications. Patients who take medications that can alter the way their blood clots (including female hormones, aspirin, and some non-aspirin pain relievers) should stop these medications prior to surgery to lower the risk that a hematoma will form. A hematoma, a pocket of blood below the skin, is the most frequent complication of face lift surgery.

Description
Face lift surgery can be performed on an outpatient basis with local anesthetics. Patients typically also receive "twilight anesthesia," an intravenous sedative that helps to lower their awareness of the procedure being performed.

There are a number of variations of face lift surgery. Which one is used will depend on the patient's facial structure, how much correction is needed, and the preferences of the surgeon performing the procedure. In a typical face lift surgery, the surgeon begins by making an incision within the hairline just above the ear. The incision continues down along the front edge of the ear, around the earlobe, and then up and behind the ear extending back into the hairline. The location of this incision is designed to hide any sign of the procedure later. The same procedure is repeated on the other side of the face. Using various instruments, the surgeon will then work to separate the skin of the face from its underlying tissue, moving down to the cheek and into the neck area and below the chin. Fat deposits over the cheeks and in the neck may be removed surgically or with liposuction at this time. The surgeon will then work to free up and tighten certain bands of muscle and tissue that extend up from the shoulder, below the chin, and up and behind the neck. If these muscles and tissue are not tightened, the looseness and sagging appearance of the skin will return. The surgeon then trims excess skin from the edges of the original incision, pulls the skin back, and staples or sutures it into place.

Preparation
Prior to the procedure, patients meet with their surgeon to discuss the surgery, clarify the results that can be achieved, and discuss the potential problems that can occur. Having realistic expectations is important in any cosmetic procedure. Patients will learn, for example, that although face lift surgery can improve the contour of the face and neck, other procedures will be necessary to reduce the appearance of many wrinkles. As mentioned earlier, patients will stop taking aspirin, birth control or female hormones, and other medications affecting blood clotting about two weeks before the procedure. Some physicians prescribe vitamin C and K in the belief that this promotes healing. Patients will also be advised to stop smoking and to avoid exposure to passive smoke before the procedure and afterward. Some surgeons also recommend antibiotics be taken beforehand to limit the risk of infection. Some surgeons also use a steroid injection before or after the procedure, to reduce swelling.

Aftercare
After the surgery, a pressure bandage will be applied to the face to reduce the risk of hematoma. The patient may spend a few hours resting in a recovery room to ensure no bleeding has occurred. The patient then returns home. Some surgeons recommend that the patient remain reclining for the next 24 hours, consuming a liquid diet, and avoiding any movements that lead the neck to flex. Ice packs for the first few days can help to reduce swelling and lower the risk of hematoma. Patients continue taking an antibiotic until the first stitches come out about 5 days after the procedure. The balance are removed 7-10 days later. Many patients return to work and limited activities within two weeks of the procedure.

Risks
The major complication seen following face lift surgery is a hematoma. If a hematoma forms, the patient may have to return to have the stitches reopened to find the source of the bleeding. Most hematomas form within 48 hours of surgery. The typical sign is pain or swelling affecting one side of the face but not the other.

Another risk of face lift surgery is nerve damage. Sometimes it can affect the patient's ability to raise an eyebrow, or distort his smile, or leave him with limited feeling in his earlobe. Most of these nerve injuries, however, repair themselves within 2-6 months.

Normal results
Some swelling and bruising is normal following face lift surgery. After these disappear, the patient should see a noticeable improvement in the contour of his face and neck. Some fine wrinkling of the skin may be improved, but deep wrinkles are likely to require another cosmetic procedure to improve their appearance.

Abnormal results
In addition to the risks outlined above, other complications of face lift surgery include infection, scarring, and hair loss near incision lines.

Key Terms

Hematoma
A complication of surgery in which a collection of blood forms below the skin.

Rhytidectomy
It literally means "wrinkle excision." It is another, misleading, term for face lift surgery.

Twilight anesthesia
An intravenous mixture of sedatives and other medications that decreases patients' awareness of the procedure being performed.
Further Reading    For Your Information  Books

Asken, Saul.

"Cervicofacial Rhytidectomy." In Cosmetic Surgery of the Skin: Principles and Techniques, edited by William P. Coleman, et al. St. Louis: Mosby, 1997.

Tardy, M. Eugene Jr., and Mark Lingensmith."Face-List Surgery: Principles and Variations." In Roenigk and Roenigk's Dermatologic Surgery: Principles and Practice, edited by Randall K. Roenigk and Henry H. Roenigk. New York: Marcel Dekker, 1996.
Periodicals
Matarasso, Alan. "Facialplasty." Dermatologic Clinics, 15 (October 1997): 649-658.
Springer, Rachelle C. "Rhytidectomy: From Consultation to Recovery." Plastic Surgical Nursing, 16 (Spring 1996): 27-30.
Organizations
American Society for Dermatologic Surgery. 930 N. Meacham Road, PO Box 4014, Schaumburg, IL 60168-4014. (847) 330-9830. http://www.asds-net.org.
American Society of Plastic and Reconstructive Surgeons. 44 E. Algonquin Rd., Arlington Heights, IL 60005. (847) 228-9900. http://www.plasticsurgery.org.

Gale Encyclopedia of Medicine. Gale Research

Laser skin tightening: non-surgical alternative to the face lift

The drive for cosmetic enhancement of facial skin with minimal risk and rapid recovery has inspired nonsurgical means of wrinkle and photodamage reduction through laser skin resurfacing. Since its inception in the 1980s and early 1990s, laser skin resurfacing has evolved from ablative technologies to non-ablative and fractional resurfacing in an effort to minimize risk and shorten recovery times. Over the past several years, a great deal of emphasis has been placed on increasing penetration depth, collagen shrinkage, and skin tightening through the use of radiofrequency and, more recently, infrared wavelengths. The compelling aspect of this approach is that it is possible to achieve a degree of skin tightening, providing a potential future alternative to surgical face-lifting.

Radiofrequency devices generate electrical energy which heats the dermis at relatively low temperatures and without the production of plume. The first such energy source was the monopolar radiofrequency device, ThermaCool (Thermage). This radiofrequency technology was the first to specifically target laxity of the face and neck. (1) A uniform volumetric heating effect is delivered into the dermis as a result of the tissue's resistance to the current flow. The electric field polarity changes 6 million times per second, and the charged particles within the electric field change orientation at that frequency. The resistance of the tissue to the particular movements then generates heat. The advantages of this system include the minimal post-operative erythema which resolves within hours and the lack of significant risk of side effects. Disadvantages of the ThemaCool system initially included the significant discomfort during treatment and inconsistency in results. In a minority of patients, dramatic improvement was observed, but the majority of patients experienced minimal improvement. In a study of the ThermaCool TC system to treat the lower face of 16 patients, only 5 of 15 patients (one-third) reported satisfactory results and photographic analysis did not yield statistically significant results. (2) Recently, modifications of the technology and the protocol have improved the consistency and extent of improvement by increasing the size of the tip and conducting multiple passes at lower energy settings. (3)

The combination of electrical and optical energy (elos) was the subsequent advance to this area, allowing for augmentation of the non-ablative effects achieved with either modality alone. The combination of bipolar radiofrequency (RF) with infrared laser at 900 nm and intense pulsed light (500-1200 nm) at lower fluences (Galaxy, Syneron) has been shown to result in the systematic reduction of skin laxity and all aspects of photodamage and rhytids. (4-5) This combination technology has also been assessed for striae (Alexiades-Armenkas, unpublished data, 2006) and cellulite. (6) It will be important to compare these evaluations to the laser or pulsed light without RF control, which is necessary to test the hypothesis regarding a synergistic effect of the RF on outcome.

Most recently, a combined monopolar and bipolar RF device has been designed (Accent, Alma Lasers), theoretically allowing greater flexibility in penetration depths applicable to a greater variety of anatomic sites. Currently undergoing trials for FDA approval for skin tightening of facial skin laxity as well as for body cellulite, it will be interesting to monitor how this device compares to prior modalities in its level of efficacy. One important potential advantage to this system is the minimal discomfort associated with treatment, obviating the need for topical anesthesia. Early indications are promising with respect to efficacy in the radiofrequency skin tightening arena, though published data are still pending.

Another method of skin tightening employing a new infrared device emitting wavelengths from 1100-1800 nm (Titan, Cutera) has been introduced for the treatment of skin laxity. This technology is also proposed to induce volumetric heating of the dermis, followed by tissue contraction. Early results, which await peer-review, indicate safety and a moderate degree of efficacy in treating skin laxity. In a preliminary study of 25 patients using fluences of 20 to 30 J/[cm.sup.2], immediate changes and moderate improvement in facial rhytides were reported. (7) In another preliminary split-face design study comparing this modality to RF, less improvement was observed with the infrared device. (8) It will be of import to monitor the efficacy of this device as the final reports become available.

In sum, laser skin tightening using radiofrequency or infrared energy sources is a compelling area of active research and currently provides a less effective alternative to surgical face-lifting. As newer, more effective devices are rapidly becoming available, the objective of achieving the non-surgical face lift may soon become a reality.

References

1. Jacobson LG, Alexiades-Armenakas MR, Bernstein L, Geronemus RG. 2003. Treatment of nasolabial folds and jowls with a non-invasive radiofrequency device. Arch Dermatol. 2003;139(10):1313-20.
2. Hsu TS, Kaminer MS. The use of nonablative radiofrequency technology to tighten the lower face and neck. Semin Cutan Med Surg. 2003;22(2):115-23.

3. Dover JS, Zelickson B, Atkin D, et al. A multi-specialty review and ratification of standardized treatment guidelines for optimizing tissue tightening and contouring with a non-invasive monopolar radiofrequency device. Amer Soc Derm Surg Abstracts. October 28, 2005.

4. Sadick N, Alexiades-Armenakas M, Bitter P, Hruza G, Mulholland S. Enhanced full-face skin rejuvenation using synchronous intense pulsed optical and conducted, bipolar radiofrequency energy (ELOS): introducing selective radiophotothermolysis. J Drugs Dermatol. 2005;4(2):181-6.

5. Doshi SN, Alster TS. Combination radiofrequency and diode laser for treatment of facial rhytides and skin laxity. J Cosmet Laser Ther. 2005;7(1):11-5.

6. Sadick NS, Mullholland RS. A prospective clinical study to evaluate the efficacy and safety of cellulite treatment using the combination of optical and RF energies for subcutaneous tissue heating. J Cosmet Laser Ther. 2004;6(4):187-90.

7. Ruiz-Esparza J. New infrared device can produce immediate and long-term skin contraction by painless low fluence irradiation. Amer Soc Derm Surg Abst. Atlanta, GA, October 28, 2005.

8. Lee M-W C. Comparison of radiofrequency vs. 1100-1800 nm infrared light for skin laxity. Amer Soc Derm Surg Abst. Atlanta, GA, October 27, 2005.

Macrene Alexiades-Armenakas MD PhD

More on Face Lift

Definition

Face-lift surgery is a cosmetic procedure that involves removing sagging skin and tightening muscle tissue of the face and neck to counter signs of aging. The procedure is also called facialplasty, rhytidoplasty, and cervicofacial rhytidectomy.

Purpose

The purpose of face-lift surgery is to improve the appearance of the face by repositioning the skin and tightening some of the underlying muscle and tissue. The procedure is designed to counter sagging and looseness in skin and muscle tissue that becomes more pronounced as individuals age. Face-lift surgery will not eliminate all facial wrinkles. For example, wrinkles around the mouth and eyes may benefit little from face-lift surgery. Also, additional procedures including blepharoplasty , chemical peel, botox injections, or dermabrasion may be necessary to achieve desired results.

The American Society for Aesthetic Plastic Surgery estimated that nearly 6.9 million cosmetic surgical and nonsurgical procedures were performed in the United States in 2002. The number of face-lift procedures increased by 6% from the previous year (2001). Among members of the American Academy of Cosmetic Surgery, 15,478 face-lift procedures were performed. The average fee for a face lift in 2002 was $7,000.

Description

A face lift takes about two hours and may be performed as an outpatient procedure or it may require hospitalization. General or local anesthetics will be used to sedate the patient. Typically, patients receiving local anesthesia will augment it with "twilight anesthesia," an intravenous sedative that helps to lower their awareness of the procedure being performed. An anesthesiologist will be present to administer the anesthetics and assist in monitoring and maintaining the patient's vital life functions.

The surgeon makes an incision within the hairline just above the ear. The incision continues down along the front edge of the ear, around the earlobe, and then up and behind the ear extending back into the hairline. The location of this incision is designed to hide any sign of the procedure later. The same procedure is repeated on the other side of the face. The surgeon separates the skin of the face from its underlying tissue, moving down to the cheek and into the neck area and below the chin. Fat deposits over the cheeks and in the neck may be removed surgically or with liposuction at this time. The surgeon tightens certain bands of muscle and tissue that extend up from the shoulder, below the chin, and up and behind the neck. If these muscles and tissue are not tightened, the looseness and sagging appearance of the skin will return. The surgeon trims excess skin from the edges of the original incision and the skin is pulled back into place. The incision is closed with sutures or staples.

Diagnosis/Preparation

Prior to the procedure, candidates meet with the surgeon to discuss the procedure, clarify the results that can be achieved, and the potential problems that can occur. Having realistic expectations is important in any cosmetic procedure. People will learn, for example, that although a face lift can improve the contour of the face and neck, other procedures will be necessary to reduce the

appearance of many wrinkles. Candidates will be advised to stop taking aspirin , birth control pills or female hormones, and other medications affecting blood clotting two weeks before the procedure. Some physicians prescribe vitamin C and K to promote healing. Candidates are advised to stop smoking For a face lift, an incision is made around the ear at the base of the hairline (A). The skin is removed from underlying tissues in a procedure called undermining (B and C). The skin is pulled up to tighten it (D). The skin is stitched into place and excess is removed (E). ( Illustration by GGS Inc. ) and to avoid exposure to passive smoke at least two weeks before and after the procedure. Some surgeons also recommend taking antibiotics prior to surgery to limit the risk of infection. Often a steroid injection is administered before or after the procedure to reduce swelling.

Aftercare

A pressure bandage is applied to the face to reduce the risk of hematoma, which is a pocket of blood below the skin. The person may spend a few hours resting in a recovery room to ensure that no bleeding has occurred. The individual then returns home. Some surgeons recommend that people stay in a reclining position for the 24 hours immediately following surgery, consuming a liquid diet, and avoiding flexing or bending the neck. Ice packs for the first few days can help to reduce swelling and lower the risk of hematoma. Individuals continue taking antibiotics until the first stitches come out about five days after the procedure. The remaining sutures are removed seven to ten days later. Many people return to work and limited activities within two weeks of the procedure.

Risks

Candidates with other medical conditions should consult with their primary care physician before undergoing a face lift. Lung problems, heart disease, and certain other conditions can lead to a higher risk of complications. Persons who use medications that affect blood clotting (including female hormones, aspirin, and some non-aspirin pain relievers) should stop taking these medications prior to surgery to lower the risk that a hematoma will form. A hematoma is the most frequent complication of face-lifts. Most hematomas form within 48 hours of surgery. The typical sign is pain or swelling affecting one side of the face but not the other.

Another risk is nerve damage. Sometimes it can affect a person's ability to raise an eyebrow, or distort the smile, or result in limited sensation in the earlobe. Most of these nerve injuries, however, repair themselves within two to six months.

Normal results

Some swelling and bruising is normal following a face lift. There should be a noticeable improvement in the contour of the face and neck. Some fine wrinkling of the skin may be improved, but deep wrinkles are likely to require another cosmetic procedure to improve their appearance.

Morbidity and mortality rates

In general, mortality and morbidity rates for forehead lifts and similar facial cosmetic procedures are very low. Almost all cases of mortality following facial cosmetic surgery involve patients who were treated for facial disfigurement because they had been severely burned or attacked by animals. Moreover, many plastic surgeons do not consider morbidity and mortality rates to be as significant as other factors in evaluating the success of facial cosmetic procedures. One group of researchers at the University of Washington maintains that the most important measures of outcome in facial cosmetic surgery are quality of life and patient satisfaction, in contrast to other, more objective measures such as complications or mortality rates.

Alternatives

Isometric exercises are recommended as non-surgical alternatives to face-lift procedures.

Injections of Botox (botulinum toxin) have been used to achieve the same results as a face lift. Botulinum toxin is a compound produced by the spores and growing cells of the organism that causes botulism, Clostridium botulinum . The toxin causes muscle paralysis. It was first used clinically in the 1960s to treat neurological disorders but also proved to be effective in paralyzing the facial muscles that cause crow's feet and frown wrinkles. Botulinum toxin, or Botox, was approved by the Food and Drug Administration (FDA) in April 2002 as a treatment for facial lines and wrinkles. Botox treatments must be repeated in approximately six months.

Coherent ultrapulse carbon dioxide laser treatment is a promising new treatment alternative to traditional face lift procedures. As of 2003, this equipment has been used by a few major institutions.

Some plastic surgeons have used a procedure called fat rebalancing to achieve outcomes similar to a traditional face lift procedure. Fat rebalancing involves relocation of fatty tissue from distant sites on the body to the face.
Gale Encyclopedia of Surgery by L. Fleming Fallon. For more on anti-aging click here.