Facelifts or Rhytidectomy - The facelift operation is probably the most well known cosmetic surgery procedure dating back many years.

The facelift has undergone significant refinements and currently remains the most predictable, safest procedure to turn back the clock of facial aging.

Despite celebrities that have distorted faces (i.e the “facelift look”) a facelift performed by a seasoned plastic surgeon with artistic ability and a focus toward facial aesthetic surgery can provide rejuvenation with an advanced facelift technique that is undetectable and looks natural.

There are many new cosmetic injections and procedures that are reportedly “replacing the facelift”. While many of these new injections (Restylane®, Botox®, etc.) may reverse some changes of aging, a comprehensive facelift remains unique in its ability to lift tissue and elevate sagging muscles and fat around the face. Distorted faces and “facelifted” looks are due to poor judgment in selecting the facelift technique and not necessarily the surgical skills of the surgeon.

Therefore, the judgment that your surgeon exercises in choosing the proper technique for your facelift is critical to reaching your goals and expectations and maintaining a natural-looking appearance. A prospective patient should interview several surgeons, and develop a feeling of trust and a strong level of comfort with the surgeon. You should request to review before and after high quality photographs (good lighting, accurate detail) that demonstrate the surgeon’s work.  The single most important factor in obtaining a natural rejuvenated look following a facelift is the surgeon that you choose.

Facelift techniques and recoveries vary. In fact, a “facelift” can mean different things to patients and surgeons alike.  In general, a “facelift” means repositioning the skin and deeper tissues of the face, jowl and neck. Improving the neck with a facelift is often considered part of the facelift procedure, however, each patient should confirm whether the neck is included in the “facelift”. Some comprehensive facelifts such as the “composite facelift” include a complete rejuvenation of the neck, face, eyes and brow in one procedure. This provides the most natural appearance in that all of the pieces of the face that have shown aging are repositioned uniquely and uniformly at the same time.

In some cases a simple limited incision facelift technique may reposition the lower face and jowl tissue. Depending on age and genetic predisposition, a limited incision facelift may provide adequate rejuvenation and still maintain facial harmony despite not modifying other areas of the face. This is where the judgment of the surgeon and the expectations of the patient must be discussed frankly and openly.

In this section, we will discuss the different types of facelift techniques, the pros and cons of these procedures and the varied recoveries that are associated with these facelifts.

Facelift techniques:

Threadlift

Limited incision (mini) upper facelift

Limited incision (mini) necklift

Limited incision lower face and necklift

Lower eyelid – cheeklift procedure

Comprehensive – Composite Facelift

Threadlift: This is a relatively new procedure that relies upon barbed sutures that are placed beneath the skin under local anesthesia in the office setting to elevate the tissues. There are tiny needles that are used to place the threads through pin sized incisions that are hidden in the hair. Again this procedure is done in an office setting under local anesthesia with an occasional patient taking oral sedation. The recovery is quick although there is some distortion and swelling of the tissues for up to 3 days. One disadvantage with the Threadlift is the risk of skin manipulation during sleep or animation in the early period after surgery. This may cause the tissue to “fall back down” as the lifted skin is pushed off the barbs that hold the tissue.

The results from a Threadlift are temporary and most seasoned surgeons find this procedure a bit “gimmicky” and still in its infancy. Obviously the allure of a quick fix in an office setting under local anesthesia is strong, but if patients expectations are not met, regardless of the minimal cost and minimal downtime this would be an undesirable circumstance. This procedure works best in elevating the eyebrows to a small degree. Further follow up is necessary to determine the long term benefits of this technique.

Limited Incision (Mini) Upper Facelift: This procedure elevates the jowl and the upper part of the neck along with rejuvenating the cheek. The incision is typically limited to the area just along the edge of the ear and therefore is well hidden and associated with a quick recovery (3-5 days back to normal work activities in a normal office setting). This procedure may be done under local anesthesia with mild sedation, there is minimal pain associated with most facelift techniques including this one. There is minimal bruising and most patients can apply makeup to the face within 2-3 days. The results are long lasting (several years) however this technique is primarily for patients who show aging specifically in the jowl (along the jawline) and in the cheek with very little aging in the neck and minimal aging in the eyebrows or eyes.

Limited Incision (mini) Necklift: This procedure is performed to establish a youthful angular jaw and neckline. It differs from the more extensive necklift in that there is only a small incision under the chin from which the fat is removed from the neck, muscles are tightened and in some cases a chin implant placed to re-establish the natural clean jawline and angular neckline. This procedure is performed in individuals who have enough remaining elasticity in their skin to redrape into the new neck contour created by the above maneauvers. The procedure is performed under local anesthesia with sedation or light general anesthesia, the recovery is typically 3-4 days in which the patient is back to normal work activities in an office setting. There is minimal bruising and minimal discomfort associated with this procedure. The results are long lasting typically more than 10-15 years and quite natural in appearance.    


Limited Incision Lower Face and Necklift: This is a more comprehensive rejuvenation including a repositioning of the neck tissue, tightening of skin and muscles, and fat removal to rejuvenate the neckline, jawline and the lower face. The recovery is just as outlined above with the minimal access facelift. There are many new names that have been attached to this procedure. Many of these so-called new procedures (Lifestyle lift, weekend facelift) are trademarked by surgeons simply to create a marketing advantage despite the technique having been around for many years. The results are quite long lasting on the neck (several years) and allows for a more complete rejuvenation of the lower face and the neck. The upper face, brow and eyes are not typically included in this technique.

Lower eyelid – Cheeklift Procedure: The composite blepharoplasty or cheeklift procedure rejuvenates the periorbital (region around the eye) area comprehensively. The undereye fat is repositioned over the cheekbone, the muscle and skin are repositioned upwards, and the youthful contours that are lost over time are re-established. This procedure avoids the “hollow eye” look that often occurs following more traditional lower eyelid procedures where the fat is removed. The recovery from this procedure is typically 7-10 days. There is very little discomfort associated with the procedure however the outer part of the eye is pulled upwards temporarily to support the lower eyelid during the healing phase giving the patient a slightly upward slant to their appearance. Some dryness to the eyes for the first 7-14 days requiring moisture tears. While this procedure may have a slightly longer “downtime” the stunning results are unobtainable with other techniques.

Composite Facelift: This is the most comprehensive facelift procedure available. Not only does it reposition all the tissues of the face in one setting creating unique harmony to the entire rejuvenation, but this procedure is the only procedure described to reverse the adverse effects of a distorted or “facelifted” look.

Today’s prevailing facelift surgery trend is to perform small facial rejuvenation procedures independently. While traditional facelift surgery may seem convenient because it results in minimal downtime, its weakness is that it fails to address the aging face as a whole. This can lead to a swept back, “facelifted” appearance and a hollow area below the eyes.

Before and After Composite Facelift

The Composite Facelift is an innovative approach to facial rejuvenation that addresses the problems associated with a conventional facelift. Unlike the traditional facelift, the Composite Facelift is ideal for restoring facial harmony to the entire face. Dr. Choucair has extensive experience and expertise in performing the full spectrum of facelift procedures, including the Composite Facelift.

Before and After Composite Facelift

Before and After Composite Facelift


Limited Incision Face Lift, Neck and Brow Lift, Fat Injection

Limited Incision Face Lift, Neck and Brow Lift, Fat Injection

For those interested in complete rejuvenation, it has long been accepted that a taut jawline, contoured neck, elevated forehead, and rested eyes create a more youthful profile. As compared to traditional facelift surgery, where different areas of the face might be treated individually and the lift is in a single direction, the success of the Composite Facelift is due to an integrated surgical technique that requires all areas of the face be moved together, keeping each adjacent area balanced and adding a vertical direction of lift. Lower eyelid surgery, cheek lift, and forehead lift are components of every Composite Facelift surgery performed at Dr. Choucair’s Dallas practice.

Before and After Composite Face Lift



COMPOSITE FACELIFT vs. TRADITIONAL FACELIFT

The traditional facelift is usually a “skin lift” or a “SMAS lift.” In the skin lift, the skin is separated from the underlying fat and facial muscles and redraped, in a single direction, toward the ear. In the SMAS lift, the lower face muscle (SMAS) is moved independently from the skin, and is also pulled toward the ear.

Typically, after this type of cosmetic surgery, one's face seems fresh and rejuvenated. But over time the natural, fresh look from the traditional facelift disappears. The face seems to "fall" and several areas of the face begin to show signs of tension and pull.

The Composite Facelift, performed by Dr. Choucair at his Dallas [and Plano practices], offers a more effective and advanced alternative to the traditional facelift and its problems.  Unlike a traditional facelift that pulls the face in one direction only – toward the ear – the Composite Facelift addresses the gravitational fall of the aging face by using a two-direction lift ('balanced lift'). In a Composite Facelift, all “parts” of the face – skin, facial fat, eyelid muscle, and SMAS muscle – are kept together when lifted, never losing their intimate relationship with one another. This reverses the progressive downward movement of the cheek, fat, and muscle and repositions this anatomy to its original position.


Comparing Techniques: The Direction of Lift


The direction of lift in the traditional facelift is singular and lateral - toward the ear - as seen in the diagram above. This is the only direction of “pull.”

The Composite Facelift direction of lift is toward the eye and ear - rather than just toward the ear. The movement of the cheek returns the eyelid muscle and cheek fat to their original positions, preventing the pull toward the ear. The forehead is lifted as well.

RECREATING THE CONTOURS OF A YOUTHFUL FACE

The most critical area of consideration in a complete rejuvenation has always been the lower eyelid and cheek area. In youth, the lower eyelid contour is shallow and convex. However, in our thirties, the appearance of the eye area undergoes predictable changes. As the skin loses its thickness with normal aging, the skeletal structure of the face becomes more pronounced. This leads to a wider, deeper, lower eyelid (fig. 1).

A Composite Facelift, with its unique manner of fat preservation and eyelid muscle repositioning, can best recreate the youthful eye. (fig. 2)



The Revision Facelift
If you’re looking to refresh a fading facelift or are unhappy with the results of previous facelift surgery, Dr. Choucair can perform a revision facelift. By utilizing innovative Composite Facelift techniques, he can correct the typical “facelifted” look and avoid problems associated with the conventional facelift. These problems include tension along the jaw line and mouth and a sunken, hollow appearance beneath the eyes.

For optimal results, Dr. Choucair combines the revision facelift with cosmetic eyelid surgery. The unique cosmetic eyelid surgery technique he uses helps to restore and reposition eye fat along the lower eyelid. Together, revision facelift surgery and cosmetic eyelid surgery can help recreate youthful contours and restore balance to a patient’s face.

As a corrective or repeat procedure, the Composite Facelift can release the tension and pull that occur along the jaw line and mouth. This, combined with a unique lower eyelid surgery ( blepharoplasty) that restores and repositions eye fat along the lower eyelid, can recreate the contours that define a youthful appearance.

A secondary facelift, or facelift revision, can correct most common problems associated with traditional facelift methods and help patients avoid problems in the future.

PROBLEM 1: LATERAL SWEEP

The most obvious problem associated with the traditional facelift is a “swept-back” look or “lateral sweep” of the lower face. The direction of pull for traditional facelifts is in one direction only: toward the ear. As time goes by, the lower face stays “up” but the unlifted deep structures of the upper cheek continue to fall “down,” thus creating a sweep toward the ear that gets progressively worse. This is more obvious in patients with dry, sun-damaged skin, since the natural lines of the face are redirected into an unnatural pattern.

A secondary facelift and cheeklift revision by Dr. Choucair corrects this imbalance by reversing the progressive movement of the cheek, fat, and muscle. Repositioning this anatomy to its original position gives a stunning youthful look as the sweep is eliminated.

PROBLEM 2: UNDONE FOREHEAD

For years, surgeons have performed the “face and eyes,” or rhytidectomy and blepharoplasty surgery, without appreciating the value of a forehead lift. A rejuvenated lower face created by this type of surgery, combined with an aging forehead, could result in facial imbalance.

To achieve a balanced natural look, Dr. Choucair performs a forehead lift so that the forehead is compatible with the rejuvenated face. It is also possible for patients with a high forehead to have their hairline lowered to a more natural level while undergoing rhytidectomy surgery.

PROBLEM 3: MALAR CRESCENT

The malar crescent is a subtle yet distinctly telling characteristic impossible to correct with a traditional facelift. This crescent-shaped fullness corresponds to the lower-eyelid muscle (orbicularis muscle) and occurs along the upper cheek area. Because the orbicularis muscle is not addressed in a traditional facelift, it appears more pronounced next to the hollowness created by the traditional lower-eyelid lift and the pull of the traditional facelift.

A corrective facelift, performed by Dr. Choucair, can eliminate this problem by lifting and moving the complete orbicularis muscle toward the eye and replenishing the fat under the eye. Correcting the bulge of the malar crescent will restore a youthful smooth contour.

PROBLEM 4: PULLED DOWN EARLOBE

Frequently following traditional rhytidectomy surgery, the earlobes appear to be pulled down too far (pixie ears) or pulled too far forward. The appearance can easily be corrected with revision facelift surgery.

PROBLEM 5: HOLLOW EYES
Since 1924, lower-eyelid fat has been removed during lower-eyelid rejuvenation procedures. This is especially true today with the advent of laser blepharoplasty, where surgeons often remove eyelid fat by using a hidden incision inside the eyelid and then lasering the surface of the skin. Whether traditional or laser, the results are the same when the fat is removed – an abrupt transition is created between the soft under-eye tissue and the cheekbone. The area beneath the eye will then appear more concave, or hollow, than before. From the front, the eye socket is more pronounced.

The youthful appearance of the eye depends on a smooth, soft transition. This is created by a special blepharoplasty revision technique performed by Dr. Choucair at his Dallas and Plano practices. Even when it appears that all of the fat beneath the eye has been removed, the “hollow eye” created by a previous surgery can almost always be corrected utilizing the orbital fat that remains. Fat injections are never used in conjunction with corrective blepharoplasty

THE FADING FACELIFT

If you feel your facelift did not last as long as you had hoped for, or you were left with less than satisfactory results, you are not alone. Many patients have discovered that the traditional facelift performs poorly over time.

However, patients unhappy with an “unfortunate” or “bad” facelift should realize that disappointing facelift results are not the fault of the surgeon or patient. These problems indicate that the traditional facelift isn't working and must be improved. Fortunately, if you’ve already received what you consider an “unattractive facelift,” Dr. Choucair can perform a facelift revision.

	The red arrows demonstrate the normal gravitational direction of aging.
	Blue arrows show the single direction of lift - toward the ear - of the traditional facelift. Early results may be pleasing.
Over time, the results of the traditional facelift begin to show signs of tension and pull. The lower pull (short blue arrow) stays tight while the upper cheek (long blue arrow), which had only a horizontal lift, continues to fall. Areas typically not addressed by a traditional facelift (red arrows) continue to descend.
	The composite facelift can correct unwanted results by lifting the muscle and fat of the cheek (red arrows) in the correct direction - toward the eye rather than toward the ear - which is the natural youthful position. Traditional or conventional facelifts don't always age well and can result in a "facelifted" appearance. The Composite Facelift can help patients avoid the following problems

EYELID REJUVENATION
To restore a smooth, youthful look to the area around the eyes, Dr. Choucair has perfected a composite lower eyelid procedure that is used by surgeons around the world. The procedure involves preserving the fat beneath the eye while repositioning the eyelid muscle. This differs from traditional lower-eyelid surgery, where the fat pads beneath the eyes are completely removed. When Dr. Choucair's eyelid procedure is combined with Composite Facelift surgery at our Dallas and Plano Practices, the results are a fabulous, more youthful appearance.


Techniques:The EyelidArea 



In traditional facelift surgery, cosmetic eyelid surgery is optional. When the procedure is performed, it typically involves removing the fat pads below the eyes without regard for possible long-term effects. Over time, fat removal can lead to a hollow appearance of the eyes.

Lower eyelid surgery is an important component of the Composite Facelift. When performing this surgery, Dr. Choucair uses a special technique to preserve fat under the eyes and ensure that there is a natural transition between under-eye tissue and the cheekbone. This results in a smooth, youthful contour.