The History of Facelifts
Patients and surgeons have widely varying definitions of the term facelift. In my practice, I prefer to refer to it as an operation on the cheeks and neck. Operations which may be added such as eyelids, forehead/brow procedures etc. are referred to separately.
We don’t really know who performed the first facelifts, but they were done somewhere near the start of the 20th century. Various reports of skin removal in the temples and around the ears to tighten the cheeks appeared in the 1920’s and 30’s and referred to procedures done as early as 1906. Traditionally, a facelift was performed via incisions which ran from the temple around the ears and into the neck that were relatively visible and only through the skin. Through these incisions, the surgeon operated under the skin for a relatively short distance under the cheeks and then pulled the skin as tight as he dared in an attempt to lift the sagging jowls and cheeks. This skin only operation left many patients with a “wind blown” appearance and unnatural shape to the mouth and the corners of the eyes and was totally ineffective at treating the changes of the neck and jawline. Its benefits were relatively short-lived…and some of the stigmata lasted a long time.
Things began to get better in the mid 1970s. the initial work done by surgeons outside of North America, prompted some Canadian and American surgeons to deal with the thin muscle layer under the skin in the neck by repositioning it, and by removing the excess fat under the chin. They were able to create a more youthful and appealing chin, neck angle and jawline.
The anatomy was first demonstrated by, a Swedish surgeon, Tord Skoog, who showed us that the platysma, a thin muscle layer of the neck, which appeared to end at the jawline, actually extended upwards into the cheek right to the cheek bone as membrane that could be used to provide most of the lifting needed. If this was tightened the excess skin of the face could be removed without stretching it too much, and the face could be restored in a much safer and more natural looking fashion.
Like many good ideas, at first the significance of this was lost on most practising surgeons since it was a revolutionary and very dramatic change from the normal, and because it required entering into areas of anatomy which were poorly understood and were, therefore, intimidating. It took twenty years for a more gradual evolution of his ideas to gain widespread acceptance. Even today inexperienced surgeons often try to get equal results with techniques that pay less attention to the natural anatomy. The operation requires attention to detail but the results are immeasurably greater.
With the advent of liposuction in the 1980’s, removal of fat became a commonplace procedure both from under the chin where it still remains of considerable use, but also in the cheeks and along the jawline and especially in the area of the nasolabial folds, those deep furrows running down from the nose to the corner of the mouth onto the jowls. Sometimes this produced great results…but sometimes the long term loss of fat produced the opposite, gaunt, unhealthy, and unnatural.
In a reversal of trends, however, augmenting the face in areas of “volume loss” became common with the use of injectable fillers, and when fat grafting to give a more permanent volume replacement developed into a reliable approach, it became a common adjunct to facelifts.
Today we understand that a youthful face isn’t a tight face. It has fullness where natural fat of youth exists, subtle and beautiful curves, a well defined jawline and neck. The skin has more thickness and more elasticity that aged and environmentally damaged skin. The role of the surgeon is to provide more youthful contours. This doesn’t mean just making the skin tight, and efforts to do this either through surgery or other treatment result in an unnatural appearance or worse.
There may be useful treatments for the skin, but these are a separate area of expertise, that of dermatologists.