Facelifts go by many names—some technical and some not-so-technical. There is the subcutaneous facelift, the SMAS facelift, the deep-plane facelift, the composite facelift, the MACS facelift, the mini-facelift, the mid-facelift, the endoscopic facelift, the S facelift, the thread facelift, the Lifestyle facelift, the short scar facelift, and, most recently, the vertical facelift. Many of these are just variations or limited versions of the others or just different access approaches to elevate the same tissues.
I would like to discuss the so-called vertical facelift because it has gotten much attention lately as the “best” approach to reversing the downward effects of gravity. Though the actual term may mean different things to different surgeons, the basic idea is to elevate some, if not most, of the tissue straight up. While this may seem to be the obvious approach to reversing facial aging, it is not that simple. Due to the various connective tissue attachments under the skin and the differences in mobility to the various parts of the face, there appears to be a forward as well as a downward descent. This is all too apparent when we look at the oblique fold of tissue going from the nostril to the corner of the mouth. Complicating this picture of facial aging is the atrophy or loss of the subcutaneous fat that also occurs in some areas, leaving a void or depression that looks as though tissue has fallen away. It appears that the best approach to reversing facial aging is a combination of some vertical as well posterior lifting, coupled with augmentation via fat or implants, if atrophy is also present. The vertical component of the lift can be in the deep subperiosteal plane or more superficially in the SMAS plane or even the subcutaneous plane. But it almost always gives a more natural result if there is some element of posterior lifting, as well. To that end, some surgeons are combining a vertical subperiosteal mid-facelift with a posterior-superior vector SMAS or subcutaneous facelift. Alternatively, others combine a posterior-superior vector MACS (minimal access cranial suspension)lift or SMAS facelift with a vertical subcutaneous facelift.
Recent statistics released by The American Academy of Facial Plastic and Reconstructive Surgery show that in 2011 the 3 most commonly performed facial procedures were rhinoplasty, eyelid surgery and Botox Cosmetic. And it is no surprise to me that this should be the case.
Rhinoplasty is one of the most transformational procedures that I do. It can make someone who has been unattractive their whole life more appealing, and it can even make a person look younger by elevating their tip. Eyelid surgery is relatively easy to perform with minimal downtime and does wonders for making someone look more relaxed, less “burned-out” and even younger. Finally, Botox Cosmetic is one of the “lunchtime” procedures, which is easy and quick to perform, relatively inexpensive and produces dramatic results in the right patient. In addition to smoothing out wrinkles of the forehead, between the eyebrows and around the eyes, it can raise downturned corners of the mouth and lessen the prominence of early neck bands.
The ideal nasal profile has a tip that is slightly higher than the rest of the bridge. In many instances, this requires raising the tip to this level. To accomplish this, there are several techniques that can be employed. The first involves narrowing each of the two tip cartilages and then sewing them together. Because each cartilage forms an arch under the tip skin, narrowing them with sutures causes them to elongate upwards (Fig. A). Another popular way of increasing tip projection involves placing a cartilage tip graft over the underlying tip cartilages (Fig. B). This has the added benefit of creating more angularity to the nasal tip, which is especially useful with thick skin. Finally, the third most common way of increasing tip projection is by placing a fixed strut of cartilage anchored to the septum to which the tip cartilages can be sutured in a more projected fashion (Fig. C). Though each of these techniques work to accomplish an increase in tip projection, the choice of which one to use depends on many factors such as the need to improve tip definition or the desire to improve the proportional relationship between the length of the nostril to the length of the tissue in front of it (the lobule).
Being a surgeon who sees many rhinoplasty patients, I am frequently asked if nostrils can be re-shaped. Many of these patients have been told that what they want is either impossible, unpredictable or very difficult to accomplish. However, it has been my experience that this is generally not the case. In fact, most nostril shapes can be improved or made to look more aesthetically pleasing—even if numerous attempts at improvement have been unsuccessful in the past.
The margin of the nostril can be raised or lowered and the attachment to the cheek can be brought in, out or even lowered. Additionally, the thickness of the wall can be narrowed. Finally, it is not unusually for several of these maneuvers to be performed at the same time.
When lowering the nostril rim, we can rotate some of the internal lining downward, if the correction is small. For larger deformities, we usually need to add a composite graft of skin and cartilage, from an inconspicuous part of the ear, to act as a “spacer”.
Raising the nostril rim is quite easy and just involves an internal resection of skin with internal and upward rotation of the hanging external skin.
Narrowing a wide nostril can be accomplished in several ways. Skin from the nostril or floor of the nose can be excised, “cinching sutures” can be placed to pull the nostrils in or nostrils can be released from the underlying bony attachments to allow them to contract inward.
Widening a narrow nostril can be effected with the use of a graft from the opposite nostril, an advancement flap from the floor of the nose or rotation of a flap just outside the nose, for severe cases.
Finally, a thickened nostril wall can be thinned by excising an elliptical slice out from between the internal lining and external skin covering.