The term 'facelift' no longer represents a single procedure but rather a variety of options, which should be planned to suit an individual patient's needs. Many factors are taken into consideration, most of which relate to the patient's anatomy (bone and soft tissue structure).

The various techniques available differ in the extent of the surgery, the 'depth' of the surgery and the particular areas of the face, which they address. As a general rule of thumb, the more that is done and the deeper the level at which it is done, the more impressive and long-lasting the results are likely to be - but also the longer the period required for a full recovery, which includes the settling of swelling and bruising.

There have been a number of very significant advances in facial aesthetic surgery since the late 1970s. Most of these have arisen from a better understanding of facial anatomy through the development of craniofacial techniques for the correction of congenital facial abnormalities.

Cutaneous Facelift
The traditional facelift, which has been done since the early part of this century, is a technique where the skin is lifted from the underlying tissues and re-draped, backwards and upwards. While the overall facial appearance will be improved, the basic structure of the deeper, ageing facial tissues is not changed. This technique is the easiest to accomplish surgically and has a relatively short convalescent period. For some patients, this will be the most appropriate procedure, particularly when the major problem is within the skin rather than beneath it or when the time available for recovery is at a premium. For most patients, however, the improvement is not usually as long-lasting.

Deep Plane Facelift
In 1973, a Swedish plastic surgeon, Tord Skoog, found that it was possible to support facial soft tissues deeper than the skin (i.e. muscle and fat) during facelift surgery, safely, and that this gave more impressive results. His ideas were developed in the late '70s by Paul Tessier, who coined the acronym SMAS for the layer which Skoog was lifting. This stands for Sub-cutaneous Musculo-Aponeurotic System, a thin but quite strong layer of tissue beneath the skin to which muscles and soft tissue are attached. By freeing the SMAS layer from its deeper ligamentous attachments, it is possible to elevate deep facial soft tissues toward a position they occupied in younger days before gravity caused them to move downwards.

The basic idea of the SMAS lift has evolved over the years - and continues to do so - so that not only are deep tissues replaced in a better anatomical site, but that by so doing the overall shape and contour of the face becomes more youthful. These deeper level techniques require a detailed knowledge of facial anatomy to avoid damage to important structures such as facial nerve branches, but in experienced hands the risk to these structures is no greater than with any other type of face-lifting procedure.

In some patients a limited scar, i.e. shorter scar procedure may be appropriate. This avoids any scars extending behind the ear and backwards into the hairline and is most appropriate when there is not too much change in the neck. Again, the deeper layers of the soft tissues of the face are supported beneath the skin. This is a variation on what has become popularly known as a MACS lift.

The volumetric facelift is designed particularly to improve contour of the cheek bone and is perhaps the most effective for true rejuvenation. It uses scars based around the ear like most other facelifts but also a small incision inside the mouth which gives access to the cheek fat pad enabling it to be moved upwards to create a better and smoother cheekbone prominence. it is often combined with eyelid surgery and endoscopic brow surgery.

Neck Lift and Platysmaplasty
All deep plane facelifts tighten the muscle of the neck to improve both the jowl area and jaw line. To eliminate vertical folds in the neck, reduce excess fat beneath the chin and restore the angle between the neck and the chin (which tends to become more obtuse with age), an additional procedure known as a platysmaplasty may be indicated.

To achieve this in some patients it is necessary to make an additional small incision beneath the chin, but in others sufficient adjustment of the neck muscle (platysma) can be achieved via the facelift incision. This will be discussed at the consultation stage.

Scars
The scars for all the above types of facelift are mostly within the hairline and hidden around the ear. They are designed in such a way that patients should be able to wear their hair in any style once scars are mature. In general, while the site of these scars makes them extremely reliable, the outcome of a particular scar in any given individual can never be guaranteed.

Additional Procedures
There are several additional procedures which may be carried out with any of the above types of facelift when required, such as brow lifting (usually using the surgical endoscope), eyelid surgery, adjustment of bony chin or cheek bones, rhinoplasty (nasal surgery) and skin resurfacing for fine wrinkles with the use of the laser.

Subperiosteal Facelift (mask lift) and Endoscopic Facelifting (endoface)
The mask lift is a completely different concept from other types of facelift. It was developed by a French plastic surgeon, Dr Paul Tessier, and introduced by him in 1980. The ideas arose from techniques using craniofacial surgery and have been adapted for aesthetic (cosmetic) purposes.

The theory and practice of this type of face-lifting is entirely different from most other varieties of facelift and it is not suitable for all patients. In essence, all of the soft tissues of the face - fat, muscles, skin, etc - are released from their deeper attachments, lifted and repositioned to the site which they occupied before gravity produced its downward drift. Generally, the most suitable patients are in a relatively younger age group (35 to 50), and have heaviness of the brows, sagging of the outer corners of the eyes and cheeks but without, necessarily, major changes in the neck. It is possible during surgery such as this to re-contour or alter the facial skeleton.

The endoscopic facelift is exactly the same procedure but, whereas the mask lift is carried out through a coronal incision (like an Alice band running from the top of one ear to the top of the other within the hair) and a second incision within the mouth, it uses small incisions within the hair and an incision in each lower eyelid, immediately below the lashes, similar to that used for blepharoplasty (eye bag surgery).

Like most surgical endeavour, facial endoscopic surgery continues to evolve. In some patients, the lower eyelid incision may be unnecessary and a small incision within the mouth is used instead, perhaps combining the procedure with laser resurfacing of the lower eyelid. In other patients, both the lower eyelid and mouth incisions may be avoided - a technique usually known as an endoscopic brow and mid-face lift.

In endoscopic surgery a surgical telescope (endoscope) is used for vision, so eliminating the need for large incisions and having the obvious major advantage of limiting scars to a minimum. The indications for these techniques generally are similar to those for a sub-periosteal facelift, but they may also be useful for patients who have previously had a cutaneous facelift but have persisting change in the deeper soft tissues of the face.

Which facelift is best for you?
There are now a myriad of options for effective facial rejuvenation surgery and to appreciate the nuances of surgical facial anatomy and the particular advantages and disadvantages of each technique can be quite difficult for a layperson or a doctor without very specific training and experience. Therefore, the various types of facelift will be discussed with you a patient in order to decide, jointly, which would be most appropriate and most likely to produce the desired result.

All facelifts are designed to give a natural, fresh look and will not produce a tight, mask-like appearance. Some lines of expression are essential in every face and these, of course, will remain. The focus of this kind of surgery should, for the most part, be upon shape rather than wrinkles. A youthful face will have full, high cheekbones with relative narrowness of the jaw area. This will produce an S shaped curve when the face is viewed obliquely - called by some the Ogee curve. As the face ages, it tends to become squarer, a trend which is addressed by effective facial rejuvenation surgery.

How long does a facelift last?
The answer to the most frequently asked question is that that this type of surgery puts back the ageing clock but, of course, cannot stop it. The rate at which ageing continues varies from one patient to another and will depend also on how carefully the skin and facial tissues are cared for, whether the patient smokes, how much sun they are exposed to and so on - but, perhaps most importantly, the genetic information that is already 'programmed into' their biological clock.

In general, the deeper the level at which the facelift is done, the longer lasting the results tend to be. The inevitable corollary of this, however, is that the more extensive the surgical procedure and the more surgical procedures which are carried out at one time, the longer the recovery time is likely to be.

How long does it take to recover from a facelift?
After a simple skin lift alone, a patient may reasonably expect to look fairly presentable after one week. However, if a deep plane type facelift is combined with brow lifting, blepharoplasty (eyelid surgery) and platysmaplasty (neck lift) then there may be more swelling. Although the majority of this dissipates over a period of approximately 14 days, it takes longer for all of the swelling to resolve and a final result to be appreciated. In general, after a procedure such as this it would be wise to allow two to four weeks recovery time (depending on employment and social commitments). Results from deep plane face-lifting are likely to improve for up to one year and this improvement will be maintained for very much longer than that which follows a skin lift alone.

There are many factors to be taken into account when deciding which is the best operation, some of them medical but others relating to lifestyle and commitments.