A 35 year personal experience with 8,000 rhytidectomies

My first experience with rhytidectomy began during my plastic surgery residency 1975-1977. During the late 1970s and early 1980s, virtually all facelift panels and courses were recommending extensive radical defatting in the subplatysmal plane, resection of digastric muscles and submandibular glands, along with full width transection of platysma muscle flaps to accomplish the ideal “youthful neck.”

As a young plastic surgeon just out of residency, I espoused these techniques as the only method to obtain the best result. Whenever I performed this operation and observed the dramatic transformation of the neck on the operating room table, I felt heroic. However, 6 months postoperatively, when my patients developed submental hollowing and neck irregularities, I regretted having been so aggressive.

I finally realized that to attempt to create the neck of a 21-year-old model in all patients was both unrealistic and poor aesthetic judgment. A good face and necklift demonstrate a sense of balance and proportion in accordance with the physiognomy and aesthetics of each patient. A woman with a full face and short neck would look unnatural with the neck of a 50 kg. 21-year-old model. As we age, softer contours and more fullness are more appropriate and pleasing. Occasionally a post-operative patient would inquire about the “submandibular bulges.” I learned to examine the glands and discuss their anatomy with the patient during the preoperative evaluation. I have patients feel their own glands while I explain that these glands may become more prominent postoperatively when fat is contoured and skin is tightened. I then discuss the possibility of gland removal, explaining that these glands secrete 45% of the mouth’s saliva. When I begin to discuss the potential risks and complications, I rarely get through half the list before the patient interrupts and says: “That’s okay, Doc, I want to leave them.”It was only after many years of patient complaints, complications, and overoperated necks that most plastic surgeons abandoned these techniques.

 

FIG1. : 1 ANO PÓS RESSECÇÃO DE GORDURA SUBPLATISMAL E RESECÇÃO SUBTOTAL DOS MÚSCULOS DIGÁSTRICOS

FIG. 2: 1 ANO PÓS “LIMPEZA” SUBPLATISMAL – GORDURA, MÚSCULOS DIGÁSTICOS, GLÂNDULAS SUBMANDIBULARES

 

 

The goal of neck contouring surgery should be a graceful-looking neck, attractive by virtue of its simplicity rather than by its complexity.

Very early I learned to perform each Face and Necklift multiple times: the night before, the day of surgery, the night after, and on every follow up visit.

In order to improve my facelift technique and results I studied the flaps carefully for vascularity, ecchymosis, and edema,  incision placement, hairline, earlobe distortions, flap rotation and vectors. Every case is a challenge:  I always strived to improve my technique and results. After over 35 years performing almost 8000 rhytidectomies I am still learning. Usually the patients are happier and less critical than I am with myself. I do not think I have ever accomplished a “perfect result.” I always see areas I wish I could have done better. When watching lectures on facelifts it is common to be impressed by the spectacular results often seen. However I always keep the proper perspective: Presenters only show their very best results (and quickly). All surgeons have selective memory for complications.

 

I discovered very early in my facelift experience that short healing time with reduced edema and ecchymosis created a positive surgical experience for the patient. That was often more valuable than a slightly better result using more aggressive, invasive techniques. I find this to be true for almost all the aesthetic facial procedures I perform including blepharoplasty.

THE 1970’s: EVOLUTION OF THE SMAS TECHNIQUE

When superficial musculoaponeurotic system (SMAS) dissection became popular after the work of Mitz and Peyronie in 1976, it was fashionable to include a dissection of the lateral SMAS directly overlying the parotid gland. I initially performed this type of SMAS dissection in the late-1970s and continued to do so into the mid-1980s, but overall I was disappointed with the effects of a simple elevation and tightening of the lateral superficial fascia. Specifically, I saw little difference in overall facial contour regardless of whether I had performed a lateral SMAS dissection or simple SMAS plication.

As I gained greater experience with SMAS dissection, I realized that to produce any effective change in facial contour, it was necessary to elevate the mobile SMAS anterior to the parotid gland. Also unless the SMAS was elevated above the zygomatic arch (high SMAS flap), it did not effectively lift the midface and infraorbital region. The problem with this more extensive SMAS dissection is that facial nerve branches are placed in greater jeopardy. I also noted that the superficial fascia tends to thin out as it is dissected more anteriorly, making it easier for the SMAS to tear. All too often, I would note thinning and tears after elevating a SMAS flap. Any significant tension placed on the flap in suturing would result in further tears. In my hands, I believed that an extensive SMAS dissection was not warranted in most patients and offered little long-term benefit in comparison with SMAS plication. I always carried my SMAS plication above the zygomatic arch to produce a contoured lifting of the jowl, cheek, and midface.

 

FIG. 3: ANTERIOR À GLÂNDULA PARÓTIDA, O SMAS AFINA E PODE SE TORNAR POUCO RESISTENTE E ROMPER QUANDO OCORRE TENSÃO COM A ROTAÇÃO

 

 

 

THE 1980s: LIPOSUCTION

With the advent of liposuction in the 1980’s, I found that I could obtain excellent neck contouring and jowl reduction-sculpting in many patients by performing liposuction combined with strong lateral platysmal suturing. Liposuction often eliminated the need for a submental incision with direct excision of fat and extensive undermining in all but the most difficult necks. I also began to reduce medial platysma work (except when the bands were prominent on active animation), because the strong lateral pull obtained by suturing the platysma to the mastoid periosteum enabled me to obtain excellent neck contouring without medial plication. Because of my disappointment with SMAS flaps, my facial contour and foundation correction was usually done with SMAS plication.

I continue to utilize open or closed liposuction in the majority of my facelifts when necessary. It has proved to be an invaluable technique and adjunct to my surgery. I have not yet found any reason to abandon liposuction as it was originally described finding no advantage or value with the newer laser assisted methods.

 

THE 1990s: SMASECTOMY

In 1992, I discovered that an alternative to formally elevating the superficial fascia was performing a “lateral SMASectomy,” removing a portion of the SMAS in the region directly overlying the anterior edge of the parotid gland at the junction of fixed and mobile. Excision and suturing of the superficial fascia in this region secures mobile anterior SMAS to the fixed portion of the superficial fascia overlying the parotid. The direction in which the SMASectomy is performed is usually parallel to the nasolabial fold, so that the vectors of elevation after SMAS closure lie perpendicular to the nasolabial fold with a more vertical vector, thereby producing improvement not only of the nasolabial fold but also of the jowl, jawline, and midface. The width of SMAS resection depends upon the fullness of the patients face and if de-bulking is advantageous. In thin face patients SMASectomy is not performed in order to preserve facial fat. SMAS plication is performed in these patients to augment and sculpt the face.

For the neck, a flap of the lateral platysma is developed in the region inferior to the mandibular border. After this lateral platysma flap is raised, the platysma is secured to the mastoid periosteum to help define the jawline and improve contouring in the submandibular region. This is the basic rhytidectomy operation that I have performed since July 1992.

For me, the advantage of lateral SMASectomy are several when one compares it with formal SMAS elevation. First, since the procedure does not require a formal SMAS flap elevation, there are fewer concerns about tearing of the superficial fascia. Second, the potential for facial nerve injury is less because the majority of the dissection is carried over the parotid gland. If the SMASectomy is performed anterior to the parotid, the deep fascia similarly will provide protection for the facial nerve branches as long as the resection of the superficial fascia is done precisely and the deep facial fascia is not violated. Third, because SMAS flaps have not been elevated, they tend to be more substantial in terms of holding suture fixation, and the problems of developing postoperative dehiscence and relapse of contour are reduced.

The SMASectomy is performed at the interface of the superficial fascia fixed by retaining ligaments and the more mobile anterior superficial facial fascia. On closure, this brings the mobile SMAS up to the junction of the fixed SMAS, producing a durable elevation of both superficial fascia and facial fat.

The width of resection depends on the fullness of the face and need to preserve fat. The excision begins over tail of parotid and extends over the malar prominence to the lateral canthus in order to lift the midface.

 

 

1994 – DEEP DISSECTION RHYTIDECTOMY: A PLEA FOR CAUTION

During the early 1990’s I listened to panels and presentations and read articles about the “super-SMAS,” “deep-plane,” “subperiosteal,” composite, and various other extended rhytidectomy procedures. In their search for the ultimate facelift, these pioneering surgeons demonstrated superb anatomic studies, beautiful illustrations, and impeccable photographs. Their presentations were well organized, stimulating, and seductive.

I always considered myself to be a bold and aggressive surgeon, and the temptation to utilize these new, deeper dissections was extremely appealing. However, I was reluctant to employ them, and kept asking myself: “why?”. The explanation is partly that I was not convinced that the results were superior to those obtained by the standard SMAS-platysma techniques or plication even though the presenters stated that in their presentations their results were more natural and long lasting. More important, I did not believe that the “implied benefits” outweigh the increased morbidity and risks, especially to the facial nerve. What needed to be answered was (1) what are the indications for these deeper more invasive newer techniques? (2) How great are the risks and complications? And most important, (3) Do the benefits significantly outweigh the risks to justify using these techniques routinely?  I expressed these thoughts in a PRS Editorial in 1994. I believe this editorial stimulated an important Facelift study which started just following the 1995 ASAPS Meeting in San Francisco.

 

1995- IDENTICAL TWIN FACELIFTS WITH DIFFERING TECHNIQUES: A 10-YEAR FOLLOW-UP

Daniel C. Baker, M.D., Sam T. Hamra, M.D., John Q. Owsley, M.D., Oscar Ramirez, M.D.

 

SUMMARY:  To evaluate the efficacies of four different surgical techniques in facial rejuvenation, two sets of identical twins were operated on by four different surgeons. The technical approaches to facial rejuvenation included lateral superficial musculoaponeurotic system (SMAS)-ectomy with extensive skin undermining (Baker), composite rhytidectomy (Hamra), SMAS-platysma flap with bidirectional lift (Owsley), and endoscopic midfacelift with an open anterior platysmaplasty (Ramirez). All patients were photographed by an independent surgeon at 1, 6, and 10 years postoperatively. At the same time interval, the cases were presented and discussed in a panel format at the annual meeting of the American Society for Aesthetic Plastic Surgery. Each operating surgeon was allowed to critique the results and discuss how his methods had changed over the intervening 10-year interval. Postoperative photographs at 1, 6, and 10 years after surgery are included to allow the reader to examine long-term results utilizing various approaches to facial rejuvenation in identical twins. (Plast. Reconstr. Surg. 123: 1025, 2009.)

Although there were differences of opinion on the subject, at 10 years postoperatively Dr. Rod Rohrich commented that “what was the most impressive in the 10-year follow-up was everybody had a really good result, and what was most amazing was they looked more alike than different; there were more similarities than differences.”

So what is it – the operator, the operation, or the patient – that is the variable most critical to determining the outcome in facelift surgery? Experts vary in their perspectives.  “It is not the surgeon, it is the technique. It is always the technique that counts,” stated Dr. Hamra. Conversely, Dr. Stuzin said, “It is interesting to see the similarities in results with a variety of techniques. It makes you think it is not necessarily the technique but the surgeon that is able to get these good results.”

Daniel C. Baker’s comments

1995: Day of Surgery, March 24: Having been openly critical of deep plane and subperiosteal techniques for years, I knew this was my ultimate test operating on the twin sister of Sam Hamra’s patient. I was nervous.

1996: First-Year Postoperative Panel:  While reviewing my slides for the panel presentation, Sam Hamra’s first words to me were “my office staff asked why I got the older twin.”

2005: 10-Year Postoperative Panel:  All twins still appear considerably better than preoperatively. All results are holding up. My main thought: “Finally deep plane and subperiosteal techniques have been demystified.” All those surgeons utilizing other techniques can feel relieved and confident with their personal choice. No doubt differences of opinion as to which variable is most important will occur. One point of agreement is accepted and sought by all of the involved surgeons, “find a technique which is consistent, predictable, reliable, and reproducible, with low morbidity and minimal risks and complications.”

2001-2013 – 21st CENTURY: LESS INTENSIVE TECHNIQUES, SHORT SCAR FACELIFTS AND RETUR TO PLICATION

“Mini lifts” have been around for almost a century; the first description of such a procedure was by Passot in 1919. These operations were usually preauricular skin excisions with minimal undermining, resulting in minimal, short-lived improvement. More recently, the concept of the S-lift with suspension sutures and SMAS plication has gained popularity.

The short scar rhytidectomy was developed out of a demand from younger female patients (aged mostly in their 40s) who sought facial rejuvenation but were adamantly opposed to any scarring behind the ears. They objected to the posterior hairline distortion, hypertrophic scars, and hypopigmentation that they often observed in their friends or mothers who had undergone facelifts.

 

ADVANTAGES AND DISADVANTAGES OF SHORT SCAR FACELIFT

The primary advantage of the short scar facelift is for the patient who often wears her hair pulled up or back. Any retroauricular scarring or disruption of the posterior hairline makes such a patient unhappy. In addition, the operation involves less dissection and is less invasive; presumably this results in less pain and a shorter healing time. In patients who develop a hematoma, the evacuation is easier with less morbidity. The short scar facelift is primarily for the younger patient with minimal cervical laxity.

There are disadvantages also. This technique is not applicable to patients, who have moderate to severe neck laxity. Using a shorts scar technique on these patients will result in undercorrection of the neck and a potentially unhappy patient requiring revisional surgery. Because the technique requires a significant vertical lift, strict attention must be given to minimizing temporal hairline shifts. In certain patients, an anterior hairline incision must be used. Fitting in dog-ears in the temporal and earlobe areas can be a challenge, and these areas take more time to soften and flatten. Exposure of the neck with short scar technique is limited, making the operation technically more difficult.

 

FIG.6: 52 ANOS/PRE-OPERATÓRIO e 65 ANOS PÓS 2o LIFTING DE FACE E PESCOÇO CICATRIZ CURTA

FIG.6: 52 ANOS/PRE-OPERATÓRIO e 65 ANOS PÓS 2o LIFTING DE FACE E PESCOÇO CICATRIZ CURTA

FIG.6: POST-OPERATÓRIO  DE 2 LIGTINGS DE FACE E PESCOÇO CICATRIZ CURTA

 

Since 1992 I have performed over 2700 short scar facelifts. Of these only 35 were males because most men present at an older age with more cervical laxity. The first 10 years I was more liberal with my selection of candidates but this resulted in revisions of undercorrected necks. Today approximately 25-30% of my facelifts are candidates for short scar lift. Two reasons for the decline in shorts scar facelifts. First I have stricter indications for a good candidate:  young (usually less than 50), good skin elasticity, minimal cervical laxity. Second the past 10 years I have seen a reduction in the number of younger women seeking facelifts, because of fillers and botox and minimally invasive techniques for facial rejuvenation.

 

TABELA 1: SUMMARY OF STEPS FOR SHORT SCAR FACELIFT

  1. The best candidates for short-scar rhytidectomy are younger, with better skin elasticity and minimal cervical laxity.
  2. When the temporal hairline shift is assessed as minimal, the preferred incision is well within the temporal hair.
  3. Perform lipoplasty before elevating skin flaps and avoid over suctioning. Whenever possible, I prefer closed SAL in the neck and jowls.
  4. If active prominent platysma bands are present, open the neck and undermine to perform medical platysma approximation.
  5. Plication is always preferred in patients with thin faces.
  6. A lateral SMASectomy is performed when debulking is aesthetically beneficial.
  7. For maximal midface correction, extend plication or SMASectomy over the malar eminence just short of the lateral canthus.
  8. If a lateral SMASectomy is performed, keep the dissection superficial to the deep fascia to avoid the parotid gland and facial nerves.
  9. After plication or SMASectomy, the last suture lifts the malar fat pad securing it to the malar fascia.
  10. Not every patient is a candidate for the short scar technique; some will benefit more from classic retroauricular and occipital incisions.
  11. Finally, do not compromise the end result just to have a shorter scar.

 

CORRECTING THE DIFFICULT NECK: STILL THE BIGGEST CHALENGE

With the advent of closed liposuction in the 1980’s I stopped opening most necks for defatting. I also tried to avoid opening the neck whenever possible but sometimes misjudged the platysma component and ultimately had to revise those necks and do open platysmaplasty. Why most surgeons prefer not to open the neck is obvious: less dissection, less bleeding, less complications such as through and through expanding hematomas. But in my hands trying to correct platysma bands and thick necks by only pulling the platysma laterally usually results in suboptimal cervical contouring,  recurrent platysma bands, and early recurrence of neck deformities. This has always been for 35 years the most common mistake requiring a major revision after 1-1 ½ years. So I have not yet found an effective long lasting technique to correct platysma deformities without a submental incision and direct platysmaplasty. Under corrected necks are the most common complaint from my patients who consult with me after surgery from another Plastic Surgeon. So today I continue to open the neck on all patients with active platysma cords which contribute to the neck deformity.

 

FACELIFT LONGEVITY

Patients usually ask “Doctor how long will me face and neck lift last?” As a resident I was taught to tell them between 5-7 years. After 15 years of doing facelifts and following them, I began telling patients 8-10 years. Today for patients with good skin elasticity I can confidently tell them 10-14 years. Why the change? Today we restore the facial foundation with SMAS flaps and plication. We restore facial volume with autologous fat grafting and fillers. All this is accomplished before redraping and excising excess skin. Simultaneously we can do full face resurfacing with peels and lasers, and utilize Botox for rhytides previously resistant to treatment. And we can maintain the result much longer with fat grafting, fillers, botox and skin resurfacing.

Of course patients with poor skin elasticity will have limited longevity (5+ years) and those with severe cervical skin excess may require a “neck tuck” after 1-2 years.

 

1995: 55 anos                             FIG 7. 2008:68 anos                2011: 71 ANOS

PRE-OPERATÓRIO             13 ANOS PÓS F&P + PEELING      3 ANOS POS 2o LIFTING DE F&P

 

1995: 55 anos                             FIG 7. 2008:68 anos                2011: 71 ANOS

PRE-OPERATÓRIO             13 ANOS PÓS F&P + PEELING      3 ANOS POS 2o LIFTING DE F&P

 

1988: 49 anos                                      FIG 8. 1997:58 anos                2012: 73 ANOS

PRE-OPERATÓRIO             9 ANOS PÓS LIFTING DE F&P    15 ANOS POS 2o LIFTING DE F&P

1988: 49 anos                                      FIG 8. 1997:58 anos                2012: 73 ANOS

PRE-OPERATÓRIO           9 ANOS PÓS LIFTING DE F&P    15 ANOS POS 2o LIFTING DE F&P

1991: 55 anos                             FIG 9. 2008:68 anos                2011: 70 anos

PRE-OPERATÓRIO           17 ANOS PÓS 2° LIFTING DE F&P    2 ANOS POS 2° LIFTING DE F&P

1991: 55 anos                             FIG 9. 2008:68 anos                2011: 70 anos

PRE-OPERATÓRIO           17 ANOS PÓS 2° LIFTING DE F&P    2 ANOS PÓS 2° LIFTING DE F&P

1993: 51 anos                             FIG 10. 2003:61 anos                2008: 66 anos

 PRE-OPERATÓRIO           10 ANOS PÓS F&P + BLEFAROPLASTIA SUPERIOR        5  ANOS PÓS 2a

1993: 51 anos                             FIG 10. 2003:61 anos                2008: 66 anos

 PRE-OPERATÓRIO           10 ANOS PÓS F&P + BLEFAROPLASTIA SUPERIOR        5  ANOS PÓS 2a

 

FIG. 11:

 1995: 50 anos                                  2010: 65 anos

PRE-OPERATÓRIO           15 ANOS PÓS 2° LIFTING DE F&P

1995: 50 anos                                  2010: 65 anos

PRE-OPERATÓRIO           15 ANOS PÓS 2° LIFTING DE F&P

FIG. 12:

    1987: 51 ANOS                                              2098: 62 ANOS                                      2008: 72 ANOS                          2012: 76 anos

PRE-OPERATÓRIO               11 ANOS PÓS 1°  F&P                    10 ANOS PÓS 2°  F&P            4 ANOS PÓS 3°  F&P

    1987: 51 ANOS                                              2098: 62 ANOS                                      2008: 72 ANOS                          2012: 76 anos

PRE-OPERATÓRIO               11 ANOS PÓS 1°  F&P                    10 ANOS PÓS 2°  F&P            4 ANOS PÓS 3°  F&P

  1987: 51 ANOS                                       2012: 76 anos

PRE-OPERATÓRIO                      PÓS 3 LIFTING DE F&P

  1987: 51 ANOS                                       2012: 76 anos

PRE-OPERATÓRIO                      PÓS 3 LIFTING DE F&P

RHYTIDECTOMY 2013
THE GOLD STANDARD FOR FACIAL REJUVENATION

Today when patients see me in consultation for face and neck rejuvenation they usually discuss alternative non-invasive, non-surgical options: fillers, lasers, radio frequency, and thread lifts. Many of these patients present with over filled and distorted faces. Many have already had these treatments spending years and great amounts of money for disappointing, poor results. Their cost and recovery downtime is often significantly greater than having a rhytidectomy.

 

I tell my patients that a well performed face and necklift combined with fat grafting or fillers, and skin resurfacing will last between 10-14 years, giving them a more natural look and be far more economical.

We as plastic surgeons have the ability to accomplish a superior natural facial rejuvenation in a more economical way than our non-surgical colleagues. The fillers and lasers and “non-invasive”

techniques are good adjuncts to our surgery and are certainly beneficial prolonging our results.

So when you see a new patient in consultation for facial rejuvenation present your face and necklift in a confident objective manner. You can offer them much more for their money than your non-surgical colleagues.

 

SOME OF MY BASIC PRINCIPLES


  1. Stay with a reliable, safe, technique which gives consistent results.
  2. Be cautious about trying new techniques until they become established, predictable, and reproducible.
  3. Maintain Humility: There will always be another surgeon who can do it as well or better than you.
  4. Remember presenters only show their very best results.
  5. Remember presenters and surgeons have poor memory for complications.
  6. Try to keep revisions less than 5%. If it goes higher re-evaluate your technique. Wait 1 year for revisions.
  7. Keep learning and improving: study incisions, flaps, scars, vectors, and results. Always try to do better.

 

CONCLUSION – SUMMARY

Although the debate continues about which rhytidectomy technique yields the best results, there is no single technique that is “best.” Most techniques are variations on a basic theme. What has clearly evolved in the 21st century is the trend to less invasive procedures with low morbidity, short recovery, and minimal scars.  Most patients are happy with simpler techniques.  I believe that deeply invasive, more radical techniques do not necessarily give better or longer lasting results. Results and longevity are more surgeon dependent than technique dependent.

 

TABLE 2: MY PRESENT RHYTIDECTOMYL
MORE PLICATION LESS SMASECTOMY
OPEN NECK PLATYSMAPLASTY FOR ACTIVE MUSCLE CORDS

SHORT SCAR FOR GOOD CANDIDATES ONLY
CLASSICAL RHYTIDECTOMY INCISIONS FOR MODERATE TO SEVERE NECK LAXITY

AUTOLOGOUS FAT AND FILLERS SIMULTANEOUSLY
FULL FACE RESURFACING SIMULTANEOUSLY
TCA PEELS- FINE RHYTIDES & SUN DAMAGE

DERMABRASION – DEEP LIP LINES

USUALLY BOTOX FOR BROW PTOSIS
GLABELLA AND FOREHEAD RHYTIDES

 

 

 

REFERENCES:

Baker,DC., Conley J. Avoiding facial nerve injuries in rhytidectomy: Anatomical variations and pitfalls. Plast Reconstr Surg 1979;64:781-795.

Baker DC. Complications of cervical rhytidectomy. Clin Plast Surg 1983; 10:543-562.

Baker DC. Deep dissection rhytidectomy: A plea for caution. Plast Reconstr Surg 1994;93:1498-1499.

Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997; 100:509-513

Baker DC. Lateral SMASectomy. Semin Plast Surg 2002;16:417-422.

Baker DC. Minimal incision rhytidectomy (short scar facelift) with lateral SMASectomy; Evolution and application. Asetetic Surj J 2001;21:14-26.

Baker DC. Minimal incision rhytidectomy (short scar facelift) with lateral SMASectomy: Operating Strategies. Aesthetic Surg J 2001;21:68-80.

Baker DC., Hamra ST, Owsley JQ, et al. Ten Year follow-up on the twin study. Presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, New Orleans, LA, April 2005.

Baker DC., Chiu ES. Reducing the incidence  of hematoma requiring surgical avacuation following male rhytidectomy: A 30-year review of 985 cases. Plast Reconstr Surg 2005; 116(7):1973-1985.