Facelifting was first performed in the early 1900s and for most of the 20th century involved skin undermining and skin excision. A revolution occurred in the 1970s when the public became exponentially more interested in the procedure and Skoog described dissection of the superficial fascia of the face in continuity with the platysma in the neck. Since then techniques have been described that involve every possible skin incision, plane of dissection, extent of tissue manipulation, type of instrumentation, and method of fixation. Many of these “innovations” provide little long-term benefit when compared to skin undermining, and expose the patient to more risk. The trends in facelifting at the present time are best summarized as follows:
- Volume versus tension—Placing tension on the skin is an ineffective way of lifting the face and is responsible for the “facelifted” look and for unsightly scars and distortion of the facial landmarks such as the hairline and ear. The current trend is toward redistributing, or augmenting, facial volume, rather than flattening it with excessive tension.
- Less invasive—That the more “invasive” techniques have not yielded benefits in proportion to their risk combined with the public demand for rapid recovery has led to simplified procedures.
- Facial harmony—The goal is to help a patient look better, not weird or operated on. Excessive tension, radical defatting, exaggerated changes, and attention to one region while ignoring another may result in disharmony. The face is best analyzed and manipulated with the entire face (and the entire body) in mind, not the individual component parts, lest the “forest be lost for the trees.”
- Recognition of atrophy—The process of aging involves not only sagging of the tissues and deterioration of the skin itself but atrophy of tissues, especially fat, in certain areas. Most patients are best served with limited defatting and may require addition of fat to areas of atrophy.