Facial Aesthetics

Facial Aesthetics

In facial aesthetics, the structure of the skin is important in determining basic surgery and treatment approaches.

When the face area is examined including the neck, it continues with the line from the scalp border to the front of the ear and goes down to the level of the collarbone. The neck area cannot be considered independent of facial aesthetics, and mostly all treatments cover both sides. All information here was prepared by including the neck in the face area, unless stated otherwise.

In facial aesthetics, the structure of the skin is important in determining basic surgery and treatment approaches. For example, in Scandinavians with thin skin structure, sun damage often begins at an early age and causes fine lines to form quickly, while the skin structure in our country is predominantly subcutaneous fat tissue, which is thicker and skin elasticity is higher. It is a structure that was destroyed in the late period.

Various classifications have been made regarding skin types, which directly concern facial aesthetics. Among these classifications in plastic surgery, the most frequently used one is the Fitzpatrick classification and 6 types are defined.

Visual Note: Fitzpatrick's classification of different skin types according to their sensitivity to the sun.

Which skin type you have will give you an idea about how you will respond to surgery or medical treatments. Especially if patients in the Type 1 group request surgery, it is important to protect them with sunscreen before and after, so that the scars left are reasonable. In Type 6 people with black skin color, the possibility of blistering scars (hypertrophic scar) increases.

There are various aesthetic proportions in facial anatomy that painters and sculptors have used for many years. These proportions are defined by dividing the face into equal parts of various sizes. Some artists consider one-third ratios to be ideal, while others consider one-fifth ratios to be ideal.

All surgeries and applications to be performed in facial aesthetics must be within the framework of various aesthetic criteria. Regarding this, the basic division that we frequently use fits the 1/3 ratio and reveals the upper, middle and lower face and neck region in facial aesthetics.

Image Note: Aesthetic proportions and reference points according to the 1/3 percent rule.

In facial aesthetics, the basic anatomical structure includes the protrusion formed by the cheekbones, the lower jaw lines and the concave area between them, creating an image called ogee lines [pronounced "oci lines"].

Image Note: Ogee lines, which are among the facial aesthetic criteria

One of the main goals of facial plastic surgery and non-surgical interventions is to provide this natural curve.

The arch structure used in buildings in architecture, where convex and concave lines follow each other, is the ogee line, also called camel neck. This curvy formation is created by providing fullness in the cheekbones and concavity in the cheek during face lift surgeries. For this purpose, the sagging cheek fat pad in the previously mentioned face lift surgeries is suspended higher to create a bump in this area. In thin patients, fat injection may sometimes be required to achieve this bump. In non-surgical techniques, filler injection can also be done to create volume at appropriate points to obtain the ogee line.

We can talk about two groups of treatments in facial aesthetics: non-surgical methods and surgeries. Non-surgical methods are explained intermittently under titles such as chemical treatments, laser, radiofrequency, liposuction and fat injection. This section mostly covers plastic surgeries .

Aesthetic surgeries of the face should be evaluated in two groups: those that concern the skin and soft tissue, and those that can be performed on the bone. Bone-related aesthetic surgeries include implant applications for the corner of the lower jaw, above the cheekbone or the tip of the lower jaw, and jaw tip advancement and regression surgeries called genioplasty to change the shape of the lower jaw tip. Please review the jaw surgery topic to get information about all these types of surgery that concern the bone .

Facial plastic surgery has two main goals; One is to get a younger, tighter skin, and the other is to create volume. Face lift surgery, which is performed to achieve a young and vigorous appearance, is often performed together with fat injection or bone implant placement surgeries aimed at providing volume. Please review the jaw surgery section to get information especially about bone implants.

Face lift surgery is not a surgery performed only for older patients. Premature aging of facial skin may be influenced by genetic or environmental factors. While young people may have facial skin with severe wrinkles and deep folds, the skin may be smooth in older people who have been well cared for throughout their lives.

Face lift surgeries can take between 2-6 hours depending on the extent of the procedures to be performed. During this period, eyelid plastic surgeries (blepharoplasty) should also be counted. Staying in the hospital on the day of surgery is important for pain control.

Depending on the procedures to be performed during the surgery, there will be scars that are generally well hidden at the fold points such as the scalp-forehead border, in front of the ear, sideburn line and behind the ear.

Image Note: Incision scars and vector corrections left in classic face lift surgery

In some patients , additional scars may remain under the chin for the part of neck lift surgery called platysmoplasty, which is performed along the mid-body axis, which is a component of face lift surgery .

At the end of the face lift surgery, dirty blood that may accumulate inside must be collected with a tool called a drain, one on the right and one on the left, coming out of the skin at the nape of the neck, and this drain is removed after two days at the latest.

After facelift surgery, elastic clothes that expose the ears and face, called a facelift mask, are worn for approximately two weeks.

The stitches of face lift surgery are self-dissolvable stitches, they are located under the skin and do not need to be removed.

In face lift surgery, vectorial advancement of tissues such as skin, SMAS (layer consisting of subcutaneous fat and connective tissue), muscle tissues and sometimes even bone may be possible.

In face lift surgery, techniques have been defined to move various tissues from their current level to more anatomical points. Among these, the SMAS (superficial muscle aponeurotic system) tissue located under the skin provides long-acting and ideal results in suspension procedures. SMAS has a mixture of connective and fatty tissue, and stretching techniques are used, either by folding it on itself and sewing it, or by removing a strip from it and joining the remaining tissues.

Image Note: SMAS tissue and plication technique

Excess skin is removed after the SMAS shaping process. Today, when long-term results are compared, it has been observed that there is no significant difference in results between SMAS tissue techniques and more complex techniques. Composite facelift is based on the hypothesis that not only soft tissues but even bone undergo displacement with aging.

In platysmoplasty surgery, the folds and wrinkles that occur due to the relaxation of the muscle called platysma, which starts by attaching to the lower jaw bone in the jowl area and continues along the front of the neck, are eliminated by stretching procedures performed on the muscle.

Image Note: Neck bands due to sagging in the platysma muscle and its corrected version.

There are two basic surgeries performed regarding neck aesthetics. Both of these are usually performed within face lift surgery. One of them is placythmoplasty, which means placing stitches in the middle axis of the muscle to remove the neck bands due to the relaxation of the muscle called platysma, which stretches the neck skin, while the other surgery is the procedure known as neck lift [Picture 6]. Plasticysmoplasty can be performed by entering through the same incision line during neck lift, or it can be performed by entering under the chin. However, in this last one, there will be a small incision line under the chin.

Image Note: Recovery of the platysma muscles with mutual tensioning stitches

MACS-lift, a limited variant of facelift, aims to eliminate sagging through a ring created with threads in soft tissue, located in front of the ear.

As botulinum toxin and filler applications have become more common, patients have also required office types of surgeries such as face lifts. In this sense, MACS-lift (Minimally access cranial suspension lift) is one of the limited surgeries performed by combining both surgery and rope techniques. The aim is to lift the skin from the base at the midface level and provide biaxial tension in the subcutaneous soft tissue with some gathering stitches. Gathering stitches are attached to some fixed points. Excess skin is also removed. This type of surgery can be done with regional anesthesia. Since its long-term results are not as satisfactory as those of a classic face lift, it is generally only applied to patients who persistently request limited surgery. The recovery process takes an average of 7-10 days. This period does not include bruising and swelling.

Image Note: Limited face lift with MACS-lift technique

There are many applications in facial aesthetics that are increasing day by day and patients want to be sure about how well they work. Many techniques that seem good in the early period may present themselves with various problems in the future. Therefore, do not seek these procedures without obtaining detailed information from your plastic surgeon.

There are techniques used for non-surgical solutions based on thread suspension on the face. Frequently used techniques include hanging with knotted or hooked ropes and spider webs .

Image Note: Spider Web Technique

The hooked or knotted ropes used in rope suspension in facial aesthetics have a structure that moves in one direction and gets stuck in the soft tissue in the opposite direction, thus creating a suspension effect on the tissue. Rope suspension takes approximately 15 minutes and can be easily done with regional anesthesia. There is potential for long-term loosening, in which case re-suspension may be performed. If the suspension is not done properly, the patient may be uncomfortable because the ropes can be felt through the skin. Suspension can also be done with knotless or hookless ropes. Especially in patients who do not have any sagging or excess skin, eyebrow lifting can be done in the same way.

In the method called spider web in facial aesthetics, temporary effective suture materials lined up in parallel vertical and horizontal lines are placed, especially in the cheek area, and a web model is created. With the accompanying multi-vector suspension procedure, it is possible to support the soft tissues on the face without surgery. Over time, a connective tissue forms in the area as a result of the body's response to the stitches. It is claimed that this provides a more permanent suspension in the areas where the stitches are applied.

Among the surgical techniques used in facial aesthetics, the technique that creates the most limited incision scar is the endoscopic face lift surgery performed with the help of a camera. Here, depending on which parts of the face the surgery involves, shaping is done through one or two separate incisions through which the instruments to be used in the surgery enter, in addition to a small incision through which the camera enters.

Image Note: Example of camera system and dissector used in endoscopic face lift.

Efforts to provide the ideal result with limited applications in facial aesthetics have also manifested themselves in surgical techniques, allowing the use of the endoscope in aesthetic plastic surgery as well as in many surgical branches. The endoscope (endo-scope; seeing inside) consists of a camera and its light source that show the area straight or at a 30-45 degree angle. Specialized surgical equipment and experience are required in endoscopic surgery [Figure 10].

Today, the endoscopic technique, which is mainly used in eyebrow lift and mid-face lift, can be an ideal solution especially for young-middle age patients who do not have excessive skin excess due to soft tissue sagging. The ropes used for suspension during the surgery are fixed in the skull by screwing or knotting around an opened channel. Endoscopic facelift surgery may take 1-2 hours longer than the classic open facelift. Things to consider before and after surgery are the same as in classic face lift surgery.

Face lift surgery is a long-lasting surgery. During the surgery, the sagging skin areas are lifted from the ground with a delicate work, the underlying soft tissue is suspended and the excess skin is removed.

Classic face lift surgery is a surgery that can take more than 3 hours, especially when eyelid surgery is included. In this surgery, all the formations that cause the aged face and skin lines are shaped one by one and moved to the position where they should normally be. Due to the long duration of the surgery, patients with significant internal diseases (such as heart failure, uncontrolled diabetes, uncontrolled hypertension, liver and kidney diseases) are not suitable candidates for such long-term surgeries. For our patients who are in this situation and insist on surgery, I recommend the surgery in stages, in shorter sections.

As with any surgery, undesirable results (complications) may occur after face lift surgery. It is important to be in contact with your doctor regarding these results in order for your process to return to normal.

The main problems that may be encountered in the early stages of face lift surgery are:

1. Accumulation of blood under the skin (hematoma):
2. It is the most common problem in face lift surgeries. These are bleedings that usually occur in the form of leakage from a small vein or veins due to situations that suddenly increase blood pressure in the head and neck area, such as strong straining or coughing. If the drains placed in the neck area are not sufficient to collect this blood, the patient may need to be taken to the operating room to drain the blood and control bleeding again. When the patient is taken back to the operating room, point bleeding foci are often observed rather than a clear bleeding focus. Generally, patients recover well after drainage of accumulated blood and control of bleeding.
3. Wound line problems:
4. Infection and wound line separation in the wound line may occur in face lift surgeries, as in all surgeries. The wound edges are cleaned and antibitotic treatment is started and stitches may need to be placed again.
5. Facial paralysis:
6. There are many facial expression muscles. These muscles are controlled by a nerve called the facial nerve , which originates from under the earlobe and spreads to the entire face.
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9. Image Note: The facial nerve runs under the SMAS tissue and distributes to the face.
10. This nerve runs under the previously mentioned SMAS tissue and is located on the surface in approximately the front 1/3 of the cheek. It is possible that the branches of the facial nerve may be damaged during this surgery, especially in the lifting procedures of deep areas performed with composite techniques. According to the SMAS tissue, this possibility is quite low as long as one stays close to the surface. For this reason, techniques aimed only at shaping SMAS have become more frequently used today. Facial paralysis may be temporary; if it belongs to one of the branches of the nerve, only one or two of the functions such as raising the eyebrow, closing the eye, and closing the mouth may be affected. Ultimately, your doctor will tell you the most accurate approach to what can be done about this problem, and the only competent branch to solve the facial paralysis problem is plastic reconstructive and aesthetic surgery.
11. Sagging earlobe:
12. During facelift surgery, the soft tissue moved from the neck is fixed to the mastoid protrusion of the skull behind the ear. This is a fixed bone point and carries all the vectorial load towards the back. If proper fixation is not made to the bone during this hanging process, the skin on the neck may also pull down the earlobe. In this case, the neck skin may need to be suspended to the mastoid process again.
13. Losses in the skin:
14. Especially in patients who use tobacco products or have uncontrolled metabolic diseases (diabetes, kidney failure), there is a tendency for wound healing problems after facelift surgery. Especially in diabetes and heavy smoking, blockages that start at the level of capillaries called microcirculation cause losses even in the facial skin with a widespread vascular network. why could it be. Therefore, I recommend that you quit smoking at least 20 days before the surgery and reduce your metabolic diseases, if any, to a controlled level.

There are a limited number of problems that may occur in the late stages of face lift surgery. One of these is swollen wound healing , and there may be basically two triggering factors. One is the person's inherent wound healing response, while the other is the enlargement of the incision scar due to excessively tense stitching of the skin. In fact, there are not enough studies on how effective any of these might be. Treatment of raised scars includes some compression garments and silicone gel applications, fractional carbon dioxide laser and steroid injections. Please follow the blog post I will write on this subject in the future.

Another problem that may occur in the late period after facelift surgery is asymmetrical results on the face . This may actually be due to the suspension made during the surgery being insufficient on one side. It may require surgical correction, or on the other hand, loosening may be attempted with botulinum toxin type A applications.