Rhytidectomy

In the first 70 years of the 20th century facelifts were performed by pulling on the skin on the face and cutting the loose parts off. The first facelift was reportedly performed by Eugen Holländer in 1901 in Berlin.[3] An elderly Polish female aristocrat asked him to: "lift her cheeks and corners of the mouth". After much debate, he finally proceeded to excise an elliptical piece of skin around the ears. The first textbook about facial cosmetic surgery (1907) was written by Charles Miller (Chicago) entitled The Correction of Featural Imperfections.[4]

In the First World War (1914–1918) the Dutch surgeon Johannes Esser made one of the most famous discoveries in the field of plastic surgery to date, namely the "skin graft inlay technique,"[5] the technique was soon used on both English and German sides in the war. At the same time, the British plastic surgeon Harold Delfs Gillies used the Esser-graft to school all those who flocked towards him who wanted to study under him. That’s how he earned the name "Father of 20th Century Plastic Surgery". In 1919 Dr Passot was known to publish one of the first papers on face-lifting, this consisted mainly of the elevating and redraping of the facial skin. After this many others began to write papers on face-lifting in the 1920s. From then the esthetic surgery was being performed on a large scale, form the basis of the reconstructive surgery. The first female plastic surgeon, Suzanne Noël, played a large role in its development and she wrote one of the first books about esthetic surgery named Chirurgie Esthetique, son rôle social.

In 1968 Tord Skoog introduced the concept of subfacial dissection, therefore providing suspension of the stronger deeper layer rather than relying on skin tension to achieve his facelift (he publishes his technique in 1974, with subfacial dissection of the platysma without detaching the skin in a posterior direction).[6] In 1976 Mitz and Peyronie described the anatomical Superficial Musculoaponeurotic System, or SMAS,[7] a term coined by Paul Tessier, Mitz and Peyronie’s tutor in craniofacial surgery, after he had become familiar with Skoog’s technique. After Skoog died of a heart attack, the superficial muscular aponeurotic system (SMAS) concept rapidly emerged to become the standard face-lifting technique, which was the first innovative change in facelift surgery in over 50 years.[8]

Tessier, who had his background in the craniofacial surgery, made the step to a subperiosteal dissection via a coronal incision.[9] In 1979, Tessier demonstrated that the subperiosteal undermining of the superior and lateral orbital rims allowed the elevation of the soft tissue and eyebrows with better results than the classic face-lifting. The objective was to elevate the soft tissue over the underlying skeleton to re-establish the patient's youthful appearance.

At the start of this period in the history of the facelift there was a change in conceptual thinking, surgeons started to care more about minimizing scars, restoring the subcutaneous volume that was lost during the ageing process and they started making use of a cranial direction of the "lift" instead of posterior.

The technique for performing a facelift went from simply pulling on the skin and sewing it back to aggressive SMAS and deep plane surgeries to a more refined facelift where variable options are considered to have an aesthetically good and a more long-lasting effect.

The SMAS (Superficial Musculo Aponeurotic System) layer consists of suspensory ligaments that encase the cheek fat, thereby causing them to remain in their normal position. This procedure is often performed in tandem with blepharoplasty as an ancillary procedure.[20][21] Resuspension and securing the SMAS anatomical layer can lead to rejuvenation of the face, by counteracting aging and gravity caused laxity.[22] Modifications to this technique led to development of the "Composite Facelift" and "Deep plane Facelift."[23]

In order to correct the deepening of the nasolabial fold more accurately, the deep plane facelift was developed. Differing from the SMAS lift by freeing cheek fat and some muscles from their bone implement. This technique has a higher risk at damaging the facial nerve. The SMAS lift is an effective procedure to reposition the platysma muscle; however, the nasolabial fold is according to some surgeons better addressed by a deep plane facelift or composite facelift.

As well as in the deep plane facelift, in the composite facelift a deeper layer of tissue is mobilised and repositioned. The difference between these operating techniques is the extra repositioning and fixation of the orbicularis oculi muscle in the composite facelift procedure. The malar crescent caused by the orbicularis oculi ptosis can be addressed in a composite facelift.

The mid face area, the area between the cheeks, flattens and makes a woman’s face look slightly more masculine. The mid face-lift is suggested to people where these changes occur, yet without a significant degree of jowling or sagging of the neck. In these cases a mid face-lift is sufficient to rejuvenate the face opposed to a full facelift, which is a more drastic surgery. The ideal candidates for a mid face-lift is when a person is in his 40s, or if the cheeks appear to be sagging and the nasolabial area has laxity or skin folds. To achieve a younger appearance the surgeon makes several small incisions along the hairline and inside the mouth, this way the fatty tissue layers can be lifted and repositioned. This way there are practically no scars. The fatty layer that lies over the cheekbones is also lifted and repositioned. This improves the nose-to-mouth lines and the roundness over the cheekbones. The recovery time is rather short and this procedure is often combined with a blepharoplasty (eyelid surgery)

The mini-facelift is the least invasive type of facelift which is similar to a full facelift, the only difference is the omission of the neck lift in the mini lift procedure. It is also called the ‘S’ lift because of the shape of the incision that is used or the ‘short-scar’ facelift. This lift is a more temporary solution to the ageing of the face which also has less downtime and is done on people who have deep nasolabial folds, sagging facial structures, yet still have a firm and well-contoured neck. The position of the incision is usually made from the hairline around the ear with scars hidden in the natural crease of the skin. The mini lift can be performed with an endoscope, which is used to reposition the soft tissues. After this, the skin is repositioned by the surgeon with small sutures.[24] This type of lift is a good alternative to the full facelift to people with premature ageing.

Blue represents the incisions in the Skin only facelift. Green represents the S-lift. Red is the extensive undermining done in several facelift techniques.

The subperiosteal facelift technique is done by vertically lifting the soft tissues of the face, completely separating it from the underlying facial bones and elevating it to a more esthetically pleasing position, correcting deep nasolabial folds and sagging cheeks. The technique is often combined with standard techniques, which provide a long-lasting rejuvenation of the face and is done in all age groups. The difference between this and other lifts is that the subperiosteal facelift has a longer period of facial swelling after the procedure.

With the skin-only facelift only the skin of the face is lifted and not the underlying SMAS, muscles or other structures. As the elastin fibers disintegrate, the skin itself loses elasticity in older patients. A skin only face lift requires skill in understanding the extent of safe removal of skin and the Vector of pull to get an optimal result. It can be done with a simple ellipse of skin removed with minimal undermining of skin flaps or more extensively with large skin flaps. It can last 5 to 10 years but some patients may want a touch-up at 6 to 12 months after the procedure. The reason that this option is considered is that it has fewer complications and quicker recovery. One of the father's of plastic surgery Sir Harold Gilles described a simple ellipse of skin excision in a socialite who was pleased with her quick recovery and outcome. Can be done for a simple jowl lift in a 35 to 45 year old patient.

A technique called thread lift or non-surgical face lift simplifies the operation. Silicone threads with barbs are used to pull the face and neck skin upwards without the need of skin excision. These are non-absorbable threads and combination of these threads with other methods of facial rejuvenation reveals even better results.[25] One such procedure is thread-lift with anti-ptosis (APTOS) sutures.[26]

In the UK aesthetic practitioners—who administer thread lifts and other treatments—are not required to have any mandatory qualifications, although some treatments can cause serious complications. In Liverpool the BBC found 26 cosmetic training academies offering courses ranging in price from £150 to £5,000 in 2021, lasting from a couple of hours online to a couple of days of face-to-face training. A professionally trained cosmetic doctor, Vincent Wong, said that a thread lift is the most dangerous procedure an aesthetic practitioner can do. A great many things can go wrong, more so than any injectable treatment, because threads stay in the skin and cannot be pulled out; while the results can be very good, the procedure can also cause irreversible damage. The professional training of Wong—already a physician with a degree in surgery—in this procedure involved four courses over three months.[27]

A nurse sent undercover by the BBC to take and secretly film a course teaching thread lifting was shocked at the unprofessionalism and unsafe practices she was taught. While exceptional sterility is required to avoid possible long-term infection, there was no attempt to control infection. The tutor touched various objects and then the patient's face, and the procedure was carried out on a chair instead of a clean bed. Several blood vessels were accidentally punctured, and the patient was clearly in severe pain. Patients drank alcohol before the treatment and vaped during it. Ashton Collins, the director of Save Face, a national register of accredited medical practitioners that provide non-surgical cosmetic treatments, said that "there's no doubt that if people following that course go on to do treatments [it] will cause a lot of complications".[27][26]

The term MACS-lift – or Minimal Access Cranial Suspension lift – allows for the correction of sagging facial features through a short, minimal incision, elevating them vertically by suspending them from above. There are many advantages to having a MACS facelift versus a traditional facelift. For starters, the MACS-lift uses a shorter scar that is in front of the ear, instead of behind, which is much easier to hide. Overall, the MACS-lift surgery is safer because less skin is raised. This means that there is less risk of bleeding and nerve damage. The operation also takes less time, lasting 2.5 hours instead of the 3.5 hours that the traditional facelift requires. There is also a shorter recovery period, 2–3 weeks instead of 3–4 weeks. Finally, the results of the MACS-lift are very natural while the traditional facelift will often result in a "windswept" look. The MACS lift has been successfully used for to correct complication after thread-lift with APTOS.[26]