rhytidectomy rhytidectomy a facelift, technically known as a rhytidectomy (from the ancient greek ῥυτίς (rhytis) "wrinkle", and ἐκτομή (ektome) "excision", the surgical removal of wrinkles), is a type of cosmetic surgery procedure used to give a more youthful facial appearance. there are multiple surgical techniques and exercise routines. surgery usually involves the removal of excess facial skin, with or without the tightening of underlying tissues, and the redraping of the skin on the patient's face and neck. exercise routines tone underlying facial muscles without surgery. surgical facelifts are effectively combined with eyelid surgery (blepharoplasty) and other facial procedures and are typically performed under general anesthesia or deep twilight sleep. rhytidectomytemporal incision behind the hairline in endoscopic midface lift (rhytidectomy). note the shiny surface of the deep temporal fascia. this plane is dissected down to the orbital rim and connected to the midface subperiosteal plane created through the sublabial incision under the upper lip, and often through a lower eyelid incision.icd-9-cm86.82medlineplus002989 according to the most recent american society for aesthetic plastic surgery facelifts were the third most popular aesthetic surgery in 2019, surpassed only by rhinoplasty and blepharoplasty. history sublabial incision through which periosteum of maxilla is elevated in an endoscopic midface lift (rhytidectomy). cutaneous period (1900–1970) 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. 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. 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," 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. smas period (1970–1980) 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). in 1976 mitz and peyronie described the anatomical superficial musculoaponeurotic system, or smas, 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. deep plane period (1980–1991) tessier, who had his background in the craniofacial surgery, made the step to a subperiosteal dissection via a coronal incision. 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. volumetric period (since 1991) 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. indications the difference between an aged eye and a youthful eye, looking at the distance from the cilliary margin to the inferior-most point of the orbicularis oculi muscle. a. increased redundancy of the nasolabial fold (caused by a descent of cheek fat) b. increased distance from the ciliary margin to the inferior-most point of the orbicularis oculi muscle (caused by decreasing tone of the orbicularis oculi muscle) c. jowl (a broken jaw line by ptosis of the platysma muscle) d. the intended effect of a facelift a facelift is performed to rejuvenate the appearance of the face. aging of the face is most shown by a change in position of the deep anatomical structures, notably the platysma muscle, cheek fat and the orbicularis oculi muscle. these lead up to three landmarks namely, an appearance of the jowl (a broken jaw line by ptosis of the platysma muscle), increased redundancy of the nasolabial fold (caused by a descent of cheek fat) and the increased distance from the ciliary margin to the inferior-most point of the orbicularis oculi muscle (caused by decreasing tone of the orbicularis oculi muscle). the skin is a fourth component in the aging of the face. the ideal age for face-lifting is at age 50 or younger, as measured by patient satisfaction. some areas, such as the nasolabial folds or marionette lines, in some cases can be treated more suitably with botox or liposculpture. contraindications contraindications to facelift surgery include severe concomitant medical problems, both physical and psychological. while not absolute contraindications, the risk of postoperative complications is increased in cigarette smokers and patients with hypertension and diabetes. these strong relative contraindications consist primarily of diseases predisposing to poor wound healing. patients are typically asked to abstain from taking aspirin or other blood thinners for at least one week prior to surgery. patients motivations and expectations are an important factor in order to determine the patient’s medical status. a psychiatric illness leading to unreasonable expectations for the surgical outcome, such as a distorted perception of reality, can be a contraindication to surgery. some kinds of hypersensitivity to anesthesia are a contraindication. surgical anatomy facelift: generally relevant anatomyhead nerveshead arteriesdetailsarteryfacial artery, temporal artery, arteria supratrochlearis, arteria infraorbitalisveintemporal veinnervegreater auricular nerve, facial nerve, mental nerveidentifiersmeshd015361anatomical terminology smas facial musculature facial nerve a dissection in the deep plane can mostly be performed safely, because the facial nerve innervates the facial muscles on the deep surface of these muscles (except for the muscles which are lying deep to the facial nerve, the mentalis, the levator anguli oris and the buccinator). the fibres of the nerve are becoming more superficially medially. therefore, the dissection of a deep plane begins further away of the surface then it ends. this allows the undermining to be carried out towards the nasolabial fold without harming the branches of the facial nerve. retaining ligaments the retaining ligaments in the face provide an anchorage of superficial structures to underlying bone. four retaining ligaments exist. the platysma-cutaneous ligaments and the platysma-auricular ligament are aponeurotic condensations which connect the platysma to the dermis. the osteocutaneous ligaments, the zygomatic ligament and the mandibular ligament, are more important. they attach to the skin and bone, leading to a counteraction of gravitational forces. these ligaments should be released surgically to obtain a fully mobile facelift flap. nasolabial folds melolabial folds (marionette lines) greater auricular nerve injury to the greater auricular nerve is the most seen nerve injury after rhytidectomy. care should be taken in elevation over the sternocleidomastoid muscle, because of the terminal branches of the nerve that pass superficially to innervate the earlobe. vascularisation the composite flap is vascularised by facial, angular and/or inferior orbital arteries. the facial artery supplies the platysma and goes on as the angular artery, which connects with the branches of the arteria supratrochlearis and arteria infraorbitalis. the parts of the face elevated are in continuity in the deep-plane and the composite rhytidectomy include the smas layer in the lower face, subcutaneous tissue and the skin as the arteries to these parts are preserved. with this option you can create a well vascularized tissue flap, which can be used to tighten the skin without loss of vascularization, this will result in fewer complications like skin slough and necrosis. procedures many different procedures are used for rhytidectomy. the differences are mostly the type of incision, the invasiveness and the area of the face that is treated. each surgeon practices multiple different types of facelift surgery. at a consultation the procedure with the best outcome is chosen for every patient. expectations of the patient, the age, possible recovery time and areas to improve are some of the many factors taken in consideration before choosing a technique of rhytidectomy. in the traditional facelift, an incision is made in front of the ear extending up into the hairline. the incision curves around the bottom of the ear and then behind it, usually ending near the hairline on the back of the neck. after the skin incision is made, the skin is separated from the deeper tissues with a scalpel or scissors (also called undermining) over the cheeks and neck. at this point, the deeper tissues (smas, the fascial suspension system of the face) can be tightened with sutures, with or without removing some of the excess deeper tissues. the skin is then redraped, and the amount of excess skin to be removed is determined by the surgeon's judgement and experience. the excess skin is then removed, and the skin incisions are closed with sutures and staples. the technique of a smas facelift, consisting of mobilisation, repositioning and fixating. smas lift 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. resuspension and securing the smas anatomical layer can lead to rejuvenation of the face, by counteracting aging and gravity caused laxity. modifications to this technique led to development of the "composite facelift" and "deep plane facelift." deep-plane facelift 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. 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. mid face-lift 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