Another look at facial aesthetics

The new facelifts.
Pr ean-Paul Meningaud,MD.
Under pressure from aesthetic medicine, facelifts have become less and less invasive and, above all, more effective.
When I was a student, facelifts consisted solely of peeling and pulling the skin. The scars were considerable. Patients had long and difficult after-effects. Their faces looked drawn. It was difficult to hide the fact that they'd had a facelift. The real effect of a facelift was barely three years.
Under pressure from aesthetic medicine, facelifts have become less and less invasive and, above all, more effective.
We had to show that much more could be achieved in terms of rejuvenation with short suites compatible with an active working life.
Facelift has become more democratic and is therefore mainly aimed at people who work. Patients must be able to recover in two weeks at most.
Modern facelifts aim to minimize scars and in all cases make them unnoticeable.
In the case of residual scars, there is still the option of masking them with medical dermopigmentation.
Facelifts now take into account the aging of the skin itself.
It's no longer just a question of tightening withered skin, but of restoring its youthfulness. Three-dimensional work. We don't want these drawn, flat, featureless faces anymore. We have to work with volumes, erasing some and recreating others. A great deal of work is now done on the muscles themselves, and not just on the skin. It is no longer the skin that bears the strain of the facelift, but the muscular plane. In addition, a better understanding of facial aging has made it possible to consider tightening certain muscle fibers, while relaxing others, sometimes within the same muscle, such as the peaucier muscle of the neck.
Facelifts have become conservative, i.e. tissue-friendly, removing less skin or fat.
In extreme cases, no skin is removed, and the reconstitution of lost volumes is sufficient. At last, neck plastic surgery has become permanently effective, with predictable results.
It took a lot of trial and error to achieve this result.
A graceful neck can now be restored by guaranteeing a 90° to 110° angle between the neck and the face without removing any skin. More on this later.
The mid-facial zone is now taken into account. Maxillofacial surgery has also made it possible to accentuate the rejuvenation of certain areas through actions on the bones of the face, either through bone cuts known as osteotomies, or through small associated prostheses, to enhance the cheekbones or erase nasolabial folds that are resistant to injection techniques.
Several advances have made this possible.
In the past, scars were simply hidden in the hair and in a crease in front of the ear.. But as the facelift was essentially based on skin traction, the scars eventually widened and became visible, prohibiting certain hairstyles. Often, they gave the appearance of earlobes pulled downwards, altering the anatomy of the face and marking the facelift for good.
Today, it is considered that facelifts should no longer be based on skin tension. After some muscles have been re-tensioned (and others relaxed), the skin should be applied without tension. In addition, a significant part of the scar may be hidden inside the ear in the external auditory canal..
A new suturing technique called trichophytic suturing makes scalp scars invisible, allowing hair to grow back through them. [1].
We owe this progress to a South Korean hair surgeon whom I had the opportunity to visit in 2015 at his institute in Seoul, the DDae Young Kim.
Finally, a recent innovation from Brazil reduces the risk of haematomas to virtually zero, eliminating the need for drains and considerably reducing the after-effects. [2].
Skin aging is taken into account. In 1996, when I was assisting DOscar Ramirez in Baltimore, USAHe was already performing simultaneous laser skin treatment.
At the same time, a number of French surgeons, notably the DVladimir Mitz [3], whose students I was, used to perform dermabrasions at the end of their facelifts. Dermabrasion is a kind of mechanical peeling.
In both cases, it was not a question of "surgical" treatment of the skin, but rather of associated medical treatment. The after-effects were fairly long and sometimes difficult, with phlyctenes (blisters), stubborn erythema (redness) and possible recurrence of herpes.
Modern treatment of burn sequelae has revolutionized surgical treatment of damaged skin.
Back in 1996, the DFuente del Campowhom I had visited at the time at theAngeles de Pedregal Hospital in Mexico CityIn the early days of the company, we used injections of purified fat to improve the quality of burned skin.
It improved what is known as the trophicity of burn sequelae, i.e. skin suppleness, elasticity, color and texture. But results were unpredictable. Sometimes the results were extraordinary, sometimes disappointing, and we couldn't understand why.
These results have been considerably improved thanks to the work of numerous surgeons, in particular DSidney Coleman [4, 5].
Aging is accompanied by a loss of volume, particularly in the cheekbones, creating what is poetically known as "the valley of tears". With age, deep wrinkles appear in the nasolabial folds. A little lower down, fat accumulates in the lower cheeks. Finally, under the chin, fat accumulates over the years.
For each patient, therefore, a specific strategy must be defined, aimed at reconstituting certain volumes and erasing others. The surgeon has several weapons in his therapeutic arsenal.
  • In particular, he can displace fat with a centro-facial lift. This involves lifting the entire area between the eyelids and the upper lip, with strong attachments to the lower orbital rim.
  • Surgery can also treat fat directly by removal or addition. With a good knowledge of anatomy, the submental region or areas once considered delicate, such as the jowls, can be suctioned. In this region, the facial nerve is in close proximity, but good knowledge of the planes and correct orientation of the suction cannula make the procedure safe.
  • The fat injection techniques explained above for improving skin trophicity (quality) can also be used to recreate volume in defined areas.
  • Finally, the surgeon can act surgically or chemically on the resting tone of muscles, which tends to increase with age and segment fat. This segmentation creates wrinkles, furrows and dark circles, as well as fat deposits on both sides.
  • As we age, we lose muscle strength. This is called sarcopenia. Paradoxically, resting muscle tone increasesAs we age, we contract.
    • At an early stage, botulinum toxin injections can be used to correct the problem.
    • A more effective and definitive correction can be achieved by sectioning or lengthening certain muscle fibers.
Three areas are mainly concerned:
. The anterior edge of the peaucier muscle of the neck ;
. The glabella where the frown lines are located (area between the eyebrows) ;
. And the area under the corner of the lips where the bitterness folds appear.
. Other muscles, on the other hand, tend to relax.
There are several techniques for doing this, some of which are minimally invasive by endoscopy. An adapted instrumentation has been created.
Dissection of the muscular plane, known as the SMAS (Superficial Musculoaponeurotic System), reduces the extent of skin dissection, and is therefore both more effective and less traumatic.
The DVladimir Mitz was the first to describe the SMAS (superficial musculoaponeurotic system), which revolutionized facelift management.The Superficial Musculo Aponeurotic System (Smas). In The Parotid And Cheek Area. Mitz, Vladimir, Peyronie, Martine Plastic and Reconstructive Surgery: July 1976 - Volume 58:80-88.
Another breakthrough has recently appeared in the field of facial rejuvenation. This involves taking into account the aging of the salivary glands.
We have four main glands: the two parotid glands and the two submandibular glands. With age, they tend to hypertrophy and shrink. Of course, this varies from one person to another, but it's always favoured by iterative weight gain/weight loss.
Hypertrophy of the parotid glands tends to result in a "pear-shaped" face.
Previously, treatment was complex, requiring surgery that risked damaging the facial nerve.
A much simpler and highly effective alternative treatment involves folding the fascia covering the gland.
In the case of the submandibular glands, it is essential to diagnose hypertrophy and ptosis prior to facelift surgery.
Otherwise, once the neck has been degreased and muscle tension restored, the glands may paradoxically appear much more prominent. If they are enlarged, they should be partially removed. This is now a well-codified and safe technique. If they are simply ptosed, they can be docked upwards.


1. Kim CK, Kim DY, Kim JY. Asymmetric dermal-subdermal suture in trichophytic closure for wide hair transplantation donor wound. Dermatol Surg. 2013 ; 39(7) : 1124-7. Dermal%E2%80%93Subdermal-Suture-in-Trichophytic-Kim- Kim/db626a9f484959a7f743827ef5bf6c377ea88ba2
2. Auersvald A, Auersvald LA. Hemostatic net in rhytidoplasty: an efficient and safe method for preventing hematoma in 405 consecutive patients. Aesthetic Plast Surg. 2014; 38(1): 1-9. NwyDGFnsbvyPRg6zRgCKpGc/?lang=en#
3. The Dr Vladimir Mitz was the first to describe the SMAS (superficial musculoaponeurotic system), which revolutionized facelift management. The Superficial Musculo Aponeurotic System (Smas) In The Parotid And Cheek Area. Mitz V., Peyronie M. Plastic and Reconstructive Surgery: July 1976 - Volume 58: 80-88. topics/medicine-and-dentistry/rhytidectomy
4. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast. Surg. 1995 ; 19(5) : 421-5. 310&lpg=PA310&dq=Coleman+SR.+Long-term+survival+ of+fat+transplants:+controlled+demonstrations.+Aesthet ic+Plast+Surg.+1995;19(5):421-425.&source=bl&ots=8ovZ 3M8ay4&sig=ACfU3U1NrHWDMY4PMxtlrACsIwJ46LlaEA& hl=fr&sa=X&ved=2ahUKEwjeu5q6oOj9AhUKbKQEHVosB-gQ6AF6BAgMEAM#v=onepage&q=Coleman%20SR.%20 Long-term%20survival%20of%20fat%20transplants%3A%20 controlled%20demonstrations.%20Aesthetic%20Plast%20 Surg.%201995%3B19(5)%3A421-425.&f=false
5. Coleman SR. Structural fat grafting. Aesthet Surg. J. 1998 ; 18(5) : 386-8. article/18/5/386/191752?login=false uploads/2014/11/Lift_and_Fill_Face_Lift___Integrating_the_ Fat.5-1.pdf
6. Hersant B., Bouhassira J., SidAhmed-Mezi M., Vidal L., Keophiphath M., Chheangsun B., Niddam J., Bosc R., Le Nezet A., Meningaud J.-P., Rodriguez A.-M.. Should platelet-rich plasma be activated in fat grafts? An animal study. J. Plast. Reconstr. Aesthet. Surg. 2018 ; 71(5) : 681-90.