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Cervicofacial rhytidectomy, commonly known as facelifting and necklifting, is a cornerstone surgical procedure for the management of facial aging and remains the second most commonly performed facial cosmetic operation after blepharoplasty. Age-related changes, including gravitational descent of soft tissues, ligamentous laxity, skin redundancy, fat atrophy, and progressive bony resorption, produce characteristic findings such as deep nasolabial folds, jowls, marionette lines, and platysmal banding. The facial aging process produces characteristic hollowing of the temporal, perioral, pre-jowl, and malar regions, and rhytidectomy is performed to rejuvenate the face by resuspending ptotic soft tissues to address hallmark signs of aging. This activity provides an overview of the historical evolution of rhytidectomy, reviews clinically relevant anatomy, and examines common and procedure-specific complications. This activity also equips healthcare professionals with the knowledge and tools needed to distinguish among contemporary rhytidectomy approaches and technical considerations, supporting informed procedural selection and individualized patient care. A broad spectrum of facelifting techniques is reviewed, with emphasis on foundational anatomic principles, core surgical concepts, and the prevention, recognition, and management of complications. The activity also highlights the importance of interprofessional collaboration among healthcare providers in optimizing preoperative assessment, intraoperative safety, and postoperative recovery. Effective team-based care is emphasized as a critical factor in improving patient-centered outcomes, minimizing complications, and enhancing overall satisfaction in the surgical management of the aging face. Objectives: Identify key anatomic landmarks and age-related structural changes that influence technique selection in cervicofacial rhytidectomy. Differentiate among SMAS, deep-plane, composite, and minimal access cranial suspension facelift techniques based on anatomic findings and desired surgical outcomes. Select an evidence-informed rhytidectomy approach that aligns with patient goals while minimizing the risk of complications such as hematoma, nerve injury, and skin necrosis.

Differentiate among SMAS, deep-plane, composite, and minimal access cranial suspension facelift techniques based on anatomic findings and desired surgical outcomes. Select an evidence-informed rhytidectomy approach that aligns with patient goals while minimizing the risk of complications such as hematoma, nerve injury, and skin necrosis. Collaborate effectively with the interprofessional healthcare team to optimize perioperative assessment, intraoperative safety, and postoperative care in facial rejuvenation surgery. Access free multiple choice questions on this topic.

Rhytidectomy, commonly referred to as facelifting, is a surgical procedure designed to reposition facial soft tissues to create a more youthful appearance. Although currently widely performed, rhytidectomy was relatively uncommon in the early 20th century because of negative public attitudes toward cosmetic surgery and the secrecy with which surgeons guarded their techniques.[1] The first documented facelift was performed in 1901 by Eugene von Holländer, who excised and reapproximated excess skin with minimal undermining. After World War I, the demand for reconstructive surgeries increased, and so did Western cultural acceptance of plastic surgery as a whole. However, it was not until after World War II, with the advent of antibiotics and the development of general anesthesia, that a more aggressive approach to facelifting became practical. In 1969, Swedish plastic surgeon Tord Skoog was the first to describe a facelift technique in which dissection was performed along the superficial facial fascia, resulting in longer-lasting rejuvenation. This fascia was later defined as the superficial musculoaponeurotic system (SMAS) in an anatomical study by Mitz and Peyronie in 1976, which subsequently led to the development of the surgical technique now known as SMAS rhytidectomy.[2] This approach may involve SMAS plication, imbrication, transposition, advancement, or a combination thereof.

In 1969, Swedish plastic surgeon Tord Skoog was the first to describe a facelift technique in which dissection was performed along the superficial facial fascia, resulting in longer-lasting rejuvenation. This fascia was later defined as the superficial musculoaponeurotic system (SMAS) in an anatomical study by Mitz and Peyronie in 1976, which subsequently led to the development of the surgical technique now known as SMAS rhytidectomy.[2] This approach may involve SMAS plication, imbrication, transposition, advancement, or a combination thereof. Today, numerous facelift techniques are available. Some surgeons favor more complex procedures that involve extensive soft tissue mobilization to comprehensively rejuvenate the face and neck. In contrast, others prefer minimally invasive approaches with shorter incisions and limited dissection. These techniques typically address more localized concerns but offer the advantage of faster recovery.[3] The "tri-plane" rhytidectomy was introduced by Hamra in 1983 to include subcutaneous elevation of cervical skin to improve neck contour. In 1990, he described the “deep-plane” rhytidectomy, which involves dissection of the zygomaticus musculature and repositioning of the malar fat pad to efface the nasolabial fold (NLF) and elevate the midface. In 1991, Hamra further developed the “composite” rhytidectomy, incorporating the orbicularis oculi muscle into the deep-plane dissection to enhance eyelid and cheek contour and allow repositioning of the suborbicularis oculi fat (SOOF), thereby smoothing and rejuvenating the transition zone between the lower eyelid and the cheek.[4] In contrast to Hamra’s progressively more invasive techniques, Tonnard and Verpaele developed the minimal access cranial suspension (MACS) facelift in 2007, which uses a preauricular and temporal incision to provide access for 3 purse-string sutures that suspend the midface, jowls, and lateral platysma.[5] More recently, techniques emphasizing shorter incisions, often referred to as S-lifts, and reduced skin elevation through so-called preservation approaches have gained popularity. These methods shorten recovery time and minimize visible scarring, including scar-related limitations on hairstyling, making them appealing to younger patients seeking surgery to achieve subtle rejuvenation without prolonged time away from work.[6]

As with any surgical procedure, complications may occur after rhytidectomy despite careful preoperative optimization of medical comorbidities and meticulous intraoperative technique. Similar to other aesthetic procedures, the most common adverse outcome of facelifting is dissatisfaction with the cosmetic result. This may stem from scarring, asymmetry, contour irregularities, or an appearance perceived as overcorrected or undercorrected, as well as from inadequate expectation management or underlying psychosocial factors. Establishing a strong preoperative rapport allows the interprofessional team to better support patients through postoperative challenges and may improve satisfaction and reduce the risk of conflict or litigation in the setting of a suboptimal outcome. Hematoma Hematoma is the most common complication following rhytidectomy, with a reported incidence of 0.2% to 8% (see Image. Upper Neck Hematoma).[35] Hematomas can be categorized as either major (expanding) or minor. Major bleeding episodes often occur within 24 hours of surgery with symptoms of subcutaneous mass, pain, and ecchymotic skin discoloration, often developing rapidly after a straining, coughing, or vomiting event; these episodes require surgical intervention to control the hemorrhage. If these episodes occur in the neck, airway compromise may ensue, and the wound should be opened emergently. In contrast, minor bleeding tends to be delayed and may result from oozing of the subdermal plexus. These episodes can often be managed with watchful waiting or bedside aspiration using a fine, sterile suction tip, such as a 10 Fr Frazier, introduced through the postauricular aspect of the incision after removing one of the cutaneous suspension sutures. Regardless of the acuity of the hematoma, it should be addressed promptly and assessed regularly for recurrence for several days after its initial appearance. If left untreated, hematomas may predispose the patient to wound infection, cause necrosis of the overlying skin, or even result in skin expansion with subsequent cutaneous ripples that persist after healing is complete, and which can be extremely challenging to fix.

In contrast, minor bleeding tends to be delayed and may result from oozing of the subdermal plexus. These episodes can often be managed with watchful waiting or bedside aspiration using a fine, sterile suction tip, such as a 10 Fr Frazier, introduced through the postauricular aspect of the incision after removing one of the cutaneous suspension sutures. Regardless of the acuity of the hematoma, it should be addressed promptly and assessed regularly for recurrence for several days after its initial appearance. If left untreated, hematomas may predispose the patient to wound infection, cause necrosis of the overlying skin, or even result in skin expansion with subsequent cutaneous ripples that persist after healing is complete, and which can be extremely challenging to fix. Several factors, including hypertension, male gender, coagulopathy or use of anticoagulants, postanesthesia nausea, vomiting, and pain, increase the risk of hematoma. Male skin is more vascular than female skin due to its greater density of hair follicles, which increases the risk of bleeding. The use of anticoagulants, antiplatelet medications such as aspirin and nonsteroidal anti-inflammatory drugs, and herbal supplements that are known to increase bleeding, such as Ginkgo biloba, turmeric, St John's wort, ginseng, high-dose vitamins (C and E), fish oils, garlic, and glucosamine, should also be discontinued 2 weeks before surgery.[36] Hypertension remains the most significant risk factor for postoperative hematoma formation, and maintaining a systolic blood pressure below 120 mm Hg has been shown to be effective in preventing them.[23] Baker et al demonstrated a reduction in the overall incidence of postoperative hematoma in male patients undergoing rhytidectomy from 8.7% to 3.97% with strict blood pressure control, and Bassiri-Tehrani et al showed a drop in hematoma rate of all facelift patients from 3.8% to 0.5%.[37][25] Preoperatively, sympatholytic medications, such as valium or clonidine, may be administered to this end. Intraoperatively, meticulous hemostasis should be achieved before closure. Postoperatively, factors that can increase agitation in recovering patients, such as nausea and pain, should also be addressed promptly. The effect of drain placement on hematoma incidence remains unclear; however, drains may help reduce the risk of seroma formation. Skin Necrosis

Hypertension remains the most significant risk factor for postoperative hematoma formation, and maintaining a systolic blood pressure below 120 mm Hg has been shown to be effective in preventing them.[23] Baker et al demonstrated a reduction in the overall incidence of postoperative hematoma in male patients undergoing rhytidectomy from 8.7% to 3.97% with strict blood pressure control, and Bassiri-Tehrani et al showed a drop in hematoma rate of all facelift patients from 3.8% to 0.5%.[37][25] Preoperatively, sympatholytic medications, such as valium or clonidine, may be administered to this end. Intraoperatively, meticulous hemostasis should be achieved before closure. Postoperatively, factors that can increase agitation in recovering patients, such as nausea and pain, should also be addressed promptly. The effect of drain placement on hematoma incidence remains unclear; however, drains may help reduce the risk of seroma formation. Skin Necrosis Skin necrosis occurs as a result of microvascular compromise from seroma or hematoma formation, or excessively thin skin flap elevation, and comorbid conditions such as smoking and diabetes. Laser skin resurfacing performed on the lateral cheek under the same anesthetic as the rhytidectomy will also increase the risk of skin necrosis. Necrosis can involve only partial-thickness of the skin or the full-thickness of the dermis with eschar formation (see Image. Full-thickness Skin Flap Necrosis). In partial-thickness necrosis, patients present with skin discoloration and desquamation. This usually resolves with conservative wound care and heals well without scarring. Nitropaste or dimethylsulfoxide may be considered to improve perfusion. Full-thickness necrosis will lead to prolonged healing time with skin abnormalities such as dyspigmentation, contour irregularities, and scarring, and may require further intervention. Wounds should be allowed to heal completely, and early debridement should be minimized to avoid further damage.

Skin necrosis occurs as a result of microvascular compromise from seroma or hematoma formation, or excessively thin skin flap elevation, and comorbid conditions such as smoking and diabetes. Laser skin resurfacing performed on the lateral cheek under the same anesthetic as the rhytidectomy will also increase the risk of skin necrosis. Necrosis can involve only partial-thickness of the skin or the full-thickness of the dermis with eschar formation (see Image. Full-thickness Skin Flap Necrosis). In partial-thickness necrosis, patients present with skin discoloration and desquamation. This usually resolves with conservative wound care and heals well without scarring. Nitropaste or dimethylsulfoxide may be considered to improve perfusion. Full-thickness necrosis will lead to prolonged healing time with skin abnormalities such as dyspigmentation, contour irregularities, and scarring, and may require further intervention. Wounds should be allowed to heal completely, and early debridement should be minimized to avoid further damage. The most significant risk factor for skin necrosis among rhytidectomy patients is smoking. Cigarette smoke contains nicotine, carbon monoxide, hydrogen cyanide, and nitric oxide, all of which have detrimental effects on microvascular oxygen transport and impair wound healing. In 1984, Rees et al reported a skin sloughing rate of 7.5% in smokers compared with 2.7% in nonsmokers who underwent rhytidectomy. A smoking cessation for 2 to 4 weeks before and after surgery is strongly recommended to avoid skin necrosis.[38][39] Another way to potentially minimize skin necrosis in smokers is the use of deep-plane facelift surgery. Because deep-plane surgery preserves the skin, subcutaneous tissue, and SMAS as a composite flap, it maintains better blood supply, thereby reducing the rate of skin necrosis.[40] Medications that can alter wound healing, such as chemotherapy and steroids, are also essential to consider prior to rhytidectomy. Patients taking these medications should delay rhytidectomy until some time after completing their course or consider canceling the procedure.

The most significant risk factor for skin necrosis among rhytidectomy patients is smoking. Cigarette smoke contains nicotine, carbon monoxide, hydrogen cyanide, and nitric oxide, all of which have detrimental effects on microvascular oxygen transport and impair wound healing. In 1984, Rees et al reported a skin sloughing rate of 7.5% in smokers compared with 2.7% in nonsmokers who underwent rhytidectomy. A smoking cessation for 2 to 4 weeks before and after surgery is strongly recommended to avoid skin necrosis.[38][39] Another way to potentially minimize skin necrosis in smokers is the use of deep-plane facelift surgery. Because deep-plane surgery preserves the skin, subcutaneous tissue, and SMAS as a composite flap, it maintains better blood supply, thereby reducing the rate of skin necrosis.[40] Medications that can alter wound healing, such as chemotherapy and steroids, are also essential to consider prior to rhytidectomy. Patients taking these medications should delay rhytidectomy until some time after completing their course or consider canceling the procedure. Lastly, skin closure should be performed without tension to minimize the risk of ischemia at the wound edges. The distal portions of the flap, particularly in the preauricular and superior postauricular regions, are most susceptible to ischemic injury and, therefore, at greatest risk for developing skin necrosis. Notably, patients undergoing revision rhytidectomy may have a lower risk of skin necrosis, as prior surgery effectively delays skin flaps and enhances perfusion through dilation of choke vessels. Nerve Injury With a reported incidence of approximately 0.7% to 2.5%, nerve injury can be avoided through a detailed understanding of facial anatomy and meticulous surgical technique.[37] Awareness of the key surgical landmarks described above is essential while performing facial dissection. Although intraoperative nerve monitoring can aid injury prevention, facial nerves are more commonly damaged by aggressive retraction or electrocautery, particularly when controlling bleeding from nearby vessels, such as the facial vein or external jugular vein, adjacent to the marginal mandibular nerve or GAN, respectively.

With a reported incidence of approximately 0.7% to 2.5%, nerve injury can be avoided through a detailed understanding of facial anatomy and meticulous surgical technique.[37] Awareness of the key surgical landmarks described above is essential while performing facial dissection. Although intraoperative nerve monitoring can aid injury prevention, facial nerves are more commonly damaged by aggressive retraction or electrocautery, particularly when controlling bleeding from nearby vessels, such as the facial vein or external jugular vein, adjacent to the marginal mandibular nerve or GAN, respectively. If a nerve is transected and the injury is recognized during surgery, immediate microsurgical epineurial repair is recommended. Motor nerve injuries may take a year to recover or may never fully recover; however, they can often be managed in the meantime with botulinum toxin injections into the contralateral facial muscle groups to improve symmetry, particularly in cases of frontal or marginal mandibular branch injury. The GAN is the most commonly injured nerve during rhytidectomy, particularly during posterior skin flap elevation. This can cause anesthesia to the inferior pinna and mastoid skin, with patients reporting difficulty placing earrings, using telephones, or combing their hair.[14] The most common motor nerve injuries involve the frontal and marginal mandibular branches of the facial nerve, resulting in brow paralysis with or without ptosis and a crooked lower lip during smiling, respectively.[13] Careful elevation of the subcutaneous flap over the zygomatic arch and the sub-platysmal flap around the angle of the mandible will help avoid injury to these nerves. If bleeding occurs in these areas, pressure and a clotting agent, such as thrombin or cellulose, should be applied rather than electrocautery. Surgical Site Infection Fortunately, cellulitis or abscess formation is a rare complication due to the robust blood supply of the face. Wound infections are most commonly caused by gram-positive cocci, such as Staphylococcus and Streptococcus, and generally resolve with antibiotics targeting skin flora. Scarring and Skin Irregularities

Surgical Site Infection Fortunately, cellulitis or abscess formation is a rare complication due to the robust blood supply of the face. Wound infections are most commonly caused by gram-positive cocci, such as Staphylococcus and Streptococcus, and generally resolve with antibiotics targeting skin flora. Scarring and Skin Irregularities Although facelift incisions are typically long, careful incision placement usually minimizes their visibility postoperatively. When scar widening occurs, it most often affects the postauricular region, where it is generally well concealed. More conspicuous preauricular scars that are widened, erythematous, or hyperpigmented may be treated with laser resurfacing, intralesional steroid injections, or topical agents such as hydroquinone. Strict avoidance of sun exposure during the first 12 months after surgery also helps reduce the risk of prominent scarring. Hypertrophic or keloid scars may benefit from silicone sheeting or, if persistent, surgical revision after 6 to 12 months. Subdermal contour irregularities represent a related concern and most commonly result from SMAS plication or imbrication, particularly when the overlying skin flap is thin. These irregularities often improve with massage and steroid injection; however, fat or filler injection may be required to correct deeper concavities. Additionally, several characteristic deformities may result from improper soft-tissue manipulation during facelifting. A "pixie ear" deformity occurs when excessive tension is applied across the skin closure inferior to the auricular lobule, causing the lobule to stretch inferiorly and appear elongated and attached (see Image. Pixie Ear Deformity). Treatment often requires V-to-Y advancement of the lobule combined with re-elevation of the neck flap to relieve tension on the closure. A "cobra neck" deformity occurs when too much adipose tissue is removed from the central submental region, between the anterior bellies of the digastric muscles, without removing a commensurate volume from the lateral submentum and upper neck. This hollowed, cobra hood–like appearance beneath the chin provides its name (see Image. Cobra Neck Deformity). This deformity is typically improved with autologous fat grafting or injections.

Additionally, several characteristic deformities may result from improper soft-tissue manipulation during facelifting. A "pixie ear" deformity occurs when excessive tension is applied across the skin closure inferior to the auricular lobule, causing the lobule to stretch inferiorly and appear elongated and attached (see Image. Pixie Ear Deformity). Treatment often requires V-to-Y advancement of the lobule combined with re-elevation of the neck flap to relieve tension on the closure. A "cobra neck" deformity occurs when too much adipose tissue is removed from the central submental region, between the anterior bellies of the digastric muscles, without removing a commensurate volume from the lateral submentum and upper neck. This hollowed, cobra hood–like appearance beneath the chin provides its name (see Image. Cobra Neck Deformity). This deformity is typically improved with autologous fat grafting or injections. The "wind-swept" deformity, most commonly seen after deep-plane facelifting, arises from excessive lateralization of the malar fat pads or overly aggressive tension on the cheek flaps, leading to widening the distance between the oral commissures. Correction is challenging, but it may be improved with a revision facelift performed several months later, providing enough time for tissue relaxation to permit redraping of the facial flaps without tension. A related aesthetic stigma is the "lateral sweep" or "swoosh" sign, characterized by curvilinear rhytids in the lower face that resemble the Nike swoosh symbol, running from the prejowl region toward the auricle. This appearance results from insufficient elevation of the midface with excessive lateral suspension of the lower face. As with the wind-swept deformity, this is best addressed with time and operative revision. Alopecia and Malposition of the Hairline

The "wind-swept" deformity, most commonly seen after deep-plane facelifting, arises from excessive lateralization of the malar fat pads or overly aggressive tension on the cheek flaps, leading to widening the distance between the oral commissures. Correction is challenging, but it may be improved with a revision facelift performed several months later, providing enough time for tissue relaxation to permit redraping of the facial flaps without tension. A related aesthetic stigma is the "lateral sweep" or "swoosh" sign, characterized by curvilinear rhytids in the lower face that resemble the Nike swoosh symbol, running from the prejowl region toward the auricle. This appearance results from insufficient elevation of the midface with excessive lateral suspension of the lower face. As with the wind-swept deformity, this is best addressed with time and operative revision. Alopecia and Malposition of the Hairline This condition is caused by injury to hair follicles during incision, aggressive use of electrocautery, or closure under excessive tension. Beveling the scalpel blade during incision, either parallel or perpendicular to the hair follicles, may minimize the appearance of the scar. Surgeons should also inform patients of the possibility of postsurgical telogen effluvium—a stress-related diffuse hair loss that occurs approximately 3 months after surgery. This condition can be observed or treated with minoxidil, but should resolve spontaneously within 6 months. If alopecia occurs, allow 6 to 12 months for healing before considering hair transplantation to rule out telogen effluvium as the etiology. When planning incisions, it is important not to disrupt the natural hairline, which can occur if attention is not paid to avoiding a step-off of the hairline when redraping postauricular skin before closure. A pretragal incision should be used in male patients to avoid posteriorly displacing the sideburns too close to the auricle or even onto the tragus. First Bite Syndrome

When planning incisions, it is important not to disrupt the natural hairline, which can occur if attention is not paid to avoiding a step-off of the hairline when redraping postauricular skin before closure. A pretragal incision should be used in male patients to avoid posteriorly displacing the sideburns too close to the auricle or even onto the tragus. First Bite Syndrome This complication has been reported after deep-plane rhytidectomy and is thought to result from injury to postganglionic parasympathetic fibers supplying the parotid gland, similar to mechanisms described following deep lobe parotidectomy or parapharyngeal space surgery.[32] Aberrant reinnervation results in a painful hypercontraction of myoepithelial cells within the parotid gland at the beginning of meals, with pain that typically diminishes after the first few bites. Although distressing for patients, symptoms can often be managed with botulinum toxin injections and typically resolve spontaneously within 6 to 12 months. Patient Dissatisfaction Patient dissatisfaction is among the most common complications following rhytidectomy. Up to 30% of patients may experience postoperative depression, ranging in severity from transient mood changes requiring reassurance to symptoms necessitating antidepressants.[41] Careful assessment of psychiatric history during the preoperative evaluation is therefore essential, as underlying mood disorders may increase the risk of postoperative depression and negatively influence perceived surgical outcomes. In some cases, dissatisfaction may occur despite technically successful surgery. Minor revision or “tuck-up” procedures are commonly required within 1 to 2 years to address isolated areas of persistent or recurrent soft-tissue ptosis. In general, well-performed facelifts provide favorable results, with many patients not requiring repeat rhytidectomy for 5 to 10 years.

Rhytidectomy is a primary surgical option for addressing facial aging and, as an elective aesthetic procedure, benefits from a coordinated, healthcare team-based approach to achieve optimal results. In the preoperative phase, establishing a strong rapport with the patient is essential, as it facilitates communication, supports adherence to recommendations, and helps manage concerns should complications arise. Clear discussion of the patient’s aesthetic goals and realistic expectations also helps in optimizing postoperative satisfaction. Effective coordination with primary care providers and relevant specialists is necessary to identify and optimize medical comorbidities before surgery, particularly cardiopulmonary conditions, as proceeding with elective surgery without appropriate risk mitigation increases the likelihood of adverse outcomes. Smoking status requires specific attention, as nicotine use is strongly associated with impaired wound healing and increased risk of skin necrosis. Smoking cessation for 2 to 4 weeks before and after surgery has been shown to significantly reduce the risk of skin necrosis.[39]