Frequently, patients at my Dallas practice ask whether a facelift, neck lift, blepharoplasty (eyelid lift), or other cosmetic facial procedures can be performed during reanimation surgery. The simple answer is yes. In fact, in order to optimize results from facial paralysis correction, it is not only necessary to perform microsurgical nerve surgery, complex eyelid surgery, and neck surgery at a high level, it is also critical to provide aesthetic results in all areas of the face.
Philosophy
Over the years, I have become significantly more open to performing facial cosmetic surgery at the same time as facial reanimation since it simply makes sense on many accounts. First, and perhaps most importantly, it can help achieve the primary goal for my patients: to return to as close as possible to normal and feel good about themselves. Improving facial aesthetics achieves that in my facial cosmetic patients who do not have facial paralysis, so why not offer this option for my facial paralysis patients?
Second, the anatomical planes, in other words, the depth in which the facial layers are opened and moved are the same as those in which I perform a high SMAS (superficial musculoaponeurotic system) or deep plane face and neck lift. In order to perform most facial palsy surgeries as well as a high SMAS or deep plane facelift, it is necessary to elevate the SMAS layer and platysma muscle and release the different retaining ligaments of the face.
Releasing these ligaments, which include the orbicularis retaining ligament, zygomatic ligament, pre auricular parotid cutaneous ligament, auriculoplatysmal ligament, masseteric cutaneous ligament, platysma mandibular ligament, mandibular osseocutaneous ligament, is necessary for achieving great results in face and neck lifts and is consistently performed in the side with facial paralysis or synkinesis during reanimation surgery. Therefore, adding the aesthetic component on the paralyzed and non-paralyzed side during surgery makes sense and optimizes results.
Safety
From a safety point of view, perhaps one of the most feared and sometimes less emphasized complications of facelifts and neck lifts, is injury to the facial nerve. This can occur both during the facelift part of the procedure and the neck lift portion of the procedure.
Having performed close to a thousand facial palsy-related surgeries provides great familiarity with the facial nerve and its branches, as well as the structures around the eye and deep structures of the neck. This familiarity is necessary for advanced facial palsy surgery, where we often repair facial nerve branches, reinnervate facial muscles, or map the facial nerve in cases of synkinesis, and always helps in more routine high SMAS, deep plane, or composite facelifts, although the first is the preferred method by me in most patients.
It’s also important to consider that performing a facelift several years after reanimation surgery is a higher-risk surgery and should be performed by surgeons who routinely deal with the facial nerve and have a good grasp of what surgery was performed previously.
Surgical Approach
When combining both reconstructive and cosmetic facial procedures, I will always start working on the paralyzed or synkinetic face and neck. Once the dissection (releasing the tissue) is completed on the paralyzed side and the relevant reconstructive work is performed, the uninjured side is lifted and then both sides are repositioned and brought into the optimal position, after which some excess skin is removed and closed. The brow lift is performed at the same time as the facelift in those patients who may need it, and the eyelid surgery is performed during the final stages.
What are the aesthetic concerns and how are they treated?
When we age, several things change in our faces, and often these are more pronounced on the paralyzed side (with the exception of the synkinetic face, in which findings may somewhat differ from the weak, paralyzed face).
Following are key changes which occur and how they can be addressed:
Volume Depletion and Descent:
When we are young, our faces seem to have more volume, especially in the cheek area. The eyelid and cheek areas seem to be confluent and harmonious as one, with a smooth transition between them. As we age, the cheek tends to descend, the lower eyelid fat may herniate (bags under the eye), and jowls in the jawline form.
The combination of these events may create a groove under the eyelid which disrupts the smooth transition between cheek and eyelid that characterizes the youthful face; the jawline is disrupted, and the neck seems saggier.
During reanimation surgery, we are frequently in the same tissue planes that need to be moved and corrected in aesthetic surgery and eyelid correction. Lifting the midface (cheek), and improving the jawline definition can readily be performed at the same time. Additional volume is frequently achieved by facial fat grafting at the same time.
Eyelid Fat Herniation and Skin Excess in Both Lower and Upper Eyelids:
As we age, the muscle around the eye (orbicularis oculi muscle) tends to weaken and stretch. This can result in bags under the eye, lower eyelid malposition (more of the white of the eye is seen), and excess skin in both the lower and upper eyelids. Very frequently eyelid surgery is needed in facial paralysis patients, especially for correcting the position of the lower eyelid. Improving the aesthetics of the eyelids by performing eyelid lifts (blepharoplasties) and addressing the fat herniation at the same time is optimal and improves the overall results.
Loss of Neck Shape and Jawline Definition:
As we age, the jawline tends to be less defined in the front, middle, and back. This occurs for several reasons. As previously mentioned, the descent of the cheeks contributes to the formation of jowls. Additionally, with age more fat is deposited under the platysma muscle in the neck, the submandibular gland tends to drop and sometimes enlarge due to increased fatty deposits, and muscles such as the anterior digastric muscles and the platysma tend to enlarge and drop. During surgery for paralysis, the face and neck are frequently explored and correction of these problems at the same time is optimal.
What To Expect After Surgery
Some swelling and bruising are expected regardless of whether surgery is performed solely for facial paralysis or whether cosmetic procedures are added. In other words, adding cosmetic surgery does not significantly add to recovery time or discomfort. No large dressing are used, and if eye surgery is performed a cool gel eye mask is provided to decrease swelling. Using cold ice packs or hot compresses should be avoided.
In the days following surgery, patients may lie down on their backs. If neck surgery is performed, drains are routinely used for the neck, and these are removed during the first visit. Sutures are removed between 5 and 9 days after surgery.
If you are ready to take the next step in discussing facelift, neck lift, blepharoplasty, or other cosmetic procedures, please request a consultation or call us at (214) 645-2353 to get started.
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