History of the development of the rhytidectomy (facelift) method

Most cosmetic surgeries evolved from procedures designed to achieve functional improvement. As a result, their descriptions, discussions, and publications on the subject have a long history. In contrast, surgery of the aging face—and rhytidectomy in particular—have their origins in procedures designed to improve patients’ self-image. Cosmetic surgery was initially viewed negatively by the medical community. Many physicians and surgeons did not believe in enhancing a patient’s self-esteem through elective cosmetic surgery and condemned the practice. Others, while recognizing the worthy goal of self-improvement, believed that elective surgery, with its inherent dangers, was not an appropriate method for achieving this goal.

The founders of facelift surgery are German and French surgeons. Lexer is credited with performing a wrinkle correction operation in 1906, but the first clinical case of such a procedure was reported by Hollander in 1912. Other European doctors, including Joseph (1921) and Passot (1919), developed their own techniques for correcting facial changes due to aging. The names of these founding fathers are still mentioned whenever their wisdom is invoked. After World War I, the practice of reconstructive plastic surgeons flourished. With the explosion of new ideas and techniques came an inevitable increase in interest in cosmetic surgery. Despite the veil of secrecy surrounding it, even the most prominent doctors of the time acknowledged its existence. Many of these recognized leaders were said to perform cosmetic surgery in their own private clinics or offices. Gilles noted in 1935 that "operations to remove wrinkles on the eyelids, folds on the cheeks and fat on the neck are justified if the patients are selected fairly."

After World War II, with the introduction of new drugs and improved pain relief, elective surgery became more feasible. In addition, the wealthy segment of society began to associate appearance with an energetic attitude toward life. However, the mystique of cosmetic surgery, surrounded by shamefaced secrecy, suspicion, and greed, did not take into account the development of ideas and progress that were being welcomed in other areas of surgery at the time. Therefore, the results achieved by facial rejuvenation surgery were limited and short-lived. Sam Fomon, a pioneer of facial cosmetic surgery and a founding father of the forerunner of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), taught cosmetic surgery to all interested parties. He acknowledged the limitations of facial skin tightening, saying, "The average duration of beneficial effect, even with the highest technical skill, cannot exceed three or four years." At that time, surgical facelift techniques consisted of limited subcutaneous dissection and skin elevation, which resulted in tension in the parotid areas and often the formation of a clear "operated face." Unfortunately, these methods did not change significantly until the 1970s. The social renaissance of the 1960s and 1970s led to an openness and acceptance of cosmetic surgery that was previously impossible. This stimulated scientific research and exchange of opinions, leading to improvements in surgical techniques and results.

The first major contribution in the first half of the last century was made by Skoog, who demonstrated the advantage of subfascial preparation. This allowed significant success in interventions in the lower third of the face. The validity of this preparation was confirmed in 1976 by a landmark article by Mitz and Peyronnie, who named this fascia the superficial musculoaponeurotic system (SMAS). Since then, many technical modifications of sub-SMAS rhytidectomy have been developed to achieve a more natural appearance. In the past, sub-SMAS preparation was performed to improve the cheek line. However, modern surgeons, given the importance of facial harmony, have focused their efforts on achieving improvements in the midface and nasolabial folds. Hamra, a pioneer of deep and mixed rhytidectomy, continues to demonstrate the good results that can be achieved in the midface. Others agree that improved results are possible with deep plane rhytidectomy. There are still surgeons who offer various methods of achieving facial harmony, including risky interventions in the subperiosteal space. And there are even those who revive subcutaneous dissection, considering it to be the method of choice in certain situations.

The variety of anatomically based rhytidectomy techniques provides the surgeon with a variety of options to combat the effects of aging. However, with recent advances in surgical technique, there is an increasing recognition of the importance of the individual patient. Each surgical technique has its own purpose. The key for the intelligent surgeon is to adequately assess each patient, both physically and emotionally, and to apply the right approach to an accurate diagnosis.

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