An analysis of unsolved problems of face-lift procedures.

The face-lift/rhytidectomy, considered a premier surgical procedure in the specialty, is designed to reverse the effects of aging on the face. Yet our understanding of aging is incomplete, for example, only recently has it been recognized that there are different fat compartments in the face: how aging affects these different compartments is not known. Some surgeons consider the baggy lower eyelid to be due to excess fat and remove the fat. Others consider the problem to be due to a weak orbital septum and recommend septal tightening, while recent work suggests that facial bone retrusion is responsible.Furthermore, many different face-lift techniques exist, with each surgeon showing good postoperative photographs. However, the face is a complex 3-dimensional structure with different contours even within an anatomic subunit, and assessment of results by a 2-dimensional photograph must be crude and inaccurate.Also, these articles discuss the surgical maneuvers necessary to achieve the purported result, but do not discuss the mechanics of the procedure. Is there a rationale for considering the SMASectomy better than submuscular aponeurotic system (SMAS) plication, for example? Basic principles of surgical wound healing will be extrapolated in an endeavor to find an answer.This article aims to highlight the divergent opinions, challenge the present thinking of the facelift procedure, and reevaluate the goals and mechanism for achieving this. Ten facets of the procedure will be examined. New methods of assessment of results are required, as photography is inadequate.