Facelift & Blepharoplasty by Dr. Juris Bunkis

Dr. Bunkis takes us through the process of a Facelift & Blepharoplasty procedure.


Speaker 1: Okay, Jo's going to have a facelift this morning as well as have some extra skin taken off from her upper lids and her lower lids tightened. And this basically occurs in the neck because there is a very thin layer of muscle that comes down here that sags and you'll see us today, lift the skin up and suture that muscle back up to where it used to be and give her nice apple cheeks.

First incision in underneath the chin and this give us access to the neck and allows us to sew the muscles together and to remove some fat. And the second incision goes around the ear. I make my incision behind the sideburn so that it doesn't displace the sideburn upwards. When we get down to the tragus, we go behind the tragus in the little fold between the ear and the chin. Then we go on the ear itself, not in the fold behind it to a point where the ear crosses the hairline. This is where I am going to go into the hair and I'll make a little curve above that so that when you look at her, you don't see the incision. That's how it's going to look.

Okay, we are going to start by injecting some local anesthesia and we inject it where we are going to be taking out the skin on the lower lids, on the cheeks. She is very comfortably sedated right now to the point where she is asleep. We keep the blood pressure on the lower side so they don't bleed as much. Here we are infiltrating the cheek.

We have injected the local anesthesia everywhere. The first thing we are going to do is suction the neck and this is done in the standard way that we do neck liposuctions when we are not doing facelifts. We put a little cannula in here and just kind of remove the excess fat and then I let this stop oozing or bleeding while I do her eyelids and we are also going to take some muscles out of her forehead between her brows so she doesn't have those 11 frowns. Here you can see the extra fat has been taken out of the neck. And next we are going to lift the skin off the muscle and I'm going to sew the muscles together. Unfortunately, there is not much you can see here. It's a very tiny opening and one person can see at a time but you can see how I do it. This is doing the resection in the neck. 

We have finished the neck part and now we are going to start with eyes. And I make my little lower lid incisions and I'm going to lift the skin off of the muscle. Then I make the upper lid incision just to allow me to excise the excess muscle, correction, the excess skin that's on the upper lid, along with the stripped muscle. Bleph scissors. You can see the skin comes off the muscle pretty readily. And the muscle that you see underneath is your orbicularis oris muscle. That muscle helps control the lid. The next thing we do is we just cauterize the strip of that muscle and we are going to cut that muscle out to give us access to the fat underneath. Okay, we have now cauterized this little strip of muscle. 

Now I'll just take out a little strip of muscle and it gives me access to the area behind it where the fat lives. And as you saw in Jo, she had pretty full upper lids, she's got a little extra fat here and that's pretty easy to find, it's right down here. This is the extra fat that we are taking out of the lid. This is the last of the fat coming out. And after this, I'm going to have a 6-O nylon and I'm just going to run the skin closed. And we take the fat out with a cautery machine just to minimize the chance for any bleeding. And then it's simply a fine little suture of 6-O nylon, just run it up and close it. That'll take another minute.

Okay, here you can see we have finished the closure and now we are going to start the lower eyelid and here we are elevating a very, very thin layer of skin, it's 17 thousandths of an inch thick, that gives you an idea of how thin it is. It's like Saran Wrap. But we are just lifting that off the muscle and this makes this a rather difficult dissection, particularly when you are making a movie and you can't turn on your lights. But this again is the orbicular muscle coming down and we are going to continue this all across until we get to the corner and elevate the skin from the muscle. Okay, I've just finished taking all the skin off the orbicularis muscle down here. When you press you can see there is a little bulge. She has a very, very small amount excess fat underneath. I'm going to just spread the muscle fibers and go in where the fat is and there you see it. I'm going to pull out the excess and I'm just going to burn it off. 

And once the fat is out, all we do is redrape the skin and just close her up again just like we did on the upper lid. Now you can see she's got a nice hollowness in here and what we are going to do now is remove the extra skin. When I pull the lid up, my nurse pulls the skin down just to put these on a little bit of tension cause the last thing we want to do is take off too much skin because that could end up pulling down the eyelids as she is healing. As you can see, it's not a very large skin excision compared to the upper lid. When you take this off, there should be no tension on that and we are ready to close it.

Okay, we have completed the eyelids, we've suctioned the neck, we haven't sewed the  muscles together yet. Now we are going to start the facelift part and in the ear, we put a little cotton ball to protect the ear canal. As I mentioned earlier, this incision starts off like a little question mark behind the sideburn and around this part of the ear. And I make it go completely behind the tragus where no one can see it. And we continue it in this little fold between the ear and the cheek around the earlobe on the backside of the ear up until this point, then we come back down and into the hair and that's where the incision goes. And we start by lifting the skin off of the cheek muscles with scissors. The resection is rather difficult in this section over the tragus as we don't want to damage the little cartilage that is in there. You see that little white cartilage shining through and it's perfectly intact and not damaged. That's the goal. And once I get a little bit of the skin up, I stop to stop the bleeding. We do that with a little cautery machine. 

I think one thing you will notice is how little it bleeds when we do these operations and that's a combination of two things. We inject local anesthesia in here that has a drug called epinephrine mixed in with it and that causes the blood vessels to constrict. And the second reasons are the anesthesiologist, Dr. Becker, who keeps the blood pressure at a lower than average level, that makes people bleed less, bruise less and allows them to heal faster. 

You can see once we get going, the resection is pretty rapid. I'm all the way down to the neck there. Okay, the cheek dissection has been finished. We finished dissecting the cheek and behind the ear and we have packed it with some gauze and now we are coming up to this area up underneath the chin. Normally, to sew the muscles together but Jo had a rather full neck so we are going to take some muscles out underneath her platisma muscles as well and that's what we are doing here, just cutting out some extra fatty tissue. Putting in our last stitch in the muscles in the neck. This is part that I love. It's like taking a cast off a nose and you can kind of see our final revelation. As we tie this and cut the knot, we can remove the retractor and you can see what her neck is going to look like. You obviously have to pull the skin back, but you can see how nice the contour is of her neck. 

Okay, we have finished our dissection and as you can see under the flap, you can see that we have all the way to the nasal labial fold and this goes right to where I fixed the muscles and goes all the way back here behind the ear, and as we look at these muscles, this is what sags as people start to age. Can you hold this please. And this is what we are going to pull back and suture back to lift her sagging muscles and after that, all we have left is the skin repair. You can see how tightly this will pull her jawline. Let's take the retractor out for a second after we cut this. I just want to show, look how nicely this has defined her jawline and how nice her neck looks. Now it's just a matter of closing the skin. 

And the ear, second stich goes below the tragus. I apologize for this light but I just can't see without it. The third stitch goes above the tragus. You can see we are not pulling, we're just laying things down wherever things can come together without tension and this avoids that windswept look that a lot a patient's end up with after a facelift. They look like they are sitting in a wind tunnel. This is not a natural look and I hate it. I just don't do that. My last lineup stitch takes place behind the ear to line up the hairline. And if you look at all of my facelifts, they don't have a stepoff behind the ear. And a lot of people when they do a facelift, they pull this way and then they have this bald patch inside their hairline. But I look where my hairline goes right there. This is where is goes below and I line it up so there's no stepoff between the two. Forcep. 

Now you can see that the hairline has been lined up and everything has been pulled up. My last step is to take out the extra skin and here I just take out what comes up to the incision with zero, zero tension. When this heals, I can show you on Colette later, you just don't see the scars. This is going to wrap around the tragus to the backside so the incision is going to be behind the tragus. And the last thing I do is I pull out the earlobe and I trim the skin around the earlobe so there is no tension on the earlobe itself. Cause if you put some tension down here, the earlobe points downward. We call that a pixie ear and that's not a very, very desirable look. I think I'm going to take out two or three millimeters and that's it underneath the earlobe. This is the place where I definitely do not want to cut.

Okay, now everything is set in. All we have to do now is put in a drain and close it up. May I have a drain please? This drain stays in until tomorrow morning and it's only purpose is to absorb a little bit of extra fluid that would otherwise collect underneath the skin and take longer to absorb and heal. 

This is what they look like when we are done. We haven't washed her off yet and put a dressing on. You'll see that in a minute. But you see how nicely the eyes are done. The incision is hidden around the ear. This is the drain that will stay in until tomorrow. That'll be out tomorrow and that little bulge will be gone. And look how nice her neck looks compared to before. And the one big take away her, look at her skin, she has zero bruises and that's the way I like to see all of my facelifts leave the room. You will see her tomorrow and she will have bruises cause after she leaves, her pressure will go up a little bit and she'll bruise a little bit but if you start looking this good, then you're final result will occur much, much quicker. You won't have as much bruising and the healing will be faster. 

This is how we do facelifts, facial rejuvenation at Orange County Plastic Surgery.

Speaker 2: Today is day one of my facelift. This morning at six am was my surgery. I got home around two. I took a nap and it's about 4:10 and I feel zero pain. No pain at all. So I just got up and cleaned my eyes with peroxide and Aquaphor and I feel great.

Speaker 1: Wow, what do you think? Feel that.

Speaker 2: Wow, nice.

Speaker 1: Your neck is gone.

Speaker 2: Yay.

Speaker 1: Look at her from the side.

Speaker 3: Whoo hoo.

Speaker 2: Good morning. It is day three and today I am more swollen that all the other days, the past two days. I have just been icing and I slept really well last night. I'm really happy about that. And all I have been taking is extra strength Tylenol, two of them every five to six hours. I just got up and took a shower this morning. Cleaned all my incisions. The girls, when I get in, will clean those but I did pretty good this morning and I will ice all day today. And my husband's been taking very good care of me.

Today is day four post op facelift. And last night I did a no no. I slept pretty much flat and I woke up more swollen. As you can see, I'm really swollen on my face. I've had ice on it all day today so far and it's gotten a little bit better but that's my own fault because I slept too flat. I need to elevate, elevate, elevate. So I cleaned all the wounds today. My eyes are looking good except for the black eyes. My chin incision is looking good so you can see the glue and on the ears, you can see the glue. And in the hairline, right there, is one little suture where he removed this glabellar muscle. Everything looks good and I'm looking forward to tomorrow.

Good morning, today is two weeks since my facelift and my eyes and I feel great. I started wearing makeup yesterday and everything feels a little bit different like kind of numb when you put on your eyeliner but it's fabulous job. Great job, Dr. Bunkus at Orange County Plastic Surgery. I love it.