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The History of Rhytidectomy
01 June 2017 (online)
The history of rhytidectomy follows the evolution of public and medical views toward cosmetic surgery. The secrecy surrounding cosmetic surgery in the early 20th century transitioned to an abundance of publications that propelled the field forward into the 21st century. This, in turn, has allowed for significant advancements in surgical techniques and increased accessibility to cosmetic surgery, including facelift surgery.
There is some degree of debate regarding the origins of rhytidectomy, as the history is obscured by the cultural environment within which early cosmetic surgery was performed. There are three main explanations for the secrecy surrounding cosmetic surgery in the early 20th century. First, the public eye held cosmetic surgery in disdain. The public felt that facelift surgery catered to one's vanity, which was heavily disapproved of in post-Victorian Europe as well as in America. The medical community also largely shunned cosmetic surgery with the sentiment that surgery should be reserved only to save lives or cure severe disabilities. Finally, many early cosmetic surgeons were financially motivated to guard their techniques to maintain dominance in the cosmetic market. These attitudes kept surgical techniques of facial rejuvenation from being advanced and refined.
The earliest facelift procedures were likely done in Europe, with American surgeons following suit shortly thereafter. Most credit Eugene von Hollander as the first to perform a surgical “lift” of the face on a Polish aristocrat in 1901, which Hollander later described in 1912. This procedure was limited to an elliptical excision of temporal, periauricular, and postauricular skin with minimal undermining to merely allow for approximation of skin edges. Charles Miller of Chicago became the first American to perform a facelift, and he began publishing extensively on cosmetic procedures beginning in 1907.  Miller presented various designs for excising facial skin in his 1924 textbook and is largely responsible for the design of skin excision most surgeons employ today. Lexer, Joseph, and Passot also made early contributions by describing similar facelift techniques based on elliptical skin excisions ([Fig. 1]).    Lexer then suggested dissection in the subcutaneous plane beyond what was necessary for closure of the wound, which was further described by Bourguet.
Injuries during World War I created a need to train greater numbers of reconstructive surgeons and for innovations in reconstructive techniques. Subsequently, accessibility to plastic surgery following the war led to increased demand, although most cosmetic procedures were still performed privately. Noël publicized the facelift through her 1925 textbook of cosmetic surgery, which included many preoperative and postoperative photographs of patients who had undergone rhytidectomy. Later, Maliniak's description of submental fat excision highlighted the importance of treating the neck as part of the aging face.
Major advances in rhytidectomy did not occur, however, until after World War II. Surgeons such as Gillies, Blair, Conway, and others performed facelifts, partly to enhance their livelihood while pursuing their interest in reconstructive procedures. The advent of better anesthesia and antibiotics allowed more aggressive techniques to be developed for facelifting. Passot's original facelift with a limited incision and very short flap in 1931 was replaced by pre- and postauricular incisions and longer flaps. In the 1960s, greater cultural acceptance of cosmetic surgery gave rise to a significant renaissance in facelift and other aesthetic procedures.
Skoog influenced a paradigm shift in the approach to rhytidectomy by demonstrating that improved results could be achieved from elevation of the superficial fascia of the face, which was first presented in 1969 and later published in 1974.  Other surgeons, including Millard (1968), Rees (1973), Conley (1970), Guerrero-Santos (1974), and many others contributed to more aggressive techniques in facelifting, leading to better and longer-lasting results.
Mitz and Peyronie performed anatomical studies to further elaborate on Gray's description of the superficial muscular and aponeurotic system (SMAS), thus validating Skoog's approach to facelift surgery. Suspension of the SMAS and the platysma became a focus of rhytidectomy practice and literature. Many surgeons described techniques of SMAS plication and imbrication.  Others argued that complete platysmal transection with lateral suspension along with medial plication resulted in a more dramatic result.  Complete platysmal transection was later largely abandoned in favor of lateral fixation of the SMAS with a limited skin incision to avoid patient complaints and an unnatural, operated appearance.
Dissatisfaction with the classic SMAS rhytidectomy's treatment of the melolabial folds and malar fat pads prompted exploration into more extended dissections. In 1984, Hamra published his experience with the triplane rhytidectomy. Hamra's variation of Skoog's superficial fascial elevation was performed by dissecting the upper face in the subcutaneous plane, the lower face in the sub-SMAS plane, and the neck in the preplatysmal plane. The triplane rhytidectomy then evolved into what Hamra termed the extended deep plane rhytidectomy, involving the release of the SMAS from vertical zygomatic ligaments at the malar eminence to improve the melolabial folds. By dissecting the orbicularis oculi, cheek fat, and SMAS en bloc from the malar eminence as a bipedicled flap, Hamra described additional youthful rejuvenation of the midface in his composite rhytidectomy. Other surgeons turned to subperiosteal elevation as an alternative approach to improve the midface and periocular area.  
Following extensive dissection techniques in the late 1980s and early 1990s, there was a trend back toward minimal dissection and limited incisions with the benefit of decreased patient downtime and decreased risks. The thread lift was introduced in the late 1990s to perform what was described as a nonsurgical lift using subcutaneous barbed threads. The thread lift has since been abandoned due to limited and short-term results. In 1999, Saylan popularized a limited scar technique combined with a vertical suspension of the SMAS to the zygomatic periosteum. The advent of ultrasound, laser, radiofrequency, and microneedling technologies offers patients options for nonsurgical rejuvenation through the stimulation of dermal collagen. The cosmetic surgery field has also embraced facial fillers, autologous fat, facial implants, and neurotoxins as a complement to rhytidectomy for facial rejuvenation.
Despite many variations in facelifts that developed over more than a century, most contemporary cosmetic surgeons perform either a SMAS rhytidectomy or deep-plane rhytidectomy. The evolution of rhytidectomy surgery has been motivated to achieve consistent, natural, and long-lasting results while minimizing recovery time and potential complications. Improved techniques and increased social acceptance of cosmetic surgery have led to a sharp rise in the demand for facelift surgery. It is the responsibility of the cosmetic surgeon to have a comprehensive understanding of each technique to choose that which will work best for the individual patient.
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