I recently saw a patient who came in because I did a facelift on one of her childhood friends and she liked what she saw: a more youthful look without looking “pulled.” She had a facelift about 7 years ago and feels that it helped a little but the skin of her lower face is “wrinkley” with some excess skin under the neck and cheek folds. She sought out a few opinions of other doctors and the suggestions ranged from fillers to implants to a revision facelift. My first inclination was to suggest another facelift. This would help the jowls and extra skin under her neck. What concerned me is that when listening to this lady, she was more distressed about the way the skin hung around her mouth and narrowing of her cheeks. As a surgeon, facelifts are more interesting and fun for me to perform, plus this patient was basically asking if a revision facelift would be the best solution without specifically stating it. However, I felt that a facelift wouldn’t be the best initial solution for her concerns. I suggested that we first try Sculptra to restore volume to her face and fill out the deflated cheeks and areas around her mouth. A facelift can be performed later to lift the drooping facial skin and muscles.

This is really about deciding priorities. I categorize facial aging into 5 categories: skin changes, dynamic muscle action, loss of volume, gravity and loss of elasticity. Everyone experiences all 5 as they age. It’s more a matter of what should be addressed and in what order. For this patient, I feel it is volume first (high volume fillers with longevity – Sculptra) then combat gravity and loss of elasticity next (facelift). 

 The face ages in 5 ways: skin, muscle action, volume loss, gravity and loss of elasticity. When the question is to fill or lift the face, both the doctor and patient need to determine the best treatment plan per the patients priorities. Steven J. Pearlman, MD, FACS

New York, NY, There were so many world authorities at this meeting that my head was spinning. One of the more interesting panels and set of presentations was on facelift surgery. Just when you think that most people agree on something there is a panel of recognized experts with a vast array of differing opinions on facelifts. The most senior was Dr. Bruce Connell, who taught or at least influenced many of the most accomplished facelift surgeons and teachers with his bi-plane, bi-directional  extended SMAS facelift. He was supported by one of his former students and now a superior teacher in his own right, Dr. Timothy Marten. Other facelift ideas were presented by the inventor of the MACS facelift, Dr. Patrick Tonnard from Belgium, Dr. William Little with totally new ideas on vertical SMAS lifting and Dr. Gaylon McCullough with an excellent perspective from his many years performing and teaching facial plastic surgery.  The outstanding statement of the meeting came from Dr. Little; when asked about his SMAS technique as a departure from the rest, he prefaced his answer by stating that he needed to watch what he said since he shared the podium with the “SMAS mafia.”

What did I take from this panel? There are many ways to perform a facelift. Most agreed that the SMAS needs to be addressed in all patients. For most, the more aggressive surgeons get with the SMAS, such as deeper plane facelifts may last longer but are technically more difficult to perform. Facelifts also need to be individualized.

As with noses, there isn’t one facelift operation that fits all. A simple short scar facelift with a few sutures in the SMAS may be easy, fast and can be done under local anesthesia and even mass marketed by national companies under catchy names, but doesn’t last for patients with more advanced facial sagging. I find myself in discussions with other plastic and facial plastic surgeons, who state, “Wow, you really do a deep plane facelift?” It takes longer and patient recovery is longer but the results are superior and the results last longer. 

In summary: there are a number of ways to perform a facelift. A more comprehensive the procedure such as the deep plane facelift may take longer to perform and take longer to heal from, but the results last longer. Steven J. Pearlman, M.D.,F.A.C.S.

New York, N.Y.

There is much buzz in the media and on the internet about non-surgical or alternative less invasive procedures instead of facelifts. These treatments include fillers, neurotoxins (Botox and Dysport), and devices such as lasers and radiofrequency machines. Many of these procedures can help restore a more youthful look, but none really lifts the face. You can follow this link to my website for a more comprehensive discussion of the 5 ways the face ages: 

1. Skin changes
2. Dynamic lines from muscles underneath
3. Loss of volume
4. Effects of gravity
5. Loss of tissue elasticity

To treat these aging causes, treatment needs to be targeted to the cause. Of course, most patients experience all 5 in some capacity. I then break down their priorities by need, time frame, importance to them, time off to heal and cost.

Targeted treatment for each or some combination is really what is best: 

1. Skin changes             Lasers and peels for the skin
2. Dynamic lines            Botox or Dysport to relax muscles
3. Loss of volume          Facial Fillers (Juvederm, Restylane, Radiesse, Sculptra, Fat)
4. Effects of gravity       Surgery
5. Loss of elasticity        Surgery

Fillers, Botox and Lasers can go far to make someone look younger, but to lift a drooping jowl, treat a “turkey neck” or low brow, nothing works like a surgical facelift or browlift.

Don’t get me wrong, my new techniques in facial fillers are really getting beautiful results. Now that I target cheeks and the mid-face with fillers, entire faces light up. But this is not a lift. There is a doctor in New York advertising a “insert letter here” lift (I am leaving out the letter as not to offend); but all he is doing is placing many syringes of facial filler deep in the face and under the skin. It’s not a lift but volumizing the face.  Fillers are a good thing, but more is not better. Plump is good but so is lifting.

Lasers and RF machines don’t really lift the face either. Most reports have been disappointing and based more on subjective findings instead of objective long term results.

So, for comprehensive facial rejuvenation, all 5 areas of the face need to be examined and treated.

Steven Pearlman, MD, FACS

The meeting started off with a superb panel on facelifts. Panelists were chosen to discuss the various popular techniques practiced around the country. These ranged from mini-facelifts to (open) suture suspension lifts, MACS lifts, deep-plane facelifts, bi-planer extended SMAS lifts and the latest: laser lifts featuring the new laser SmartLift^TM.

The goal of facelifts are to re-suspend drooping facial tissues by tightening the underlying muscle layer called the SMAS, then gently laying down the skin, without tension, to obtain natural long lasting results. Each of the above techniques has advantages and disadvantages. My main take home lesson was that there is no one facelift for every patient. Mini-lifts have a place for patients who need minor improvement of the jowls, jawline and mild skin excess under their chin. For patients with heavy faces, the deep-plane facelift is still king.

I was enthralled by the laser lift.  I recently purchased the SmartLipo Laser to use for neck contouring and to enhance liposuction results. I have been using it since August for neck liposuction, skin and jowl tightening and getting fabulous results. This laser can also be used to raise the skin for a facelift. By using the laser there is less bleeding and the skin flat is elevated more smoothly and rapidly… which all leads to less downtime and recovery, which gets the patient back to work quicker.

Consultations, as well as the follow-up, are performed by various individuals, it might be the doctor who will be doing your surgery or it might be a nurse or physicians assistant. Please ask yourself these questions before signing on:

Do you really know the credentials of the doctor who will actually be doing your surgery?

How many years have they been in practice?

Are the before and after photos in the advertisements from this doctor? Are there options or differences between this procedure and other facelifts? Where these options discussed?

What are the advantages and disadvantages of the lifestyle lift?

What are the limitations of this lift as compared to other available procedures?

Do you really know and feel comfortable with the surgeon who will be doing your surgery? Like other areas of cosmetic surgery, cookie-cutter procedures do not always give the best results. A recent study by a very highly respected surgeon and teacher, Dr. Peter Adamson, as published in the Archives of Facial Plastic Surgery, demonstrated a longer lasting result from the deep plane facelift over a SMAS plication facelift. Plus, the SMAS plication is actually a more highly accepted procedure than that done in the lifestyle lift by most facelift experts. What does this mean? A more comprehensive facelift technique will last longer than a simpler one. Which is best for you? That really depends on your anatomy and what needs to be lifted. So, to lump all patients into a very simple procedure under local anesthesia might sound enticing, but might not give you the most long lasting results.  

As for the procedure to be done under local anesthesia: sure, it sounds very nice not getting anesthesia other than local. General anesthesia (and deep sedation) has been around for many decades. As a matter of fact the incidence of serious complications from general anesthesia has gone down by more than 1000 times over the past 30 years. Anesthesia is one of the few specialties where malpractice rates have actually gone down. Yes, this is preferable for a more aggressive facelift, but then again you will get a result that will likely last for many more years.  So, in reality, you will likely be getting what you pay for; a simple procedure that is safe and performed under local anesthesia.

Would you rather have a longer lasting result from a doctor who you have researched and likely with more experience?