Facelift surgery is well known to lift, remove and tighten skin that is recruited from the jowls and neck. In its most simplest form, a facelift chases sagging and loose skin from the neck and jawline back to where its removal offers the best incision placement and resultant scar creation…in and around the ears. In its infancy, facelift surgery was all about just removing skin and the wrinkles that it contained, hence the original name of rhytidectomy. (the removal of rhytids or wrinkles)

But for decades the lifting of an aging face has gone deeper to involve more than just skin. A layer under the skin, known by the acronym SMAS (submusculoaponeurotic system), has been lifted as well. The ability to provide deep lifting to the SMAS of the face increases the longevity of a facelift’s effects and helps reduce skin surface irregularities such as abnormal looking pull lines and other facial distortions.

The concept of SMAS modifications in facelifts has undergone a tremendous amount of scrutiny from anatomic dissections published in journals to endless roundtable discussions at innumerable plastic surgery meetings. Some plastic surgeons endorse its most extensive use and  these procedures are generally called ‘deep-plane facelifts’. Other plastic surgeons have an opposite approach and use minimal to no manipulation of the SMAS in their facelifts based on the premise of a quicker and less complicated surgery. It is this group of facelifts that have the most diverse number of monikers such as Lifestyle Lifts and Quicklifts to name a few.

The trend in SMAS facelifts today has trended back now to the concept of less is more. The raising of an extensive SMAS flap, once the gold standard in facelift surgery, is not so today. SMAS techniques are more about limited deep undermining or more simple lifting and tightening it by sutures alone. (imbrication) The more rapid and safer execution of this part of a facelift is a big reason for this trend. There is very little chance of nerve injury and the bulk or volume of the face is preserved. This is particularly advantageous in the thin patient with little SMAS thickness anyway.

In the past I would do a SMAS elevation underneath the facial skin is thick or heavier patients and do only a SMAS imbrication in thinner patients. But in looking at the results months later it was impossible to tell the difference between the two SMAS techniques. So today I just perform a good SMAS imbrication on all facelift patients. Their recovery is quicker and the results appear to be just as good.

The time saved from doing deep SMAS lifting is now spent on other adjunctive facial procedures that add more benefits to the overall facelift procedure. This is usually fat injections around the mouth and nasolabial folds and skin resurfacing with the fractional laser or chemical peels.

Dr. Barry Eppley

Indianapolis, Indiana

Any patient that undergoes a facelift has understandably great expectations given the commitment involved. But a facelift alone can not correct all facial aging problems. Preparing for a facelift is not only a matter of education but also benefits from before and after surgery skin care. When a patient is looking for and is ready for a facelift, their skin is also ready for a makeover as well.

Because a facelift only treats the sag in the skin and underlying tissues due to effects of gravity and other environmental factors, additional skin issues such as finer wrinkles, brown spots, large pores, red spots and generalized poor skin texture are not treated. Simply lifting up and pulling the skin tight will not get rid of every facial imperfection. Undergoing skin treatments both before and after a facelift can really put the ‘icing’ on the effects of the surgery.

Treatment options before a facelift can include microdermabrasion combined with light chemical peels (what I call a medical microdermabrasion) or medium-depth chemical peels like a Vi peel or the Perfect peel. These should be done no sooner than three or four weeks before surgery. These skin treatments will really freshen up the skin and an immediate improvement in skin texture will be seen.

In addition, the use of Retin-A is a great topical daily treatment in addition to or in lieu of the patient’s existing skin care regimen. While Retin-A has been around for decades and is not a sexy new topical agent, its benefits to the skin are well proven. It makes the skin healthier by thickening the dermis and improving its vascularity. This makes it heal better after surgery or just skin resurfacing. The strength of the cream or gel and how many times to apply it daily depends on the patient’s skin. The thicker the skin, the greater strength and number of applications it will tolerate without becoming too irritated.

After facelift skin care initially can include oral and topical Arnica and mineral makeup to cover the bruising. A return to one’s normal skin care regimens should wait a few weeks after surgery until the bruising is gone and most of the swelling has subsided. A month to six weeks after a facelift is a good time to have a microdermabrasion treatment to exfoliate the skin and buff up the facelift result. While there are many skin care product lines available, the use of topical Retin-A at some frequency of application after a facelift is always a good product to incorporate into one’s skin care regimen.

For many facelift patients, this surgery may be done only once in their lifetime. Many of these patients have never had a good skin care regimen and this surgery provides an opportunity to embark on one. Helping the facelift patient enhance and protect their surgery efforts is a valuable educational service.

Dr. Barry Eppley

Indianapolis, Indiana

Many treatments have been touted over the years to create a facelift-like effect from topical creams to devices in lieu of having the actual surgical procedure. Today’s ‘alternative facelifts’ have taken on a very different approach and it is done through largely an injectable approach. These are all about adding volume to the face, plumping it out in select sunken facial areas. In many ways these are facial reinflation methods which work best for those patients who have lost volume and have a little loose or saggy skin.

These volumetric facelifts are comprised of two basic approaches. The first is the generic liquid facelift which completely uses synthetic injectable fillers and promises nothing more than a limited time period of benefit. The now more appealing, and the group that has caught the most press and is also heavily marketed, is the autologous injection techniques which promise more than just a short-term effect…they promise a rejuvenation of tissues as well.

These autologous injection techniques use either blood products such as platelet-rich plasma (PRP, e.g., the Vampire Facelift) or one ‘s own fat which is obtained by liposuction. Because our fat stores are now known to contain large amounts of stem cells, these type of liposuctioned-derived injections have become known as ‘stem cell facelifts‘. They have become heavily touted on the internet and many patient testimonials as to their rejuvenative benefits can be found online.

But what is a stem cell facelift actually? In reality, it is a bit of a misnomer. It starts with liposuction to harvest fat, usually from the abdomen, which is then processed during the procedure to get rid of most of its fluid contents. (blood, tumescent fluid, free fatty liquids) What happens next varies by the doctor doing it. Some will proceed to inject the fat concentrate while others may further process the fat to obtain a greater cellular concentrate of the material which presumably has more stem cells per injected volume.

For those just taking concentrated fat and injecting it (aka fat injections), any stem cells that are in the fat are inadvertently carried along with it. How many stem cells and how active they are after being injected into the face is anyone’s guess. This is a stem cell facelift in the loosest use of the term.

To those who do a stem cell preparation step with the fat (usually a mechanical process that separates the stem cells from the fat and then they are injected along with the fat), this is a purer form of a stem cell facelift. Such higher concentrations of stem cells are purported to induce skin rejuvenation allegedly because of the growth factors that are produced by the stem cells. But no one really knows for sure.

While the appeal of the stem cell facelift is undeniable, does it really work? The regenerative properties of adult stem cells has been vigorously studied for decades in a  wide variety of medical conditions. But their use in aesthetic medicine is very new and, as a result, the medical evidence supporting their effectiveness is presently very weak. The marketing claims are high, but almost all the clinical evidence of its effectivenss is anectodal….and very short-term.

To really answer the question of the effectiveness of stem cell facelifts, split-face clinical studies would have to be done. Patients would have to submit to one-half of their face being injected with fat and the other half with fat that contained concentrated stem cells with postoperative assessment of appearance and skin improvement. Such studies are hard to conduct although patient recruitment would likely not be difficult.

Stem cells have a lot of regenerative potential but whether that applies to aesthetic conditions like facial aging remains to be seen. I like the concept very much but it remains a clinical procedure that is in the earliest stages of development. And as often happens in many developing aesthetic techniques, the marketing and promotion of it gets way ahead of the actual science to support it.

Dr. Barry Eppley

Indianapolis, Indiana

While facelifts have continued to increase in popularity and overall numbers, the procedures has also undergone a bit of paradigm shift over the past decade. While once thought of as a procedure of older age and to be done closer to or after retirement, greater numbers of facelifts are done today in middle aged patients. When done at this stage in life, it is highly likely that one will outlive the benefits of the initial operation and live to ‘need’ another one.

While every facelift patient always asks how long it will last, this question takes on even greater relevance in the middle-aged patient who has it done today. In the March 2013 issue of the journal Plastic and Reconstructive Surgery, a paper was published entitled ‘A 20 Year Experience with Secondary Rhytidectomy: A Review of Technique, Longevity, and Outcomes’. While the purpose of the paper was to look at techniques unique to those patients who are undergoing a second facelift, it cast great relevance to the duration of facelift results.

In this paper, they report over 800 facelifts performed over the time period studied of which 60 were secondary facelifts. The average time between the first and the second facelift was 9 years. Interestingly there were 10 patients who actually had a third facelift and the time between the second and the third facelift was 7.5 years.

There have been numerous studies of late that have looked at how long a facelift lasts. The numbers reported range anywhere from 7 to 14 years depending on the paper and the number of patients studied. Putting all of these paper together, it would be fair to say that the ‘average’ length of facelift durability can be safely rounded off to the 10 year mark. There are a large number of variables involved in how long a facelift lasts from the surgical technique used to the genetics and environmental factors of the patient’s rate of facial aging.

There is also the extreme variability in the level of the patient’s ‘need’ that warrants a second facelift. Some patients will want to do something as soon as they see a little bit of recurrent jowling or loose neck skin. Conversely other patients may not want to do something until they see a near or complete return of their initial signs of aging that motivated them to have the procedure in the first place. The reality is that no one can predict how long a facelift will last in anyone on a per patient basis. The best number that can be given is a popoulation average…which is 9 to 10 years.

Dr. Barry Eppley

Indianapolis, Indiana

Technology and social media have caused many positive human interactions and experiences. They have made connecting to those close and far away as easy as the push of a button and available in a matter of seconds. They also allow us to visually share every aspect of our lifes, whether others really care to see them or not.

Several instantaneous visual methods of human communication that was not available even five years ago are Skype and FaceTime. While FaceTime is unique to the iphone, Skype can be done on the computer, iPad or on a variety of smartphone models. I have used it extensively over the past few years and a consultation that I did just a few weeks ago illustrates how easy it is to have a plastic surgery consultation today….on my iPadmini I was talking to a young female in regards to a lip procedure while she was being driven in a car on the way to Kentucky on her iPhone. You virtually can connect with anyone just about anywhere in real time.

One interesting aspect of these visual virtual connections is that we can see ourselves in the computer or on the phone. Unless you are a child, most of us would agree that we usually don’t like the picture that we see of ourselves. Some of this is because most people have a distorted image of how they really look…and seeing pictures of ourselves does not visually match the image to which we are mentally familiar. Some of it is also because there are conversion ratio errors in the picture display that really does distort our face. (appear more bloated than one really looks) There is also the reality that those of us who are middle aged and older really do look that way and are showing our age.

These visual facial aging changes have spurned some to pursue plastic surgery for some facial rejuvenation improvements. A plastic surgery procedure known as the FaceTime Facelift has even been touted as the surgical solution for those puffy eyes, double chins and dangling necks that may be discovered in a video chat session…if not seen in pictures long before any video chat.

Whether one is having a virtual-spawned facelift procedure or not, facelift surgery has taken on many forms and variations over the years. Often with catchy marketing names and touted in various ways, the underlying theme of all surgical facelifts are the same. It is a lower 1/3 of the face procedure that changes the jowls and the neck. Incisions are made around the ears, skin is lifted various distances from the ears into the face and neck and the deeper tissues (plastysma muscle and SMAS) manipulated for a tightening effect in various ways. The skin is then lifted, tightened and excess removed. Such facial tissue manipulations will really take about 10 to 14 days for the significant part of the recovery.

Within each facelift, most plastic surgeons have developed their own technical variations for many steps of the procedure. These variations, however, do not usually make the procedure have less of a recovery, connote a magical technique or necesarily create a better or longer-lasting result. These are facelift nuances that work best in each plastic surgeon’s hands to create a satisfying result.

While a picture may be worth a thousand words, a video may leave one with an image that words alone can not really satisfy. What may have started as a casual conversation with a friend or relative may have unintended consequences that may lead one to making a new friend…their local plastic surgeon!

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley,

Thank you for doing such a great job on my facelift and nostril narrowing!  Only three people knew that I was having surgery and at  my family’s Christmas dinner, some people commented that I looked good and asked if I had lost weight.  I was always very self conscious about my nose and jaw line.  When having a conversation, I would not look directly at the person or try to cover the bottom part of my face with my hand. Both those fears are now over! My confidence level has been lifted and should be even better after the brow and eye lift surgery next year. You’ve made a difference in my life.  We’re lucky to have you here in Indy.  Thank you again.

Charlotte H

Terre Haute IN

Comment:

One of the great fears of undergoing any form of a facelift is that everyone is going to know and that it may look unnatural. (pulled too tight) In reality most of these fears are unfounded and are based on what one sees or is reported on in celebrities and other tabloids. (who often have had numerous procedures done over time and have a different set of aesthetic goals which can be different from that of the general public) Understanding that a facelift is limited to the neck and jowl areas and if done by itself can be a fairly quick recovery facial rejuvenation procedure. This is particularly true of the more limited or short scar facelifts. Often one can look very presentable in as short as a week after surgery as this patient testimonial indicates. In fuller more extensive facelifts that may involve other facial areas (eyes, brows, etc) a presentable recovery may take two weeks or longer.

When it comes to looking unnatural after a facelift, that concern is perceived as being pulled too tight to the point of even having the corners of the mouth altered. For short scar facelifts this is technically impossible because it is a more limited type of facelift from which there can only be so much skin pull. More commonly the concern with limited facelifts is whether the result achieved is enough to fully rejuvenate and satisfy the patient. In fuller facelifts which have a greater neck lifting component to them, this potential unnatural look is a possibility. But a skillfully done facelift not only avoids this potential concern but does a masterful job of hiding the incisions in and around the ears…which are the real telltale signs of having had a facelift.

Dr. Barry Eppley

Indianapolis, Indiana

When it comes to facelift surgery, the one brand name that many people recognize is that of the Lifestyle Lift. While most people don’t really know what it is, they know the name as a result of marketing efforts by the company that has promoted it since its inception over a decade ago. Like many products and services, the internet is full of many positive and negative reviews of the Lifestyle Lift. For a wide variety of reasons, many plastic surgeons have taken exception to the branding and promotion of the Lifestyle Lift. While there are certainly economic competitive factors at work in its professional criticisms, its negative perception amongst plastic surgeons goes deeper than just that one issue.

In the November 2012 issue of Plastic Surgery Practice, an article entitled ‘Face Off’ was published that offered one viewpoint to the Lifestyle Lift. This article interviewed nine plastic surgeons who provided their collective opinions and was written as a counterpoint to a previously published article in the same publication entitled “Defending the Lifestyle Lift’ by a single plastic surgeon.* The article covers six counterpoints about the procedure. Their points may be summarized as follows.

The Lifestyle Lift is purported to be a new and revolutionary procedure. The surgical technique is one of a variety of well known ‘mini-facelift’ techniques that results in facial rejuvenation with emphasis on improving the jowls and neck. There are no published reports in the medical literature over the past ten years on the Lifestyle Lift which report on its novel technique or its long-term outcomes.

The photography of Lifestyle Lift results may not accurately reflect what is being promoted. Many of the patient sappear to have had more procedures done than what any facelifting can achieve and could not be performed in its approximate one hour time frame. The company has now added in fine print statements that the patients shown may have had more extensive procedures.

The Lifestyle Lift is a safer facelift method. Because the procedure may be performed under local or light sedation anesthesia, the inference is that this is safer than having the procedure done under general anesthesia. However, Lifestyle Lift centers are not known to have accreditation by any office or surgery center-based surgical facility…at least not yet on a national basis. Conversely, board-certified plastic surgeons are required to have such accreditation if they are to remain members in good standing.

Outcomes, particularly long-term, of the Lifestyle Lift are undocumented beyond a few months. The criticisms here are largely anectodal and from numerous sources of dissatisfied patients. While every surgeon ‘sells’ surgery to some degree, the inference is that a corporate owner may have a higher priority for numbers than outcomes.

The Lifestyle Lift uses undocumented advertising claims. Promoting improved safety, a quicker recovery, and a procedure that is done in about an hour are the backbone of its marketing message. The critics counter that there are no clinical studies that support these assertions and that such promotions run askew of the ethical advertising guidelines of the American Medical Association.

The company behind the Lifestyle Lift is litiginous. Numerous examples are cited in which legal action has been taken to remove or suppress written commentaries about the procedure from different companies and surgeons. Such responses to criticism are believed to run counter to the principle of free speech.

The Lifestyle Lift has been done on tens of thousands of patients over the past decade all across the U.S.  The corporate promotion of any surgical technique is bound to run into a large number of critics, both from patients and competing surgeons. Such criticisms are bound to exist, even in the face of many satisfied patients, as pleasing patients in large numbers becomes precariously difficult when high expectations are set by how it is promoted.

Dr. Barry Eppley

Indianapolis, Indiana

• To gain proper perspective the original article on Defending the Lifestyle Lift should be reviewed.

Patients that present for a plastic surgery consultation requesting a facelift always have a standard set of concerns and questions. Once they find out what a facelift really is their initial concern is that they don’t want to look unnatural or have a ‘wide-swept’ look. While everyone wants the best result possible, they don’t want to be overdone. Few patients come in wanting their face to be pulled as tight as possible no matter if that type of result is longer-lasting.

The inevitable question then arises, and understandably so, about how long does a facelift last? While it is acknowledged that a facelift is not a permanent operation, they want to know if the money they are spending will last more than a few short years. The answer to the facelift longevity question is affected by many variables such as the type of facelift performed, skin type of the patient, aging genetics of each patient and other environmental and lifestyle issues. (e.g., sun exposure, smoking) Numerous studies in the past give variable ranges of the sustained benefits of a facelift, often numbering anywhere from 7 to 12 years after surgery.

In the December 2012 issue of the journal Plastic and Reconstructive Surgery, a paper entitled ‘ How Long Does A Facelift Last? Objective and Subjective Measurements over a 5-Year Period was published. In this study the use of standardized photographs, objective measurements and a scoring system was used to study over a ten year period 50 primary facelift patients at 5.5 years after surgery. By objective measurements, the jowls showed a 21% relapse in position after five years. The cervicomental angle had a relapse of 69% in sharpness after five years. By subjective assessment, scores showed significant improvement in all areas following a facelift including the jowls, nasolabial folds and marionette lines. At 5.5 years after surgery, there was no subjective worsening of any facial area except for the neck. Subjective assessment also indicated that 76% of patients still appeared younger 5.5 years after a facelift than before having it done.

This study is interesting not only because it shows persistent improvement in appearance over 5 years after a facelift but that differential aging occurs. While the jowl, nasolabial and marionette lines remain well corrected over the duration of the study, the most noticeable area of relapse is in the neck. In essence, the neck is the most unstable area of a facelift and is the first to show recurrent aging. (i.e., loss of correction)

Why might the neck not hold up as well as those structures above the jaw line after a facelift? There are numerous explanations including the thinner and less elastic skin that often exists in the neck and that much of the pull and tissue resuspension of a facelift is lateral or closer to the ear rather than more directly in the midline of the neck. Regardless of the reason, patients need to be counseled before surgery that the dramatic change in the profile of the neck may be the most unstable over time.

As this reported study shows, the results of a facelift remain gratifying at five years after surgery. But the result does suffer some deterioration over this time period that is most reflected in the neck and the profile of the cervicomental angle   

Dr. Barry Eppley

Indianapolis, Indiana

The facelift is one of the most recognized surgeries for facial aging. Patients ranging from their forties until the late eighties receive substantial benefits from a variety of facelift techniques. Cleaning up loose skin and fat from the neck and jowls and re-creating a youthful jawline is the objective of any facelift procedure and it is highly successful in doing so. Most every plastic surgeon has great examples of some dramatic before and after surgery examples demonstrating the powerful effects of the procedure.

One of the most frequently asked questions by potential patients for the procedure is how long does a facelift last? This very question speaks to the fact that a facelift is not a permanent procedure, it treats the symptoms of the underlying problem (aging and gravity) but does not cure the ‘disease’. While there are debates as to how long the effects of a facelift persist and it does vary for each individual patient,  one issue that patients are completely unaware of is that a facelift is not a perfect procedure. It is not equally effective for aging issues across the face, particularly the central neck and mouth area which often show the least persistent improvement as they are furtherest from the location of tissue pull and tightening. (around the ears)

For some patients, they comment on the lack of the dramatic improvement they expected around the mouth or central neck or that there has been some skin laxity in these areas that has reappeared. This reappearance of skin rolls is known as rebound relaxation and is reflective of the viscoelastic properties of skin, it can be stretched out but there will be some recoil back. Some people interpret this as a ‘failed’ facelift that has not lasted but this is not true. It is reflective in many cases of the degree of aging problem and/or the natural properties of the patient’s skin.

Because of some rebound relaxation, patients should be aware that they may need a secondary facelift or tuck-up within a year or two after their procedure to either achieve the best result or to re-establish the more complete initial result that they saw. Addressing the need for secondary facelifts in the December issue of Plastic and Reconstructive Surgery was an article entitled ‘The Staged Facelift: Addressing the Biomechanical Limitations of the Primary Rhytidectomy’. Employing  the definition of most plastic surgeons (not patients), a successful facelift is a result that makes the patient appear up to 10 years younger and lasts as least two years. Therefore, any form of a tuck-up done within two years would be called a secondary facelift. (I prefer to call it a secondary tuck-up) In this paper, the authors looked at a series of nearly 750 patients who had undergone a facelift and looked at how many secondary facelifts were done.

How many patients in this paper underwent a secondary facelift? Nearly fifty patients or 6% of the study series had them. The need for the secondary procedure were early symptoms of skin looseness  around the mouth and central neck or incomplete correction of the neck  angle the first time around.  High rates of patient satisfaction occurred with these secondary procedures.

The take home message is that not all facelifts do an even or complete job of rejuvenating the face and neck or lasts forever. Just because some recurrent skin laxity occurs in the first months to years after the procedure does not make the facelift a failure or is reflective of a plastic surgeon’s ability. Some patients will benefit from an additional procedure which is usually far less in scope than the original facelift.  Prospective facelift patients should be aware of this possibility before ever having surgery as this potential need is not rare.  

Dr. Barry Eppley

Indianapolis, Indiana

Injectable fillers have an invaluable role in facial rejuvenation. Most everyone knows their use for lip augmentation and nasolabial fold reduction. These two areas are still probably their most common usage in most practices. But injectable filler use has been extended in the past few years to the broader concept of facial rejuvenation. In this approach, larger volumes/syringes of materials are used to create a facial plumping effect. Some call this a non-surgical or liquid facelift although this is more of a marketing term rather than as a substitute for what a real facelift achieves.

 But despite the use of injectable fillers to create a more global facial effect, they have very specific disadvantages particularly in regards to several common issues that I see. Poor or unrealized cosmetic outcomes is one problem area as some patients expected more from the products that they achieved. The second area is that of cumulative costs. Even when they work well, no injectable filler treatment is permanent.

Thus it is important that prospective patients know the pros and cons of injectable fillers in regards to facial rejuvenation. In short, their main benefits are that they provide temporary improvement for those who are trying to postpone surgery or as an enhancement to an existing surgical result. They are not a surgical replacement. They are a surgical alternative with lesser effects but certain benefits. The decision for injectable fillers is often based on economic considerations. Patients may well recognize that fillers are temporary but they are more affordable than surgery and certainly have a faster recovery.

While I see several patients a week who present with an interest in facial fillers with the main objective of an affordable and quick fix, it is important for me to review all their options. Patients understandably are misinformed and misled by many articles that they have read in popular magazines and on the internet. By reviewing all options that are available, patients can make informed decisions. This is particularly poignant today with the advent of injectable fat grafting which serves as an intermediary treatment option between injectable fillers and surgery for some aesthetic concerns.

What can injectable fillers do that creates a facial rejuvenative effect? Besides larger lips with less wrinkles and less deep lip-cheek grooves, other uses include cheek augmentation/lifting and the treatment of hollow undereyes known as tear troughs. Additional aesthetic uses are skeletal highlighting of the brow bones, cheeks, chin and jaw angles. Do these constitute a facelift effect? Sort of but not really. A surgical facelift moves skin and deep tissues up and back, a tissue shifting and relocation effect. Injectable fillers merely push tissues outward but not really upward. For the person who is in their mid-40s with early signs of facial aging, this injectable filler effect may be very useful. For the 60 year-old that comes in with sagging jowls and a droopy neck, volumizing is not a reasonable approach.   

Dr. Barry Eppley

Indianapolis, Indiana