Why You Shouldn’t Fear The F Word: Where The Facelift Fits in Modern Plastic Surgery

Park Avenue Plastic Surgery Class

Episode 4

Why You Shouldn’t Fear the F Word:  Where The Facelift Fits in Modern Plastic Surgery

Everyone would like to avoid surgery if possible but deep down everyone knows at some point, you’ll need a facelift to look your best.  Preconceived notions about facelift are based on news stories, fears, and some misconceptions, starting with the history of facelifts.  The facelift started in 1901 as skin only operation removing a wedge of skin in front of the ear to reduce laxity.  Most of 20th century the operation remained skin only with minor modifications.  Facelifting was the territory of starlets and socialites, a distilled fraction of the population that brought enough attention to the facelift to make it the prototypical plastic surgery operation of all time.

Things began to change in the latter part of the 1970’s to an approach that was not skin only but involved additional modifications to the neck muscles and connective tissue layers of the face, repositioning and tightening them.  The SMAS facelift refers to this in part –SMAS being an acronym for subcutaneous musculo-aponeurotic system –the layer of muscle and connective tissue located just beneath the skin in the face and neck.

In the 1990’s techniques were developed to move tissues in a single plane deeper in the face –the deep plane facelift.  Other techniques such as extended SMAS and modifications of the extent of undermining and the direction of redraping of  skin were all attempts to create more complete correction of nasolabial fold and marionette line or to overcome some other limitation of the degree or durability of correction in one part of the face or another.   Although controversy remains about which technique is best, most facelifting in the 21st century is multiplanar.  I believe this allows correction of laxity and position of each plane in the face and neck, permitting redraping in different directions as needed to maximize correction, and restore a youthful facial shape.

Given all the improvements in knowledge and techniques why is there so much reluctance?  People would like to avoid surgery and downtime if at all possible.  Modern life has gotten even busier making it harder to fit recovery time into the schedule.  Also, we are visible to the public much more of the time with videoconferences, social media and constant cell phone selfies.  It’s much harder to hide our appearance, even for a few days.

Current trends in facial rejuvenation are focused on earlier treatment  with non-surgical techniques.   Still, there comes a time when there is no meaningful way to look your best or address some of the prominent aging changes with out a facelift.

Misconceptions about the facelift drive the fear and don’t mesh with realities of the modern facelift.

  • Fear of anesthesia –different levels are possible from general, intravenous (IV) anesthesia like for colonoscopy, local anesthesia or local with oral sedating medications. Advances in modern anesthesia have really enabled the explosive growth of ambulatory surgery over the past few decades even for procedures much more extensive than a facelift.
  • Fear of showing scars/ an unnatural look/ change who you look like.  In skillful hands you should look perfectly natural after a facelift.  The many facelift results that we walk past every day go unnoticed because of how natural they look.  The goal is to look like yourself the way you looked in past decades.  Rejuvenation surgery is all about this not changing who you look like at all, just restoring a rested look with no tell-tales of a facelift.
  • The facelift is not just about taking out loose skin. It’s about restoring the youthful shape of the face which has been lost in aging.
  • The facelift continues to evolve with better understanding of facial anatomy, for example where SMAS dissection is needed to release tissue for repositioning, where undermining does not add to the result. This means less incision, less dissection but with more precision to achieve more complete correction with less recovery -a classic win/win.
  • The facelift alone will not fix all of your aging changes. If you have aged enough to need a facelift, many other facial features have aged with you.  Adjunctive treatments help with things the facelift does not addressing.  Eyelid changes, wrinkles, and extensive volume loss are some examples of things on this list.
  • Facelift vs. necklift. The medical name of the procedure is officially cervicofacialplasty, which means the face and neck are addressed.  Minifacelift, necklift, and other partial or reduced procedures are frequently performed but the nomenclature is not important.  Each surgeon has a range of techniques that work well in their hands which they vary based on each individual patient’s facial structure and the type and degree of aging changes present.

What does the facelift do exactly?  The facelift is best at tailoring out hanging or loose skin in the neck and jowl areas sharpening the appearance of the jawline.  The shape and height of the cheek is restored along with the appearance of the emainder of the face.  The facelift does not provide correction for the eyelids or eyebrows, which can be treated with other procedures at the same time.

What does the facelift do exactly?  The facelift is best at tailoring out hanging or loose skin in the neck and jowl areas sharpening the appearance of the jawline.  The shape and height of the cheek is restored along with the appearance of the emainder of the face.  The facelift does not provide correction for the eyelids or eyebrows, which can be treated with other procedures at the same time.

What is the role of the facelift?  The facelift continues to be the big facial reset once obvious visible changes in skin laxity are present.  A facelift twill be medically indicated/appropriate/beneficial at a different age for each individual but in the population as a whole, some patterns and typical ages are shown by the statistics.  most of the time.  Each individual’s perception of and concern with their appearance,  and when he or she is psychologically ready to make a big intervention varies much more widely.

What are the ages?  Data compiled by The  Aesthetic Society shows the trends clearly.  I compared statistics looking at percentage of facelift patients in a given age bracket in 2000 and 2019 (I picked 2019 because it was before the start of the pandemic which put a big temporary dent in the rates of elective surgery).  In 2000, 31% of facelift patients were 35-50 years old and in 2019 the number was 8.5%.  I believe this is a sign of the impact of all the non-surgical treatments which developed during that time span which are particularly useful in maintaining the appearance of younger patients.  Also, improvements in lifestyle have helped our appearance to age more slowly.  In 2000 only 15% of facelift patients were 65 years old or older.  By 2019, the number had jumped to 36% .  Several factors come to mind when looking at this:  1) people are still getting facelifts but at an older age.  2) more people over 65 are still working, socializing and placing a high priority on looking their best.

People often put off scheduling a facelift consultation but facelift or not, you need to have an ongoing relationship with a plastic surgeon to work on maintaining appearance and preventing aging changes.  Smaller treatments will postpone the need for a facelift and you will have a working relationship with a plastic surgeon to have a dialog about when or if a facelift is on the upcoming agenda.

Are there non-surgical options to replace facelift?  Currently, there is no meaningful substitute for the facelift.  There are currently no techniques that produce a facelift-like result in either degree of correction or durability with non-surgical techniques.  The facelift is not about to be obsolete.  But early intervention with non-surgical techniques for facial maintenance can often postpone the need for facelift for a decade or more.

Important Takeaways:

In skillful hands you look perfectly natural and rested after a facelift.

Anesthesia is very safe and can be limited in a variety of ways.

Facelift has less recovery than ever before –typically 1-1.5 weeks for routine work and socializing is possible.

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Links

Transcript

Doreen Wu (00:00):
Welcome back to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I’m your cohost Doreen Wu. And I’m here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The title of today’s episode is “Why You Shouldn’t Fear the F Word: Where the Facelift Fits in Modern Plastic Surgery.”

Doreen Wu (00:31):
Everyone wants to preserve their youth and beauty. And most people would prefer to avoid going under the knife. As our faces begin to age and show signs of wear and tear, we have to start considering the facelift as a potential option. Now, understandably, this can produce some anxiety and oftentimes our thought process and decision-making can be colored by media stories and personal experiences. We are here today to clear up the uncertainty surrounding facelifts and debunk the myths, but first let’s travel back in time to where it all began. Dr. Bass, can you tell us a little bit about what a facelift surgery looked like in the early 1900s?

Dr. Lawrence Bass (01:15):
So facelifting started in about 1901 as a skin only operation, a wedge of skin, usually in front of the ear was cut out and the skin stitched up and this provided reduction in laxity and a boost to the face. And this was fundamentally how facelift worked for most of the 20th century. And during this time, this is really the era of starlets and socialites. The people who had plastic surgery were a very distilled portion of the population, but this was the prototypical plastic surgery operation of all time in aesthetic plastic surgery. So when people think of aesthetic or cosmetic plastic surgery, they think facelift.

Doreen Wu (02:09):
That’s a really interesting mental image that you just painted with the older facelifts being a wedge of skin being cut out. I’m curious, since then, how has the facelift changed over time?

Dr. Lawrence Bass (02:24):
Starting in the 1970s and extensively in the 1980s, surgeons started addressing more than just one plane, just removing skin and re draping skin. They started to take the connective tissue and muscle layers deeper in the face and repositioned and tightened them up as well. So this is the so-called SMAS layer, which is a connective tissue layer overlying the muscles in the face, along with some of the superficial neck muscles, uh, redraping, these and repositioning, uh, became a central part of facelift surgery. Then in the 1990s, there were attempts to do a single plane of elevation deeper to this, the so-called deep plane facelift and attempts to correct other aspects of facial aging, like create a more complete correction of the nasolabial fold the fold between the cheek and the upper lip, just by the side of the nose and the marionette line. The line that runs from the corner of the mouth down to the jawline. And a lot of that 1990s activity has since been abandoned. Some of that’s controversial, whether deep plane is fruitful or not, but most facelift now in the 21st century is multi planer facelift with both deeper layers, SMAS and muscle layers and skin redraping.

Doreen Wu (04:01):
Sounds like over time, we have really gained a deeper understanding of the anatomy of the face. And there’s been a lot of improvement in the techniques with all of these different advancements and such. Why is there still so much fear and reluctance surrounding facelifts?

Dr. Lawrence Bass (04:18):
Well, if everyone had a choice, of course, they’d rather get a great result, have their face look young again with no downtime and no surgery. And that’s perfectly understandable. And in fact, as we’ve entered the 21st century, typical busy, modern life makes it even harder to afford downtime to have a surgical procedure. So the whole trend has been towards earlier rejuvenation using non-surgical techniques. However, there comes a time when there’s no meaningful way to improve the face without using a facelift. The facelift is still the big reset in facial aging. And at some point in time, you’re going to need a facelift. If you want to look your best, the reason people still worry about it largely or evolves around their perception of the facelift, not the realities of what modern facelift is like. So one fear is fear of anesthesia and facelift is done with different levels of anesthesia, depending on the surgeon’s preference and where they’re working.

Dr. Lawrence Bass (05:33):
But sometimes it’s general anesthesia. Sometimes it’s sort of colonoscopy, anesthesia, uh, which gives a quick recovery. Some surgeons do the procedure with just local anesthesia, local anesthesia with a little oral tranquil, but modern anesthesia has really been the powerhouse of an enabling ambulatory surgery. So the ability to have excellent anesthesia, be comfortable for even procedures, much more extensive than facelift, and then wake up and go home an hour later and recover at home has really been enabled by advances in anesthesia. So you feel well, you’re not nauseous and you’re able to function at home on your own. Uh, another big factor is a fear of showing the scars or some unnatural feature or having the facelift change your appearance. So you no longer look like yourself. And in skillful hands, you should be able to have a facelift, even two or three facelifts and look perfectly natural. We see the bad results because they’re very visible walking around, but normal facelift results, which look perfectly natural are invisible. So we’re not aware they’re even out there.

Doreen Wu (07:02):
So it seems like the facelift has really evolved over time, moving away from getting that tight skin appearance to a more natural look, no more wind tunnel appearance, so to speak. I think it’s safe to say, would you agree, Dr. Bass, that the goal of a modern facelift is to take years off of your appearance for patients to look like a younger version of themselves?

Dr. Lawrence Bass (07:25):
Yes, that’s exactly right. Doreen. We’re really trying to make you look like yourself. Just the way you looked 10 or 20 years ago. There are other things we do in plastic surgery where we’re trying to change what you look like. We do that in rhinoplasty surgery or adding cheek implants, or all, all kinds of different things. But in facial rejuvenation like facelift, we’re trying to make you look like yourself, just rested the way you looked a few years ago. Uh, we also have come to a better understanding of what happens to the face as we age and what kind of things we should be trying to do in facelift. So over the last 20 or 30 years, we’ve recognized to a much greater extent that facelift is not about just taking out loose skin. It’s really restoring the youthful shape of the face, which changes as we age.

Dr. Lawrence Bass (08:23):
We’ve also gotten a better understanding of the anatomy, which parts of that SMAS layer are mobile and fixed, uh, therefore which part needs to be released and which part will move on its own without any extra dissection. Uh, we’ve understood how to rework the neck muscles to restore the youthful architecture and facelift overall has come to less incision, less dissection, but at the same time provided us with more complete correction and less recovery. So that’s really a win-win. The other change is rather than try to force the facelift to do things that’s not well suited for like correct the nasolabial fold or the marionette line or create or correct volume loss in the cheeks. We’re increasingly relying on adjunctive treatments to work on other features that facelift doesn’t particularly address.

Doreen Wu (09:27):
Earlier you mentioned that the facelift also can address the neck muscles. So when I, well, the word facelift has the word face in it. I just want to clarify, does a facelift, can it also help with loose skin and other parts of your neck?

Dr. Lawrence Bass (09:43):
Yes, I mean the technical medical name for facelift is cervical facial plasty. And so that means the neck and the face. And there’s a lot of nomenclature out there about neck lifts and facelifts and different kinds of facelifts and many facelifts. Most of that is marketing nomenclature and not really important from a technical point of view. Each surgeon has a collection of techniques that they use, depending on the anatomy. They find what your bone structure is like, how much fat you’ve lost in the face, or how much fat you have remaining in the face, uh, as well as other factors. Um, so the main area that facelift addresses best is looser hanging skin in the neck, the jowl and sharpening the jawline, but the facelift does address cheek shape and position and the appearance of the remainder of the face as well.

Doreen Wu (10:43):
So a facelift kind of addresses the entire that entire area. Um, I think it really helps to create that natural rejuvenated, well rested appearance that prompts your friends and your family to say, wow, you look really good, but they can’t quite put their finger on what change. You mentioned that there are other treatments that can be used in conjunction with the facelift. Can you talk a little about what they are and why they’re an important part of facial rejuvenation?

Dr. Lawrence Bass (11:14):
Sure. One of the biggest things that facelifting can’t address is the quality of the skin itself. So we’re repositioning the fabric of our skin, like the sheet on a bed. So it’s not rumpled up and loose so that it’s flat and smooth, but that fabric itself has been damaged by sun and years. Uh, so restoring the quality of the skin is something that relies on chemical peels, laser peels, and a range of other laser and energy based treatments. And that’s going to have a big effect on how the face age is going forward. I mentioned the perioral changes, the folds around the mouth nasolabial fold and marionette line. If you look in the mirror and pull hard enough on your face to really flatten out those lines, you’ll notice that you’re distorting the shape of the mouth. This is exactly what we’re trying to avoid doing with a facelift.

Dr. Lawrence Bass (12:22):
So by definition, we need other techniques to help us more completely correct those lines. That’s commonly done with fillers, or if we’re in the operating room often with fat grafting, there are a lot of changes around the eyes and the facelift does not address that sometimes that’s eyelidplasty or blepharoplasty surgery on the eyelids. Sometimes that’s chemical peels, fat grafting fillers. There are a whole range of things that happen around the eyes, which is really a subject unto itself. And finally, it’s facial shaping. As I said, the facelift is really a shaping operation for the face. And by repositioning the SMAS and working on the SMAS, we can restore a lot of the balance of upper and lower face width that gets distorted with aging and bring back the youthful shape. But some people don’t have enough remaining tissue in their face to really bring them back where they came from. And so fat grafting can help us with that.

Doreen Wu (13:26):
You know, it’s funny that you mentioned fat because that’s another scary word that begins with F I’m not so sure I would want to add fat to my face. Why is that an important and increasingly popular procedure that’s being done in conjunction with facelifts?

Dr. Lawrence Bass (13:41):
Yeah, I get that feeling a lot. You know, most Americans would like to get rid of a little bit of fat, not add any back in, however, for most of us, unless we’re very overweight, we are actually losing fat in our face. And this is an event that starts in our twenties, you know, 25, we may have the baby face, but then we start losing fat later in our twenties and on into our thirties. And that gives us a more sculpted look. And often that’s a better look in many ways than we had at 25. However, it doesn’t stop there. And eventually that fat loss becomes too much of a good thing. If you think of someone who’s very elderly and how gaunt and empty their face looks, that shows you where this journey ends and that’s because we continue to lose fat. And as we get into our later fifties and sixties, we’re also losing muscle volume in the face and we’re losing bone volume in the face. So all of these losses contribute to a change in shape that we would like to reverse as part of facelift or facelift with some adjunctive fat grafting.

Doreen Wu (15:03):
It seems like aging is this battle that we can never really win. Um, but it sounds like the facelift can produce some really great results. I’m wondering, should people wait until a certain age before getting a facelift? In other words, how do I know if it’s the right time?

Dr. Lawrence Bass (15:20):
Well, first of all, I think you’re right during, you know, we’re never going to win the war against aging either with our appearance or health in general, but we’d like to win an awful lot of battles along the way, even though we know sooner or later we’re going to lose the war. So facelift is really, as I said, the big facial reset and medically, this is going to come at a different time for different people, depending on how they’re aging separate from that. There’s a time when you are psychologically ready when you feel that it’s an important part of your beauty plans and looking good and feeling good about how you look to undergo the facelift. And that’s a personal decision that varies a fair amount from person to person. But, you know, there are statistics on this and the aesthetic society has been collecting statistics since the late 1990s.

Dr. Lawrence Bass (16:25):
And they tell us some interesting things. So let’s look at the age distribution for facelift in the year 2000 and in 2019. And I picked 2019 because that’s before the pandemic began, because that obviously had an impact on how many procedures were being done. So if we look at 2030, 1% of patients having a facelift were aged 35 to 50. If we look at 20, 19, only eight and a half percent of, of people having a facelift were 35 to 50, that’s a big drop. Absolutely. And, and that’s a commentary on how productive all of the non-surgical treatments have been at helping us look better in conjunction with better lifestyle. You know, we all know sun ages the skin, everyone is smoking less, which is a big skin aging factor. So changes in lifestyle have, let us age more slowly, but also all of the non-surgical treatments, keep us looking good, not needing a facelift for a while longer. Let’s look at the other end of the spectrum in the year 2000, 15% of facelift patients were age 65 or older, but in 2019 36% of facelift patients were age 65 and older. So folks are reaching the point where they’ve aged enough to need a facelift at a later stage, but we’re also more active for longer, still working, still socializing, still having a priority on looking our best.

Doreen Wu (18:17):
And even when, um, let’s say a 60-year-old woman comes in and gets a facelift, she can still sail into the sunset and enjoy the results of her facelift. She’s not putting it off until she’s 80. I feel like another common trend is that many people put off scheduling a face consultation because they don’t think they’re old enough, but now we know that there’s no optimal age per se. And that when performed by a skilled plastic surgeon, the facelift can benefit people of all ages, not just quote unquote older adults.

Dr. Lawrence Bass (18:53):
I feel this is why it’s really important to be engaged in or in an ongoing relationship with a plastic surgeon, someone who’s going to help you maintain your appearance and prevent aging changes for as long as possible. If you’re working with small treatments, you’ll postpone the need for facelift, and you’ll already have a trusting and collaborative relationship with your surgeon so that you can work together to decide when, or even if a facelift is on the agenda for your youth and beauty plan.

Doreen Wu (19:25):
That makes me think of another point, given that going under the knife is a big decision and not one to be taken lightly. What if I’m not ready to take the plunge yet? Are there non-surgical options that are available?

Dr. Lawrence Bass (19:40):
This is the question everyone’s always asking. And of course, as I said earlier, we’d love to get a facelift like result without having to have a facelift. But currently there is no technique that gives us the degree of correction or the durability of correction that we get with a facelift. So there really is no substitute once you’ve aged enough to medically need a facelift, we’re not going to be able to get you that result without doing a facelift. And as a technology researcher, I don’t see anything on the horizon in the next five or 10 years, that’s likely to make the facelift obsolete. However, early in the aging game, as I said, a number of treatments and techniques can help you postpone the facelift often for a decade or more. And I think that’s what that data from the year 2000 versus 2019 shows us that we can push off the facelift maybe for a decade, if we’re doing a good amount of active facial maintenance.

Dr. Lawrence Bass (20:46):
The, the last important point about this though, is those non-surgical options. You know, they do what they do. They’re great options if you’re in the right place and time to benefit from them, but trying to push them too hard to produce a facelift, just produces trouble, distortion complications, or an unnatural look. Perfect example is fillers. A lot of folks, either who don’t do surgery or who don’t want to have surgery are trying to avoid a facelift by just pumping themselves up with fillers, adding fillers to restore volume. You’ve lost is a good idea. It makes you look the way you used to look. Uh, you can even accent certain features modestly. That’s a good idea, but pumping you up just to take laxity out of the skin is going to end up distorting your appearance because you’re putting more volume than what you’ve lost with aging

Doreen Wu (21:43):
Too much of a good thing can be a bad thing, essentially. So Dr. Bass, to wrap this all up, can you tell me what are the key reasons to not fear the F word?

Dr. Lawrence Bass (21:54):
I think the big idea about facelift is in skillful hands. You look like yourself, you look perfectly natural and rested. Uh, it is a very safe procedure. The anesthesia required is not heavy amounts of anesthesia. The recovery time is less than it’s ever been before. Typically somewhere on the order of a week to a week and a half. I’ve had patients come in saying they think it’s three months for them to recover from a facelift. Well, who can afford to take three months off of whatever it is they’re doing in life? Nobody really, uh, but it’s really only about a week to a week and a half of downtime before routine work and socializing is okay. So I think for these reasons, if you are looking at skin laxity and aging changes that are really bothering you and it’s time medically, it’s, it’s a great option for restoring youth and beauty.

Doreen Wu (22:53):
Well, if you find yourself still fearing the F word, be sure to tune in to our next episode, to hear what you can do to postpone the need for a facelift. This is Doreen Wu, thanking you for joining Dr. Bass and me for this discussion of facelift and why we don’t need to fear it. Don’t forget to join us next time for our episode titled before the facelift, how a multifaceted program of non-surgical treatments can add a decade before the facelift.

Speaker 3 (23:20):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class Podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.

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