Norman Leaf MD FACS

Sep 04 2015

Why is There So Much Confusion About Facelifts?

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Why is There So Much Confusion About Facelifts?

SMAS Lift, Deep-Plane Facelift, Mini-Lift, Short-Scar Facelift, MACs Lift, Mid-Face Lift, Life-Style Facelift, Doctor ------ Lift, Magic Lift...

It’s no wonder that prospective patients are sometimes confused by all these different names…I myself have been at a loss to explain several of them. But it’s not the facelift operation itself that confuses me…that part I’ve got down pat (and I should, after nearly 40 years of constantly improving my game)…it’s why there’s so much marketing-driven emphasis on the name.

First and foremost these are all surgical procedures, except for the last one, (which I just made up) and as such, should be performed by surgeons, particularly plastic surgeons. Not “cosmetic surgeons”…that title does not indicate any degree of proficiency whatsoever. Any doctors with a medical degree and no level of training whatsoever can refer to themselves as cosmetic surgeons, because there is no legitimately-sanctioned competency board for “cosmetic surgery.”

So, getting back to the wild profusion of names for similar operations, let me try to shed some daylight on how they differ. There are facelifts and there are facelifts; some are well-accepted variations on the basic themes, and others are just names meant to impress and attract patients. It’s easiest to start with the latter, because subjecting them to transparency tests reveals all.

“Life-Style Lift”: Patients have asked me…what is it? The simple answer is that it’s not an operation at all. It’s the name of a marketing company that has been seemingly successfully operating in many areas around the country. I should say had been operating, because they recently closed down after declaring bankruptcy. I feel it was morally bankrupt from the start, in the sense that their very slick advertising campaign was intentionally misleading. The campaign was, however, quite effective; the promise of beautiful, natural results at rock-bottom costs…no need to go to fancy plastic surgeons who charge much, much more…is always an appealing thought (except to us fancy plastic surgeons). In order to keep prices extremely low, the company would hire local surgeons by the day, some of whom might have had very little training or experience, and require them to complete the procedure in about 90 minutes, and then to do 3 or 4 of them in a day. Furthermore, the doctor wouldn’t have to waste time meeting with the patients in advance, to determine if the operation was suitable or even safe for the patient, or waste time with follow-up visits…the company would take care of all of that. All the doctor had to do was show up and operate.

But the most confounding thing of the Life-Style Lift was that people were led to believe it was actually a unique procedure, something that only could be achieved through the auspices of that company’s many outlets. I have personally seen more than a few patients who were unhappy with their results from the LSL, and I have found on examination that there was very little similarity between many of them. It appeared that the operations they received depended on the decisions made by whichever surgeon was operating that particular day. There was no one procedure that could properly be called a Life Style Lift…in fact, the only common thread I could see was that most of them appeared to have been done hastily and mostly in a slapdash manner. Of course, I only saw the patients that were unhappy with their results. I’m sure there were some that were pleased.

Regarding the Doctor ------- Facelift (insert name of doctor who believes that affixing his name to it would make people assume that he and the procedure are something pretty special), most of these proprietary names are simply and completely marketing ploys. It doesn’t necessarily mean the doctor isn’t adequately trained or skilled, but it’s usually a tip-off that the doctor has resorted to self-aggrandizing tactics to peddle his wares. I personally don’t know of a single plastic surgeon I respect who has his or her name attached to any procedure, although many times a newer technique will become known to the profession by the name of the doctor who introduced it. When that happens, say, following the publication in one of our highly-vetted journals, it is an acknowledgment of respect from the author’s peers, not a self-appointed bit of bragging, and it becomes a routine part of the plastic surgery nomenclature.

The moral: if the procedure is only performed by one doctor or by one company, don’t assume it’s because no one else is smart enough or up-to-date enough to do it. It’s inevitably a blatant marketing ploy, and most really good surgeons don’t need to do that, even in today’s highly competitive marketplace.

Returning to the more accepted procedures, variations, and options, it’s reasonable to first ask what the patient wishes to improve. Most commonly, it’s the sagging neck. After that, it’s the jowling of the cheeks, the loss of definition of the jawline, the fullness and loose skin of the eyelids, and possibly a receding chin or low, angry-looking forehead and brows. The fine lines and discoloration associated with sun-damaged skin is best treated with the laser, which can be used at the same time as a facelift or by itself.

Restoring the face to a more youthful appearance is much more than tightening skin…if that’s all that’s done, the skin will look pulled and the change will be pretty short-lived. And it’s more than just injecting fillers or fat…this is helpful to a point, but a bit too much and the face simply appears fat. It’s much more important to restore the infrastructure of the face first. Once the infrastructure is restored, the skin can then redrape over the newly tightened deeper surface without any pulling at all. So, how is this done?

There are essentially two ways to do this. In both cases, the skin has to be partially elevated to get at the deep layer. What’s done after that depends on the preference and skill of the operating surgeon; many feel that there is an actual lessening of facial fat with age, and others feel that the facial fat has just dropped down over time with the gravitational pull. In many cases, both scenarios apply. When facial fat has actually been lost, fat can be transferred from one part of the body, the abdomen or the thighs, to the face in a process called fat grafting.

I tend to feel that the fat has not so much been lost, but has merely descended with gravity. That which previously had provided a youthful, high, rounded cheekbone area has dropped down to create a jowl. So my goal is to elevate that cheek fat back to where it was in youth. This is generally done by isolating, lifting and securing a separate layer of the deep tissue, (SMAS…an acronym for Subcutaneous Musculo-Aponeurotic System) which includes the muscle layer, the facial fascia and the accompanying fat pads. The skin then simply redrapes without tension over the tightened framework, without looking pulled. Still, in patients with a gaunt appearance, I will also do some facial fat grafting.

The SMAS layer extends down below the jawline into the neck, where it blends with the platysma muscle. That’s the flat sheet of muscle that extends from the collarbone upward past the jawline and into the SMAS of the face. With age, this muscle forms into bands , producing the cords under the chin we see when we grimace in the mirror or in an unfortunate selfie. The platysma also acts like a hammock and supports the contents of the neck area, including the salivary glands and some fat under the chin. When we lift the SMAS vertically, it tightens everything, including the jowl and the neck. We also pull the platysma muscle backward to the area under the ears, where we suture it snugly…this combination produces a very firm and youthful neck and jawline. Often we will also sew the bands together under the chin and remove some fat there too. The operation is usually referred to as the Extended SMAS Facelift, and it’s the commonest one I do. Another term is the Deep Plane Facelift, which is very similar, except the deep layer is freed up even more, and there is less separation of the skin from the muscle layer.

How we actually get into the deep layer is variable, but always requires some incision in the skin. The goal is to make that incision as invisible as possible. The “Short-Scar” technique does, as implied, have a shorter scar than the full incision technique. While this sounds like an advantage, it is difficult to get a significant improvement in a very loose neck. If the main reason for the operation is sagging cheeks and jowls, the short scar is usually adequate; but if there is a substantial amount of drooping of the neck area, it’s best to use the longer incision, so the sagging neck muscles and skin can be moved back more securely.

In fact, the short incision and the long incision require the exact same amount of potentially visible scar…that which is in front of the ear. The longer scar is only longer when including the segments of the scar behind the ear, which is essentially invisible.

With either incision, the SMAS layer can be dealt with in several ways, other than the one I described above. It can simply be plicated, or pleated, which tightens it. A section of it can be removed (SMAS-ectomy) and the edges sutured together to create a lift, or it can be tightened by two or three long suture loops that constrict it in a laundry-sack fashion, tightening the deep layer (MACs Lift). The advantage of the MACs Lift is that it’s a pretty quick procedure, done through the short scar incision. And just to confuse you even more, an Extended SMAS Lift can also be done through a short scar exposure as well.

The term MINI-lift can refer to any of the short scar procedures, and is not really descriptive of anything else. In the past, some doctors performed a really mini procedure, removing a little strip of skin in front of the ear and pulling it together; the result looked a little better for at least a month or two, before the skin just stretched out and looked strange. Many patients who are frightened by the idea of surgery in general, prefer to use that term so they don’t think they’re undergoing a major procedure. I have seen many patients who consult with me tell me that they previously had a Mini Lift…yet when I examine them I see the scars of a full, long incision facelift incision. It’s a natural tendency of a person to attempt to minimize the extent of their cosmetic procedures, as opposed to the embellishment of their more essential, serious operations…”You had a two-vessel coronary bypass? You call that Heart Surgery?!? I had a four-vessel bypass!!” Bragging rights don’t really apply that well to aesthetic surgery.

There’s one more facelift term; the Mid-Face Lift. That’s a procedure in which the cheek fat is elevated without tightening the skin. This can be done through an incision in the lower eyelid, (exactly the same one used for doing lower eyelid tightening) or through a small incision in scalp of the temple. It’s good for patients with just some hollowing and drooping of the cheek, without a great deal of jowls or neck looseness. Of course, when any of the other facelifts is done, the mid-face is also lifted; no need for a separate Mid-Face Lift.

I think I’ve exhausted most of the nomenclature generally used to describe facelifts. The only thing I have left to say about them is this: there are well-done facelifts and badly done facelifts. Those don’t require any more specific terminology. I hate using the word botched, but you know what I mean.

The Point: no one recognizes a well-done facelift, but everyone notices a lousy one.


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