Patients may ask about alternative procedures such as a tuck or laser facelift that avoid the incisions that come with a facelift. This is reinforced by some operators who advertise procedures that supposedly can deliver the result of a facelift, without the surgery. It is important for patients to know exactly what to expect from each procedure so that they don’t have unrealistic expectations or disappointments.

Suspension sutures

Surgeons have tried to suspend the face using sutures introduced through the temple called “suspension sutures.” The problem has been that sutures tend to pull through the tissues. One surgeon who promoted this technique no longer does them regularly, relying on overlapping (“imbrication”) of local tissue in the cheek instead. However elegant in diagrams, long distance fixation does not work well in the human body. The farther the fixation point from the tissue being elevated, the less reliable the lift. This is true not only for the face, but also for the lower body in lower body lifts. Suspension sutures have never been shown to be effective in cosmetic breast surgery either.

"Laser lifts" avoid the incisions that come with a facelift and are often touted by operators who advertise procedures that are supposed to deliver the result of a facelift without the surgery.

One patient consulted with me after having a procedure she saw on a talk show which promised the results of a facelift, using a laser under the skin to tighten it with only a small incision under the chin. Declining my recommendation of a facelift, she flew to Coronado Island to have this 'weekend facelift,' performed by a dermatologist. Predictably, this procedure did not correct her saggy jowls or neckline. She was disappointed with her experience and was understandably nervous about proceeding a second time with the appropriate facelift procedure she needed in the first place.

Laser treatments smooth facial wrinkles. For younger patients with minimal facial sagging, this may suffice because there is some skin tightening which accompanies the laser resurfacing. However, the effect is limited. To most effectively treat jowls, neck skin loosening and elevate the cheek tissue, a facelift is needed.

'Mini-lifts' sound attractive - perhaps the right combination of at least some surgical results and a minimum of downtime and expense. However, because this is often little more than a skin-only type of procedure, it is less effective and less durable than a deep-plane facelift and only marginally less expensive. A facelift ideally elevates the deep tissue of the face and treats the cheeks, jowls and neckline to achieve a harmonious result which truly rejuvenates. Furthermore, the mini-lift scar still courses around the ear. In my opinion, if you are going to have such a scar, it is best to make the most of it and maximize the trade-off between a scar (the cost) and rejuvenation (the benefit). It is better to be bold and get the results rather than compromise for something less.

'Minimal access'procedures such as the 'MACS lift', which has received much attention lately, cause scars that may still be quite conspicuous in the temple or highly visible along the hairline (the scar is frequently hidden by hair in photographs.) Recognizing its limitations, the authors have revised this approach to include an incision behind the ear. The incision now resembles a typical facelift scar and cannot be considered 'minimal.'

Midface Lift refers to the elevation of the cheek (“malar fat pad”). It is a component of the deep plane facelift that uses the SMAS as the handle to elevate the midface. Some pioneering surgeons attempted to elevate the cheek using the same lower lid skin incision used to perform a lower blepharoplasty. It seemed like a good idea to try to make use of this incision to go beyond just redraping the orbicularis muscle, elevate the midface too, and do it without going to the trouble of making facelift incisions, a “minimally invasive” approach. Sounded like a winner.

But it didn’t work well in practice and, to their credit, the authors quickly alerted other plastic surgeons of its shortcomings. But even more importantly, these deep tissue dissections through the eyelid allowed scar tissue to pull down on the lower eyelid, and a number of patients developed ectropion deformities. The patient who presented for cosmetic surgery to look better now looks worse. Not only that, he or she will need additional surgery to treat a difficult problem. Plastic surgeons call this “turning a cosmetic patient into a reconstructive patient.” It does not take many such patients for a surgeon to reconsider a technique. An effort to minimize backfired.

Short Scar Facelift procedures have an obvious marketing appeal. After all, who doesn’t want less scarring? This approach reduces the length of the scar behind the ear and may suffice in younger patients, but most patients have enough loose neck skin that limiting the scar here may compromise the degree of neck skin tightening that is achieved. Also, the abbreviated postauricular scar may cause skin puckering behind the ear (“dog ear”), a visible stigma of surgery. Further, only the portion of the scar that is normally well-hidden behind the ear is shortened. The more conspicuous portion of the facelift scar, in front of the ear, remains the same.

'Lifestyle lifts' are in vogue at the moment and heavily advertised. I have seen a patient who had this procedure, attracted by the promise of results and minimal downtime. She required reoperation to correct significant scar deformities that resulted from inexpert surgery. See patient V.C. in Patient Photographs.

Lengthy Temple Incisions are Unnecessary

Ironically, the “short scar” and MACS lift include lengthy incisions in the temples, which is the portion of the facelift scar which may be abbreviated without compromising the result, and a conspicuous portion of the facelift scar. It makes more sense to shorten the scar in the temple, where it is obvious, than behind the ear where it is usually is well-concealed.

In fact, the incision I use is no longer than the short scar and (original) MACS lift incisions – it is just positioned differently – shorter in the temple and a little longer behind the ear. Patients need to be able to wear their hair up and back, exposing their ears, without worrying about scars.

Scar Satisfaction

Our survey showed that 98% of patients were satisfied with their facelift scars. This high degree of scar satisfaction is reassuring, and allows the surgeon to use the procedure to maximum effect without being preoccupied by concerns about scarring.

It is important to remember that the scar is the “cost” of this procedure and needs to be good enough so as not to outweigh the benefit. It does not take much scar deformity to negate a marginal benefit. In the best scenario, there is a significant reduction in apparent age without a conspicuous scar. Marginal rejuvenation in the presence of a conspicuous scar deformity is obviously a net negative. Equivocal rejuvenation and an excellent scar is a wash. It is not good enough just to have a great scar.