Frequently Asked Questions about Alternative Treatments
Q. I don't think I want to have a facelift. Can I have laser treatment instead?
- 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, there is no substitute for a facelift.
Q. Is it true that mini-lifts provide many of the same benefits for a lot less money and with less downtime?
- "Mini-lifts" are little more than a skin-only type of procedure and are less effective and less durable than a deep-plane facelift. 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. Most patients agree that, iff you are going to leave 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"). The cost difference is typically not as big as you might think, and certainly there is no economy in having to have another procedure a year or two later.
Q. Scarring is a big fear of mine. Do you do a "short scar: facelift?
- The so-called "short scar" facelift has obvious marketing appeal. In this approach, the length of the facelift scar behind the ear is reduced. This type of limited lift may be enough for young patients with minimal skin laxity. However, most, patients presenting for a facelift have enough loose neck skin that limiting the scar behind the ear is likely to compromise the result by limiting the degree of neck skin tightening that is possible. Also, the abbreviated scar may cause some skin puckering behind the ear ("dog ear"), a visible stigma of surgery. The conspicuous portion of the scar, in front of the ear, remains the same length; it is not shortened at at all. As it turns out, our patients tend to be very satisfied with their scars; only 2% reported scar dissatisfaction.
Q. Is it possible to reduce my scar with a "Minimal access" procedure such as the "MACS lift?"
- Although the "minimal access" procedure is marketed as such, the scar may still be quite conspicuous in the temple and also visible along the hairline (this scar may be hidden by hair in photographs). Recognizing its limitations (inadequate treatment of the neck), 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."
Q. What about "Lifestyle lifts?"
- "Lifestyle lifts" are currently advertised and 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."
Frequently Asked Questions: The "When's" and "Why's" of Facelifts
Q. How do I know if I am ready for a facelift?
- It takes courage to see a plastic surgeon. You have no doubt seen media coverage of plastic surgery and facelift storylines graphically presented on prime time television. Many of my patients ask about celebrities who had plastic surgery. They don't want to look artificial. They are worried about the reactions of friends and family. They feel guilty about such an indulgence and spending on themselves. Yet, they still work up the nerve. The fact that patients arrive at my doorstep despite all of these influences is evidence of the profound unhappiness that motivates them, an unhappiness that faces them every time they look in the mirror. One older patient of mine who lived alone confided that she had all the mirrors in her house taken down. I thought she was kidding at first, but she was serious.
- This procedure is used to improve the tone of the face. Hereditary factors and aging cause gradual relaxation of the facial tissues. The skin loses elasticity and gravity accentuates the sagging of the facial tissues. Most of my patients observe this process over a period of several years. Others say it seemed to happen almost overnight. They may pull the skin back when looking in the mirror to see the changes.
- There is no specific age that one should use in determining when to have a facelift. My youngest patient was 33 and oldest 85. A very common age is around 50. Most women are noticing jowls at this age. Also, it may be a watershed time in their lives. The reality of middle age with grown-up kids and, perhaps, finally the opportunity to do something for oneself rather than for others. But, there is no "ideal" age for a facelift and likewise, no specific reason to delay the surgery until a certain numerical age.
- Most plastic surgeons agree that having a facelift earlier rather than later, while the skin has greater elasticity avoids deeper creases that can be more difficult to treat later on. With proper skin care (i.e. sun protection), and future touchup procedures as needed, many patients can maintain an appearance much younger than their chronological age well into their later years. A "50,000 mile overhaul followed by tune-ups", so to speak.
- Patients, who decide to have a facelift, may say to me, "AI love my mother, but I don't like seeing her when I look in the mirror. I'm getting that jowly, double-chinned look that runs in my family, and that crease along the side of my nose."
- Often, an important family event such as a wedding or a reunion, for example, provides the impetus to make changes. Patients may see their facial profiles in photographs and are surprised at how they look, not knowing that "it had got that bad." Most of my patients have thought about the procedure for a long time - months or even years - before having it.
- Many patients tell me that their spouses are supportive, but hesitant. "He tells me he loves me just the way I am. But I'm doing this for me." These words are the ones that tell me the patient is ready and has the right motivation. She is doing it to feel better about herself, not to please others.
You might be a candidate for a facelift if:
- You don't like looking down because your jowls sag more.
- When looking in the mirror, you pull up on your face with a finger on each temple to take up the slack in the skin.
- You don't like the appearance of loose skin or vertical bands of the neck.
- You don't like how you're starting to look in pictures, particularly profile views.
- You feel like you're finally looking like your parents.
- Your aging appearance is starting to affect your mood and self-esteem.
WHAT CAUSES FACIAL AGING?
- Typically, skin laxity starts to become noticeable in one's early forties. Many women are having facelifts in their midforties.Patients that I see in their early fifties often tell me, "You know, I was doing alright up until just last year. Then my face just seemed to fall apart." Sometimes, they may make a correlation with menopause or a stressful life event such as a divorce or loss of a parent.
- The chronological age is really not important. What is important are the findings themselves - loose skin, sagging cheeks, jowls. When these are present and troubling to the patient, a facelift may be recommended, whether she is 45 or 55. I have patients in my practice who were ready for a facelift at 42 (Patient C.C. in Photographs). Others may wait until their fifties before their skin tone has loosened enough to have a facelift. There are very few genetically-advantaged patients who would not benefit from a facelift by their mid-fifties.. It amuses plastic surgeons to see actresses who say they have no interest in cosmetic surgery in their forties; invariably they come to another conclusion one morning while looking in the mirror in their fifties. Mothers say to their disapproving daughters, "just you wait."
- Genetics are most important. If you want a glimpse at your future appearance, just take a look at your parents or other close relatives.
- Sun exposure matters, particularly in lighter-skinned patients with less ultraviolet protection from melanin, who are therefore more susceptible to "photo-aging." Fortunately this effect is avoidable with diligent use of sunscreen and hats. In fact, the skin will improve with sun protection, even in middle age. Patients should not feel that the damage has already been done and there is little point in changing their habits.
- Ethnicity and gender make a difference. Fairer skin types tend to wrinkle and sag more than darker skin types. Thin skin ages faster than thicker skin, and this is why females tend to come in at an earlier age than men. In my practice, Caucasians present for facelifts earlier and more commonly than Asians, Hispanics, African Americans and other patients of color.
Q. Does smoking matter?
- Conventional wisdom holds that the mechanics of tightening your lips around a cigarette causes more lines around the lips, commonly known as "smoker's lines". But we see these in plenty of non-smokers too. Of course, smoking cannot be good for the skin, but whether it affects skin aging is unknown. One thing is certain - smoking interferes with skin circulation and is to be avoided around the time of surgery because it increases the risk of healing problems.
Q. What are the most common reasons for having a facelift?
- Patients often bring up the issue of "vanity" and wonder if it is an acceptable reason for wanting a facelift. My response is: "Is it okay to want to repaint your house, get some new clothes, or change in an old clunker for a new car? Why would it not be okay to spruce up your facial appearance?"
- People in many parts of the world, Brazil, for example, do not find it necessary to justify such vanity. Perhaps, it is the American Puritanical heritage that makes us question such "self-indulgence." The purist would eschew jewelry and makeup, and leave her hair looking like Albert Einstein's, or maybe cover it with a Pilgrim's hat. It strikes me that one's appearance is more important than jewelry, and perhaps jewelry is a poor substitute. Is cosmetic surgery the 21st century extension of jewelry? One of my patients called her cosmetic surgery her "everyday jewelry." At least vanity is not included among the seven cardinal sins.
- Having a facelift is really just an extension of one's desire for self-improvement, to "look one's best." It can have a profound psychological benefit! Many of my patients are also losing weight, exercising, quitting smoking, eating better, having cosmetic dentistry, whitening their teeth, undergoing LASIK treatment so they don't need to wear glasses, and having their varicose veins injected. Timing is often related to a watershed life event – children leaving for college, marital breakup, turning 50, substantial weight loss, change in job, retirement, or moving to a new city.
- The traditional view is that a facelift is not supposed to be undertaken in response to an external life event and there should be no expectation that a facelift will solve one's problems (when it may have been closer to the truth to say that past techniques may simply not have been up to the job). The over-the-top Nip/Tuck series promoted the dark view of cosmetic surgery as a false prophet of happiness, a desperate and often pathetic diversion for those whose who fail to confront their internal issues. These old ideas are being reexamined. Life events may well trigger a patient's decision to have cosmetic surgery. The example I see regularly is the woman whose husband left her for a younger woman, some of whom are featured in the Patient Photographs section. This always impresses me – the fact that a youthful appearance alone can trump all the advantages of having a partner with shared life experiences, memories, and children, and the tremendous personal and financial upheaval that results from divorce. Obviously, there may be other considerations, but, undeniably, lost youth is the big one. It is a big psychological boost for her to "ramp up" her appearance. It helps her to make a new start.
In truth, many patients do experience a psychological improvement from cosmetic surgery. It is not unreasonable for them to think that this may have a positive effect on their quality of life. I've been told by many of my patients (including psychologist-patients) that a few hours under the scalpel was more helpful in boosting their self-esteem than hours of psychotherapy.
Q. Does the workplace put pressure on people to look young?
- I am struck by how many of my patients tell me that work pressures are part of their decision to have surgery. They say that while there is no official age policy where they work, but there is an "unofficial" one. If this were not the case, why is it that early retirement is offered or encouraged for employees over 55? A local major telecommunications employer just settled a multimillion dollar suit brought by its older employees, including patients of mine whose concerns were obviously justified.
- Typically these patients are about 55 years old and feel they are on the cusp of being "over the hill" and this is not some frivolous concern. They may feel that they could lose their job to a younger employee. Often, it is not necessarily being older that is the problem, it is looking older. While it is shameful to treat older, experienced employees this way, it is also a reality. Patients tell me there is no fighting it. It is a sad commentary on our values, but a bias that is unlikely to change.
My own mother told me that if she had not had a facelift at age 58 (yes, I did it), she would not have been able to stay on and eventually retire at a time of her own choosing, which was 67.
Cosmetic surgery not only has personal importance; it can help keep people in their jobs.
Q. Why do some people have multiple facelifts?
- Most of us know of people who have had not just one facelift but two or three. The perception is that these people must be unbearably vain. But, this is not necessarily the case. There People do not have a second or third facelift because they enjoy having facelifts. Rather, it is because the benefits have been lost. Their early facelifts may have been "skin only" tightening procedures. These procedures can produce a temporary "drawn tight" look.. There is some benefit, but this is followed by skin sagging only a few years later. The skin is notorious for its ability to stretch. This was the impetus for the development of techniques that pulled tight on the inelastic connective tissue layer below the skin.
In fact, I have redone many such facelifts (See L.B. in Patient Photographs), some as soon as one to two years after the original, which was probably a "skin only" lift with minimal or no deep plane dissection. Even on some of my own patients treated using the deep-plane lift, I have done secondary facelifts for patients with particularly resistant jowls.
- Fortunately, a facelift can be redone. The original scars are included in the skin which is removed. It is often possible to improve the scars by reducing tension on the earlobe and tucking the scars in closer to the ear and into the hairline to help make them less conspicuous. The surgery proceeds much as a primary facelift does and, perhaps surprisingly, does not pose much greater difficulty for the surgeon (unlike a redo rhinoplasty). Usually a smaller amount of excess skin is removed, sometimes just the scar. The emphasis is on the deep-plane lift, which may not have been done before or perhaps not as extensively.
Q. How young will I look after a facelift?
- Surgeons often claim that a facelift will take a certain number of years off your appearance. A number I often hear at meetings is ten years. I have even seen such a number used in advertisements for skin cosmetics and laser treatments.. However, these estimates are purely wishful-thinking. Photographs showing such an apparent difference in age invariably show best case results, with lighting, makeup, jewelry, and facial expression all more favorable in the after picture.
How much younger will I look? Perhaps surprisingly, we now have some answers:
||Apparent age reduction
||1.0 - 13.6
|Facelift and blepharoplasties
||2.2 - 9.5
|Facelift, blepharoplasties, and forehead lift
||1.1 – 14.2
|All facelift procedures
||0.8 – 14.2
* 71 patients.
In our survey, photographs of patients taken before surgery and at least 6 months after surgery, without makeup and under identical photographic conditions, were shown to members of the public who attended a Women's Exposition. The "age guessers" were asked to judge the age of the person in the photograph, not knowing anything about the individual. Two different books of photographs used, each alternating before and after photographs so that the age guessers did not view both before and after photographs of the same patient. The results of this study showed that the average reduction in apparent age after a facelift alone was 4.6 years. Patients treated with blepharoplasties were compared to patients without blepharoplasties. Doing eyelid surgery, on average, provided another 2 years of reduction in apparent age. The same was found to be true for forehead lifts. Laser resurfacing, on average, provided 2.5 years of age reduction. An interesting finding was that smokers' apparent age reduction averaged 8.1 years, significantly more than nonsmokers (5.6 years), perhaps because they looked older to start with.
There was no significant difference when patients were compared by gender, decade of life (forties, fifties, sixties…), or body mass index. None of the 71 patients was judged to look older after surgery and some patients were judged to look 14 years younger. This data represents the only information available regarding objective assessment of apparent age after cosmetic surgery. It is the first solid evidence that cosmetic surgery is effective.
Interestingly, 97% of patients themselves thought they looked younger and patients themselves thought they looked an average of 12 years younger (range 0 – 27.5 years)!
Q. How Long Does a Facelift Last?
- This is one of the most common questions asked by patients. Almost everything in life wears out - the car, the washing machine, etc. - so they want to know when their facelift will finally wear out too. They would appreciate adefinite answer.
But, the answer is more complex and requires an understanding of what a facelift does (reduce apparent age) and what it does not do (stop the aging process). By lifting and restoring tone to the face, a facelift can reverse many of the effects of time and gravity. Combined with other techniques, one's apparent age may be reduced. Our study found that combined facial rejuvenation reduced apparent age by an average of 6 years, so a 56 year-old now looks 50. In ten years, she will appear to be 60 years old, not 66. So the facelift turns back the clock. Patients will always look younger than if they had not had the lift.
- So,when might a patient return to have another facelift? If she is unhappy with the way she looks now, and can expect to have a similar appearance in six years, it makes sense that she might return at that time for another lift. However, in practice, few patients return before ten years. And, in some areas, such as the neck, the surgical improvement may hold up much longer than six years: (See B.W. and B.K. in Patient Photographs).
- The "six-year reduction" does not consider maintenance procedures along the way. In fact, patients do return for touch-up procedures after their lifts. They may return every few years for a light laser resurfacing or fat injection.With such maintenance, they may look better in six years than they did before surgery today. I have patients in their fifties and sixties who think they look better than they did a decade ago and some fifysomethings (Patient B.W. in Patient Photographs) who say they never looked better.
Some surgical changes may persist beyond a decade. Double chins are an example. Fat removed under the chin does not come back, although the skin will gradually loosen. Patients treated simultaneously with a chin or chin/jowl implant will always have a more balanced and pleasing profile. If skin is protected from UV exposure, the skin quality may actually improve. The results of eyelid surgery may well last beyond ten years. Frequently, the eyelids look better than they did in pictures ten years ago. It is important for the reader to maintain a healthy skepticism: that is why long-term follow-up photographs are important and are included in the Patient Photographs section.
- In practice, I have done plenty of "maintenance" touch-up lasers and fat injection. I have done facelift revisions on several patients whom I treated with a deep-plane lift previously, incorporating a tightening of the subcutaneous fat layer in the jowls ("imbrication") for patients with persistent jowls despite a previous deep-plane lift.
In fact, the effect of the facelift does not wear off at some point. Women and men will always look younger than if they had not had the surgery, one month after surgery or ten years after surgery.
- We do not yet have a way to stop the effects of aging (cellular degeneration, possibly due to the harmful effect of free radicals on our DNA), gravity, and we certainly cannot stop time. But, what we can do is reverse some changes that these have produced. Gravity and loss of skin elasticity allow the skin to sag with time, cheeks to fall, jowls to form, and skin around the neck to loosen. We have the ability to lift up the cheeks, tighten the jawline, and remove loose skin. We can restore tone to the face. The cells are not any younger, of course, but the appearance is younger. Laser resurfacing can do more. It actually does promote new collagen formation and replacement of sun-damaged skin cells with new skin cells. Fat injection introduces stem cells which may have beneficial effects that are presently being investigated. Research has confirmed their reparative properties when introduced into other tissues.
Time marches on as it did before the surgery. Gradually, the skin relaxes and new wrinkles form. Perhaps, in six years, the skin will have loosened to the same degree it was at the time of surgery. But even then, the appearance will be six years younger than it would have been without surgery.
- The question: "Can we look young indefinitely?", would not have been taken seriously even a decade ago. While this question may have been answered with a resounding "NO" even a decade ago, there are now serious plastic surgeons, including myself, who believe that, with properly timed interventions, women and men can maintain a youthful appearance well into old age.
For example, one could have a facelift at fifty, followed by laser touch-ups, fat injection to maintain volume, well into a patient's senior years. I have patients in their seventies who swear that they are going to fight the aging process every step of the way. They look youthful and vital. They refuse to look old and feel irrelevant. I have patients in their fifties, sixties, and the occasional septogenarian (See Patient W.A. in "Patient Photographs") that can still turn heads.