Facelift on the Cutting Edge w/ Dr. Sherrell Aston

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Welcome to Park Avenue
Plastic Surgery Class,

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a podcast where we explore controversies
and breaking issues in plastic surgery.

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I'm your co-host Doreen Wu,

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a clinical assistant at Bass
Plastic Surgery in New York City.

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I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,

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educator and technology innovator.

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The title of today's episode is
Facelift on the Cutting Edge.

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We talk about facelift and neck lift
quite a bit on the podcast. Dr. Bass,

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what do you have in store for us today?

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We do discuss facelift
from various aspects.

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Since it's the major
reset for facial aging,

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most of what we've discussed represents
my perspective on the facelift,

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and we've also had some experts
to go back and forth over

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specific issues.

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What I'd like to do today is review the
progress that facelifts have made over

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the past few decades and
outline some of the current

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controversies and cutting edge techniques.

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To do that,

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I've asked my chairman and mentor
in aesthetic plastic surgery,

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Dr. Sherrell Aston to
join us for this episode.

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Dr. Aston is a professor of
plastic surgery at New York

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University,

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a past president of the American
Society for Aesthetic Plastic Surgery,

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and was the chair of
plastic surgery at Manhattan

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Eye, Ear and Throat Hospital for 23 years.

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He also has run an international

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symposium that was for
many years the largest

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aesthetic plastic surgery
meeting in the world,

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and leaders in plastic surgery from
all over the world would come to

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update their techniques by
attending this meeting and listening

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to the lectures and watching
the live surgery that was

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demonstrated at the meeting.

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Dr. Aston is also a host of
the Plastic Surgery Show on

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Doctor Radio,

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and he really is an expert in particular

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on facelifting among his many
other aesthetic plastic surgery

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skills and one of the most accomplished
aesthetic plastic surgeons in

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the world today.

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So we're very fortunate to have
him join us on the podcast.

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Dr. Aston,

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it's truly a pleasure to have you join
us and to get a chance to discuss the

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intricacies of facelifting with you.

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Thank you for that kind
introduction, Dr. Bass,

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and it's a pleasure to be here with
you and of the meetings that we

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produce, a cutting edge surgery symposium.

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You've been a part of that many
times and shared your information

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with the world,

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and certainly you know that
I respect your expertise,

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your judgment, your surgical skills,

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and all of the things that you've done
to contribute to our specialty over the

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years. So it's a pleasure
to be here on your podcast.

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Welcome Dr. Aston. Thank you for
taking the time to join us today.

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So to start us off,

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what is the difference between a facelift
and a neck lift or are they part of

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the same thing?

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Yeah, well, most of the time a facelift
and neck lift are going together.

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If plastic surgeons are talking
to each other and we say facelift,

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unless a plastic surgeon defines that
differently, and I'll tell you how,

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unless a plastic surgeon
defines it differently,

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talking to his colleagues
and I say a facelift,

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he would be assuming that you're
going to be tightening the face,

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and that means from the corner of the
eye down to the jaw area and under the

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mandible a bit.

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And you would assume that also
includes the neck. If you said,

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I'm going to perform a
short incision facelift,

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they'll lay public and often
refers to that as a mini lift,

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then you know that you're only
really lifting the face from the

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corner of the eye down to the jawline,

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but it doesn't change
the neck. A great deal.

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It will change the neck some,

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but not to the extent if
you're doing the facelift.

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And it's really a matter of where
the stitches are placed, facelift,

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the stitches if face and neck lift,

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which as I said most of
the time goes together,

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the stitches go around
the front of the ear,

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some way hidden in the creases or
behind the cartilage of the ear,

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depending on the individual.
Then they go under the ear,

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low back of the ear and up in the hair.
If we are just doing the mini lift,

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the facelift portion, short scar facelift,

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if surgeon is talking to surgeon,

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then the stitches would stop at the
earlobe but not go up behind the ear.

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So that's sort of the basic difference.

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And as we sit here today,

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what is the role of the facelift and
neck lift on the aesthetic playing field?

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Well, the facelift,

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facelift neck lift is a gold
standard for facial rejuvenation.

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It lets you recontour the
underlying foundation,

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which is the most important thing we
do in changing the line foundation.

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Maybe we'll get to that in a little
bit later and take away the extra

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skin. So it's a gold standard.

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And then we have complimentary
things that we do in addition.

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What are some of the changes that
you've seen over the last 40 years?

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How has the facelift gotten better?

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Well, if we talk about the last 40 years,

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you have to remember that in
the early seventies and even in

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the through to the early eighties,

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many times facelifts for many
surgeons just meant lifting the skin.

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The underlying foundation was not
really altered in a significant

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fashion. But then in the mid seventies,

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as some of us started developing,

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the techniques which are being
used today changing the underlying

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foundation in terms of you
know in lay public as SMAS,

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the platysma muscle. So we start
changing the underlying foundation,

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taking away the extra skin, but
rereally draping the extra skin,

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over a changed underlying foundation
in the face, the cheeks and neck,

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the jawline altogether.

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And we were got away from
that pull stretch look of just

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a face tightening procedure
by pulling on the skin.

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What are some common treatments that
are performed at the same time as a

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facelift?

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Well, today with the facelift,
of course we do eyelid surgery,

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brow lifts when we indicated,

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but let's just limit our comments right
now to the face or the face to face and

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neck because we can talk about all
those other areas for a long time.

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But today, we compliment our facelifts
by adding autologous fat grafts.

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That means we take fat
from various parts of body.

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Most often they would take fat from the
medial thighs if the patient has it or

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from the abdomen. The fat that's
taken from the medial thighs.

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Thighs tend to have the greatest
survival rate and the abdomen

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being next.

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But we take that fat out with just
a little syringe aspirate out fat.

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We prepare that fat in certain ways,

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which would take too much
time to go into right now.

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And then we inject that fat into the
areas of the face where a person has

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lost volume,

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the face has fat in different

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layers, if you will.

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There's a superficial fat layers in the
face which give the contour of the face

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and the deep compartments of
fat in the face in both the

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superficial and the deep lives of the
fat become attenuated atrophy with a

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passage of time. And today,
as part of facelift procedure,

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we restore that to make
the faces look much,

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much better at complimenting all
of the advanced procedures that we

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can do to the underlying smash
portion of the phase or the

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underlying foundation.

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And I think that's important
that we're repositioning,

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but we want to shape the phase.

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We want to improve the quality
of the skin that's aged

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and that adds to what
we accomplish with the

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facelift itself.

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So multimodality approach brings
a more complete correction

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and addresses more of the changes that
have taken place over the decades of

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aging that led up to the facelift.

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And let me just add to that if I could,

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because today we are doing radio
frequency to make the quality of

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the skin better, FaceTite,
AccuTite along with the facelift.

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And with doing that, with changing
the underlying foundation,

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we can get an architectural rejuvenation,
the face in terms of contour.

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And by adding the
radiofrequency technology,

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we can get a anatomical biological

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rejuvenation of the skin itself.

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I know Dr. Bass does,

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I do almost every facelift
adding to technology to make the

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skin quality better. Facelift
takes away the extra skin,

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then we've got to make
the skin better quality.

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Now let's talk about the results.

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How much improvement can I
expect and how long will it take?

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How long will the surgical
procedure take or?

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My mistake. How long will it last?
How long will the results last?

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How long will it last? Well,
the result will last forever.

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From the standpoint when you reset
the clock on the face if you will,

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then you've reset that forever.
You'll continue to age.

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But at 20 years after a facelift,

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you'll look better than nature
than intended for you to look.

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You'll look better 20 years later
than if you had not had the procedure.

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So it's essentially lasting forever.

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It's just the aging process
continues unless you're unfortunate.

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And so that's a key point that we're,

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we're setting the clock
back. We never stops moving,

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but you'll never be as
bad as you were before.

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And it's going to vary a little bit
from person to person modulating the

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biology of the skin, the
aging changes in the skin.

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As Dr. Aston mentioned,

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using radio frequency
is going to improve your

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chances of getting longevity
out of the facelift.

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And so again,

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this multimodality approach gives
you benefits not only in your

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time zero results,

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but in what you're going to get out
of the facelift in the long run.

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Now I'm curious, Dr. Astin, is there
a preferred technique in your hands?

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Well, I do different techniques.

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If we're talking about changing
the underlying foundation,

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then I do different techniques
according to the patient's anatomy.

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And you don't have to be a plastic
surgeon to just think about the fact,

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and I'll look at 20 people you see
today and decide in your mind if

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those faces all look to you like they
should have the same facelift technique if

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they're going to have a facelift
because the facial anatomy is different.

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The asymmetry of the face is quite
significant in a huge percentage

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of people.

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There are some characteristics of facial
asymmetry that nature repeats over

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and over and over, and we don't
have to go into those right now,

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but it's definitely true, just like 89%
of people in the world are right-handed.

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There's certain facial characteristics
that are repeated over and over in the

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face. But the bottom line is I use a
different technique according to the

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individual's facial architecture to try
to give 'em more symmetry than nature

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had given them.

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So let's talk in more detail about
the technique used under the skin

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during the facelift. As you
said, the old facelifts 1970s,

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even part of the 1980s were skin only,

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but almost all first time or
primary facelifts performed

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today will include some measures
to address the deeper tissues

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under the skin,

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the muscles and connective tissue
or SMAS layer under the skin.

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So Dr. Aston, I think the biggest
current controversy in facelift

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is the big divide selection of a SMAS

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technique versus a deep plane technique,

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or to put it in more proper language,

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a composite technique because that's
really what the deep plane approach is.

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So for many of us, this
is a long settled issue,

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but it's still widely discussed out there.

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Can you tell us your thoughts?

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Absolutely. Dr. Bass, and thank you
for asking that question. Well, listen,

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let's just tell our listeners this.
Think about the layers of the face.

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The first thing layer you
have is going to be the skin.

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Directly on the skin is
the subcutaneous layer.

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That's a little fat layer
right under the skin.

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And under that layer is the mass
that Dr. Bass just referred to,

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which means superficial
musculo apron neurotic system.

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And that system of fibrous
networks, fibrous tissue,

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provides the connections of the
underlying foundation to the skin

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and the muscles that move the
face. So when you're small,

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it's the attachments that go from the
SMAS up to the skin that move your skin

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as you animate. Now,

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once you go under the SMAS,
you are in the deep plane.

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You can't,

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for practical reasons go deeper
than under the SMAS because when you

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do that,

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you're right on top of the facial
nerves and nerves that move the face.

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So I essentially am in
the deep plane with every

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single facelift I do because I'm under
the SMAS, has to be an extreme arrest,

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a situation where you've
got a secondary or a

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tertiary facelift,
someone who's super thin,

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and there's no way to go into that
plane without injuring facial nerves and

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nobody in their good judgment
are going to do that.

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But primary facelifts and most
secondary facelifts that I do today are

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in the deep plane. Now,

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the controversy today has really been
stirred up into public's mind by social

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media because people talking about the
deep plane without a true definition

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so people can understand
what they're talking about.

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But let for sure factually,

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00:15:11,180 --> 00:15:14,720
anatomically, anytime
you are deep to the SMAS,

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00:15:15,590 --> 00:15:17,270
anytime you've raised up the SMAS,

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you are in the deep plane
and Dr. Bass referred to the

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composite facelift,

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00:15:25,610 --> 00:15:30,050
and that actually means leaving a skin

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00:15:31,220 --> 00:15:36,050
and muscle fat and the anterior
portion of the face attached to the

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skin. In my opinion, first of all,

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that is not regardless of
what the internet says,

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regardless of what social media says,

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00:15:44,180 --> 00:15:48,290
that is absolutely not a new technique

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00:15:48,830 --> 00:15:52,700
developed by anybody who's
practicing plastic surgery

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00:15:54,260 --> 00:15:58,580
today. And that the deep
plane was originally

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00:16:00,110 --> 00:16:04,280
described by Dr. Tord Skoog
who passed away many years ago.

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But in my opinion,

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when you do the deep plain
technique that's social media

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00:16:12,471 --> 00:16:13,490
advertised today,

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00:16:13,491 --> 00:16:16,940
you're requiring the skin to hold
up the underlying foundation.

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I always go under the skin,

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00:16:21,290 --> 00:16:24,020
across the face as far
as I think I should go,

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and then go also under the sma.

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00:16:28,310 --> 00:16:30,680
We do different things with this SMAS.

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Once we have dissected
that as a separate layup,

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00:16:35,270 --> 00:16:39,620
you can think of that as like two
pages in a book raise up the skin,

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00:16:39,621 --> 00:16:43,400
and then you raise up the second
layup when you go under the sma,

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00:16:44,030 --> 00:16:48,830
how you rotate that second
layer where you place the tissue

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00:16:48,831 --> 00:16:52,820
that you've now undermined as
surgeons would say to each other,

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00:16:53,270 --> 00:16:58,040
how you place that undermined
tissue will give a different

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00:16:58,041 --> 00:17:02,180
shape in the face
according to where you move

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00:17:02,570 --> 00:17:04,640
your SMAS layer.

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00:17:05,270 --> 00:17:10,220
And so we use it in different positions
for different people to get the most

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00:17:10,221 --> 00:17:13,820
elegant results for. Did you think
that's a reasonable summary, Dr. Bass?

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00:17:14,300 --> 00:17:17,090
Yeah, I think that's an excellent summary.

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You're hearing it from
the expert's expert,

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and I've thought about this a long time.

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Most plastic surgeons spend
a lot of time thinking about

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00:17:28,520 --> 00:17:32,690
exactly what they do in a facelift and
exactly how they can make it better,

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00:17:32,691 --> 00:17:35,060
exactly who should get which technique.

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00:17:35,870 --> 00:17:40,730
And one of the big teachings
today about facial aging is

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00:17:40,731 --> 00:17:44,750
that every fat pad, the deep fat pads,

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00:17:44,751 --> 00:17:46,730
the superficial fat pads,

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00:17:46,731 --> 00:17:50,670
everything that makes our
facial shape and position

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00:17:51,270 --> 00:17:55,380
shrinks differently from
the other parts and descends

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00:17:55,381 --> 00:17:59,460
differently from the other parts. And so

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00:18:01,290 --> 00:18:05,370
making a single vector of

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00:18:05,430 --> 00:18:10,350
positioning for all of the tissues
of the face as a rejuvenation

286
00:18:10,351 --> 00:18:14,490
maneuver seems intrinsically
inadequate to me

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00:18:15,000 --> 00:18:19,980
compared to looking at each
component of the face and

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00:18:19,981 --> 00:18:24,630
positioning that I think
of it in a multiplane our

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00:18:24,631 --> 00:18:28,950
way and the vector of where things
move and how they're brought

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00:18:28,951 --> 00:18:33,600
together in each zone of the face
and neck at each layer of the

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00:18:33,610 --> 00:18:36,360
face and neck is different.

292
00:18:37,530 --> 00:18:42,510
It's not all of those regions
done the same way at the

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00:18:42,511 --> 00:18:45,660
same time, and it's different
from person to person.

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I agree wholeheartedly.

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00:18:47,941 --> 00:18:52,480
Dr. Bass and the vector of
lifting of the underlying

296
00:18:52,500 --> 00:18:57,360
foundation is often different
than the vector of draping

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00:18:57,361 --> 00:19:01,680
the excise skin because with the skin,

298
00:19:01,681 --> 00:19:05,370
we want to maintain proper
hairlines, et cetera.

299
00:19:06,420 --> 00:19:10,470
You can change the underlying foundation,

300
00:19:10,471 --> 00:19:12,600
put the skin back over top of it,

301
00:19:12,870 --> 00:19:16,890
different vector than you've changed
the underlying foundation and it doesn't

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00:19:16,950 --> 00:19:18,870
look like it's pulled and stretched,

303
00:19:19,080 --> 00:19:24,030
and you're not relying on that
skin to hold up the fatty layer

304
00:19:24,450 --> 00:19:29,430
because you've already separated the fat
from the skin anteriorly on the face.

305
00:19:30,150 --> 00:19:34,980
At least that has been my
experience over the years that I've

306
00:19:35,160 --> 00:19:40,050
been doing this, and I'm
pretty sure Dr. Bass, you do

307
00:19:42,180 --> 00:19:45,810
smash flaps when you think
they're indicated and do
different smash procedures.

308
00:19:46,590 --> 00:19:47,423
People

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00:19:48,780 --> 00:19:53,100
in social media frequently who talk about

310
00:19:53,280 --> 00:19:58,140
SMAS flaps don't really have
an appreciation of what you can

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00:19:58,150 --> 00:19:59,850
do, contour the face.

312
00:19:59,851 --> 00:20:03,300
But if you look at the results
that Dr. Bass produces,

313
00:20:03,301 --> 00:20:06,630
the results that I try to deliver,

314
00:20:06,631 --> 00:20:11,400
you can see a difference in
terms of the face compared to

315
00:20:11,401 --> 00:20:14,340
someone who's just had
everything pulled together

316
00:20:16,140 --> 00:20:17,430
as a composite.

317
00:20:17,820 --> 00:20:20,430
Right, it's not just laxity,

318
00:20:20,440 --> 00:20:24,930
it's restoring youthful facial shape and

319
00:20:25,350 --> 00:20:29,250
that differential vector
for each component.

320
00:20:32,580 --> 00:20:37,140
So I think it's clear and
experienced surgeons would probably

321
00:20:37,141 --> 00:20:38,310
universally agree.

322
00:20:38,320 --> 00:20:42,750
There's not a single best
technique that should just be

323
00:20:43,050 --> 00:20:47,320
cookie cutter applied to every
patient that darkens your

324
00:20:47,321 --> 00:20:48,154
doorway.

325
00:20:48,910 --> 00:20:52,930
But there are a lot of variations
in what's done with the sma.

326
00:20:53,650 --> 00:20:57,460
There are high SMAS techniques,
extended SMAS techniques,

327
00:20:57,461 --> 00:20:58,870
the FAME technique,

328
00:20:58,880 --> 00:21:03,130
which Dr. Aston developed
a finger assisted

329
00:21:03,140 --> 00:21:07,630
malar elevation, elevating
the cheek soft tissues.

330
00:21:08,680 --> 00:21:12,370
People sometimes do things
called strip SMASectomies,

331
00:21:12,820 --> 00:21:15,340
and there's also mass plications.

332
00:21:15,341 --> 00:21:18,580
So to the extent you can,

333
00:21:18,790 --> 00:21:22,630
because I've just listed
a few of the more common,

334
00:21:22,640 --> 00:21:26,440
but not an exhaustive list of the options,

335
00:21:27,280 --> 00:21:32,230
share with me your mental
algorithm of how you pick and put

336
00:21:32,231 --> 00:21:34,420
which patient with which technique,

337
00:21:35,740 --> 00:21:38,620
who really needs one
approach versus the other.

338
00:21:39,160 --> 00:21:43,750
Sure. Well, the high SMAS technique, well,

339
00:21:43,751 --> 00:21:44,290
first of all,

340
00:21:44,290 --> 00:21:48,670
each of those procedures you just talked
about moves down the line foundation in

341
00:21:48,671 --> 00:21:49,504
a different way.

342
00:21:49,990 --> 00:21:54,790
The highest mask techniques allows
you to take soft tissue up above the

343
00:21:54,800 --> 00:21:59,230
cheekbone, more towards the
lateral canthus of the eye,

344
00:21:59,920 --> 00:22:04,870
and that lower temporal hollering
that occurs and also lets you shape

345
00:22:04,900 --> 00:22:07,870
the cheekbone area itself.

346
00:22:08,170 --> 00:22:10,840
So when you evaluate the
patient preoperatively, you say,

347
00:22:10,900 --> 00:22:13,090
where does this person need volume?

348
00:22:13,780 --> 00:22:18,430
And if you need it higher above
the cheekbone as well as on the

349
00:22:18,431 --> 00:22:19,264
cheekbone,

350
00:22:19,630 --> 00:22:23,590
then a high SMAS is an
excellent procedure.

351
00:22:24,160 --> 00:22:29,110
An extended smma procedure
really has to do with how far

352
00:22:29,530 --> 00:22:31,960
anteriorly you release the sma.

353
00:22:32,650 --> 00:22:37,330
And there's some ligaments in the face
where smma is attached called the masic

354
00:22:37,360 --> 00:22:40,420
ligament, zygomatic ligaments.
So with the extended SMAS

355
00:22:42,340 --> 00:22:46,930
technique, you're going anteriorly,
you're dividing those ligaments. Now,

356
00:22:46,940 --> 00:22:48,190
when I do a high SMAS,

357
00:22:48,220 --> 00:22:53,200
I take down the mater in zygomatic
ligaments routinely because

358
00:22:53,230 --> 00:22:54,790
that's how you get the flap to move up,

359
00:22:54,791 --> 00:22:59,050
to give you the most volume that you
can get out of the tissue you have,

360
00:22:59,440 --> 00:23:02,650
but an extended SMAS flap,

361
00:23:03,760 --> 00:23:06,580
it's the extension of your dissection,

362
00:23:06,581 --> 00:23:09,820
and then you can do with that
tissue where you need it.

363
00:23:10,240 --> 00:23:14,020
You can put it high, you can put
it a level of zygomatic arch,

364
00:23:14,590 --> 00:23:18,790
the FAME procedure that
I described in first in

365
00:23:18,791 --> 00:23:20,830
1992,

366
00:23:22,330 --> 00:23:27,040
because the dissection goes into
pre zygomatic space, if you will,

367
00:23:27,220 --> 00:23:31,000
and that's very anterior on
the face. That procedure,

368
00:23:31,510 --> 00:23:36,430
it is limited in terms of
the patients that I think

369
00:23:36,431 --> 00:23:38,500
are good candidates for it,

370
00:23:39,550 --> 00:23:44,290
and it is a composite lift technique

371
00:23:44,620 --> 00:23:47,060
that I described before,

372
00:23:47,540 --> 00:23:52,160
and therefore I think it's only
good for certain anatomical

373
00:23:52,161 --> 00:23:56,660
patients. I also think it
depends on the skin quality,

374
00:23:56,990 --> 00:24:01,760
but a SMAS flap technique gives me a

375
00:24:01,761 --> 00:24:06,320
better result. I compare
my results with my results,

376
00:24:06,740 --> 00:24:09,830
my patients with my patients who've
had the different techniques.

377
00:24:09,840 --> 00:24:14,720
I spent hours and hours sitting at the
very desk where I am now studying the

378
00:24:14,730 --> 00:24:16,880
results of the techniques over the years.

379
00:24:17,480 --> 00:24:21,740
So I have a small group of
patients where I do the fame

380
00:24:22,010 --> 00:24:26,960
procedure four. But in those
patients where I do the fame,

381
00:24:27,050 --> 00:24:32,000
I also do an extended SMAS
dissection and I've got

382
00:24:32,420 --> 00:24:35,810
pictures showing and doing
both, as I said, but,

383
00:24:37,280 --> 00:24:38,113
and then the SMASectomy

384
00:24:39,680 --> 00:24:43,610
means you're taking away some of the SMAS,

385
00:24:44,360 --> 00:24:49,010
you cut a strip of the SMAS
out and people will have full

386
00:24:49,011 --> 00:24:49,731
faces.

387
00:24:49,731 --> 00:24:54,500
Or if you want to move the
SMA to give certain contour in

388
00:24:54,501 --> 00:24:56,450
specific areas of the face,

389
00:24:56,810 --> 00:24:59,720
you can do that with a mastectomy.

390
00:25:00,170 --> 00:25:03,470
It's not a procedure that I do very often.

391
00:25:03,471 --> 00:25:06,680
I'm more likely do one of the others.

392
00:25:07,190 --> 00:25:12,170
And the SMAS Plication
procedure is a procedure where

393
00:25:12,171 --> 00:25:15,560
you actually fold tissue over on itself,

394
00:25:15,980 --> 00:25:18,920
and it is a very good procedure.

395
00:25:19,280 --> 00:25:24,200
It's not a cop-out procedure
at all that because

396
00:25:24,201 --> 00:25:28,580
you've not dissected under
the SMAS to do that because in

397
00:25:28,730 --> 00:25:32,690
properly selected patients where
you need fullness right along the

398
00:25:34,250 --> 00:25:38,090
zygoma, right along the
jawbone, if you will, cheekbone,

399
00:25:38,091 --> 00:25:39,410
not jawbone the cheekbone,

400
00:25:39,860 --> 00:25:43,550
you'll get excellent results
with a SMAS Plication.

401
00:25:43,850 --> 00:25:47,060
But you also have to know it's not
going to give you any fullness above

402
00:25:48,630 --> 00:25:49,490
the cheekbone.

403
00:25:49,790 --> 00:25:54,680
So you have to evaluate which
technique you're going to use.

404
00:25:55,490 --> 00:26:00,200
Then I also do a procedure that I
call a release SMAS Plication where I

405
00:26:00,201 --> 00:26:01,610
release the whole mass,

406
00:26:02,060 --> 00:26:06,320
take down the mass just like we talked
about with a house mass and extended

407
00:26:06,650 --> 00:26:07,100
mask,

408
00:26:07,100 --> 00:26:12,050
but leave the tissue tissue
attached at the zygomatic arch I

409
00:26:12,830 --> 00:26:13,160
implicate.

410
00:26:13,160 --> 00:26:17,810
And that is the most powerful of all the
techniques that I can do to contour the

411
00:26:17,820 --> 00:26:21,140
upper face level. It
gives an excellent result,

412
00:26:22,280 --> 00:26:27,170
it'll take people back to the
cheeks that they had a much younger

413
00:26:27,171 --> 00:26:29,540
point in their life if they ever had it,

414
00:26:29,570 --> 00:26:34,550
because we can give patients with that
technique results that they never had

415
00:26:34,551 --> 00:26:35,384
in their life.

416
00:26:36,140 --> 00:26:40,550
So that's really a
fantastic summary and an

417
00:26:40,560 --> 00:26:44,790
outstanding overview of some of the
effects of all of these different

418
00:26:44,791 --> 00:26:45,624
techniques.

419
00:26:46,350 --> 00:26:51,210
And I hope that helps the
listeners understand there's a

420
00:26:51,211 --> 00:26:56,160
lot of very technical detail
in what's being done under the

421
00:26:56,161 --> 00:26:56,994
skin.

422
00:26:57,180 --> 00:27:01,950
Plastic surgeons spend a long stretch of

423
00:27:01,951 --> 00:27:06,210
years training and
refining their techniques.

424
00:27:06,720 --> 00:27:11,520
And so there isn't a one single best

425
00:27:11,521 --> 00:27:16,380
technique branded technique
names don't really

426
00:27:16,390 --> 00:27:20,820
convey the complexity of what
surgeons are trying to accomplish

427
00:27:20,850 --> 00:27:25,410
underneath the skin to create the most

428
00:27:25,420 --> 00:27:28,950
beautiful face and the
most rejuvenated face.

429
00:27:31,350 --> 00:27:36,120
And so a dialogue with your
surgeon about what your

430
00:27:36,130 --> 00:27:37,350
aesthetic goals are,

431
00:27:37,351 --> 00:27:42,150
where you've seen changes in your
face is probably more important

432
00:27:42,151 --> 00:27:46,710
than trying to learn enough
about different techniques

433
00:27:46,711 --> 00:27:51,600
to direct your surgeon to
perform a certain technique.

434
00:27:52,020 --> 00:27:56,070
It's really a partnership and you're
counting on the surgeon for that technical

435
00:27:56,080 --> 00:28:00,780
expertise and you understand
what the aesthetic goals

436
00:28:00,781 --> 00:28:04,890
are and what's causing you
distress in your facial appearance.

437
00:28:05,790 --> 00:28:10,410
And the surgeon can work on the best

438
00:28:10,411 --> 00:28:12,680
options for reversing those changes.

439
00:28:13,980 --> 00:28:18,570
Another point that I think is important
to make Dr. Bass is the sense of

440
00:28:18,571 --> 00:28:23,100
aesthetics of the surgeon
are also extremely important
because a lot of people

441
00:28:23,460 --> 00:28:28,380
who would say they're technically
competent to perform a certain procedure,

442
00:28:29,070 --> 00:28:33,600
but if their aesthetic judgment
of what really looks good is not

443
00:28:33,601 --> 00:28:37,290
consistent with yours, then you
might not be happy with the result.

444
00:28:38,340 --> 00:28:42,360
And we know we see some
people even today that are

445
00:28:44,820 --> 00:28:48,780
overdone, sort of a
simple word of saying it,

446
00:28:49,500 --> 00:28:53,460
but looking like they've had a
facelift and people shouldn't look

447
00:28:54,030 --> 00:28:55,680
operated on when they have a facelift,

448
00:28:55,740 --> 00:28:58,590
they should look great
but not operated on.

449
00:28:58,591 --> 00:29:02,670
So you need to make sure that the
aesthetic judgment of your surgeon is

450
00:29:02,680 --> 00:29:06,150
consistent with your aesthetic
judgment, right, Dr. Bass?

451
00:29:06,480 --> 00:29:10,530
Absolutely. And we're both
Park Avenue plastic surgeons.

452
00:29:11,040 --> 00:29:13,830
You are the quintessential
Park Avenue plastic surgeon,

453
00:29:15,540 --> 00:29:17,340
so you're on the right podcast.

454
00:29:17,520 --> 00:29:20,970
This is the Park Avenue
Plastic Surgery Class podcast.

455
00:29:22,170 --> 00:29:24,780
But in our environment,

456
00:29:25,200 --> 00:29:27,540
natural is king.

457
00:29:28,830 --> 00:29:32,070
It's key to preserve a natural look.

458
00:29:32,460 --> 00:29:36,600
No telltales, no signs of an operation.

459
00:29:37,440 --> 00:29:42,250
It's you the way your mom would
recognize you way you look

460
00:29:42,251 --> 00:29:46,870
10, 15 years ago. Not some altered you.

461
00:29:47,260 --> 00:29:48,093
Now,

462
00:29:48,100 --> 00:29:52,840
there are a couple of other issues in
plastic surgery that we can sort through

463
00:29:52,841 --> 00:29:57,430
since we have Dr. Eston with us
to share his expert perspective.

464
00:29:58,300 --> 00:30:03,100
There are some major variations in
which skin incisions are used both in

465
00:30:03,101 --> 00:30:06,010
front of and behind the ear.

466
00:30:06,910 --> 00:30:10,780
Dr. Bass mentioned the incision in
front of the ear. So I'm wondering,

467
00:30:10,781 --> 00:30:14,410
Dr. Aston, what is your preference
for this? What are the options?

468
00:30:14,800 --> 00:30:16,450
Well, it depends on the
patient. First of all,

469
00:30:16,480 --> 00:30:20,260
let's say what is absolutely necessary,

470
00:30:20,261 --> 00:30:23,890
you have to have an incision
that starts in the temporal hair,

471
00:30:23,891 --> 00:30:26,950
follows a contour of the
upper portion of your ear,

472
00:30:27,430 --> 00:30:32,380
and somehow it gets down to your
ear lobe. And when I say somehow,

473
00:30:32,381 --> 00:30:36,550
that means it either goes in a
skin crease in front of the tragus,

474
00:30:36,551 --> 00:30:40,870
that little piece of cart that's sticking
up when you put your finger in your

475
00:30:40,871 --> 00:30:41,704
ear,

476
00:30:41,740 --> 00:30:46,600
it's either got to go in front of that
in the skin crease or around the inside

477
00:30:46,610 --> 00:30:49,060
edge of that so you don't see it. To me,

478
00:30:49,070 --> 00:30:53,560
the most important thing is
the quality of the skin in the

479
00:30:54,010 --> 00:30:58,750
cheek and the quality of the
skin on the tragus because if you

480
00:30:58,751 --> 00:31:02,800
look at people, look at yourself in
the mirror, look at your relatives,

481
00:31:03,160 --> 00:31:07,600
you'll see that the skin
on the tragus is often very

482
00:31:07,610 --> 00:31:11,830
delicate, maybe no texture at all.

483
00:31:11,830 --> 00:31:13,150
It's just very smooth,

484
00:31:13,151 --> 00:31:17,770
almost looks like baby skin and the
skin on the cheek that you're going to

485
00:31:17,771 --> 00:31:21,400
lift will have wrinkles and
crinkles and that sort of stuff.

486
00:31:22,000 --> 00:31:26,320
If you make your incision
behind the tragus in those

487
00:31:26,321 --> 00:31:30,550
patients, then when you
take off your extra skin,

488
00:31:30,551 --> 00:31:34,090
you raise up the skin flap,
you take away the extra skin,

489
00:31:34,091 --> 00:31:38,110
and you put that cheek skin on tragus,

490
00:31:38,530 --> 00:31:40,720
it will look odd.

491
00:31:40,750 --> 00:31:44,680
It'll catch the eye from a distance away.

492
00:31:45,520 --> 00:31:49,660
If the cheek skin is consistent
with the skin on ETUs,

493
00:31:50,050 --> 00:31:53,980
then I put the incision around the back
of the tragus so there's nothing going

494
00:31:53,981 --> 00:31:57,010
around the front of your ear
in that little skin crease.

495
00:31:57,490 --> 00:32:00,370
But today we know how
to make those incisions,

496
00:32:00,700 --> 00:32:05,050
whether it's in front of the tragus or
around the back of the tragus in such a

497
00:32:05,051 --> 00:32:09,100
way that it's going to be
hidden for all social reasons.

498
00:32:09,101 --> 00:32:13,570
And we can make them so that the
incision when there's a lot of discussion

499
00:32:13,571 --> 00:32:18,070
before surgery, but I think it's not
much of a discussion after surgery.

500
00:32:18,580 --> 00:32:21,310
You assume people heal
well, as most people do.

501
00:32:22,120 --> 00:32:22,480
Yeah,

502
00:32:22,480 --> 00:32:27,430
I think that's the incision
everyone worries about
because it's out where people

503
00:32:27,431 --> 00:32:30,220
can see it. The other
incisions are much more hidden,

504
00:32:30,550 --> 00:32:34,990
but that's the incision that
rarely gives a problem and

505
00:32:36,070 --> 00:32:38,590
heals beautifully and is usually,

506
00:32:41,300 --> 00:32:44,360
but as you can see, again,
there's no one answer.

507
00:32:44,361 --> 00:32:49,040
Customization is key based
on the individual patient's

508
00:32:49,041 --> 00:32:51,050
skin quality. Now,

509
00:32:51,950 --> 00:32:56,540
do you differ that for men and women or
are there other changes in what you do

510
00:32:56,541 --> 00:32:58,610
when you're doing a lift for a man?

511
00:32:59,120 --> 00:32:59,990
Sure. Well,

512
00:33:00,530 --> 00:33:05,480
there are few men who will have
a significant amount of non hair

513
00:33:05,481 --> 00:33:09,170
bearing skin, no beard
in front of the ear.

514
00:33:09,440 --> 00:33:13,280
There'll be a strip of
good skin without whiskers.

515
00:33:13,760 --> 00:33:14,960
They whip through your finger.

516
00:33:15,230 --> 00:33:18,290
But the percentage of men
who have that are small.

517
00:33:18,291 --> 00:33:22,970
Most men have their beard going right
up to the tragus or very close to the

518
00:33:23,570 --> 00:33:26,120
trauss. And if you're
doing a facelift on a man,

519
00:33:26,121 --> 00:33:30,260
you're sure going to get
a few millimeters to much,

520
00:33:30,261 --> 00:33:32,570
much more of extra skin out.

521
00:33:32,810 --> 00:33:37,700
So I personally never put an
incision behind the tragus

522
00:33:37,701 --> 00:33:40,730
on a man where a beard
would go up on the tragus.

523
00:33:41,060 --> 00:33:44,810
Trying to shave the tragus
is kind of difficult,

524
00:33:44,820 --> 00:33:47,660
but having hairs growing out of
your tragus is not very good.

525
00:33:48,230 --> 00:33:49,280
So the majority of men,

526
00:33:49,290 --> 00:33:52,880
we use the skin crease in front of the
ear and the majority of men who are

527
00:33:52,881 --> 00:33:57,860
requesting a facelift will have a
skin crease in front of the ear.

528
00:33:58,520 --> 00:34:00,890
That's really perfect
for hiding your stitches.

529
00:34:00,900 --> 00:34:05,270
Main thing is maintain the normal
tragus. But other than that,

530
00:34:05,271 --> 00:34:09,380
I don't vary the incision
between men and women at all.

531
00:34:10,100 --> 00:34:12,650
With regard to the incision
at the back of the neck,

532
00:34:12,890 --> 00:34:15,530
do you go into the hairline
or along the hairline?

533
00:34:16,100 --> 00:34:17,780
I never go along the hairline.

534
00:34:18,230 --> 00:34:22,520
I put the incision
behind the ear and it's,

535
00:34:24,510 --> 00:34:28,700
it's almost a small SS shape
incision with the curve in it.

536
00:34:29,090 --> 00:34:31,130
But I go to the top of the ear,

537
00:34:31,250 --> 00:34:36,110
so there's only one centimeter
of skin behind the ear that's

538
00:34:36,111 --> 00:34:41,030
not in the hair, and that one centimeter
is where the ear attaches to the head.

539
00:34:41,810 --> 00:34:46,700
So I curve that incision so that
I restore the hairline back to

540
00:34:46,701 --> 00:34:50,300
the original hairline that
the patient has on the table.

541
00:34:52,640 --> 00:34:56,600
And in order to see the portion of
the incision that's not in the hair,

542
00:34:56,610 --> 00:35:00,230
you have to pull the ear
forward and look behind the ear.

543
00:35:00,410 --> 00:35:02,150
So I reestablished the hairline.

544
00:35:02,151 --> 00:35:06,080
I think today different people
have different ideas about that,

545
00:35:06,380 --> 00:35:09,950
but today I think that
that is a ponytail lift.

546
00:35:10,070 --> 00:35:13,550
You can wear your hair straight up on
top of your head and you're not going to

547
00:35:13,551 --> 00:35:16,010
have it. You can put that
incision in a man's hair.

548
00:35:16,310 --> 00:35:21,200
He can cut his hair if it's whatever
usual short length he wants to,

549
00:35:21,440 --> 00:35:25,310
as long as that hairline doesn't have a
step in it doesn't have a break in it,

550
00:35:26,180 --> 00:35:28,400
then it's not going to show.

551
00:35:29,420 --> 00:35:33,290
And that's the artistry in planning
the incision appropriately so that the

552
00:35:33,291 --> 00:35:38,130
hairline looks correct
and keeps the scar out of

553
00:35:38,131 --> 00:35:42,630
the non hair bearing neck skin where it

554
00:35:42,690 --> 00:35:44,880
potentially could be more visible.

555
00:35:45,930 --> 00:35:49,470
So I think that's a hundred percent true,

556
00:35:50,010 --> 00:35:54,480
and I occasionally see a scar along the

557
00:35:54,481 --> 00:35:55,860
hairline not in it,

558
00:35:55,861 --> 00:36:00,540
and I wonder why that was done and do my

559
00:36:00,541 --> 00:36:05,160
level best if I'm doing a
secondary lift to try to undo that

560
00:36:05,640 --> 00:36:09,300
if I'm able. Let me mention
another variation though,

561
00:36:09,510 --> 00:36:13,410
that's getting a lot of
attention. Mini lifts.

562
00:36:13,830 --> 00:36:17,220
Mini lifts are trending
right now. So Dr. Aston,

563
00:36:17,340 --> 00:36:19,500
what are they and who are they best for?

564
00:36:19,830 --> 00:36:20,041
Well,

565
00:36:20,041 --> 00:36:24,900
the mini lifts are what the plastic
surgeons talking to each other or short

566
00:36:24,901 --> 00:36:27,840
incision facelifts that we
mentioned a little bit earlier.

567
00:36:27,841 --> 00:36:30,600
That means you have the
stitches around the ear,

568
00:36:30,601 --> 00:36:35,460
the front part of the ear behind the
cartilage of the tragus down to the

569
00:36:35,461 --> 00:36:36,294
ear lobe.

570
00:36:37,170 --> 00:36:42,030
And that is a great procedure
for the person who is coming

571
00:36:42,031 --> 00:36:46,710
along as many people are doing
today when they have laxity that's

572
00:36:46,720 --> 00:36:48,390
limited to the face,

573
00:36:48,391 --> 00:36:52,770
the jawline from the corner of the eye
down to the jawline and a little bit on

574
00:36:52,771 --> 00:36:56,670
the neck. If you have a little fat
under the jawline, that sort of stuff,

575
00:36:56,671 --> 00:36:59,130
you can liposuction that
out at the same time.

576
00:36:59,520 --> 00:37:04,440
But it is primarily a procedure
that's meant to correct from

577
00:37:04,441 --> 00:37:08,580
the corner of your eye down to your
jaw under the jawline, as I said,

578
00:37:08,581 --> 00:37:10,170
for a little bit to get rid of the jaw.

579
00:37:10,500 --> 00:37:15,030
But it doesn't give you the
changes that you need in the neck

580
00:37:15,031 --> 00:37:18,270
often. But it's a great procedure.

581
00:37:18,271 --> 00:37:22,230
We do a lot of what we call short
scar facelifts. You do that,

582
00:37:22,231 --> 00:37:26,100
add some of the radiofrequency
technology with it,

583
00:37:27,630 --> 00:37:29,040
compliment chain, skin quality,

584
00:37:29,310 --> 00:37:34,260
maybe do the radiofrequency
on the skin of the neck and

585
00:37:34,261 --> 00:37:36,210
just do the short incision facelift.

586
00:37:36,211 --> 00:37:39,690
We do that often do to
radiofrequency technology,

587
00:37:39,691 --> 00:37:44,430
improve the quality of the
skin it gets with the Morpheus,

588
00:37:44,670 --> 00:37:47,910
gets subdermal, adipose, remodeling,
tightening of the skin of the neck,

589
00:37:48,210 --> 00:37:49,770
short incision in the face.

590
00:37:50,100 --> 00:37:54,090
It's a shorter procedure
on the operating tables,

591
00:37:54,091 --> 00:37:56,280
shorter procedure with recovery time.

592
00:37:56,790 --> 00:38:00,510
And so it's a very good
procedure if the patient

593
00:38:01,590 --> 00:38:02,940
is a candidate for that.

594
00:38:03,810 --> 00:38:06,210
Yeah, I mean, it's about
the stage of aging.

595
00:38:06,211 --> 00:38:11,190
So for someone who hasn't
aged enough to need

596
00:38:11,191 --> 00:38:14,940
the full facelift, but they say,

597
00:38:15,600 --> 00:38:17,700
I don't want to fool with things.

598
00:38:17,710 --> 00:38:22,650
I really want this to get cleaned up
and let me stop thinking about it for a

599
00:38:22,651 --> 00:38:23,484
while.

600
00:38:23,700 --> 00:38:28,200
This is going to be a meaningful
approach compared to doing

601
00:38:29,010 --> 00:38:31,230
more limited kind of treatments.

602
00:38:31,710 --> 00:38:36,370
I never approve of the
concept of just pumping

603
00:38:36,371 --> 00:38:39,250
people up with filler and volume.

604
00:38:40,060 --> 00:38:42,940
Replacing lost volume is okay,

605
00:38:42,970 --> 00:38:47,770
but trying to chase laxity
with volume is a big

606
00:38:47,771 --> 00:38:50,890
mistake because that's
going to be unnatural.

607
00:38:51,190 --> 00:38:53,890
So for patients that are not at a stage,

608
00:38:53,920 --> 00:38:56,380
a later stage with a full lift,

609
00:38:56,770 --> 00:38:59,410
the mini lift can be a great solution,

610
00:39:00,040 --> 00:39:05,020
but it's going to really jump in
there and make a change and make

611
00:39:05,021 --> 00:39:09,460
it durably in ways that
a lot of non-invasive

612
00:39:09,461 --> 00:39:11,860
treatments will fail to do.

613
00:39:12,520 --> 00:39:17,200
And Dr. Bass, okay, let me just add to
that. Sure. Dr. Bass suggested this.

614
00:39:17,440 --> 00:39:20,350
There is no such thing
as a filler facelift.

615
00:39:21,340 --> 00:39:25,000
It expands the face. It
will not lift the face,

616
00:39:25,450 --> 00:39:27,160
but it expands the face.

617
00:39:27,161 --> 00:39:31,330
But the downside to that
is that you get lymphatic

618
00:39:31,331 --> 00:39:34,690
obstruction from the fillers.
And so as time goes on,

619
00:39:34,691 --> 00:39:38,290
when you put a lot of fillers
in the face trying to lift it,

620
00:39:38,680 --> 00:39:43,570
then the tissues start to get thick
from the cheek down to the nasolabial,

621
00:39:43,571 --> 00:39:48,310
fold the corner of the nose. And some
people get that Howdy Doody look. Now,

622
00:39:48,311 --> 00:39:51,850
having said that, there's a lot
of fillers used in my office,

623
00:39:51,851 --> 00:39:54,250
a lot of fillers used
in Dr. Bass's office.

624
00:39:54,850 --> 00:39:58,030
I know because we believe
in fillers properly used,

625
00:39:58,240 --> 00:40:00,730
but it's not a substitute for facelift.

626
00:40:00,880 --> 00:40:04,420
And we see more and more people
today who have been overfilled.

627
00:40:04,840 --> 00:40:08,080
There's actually a resurgence
of facelifts today,

628
00:40:08,890 --> 00:40:11,230
people who recognize the fact that one,

629
00:40:11,231 --> 00:40:14,860
I should not have more filler because
the shape of my face is beginning to

630
00:40:14,861 --> 00:40:17,920
change in a way that I never was before.

631
00:40:19,060 --> 00:40:22,600
As people have mentioned
things to me, my mother,

632
00:40:22,601 --> 00:40:25,630
my sister says what's
happening to their face?

633
00:40:26,140 --> 00:40:31,000
And we also see a lot of patients
today who are good candidates

634
00:40:31,001 --> 00:40:35,830
for that short incision facelift or
many facelift because they recognize

635
00:40:35,831 --> 00:40:40,180
what I've just said on friends,
they've heard people talk about it,

636
00:40:40,181 --> 00:40:44,290
and they know that they can
get a short incision lift,

637
00:40:44,950 --> 00:40:48,640
mini lift, as they may call it, mini
lift. They'll get a better result,

638
00:40:48,670 --> 00:40:50,680
better contour, last longer,

639
00:40:50,890 --> 00:40:55,360
and turn out to be cheap in the long
run if they care about the costs.

640
00:40:56,170 --> 00:41:00,430
So I suspect Dr. Bassett agrees that a

641
00:41:01,360 --> 00:41:03,640
short scar facelift in a proper patient,

642
00:41:03,940 --> 00:41:06,760
it's just a home run in
terms of facial rejuvenation.

643
00:41:07,300 --> 00:41:10,090
Absolutely. And as I said,

644
00:41:11,080 --> 00:41:15,520
replacing volume that's
lost with filler is rational

645
00:41:15,521 --> 00:41:17,770
and aesthetically good,

646
00:41:17,771 --> 00:41:22,540
but just trying to make the filler do
something it was never designed for

647
00:41:22,541 --> 00:41:24,160
is a big mistake.

648
00:41:26,350 --> 00:41:31,000
And also it's traumatic
to tissues to inject.

649
00:41:31,270 --> 00:41:35,660
Too often surgeons know
they would never do

650
00:41:36,410 --> 00:41:36,981
20,

651
00:41:36,981 --> 00:41:41,930
30 facelifts on a patient because
that's too much for tissues

652
00:41:41,940 --> 00:41:42,773
to take.

653
00:41:42,950 --> 00:41:47,630
And I think a lot of folks
feel that nonsurgical

654
00:41:47,631 --> 00:41:52,250
treatments have no limits
in how many times or

655
00:41:53,420 --> 00:41:56,720
over how short an interval
they can be repeated.

656
00:41:57,380 --> 00:42:01,910
And it's important to be safe
and gentle with your tissues

657
00:42:02,330 --> 00:42:05,360
and not overdue treatments.

658
00:42:05,361 --> 00:42:10,010
Treatments are excellent
and extraordinarily safe in

659
00:42:10,011 --> 00:42:14,780
aesthetic plastic surgery when they're
done the way they're intended to be done

660
00:42:14,781 --> 00:42:17,750
and overdoing them, big mistake.

661
00:42:18,140 --> 00:42:21,650
And so trying to and run the facelift,

662
00:42:22,430 --> 00:42:23,930
and as Dr. Aston said,

663
00:42:23,960 --> 00:42:28,580
we both do quite a bit of
nonsurgical treatments along

664
00:42:28,581 --> 00:42:33,290
with surgical options, but
where they're appropriate.

665
00:42:35,630 --> 00:42:37,520
So Dr. Aston, to me,

666
00:42:37,640 --> 00:42:41,750
the neck is always the
sharpness of the jawline.

667
00:42:41,751 --> 00:42:46,610
The sharpness of the neck is
always how a facelift really gets

668
00:42:46,611 --> 00:42:49,850
judged. That's really where it counts.

669
00:42:49,880 --> 00:42:54,110
And there's a lot of work
going on trying to improve the

670
00:42:54,111 --> 00:42:57,500
results in the neck. And in fact,

671
00:42:57,501 --> 00:43:01,660
you just chaired a session at The
Aesthetic Society annual meeting

672
00:43:03,140 --> 00:43:06,230
looking at some of these newer techniques.

673
00:43:07,040 --> 00:43:11,210
Some are very creative,
some are very aggressive.

674
00:43:12,230 --> 00:43:17,090
What are the issues here and what do
you think is coming for the neck based

675
00:43:17,091 --> 00:43:21,320
on some of the things that were presented
during this panel that you moderated?

676
00:43:22,130 --> 00:43:26,270
Sure. Dr. Bass, we've been talking
about this mass in the face,

677
00:43:26,720 --> 00:43:31,250
we haven't talked about the
platysma muscle in the neck
and the platysma muscles

678
00:43:31,250 --> 00:43:31,633
is a broad,

679
00:43:31,880 --> 00:43:36,170
flat muscle that rises in deltoid
and pectoral regions comes up above

680
00:43:37,490 --> 00:43:41,510
the collarbone across the
neck up to the jawline,

681
00:43:42,530 --> 00:43:47,480
and it is the muscle that gets
those cords on the neck as one ages.

682
00:43:48,200 --> 00:43:51,290
And just as we fix this mass in the neck,

683
00:43:51,590 --> 00:43:55,940
the SMAS and the platysma muscle
are in continuity above the

684
00:43:56,270 --> 00:44:01,160
jawline. So when we're moving the SMAS
and platysma majority of our face,

685
00:44:01,400 --> 00:44:05,690
we're moving them together.
Now, there are some patients,

686
00:44:05,810 --> 00:44:10,220
and Dr. Bass is referring to a panel of
chaired at The Aesthetic Society meeting

687
00:44:10,490 --> 00:44:12,920
on isolated neck procedures.

688
00:44:13,310 --> 00:44:17,450
And there are patients for whom
we do isolated neck procedures,

689
00:44:17,810 --> 00:44:22,460
and that means contouring the jawline
and contouring the neck according

690
00:44:22,461 --> 00:44:25,370
to the anatomy the patient presents with.

691
00:44:25,700 --> 00:44:29,180
Sometimes patients will present
with a lot of fat in the neck.

692
00:44:30,200 --> 00:44:32,070
If they have fat in the
neck and loose skin,

693
00:44:32,071 --> 00:44:34,710
then we'll do radiofrequency technology.

694
00:44:34,711 --> 00:44:38,490
We use accu to face tighten the
neck and liposuction the fat out.

695
00:44:39,750 --> 00:44:44,520
If the problem of the muscle
cords in the neck or the muscle

696
00:44:44,730 --> 00:44:49,620
cords come off of the neck in
an obtuse angle from under the

697
00:44:49,621 --> 00:44:53,010
chin, they don't have what we
call a deep cervical metal angle.

698
00:44:53,400 --> 00:44:57,840
Then we have to fix the muscles
themselves. And for many years,

699
00:44:57,841 --> 00:45:02,460
we have been fixing the muscle
through incision under the chin

700
00:45:02,850 --> 00:45:06,570
and contouring the neck,
giving a good chin,

701
00:45:06,571 --> 00:45:10,560
jawline neck without any of
the incisions behind the neck.

702
00:45:11,340 --> 00:45:14,460
If there is fat under
that muscle on the neck,

703
00:45:14,461 --> 00:45:18,750
then we have to remove that fat also.

704
00:45:19,200 --> 00:45:23,790
But you have to remove it appropriately
so that you don't get a deep depression

705
00:45:23,791 --> 00:45:26,520
just under the chin. So like the face,

706
00:45:26,670 --> 00:45:29,490
it's a matter of analyzing the issues.

707
00:45:29,910 --> 00:45:34,890
If the patient just wants
their neck operated on,

708
00:45:34,900 --> 00:45:38,580
and it's consistent with the face
because you have to remember,

709
00:45:38,880 --> 00:45:40,410
if you just fix the neck,

710
00:45:40,800 --> 00:45:44,880
you're getting a limited amount of
change along the jawline in the neck.

711
00:45:45,180 --> 00:45:48,480
You can get a wonderful
change in some of the jawline,

712
00:45:49,170 --> 00:45:51,180
the lower portion of the jawline.

713
00:45:51,190 --> 00:45:55,470
But anything really above the border of
the mandible is not going to change a

714
00:45:55,480 --> 00:45:59,460
lot just by doing neck unless
you do something in that area.

715
00:45:59,520 --> 00:46:03,570
And that is one of the places we can
add the radiofrequency technology,

716
00:46:03,930 --> 00:46:05,370
just do a neck procedure.

717
00:46:06,180 --> 00:46:10,680
If there are people who are
talking about doing procedures with

718
00:46:10,681 --> 00:46:12,900
removing the submandibular gland,

719
00:46:13,380 --> 00:46:17,310
which goes under the platysma
muscle and removes the muscles,

720
00:46:18,000 --> 00:46:21,030
or excuse me, removes the
gland, the submandibular gland,

721
00:46:21,600 --> 00:46:24,780
you can feel like an
acorn under your jawline.

722
00:46:27,990 --> 00:46:30,000
My impression of the results,

723
00:46:30,000 --> 00:46:34,110
I've seen that too many of those
people have a hollow in their neck.

724
00:46:34,230 --> 00:46:37,620
They look great in the first
six months and a year out.

725
00:46:37,621 --> 00:46:40,110
You can see a depression in the neck.

726
00:46:40,500 --> 00:46:45,270
I think the concept of trying to
make everybody's neck look like the

727
00:46:45,271 --> 00:46:49,680
neck of a model who
weighs 90 pounds and is

728
00:46:49,740 --> 00:46:53,040
anorexic, you'll see
that kind of depression,

729
00:46:53,041 --> 00:46:56,220
but you'll also see that kind of
depression in neck and people who've had

730
00:46:57,150 --> 00:47:01,740
so-called radical neck
dissections for cancer procedures.

731
00:47:02,310 --> 00:47:04,800
So I leave the submandibular
glands in place.

732
00:47:04,801 --> 00:47:06,330
I'd rather discuss it with the patient.

733
00:47:06,690 --> 00:47:11,400
There are procedures where you can
put sutures under the skin of the

734
00:47:11,401 --> 00:47:12,234
neck

735
00:47:14,370 --> 00:47:19,320
and into the muscle and try
to tighten the muscle in that

736
00:47:19,740 --> 00:47:20,160
way.

737
00:47:20,160 --> 00:47:24,900
The people who presented at the panel
showed very good results with doing that.

738
00:47:25,290 --> 00:47:29,530
I think there's a select group of
patients who are candidates for

739
00:47:29,890 --> 00:47:33,550
those kinds of muscle
tightening procedures,

740
00:47:33,940 --> 00:47:38,920
but the people on our panel
showed great results in their

741
00:47:38,921 --> 00:47:39,754
hands.

742
00:47:40,270 --> 00:47:45,220
So I think there are people who have
an isolated neck problem and we fix

743
00:47:45,221 --> 00:47:49,300
them. And I've done many patients where
all we did was the neck over the years.

744
00:47:50,200 --> 00:47:52,150
And there are just
different ways to do that,

745
00:47:52,151 --> 00:47:54,370
just like there are different
ways to fix their face.

746
00:47:55,210 --> 00:47:59,940
We're starting to hear a mention of the
deplane neck lift similar to the deplane

747
00:48:00,010 --> 00:48:04,390
facelift in some social
media. So Dr. Aston,

748
00:48:04,391 --> 00:48:08,440
what does this about and what does
it add to neck lifting, if anything?

749
00:48:09,580 --> 00:48:12,640
Well, Dr. Bass, you're right.
We are hearing a lot mentioning,

750
00:48:12,650 --> 00:48:17,590
and it comes up in social media
now about deep plane neck lift.

751
00:48:18,160 --> 00:48:23,080
Well, that is about as nebulous a
description as a deep plane facelift.

752
00:48:23,110 --> 00:48:27,250
I mean, because we don't know what
they mean by deep plain neck lift.

753
00:48:27,550 --> 00:48:32,380
We have to assume that the people
are talking about going under the

754
00:48:32,381 --> 00:48:35,950
platysma muscle in the
neck, taking out the fat,

755
00:48:36,490 --> 00:48:39,340
and taking out the submandibular gland.

756
00:48:39,790 --> 00:48:44,350
There are many people that we
have to remove fat from under the

757
00:48:44,351 --> 00:48:45,610
platysma muscle.

758
00:48:46,570 --> 00:48:50,290
There are no patients for whom I
take out the submandibular gland.

759
00:48:50,980 --> 00:48:55,660
And the reason I don't do that is
because the early results may look good,

760
00:48:55,661 --> 00:49:00,010
but the long-term results with
moving the submandibular gland under

761
00:49:01,060 --> 00:49:04,960
the platysma muscle gives a
depression in the side of the neck

762
00:49:06,700 --> 00:49:11,620
that frequently glossed
over quickly in cases shown

763
00:49:11,920 --> 00:49:13,150
at meetings.

764
00:49:13,600 --> 00:49:18,580
But the anatomy of the
neck can be overly operated

765
00:49:18,581 --> 00:49:23,140
and you wind up with the neck that's not
consistent with the head sitting on top

766
00:49:23,141 --> 00:49:27,610
of it. So I think that when you're
talking about deep plane and neck lift,

767
00:49:28,210 --> 00:49:32,860
there are few people who really can
get an excellent contouring with

768
00:49:32,920 --> 00:49:36,070
specific kinds of problems on the neck.

769
00:49:36,071 --> 00:49:40,390
But just because someone
mentions deep plane neck lift,

770
00:49:40,720 --> 00:49:42,550
don't think that's what you need.

771
00:49:43,750 --> 00:49:47,350
And again, just as deep plane
facelift is really not a new

772
00:49:47,360 --> 00:49:50,320
concept,

773
00:49:50,320 --> 00:49:53,200
doing things under the platysma muscle,

774
00:49:53,500 --> 00:49:57,310
if that's what they mean by
deep plane, is not a new thing.

775
00:49:57,760 --> 00:50:02,500
Chasing either fat
under the platysma along

776
00:50:02,501 --> 00:50:05,650
with fat that's over the platysma,

777
00:50:06,790 --> 00:50:10,300
which we do routinely,

778
00:50:10,300 --> 00:50:12,310
chasing sometimes some of the muscle

779
00:50:12,340 --> 00:50:13,330
prominence.

780
00:50:13,870 --> 00:50:17,440
I'm with you when it comes
to the submandibular glands.

781
00:50:17,441 --> 00:50:19,840
I don't touch them surgically,

782
00:50:20,290 --> 00:50:24,670
but you can Botox the

783
00:50:24,680 --> 00:50:26,980
glands and get some,

784
00:50:30,050 --> 00:50:34,910
and I recently reviewed an article
about that for the aesthetic surgery

785
00:50:34,911 --> 00:50:35,744
journal,

786
00:50:36,440 --> 00:50:41,240
but that technique is a way to safely

787
00:50:41,241 --> 00:50:44,510
chase it and reversibly chase it.

788
00:50:44,511 --> 00:50:48,800
So if you get in effect
that's unwanted or overblown,

789
00:50:49,250 --> 00:50:50,750
you are not stuck with it.

790
00:50:51,290 --> 00:50:53,330
Good way to deal with that. Dr. Bass,

791
00:50:54,170 --> 00:50:58,790
and I concur that these things we're
talking about removing fat beneath the

792
00:50:58,790 --> 00:51:02,270
platysma muscle is not new.

793
00:51:02,960 --> 00:51:05,570
Well, this has certainly been
an informative discussion.

794
00:51:05,870 --> 00:51:07,730
Before we wrap up Dr. Aston,

795
00:51:07,820 --> 00:51:11,510
what takeaways would you
leave our listeners with
when it comes to the facelift

796
00:51:11,511 --> 00:51:12,344
and the neck lift?

797
00:51:12,680 --> 00:51:16,220
Well, the face and neck
lift, as I said earlier,

798
00:51:16,340 --> 00:51:18,500
is a gold standard for
facial rejuvenation.

799
00:51:18,501 --> 00:51:22,430
But today we have to complement
that with contouring the face,

800
00:51:22,820 --> 00:51:27,680
using specific movements of the underlying
foundation to give more youthful

801
00:51:27,681 --> 00:51:31,910
appearance and often give an appearance
that's better than a patient originally

802
00:51:31,911 --> 00:51:32,690
had.

803
00:51:32,690 --> 00:51:37,130
We complement the results that we
get with the facelift by changing the

804
00:51:37,140 --> 00:51:41,840
underlying foundation to give
a more youthful architectural

805
00:51:41,841 --> 00:51:45,620
foundation. We complement
the results we get with that,

806
00:51:45,621 --> 00:51:50,360
with modifying the quality
of the skin by using

807
00:51:50,361 --> 00:51:53,540
technology that we didn't have before.

808
00:51:53,990 --> 00:51:58,310
I think that today's facelifts
are the most elegant time in

809
00:51:58,760 --> 00:52:03,140
history of facelifts because we
have the ancillary procedures.

810
00:52:03,141 --> 00:52:07,670
We didn't have studied the
anatomy in great detail,

811
00:52:08,060 --> 00:52:11,810
and particularly with the autologous
fat grafts to help contour

812
00:52:12,950 --> 00:52:13,783
the face.

813
00:52:14,330 --> 00:52:19,070
So I think it's important to
know what facelift is all about.

814
00:52:19,160 --> 00:52:21,170
And if you talk to a surgeon,

815
00:52:21,500 --> 00:52:25,970
make sure that their aesthetic judgment's
consistent with yours in terms of what

816
00:52:25,980 --> 00:52:28,820
you want to achieve, the shape face,

817
00:52:28,821 --> 00:52:31,640
the contours that you would
like to see in your face.

818
00:52:32,720 --> 00:52:36,980
And if you do that in the hands
of a surgeon with experience,

819
00:52:36,981 --> 00:52:39,650
you should be able to
have a very nice result.

820
00:52:40,610 --> 00:52:43,520
Many important points
phrased there. Dr. Bass,

821
00:52:43,521 --> 00:52:44,960
would you like to add any takeaways?

822
00:52:45,590 --> 00:52:49,580
Well, mostly I'm reiterating
what Dr. Aston just said,

823
00:52:49,581 --> 00:52:51,650
probably not quite as eloquently,

824
00:52:52,280 --> 00:52:57,200
but the facelift is the
major reset for major skin

825
00:52:57,201 --> 00:53:01,820
laxity. There really is no
meaningful substitute currently,

826
00:53:01,821 --> 00:53:04,460
and I don't see one on the horizon.

827
00:53:05,390 --> 00:53:10,190
I look at all kinds of new
technologies and advanced research and

828
00:53:10,790 --> 00:53:13,790
where the facelift is
not about to be obsolete.

829
00:53:14,300 --> 00:53:16,910
There's no one size fits all approach.

830
00:53:17,480 --> 00:53:20,210
Facelifting is about customizing many,

831
00:53:20,211 --> 00:53:24,890
many anatomic considerations
to each individual patient's

832
00:53:24,900 --> 00:53:28,890
needs and their individual stage of aging.

833
00:53:29,370 --> 00:53:32,430
The techniques will vary
based on those factors.

834
00:53:32,880 --> 00:53:35,280
There is no one best technique.

835
00:53:36,030 --> 00:53:40,560
So I think you can see from listening to
Dr. Aston talk about everything that's

836
00:53:40,570 --> 00:53:44,490
happening with the facelift,
that the facelift is on the move.

837
00:53:44,491 --> 00:53:49,260
It's continuing to undergo
evolutionary change

838
00:53:49,270 --> 00:53:51,750
more than revolutionary change,

839
00:53:52,260 --> 00:53:56,430
but the procedure continues to get faster,

840
00:53:56,440 --> 00:53:57,360
easier,

841
00:53:58,140 --> 00:54:02,280
more complete in the
correction and more natural.

842
00:54:02,820 --> 00:54:07,470
So basically, it's not your
grandmother's facelift.

843
00:54:08,190 --> 00:54:09,090
Dr. Aston,

844
00:54:09,091 --> 00:54:13,560
I'd really like to thank you for joining
us for this discussion of facelift.

845
00:54:14,460 --> 00:54:16,860
It's a favorite topic for both of us,

846
00:54:17,250 --> 00:54:21,690
and I can't think of anyone
I'd rather discuss it with.

847
00:54:21,690 --> 00:54:23,550
Without a doubt, when
it comes to facelift,

848
00:54:23,790 --> 00:54:26,190
you are the expert's expert,

849
00:54:26,850 --> 00:54:31,830
and I'm grateful to you for sharing
your tremendous breadth and depth

850
00:54:31,831 --> 00:54:33,780
of experience with our listeners.

851
00:54:34,650 --> 00:54:37,440
You're very kind, Dr. Bass.
It's a pleasure to be here,

852
00:54:37,890 --> 00:54:42,300
and I look forward to many more
discussions with you about facelift

853
00:54:42,780 --> 00:54:47,670
as we continue to do procedures
that we really love doing and

854
00:54:47,671 --> 00:54:50,130
making patients happy with the results.

855
00:54:50,790 --> 00:54:54,630
I'll echo Dr. Bass and say thank you
once again to Dr. Aston for sharing your

856
00:54:54,631 --> 00:54:57,570
perspective and technical
expertise with all of us today.

857
00:54:57,960 --> 00:55:02,040
I could really sense the excitement of
the cutting edge and facelift today from

858
00:55:02,041 --> 00:55:02,874
the discussion.

859
00:55:04,020 --> 00:55:07,740
Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.

860
00:55:08,130 --> 00:55:09,630
Follow us on Apple Podcasts,

861
00:55:09,690 --> 00:55:11,760
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862
00:55:12,180 --> 00:55:15,270
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863
00:55:15,271 --> 00:55:18,780
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864
00:55:18,810 --> 00:55:19,680
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865
00:55:20,400 --> 00:55:25,260
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