Facelift Series #2: Does & Doesn't w/ Dr. Kylie Edinger

Summer Hardy (00:01):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Summer Hardy, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. Today's episode is the start of a new series about the facelift. What are we talking about in this episode, Dr. Bass?

Dr. Lawrence Bass (00:28):
To put it in simple terms, Dr. Edinger and I are going to talk about what the facelift does and what the facelift doesn't do.

Summer Hardy (00:37):
So overall, what does the facelift do?

Dr. Lawrence Bass (00:41):
The facelift is really a procedure that number one chases skin laxity in the face that's loose or hanging skin. It's also a face shaping operation and increasingly is associated with facial volume restoration through things like fat grafting. So in general, in this series, when we say facelift, we'll be referring to the most commonly performed procedure, which addresses features in both the face and the neck. And in medical terms might be called cervical facial plasty. So that's neck and face. That's what most patients are having, except in selected circumstances very early in the game or late in the game or after a previous lift where only a portion needs to be redone. So we'll get to all of these subdivisions elsewhere in this series, but we'll focus most on what patients at most ages are having done. There's a big difference in the terminology that beauty magazines and internet marketing use and the terminology that surgeons use medically when talking to each other about facelifts, that's probably more technically accurate. So Dr. Edinger and I will try to relate commonly used terminology on the internet with what that technically translates into in the surgery to the extent that that's possible.

Summer Hardy (02:21):
Okay, that makes sense. So who's the patient who should be thinking about a facelift?

Dr. Lawrence Bass (02:27):
So that's another way of saying what does the facelift fix? Because if you have the things the facelift fix, then maybe you should be thinking about facelift. And that's really the point of this episode. We're talking about what a facelift does, what it can fix or improve and what it doesn't.

Dr. Kylie Edinger (02:47):
So a facelift is really a surgical procedure that's performed in the skin and the muscular layers of the face and neck with a goal of restoring midface volume, eliminating jowling, softening nasal labial folds, and then also creating a cleaner and sharper neckline for patients.

Dr. Lawrence Bass (03:04):
And basically when you think of these different areas, I mean the jowl sits along the jawline. There's also fullness in an area above the jowl just to the side of the corner of the mouth that's not necessarily well corrected by a facelift. That jawline irregularity, as Dr. Edinger said, is sharpened up and a number of things in the neck get chased. Things like vertical bands that may come from muscles hanging skin under the chin and under the jawline. And also the angle between the vertical part of the neck that goes from our Adam's apple down or a little bit above that, and the horizontal part that's under our chin that gets more oblique or obtuse as we age in sharpening what we medically call the cervicomental angle is an important part of the left. So all of those changes in the neck softening the nasolabial folds and marionette lines as Dr. Edinger said. And part of that is done by resuspending the midface and upper face tissues, but particularly the midface tissues. And this takes some of that slack out of the nasolabial area, but it also brings the tissues back up over the cheek where they came from and helps to shape the cheek back to that youthful uniform shape rather than individual sags and bags and flattened areas.

Summer Hardy (04:45):
Okay. And how does the facelift achieve these changes basically?

Dr. Kylie Edinger (04:51):
To really simplify things, facelift addresses both the overlying loose skin that we develop as we age, and it also addresses that deeper muscular layer of the face and neck that Dr. Bass was talking about. There are several surgical techniques to tighten that muscular layer of the face and neck, which we'll address in later episodes, but all of them serve the same purpose. And for storing your midface volume, tightening those deeper structures, removing excess skin and trying to put things back where they first started before the aging process kicked in.

Dr. Lawrence Bass (05:22):
And so this draws heavily on understanding what changes take place during aging, and we're going to discuss that in an upcoming episode. What changes in the face as we age, but we're trying to take things that shrank and maybe fat graft them, take things that have spread out or descended, bring them back both at the skin level and at the muscle and muscular fascia level. And that mass layer is basically connective tissue that sits between the skin and the muscles themselves. So modern facelift generally involves repositioning and working on all of these tissue planes as part of the procedure, as Dr. Edinger said, different ways to do that. Kind of like saying more than one way to skin a cat. Not necessarily a best way, but a variety of ways which we will discuss, but repositioning those things in a vector back where it came from, which increasingly is up not back like in historic facelifts, although it's not as simple as that because different layers may and in different parts of the face and neck, the direction of draping needs to be somewhat different.

Summer Hardy (06:46):
Got it. So when is it the time for the facelift? Is there a best age?

Dr. Kylie Edinger (06:51):
Well, our statistics tells what's happening in the United States population. According to a 2023 statistic from The Aesthetic Society in collaboration with CosmetAssure, 8% of patients are in the 35 to 50 year age range, 48% of patients, the majority, are in the 51 to 64 age range, and 44%, just less than the majority, are in the 65 age range and up.

Dr. Lawrence Bass (07:16):
So that's kind of the answer to your question Summer by age, but it's also really about findings because everyone ages according to a standard kind of process. There are things that to all of us as we age, but when those things happen is a little different. Some people age prematurely, most people are aging with the herd, with the whole group of other folks their age, and some folks are lucky and they're aging more slowly. So if you are noticing a lot of changes, you can confirm with a plastic surgeon and they'll tell you what they think. If they think it's too early, you're taking your big playing card of the facelift and using it too soon, they'll tell you that. And if they think you should have been in five or 10 years ago, they'll tell you that as well. But those ages give you a general sense of who's doing facelifts.

(08:15):
And this is a lot different than when I first went in practice. When I first went in practice, facelift age was much younger on average than is today. And part of the reason that age has moved to older numbers is because we have healthier lifestyle. We smoke and drink less, we exercise more, hopefully we try to eat better, but also we have all of the nonsurgical treatments that help reverse early aging changes and help slow facial aging. So I think that's pushed the age up below. Now we're seeing a trend back towards younger ages a little bit, but what those numbers tell you is that very few people in their thirties need a surgical lift. And if so, it would probably be some kind of a mini lift. Sometimes actors, models, newscasters, people that make their living in front of a camera or lifting in their late thirties, but forties lifting really begins. Fifties is a hot time for lifting. But for people in their sixties and beyond who may not have gotten to it previously, you can see that 44% are 65 or older, so it's not too late if you didn't get a chance to do it previously. And that's still a common age group for surgical lifting.

Dr. Kylie Edinger (09:47):
Absolutely, and I think deciding when to have a facelift like Dr. Bass was saying, is a very personal choice. There's no set point, but it's the same for every patient or a magic number that patients should shoot for. The best time to do a facelift is when you start to notice those changes in your appearance and they start to bother you specifically regarding loss of volume in your cheeks, steepening of those nasolabial folds, the jowling along the neckline, loose skin in your neck, and then banding in your neck as well. These are all signs of aging that can be addressed whenever they start to bother you and whenever you decide you want to do something about them to restore your appearance, and confidence again.

Dr. Lawrence Bass (10:23):
Yeah, I think that's exactly right Dr. Edinger. If it doesn't bother you yet, you may know you don't look the same as 25 years old, but maybe it doesn't bother you much yet, then it's probably not time to have a facelift right then. However, if it's starting to really bug you every time you're fixing your hair or putting makeup on or getting ready to go out and look in the mirror, you notice some of those changes or every time you see yourself in a photograph, you see that saggy area and it's bugging you, that's telling you that maybe it's time to start chasing it.

Summer Hardy (11:07):
Okay. So I think I have the idea of the what, when and how now, what is it that the facelift does not do?

Dr. Lawrence Bass (11:14):
So if we think about features that are not treated, they basically fall into a couple of categories. There are some things that will have a little bit of impact when you have a facelift, but if it's your primary concern area, you should probably be doing a different treatment or procedure. And then there are some things that the facelift simply doesn't address. They're just not part of either the anatomic area the facelift works in or they're not part of what the facelift is changing because of how the facelift works. And so you need a separate treatment either done at the same time, because we often do a few procedures together, which can be safely done and does not have a big impact on recovery time or sometimes treatments that need to be done at a separate sitting or separate office visits. So things like skin quality facelift is going to reposition the skin, but your skin is still decades older than it was in your twenties, and you're going to need separate treatments to make that skin quality look better, even though the facelift puts the skin back where it came from.

(12:35):
That's pretty logical. Things that are outside the anatomic area of the facelift are things like eyelid bulging fat or hanging skin drooping of the eyebrow, lip wrinkles like lipstick, bleed lines and crepey changes, which are analogous to wrinkles in the lip that occur in the lower eyelid area and wrinkles like crow's feet at the side of the eye. So those are things the facelift does not explicitly chase and need to be addressed often with an additional procedure done at the same time as a facelift. And then there are things on the face that the facelift helps you with, as I said, but if you're really concerned about that feature, it's probably going to take a separate treatment. So facial volume by positioning and shaping the volume, you get some restoration of youthful shape, but you have lost volume, and that sometimes needs to be boosted with fat grafting.

(13:45):
Wrinkles on the face will look a little less prominent as that skin is redraped, but that's really a wrinkle in the fabric of the skin and just repositioning the skin doesn't eliminate that. So things like laser peels, chemical peels, or some other options like that are a typical option. Nasolabial and marionette lines, as Dr. Edinger mentioned, these do improve and that's a good thing, but if you sit and look in the mirror and pull those lines, pull your facial skin until those lines go flat, you'll see that your face looks distorted. And that's exactly what we're not trying to do with a facelift. We don't want any distortion or change in appearance. So predictably, the facelift is not going to completely eliminate those features, and that's part of the reason why American industry developed fillers that are injectable and why we pursue things like fat grafting. And the last one that I would mention is transverse lines or side to side lines on the lower part of your neck. Again, redraping some of that skin helps them look a little less noticeable, but those lines are very tough to completely eliminate, and that takes energy treatments that do skin resurfacing that's safe for the neck, or sometimes active dermal matrix fillers that can stimulate collagen and try to fade those lines somewhat.

Dr. Kylie Edinger (15:25):
I agree with all of those things. I just want to reiterate something that Dr. Bass said, which is something that the facelift doesn't do or should not do, which has changed the way you look and make you unrecognizable or no longer you. A facelift should help reset the clock and restore your youthful appearance, but you still want to look like you and you want the features that make your face who you are. So a refresh version of yourself, but not something distorted.

Summer Hardy (15:48):
Okay. All of that makes a lot of sense. So what can you tell me about the durability of the facelift?

Dr. Kylie Edinger (15:54):
This is also an answer that varies from patient to patient. We typically tell patients that a facelift will reset the clock by about 15 years, but you're going to continue to age as you normally did after your facelift. Some patients age slowly, they may only need one facelift in their lifetime. Others may age at a more rapid rate, may require another facelift 10 to 15 years after their first facelift. It depends on many factors including your skin quality, your skin elasticity and collagen composition, your genetics and other factors. So it's variable from person to person.

Dr. Lawrence Bass (16:30):
That's a great point, and the important thing to remember is aging never stops. We would like it to, but it doesn't. That's just a reality. However, having done a facelift, you'll never look as old as you would have had you done nothing. So even 10 to 15 years later, if you didn't have a facelift, you would look 10 to 15 years older from where you started before the facelift. And having a facelift, you'll always look better than what you would've looked like without the facelift.

Summer Hardy (17:06):
And then what do patients say or ask in a consultation where they often don't understand the limitations of a facelift?

Dr. Lawrence Bass (17:13):
For me, my experience is that patients often don't understand that all of the wrinkles on the face are not going to be eliminated by facelift. Again, that's typically a laser resurfacing or a chemical peel, and that will minimize wrinkles, but not necessarily eliminate all of them. Areas like the nasolabial folds, I mean, first of all, we're not trying to eliminate them because 15 year olds have nasolabial folds. So that's a natural facial feature. We just want it to be very gentle and minimal, but that's commonly done with fat grafting or fillers. It will improve with facelift, but not be fully corrected and upper facial areas like the areas we typically put Botox in, the lines between the eyebrows, lines in the forehead, those are not treated by facelift. It's outside the anatomic area where the surgery is taking place and changes likewise in the eyelids themselves and the eyebrow.

(18:22):
The other thing I would say about what the facelift won't do for what needs to be done is that a lot of patients come in and they feel like they only have a little drop of aging change, and partly it's the plastic surgeon's job to try to show them where some of the changes are, and we do this with photography during the consultation, but if you are in your seventies and you never had a lift, there's not just one little spot in your face or your neck that's aged. You're squarely in facelift territory. And chasing that skin laxity and getting it reasonably corrected is an important part of looking your best. If it concerns you, and if it doesn't concern you, then you go out and enjoy your life. The other thing is to recognize, again, just that there are all these different aging changes and the tendency of a lot of what's happening out there in internet, social media, beauty magazines is to squash all these changes together. And the really important thing is to do the opposite, to tease these out, identify which features are concerning to you, and then determine with your experienced plastic surgeon, what procedure or treatment is going to correct those features that you're concerned with.

Summer Hardy (19:51):
Okay. And before we end this episode, Dr. Edinger, do you have any takeaways for our listeners?

Dr. Kylie Edinger (19:57):
Yeah, I couldn't agree more with what Dr. Bas just said. The biggest things are that you've just got to do your research and you have to know the limitations of the facelift, what it can do and what it can't do. Hopefully this episode helps with that. And then again, just remembering that these changes are happening to each of us and when we decide to do something about them as dependent on the patient, remember, the goals are to restore a natural appearance and just do a more refreshed version of yourself. We're not trying to change who you are or what you look like. Just trying to reset the clock for you.

Summer Hardy (20:26):
And Dr. Bass, can you share your takeaways?

Dr. Lawrence Bass (20:29):
Well, I think Dr. Edinger summarized it beautifully, but I'll take a shot at it. So facelift is about skin laxity. It's the big facial reset in restoring your aging face. It has the biggest impact of anything we do, and the gold standard for correcting facial and neck skin laxity, the greatest degree of correction and the greatest durability. We chase hanging skin in the neck and under the chin, neck banding and jawline, irregularity, jowls and flattening of the cheeks. This is never going to be a hundred percent correction, but most of the time we get most of it. As I mentioned, it doesn't fix all things. All of our treatment options really focus on particular aesthetic features. So you may have a mild defect on a whole bunch of features, but you're primarily going to chase the laxity and restore facial shape. Skin quality in particular, pigment, pigment, irregularity, brown spots, redness, wrinkles, rough texture, or things that really have to be treated with other kinds of interventions, not the facelift and other aging changes in other anatomic areas in the neighborhood like the eyes, the eyebrow, need separate procedures, and it's okay to leave those off, but you don't want to leave them off and then be looking at them after you have the beautifully restored face and be back in three months to do another procedure. It would've been better to do it all at once. If you don't think you'll do it any time in the next several years, reasonable to leave it off. So as I mentioned earlier in the podcast, it is very common to do additional treatments at the same time as the facelift to maximize the result. Things like fat grafting, chin implants, and some of the associated procedures for skin quality or other areas of the face like eyelids. But things like fat grafting and hin implants in particular, can help with that mission of restoring facial shape and maximizing the redraping of the skin. So finally, your aesthetic concerns mated with the advice of an experienced facelift surgeon is an important partnership in you achieving your beauty goals successfully. So this is a theme you'll hear again and again from both me and Dr. Edinger during this series.

Summer Hardy (23:12):
Thank you, Dr. Edinger and Dr. Bass for getting this series off to a great start with a discussion about what the facelift does and what does not do. It really focuses my attention on the content to come. I can't wait. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that is coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram at @drbassnyc.