Facelift Series #4: Facelift Fears

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. The title of today's episode is Facelift Fears, another in our Facelift series. What are we talking about in this episode, Dr. Bass?

Dr. Lawrence Bass (00:30):
Today's topic is things that people worry about when it comes to having a facelift. Things to keep them from going ahead with one or just make them feel that somehow it's not a good thing that facelift is bad or undesirable. And some of these things are conscious things you think about and you can state out loud. And other things are just general impressions of the procedure or impulses that we have about having the procedure. And fears and caution are a vital part of our self-preservation instincts, and that's a good thing, but only up to a point because if taken too far, our fears prevent us from achieving our goals. And this is true not just in plastic surgery but in all of life. But of course here we're talking about achieving our beauty goals. So being paralyzed by these fears prevented from taking action ends up being counterproductive to the goals of self-preservation and maintenance because self-preservation instincts and body maintenance are closely related to our desire to maintain our beauty. So it's an interesting back and forth at play here, which points out the need for balance in all things.

Summer Hardy (01:56):
That all makes sense, but let's get to some specifics. Dr. Bass, Dr. Edinger, can you tell me about some of the things that patients fear?

Dr. Lawrence Bass (02:03):
There are two basic categories of things. There are medical risks and there are appearance concerns.

Dr. Kylie Edinger (02:13):
I have the top of the list for medical concerns. It's being afraid of anesthesia. There are several types of anesthesia that are used in facelift, including general anesthesia where you go completely to sleep, a twilight or sedated form of anesthesia, and then also local anesthetics who are minimal to no sedation is on board. The risk for anesthesia overall are very low and we get medical clearance on all patients who are at a higher risk to make sure that they're safe to surgery.

Dr. Lawrence Bass (02:41):
And that's an important point. There is a degree of risk in everything we do, not just in medicine but in life. But of course, if those risks are very, very low, it's reasonable to go ahead. So I hear the concern about anesthesia all time. That process of anesthesia can be varied based on the individual facelift surgeon's preference and discussion that a patient has with the anesthesiologist to get to something that everybody is comfortable with and believes is safe. But typically some type of anesthesia is used for most facelift today, but the risk of having a serious problem from anesthesia is like the risk that you'll die in a car crash this year. And that's a real risk. I mean, when we're driving in the car, we look before we pull into the intersection, we look both ways. We make sure the light is green, but the risk is not high enough to make us hide at home in our apartment and not go out.

Dr. Kylie Edinger (03:54):
Some people are also worried about the pain they're going to experience after surgery. Good news here is there's very little pain after facelift surgery. We get great pain control with little to no narcotic pain relievers and most patients are very comfortable following surgery.

Dr. Lawrence Bass (04:09):
And patients tend to describe the discomfort as more of a bruised, swollen feeling than actual pain. So it's pretty low on a scale of discomfort from one to 10, it's probably somewhere in the two to three range for most of the recovery period, and that's the typical experience of my patients. I often prescribe 15 or 20 pain reliever tablets and most of my patients are taking three or four of them in the first couple of days and then they just take Tylenol.

Summer Hardy (04:44):
Okay. And are there other medical risks?

Dr. Lawrence Bass (04:46):
Well, patients worry about all kinds of medical problems that can occur during the healing and there are some things that they have to consider that we either know are going to occur or that could occur and Dr. Edinger will tell us a little about those.

Dr. Kylie Edinger (05:06):
First of all, everyone is going to get some degree of bruising and swelling. The amount they get and the duration that it lasts is variable for each patient. Typically a couple of weeks for most of the bruising and swelling to reside is common for patients. Patients are also commonly afraid of what their friends and their neighbors are going to say if they don't want anybody to know that they had a procedure done. I've had patients get very creative in their responses to neighbors and friends in order to hide the fact that they had surgery done and it is something that can easily be hidden. The other fear I commonly get asked about is how long the incisions are going to take to settle and how to best hide them. And these are things that are super common that we have all patients ask about and that were really tricky in surgery, hiding them and helping you afterward to make sure that people won't know when you walking down the street, friends of the family you don't want anybody to know.

Dr. Lawrence Bass (05:58):
And perspective on this varies a lot in different parts of the United States. I practice in the northeast, in New York City, most people are not telling friends, family and certainly not telling coworkers that they had some kind of surgery done. They don't want to discuss it publicly, so they're trying to hide it. And the key part of that is planning enough time for recovery, enough time to be out of the public eye so that you'll look presentable, not stimulate a lot of questions when you return from the procedure. If you try to short circuit that recovery time, you don't allow yourself enough time. You're more likely to get caught out. Now other parts of the country, they're not very concerned that someone knows they had a cosmetic procedure or they're very open about it and they're showing people. And so this issue goes away, but where I practice, most folks are trying, not that it's anything to be ashamed of, but they are not trying to make a point of it to anyone else, and that's something you just have to plan for a little bit.

(07:12):
Although there is some variation and we will talk in a later podcast episode about how to prepare to get good results with your facelift and have a minimum of recovery, how to take care of the facelift in the early healing period and some technical things that facelift surgeons are doing these days that help us really telescope down that recovery time. The other thing that's important to realize is it's a little different for men versus women and even women with very short hairstyles have some of the same issues that men have with a short hairstyle. It's harder to camouflage incisions until they fade with longer hair. It's a little easier to pull a little hair in front of an incision so folks don't see it until it has a little time to be better healed. And if you wear makeup when you go out, it's easier to camouflage.

(08:13):
If there's a little trace of a bruise that's 80 or 90% gone, that will camouflage pretty easily with makeup. If you can't go out with makeup on, it's not part of how you dress or how you go out, then it's going to be harder. So since most men don't wear makeup, they have to worry a little more about how they're going to hide that bruising than most women who even if they don't routinely wear makeup, could feel comfortable going out with some makeup on. And in this way, some stage actors actually do pretty well because stage makeup is very heavy and it will hide bruises really well and so they can return to working with that heavy stage makeup on even when a few things are still showing.

Summer Hardy (09:01):
Got it. Are there other surgical risks you can tell us about?

Dr. Kylie Edinger (09:06):
Risks we talk with patients about are hematomas or bleeding after surgery that may or may not have to go back to the operating room to address infections, skin loss, nerve injury, those are the main ones.

Dr. Lawrence Bass (09:20):
We're going to talk about all of these in some of those episodes I mentioned how we prep for that, how we take care of things during the early recovery and some advanced techniques and technologies that surgeons are using to help these days. But overall, it's important to follow all of the rules, the restrictions, the care plans to have a careful medical history and a careful medical clearance because that will minimize risks bleeding. The big thing is tight blood pressure control skin loss relates to nicotine, whether it's in tobacco vaping or some kind of nicotine replacement medication that really has to be eliminated to minimize risk of skin loss and nerve injury risks are fortunately very, very low. That's part of the virtue of seeing an experienced facelift surgeon that they're intimately familiar with the anatomy. Some facelift techniques bring you closer to some of the facial nerves than others, and so somebody needs to be experienced if they're doing those techniques, and that is something to discuss how much effect that has on risk with each individual surgeon.

(10:50):
There are also some very, very aggressive facelift techniques and at first blush, sometimes that sounds really appealing. Well, I want the best facelift, the most aggressive facelift. I want to look the youngest, but that sometimes costs you in risk or in recovery time with maybe a little benefit, maybe no added benefit. So following a standard technique that's in widespread use that's been refined both by the surgical community in general and by the individual plastic surgeon and their experience of doing many, many facelifts is what gives you the best safety margin to avoid any kind of mischief during surgery.

Summer Hardy (11:37):
Okay, and that brings us to appearance concerns now, what can you tell us about those?

Dr. Lawrence Bass (11:43):
So topping the list is the fear of looking unnatural or changing the way you look, and this is an understandable concern for patients. It's something patients worry about a great deal, but it's not a big problem in a typical first or second facelift with an experienced facelift surgeon, there are things we do in plastic surgery that are designed to change who you look like when we're doing that intentionally at the patient's request. Things like rhinoplasty, adding cheek implants or procedures where we move or change the bones of the face. We're trying to reshape things, make you look like someone a little different. Facelift is about rejuvenation. It's about keeping you looking like yourself. Just the way you look a number of years back when you were a little bit younger and modern facelift should not distort your appearance. It should preserve your appearance and just restore the use of your appearance.

Dr. Kylie Edinger (12:53):
And I'll just put some more detail into those issues. When it comes to looking unnatural, is this something we are very aware of and work very hard to keep you looking like a natural or fresh version of yourself. Like we've said multiple times, we don't want anyone to know you had surgery, you haven't been to recognize that you look more refreshed in regards to changing the way you look. Again, we don't want to change who you are and what you look like in your defining features. We just want to set the clock back for you and getting you a chance to look like you're younger self regarding an incomplete correction. You work really hard to walk that fine line that exists between making you look operated on and unnatural and not being aggressive enough and leading you with perhaps some residual neck or skin laxity. All patients ask about symmetry and I always say that we are asymmetric to begin with and will be asymmetric to end with. We try hard not to introduce any new asymmetries and we're always mindful it's alon a when we start so we can make things look as symmetric as possible.

Dr. Lawrence Bass (13:47):
I agree with all of those points Dr. Edinger made. I think that's all very important stuff. The best compliment I can get on one of my facelifts is when a patient says they disappeared for a week or two to recover and their friend said, oh, you looked so rested when you came back from that vacation and coming back. And if somebody said, oh, you had a great facelift, that's not a great facelift because they could see you had a facelift. We want them to just say, oh, you look so rested. Did you lose weight? They know you look great, but they can't put their finger on why. So that's the goal and that's what modern face lifting is designed to produce for you. I comment on symmetry also as Dr. Edinger said a hundred percent of us are asymmetric, and in fact, if we were literally symmetric, we'd look unnatural because there is no human that's symmetric.

(14:48):
Our eye would tell us that doesn't look normal. But asymmetry, we'd like to be small. And so where we see an asymmetry and an aging change, we're going to adjust our technique. We typically have to do slightly different things on each side of the face based on the floor or foundation anatomy that's in the face, the bone structure, which may be a little asymmetric and based on how each side of the face has aged, we get differential sun exposure because our left side driving around tends to get more sun than our right side. And so aging changes are going to be a little different and surgeons know this. We compensate for that. We'll hopefully move you towards symmetry. But as Dr. Edinger said, we're never going to get to perfect symmetry. And in fact, we wouldn't really like to because we would look unnatural if we did.

Summer Hardy (15:50):
You two have talked about a lot of concerns. What about scars? Is that a major concern for patients?

Dr. Lawrence Bass (15:56):
Yes, it is. It's a big fear that patients talk about quite a bit. And one thing we have to accept with any kind of a surgical procedure is there's always going to be some kind of a scar, but the facelift scars fade over time. They're never invisible, particularly the incision in the crease behind the ear. The retroauricular incision is something your hairstylist can see. You can never hide that from them. Hopefully they're not talkative and they won't say anything to anyone else but they've seen it before, believe me, especially in a place like New York City. So patients worry an awful lot about the scars and they worry more about the scar in front of the ear and that's because that's where people can see it. But that scar is the incision that typically heals the vest in facelift and the hardest to see.

(16:54):
So it's usually not a problem after facelift surgery and enough time for healing. The exception to this is when you are a known hypertrophic scar former, you had a previous surgery or a previous injury and it healed with a hypertrophic scar, not just a bad scar because you scraped your knee and picked at it for two weeks while it healed and you got a scar from that. But you had to see the doctor, they were treating a hypertrophic scar or if you are a keloid scar former and people with a clear strong history of making those kinds of scars need to have a careful discussion with their facelift surgeon. But most of the rest of us can point to a few little injuries or maybe a surgical scar and if there wasn't a particular problem with healing from that scar, it indicates we'll probably do well with facelift.

(17:54):
If we run into a problem with a scar, there are quite a few things we can do to treat those, including injecting various anti-inflammatory medicines, topical applications, and silicone gel strips. There are a number of laser treatments we use for scars, and I've done a fair amount of research into this and I treat a lot of problem scars with a variety of laser devices as well as the option to surgically revise the scar just in a small local anesthesia procedure, trim out a little bad portion of scar and titch it very tiny in the hopes that not during a big operation, it will heal a little better the second time around.

Summer Hardy (18:40):
Is there anything wlse listed should be aware of?

Dr. Kylie Edinger (18:42):
For the overarching theme here of appearance concerns, this is a reminder that this isn't a permanent solution that's going to stop the clock and end the aging process. This is a tool to set the clock back, but the clock is going to keep ticking. The surgery typically lasts 10 to 15 years like we had mentioned before, and then you're often going to need to repeat it again.

Summer Hardy (19:04):
And before we close out this episode, can you share your takeaways, Dr. Bass?

Dr. Lawrence Bass (19:08):
Just to recap what we've discussed, it's natural to have fear. Fear is protective. It shows you're human and you're thinking about things. I get worried when I have a patient who seems oblivious. They have no concerns. I'd rather have a patient who's consumerist and wants to understand what's involved and what the risks are. Fortunately, the risks are minimal. In modern plastic surgery, these things are very well studied in very well refined. So despite having these fears, the medical risks are very low and steps that we take during the medical clearance and during, after the procedure work to keep them at an absolute minimum. The fears that are related to appearance or natural, I don't think there's a plastic surgery patient who doesn't wonder about and worry a little bit about how they're going to look and how the procedure's going to come out. But with a well performed procedure by a plastic surgeon who is experienced in facelift, this can restore your younger appearance rather than altering your appearance.

(20:22):
The risk of telltales is minimal and the scars generally healed to be difficult to impossible to see a problem. Scar, as we just discussed, can be revised or treated. So overall, if you're bothered by skin laxity, you're middle aged or older, some form of surgical face lifting is almost always the correct option. There are non-surgical treatments, but they won't get you the results you're looking for in these circumstances once you've hit the point of what medically we call moderate laxity, the facelift has continued to evolve to be a more complete correction with less recovery and less risk than historically. So it's not your grandmother's facelift, it's a 21st century facelift, which believe me, is bigger and better. For that reason, it's not worth letting fear keep you from looking your best and showing the face that you want to the outside world.

Summer Hardy (21:25):
Definitely. I feel much better about the facelift when I hear the facts. Thank you, Dr. Edinger and Dr. Bass sharing what worries people about the facelift and helping to separate fear from reality. 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 @drbassnyc.