Why You Shouldn’t Fear the F Word: Where The Facelift Fits in Modern Plastic Surgery

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Welcome back to another episode of
Park Avenue Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery. I'm your cohost Doreen Wu.

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And I'm here with Dr. Lawrence Bass
Park Avenue plastic surgeon, educator,

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and technology innovator.

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The title of today's episode is
"Why You Shouldn't Fear the F Word:

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Where the Facelift Fits in
Modern Plastic Surgery."

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Everyone wants to preserve
their youth and beauty.

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And most people would prefer
to avoid going under the knife.

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As our faces begin to age and
show signs of wear and tear,

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we have to start considering the
facelift as a potential option. Now,

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understandably,

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this can produce some anxiety and
oftentimes our thought process and

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decision-making can be colored by
media stories and personal experiences.

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We are here today to clear up
the uncertainty surrounding
facelifts and debunk

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the myths, but first let's travel
back in time to where it all began.

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Dr. Bass,

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can you tell us a little bit about what
a facelift surgery looked like in the

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early 1900s?

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So facelifting started
in about 1901 as a skin

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only operation, a wedge of skin,

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usually in front of the ear was

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cut out and the skin stitched up
and this provided reduction in

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laxity and a boost to the face.

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And this was fundamentally how
facelift worked for most of the

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20th century. And during this time,

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this is really the era of
starlets and socialites.

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The people who had plastic surgery
were a very distilled portion of the

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population,

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but this was the prototypical
plastic surgery operation of all

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time in aesthetic plastic surgery.

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So when people think of aesthetic
or cosmetic plastic surgery,

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they think facelift.

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That's a really interesting mental
image that you just painted with the

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older facelifts being a wedge of
skin being cut out. I'm curious,

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since then, how has the
facelift changed over time?

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Starting in the 1970s and
extensively in the 1980s,

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surgeons started addressing
more than just one plane,

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just removing skin and re draping skin.

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They started to take the connective tissue
and muscle layers deeper in the face

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and repositioned and
tightened them up as well.

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So this is the so-called SMAS layer,

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which is a connective tissue layer
overlying the muscles in the face,

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along with some of the superficial
neck muscles, uh, redraping,

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these and repositioning, uh,

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became a central part of facelift surgery.

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Then in the 1990s,

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there were attempts to
do a single plane of

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elevation deeper to this,

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the so-called deep plane facelift
and attempts to correct other

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aspects of facial aging,

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like create a more complete correction
of the nasolabial fold the fold between

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the cheek and the upper lip,

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just by the side of the nose
and the marionette line.

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The line that runs from the corner
of the mouth down to the jawline.

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And a lot of that 1990s activity
has since been abandoned.

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Some of that's controversial, whether
deep plane is fruitful or not,

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but most facelift now in the 21st
century is multi planer facelift

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with both deeper layers,

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SMAS and muscle layers and skin redraping.

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Sounds like over time,

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we have really gained a deeper
understanding of the anatomy of the face.

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And there's been a lot of improvement
in the techniques with all of these

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different advancements and such.

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Why is there still so much fear and
reluctance surrounding facelifts?

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Well, if everyone had a choice, of
course, they'd rather get a great result,

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have their face look young again
with no downtime and no surgery.

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And that's perfectly
understandable. And in fact,

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as we've entered the 21st
century, typical busy,

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modern life makes it even harder
to afford downtime to have a

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surgical procedure.

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So the whole trend has been
towards earlier rejuvenation using

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non-surgical techniques. However,

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there comes a time when there's
no meaningful way to improve

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the face without using a facelift.

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The facelift is still the
big reset in facial aging.

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And at some point in time,
you're going to need a facelift.

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If you want to look your best,

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the reason people still worry about
it largely or evolves around their

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perception of the facelift, not the
realities of what modern facelift is like.

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So one fear is fear of
anesthesia and facelift is done

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with different levels of anesthesia,

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depending on the surgeon's
preference and where they're working.

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But sometimes it's general anesthesia.

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Sometimes it's sort of
colonoscopy, anesthesia, uh,

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which gives a quick recovery.

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Some surgeons do the
procedure with just local

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anesthesia, local anesthesia
with a little oral tranquil,

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but modern anesthesia has really
been the powerhouse of an enabling

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ambulatory surgery.

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So the ability to have
excellent anesthesia,

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be comfortable for even procedures,

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much more extensive than facelift,

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and then wake up and go home an
hour later and recover at home has

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really been enabled by advances
in anesthesia. So you feel well,

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you're not nauseous and you're able
to function at home on your own.

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Uh, another big factor
is a fear of showing the

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scars or some unnatural feature
or having the facelift change

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your appearance. So you no
longer look like yourself.

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And in skillful hands,

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you should be able to have a facelift,

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even two or three facelifts
and look perfectly natural.

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We see the bad results
because they're very visible

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walking around, but
normal facelift results,

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which look perfectly
natural are invisible.

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So we're not aware they're even out there.

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So it seems like the facelift
has really evolved over time,

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moving away from getting that tight
skin appearance to a more natural look,

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no more wind tunnel appearance, so
to speak. I think it's safe to say,

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would you agree, Dr. Bass,

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that the goal of a modern facelift is
to take years off of your appearance for

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patients to look like a
younger version of themselves?

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Yes, that's exactly right. Doreen.

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We're really trying to make
you look like yourself.

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Just the way you looked
10 or 20 years ago.

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There are other things we do in plastic
surgery where we're trying to change

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what you look like. We do
that in rhinoplasty surgery
or adding cheek implants,

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or all, all kinds of different things.

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But in facial rejuvenation like facelift,

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we're trying to make
you look like yourself,

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just rested the way you
looked a few years ago. Uh,

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we also have come to a better
understanding of what happens to the face

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as we age and what kind of things we
should be trying to do in facelift.

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So over the last 20 or 30 years,

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we've recognized to a much greater extent
that facelift is not about just taking

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out loose skin.

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It's really restoring the
youthful shape of the face,

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which changes as we age.

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We've also gotten a better
understanding of the anatomy,

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which parts of that SMAS layer
are mobile and fixed, uh,

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therefore which part needs to be released
and which part will move on its own

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without any extra dissection. Uh,

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we've understood how to
rework the neck muscles to

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restore the youthful architecture
and facelift overall has

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come to less incision, less dissection,

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but at the same time provided us with
more complete correction and less

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recovery. So that's really a win-win.

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The other change is rather than try to
force the facelift to do things that's

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not well suited for like correct the
nasolabial fold or the marionette line

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or create or correct
volume loss in the cheeks.

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We're increasingly relying on
adjunctive treatments to work on

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other features that facelift
doesn't particularly address.

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Earlier you mentioned that the
facelift also can address the

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neck muscles. So when I, well,

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the word facelift has the word
face in it. I just want to clarify,

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does a facelift, can it also help with
loose skin and other parts of your neck?

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Yes, I mean the technical medical
name for facelift is cervical

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facial plasty. And so that
means the neck and the face.

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And there's a lot of nomenclature out
there about neck lifts and facelifts and

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different kinds of facelifts
and many facelifts.

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Most of that is marketing nomenclature and

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not really important from
a technical point of view.

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Each surgeon has a collection
of techniques that they use,

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depending on the anatomy. They find
what your bone structure is like,

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how much fat you've lost in the face,

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or how much fat you have
remaining in the face, uh,

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as well as other factors. Um,

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so the main area that facelift addresses

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best is looser hanging skin in the neck,

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the jowl and sharpening the jawline,

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but the facelift does address cheek
shape and position and the appearance of

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the remainder of the face as well.

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So a facelift kind of addresses
the entire that entire area.

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Um, I think it really helps to
create that natural rejuvenated,

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well rested appearance that prompts your
friends and your family to say, wow,

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you look really good, but they can't
quite put their finger on what change.

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You mentioned that there are other
treatments that can be used in conjunction

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with the facelift.

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Can you talk a little about what
they are and why they're an important

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part of facial rejuvenation?

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Sure.

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One of the biggest things that
facelifting can't address is the

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quality of the skin itself. So we're
repositioning the fabric of our skin,

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like the sheet on a bed.

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So it's not rumpled up and loose
so that it's flat and smooth,

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but that fabric itself has
been damaged by sun and years.

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Uh, so restoring the quality
of the skin is something that

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relies on chemical peels, laser peels,

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and a range of other laser
and energy based treatments.

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And that's going to have a big effect
on how the face age is going forward.

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I mentioned the perioral changes,

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the folds around the mouth
nasolabial fold and marionette line.

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If you look in the mirror and pull hard
enough on your face to really flatten

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out those lines, you'll notice that
you're distorting the shape of the mouth.

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This is exactly what we're trying
to avoid doing with a facelift.

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So by definition,

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we need other techniques to help us
more completely correct those lines.

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That's commonly done with fillers,

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or if we're in the operating
room often with fat grafting,

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there are a lot of changes around the
eyes and the facelift does not address

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that sometimes that's eyelidplasty
or blepharoplasty surgery

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on the eyelids. Sometimes that's
chemical peels, fat grafting fillers.

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There are a whole range of things
that happen around the eyes,

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which is really a subject unto itself.
And finally, it's facial shaping.

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As I said, the facelift is really
a shaping operation for the face.

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And by repositioning the
SMAS and working on the SMAS,

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we can restore a lot of the
balance of upper and lower face

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width that gets distorted with
aging and bring back the youthful

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shape.

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But some people don't have
enough remaining tissue in
their face to really bring

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them back where they came from. And
so fat grafting can help us with that.

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You know,

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it's funny that you mentioned fat because
that's another scary word that begins

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with F I'm not so sure I would
want to add fat to my face.

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Why is that an important and increasingly
popular procedure that's being done

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in conjunction with facelifts?

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Yeah, I get that feeling a lot. You know,

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most Americans would like to
get rid of a little bit of fat,

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not add any back in,
however, for most of us,

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unless we're very overweight,

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we are actually losing fat in our face.

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And this is an event that starts
in our twenties, you know, 25,

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we may have the baby face,

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but then we start losing fat later in
our twenties and on into our thirties.

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And that gives us a more sculpted look.

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And often that's a better look
in many ways than we had at 25.

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However, it doesn't stop there.

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And eventually that fat loss
becomes too much of a good thing.

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If you think of someone
who's very elderly and

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how gaunt and empty their face looks,

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that shows you where this journey
ends and that's because we continue to

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lose fat. And as we get into
our later fifties and sixties,

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we're also losing muscle volume in
the face and we're losing bone volume

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in the face.

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So all of these losses
contribute to a change

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in shape that we would like to
reverse as part of facelift or

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facelift with some
adjunctive fat grafting.

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It seems like aging is this battle
that we can never really win.

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Um, but it sounds like the facelift
can produce some really great results.

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I'm wondering, should people wait until
a certain age before getting a facelift?

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In other words, how do I
know if it's the right time?

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Well, first of all, I think
you're right during, you know,

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we're never going to win the war against
aging either with our appearance or

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health in general,

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but we'd like to win an awful
lot of battles along the way,

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even though we know sooner or
later we're going to lose the war.

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So facelift is really, as I said,

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the big facial reset and medically,

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this is going to come at a
different time for different people,

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depending on how they're
aging separate from that.

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There's a time when you are
psychologically ready when you feel that

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it's an important part of your
beauty plans and looking good and

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feeling good about how you
look to undergo the facelift.

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And that's a personal decision
that varies a fair amount

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from person to person. But, you know,

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there are statistics on this and
the aesthetic society has been

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collecting statistics
since the late 1990s.

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And they tell us some interesting things.

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So let's look at the age
distribution for facelift

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in the year 2000 and in 2019.

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And I picked 2019 because that's
before the pandemic began,

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because that obviously had an impact
on how many procedures were being done.

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So if we look at 2030,

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1% of patients having a
facelift were aged 35 to 50.

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If we look at 20, 19, only
eight and a half percent of,

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of people having a facelift were
35 to 50, that's a big drop.

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Absolutely. And,

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and that's a commentary on how productive
all of the non-surgical treatments

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have been at helping us look
better in conjunction with better

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lifestyle. You know, we
all know sun ages the skin,

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everyone is smoking less,

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which is a big skin aging factor.

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So changes in lifestyle
have, let us age more slowly,

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but also all of the non-surgical
treatments, keep us looking good,

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not needing a facelift for a while longer.

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Let's look at the other end of
the spectrum in the year 2000, 15%

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of facelift patients were age 65 or older,

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but in 2019 36% of

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facelift patients were age 65 and older.

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So folks are reaching the point
where they've aged enough to need a

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facelift at a later stage, but
we're also more active for longer,

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still working, still socializing,

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still having a priority
on looking our best.

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And even when, um,

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let's say a 60-year-old woman
comes in and gets a facelift,

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she can still sail into the sunset
and enjoy the results of her facelift.

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She's not putting it off until she's 80.

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I feel like another common trend is that

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many people put off scheduling a face
consultation because they don't think

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they're old enough, but now we know
that there's no optimal age per se.

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And that when performed by
a skilled plastic surgeon,

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the facelift can benefit
people of all ages,

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not just quote unquote older adults.

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I feel this is why it's really
important to be engaged in or in an

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ongoing relationship
with a plastic surgeon,

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someone who's going to help you maintain
your appearance and prevent aging

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changes for as long as possible. If
you're working with small treatments,

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you'll postpone the need for facelift,

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and you'll already have a trusting and
collaborative relationship with your

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surgeon so that you can work
together to decide when,

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or even if a facelift is on the
agenda for your youth and beauty plan.

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That makes me think of another point,

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given that going under the knife is a
big decision and not one to be taken

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lightly. What if I'm not
ready to take the plunge yet?

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Are there non-surgical
options that are available?

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This is the question everyone's
always asking. And of course,

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as I said earlier,

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we'd love to get a facelift like result
without having to have a facelift.

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But currently there is no technique
that gives us the degree of correction

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or the durability of correction
that we get with a facelift.

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So there really is no substitute once
you've aged enough to medically need a

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facelift,

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we're not going to be able to get you
that result without doing a facelift.

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And as a technology researcher,

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I don't see anything on the horizon
in the next five or 10 years,

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that's likely to make the
facelift obsolete. However,

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early in the aging game, as I said,

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a number of treatments and
techniques can help you postpone

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the facelift often for a decade or more.

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And I think that's what that data
from the year 2000 versus 2019 shows

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us that we can push off the
facelift maybe for a decade,

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if we're doing a good amount of
active facial maintenance. The,

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the last important point about this
though, is those non-surgical options.

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You know, they do what they do.

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They're great options if you're in the
right place and time to benefit from

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them, but trying to push them
too hard to produce a facelift,

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just produces trouble, distortion
complications, or an unnatural look.

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Perfect example is
fillers. A lot of folks,

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either who don't do surgery or
who don't want to have surgery

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are trying to avoid a facelift by just
pumping themselves up with fillers,

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adding fillers to restore volume.
You've lost is a good idea.

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It makes you look the
way you used to look. Uh,

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you can even accent certain features
modestly. That's a good idea,

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but pumping you up just to take laxity
out of the skin is going to end up

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distorting your appearance because you're
putting more volume than what you've

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lost with aging.

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Too much of a good thing can be a
bad thing, essentially. So Dr. Bass,

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to wrap this all up,

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can you tell me what are the key
reasons to not fear the F word?

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I think the big idea about
facelift is in skillful hands.

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You look like yourself, you look
perfectly natural and rested. Uh,

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it is a very safe procedure.

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The anesthesia required is not
heavy amounts of anesthesia.

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The recovery time is less
than it's ever been before.

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Typically somewhere on the order
of a week to a week and a half.

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I've had patients come in saying they
think it's three months for them to

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00:22:24,231 --> 00:22:26,110
recover from a facelift. Well,

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who can afford to take three months off
of whatever it is they're doing in life?

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00:22:29,951 --> 00:22:32,110
Nobody really, uh,

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00:22:32,111 --> 00:22:35,630
but it's really only about a week to
a week and a half of downtime before

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00:22:35,780 --> 00:22:40,380
routine work and socializing is
okay. So I think for these reasons,

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if you are looking at skin laxity
and aging changes that are really

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00:22:45,781 --> 00:22:50,020
bothering you and it's
time medically, it's,

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it's a great option for
restoring youth and beauty.

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Well, if you find yourself
still fearing the F word,

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be sure to tune in to our next episode,

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to hear what you can do to
postpone the need for a facelift.

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00:23:02,570 --> 00:23:03,620
This is Doreen Wu,

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00:23:03,621 --> 00:23:08,020
thanking you for joining Dr. Bass and me
for this discussion of facelift and why

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00:23:08,021 --> 00:23:09,060
we don't need to fear it.

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Don't forget to join us next time for
our episode titled before the facelift,

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how a multifaceted program of non-surgical
treatments can add a decade before

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the facelift.

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00:23:20,340 --> 00:23:23,410
Thank you for joining us in
this episode of the Park Avenue,

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00:23:23,411 --> 00:23:28,010
Plastic Surgery Class Podcast with
Dr. Lawrence Bass Park Avenue plastic

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00:23:28,490 --> 00:23:31,610
surgeon, educator, and
technology innovator.

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00:23:31,910 --> 00:23:34,480
The commentary in this
podcast represents opinion.

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00:23:34,710 --> 00:23:37,120
This podcast does not
present medical advice,

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00:23:37,460 --> 00:23:41,480
but rather general information about
plastic surgery that does not necessarily

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00:23:41,540 --> 00:23:44,640
relate to the specific conditions
of any individual patient.

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00:23:45,020 --> 00:23:49,760
No doctor patient relationship
is established by listening
to or participating

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00:23:49,900 --> 00:23:50,733
in this podcast,

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00:23:50,990 --> 00:23:55,000
consult your physician to advise you
about your individual healthcare.

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00:23:55,260 --> 00:23:56,680
If you enjoyed this episode,

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00:23:56,900 --> 00:24:00,880
please share it with your friends and
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00:24:00,881 --> 00:24:04,950
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00:24:05,250 --> 00:24:07,550
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