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Making Sense of Different Facelift Techniques from Beverly Hills, Los Angeles, Manhattan, Paris, London

More than a decade ago, a few of the most notable facelift plastic surgeons in the country participated in a meeting where they performed a live facelift on a group of twins. Each plastic surgeon used his own published technique and a year later the results were evaluated by a group of plastic surgeons. The purpose of this famous “twins study” was to establish if one technique would stand alone as the “gold standard” to achieve the best result. Unfortunately, there was no winner. No one technique was singled out as “the best technique”.  No result stood out clearly as the best! The conclusion was that no matter what technique anyone used, it was the skills of the surgeon that mattered, and all the results were similar because they were all good surgeons! A bit disappointing, wasn’t it?

In retrospect, there is some truth in the conclusion: it is undeniable that the ability, judgment and skills of the plastic surgeon do play an essential role in a successful outcome in a facelift. Experience helps preventing complications, a sense of beauty dictates what is needed and the skills of the plastic surgeon make it happen.

What about techniques?

Every plastic surgeon uses some form of basic technique that he modifies accordingly, depending on situations determined by patient’s anatomy, age, risks factors, etc.

How does the patient (the consumer) make sense of all of the different techniques?

The plastic surgeons use their own terminology to identify in one technique or the other, and this is passed on to the patient with the implication that it would be easily understood. But most of the time, it is not.  So let’s try to shed some light on this subject.

Like anything else, facelift surgery is subjective to trends, and, like any trend, techniques come and go. We all get excited about a new technique and for a while everyone will incorporate it into their armamentarium only to find out that it does not deliver the results we were expecting. At that point, the search is on for something else to fill the gap.

Let’s review the most popular techniques and try to establish benefits and downsides of each of them.

Probably the most popular of the facelift techniques (and the most used) is the so-called SMAS facelift. The SMAS (Superficial Muscolo-Aponeurotic System)  is a thin layer of tissue which overlies the muscles of facial expression. It was discovered in the 1970s and since then has become probably the workhorse of facial plastic surgery. Before that, the facelift was basically a skin-only procedure where only the skin was elevated through the classic incisions around the ears, pulled, and stitched together.

The SMAS facelift consists of isolating and elevating this thin tissue over the facial muscles and transpose it upward. By doing that, it transmits the pull to the skin that is elevated at the same time. The benefit of this technique is that the tension of the pull is transmitted to the SMAS layer so the skin can be pulled with less tension. The downside is that the direction of pull of the SMAS is horizontal or at best oblique in the High SMAS (a recent modification of the technique) giving the face a un-natural pull.

There have been a lot of spin-offs on the SMAS techniques like the one I mentioned before, the High SMAS and several others, like the SMASECTOMY where the SMAS instead of been repositioned is partially excised. In my opinion, it does not make any sense of excising any structure of the face but the skin because by removing something the face loses volume when in fact we want to add volume to an aging face that is deflated. The other variations of the SMAS facelift consist of folding, cutting or moving the SMAS a few millimeters up, down, left or right and it is hard to believe that by doing that the final result would change substantially.

The subperiosteal facelift was in vogue a few years ago. It consists of moving the facial tissues upward by relying on the periosteum, which is a thin layer of tissue right above the facial bones. The benefit of the subperiosteal facelift is that you move the deeper structures of the face as a unit therefore being able to reposition all the layers at once. The subperiosteal technique has been plagued by severe swelling and a longer post-operative recuperation, so it is now used only in select cases where a mid-face elevation is warranted.

Another popular facelift technique is the so-called “Deep Plane Rhytidectomy” or Deep Plane Facelift and the Composite Facelift, which is an evolution of the Deep Plane Facelift. The concept is to mobilize the facial structures from underneath the facial muscles and incorporate the area of the lower eyelid and cheek as a unit. The benefits of this technique are, like in the subperiosteal facelift, the facial structures are moved as a unit avoiding the pitfalls of the SMAS facelift. The problem is that the dissection is done in the plane where the facial nerves interconnect with the facial muscles and, therefore, are at risk of being injured. Also, the post -operative course is longer due to excessive swelling and bruising. And still, in my opinion, the vector of pull is not vertical but horizontal, so it creates a “done” look.

There also being a surge facial rejuvenation techniques that incorporate fat grafting in facelift techniques. In my opinion, most of them are not done properly because they are forced to place the grafts in areas of the face where the skin has not been mobilized for survivability issues and, for this reason, does not help in delivering a natural result.

Lastly, there is been a push for less invasive techniques like the lifestyle facelift and the short scar facelift. The first one is a modified version of a very conservative facelift, and the only claim to fame is that it is done under local anesthesia. I do offer most of the facial procedures under local anesthesia, so there is no point of getting a lifestyle lift when a more sophisticated version is available at the same conditions.

The short scar facelift claims less visible scars, but it is a gimmick. The scars are still present in the front of the ears where they are most visible and are shorter in the back. It is a recycling of the old style mini-lift.

The shortcomings and the downsides of all the techniques I have described have pushed me in the last 20 years to develop my own techniques. First, with the vertical facelift, I completely changed the vector of pull of the facial tissues, switching from the traditional horizontal vector to a much more natural vertical vector and in doing so avoiding the” pulled” look. Then with the regenerative facelift I combined the use of stem cells in the vertical lift by placing the cell-enhanced grafts under the facial musculature avoiding the known pitfalls of fat grafting like irregularity and poor take. The stem cell regenerative facelift is the last generation of my facelifts, and it is in my opinion, hands down, the most advanced facelift in the world. The most comprehensive photo gallery available with one of the best facelift before and after photos and pictures are a testament of the validity of the technique.