Though many facelifts are performed in Beverly Hills, the percentage of those that would be considered “excellent” or even “good” is not as high as one would expect. But rather than going into why this is the case, I would like to discuss what constitutes an excellent result. It goes without saying that there should be no serious complications, such as permanent sensory or motor nerve injury or loss of skin with resultant scarring. The result should make you look younger and refreshed. In many instances, colleagues at work will comment that you “look good” or “well rested” and that maybe you should take more “vacations”, like the one they think you just returned from. It should not look like you recently had surgery! The incisions should be imperceptible or well hidden. There should be no distortion of your features, like the corners of the mouth or eyes or the ears. There should be no significant asymmetries between the two sides of the face, and improvement in the face should be matched by a similar improvement in the neck. Finally, there should be no “lumps” or “depressions” following the surgery, nor should there be localized discolorations or edema, suggestive of damage to the vascular or lymphatic networks under the skin.
Facelifts go by many names—some technical and some not-so-technical. There is the subcutaneous facelift, the SMAS facelift, the deep-plane facelift, the composite facelift, the MACS facelift, the mini-facelift, the mid-facelift, the endoscopic facelift, the S facelift, the thread facelift, the Lifestyle facelift, the short scar facelift, and, most recently, the vertical facelift. Many of these are just variations or limited versions of the others or just different access approaches to elevate the same tissues.
I would like to discuss the so-called vertical facelift because it has gotten much attention lately as the “best” approach to reversing the downward effects of gravity. Though the actual term may mean different things to different surgeons, the basic idea is to elevate some, if not most, of the tissue straight up. While this may seem to be the obvious approach to reversing facial aging, it is not that simple. Due to the various connective tissue attachments under the skin and the differences in mobility to the various parts of the face, there appears to be a forward as well as a downward descent. This is all too apparent when we look at the oblique fold of tissue going from the nostril to the corner of the mouth. Complicating this picture of facial aging is the atrophy or loss of the subcutaneous fat that also occurs in some areas, leaving a void or depression that looks as though tissue has fallen away. It appears that the best approach to reversing facial aging is a combination of some vertical as well posterior lifting, coupled with augmentation via fat or implants, if atrophy is also present. The vertical component of the lift can be in the deep subperiosteal plane or more superficially in the SMAS plane or even the subcutaneous plane. But it almost always gives a more natural result if there is some element of posterior lifting, as well. To that end, some surgeons are combining a vertical subperiosteal mid-facelift with a posterior-superior vector SMAS or subcutaneous facelift. Alternatively, others combine a posterior-superior vector MACS (minimal access cranial suspension)lift or SMAS facelift with a vertical subcutaneous facelift.
Recent statistics released by The American Academy of Facial Plastic and Reconstructive Surgery show that in 2011 the 3 most commonly performed facial procedures were rhinoplasty, eyelid surgery and Botox Cosmetic. And it is no surprise to me that this should be the case.
Rhinoplasty is one of the most transformational procedures that I do. It can make someone who has been unattractive their whole life more appealing, and it can even make a person look younger by elevating their tip. Eyelid surgery is relatively easy to perform with minimal downtime and does wonders for making someone look more relaxed, less “burned-out” and even younger. Finally, Botox Cosmetic is one of the “lunchtime” procedures, which is easy and quick to perform, relatively inexpensive and produces dramatic results in the right patient. In addition to smoothing out wrinkles of the forehead, between the eyebrows and around the eyes, it can raise downturned corners of the mouth and lessen the prominence of early neck bands.
The ideal nasal profile has a tip that is slightly higher than the rest of the bridge. In many instances, this requires raising the tip to this level. To accomplish this, there are several techniques that can be employed. The first involves narrowing each of the two tip cartilages and then sewing them together. Because each cartilage forms an arch under the tip skin, narrowing them with sutures causes them to elongate upwards (Fig. A). Another popular way of increasing tip projection involves placing a cartilage tip graft over the underlying tip cartilages (Fig. B). This has the added benefit of creating more angularity to the nasal tip, which is especially useful with thick skin. Finally, the third most common way of increasing tip projection is by placing a fixed strut of cartilage anchored to the septum to which the tip cartilages can be sutured in a more projected fashion (Fig. C). Though each of these techniques work to accomplish an increase in tip projection, the choice of which one to use depends on many factors such as the need to improve tip definition or the desire to improve the proportional relationship between the length of the nostril to the length of the tissue in front of it (the lobule).
Being a surgeon who sees many rhinoplasty patients, I am frequently asked if nostrils can be re-shaped. Many of these patients have been told that what they want is either impossible, unpredictable or very difficult to accomplish. However, it has been my experience that this is generally not the case. In fact, most nostril shapes can be improved or made to look more aesthetically pleasing—even if numerous attempts at improvement have been unsuccessful in the past.
The margin of the nostril can be raised or lowered and the attachment to the cheek can be brought in, out or even lowered. Additionally, the thickness of the wall can be narrowed. Finally, it is not unusually for several of these maneuvers to be performed at the same time.
When lowering the nostril rim, we can rotate some of the internal lining downward, if the correction is small. For larger deformities, we usually need to add a composite graft of skin and cartilage, from an inconspicuous part of the ear, to act as a “spacer”.
Raising the nostril rim is quite easy and just involves an internal resection of skin with internal and upward rotation of the hanging external skin.
Narrowing a wide nostril can be accomplished in several ways. Skin from the nostril or floor of the nose can be excised, “cinching sutures” can be placed to pull the nostrils in or nostrils can be released from the underlying bony attachments to allow them to contract inward.
Widening a narrow nostril can be effected with the use of a graft from the opposite nostril, an advancement flap from the floor of the nose or rotation of a flap just outside the nose, for severe cases.
Finally, a thickened nostril wall can be thinned by excising an elliptical slice out from between the internal lining and external skin covering.
We constantly see celebrities who suddenly look different with telltale signs of having had some plastic surgical procedure. And though the procedure may have been executed successfully, from a technical standpoint, the final aesthetic result is “off”. In many cases they look younger, but not necessarily better. And, on the other hand, in many cases they look older, though their face may appear tighter. There are many characteristics that contribute to a youthful, beautiful face. In some facelift techniques, the face appears narrower, though smoother. Since youthful faces are generally fuller, such a result would be unwelcomed and detract from the overall effect. Also, eyelid surgery that produces a “high fashion” hollowing out of the upper eyelid space may also be a questionable improvement, since youthful eyes are usually fuller in this region. And browlifting, unless performed conservatively with the difference between male & female aesthetics kept in mind, may look “odd” or inappropriate. Finally, various lip procedures may change a characteristic pout or contour into something less attractive.
So it is important for the surgeon to recognize all of these subtleties when doing these surgeries, to produce a result that makes the patient look better—not different.
In my blog posting on 11 September 2011, I presented photos of an extensive cancer resection which was reconstructed using a “pinwheel flap”. I am presenting a follow-up photo , approximately five months after the surgery, which shows a barely perceptible scar with hair growing through the flaps. The hair has been pulled away to demonstrate the result.
Being a facial plastic surgeon who specializes in nasal surgery, I have been somewhat dismayed by the relatively recent increase in cosmetic as well as reconstructive procedures that are much more extensive than they need to be. This is not to say that the results aren’t acceptable or that it is being performed by inexperienced surgeons. However, one must always consider the associated morbidity or “collateral damage” that these procedures produce. When we consider cosmetic nasal surgery, especially revisional following prior poorly executed rhinoplasty, I am seeing many patients who come for second opinions because they were told they need a “rib graft”. While a rib graft may get the job done, it results in another operative site on the chest with its associated scarring, pain and risk of lung collapse. It is my procedure of “last choice” when there are no other alternatives such as nasal septal cartilage, ear cartilage or occasionally synthetic implants. And, to this date, I have never been disappointed in a result from the use of these materials in patients who were told that they needed a rib graft.
Regarding reconstructive nasal surgery following trauma or cancer surgery, I have seen a huge increase in the use of forehead flaps. These require an unsightly flap of tissue from the forehead attached to the nose for a period of three weeks, a second or more additional surgeries and resultant forehead scarring (which is usually acceptable). Once again, there are usually many alternatives like local flaps, skin grafts or composite (skin plus cartilage) grafts. Obviously, the main object of cancer surgery is complete removal of disease. However, it is still important to “factor in” the post-operative morbidity and, at least, to consider these other alternatives.
I recently did an interesting and challenging rhinoplasty on a patient in which I lowered and widened his nostril using an adjacent skin flap.
I will post the final results on a later blog.
I just set up my professional facebook account under Stephen J. Pincus, M.D., F.A.C.S.
This new account will allow me to share with my facebook friends all of the new and interesting things that are happening in my practice.