Facelifts and Neck Lifts

Facelift surgery is probably the best-known cosmetic facial procedure and is the absolute gold standard for lower face and neck rejuvenation. Although there are many new technologies that supposedly address skin and neck tightening, none of these can come close to the improvement and longevity of traditional facelift surgery.

Facelift surgery was developed and refined over a century ago and has undergone many changes. The facelift that your parents may have had is not the same as today's contemporary techniques. A generation ago, a facelift had an average hospital stay of 3-4 days. Most of our patients today are home by 2:00 the same day and have the procedure performed in our fully accredited surgery center. With the recent advances in instruments, technology and anesthesia, facelift surgery has never been easier or more affordable.

Another difference in today's facelift patient is the age. Today's patients do not want to wait until they look old to have cosmetic surgery. They want to stay younger looking all their life. In the past, most patients waited until their sixth decade and underwent a big operation with an extended recovery. Today's patients opt to have smaller procedures along the way and avoid the overhaul their parents had. Performing smaller cosmetic procedures along the way may require the patient to have them again later in life, but again, they will avoid looking aged.

If it sounds too good it probably is! Don't be fooled by any technology that reports facelift type results without surgery. This includes Thermage, Fraxel and Thread Lifts. This is not to say that these therapies do not do anything, but they cannot hold a candle to the improvement and longevity of contemporary facelift surgery. We routinely see patients in our office that were treated somewhere else with a "new miracle technology" to tighten their face and neck and are embarrassed and frustrated that they wasted enough money to have paid for a real facelift. If any doctor reports significant results from a non-surgical procedure, demand to see 20 STANDARDIZED before and after pictures at least 1 year after the procedure. Also make sure they are pictures of actual patients taken by this doctor and not company pictures. If someone can show you results like this, then the procedure may be worth consideration. So far we have never seen any technology meet this challenge. We see many disgruntled patients every month who wasted their hard earned money on a promise that sounded too good to be true.

What about the "Miracle" facelifts you see on TV and in magazines?

It is very common to see magazine ads and TV commercials that advertise "revolutionary" new facelifts with small recovery and "amazing" results. It is very trendy at this point in time to "invent your own facelift" and give it a fancy name. Remember, facelifts have been around for a century and although many improvements have been made, beware of any technique that claims to be radically different from the rest. Facelifts that "have no downtime", "no bandages", "no swelling or bruising", "no scars", etc. can be very deceiving. Most of these lifts are merely conservative facelift techniques that are being marketed as some miraculous advancement. It is not that they don't do anything, as they are usually OK for patients with minor aging. Performing a very small or conservative facelift (regardless of the name) on a patient who needs a bigger lift is a big mistake. If a patient has moderate oraging changes and they undergo minimal technique facelift the extent of the aging will frequently not be addressed. Conservative facelifts certainly have a place in cosmetic surgery, but only for younger patients with minor aging. Performing a small facelift on a patient who needs a bigger facelift will cause disappointment. The lift won't be as tight or last nearly as long. We see this happen frequently where a patient with moderate or advance aging changes falls prey to a "miracle" minimally invasive facelift at another office and now presents to our office unhappy with their result and requesting a fix. The problem is usually that the patient had too small of a procedure for the amount of aging they had. These heavily marketed techniques sound great, but in reality they are just the same type of conservative facelifts that have been around for years. They are fine for minor aging but can't compete with more comprehensive techniques.

If someone ever does develop a non-invasive technique that is more effective than facelift surgery, it will be front page news and every doctor will perform the technique, not just the ones that name their own facelift techniques. Surgeons that perform many facelifts realize that facelift surgery is a very precise and demanding procedure. If there were an easier way to do it, no one would still be doing it the old way. On your way to work tomorrow you won't see a horse on the expressway. The invention of the combustion engine was so superior that virtually no one ever again rode a horse for transportation. The same principle exists for facelift surgery. If a miracle technique is discovered, everyone will do it.

Many of these lifts are marketed by companies that franchise doctors and we have seen way too many unhappy patients that needed a real facelift and were not only very disappointed, but we had to redo the facelift, so the patient ended up spending twice as much!  Also, when these patients go back to express their dissatisfaction and get a refund, their case has to go before a "company review board" and inevitably they are turned down due to the fine print they signed in their miracle paperwork.  Look before you leap!  Buyer beware.  Do your homework.  What may sound like a great deal can quickly turn out to be a nightmare.  If you are thinking about having a "corporate" facelift, Google the name of the company or the lift, and you will probably be shocked with the negative experiences of many other patients.  Make sure your surgeon knows how to do all types of facelifts and will back up his or her work. 

You get what you pay for, but not just in terms of money as most of these lifts are more expensive than Dr. Niamtu's comprehensive facelift.  You get what you pay for in terms of recovery.  If  you really want to reverse years of aging, you need the type of lift that will take 10 days to 2 weeks to recover.  Unless you have very minor aging (38-42 years of age) these "revolutionary" lifts don't address the problem for a natural and long lasting result. The biggest reason that unhappy patients give for falling for a "miracle type of facelift" was the lure of a quick recovery.  Short recovery is greatly overplayed by these companies.  Remember, two weeks out of the rest of your your life to reverse a half century of aging is not a bad deal.  A "real" facelift takes 10-14 days to heal.

For more information on why "miracle" facelifts are not a good choice see Dr. Niamtu's Blog

Types of Face Lifts

Facelifts are like snowflakes as no two procedures are exactly the same. Each patient has different aging characteristics and requires customized treatment. Failure to observe this fact will result in an unnatural appearance.

One interesting question is "what is a facelift"? Different patients and doctors have different definitions for this. In reality, a facelift is a procedure with incisions in front of and/or behind the ear. A facelift by definition tightens the lower face and neck. Some patients have a facelift and at the same time have other surgical procedures such as eyelid surgery, brow surgery, etc. Some patients call the combination of all of these procedures a facelift, but again, a facelift by definition is a single procedure for the lower face and neck. Some patients elect to have a facelift by itself while others have facelift surgery with additional procedures.

The best way to understand facelift options is to realize that facelifts come in three sizes; small, medium and large. Patients with minor aging need small lifts, patients with moderate aging need a medium lift and patients withaging probably need a larger lift.

The above illustration shows the changes that occur as we age. The patient on the left has minimal lower facial aging and would be a candidate for the "weekend facelift".  The middle has moderate aging and is a candidate for the "minilift" and the patient on the right has moreaging and would require a "comprehensive facelift" for optimal surgical rejuvenation.

There are exceptions to this. For instance an older patient may need a large lift but they may not be healthy enough for a large procedure and may need to settle for less improvement with a smaller surgery. A similar situation may be a patient who needs a bigger procedure but does not have enough time off work or finances for the bigger procedure. These patients may settle for moderate improvement as a trade off.

In our practice we sometimes refer to the small lift as a "weekend facelift" because much of the healing occurs over that period. It is not uncommon for patients having this type of lift to have surgery on a Thursday and return to work on the following Tuesday. We also refer to the medium size facelift as a "minilift" as it is a conservative procedure for moderate aging. We refer to the larger lifts as a "comprehensive facelift". This is a more extensive procedure for moreaging of the face and neck.

Comprehensive Facial Rejuvenation

If you look closely, you will notice that many of the patients on the various facelift pages have had other procedures besides facelift surgery. It is most common for patients to have other cosmetic facial surgery procedures at the same time as their facelift. There is some economy of scale in this case as the patient can have multiple surgical procedures but only endure a single recovery and anesthesia. Also, when multiple procedures are performed at the same time the fees are frequently discounted. The biggest advantage of multiple procedure surgery is the ability to perform comprehensive rejuvenation with a single recovery and anesthetic.  If a patient is in good health, there is usually no reason not to perform multiple simultaneous procedures.

All cosmetic surgery is elective so no patient really needs it. Some patients desire to take baby steps and perform only a single procedure at a time. This type of patient may do their eyelids this year, a facelift next year, etc. On the other hand many patients prefer to get as much rejuvenation as possible from a single surgery and recovery. Sometimes multiple surgical procedures work great for a given patient while it may be too much recovery for another patient. Each case is different and Dr. Niamtu can assist your decision making process.

There are three main things that determine what type of surgery can be performed and if multiple procedures are possible.

• The general health of the patient.
• The ability to take time off of work or play.
• The budget of the patient.

If a patient is healthy, then multiple procedures are usually not a problem and routine facelift surgery can be performed.  Since we are a fully accredited surgery center, we have the much of the same requirements as local hospitals and all patients receiving facelift surgery must see their physician for history, physical and appropriate lab exam. Patient safety is our prime concern.

If a patient can only take one week off of work, then conservative procedures must be considered. Generally, larger procedures or multiple procedures require two weeks of recovery.  The larger facelifts have about a two week recovery.  Patients that have the ability to work at home can usually do this after the first week.  Some of our patients occasionally return to work less than two weeks and once in a while a patient many take longer than two weeks, but our average patient is presentable at 14 days.  If a patient is having surgery in advance of an important event such as a family wedding or reunion, Dr. Niamtu recommends that they have their surgery 4-6 weeks  before the big event. It is interesting that most patients want to keep their surgery a secret, while others will go back to work after a week and show off their healing surgery.  Our staff can assist patients in getting back to work as early as possible and much can be hidden with hair, makeup and sunglasses.

When Should I Have a Facelift?

Patients often ask when they should have a face lift and how long will the effects last? Basically, a patient is a candidate for a facelift when the jowls (excess skin under the cheeks) and neck skin begins to sag. Put simply, if you think that you need a facelift, you probably do.

To get an idea of how you may look with a facelift, lie on the floor on your back, lift your chin and hold a mirror over your face. This counteracts the effects of gravity and can simulate the basic improvements of the face and neck that can be achieved with cosmetic facial surgery.

How Long Will My Facelift Last?

This is a very common question. In some respects the surgery will last forever. If I had a 55 year old patient and his or her twin and I performed a facelift on the patient but not the twin, the patient will pretty much always look younger.

Although we can turn back the clock, we can't stop it, so all patients will continue to age. Most minimally invasive procedures will not last as long as more comprehensive ones. Dr. Niamtu performs facelifts that involve treating multiple layers of the face the neck including the muscle, connective, fat and skin. This type of facelift is harder to do and takes more effort on the part of the surgeon, but studies have shown these techniques to last 10-15 years. This does not mean that on the tenth year everything falls, but simply that as we age, the tightened tissues will slowly begin to sag with time. In rare cases some patients with elastic skin or weight gain may need a touch up procedure in 1-2 years after a lift. Other patients with healthy skin and those that take care of themselves may have cosmetic results that last 20 years or longer. No one can provide a guarantee on how long any cosmetic procedure will last and many variables are involved including the patients genetics, healing and after care as well as what type of surgical procedure was performed. One thing that can be safely said is that facelift surgery in experienced hands is an excellent long term investment.

The Facelift Procedure

Most patients that present to discuss facelift surgery are apprehensive because the word "facelift" is scary.  A generation ago, a facelift was much harder, too much longer to recover,  required general anesthesia and was more expensive.  Patients are also nervous about the incisions and the final result. These concerns are understandable and it is easy to put their minds at ease regarding the common misconceptions regarding facelift surgery. First of all, as mentioned earlier, facelift surgery is much simpler that it was a generation ago. As for the anesthesia, patients are relieved to know that their facelifts can be performed with light IV anesthesia. Finally, the incisions are truly hidden and rarely problematic. Dr. Niamtu goes to great lengths to use the smallest incision techniques available and to make incisions that will be hidden and look natural. There is never a need to shave any hair as some patients fear.  As for the "result", today's facelifts are much more natural when performed by surgeons that truly understand the face.  For almost 30 years, Dr. Niamtu has limited his practice to surgery of the head and neck and has always been a "student" of the face.  He understands that contemporary facelift surgery involves not only tightening, but also restoring youthful volume.  It is easy to make a patient look tighter, but with modern techniques such as facial implants, fat transfer and filler injection, they can look younger and not just tighter.

For the small or weekend type facelift the incision is only in the front of the ear as shown in the image below. This very conservative incision makes this a perfect procedure for the patient desiring minor to moderate correction without significant downtime.

For the medium facelift and larger facelifts the incision is made in front of and behind the ear. The incision is hidden in the hair in the sideburn area and behind the ear. It is also hidden inside the ear and behind the lobe and the ear. In reality, very little of the actual facelift incision is visible to others.

The incisions for the medium and larger facelifts are carefully designed to be hidden by the hair and the ear.

Facelift incisions heal extremely well and are rarely a problem in terms of scars.  If a scar does form, it is usually easily corrected with simple laser treatment.  The images below are typical of healed facelift incisions and many other examples of Dr. Niamtu's incisions can be seen on our incision gallery.

 

The patients shown above exhibit minimal scars typical to most facelift incisions.

Although there are many types of facelifts, Dr. Niamtu performs a multiple layer lift. This means that not just the skin is tightened, but the deeper layers as well. This type of lift is more technically difficult but the lift is superior, its results last much longer than skin only techniques.

The patient is sedated with IV anesthesia, and local anesthesia is used as well to decrease the amount of anesthetic drugs necessary. The local anesthesia also reduces blood loss and controls pain when the surgery is finished.

Platysmaplasty and Submentoplasty

Virtually all but the smallest facelifts require a procedure called platysmaplasty or submentoplasty.  This step is omitted by many surgeons as it is more technically difficult and takes more time.  If you are considering having a facelift make sure to ask you surgeon if he or she will be addressing the midline platysma muscles and submental regions.  A tighter, longer lasting and more natural result will result from these important procedures.  Unfortunately, some surgeons are simply lazy and do not perform them.  A facelift without addressing the midline deep tissues may look fine for a year or two, but when the neck bands and sagging return, patients will wish they had this performed.  The image to the left shows a left sided platysma muscle.  Dr. Niamtu comprehensively addresses this muscle by tightening the platysma muscle in the center of the neck (this improves neck bands and "turkey neck") and the lateral platysma which also creates a natural appearing, long lasting lift.  Submentoplasty involves tightening the deep tissues of the floor of the mouth, which is also very important to improve chin/neck aesthetics.  Liposculpture involves sculpting the excess fat in the chin, floor of the mouth, neck and at the border of the jaw.  Some of this fat is "bad fat" and needs removed with liposuction, while much of the fat under the skin is "good fat" and is needed for a natural result.  This fat is not suctioned away, but rather is sculpted to blend in and provide youthful contours of the unique area of the chin, jaw border and neck.  Over treating the fat in this region will make a patient look gaunt or cause irregularities.

The above image shows how Dr. Niamtu tightens the aging platysma muscle in the midline of the neck

What is the SMAS?

SMAS stands for superficial musculoaponeurotic system system and represents the deeper tissues in the face.  It is a well recognized fact that the SMAS must be tightened to achieve a tight, natural and long lasting facelift.  Some surgeons do not routinely treat the SMAS tissues when performing facelift surgery.  These types of lifts simply do not last as long as when the SMAS is treated.  BEWARE of a skin only facelift; it may be faster and cheaper, but will not last as long.  Dr. Niamtu discusses the importance of treating the SMAS in facelift surgery in his textbook on cosmetic facial surgery.

Although there a numerous ways to treat the SMAS layer in facelift, Dr. Niamtu generally uses a procedure called SMASectomy.  In this procedure, a section of the SMAS is removed (middle picture below).  This serves to not only slim the facial region, but allows the edge of the SMAS excision to be pulled towards the ear and sewn together.  This produces maximum tightening of the SMAS which will serve as the foundation of a long lasting, natural appearing facelift.  Dr. Niamtu uses numerous, deep permanent sutures in this region which helps the result last.  Some surgeons place 1-2 "purse string" sutures to support the SMAS which can easily stretch or tear and affect the final result.

The left hand figure shows a representation of the SMAS under the skin.  The middle figure shows a SMASectomy where a section of excess SMAS tissue is removed.  The right hand figure shows the SMAS tightened and sutured with permanent sutures.

The goal of a facelift is to provide a natural appearance and avoid an "operated look". Ideally, only the surgeon, the patient and his or her hairdresser should know.

How do you know you have the right facelift surgeon?

Like most things in life, there is no clear cut answer for this question, but doing some homework can pay off in the long run.  There are several misleading myths that confuse patients.  Myth number one is "only have a board certified plastic surgeon do your surgery".  Obviously, your surgeon should be board certified, but his or her specialty has very little to do with their competence and outcomes.  This myth is propagated as a marketing tool for plastic surgeons.  It is like saying "a Lexus is the only safe car"; we can all see through statements like this.  In reality there are numerous types of competent specialists including plastic surgery, ENT, oral and maxillofacial surgery, dermatology and ophthalmology that excel at facelift surgery.  The actual specialty is much less important than the experience of a surgeon.  Most patients would choose a surgeon from, say a dermatologist that performs several facelifts a week instead of a plastic surgeon that performs one a month.  Although there are many talented plastic surgeons that excel at breast and body cosmetic surgery, they may have very little cosmetic facial surgery experience and only "dabble" in facelift surgery.  A oral and maxillofacial surgeon or ENT trained cosmetic facial surgeon are likely to specialize in head and neck surgery only. 

The second myth is that "new facelifts" can be done with the same results but much less anesthesia, recovery, downtime, incisions, etc.  As you browse the facelift pages on this site, you will understand why this remains a myth.

The following are some important indicators to consider when choosing a surgeon.

• Is your surgeon board certified in a specialty that deals with the face?
• Do they operate only in an accredited surgery center?
• How many facelifts does your you surgeon perform a week?
• Can your surgeon show you hundreds of before and after pictures of their own work?
• Is your surgeon involved with teaching and scientific publishing on the topic of facelifts?
• Can your surgeon provide you with patients that have had facelift surgery to discuss their experience?
• Can you get in touch with your surgeon if you have a problem?  Cell phone?
• Does your surgeon "dabble" in facelift surgery or is it one of the major parts of his or her practice?

Dr. Niamtu is very involved with teaching facelift to other surgeons in the USA and abroad.  He teaches specialties including Facial Plastic Surgeons, Plastic Surgeons, Ocuolplastic Surgeons, Oral & Maxillofacial Surgeons, Dermatologists and other surgical specialties.  Dr. Niamtu has written a comprehensive textbook about cosmetic facial surgery and facelift surgery, authored a comprehensive DVD live surgery series and has numerous publications on facelift surgery.  In addition he is considered an opinion leader on facelift surgery and is frequently interviewed by cosmetic publications and TV and radio media.

Dr. Niamtu is a frequent speaker on contemporary facelift techniques

Click on any image below to open PDF

Dr. Niamtu among distinguished faculty at St. Louis Facial Plastic Surgery Facelift Course Nov. 2010

Dr. Niamtu presented lectures on facelift surgery at the St. Louis University oculoplastic and facial plastic surgery course in July 2010

Dr. Niamtu lectured and performed live facelift surgery in Klagenfurt,  Austria in June 2010

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2009 St.Louis University Facelift Course

Dr. Niamtu speaks of facelift techniques in Athens, Greece June 2010

2008 St. Louis University Facelift Course

Dr. Niamtu regularly teaches at the St. Louis University Facelift Course in the Department of Facial Plastic Surgery click above to enlarge.

Dr. Niamtu and Dr. Mike Nayak demonstrate facelift techniques at the St. Louis UniversityTechniques in Facial Rejuvenation Course

Dr.  Niamtu instructing at Las Vegas Facial Surgery Course Click to enlarge

Dr. Niamtu demonstrates facelift techniques at St. Louis University Click on above to enlarge

Dr. Niamtu teaches comprehensive cosmetic facial surgery courses in Richmond, Virginia

Click here to view Dr. Niamtu's Blog with more articles and opinions about facelift surgery

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