Minimally Invasive Facelift: Counterpoint
I was recently asked by a major cosmetic publication to discuss my feelings on minimally invasive facelifts. Although I think they are a possible option for younger patients, I believe they are over used on patients that actually require a more comprehensive facelift and therefore lead to many unhappy patients that are left with a lesser result, all in an effort to attempt to shave a few days off of recovery. The following represents my thoughts on this issue.
Facelift surgery has been around it its current form for about 100 years. During that time, virtually every permutation of the procedure has been attempted; some with success, some without.
In today’s fast moving cosmetic market, companies, media, surgeons and patients eagerly await “new advances” for devices and procedures. We all want a simpler means of obtaining similar results but sometimes the cart gets in front of the horse.
Let me preface this discussion by saying that the best facelift technique is the one that works well in the hands of the specific surgeon, provides good results with low complications and most importantly, happy patients. This means that there are many ways to approach lower face and neck aging. I have a large facial surgical practice and my patients expect dramatic results. Many of them have already had negative experiences with minimally invasive facelifts and are very frustrated. This patient will only be happy with a comprehensive facelift. Having said that, my good friend down the street is a dermatologist and performs only minimally invasive facelifts with local anesthesia. His patients are also happy and that procedure works fine in his office with his patients. So, we are both doing the right thing.
Also, I must point out that there are many renowned cosmetic surgeons that are staunch advocates of minimally invasive facelifts, so they obviously work well for these people. I consider a minimally invasive facelift (also called short scar facelift) to be a lift with an only a preauricular incision that terminates at the mastoid region with no posterior auricular and scalp incision. These lifts are also usually performed without midline platysmaplasty and frequently utilize variations of purse string sutures.
Expressing my feelings on minimally invasive facelifts may be discounted by short scar advocates, but I can back up what I say in my series of almost 700 facelift procedures over the past 12 years. Is 700 facelifts a big number? For some surgeons it is not as they have partners, fellows, interns, etc. that may do a big part of each procedure. In my office, it is me alone, every cut and every stitch, so my 700 may be more experience than someone else who has done 1,500.
The remainder of this article will deal with why I personally, don’t favor minimally invasive facelifts. It is not that I never do a short scar facelift, but my parameters are only for young individuals with minimal aging. This means patients with early jowling and almost minimal neck laxity. I perform an average of two facelifts each week. Last year I performed almost 80 facelifts and of these, only two were short scar lifts, so it represents 2.5% of my yearly lifts.
There are many reasons that I don’t favor these lifts but the primary reason is that I am thoroughly convinced that even younger patients need a larger lift. I have a policy when I perform a short scar lift that during the procedure if I ascertain that the patient will be better served with a traditional lift, I have their permission to convert to a conventional pre and post auricular procedure. I have changed to the larger lift in mid surgery numerous times and have been glad I did as even patients that did not exhibit significant neck laxity actually had impressive skin excess as evidenced when the posterior auricular incision was completed .
I think there are many reasons that short scar facelifts have become fashionable. Number one, there are a lot of different specialties that now perform cosmetic facial surgery including facelift surgery. Some of these practitioners did not have training in larger lifts and therefore feel comfortable with the smaller variety of lift. Similar to this, some surgeons do not have the ability or the facility to utilize IV anesthesia or general anesthesia and the minimally invasive lift can be performed with local anesthesia. This is all fine and well, again safe surgery with good outcomes and happy patients is the bottom line.
Another reason for the increased popularity of these lifts is the significant media hype that is so pervasive in our society today. Many consumers equate “new” with better. This is an area where I begin to have problems with the promotion of these small lifts. I can’t turn on my TV without seeing ads for what I call “franchise facelifts”. These are corporate entities include franchised physicians and the targeted marketing drives patients to these surgeons. My problem is not with the surgeons but rather with the franchise. This type of lift is promoted as “new” and “revolutionary” and catch phrases such as “takes about an hour”, “no bandages”, “drive home from office after your lift” and “go back to work in several days”. I take great umbrage to these statements and the way they are presented. First of all, short scar facelifts with purse string sutures are not new and have been done for almost a century as evidenced by the diagram from a 1927 French textbook (figure 1).
This figure from a 1927 textbook shows the same procedure being performed by some doctors and advertised on TV as “new” and “revolutionary”.
Secondly, the before and after images shown in these commercials and accompanying literature are not standardized and the results appear more dramatic than they really are. The old trick of taking the pre facelift picture with the chin tucked in and no flash, then taking the post facelift picture with the chin extended and using a flash is a well known means of manipulating an actual result. Also, if you look at the fine print, some of the patients also had platysmaplasty and simultaneous laser skin resurfacing, hence the minimally invasive theory goes out the window. I think this form of marketing is unethical and I (as well as many colleagues) have retreated unhappy patients that underwent “franchise” facelifts. These patients feel betrayed as they were promised a maximum result with minimum surgery and they still have laxity. They paid more than I charge for a traditional facelift and now have to have a second surgery to get the result they could have gotten in the first place if they had an age appropriate facelift. Buyer beware!
The other reason that I think these lifts have become popular is that some surgeons get lazy. I realize that I am going to take some torpedoes with this statement, but I think it is true. A traditional facelift (pre and post auricular incisions, platysmaplasty and SMAS treatment) is a lot of work. If you are the sole surgeon and do it correctly, it is an intense procedure. I have seen numerous colleagues slowly back off from the traditional procedure. First they omit platysmaplasty and maybe do less with the SMAS, next they eliminate the posterior incision and pretty soon they are only doing short scar lifts without platysmaplasty. Most say they get the same results, but I personally question this. I too have gone through phases in my career where I attempted to eliminate platysmaplasty and posterior incisions, but I have consistently gone back to basics because I felt I had better, longer lasting results. Some readers may say “well, maybe he is not proficient with the short scar techniques”. Fair question, but I think my experience trumps that.
As many surgeons have become much more conservative in their approach to facelift surgery, I have become more aggressive and can clinically justify my decisions.
My biggest problem with short scar facelifts is the lack of a post auricular incision that extends into the scalp. To me, this is the most important vector to truly manage significant cervical and submental skin laxity. Any sacrifice in this vector will affect the surgeons ability to tighten the neck. I realize that with some short scar procedures proponents advocate a more vertical flap tension to compensate, but again, no one can convince me that this is as effective as the traditional posteriolateral vector used with post auricular incisions. In reality, all facelift incisions should be engineered to be perpendicular to the vector of pull for skin excess and thus the traditional 10 o’clock and 2 o’clock vectors are in my mind, superior.
My second big problem with short scar lifts is that many surgeons omit platysmaplasty. I abandoned this myself for several years and saw less dramatic necks that developed banding within several years. This led me to resume with even more aggressive submentoplasty and all of my rhytidectomy patients receive simultaneous platysmaplasty. I do not perform submental liposuction as the first step, but rather perform a subcutaneous scissor dissection with care to leave adequate submental and cervical fat attached to the dermis. I then, prefer to perform “open” liposuction where I can actually see what I am removing or sculpting. I am fairly aggressive with this liposuction as I like to see the actual platysma muscle. I then perform a midline plication with 2-0 braided nylon sutures from the mandibular border at least to the thyroid cartilage if not below. I place 5-7 sutures and this not only tightens the neck, but also elevates the submental tissues and allows for the best cervicomental angle possible. I generally do not remove subplatysmal fat unless grossly excessive as this contributes to a central depression. If the patient has microgenia, a silicone chin implant is frequently inserted. I am always amazed by the amount of excess skin present after aggressive platysmaplasty and submentoplasty. I am thoroughly convinced that this skin excess would not be as impressive without platysmaplasty and would be more prone to early relapse.
As I stated earlier I am not a fan of purse string sutures. I think that suspending the SMAS with one or two sutures leaves too much room for laxity. My average preauricular flap dissection is 6-8 cm and I perform a SMASectomy that is closed with five to eight 2-0 braided nylon sutures. These sutures secure the distal SMASectomy incision to the fixed SMAS over the parotid and begin at the malar region and extend into the superior cervical area below the mandibular border. I am convinced that this repair is solid, addresses multiple SMAS vectors and will not relapse when patients turn their head or sneeze in the early post op period. Although some surgeon do not advocate significant skin removal, I typically remove 3-6 cm of skin on older patients.
The problem with trying to redistribute posterior skin in short scar procedures without a post auricular incision is the significant mastoid skin bunching that occurs and takes months to resolve. Where does it go? It is not magic, it flattens out with time (sometimes a long time) but there is still excess skin present, it is just redistributed. My answer is to remove it in the first place.
In conclusion, there exists a trend to perform less invasive facelift surgery, primarily to decrease recovery time and make the surgeons life more simple. I do believe that these short scar lifts are appropriate on some patients but at the same time feel that the do not comprehensively address the average facelift patient (fifth decade and beyond). I feel that these smaller lifts are over rated and too often performed on patients that should have had a larger lift. I can back this up by the revision facelifts that I do on patients that should have had a larger lift in the first place. In terms of recovery, my average patient is suitable for work in two weeks. That may be a long time for some surgeons and patients, but I tell my patients that to take two weeks off to reverse a half century of aging is really not a bad deal.
I fully realize that many surgeons will disagree with me and as previously stated, if their smaller procedure works better in their hands and they have lasting results with happy patients, then we are all winners. I do things the way I do because my experience has shown that in my hands a more aggressive lift produces more natural and longer lasting results. To each his own. I believe there is a time for minimally invasive facelift, but it is not “most of the time”. I feel that using these smaller procedures on the average facelift patient is a short cut facelift and the patient will have short cut results. When patients ask me about “lunchtime facelifts” I tell them they will last till “dinner time”. Patients get what they pay for. Not in terms of money, but in terms of recovery. Facelifts that heal in a week or less are simply not comprehensive enough to compete with traditional facelift procedures.
Tight, natural and long-lasting results are very predictable with traditional facelift surgery. Unfortunately, there are surgeons that would attempt to perform a minimally invasive lift on the above patient. It is simply not possible to obtain the results and longevity with minimally invasive procedures.
To learn more about facelift surgery and other cosmetic facial surgery procedures by Dr. Joe Niamtu in Richmond, Virginia visit www.lovethatface.com
Joe Niamtu, III DMD
Cosmetic Facial Surgery