Facial aging happens differently from person to person. For instance, some people have sagging skin that is mostly concentrated around their eyes, while others have most of the bagginess along their jaw line and neck.
Nonetheless, facial aging often affects multiple areas almost to a similar degree and thus facelift and neck lift are commonly performed together. Combining them in one surgery also makes sense because the standard facelift incision is simply extended into the nape.
This is an incision pattern used in facelift and neck lift approach. Take note that all scars are hidden.
(Note: Standard facelift entails an incision that starts inside the hairline at the temple area, which then curves in front of the ear and behind it. And with a concurrent neck lift, the scar is slightly extended into the nape, specifically behind the hairline, to hide any surgical stigmata).
Renowned Los Angeles plastic surgeon Dr. Tarick Smiley has recently demonstrated on Snapchat the rejuvenation effects of this combo approach, particularly when combined with a SMAS lift technique.
SMAS refers to a soft tissue layer found beneath the facial skin and fat. During facelift, Dr. Smiley not just removes the loose skin and elevates the remaining skin; he also tightens this underlying structure.
To further ensure a congruous result, he also tightens the platysma muscle of the neck by using internal sutures, which essentially act as a sling.
The compounded effects of these techniques are tauter jawline, restored volume of the cheek, more youthful chin-neck transition, and smoother neck appearance.
The direction of pull also plays a critical role in facelift and neck lift. The correct vector can create a tauter jawline and restore the youthful plumpness of the cheek, whereas an incorrect one can spell disaster—e.g., wind tunnel effect or overly tight mid face, lateral pleating of the neck skin, and skin bunching around the earlobe.
In a recent Snapchat video, Dr. Smiley says the correct direction of pull is 45 degrees angle, adding that in no way that the soft tissue should be pulled in a blunt horizontal or vertical manner to avoid any telltale sign of surgery.
Multiple plastic surgeries or combo procedures have become a common approach in facial rejuvenation. Typically, patients require facelift combined with structural fat grafting/injection, brow lift performed concurrently with forehead lift, and facelift with a simultaneous neck lift or neck liposuction.
In many cases, facial combo procedures, which generally involve closely related surgeries, make sense as they reduce the total time in surgery. Of course, the approach can also pare down the cost.
A huge chunk of plastic surgery expenditure comes from the anesthesia fee, surgical facility fee, and surgeon fee. Consequently, stacking multiple procedures means the additional cost related to anesthesia and surgical center is ruled out of the equation.
Some plastic surgeons even package certain procedures at a discounted rate, which further makes multiple plastic surgeries a cost-effective approach.
Nonetheless, patient safety should remain the utmost priority and so combo procedures come with stricter safety guidelines. For instance, being under general anesthesia for more than 5-7 hours is known to increase the risk of complication (cardiovascular issues and prolonged recovery) and so all efforts are made to complete any elective surgery within this time frame.
To further promote patient safety, leading Orange County plastic surgery expert Dr. Tarick Smiley says any combo surgery, or any type of elective plastic surgery, should only be done in an accredited surgical facility or hospital setting.
Accredited surgical facilities and hospitals are staffed by qualified medical practitioners and are fully equipped with medical apparatus should complications arise.
Due to the perceived challenges that come with multiple plastic surgeries, Dr. Smiley emphasizes the importance of lab screening and honest discussion between the surgeon and his patient. The goal is to rule out chronic medical conditions, or if they have been detected during physical exam, address them well in advance of the surgery through medications and lifestyle changes.
During pre-op consultation, Dr. Smiley says a prudent patient should disclose her medical background, previous test results, and medications, including those seemingly innocuous herbal supplements and vitamins, some of which have been found to interfere with healing.
To recap, multiple plastic surgeries on face are generally deemed as a cost-effective and safe approach provided these elements are present:
- The total time under general anesthesia does not exceed the standard safety limit.
- The surgery is performed by a board-certified plastic surgeon.
- The combo surgery is performed in an accredited surgical facility/hospital, which is staffed by qualified medical practitioners, including a licensed anesthesiologist.
- The patient is physically fit based on lab screening and is “honest” during pre-op consultation (in no way should a patient hide or omit medical information to avoid complications).
The effects of facial plastic surgery on perceived youthfulness and attractiveness have already been demonstrated by several studies, which typically included ordinary observers who were asked to rate before-and-after photos. However, youth and beauty are not the only defining elements of the face; assertiveness, agreeableness, trustworthiness, and femininity/masculinity also play a role.
A 2015 study conducted by researchers at Georgetown University has shed light on the issue of perceived personality traits and how these could be altered by facial plastic surgeries such as face lift, brow lift, neck lift and eyelid lift. Rhinoplasty, or nose job in layman’s term, was not included because it has no or very little effect on a person’s neutral expression, they suggested.
To eliminate confounding variables like ethnicity and gender, the researchers presented before-and-after photos of 30 white female patients who have had some type of facial plastic surgery. About 170 respondents answered the survey posted online.
The pre- and post-operative photos of the same patient were not presented in a photographic set to prevent recall bias or direct comparison, the researchers noted in the study.
Patients who have had facelift and lower eyelid surgery scored the highest in the personality trait assessments that included perceived attractiveness, social skills, femininity, and likability.
Interestingly, a separate study has suggested that people with high eyebrows and prominent cheekbones were perceived to be more honest even though there was no evidence that facial features were linked to personality traits.
Individuals with flat or sunken cheeks and furrowed brows, on the other hand, were perceived to be less trustworthy.
Meanwhile, a team of psychologists at the New York University has suggested that it takes 33 milliseconds, or a fraction of a time it takes to blink, for the brain to decide a person’s trustworthiness based on his/her face.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley, who was not part of the study, says the findings did not surprise him, as increasing the oblique frame—the distance between the brow and upper lid crease—during brow lift surgery not just leads to a more youthful countenance, but also results in improved trustworthiness and femininity.
Dr. Smiley says that a sagging brow may lead to a perennially angry or sad appearance, depending on the degree or angle of droop, and so a conservative elevation during brow lift can improve a person’s neutral expression—or even her non-physical personality attributes.
Facelift can also improve the perceived likability and trustworthiness by correcting the sunken cheeks, which is done by elevating the drooping cheek fat pad into the deeper tissue.
However, Dr. Smiley warns that the success of facial surgery relies largely on the surgeon’s qualifications and experience, adding that pulling the skin more than a few millimeters than intended, or using incorrect vector of pull, can lead to unnatural results or “weird expression.”
“Prudent patients should ensure that their plastic surgeons are board certified and have been performing the sought procedure on a regular basis,” he says.
The standard brow lift technique uses an ear-to-ear incision across the top of the head, within the hair-bearing scalp. While it provides the most lifting effect, it comes with one major downside: Patients whose “starting” forehead is big may end up with a “five-head effect.”
People use the humorous term five-head to describe a forehead that is oddly large that five fingers can all fit on the space between the hairline and eyebrow, instead of just four fingers.
Standard brow lift vs. endoscopic technique
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says that most brow lift patients either want to maintain their forehead height or even slightly reduce it, making the standard technique inadvisable because it can elevate the hairline by up to 1 inch.
A hairline that is too high not just results in the five-head appearance, but it also has a masculinizing effect on the female face. Nonetheless, the standard brow lift remains ideal if the patient has a notably short forehead (which may sometimes lead to a primitive look) and desires to change this feature.
But for most patients, placing the incision precisely at the hairline, instead of inside the scalp, provides the most auspicious results—i.e., it maintains the hairline height or it can be even elevated if the patient wants to shorten her forehead.
The endoscopic technique is another type of brow lift that has no or very little effect on the hairline height; this often involves 4-5 tiny keyhole incisions placed behind the hairline. It favors patients with minimal forehead and brow sag.
With the right incision pattern based on the patient’s desired goals and starting anatomy, brow lift can provide natural looking effects. This is particularly true when the lateral brow or “tail end” is elevated, with no or very little change in the height of its medial or inner aspect.
To ensure that the scar remains hidden, all efforts are made to reduce the tension on the skin especially during the healing stage. Hence, most skilled surgeons use the horizontal and vertical mattress sutures so that the deeper structures carry most of the tension, instead of the skin.
When doctors mention 3D facelift procedure, they typically refer to a more holistic facial rejuvenation method, meaning that loose skin and soft tissue laxity is not the only thing addressed, but also the fat or volume loss.
As a stand-alone procedure, facelift tightens the skin and elevates the deeper structures of the soft tissue, bringing them closer the skeleton. While this mechanism creates a tauter appearance, it does not address facial volume loss; in fact, it may even aggravate the gaunt visage.
The patient has received facelift combined with structural fat grafting. Hence, at one year postop her appearance remains youthful and attractive.
To address the inherent problem of facelift, leading Beverly Hills plastic surgeon Dr. Tarick Smiley often combines it with structural fat grafting. It starts with collecting small amounts of fat from tummy or thigh (or any area that carries excess fat), filtering out any biomaterial aside from fat cells and stem cells, and then injecting them into the soft tissue.
By incorporating structural fat grafting, doctors are able to create a more youthful dimension—i.e., there is adequate plumpness commonly found in young faces—which is the main advantage of 3D facelift procedure over the standard approach.
3D facelift procedure also prevents the classic signs of facelift, which include abrupt lid-cheek transition and flatness of the cheeks. Moreover, this new approach can smooth out deep laugh lines and hide the pre-jowl sulcus, which is the dip on each side of the chin.
Furthermore, fat grafting has been tied to improvement in skin texture, one of the auspicious benefits of using fats that are naturally infused with stem cells, which are known for their rejuvenating effects; they have also been found to increase the survival rate of grafts.
Any amount that survives after 2-3 months is expected to be near permanent or at least 12-15 years, as suggested by Dr. Smiley.
In addition to structural fat grafting, facelift may also be combined with other procedures such as neck lift, brow/forehead lift, eyelid surgery, and chin implant. The idea is to create a more congruent result that is less susceptible to gravity and aging.
Facial fat transfer procedure is an already established technique to rejuvenate the aging face. In the past, doctors were only focused on addressing the loose skin and soft tissue laxity without taking into account that facial volume loss (or fat loss) was also contributing to the aged appearance.
But nowadays, skilled plastic surgeons typically combine facial fat transfer procedure and facelift, a combo procedure that accomplishes two goals: tighten the loose skin and restore the lost volume. With this approach, which is also referred to as three-dimensional facelift, patients enjoy more natural and more “stable” results, meaning no surgical stigmata appear years after their surgery.
Leading Inland Empire plastic surgeon Dr. Tarick Smiley, who commonly combines facelift and facial fat transfer procedure in one surgical setting, explains some of the most surprising facts about the latter.
- Only a few teaspoons of unwanted fat is needed.
The tummy area is the usual donor site, where a few teaspoons is collected and is later processed and re-injected into the soft tissue of the face. Meanwhile, it is not uncommon practice to slightly over-fill the recipient site since it is expected that about 25-30 percent of the volume will be resorbed by the surrounding tissue; anything that remains 2-3 months postop is expected to be near permanent.
- Facial fat transfer procedure is “cheaper” than dermal fillers in the long run.
The average cost of facial fat transfer is $2,000-$5,000, while dermal fillers are typically priced at $250-$600 per treatment. Despite its higher “upfront” cost, in the long run it is more affordable than the standard fillers because of its near permanent results—i.e., 12-15 years.
Dermal fillers, meanwhile, typically require touch-ups performed at 3-4 months interval should the patient desire to preserve her rejuvenated appearance.
- It can be performed simultaneously with “hand rejuvenation” procedure.
In Dr. Smiley’s previous post on Snapchat, a female patient had fat injection not just to her face but also to her hands (and fingers) to correct their thin and wrinkled appearance.
- All the biomaterials are removed prior to fat injection.
It is important to remove the oil, red blood cells, and other “non-fat” biomaterials to achieve near permanent results and high survival rate of fat grafts. Centrifuge is particularly helpful during the purification method because it separates materials based on their weight.
- Blood vessels need to grow into the grafted fat.
In order for the grafted fat to persist long term, blood vessel ingrowth must occur. Hence, Dr. Smiley highlights the importance of micro-droplet injection in which layers of fat are gradually created (less than 0.1 cc at a time) during surgery.
Without blood vessel ingrowth, which is medically referred to as vascularization, the surrounding tissue will resorb the grafts within months.