Ultherapy or facelift for facial rejuvenation? While both can rejuvenate the face by reducing skin laxity, they work quite differently and so the ideal approach will depend on the patient’s underlying anatomy, amount of correction required, and aesthetic goals.
Ultherapy is an FDA-approved non-invasive treatment that tightens not just the skin but also the deeper soft tissue. Just like facelift, it also reaches the SMAS plane (fat, tissue, and muscle) by releasing ultrasound designed to bypass the skin in order to reach the deeper layers.
Photo credit: Ultherapy website
The ultrasound triggers more collagen production, leading to tighter skin. Nowadays, it is most commonly used to tighten the jawline, peri-orbital area (around the eyes and brows), neck, and décolletage (chest region that is visible when one is wearing a low neckline dress/top).
Most patients will only need one treatment, although a few may require a touch-up to achieve their desired results. Meanwhile, this 1-1.5 hour treatment provides rejuvenating effects that last 18-24 months.
One of the selling points of Ultherapy is the little to no downtime, a far outcry from the 1-2 weeks social recovery required by facelift surgery.
But as with any non-invasive facial rejuvenation treatment, Ultherapy only suits patients who require less amount of correction and thus it is commonly performed in people 50 years and younger.
For patients who require more correction, i.e., they are usually 55 years and older, the standard facelift still provides the best and most predictable results, says renowned Orange County plastic surgery expert Dr. Tarick Smiley.
During facelift, the SMAS plane, which is beneath the skin, is elevated and tightened to create more chiseled jawline, smoother neck, and fuller cheeks/mid face. In addition, a small amount of excess skin is removed with the use of incision made behind the hairline that runs around the ear’s curvature for optimal scar concealment.
One caveat of facelift is the social recovery that often takes a week or two. Furthermore, it is only reserved for patients who are physically fit and have no healing problems.
The results of SMAS facelift, according to anecdotal reports, can last an average of 10-12 years. This is particularly true for patients with good skin elasticity and will receive touch-ups, which may be in the form of Ultherapy, fillers, medical-grade chemical peels, or a combination of them.
The “right” breast implants on a bony chest can help improve its appearance. Patients with this “anatomical feature” also typically have wide cleavage gap and little soft tissue coverage, which must be improved as well.
Dr. Tarick Smiley, one of the leading Orange County plastic surgery experts, has recently shown on his Snapchat the effects of “meticulously selected” breast implants that have had improved the bony chest appearance and visible dents of a female patient.
Dr. Smiley used a pair of slightly wider breast implants to “conceal the visible dents” along the sternum and to improve the wide gap between the breasts. Nonetheless, the implants’ base matched the horizontal measurement of the chest otherwise the patient would face a higher risk of scalloping, rippling, and malposition.
To further ensure natural-results—i.e., proportionate to the patient’s body and with no surgical stigmata—the celebrity plastic surgeon used small silicone implants (i.e., 400 cc).
The use of smaller silicone implants particularly suit the patient because of her limited breast tissue coverage and low body fat percentage. These implants were filled with a medical-grade silicone gel designed to simulate the cohesiveness of natural soft tissue.
Saline implants, meanwhile, would not suit the patient because of her little soft tissue coverage that could predispose her to higher risk of rippling and increased palpability. These implants have outer silicone shell filled with salt-water solution; hence, they may lead to firmer results and too globular breast contour when used by thin and small-breasted women.
To further ensure soft and natural contour, Dr. Smiley positioned the implant beneath the patient’s pec muscle, which provided more coverage than the over-the-muscle implant placement.
Even without fat grafting, the right implant design and volume was enough to conceal the patient’s bony indentations of her cleavage.
In general, Dr. Smiley says he reserves fat grafting for patients with “very poor upper-inner breast pole” that an implant-alone approach may not be enough to deliver satisfying results.
Fat grafting that is a part of composite breast augmentation, he says, also suits patients with certain types of deformity.
Extensive liposuction surgery often pertains to large volume fat removal, i.e., more than 5 liters of fluids (fat, blood, and wetting solution) from the patient. It may also refer to treating multiple areas of the body under one surgical setting.
Dr. Tarick Smiley, a prominent Orange County plastic surgery expert, has recently posted a series of videos on Snapchat to demonstrate one case of extensive liposuction involving the anterior abdomen, flanks, lower back, “bra rolls,” upper arms, inner thigh, and “double chin.”
One of the challenges of extensive liposuction is the increased risk of fluid imbalance, although Dr. Smiley says that certain steps can prevent or at least reduce the complication rate.
- Meticulous patient selection
The ideal candidate should have no chronic medical condition that may increase the risk of complications. Hence, all Dr. Smiley’s patients are required to pass lab screening prior to surgery,
- Accredited surgical facility
Accredited surgical facilities adhere to strict patient safety protocol and are staffed by licensed and well-trained medical professionals.
- Well-trained anesthesiologist
A well-trained board-certified anesthesiologist accompanies Dr. Smiley in every surgery to further ensure patient safety. It should be noted that the anesthesiologist’s tasks not just include administering anesthesia; he also monitors vital signs such as blood pressure, oxygen level, and heart rate during surgery.
Furthermore, the “ideal” anesthesiologist is properly trained in the infusion and removal of large volume of fluids, allowing him to identify the risks and keep these well under control.
While this equipment is more commonly used in hospitals during prolonged surgeries, in large volume liposuction this can also be helpful in controlling blood loss. It works by filtering out the red blood cells, which are inadvertently collected during liposuction, and infusing it back to the patient.
By almost eliminating blood loss, Cell Saver is known to promote patient safety and lead to shorter downtime.
- Tumescent liposuction technique
Despite the proliferation of new liposuction technologies (e.g., laser and ultrasound), the standard technique provides the most predictable results. This involves infiltrating the fatty area with tumescent solution, which is a concoction of saline (sterile saltwater), lidocaine (local anesthesia), and epinephrine.
Epinephrine constricts the blood vessels and thus reduces the amount of blood loss and surgical trauma.
While fat injections or dermal fillers can serve as an alternative to lower eyelid surgery, not all patients with under eye-bags can benefit from them.
The appearance of under eye-bag or “shadowing” is caused by different or even a combination of factors. Excess skin, herniated deep fat, loss or “shrinkage” of superficial fat (beneath the skin), or a combination of these variables may contribute to this aesthetic issue.
Before and after photos of a patient who have had fat transfer in her lower eyelid.
Basically, a “true” or standard lower eyelid surgery uses incision positioned very close to the lash line so the eyelashes can conceal the resulting scar. Referred to as an external incision technique, this allows the surgeon to remove excess skin and fat and possibly reshape the muscle.
However, not everyone with under eye-bags has excess skin. If the extra fat primarily causes this appearance instead, dermal filler injection (e.g., Restylane and Juvederm) can conceal the unsightly bulge.
The main purpose of dermal filler (as an alternative to lower eyelid surgery) is to make the lower lid bulge the same level as the upper cheek. This is a rather straightforward approach and does entail no or very little downtime; hence, it appeals in patients with busy schedule and cannot afford surgery and its ensuing “social recovery.”
But there is one caveat when dermal fillers are used to conceal the under eye-bag caused by excess fat: Touch-ups are generally needed at 6-12 months interval.
Meanwhile, fat injection or fat grafting is a method that provides longer-lasting effects than dermal fillers, with studies suggesting that its results last an average of 12-15 years. The procedure starts off with the collection of superficial fat (beneath the skin) usually in the tummy; only a few teaspoons are needed since the lower eyelid is just a small area.
The collected fat volume is then put in tubes and processed through centrifugation; the idea is to discard the oil, red blood cells, and other biomaterials except the fat cells. Afterwards, the purest form of fat is injected to conceal the bags.
It is important to note that fat injection and dermal fillers are basically volumizers (they add volume) and so they can also address the deep tear trough and the abrupt lid-cheek junction that come with aging.
It is not uncommon to combine volumizers with excision-based lower eyelid surgery to achieve the best results possible. This is particularly true for patients with excess skin, herniated deep fat, and abrupt lid-cheek transition, as suggested by leading Orange County plastic surgery expert Dr. Tarick Smiley.
Due to the laxity of skin and other supportive structures, the deep fat along the lower lid becomes prominent (i.e., it bulges out) with aging. In contrast, the superficial fat “shrinks” and thus gives the appearance of deep tear trough or abrupt transition between the lid and cheek.
To address the aforementioned problems, a small linear incision is made within the lower lid that allows the surgeon to remove the excess skin and reduce the deep fat pad. For additional fine-tuning, fat injection is used to create a smoother lid-cheek junction.
The degree of arm lift pain after surgery greatly varies from patient to patient due to individual pain threshold, physical fitness, and extent of surgery (short vs. long incision technique).
Dr. Tarick Smiley, a prominent Orange County plastic surgery expert, says it is expected to experience temporary pain, numbness, tingling sensation, skin sensitivity, and tightness following an arm lift surgery, or medically referred to as brachioplasty.
During an arm lift, Dr. Smiley says the excess skin is removed with incisions made within the armpit fold; however, patients who require extensive correction will need their scar extended into their elbow to achieve the most natural, smoothest results possible.
(Note: Aside from skin excision, the operation also involves reshaping and tightening the fascia, which connects the skin to the muscle. This additional step also contributes to the amount of arm lift pain after surgery.)
The perpendicular scar from “full” or standard arm lift is generally positioned on the inner aspect of the arm so it remains hidden most of the time.
In the first few days, most patients will need narcotics painkillers to help them cope with the discomfort. However, these can be minimized with the use of Exparel injection, which can numb the surgical site for up to four days.
Dr. Smiley, who regularly posts educational videos on Snapchat, often uses Exparel in body contouring surgeries. This medication is injected directly into the muscle before closing the incisions with sutures and has eliminated the need for pain pump, a balloon-like device that slowly releases numbing drugs for several days.
Most patients are “back on their feet” about a week postop and may choose to return to work provided it is only a desk job. Meanwhile, it remains prudent to avoid heavy lifting, rigorous exercise, and stretching the arms for at least six weeks.
Dr. Smiley says that most bruising and swelling will resolve 2-3 weeks. At this period, the use of compression garments might help with their resolution and to some extent even control the pain.
While bruising and swelling tend to resolve easily with time, this may not always be the case with the “lingering” pain or discomfort, which could emanate from sensory nerves starting to “wake up”.
It is important to note that during surgery, some small nerves are injured and can take months to recover fully. While the pinprick sensation or shooting pain is rather inconvenient, this is actually a good sign that the nerves are gradually repairing themselves.
Should the discomfort remain persistent, some patients may take Tylenol and anti-inflammatory drugs, or massage the affected area, provided their surgeons give them permission.