The theories of facial aging have changed over the years, and the original face lifting descriptions in New York were performed as simple skin lifts or excisions. As our understanding of the anatomy has improved, it was recognized that repositioning the deeper connective tissue layers became important. This led to a myriad of procedures that will be described below. More recently, it has been recognized that there is not only changes to the connective tissue causing laxity of the skin and underlying soft tissues, but there is also facial deflation or atrophy of the fatty soft tissue layers as well leading to sagging. The goal of face lifting procedures, for Dr. Wallach’s Manhattan New York patients, is to create a more youthful appearance by lifting the sagging tissues and elevating them, but they may need to be re-inflated due to facial fat and soft tissue atrophy. Describing how a roller coaster track is shifted as an analogy can be used to describe what a facelift does. A face lift can reposition the soft tissues just like the tracks of the roller coaster can be moved to change where the highs and lows are. Face lifting procedures can accomplish this, but further rejuvenation is required to treat the fine lines and wrinkles that a face lift will not treat. Just like removing the rust from the roller coaster’s tracks, this can be accomplished with lasers, chemical peels, and skin care products.
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No one New York patient undergoes the same exact face lift. It is very important when performing the surgery to avoid creating “telltale” signs, or unfavorable looking results that make the face appear “unnatural.” This would include distortion of the ear shape, hairline and/or sideburn. Dr. Wallach, a New York City Plastic Surgeon, usually works on the deeper layers of the face to provide the so-called “lift” and to create a “natural” result. The deeper tissues of the face are mobilized to recreate the soft tissue appearance of a youthful face. Most importantly, he does not “pull’ on the skin which can result in a distortion of the face. He uses the analogy of a bed to describe this. The deeper tissue of the face is like the mattress of a bed and the skin is like a sheet covering the mattress. In order to smooth out the bumps in the mattress, or improve the contour of the face you have to work on the mattress, or the deeper tissues of the face. Dr. Wallach always tries to provide the maximum result with the minimum amount of incisions. Therefore, some patients may undergo a short- scar facelift (mini-facelift) to improve their neck and jowls while others may require a more involved procedure that improves the neck, jowls, and cheeks. The surgical procedure usually takes between 2 and 4 hours to perform. The recuperation is from 1-2 weeks. Dr. Wallach has presented at national meetings and published articles on this subject in peer-reviewed journals.
1) Non-Invasive Approaches
a) Fat Injection – Facial rejuvenation techniques have evolved. In the past, skin and soft tissue laxity were treated solely with face lifting techniques. As the understanding of facial aging has improved, it is apparent that not only does the skin lose elasticity and sag, but facial atrophy, more specifically facial fat loss, is also a key component to facial aging. This is a reason why facial fillers have become so popular. However, most of these available filler products dissolve overtime and last an average of 6 months to a year. They are great products and Dr. Wallach uses them frequently. Fat injection techniques have improved significantly as the understanding of how to harvest and inject the fat has been refined. With this in mind, many plastic surgeons have been incorporating facial fat injection into their armamentarium of facial rejuvenation solutions. It has revolutionized some of the facial rejuvenation work that can be accomplished especially in a very thin, hollow looking face. Sometimes this is used as the sole means of rejuvenation but many times it is performed in conjunction with face lifting procedures. The fat injected has to incorporate a blood supply from the local tissue. If it does not, then some will resorb and repeat treatment may be necessary.
b) Liquid Face Lift – The liquid face lift is a marketing phrase that refers to a non-surgical procedure incorporating both facial filler material such as Restylane™, Restylane Lyft, Juvederm, Radiesse, and Sculptra along with using the neuromodulators, Botox™ or Dysport. As our knowledge of facial aging has evolved, these products have become more important. The filler materials can be used to fill the depressed cheeks that as a side benefit may improve the nasolabial folds (creases along the sides of the nose and mouth) indirectly. The nasolabial folds can be injected directly as well. Facial wasting along the sides of the mouth can also be treated by filler injections to treat the marionette lines. Jowling can be camouflaged to some extent with filler injections, and jaw line deformities can be improved as well. Areas around the eyes such as the tear trough can be filled to soften the “double-bubble” deformity of the lower lid -cheek attachments that appear with increasing age. In addition, cheek hollows and lines of the upper face can be filled. Temporal hollowing can also be treated in a similar manner. Even brow elevation can be accomplished with fillers. In addition, the neuromodulators such as Botox and Dysport can treat overactive frontalis muscle that causes transverse forehead lines, overactive corrugators that lead to “11” lines, and lateral crow’s feet lines that are caused by the overactive orbicularis muscle. Treating the lateral brow with neuromodulators can create lateral brow elevation. In addition, the neuromodulators can treat some neck bands due to overactive platysma muscles. Lip lines, chin puckering, and overactive depressor angulioris muscles of the lower lip region can also be treated. The key in using these products for facial rejuvenation is to not over do it. Some patients are over treated by their injector possibly because the injector has not been trained properly in aesthetic rejuvenation or the injector does not offer other procedures such as face lifting, brow lifting, or eyelid lifting procedures. Inevitably some patients look “puffy” or like marshmallows. Too much product can make someone look as unnatural as someone who has had too much surgery!
c) Chemical Peels, Lasers, and Skin Care Products – As stated previously, using the roller coaster analogy, the fine wrinkles and sun damaged skin, like the rust on the roller coaster tracks can be treated with chemical peels, lasers, and skin care products ( see the section on Non-Invasive Procedures). This is not treated with a face lift but is an important ancillary procedure to make the face lift of filler procedure results look that much better. There are numerous laser and light based regimens that can improve the skin quality. For instance, Erbium laser peels either performing microlaser peels, or deeper peels can be of benefit for some to improve fine lines, skin color, and tone. Thermascan laser treatments can help with pore size and skin tightening. Intense Pulsed Light (IPL or Sciton laser system BBL) can help with tightening the skin, treat sun spots, and general dyschromia. BBL-ST is also a light based system that can tighten the skin. Skin care products are also a great ancillary product to be used as well.
2) Surgical Incisions
a) Limited Incision – Otherwise known as a “short scar” approach. This is an incision usually confined to the region from the base of the earlobe to the sideburn region. This is most commonly used for Short Scar Face Lift techniques in which a SMASectomy, SMAS plication, or a MACS face lift (see below) is performed. This incision does not permit adequate redraping of loose neck skin and so it is not a good incision to use for patients that require extensive neck work. It is a good choice for those patients in New York that need some jowl and cheek elevation with minimal need for neck work. In addition, it is a quicker procedure, so it may be better for patients who are not candidates for longer procedures.
b) Full Face Lift Incision – The traditional face lift incision extends from the temporal hairline then goes in a pretragal incision ( in a skin crease in front of the ear notch) and then follows around the earlobe along the ear sulcus behind the ear and then extends transversely into the hairline. If patients have very loose neck skin or upper cheek and face skin, then these incisions may leave the patient with a “wind-blown” look with loss of hair behind the ear and along the temple. Not uncommonly, female patients will lose their sideburn in this situation. Dr. Wallach often uses modifications of these traditional approaches to camouflage the incision and preserve the hairline so patients look more natural. This often includes a sideburn type of incision, an incision hidden behind the tragus or ear notch called a retrotragal incision, and then in patients with loose neck skin he will place the posterior incision along the hairline. Dr. Wallach, a Manhattan NY Cosmetic Surgeon, applies these same techniques in men and is able to preserve their natural hairline.
3) Face Lift Techniques
a) Composite Face Lift – Is a face lift procedure in which the tissues are dissected below the Superficial Musculo-Aponeurotic System (SMAS), the connective tissue layer over the muscles. This is a deeper dissection plane than a SMAS face lift of skin face lift. This procedure moves the cheek fat superiorly as one unit with the overlying skin. This procedure is probably safer in smokers than more traditional techniques.
b) Deep Plane Face Lift – Is a subperiosteal (just above the bone) lift that is performed at a deeper plane than more traditional facelift techniques( SMAS or composite lift). This form of face lift treats mainly the upper 2/3 of the face and is commonly performed in conjunction with a brow lift and often using an endoscopic approach. This provides correction of facial aging mainly in the brow and the mid-face region.
c) Extended High SMAS Face Lift – The SMAS refers to the Superficial Musculo-Aponeurotic System, a connective tissue layer below the skin and above the facial muscles. This procedure is a variation of the SMAS facelift (see below) but the incision into the SMAS is made higher in the cheek usually at or above the level of the cheek bone. This higher incision allows for better elevation of the cheek soft tissues than the lower incision SMAS. It can be used to also accomplish a mid face lift. The SMAS itself can be used to augment the cheeks as well and improve the neck contour. It can provide for a fuller cheek appearance but because the incision is higher on the cheek there is a slightly higher potential for a facial nerve injury.
d) MACS Face lift -Refers to a Minimal Access Cranial Suspension lift. This is a limited incision face lift procedure. An incision is made in the area hidden in the front of the ear. Limited undermining is performed and then sutures are placed to 1) suspend the soft tissue and elevate the cheek and 2) improve the jaw line by and then using suspension sutures to improve the jaw line and elevate the cheek region.
e) Mid-Face Lift – The mid-face lift is a procedure that focuses on the cheek and lower lid junction. The goal is to elevate the cheek fat pad and treat the lower lid region as well. This can be done as an isolated procedure using only a lower lid incision. The soft tissue around the cheek is freed and secured to the temporal fascia of the face. A canthopexy or a support procedure for the lower lid is also performed at the same time. Commonly mid-face treatment is performed during other face lift procedures using the access during the face lift procedure such as in a deep plane face lift, a composite face lift, and a SMAS facelift.
f) Neck Lift – A neck lift refers to the treatment specifically of the neck itself. Access to the neck as an isolated procedure can be performed through incisions behind the ear, and in the submental (under the chin) crease. Neck lifts are commonly treated in conjunction with a face lift. There are multiple structures in the neck that may warrant treatment.
1) Digastric muscles – They are muscles that can impact the contour of the submental region and may require partial excision.
2) Neck Fat Removal – There may be fat above and below the platysmamuscle( muscle found just under the neck skin). Fat above the muscle can be removed either directly or by suction assisted lipectomy (SAL). If liposuction is the only procedure, this can be performed through small incisions behind the ear and under the chin. Removing fat under the platysma muscle will require the exposure obtained during a neck lift procedur.e
3) Neck skin – Commonly patients complain of a “turkey gobbler” neck as they age. This is often due to loose neck skin. Removal of the excess skin can be performed after neck skin undermining and the incisions can be hidden within or along the hairline.
4) Platysma Bands – They form the vertical bands of muscle that originate from the lower neck and extend to the chin region. These can cause dynamic bands(seen with motion) or static (seen when at rest). They can be treated by imbrication or plication of the muscles in the midline or by partial or complete transection to allow the muscles to redrape.
5) Submandibular glands – They can be prominent in the area under the mandible (jaw). Some surgeons will partially excise them to improve the neck contour. However, some risks of removing the glands include bleeding and dry mouth.
g) Skin Only Facelift – A skin excision only face lift is sometime performed. This will only treat skin laxity. It is best for patients with loose skin, and for patients whose health limits the amount of surgery that they can have. It is a fairly quick operation, with less downtime than some other procedures, and with a lower risk of complications. A major disadvantage is that it is not good for patients with significant soft tissue atrophy or facial soft tissue descent.
h) SMASectomy – This is another variation of the SMAS procedure but instead of incising the SMAS and lifting it, an ellipse of SMAS is excised (cut-out) along the line perpendicular to the pull vector. This is usually an oblique ellipse. The risk of injury to the facial nerve is lower than with some of the other techniques described but it may not give the same elevation as those procedures that use an elevation of the SMAS. This is also a shorter surgical time as compared to that during the elevation techniques.
i) SMAS Facelift – The SMAS refers to the Superficial Musculo-Aponeurotic System, a connective tissue layer below the skin and above the facial muscles. After the skin is elevated, the SMAS is appreciated. Treatment of this layer can be done in several different ways. Commonly it is incised, elevated, and pulled back in a superomedial direction. Depending upon the level at which it is cut will determine what area will be best treated. A low incision will primarily treat the lower face and jowl region. It can also be used to improve the neck contour. This low incision is usually made close to the inferior border of the cheekbone or just above the superior border of the parotid gland. The underlying facial nerve, which activates the facial muscles, is protected in this region by the parotid capsule.
j) SMAS Plication – SMAS plication refers to the technique used when the SMAS is not elevated or incised, and is just imbricated (or overlapped). This is performed more commonly in patients who do not have a well-defined thick SMAS. This procedure like the SMASectomy shortens the surgical time and is sometimes reserved for patients with higher medical risks, or in patients whose facial aging is not as severe as others.
k) Stem Cell Face Lift – This is a marketing ploy phrase. There is actually no such thing as a stem cell face lift, but some surgeons market this phrase as fat grafting to the face either separately or in conjunction with a face lift. Stem cells are found within fat graft harvest specimens. So technically there are stem cells but there is no scientific evidence that stem cells offer any benefit.
If you would like more information about Dr. Wallach and his success with New York City Facelift procedures, we invite you to contact our Manhattan office at (212) 861-6400 or by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028; or using our contact form to request additional details.
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