Facial Plastic Surgery Blog

Sam P. Most, M.D., F.A.C.S.
www.drmost.com

What is a facelift?

As a facial plastic surgeon, I commonly find myself explaining to my patients the details of a facelift. The term has always been a bit misleading, as it typically refers to a procedure that does nothing for the eyes or forehead (which are also part of the face, last time I checked). However, I find myself thinking about this more and more, as this term is now being used for a number of procedures.

The medical definition ‘rhytidectomy’, the common medical term for facelift (which, by the way, means ‘wrinkle excision’), is a surgical procedure that tightens the lower face and neck. There are multiple variations of the rhytidectomy.

For example, the “minilift” is a term that may be used to describe any type of facelift that is meant to suit the more active lifestyle. Lifts that are thus labeled are sometimes modified by the surgeon ever so slightly and renamed as if proprietary. More often than not, they are insignificant modifications to a procedure that has been around for a while. In any case, these types of lifts typically offer slightly less downtime but a lesser result in the long term (that is, more than 1 year). Rigorous studies regarding the effectiveness of various types of mini-facelifts are lacking. Thus, one must rely on anecdotal evidence, which is often inadequate.

What about “MACS” lifts?

The MACS lifts originated in Europe, and is an acronym for ‘Minimal Access Cranial Suspension”. In this technique, a type of mini-lift is performed. The addition is the use of sutures from above the ear to the tissues of the mid-face, jawline and jowl areas. Thus, this is really variation of the minilift. A number of surgeons have used sutures in various ways, in combination with a min-lift, to good effect. As I mentioned above, however, it is important to understand that the longevity of these types of lifts is probably less than the more traditional lifts.

What is a “Deep Plane Facelift”?

The so-called ‘deep plane’ facelift is also a term that, in the strictest sense, refers to a specific type of lift. However, in the facial plastic surgeons’ parlance, it may refer to a more substantial repositioning of facial tissues that ostensibly gives a more long-lasting and natural result. This is the facelift that is typically most often used by experienced facial plastic surgeons (such as myself). Non-facial plastic surgeons (such as dermatologists or ophthalmologists) who have started to do facial cosmetic surgery do not typically have training to do this procedure and thus stick to the so-called mini-lifts (though they may call them ‘facelifts’).

What about non-invasive facial rejuvenation?

Facial rejuvenation is undergoing a revolution. While initially we as surgeons thought the revolution would be from the knife to totally non-invasive procedures, things don’t appear to be panning out quite that way. Rather, we seem to be arriving at the conclusion that in order to rejuvenate the face, an individualized approach that may combine both non-invasive and surgical techniques is the most appropriate.

For more information regarding facelifts, visit http://www.drmost.com/faclft.html

The Facial Rejuvenation Revolution
Sam P. Most, M.D., F.A.C.S.
www.drmost.com
In the past few years we have seen a significant evolution in thinking about facial rejuvenation.  In this space I hope to shed some light on this, and what this means when you visit the doctor’s office.  In the past, facial aging has been thought of as primarily a battle lost to the effects of gravity.  We understand now, however, that the process of aging is a complex one, and involves more than simply sagging of the skin on the face.  Recent research has shown that the changes that occur are, to use an oft-used phrase, ‘more than skin deep’.
For example, we know that what we see in an aging face is partly due to changes in the skin at the microscopic level—changes in pigment cell and collagen fiber organization, as well as loss of elasticity (the ability of the skin to stretch and “bounce back”).  While in the past it was thought that fat should be removed from the face (especially in areas such as the upper and lower eyelids), we realize that one of the stigmata of facial aging is loss of facial fullness, partially due to fat loss or redistribution .  Finally, we are just starting to understand the interaction of the facial fat and muscle with the cartilage and bony skeleton, and what makes a young face look the way it does.  All of these have changed the way we (as facial plastic surgeons) approach our patients.

What can I do?

What can YOU do to reduce the effects of father time?  First, take care of yourself.  Eat a healthy, balanced diet.  Don’t smoke. Cleanse, moisturize and protect your skin.  Avoid the sun .  Even if you do all of the above, there are some things you will not be able to control.  You can’t go back in time and tell your twenty-something self to be more careful with your skin.  You cannot stop the biology of aging (despite what you may read on the internet).  No anti-aging cosmeceutical yet exists that can penetrate your skin and change the process of aging .  Even if you do all of the above, the time may come when you search for ways to rejuvenate your face.
“It’s not your mother’s facelift anymore”
As I alluded to above, the old way of thinking about facial rejuvenation was ‘tighter is better’.  Given what I discussed above, I’m sure you can appreciate that our approach to facial rejuvenation has likewise changed.  While in the past the primary approach for facial rejuvenation was surgery (a ‘facelift’); we now have many non-invasive techniques that can be used to restore a youthful appearance to the face.
Non-invasive facial tightening
Chemical peel, dermabrasion, and laser peels are tried-and-true methods for removing skin wrinkles.  You have probably heard of these procedures, or you may know someone who has undergone one of these.  While these techniques have been around for a while, most all of the new research has centered on improvement of the laser.  Specifically, the goal has been to reduce the ‘downtime’ associated with it maintaining its benefits.  The latest technology involves treating only a fraction of the skin with the laser, thereby stimulating rejuvenation with less downtime (this is called a ‘fractionated laser’; some brands include Pixel and Fraxel).
You may have also heard of techniques that promise ‘nonsurgical facelifts’.  One of the first such techniques was Thermage®, but many similar techniques have come along.  The premise of these technologies is to transfer energy (often in the form of heat) to the deep tissues of the face, thereby ‘tightening’ the tissues that have ‘loosened’ over time.  The results on this have been mixed.  Some studies have shown that about 1 in 3 patients will have a noticeable effect.  Unfortunately, we cannot tell who those patients will be.
Injectables
There are 2 main types of injectables.  Muscle ‘freezers’ and facial fillers.  Botulinum toxin type A (most commonly Botox®) is the most commonly used ‘muscle freezer’ and is one of the most common facial rejuvenation procedures in my practice in the San Francisco Bay Area (as it is nationwide).  It works by temporarily blocking the muscle from getting a nerve signal.  Since muscle movement causes some types of wrinkles, it is only effective in treating so-called ‘dynamic’ wrinkles.  Note that Botox® is FDA approved for use in the glabella (the area between the eyebrows), but is commonly used ‘off-label’ in other areas of the face.  It takes about a week to show its effects, and lasts typically 3-4 months.
The other main category of injectables are the fillers.  Classically, collagen was used to ‘plump’ the face, especially the lips.  Given what we now know about loss of volume throughout the face, our use of fillers has expanded to include virtually all areas of the face.  Our repertoire of materials has also expanded far beyond collagen.  The hyaluronic acid (a naturally occurring substance) derivatives include Restylane®, Perlane®, and Juvederm®, to name a few.  Radiesse® is derived from a calcium base.  Other, more permanent fillers, include Artecoll®.  The ultimate injectable is your own tissue, namely, your own fat.  In this procedure, called fat transfer, we move small droplets of fat from an undesirable place to areas of the face that need more volume.
What about surgery?
The non-invasive procedures can only do so much.  When you and your surgeon feel the time is right, surgery may the best choice to give a natural, more long-lasting result.  As you can see, there are a number of options available prior to taking the plunge into a surgical procedure.  Surgery of the face to reverse aging includes brow rejuvenation (endoscopic browlift), eyelid lifts (blepharoplasty), and lower face/neck lifts (rhytidectomy).  These procedures can be done alone or in combination.  Each of these has undergone its own evolution, the discussion of which is beyond the scope of this summary.  Suffice to say that the trend is towards more conservative and natural-looking results.
OK, I want to take that first step…

Do your research.  Find someone who has experience and limits their practice to the face.  Importantly, this person should be familiar with the full range of facial treatments (surgical and nonsurgical).  Finally, it is important to find someone you trust will give you an honest assessment.  The goal of facial rejuvenation in 2009 is just that—rejuvenation.  This implies a natural restoration of facial youthfulness.  Our goal as facial plastic surgeons is to achieve this as safely and effectively as we can, with as minimally invasive a procedure as possible.

Facial Plastic Surgery Videos

To learn more about Facial Plastic Surgery techniques, from the minimally invasive technologies (such as Fraxel, Pixel, and Thermage) to the latest twists to more traditional surgical techniques, look for online lectures on these topics.

We have posted several videos on topics such as these online, and these can be found on YouTube or at http://www.drmost.com/video_main.html

Furthermore, you can view Dr. Most’s most recent lecture on the Research Channel.
To check on airtimes, or to watch this video online now, click here.

Seminars in Facial Plastic Surgery (Fraxel, Pixel, Thermage, Facelift and Botox discussed!)

Dr. Most will be hosting his next Seminar on the latest Advances in Facial Plastic Surgery on Wednesday evening November 19th, at 801 Welch Road, Stanford, CA.

Topics to be discussed:
-Lasers peels and types (CO2, Pixel, etc)
-Chemical peels and types
-Botox®
-Restylane® and other hyaluronic acid-based fillers
-Radiesse®
-Facelifts, minilifts
-Eyelid Surgery

-Plus more!

Refreshments will be provided.

Please RSVP to info@drmost.com or call 650 736 FACE (3223) to reserve a seat!

Our seminars have been very popular and informative in the past, we hope you join us!
For directions or maps, please visit www.drmost.com

Each fall the American Academy of Facial Plastic & Reconstructive Surgery meets. Here, leaders and students in the field of facial plastic surgery meet to discuss the latest advances in the field. For me, it is an opportunity to visit with my colleagues from around the country and learn what they’re up to.

One common theme the past few years has been an increasing emphasis on non-invasive procedures. Several techniques have now been around for a number of years, and we can start to see which ones work and which ones don’t. Below are a few of my observations, which are, of course, simply my opinion and should not be construed as medical advice.

Injectable fillers
These continue to be quite popular. Several new fillers are likely to be FDA-approved in the next few years, and will likely add to our arsenal of materials to use to treat wrinkles or depressions that occur due to aging.
Hyaluronic Acid Derivatives (e.g., Restylane®, Perlane®, others)
These remain popular and are well-tolerated. Hopefully, longer-lasting formulations will be coming.
Hydroxyapetite Gel (e.g., Radiesse®)
Also a good choice for the face, but probably not for the lips, as there have been some problems with injections in that area. I have been using this to revise other folks’ rhinoplasties with good success (see www.sfrhinoplasty.com)
Sculptra
Not really a filler, as it induces your body to make collagen and ‘fill’ itself in. This product was initially greeted with great fanfare. The consensus seems to be that it certainly is effective, but may not be for everyone. Repeat injections are necessary to get the effect, and it is rather expensive.
Collagen-may be making a comeback in the next few years, stay tuned!

Threat lifts
Thread lifts made a big splash last year. These were hailed as the end of the modern facelift procedure. Featured on Oprah, huge publicity followed. We now know that the technique certainly is intriguing and may have its place in certain situations. For example, it may be used for isolated, shorter-term treatment of the aging face in younger (40-ish) patients, or at the same time as a mini-facelift. However, it is definitely not a replacement for the traditional facelift, which remains the most reliable and best procedure for treatment of the aged face and neck. AND I’m glad to say the manufacturers of the technology agree with the surgeons on this point! I think the technology is exciting and as surgeons we can look to use this as an additional tool to treat the aging face…..
MORE ON THE LATEST IN MINIMALLY INVASIVE TECHNIQUES TO FOLLOW!

For more information on the lateset in minimally invasive facial rejuvenation, visit www.drmost.com