I am currently investigating facelift and lower eyelid surgery. I have two doctors that I've narrowed down to perform different types of lifts. One uses a more traditional SMAS type lift (45 degree vector) and the other an ENT Dr. suggested a deep plane lift (60 degree vector). What is your opinion of which lift might be better for a 56-year-old woman with a very saggy neck? Both doctors said they would place a suture under my neck.
Type of Facelift Best for a 56-year-old Woman?
Doctor Answers (33)
Choosing between facelift types
The most important goal of a facelift procedure is what the facelift will do for you and your unique anatomy. The most effective way of accomplishing this is through a very experienced surgeon who listens to you, and creates a procedure that maximizes your result.
We do not typically perform either the traditional SMAS or the deep plane lifts as they reduce tissue when the SMAS is pulled and then resected. We prefer multivector operations where volume and skin are treated differently, each pulling and restructuring in their optimal direction for the patient's anatomy and aesthetic needs. Not every patient's tissues should be pulled at 45 degrees, or 60 degrees, to achieve the best result. Especially if the skin goes along with the deep layer (i.e. deep plane or composite), loss of the sideburn and a high lateral tension appearance can result.
Nor is any one technique right for every patient. A patient with flat cheekbones requires a completely different technique than one with excessively prominent cheekbones.
Volume replacement goes hand in hand with pulling, since both drooping and loss of volume have typically occurred.
Good earwork is the hallmark of a top plastic surgeon. Examine the pictures carefully and critically for how the ears appear after the procedure!
The neck should typically be addressed as well, not just through facelift incisions but through an incision below the chin. How this is performed varies widely, and patients should examine each plan for how logical it seems, as well as what results the patients in the before-after photos have obtained.
A well done facelift often combines ancillary proeceures such as cheeklifts, upper eyelid surgery, browlifts, lip lifts, laser resurfacing, DAO release, LiveFill (R) placement, etc. The 360 facelift concept of looking at the face as a whole and addressing all (or as close to all as technology permits) is preferable to having a standard way of doing every facelift, in my opinion.
As often as not, patients have had prior "work". Rather than exacerbate the problems of the past, the plan should directly target "older style work" to reduce or eliminate signs of surgery. Specific, targeted steps are necessary to accomplish any revision work in particular, and a harmonious result in general. It will not occur by chance.
Facelift Options and Choices
When choosing a plastic surgeon it is imperative to select a surgeon who is certified by the American Board of Plastic Surgery. Often, plastic surgeons who perform a great deal of aesthetic or cosmetic surgery will also be members of ASAPS. A plastic surgeon who is a member of ASAPS is an indication that a surgeon has significant interest in aesthetic plastic surgery. When evaluating a surgeons training, look for completion of a plastic surgery fellowship. A fellowship is an elite qualification that only a small percentage of surgeons performing cosmetic plastic surgery can claim. , a surgeon who has had an additional fellowship of training has completed focused and intense specialized training in a particular area of interest
Be careful about investigating board certification. Some doctors today are promoting themselves as being double board certified, triple board certified and even quadruple board certified.
Thousands of physicians with no residency training in plastic surgery and without certification from the American Board of Plastic Surgery (the only Board recognized by the American Board of Medical Specialties that certifies plastic surgeons) promote themselves as `cosmetic surgeons' and `plastic surgeons'. Some are primary care physicians, some are emergency room doctors; some have never completed a residency training program in any specialty and are not eligible to take any specialty board exam. Many take `weekend courses' on liposuction, or breast augmentation, or facelifts, then return to their practice and begin promoting that procedure and performing it on patients.
The minimum amount of training in plastic surgery that will allow a physician to be eligible for certification by the American Board of Plastic Surgery is five years, and many board-certified plastic surgeons, myself included, have several additional years of training in general surgery and plastic surgery. There are a number of reasons for such a significant training requirement. Chief among them are the following: one does not acquire sophistication in diagnosis and treatment planning, superior surgical skill, and the capacity to minimize the possibility of complications and unfavorable outcomes by taking weekend courses. It requires years of training experience under the direction of talented mentors. It requires devotion to the art and practice of plastic surgery.
Be careful in evaluating physicians whose `Board Certification' is by a `Board' which is not recognized by the American Board of Medical Specialties (ABMS), and who belong to an `Academy' that does not require residency training in plastic surgery. Some will claim that they are `double-' or even `triple-board certified', when only one (and occasionally none) of those `boards' are recognized by the ABMS. Visit the ABMS website to see which specialties have ABMS recognition.
It takes just a few mouse clicks to verify a surgeon's credentials online. Make sure that the surgeon or surgeons that you are considering are certified by the American Board of Plastic Surgery and are active members of the American Society of Plastic Surgeons (ASPS). ASPS members are also eligible for membership in the exclusive American Society of Aesthetic Plastic Surgeons (ASAPS), the premier professional association of board-certified plastic surgeons with a specialty practice in cosmetic surgery
Selecting a plastic surgeon should always start with board certification by the American Board of Plastic Surgery, but it doesn't end there.
Choosing Your Surgeon
There is endless information about plastic surgery available online, some of it helpful, some of it hogwash. Many patients learn about treatment options and narrow their search for a plastic surgeon with the help of their computer. And then they make one or two or more appointments, and on the basis of these encounters decide on a surgeon. Some patients already have a particular plastic surgeon in mind, based on the recommendation of satisfied patients or the surgeon's reputation.
Regardless of how you decide who you see, ask yourself the following questions after your consultation appointment(s):
Is this surgeon qualified to perform the surgery I am considering?
Do I like this person? Will I enjoy seeing them over the course of my surgery and recovery?
Was my complete medical history taken and examined in detail?
Did this physician truly listen to me as I explained my thoughts about the improvement I am seeking?
Does this physician share my aesthetic sensibility? Do they understand me and are they able to provide exactly what I am looking for?
Was I provided with a thorough understanding of all options available (both surgical and non-surgical)?
Was I shown photographic examples of surgical outcomes that give me confidence?
Was the office staff professional, friendly and accommodating?
Was I pressured in any way to proceed with surgery?
Does this surgeon perform aesthetic surgery exclusively or is aesthetic surgery a small percentage of the pratice?
Listen to what your heart and your gut tell you when you are evaluating your consultation experience. Only move forward if you can do so with confidence about the experience you expect to have in a given plastic surgery practice, and about your ultimate outcome as a surgical patient.
Your experience with the consultation process is a good indication of what you are likely to receive as a surgical patient in any practice. If the process is well-organized and enjoyable, the staff is respectful and efficient, and the physician takes adequate time to understand your individual needs and communicates effectively, then you have a very high likelihood of being treated in a similar fashion if you become a surgical patient of that practice. If the process is disorganized or rushed, if the staff is discourteous or unprofessional, or if the physician does not give you confidence that your needs will be met, then don't expect things to get any better once you are a surgical patient.
You must be absolutely certain that your plastic surgeon's aesthetic sensibility matches your aesthetic goals. I have a very particular aesthetic vision, and I do not pretend to be the plastic surgeon for everybody. I strive to produce surgical results that are natural-appearing, results that do not advertise a trip to the operating room. For example, I do not perform breast augmentation for patients that are seeking an overly large and distinctly `done' breast appearance. And I have a particular distaste for cheek implants, as I think they rarely produce natural-appearing cheek contours, and instead prefer to enhance facial volume by means of structural fat grafting. Make sure that your plastic surgeon's philosophy and preferred approaches are consistent with the goals that you have in mind.
Adequate communication is obviously invaluable, and you should be able to communicate clearly and easily not only with your doctor, but also with your doctor's staff. Over the course of preparing for and recovering from aesthetic surgery, your doctor's staff will have an important and active role. Make sure that your interaction with the staff gives you confidence that you will receive the care and attention that you expect, and deserve, postoperatively.
Verify that major surgical procedures are performed in an accredited surgery center and that anesthesia care is provided by board-certified M.D. anesthesiologists. If you are most comfortable with overnight observation after surgery with the bedside care of an R.N., verify that this is available to you. Look up your surgeon on your state's Medical Board website to verify that they are in good standing and have no public record of sanction or limitation of their license to practice.
Be confident enough to ask some `difficult' questions. Feel empowered to ask any physician questions like: What are your complication and reoperation rates for this procedure? Has a cosmetic surgery that you performed ever resulted in a lawsuit? Have you had any serious complications and unplanned hospitalizations after cosmetic surgery? Have you ever been disciplined by a state medical board? I am never offended by these kinds of questions, and no competent and qualified surgeon should be. In my opinion it is actually the savvy prospective cosmetic surgery patient who does this kind of `due diligence'.
FACIAL REJUVENATION: no two surgeries are alike
I prefer the term 'facial rejuvenation' over the more antiquated term 'facelift', as many patients that I see who seek a more youthful and refreshed facial appearance undergo a set of surgical procedures very different from what would have been considered a 'facelift' twenty-five years ago.
The word 'rejuvenation' means, literally, 'to make young again'. In each individual, different facial changes occur with age. One person may be unhappy with 'baggy eyelids', while another has 'droopy eyebrows'. One person may be troubled by 'jowls' in the lower face, while another would like an improvement in their 'floppy neck'.
Surgical treatment of facial aging changes must therefore be carefully individualized to match each patient's aesthetic needs and desires. No two 'facelifts', by necessity, are the same. In helping a patient to make decisions about plastic surgery for facial rejuvenation, I always examine and assess how each aesthetic area or 'unit' of the face contributes to an individual's overall appearance: the brows and eyelids, the cheeks or 'midface', the lower face and chin, and the neck. An individualized surgical plan is then developed which addresses each patient's specific concerns and needs.
Plastic Surgery of the Face in the 21st Century
The specialty of Plastic Surgery has been undergoing a 'paradigm shift' in the approach to surgical treatment of facial aging changes over the last two decades. This shift has consisted of a departure from older 'subtractive' techniques to newer 'restorative' techniques.
Surgery which consists mainly of removing (subtracting) skin and fat and pulling tissues tight will lead, in many instances, to a 'skeletonized' and therefore more aged (or "done") appearance. Facial soft tissues (and even the facial bones) actually lose volume and projection with age, and it is thus inevitable that surgery which focuses only on removing tissue will in some fashion 'age' the face.
The contemporary approach to surgical rejuvenation of the face consists more and more of an attempt to restore facial volume and contour, in an attempt to emulate youthful facial features. My personal approach to facial rejuvenation is to first maximize repositioning and recontouring of facial aesthetic areas, and to remove only as much tissue as is necessary.
I also find that structural fat grafting, using a patient's own fat from the abdomen or hips, is an extremely effective means to help restore the facial volume associated with a youthful appearance. The importance of restoring facial volume is readily apparent when I review with a patient a number of photographs from their twenties and thirties. The meticulous addition of soft tissue volume by means of fat grafting is one of the most powerful means now available for 'turning the clock back.'
The surgeon is the most important factor
The most important part of getting a good result from plastic surgery, is the surgeon you choose. Most people choose a board certified plastic surgeon.
Having done extensive studies of face lift techniques on identical twins, I can personally state that it is a much more complicated topic than you realize. Your age is not as important a factor as the quality of your skin and the amount of laxity.
Don't get too hung up on the type of lift. You're paying your surgeon to apply their expertise to you, in order for the surgeon to pick the best technique for you.
With over 20 years of experience, I can assure you that this is not a one size fits all operation.
If a surgeon "performs a certain face lift technique," frankly it sounds like a sales job to me. Every operation should be tailored to that particular patient's needs and many different operations can yield excellent results. In general, I advise the smallest operation to give the maximum improvement with the least risk.
Each operation is tailored to the difficulty of that particular situation (patient). Performing surgery is like playing the violin. Some surgeons make beautiful music, and others just play a bunch of squeaky notes, using the same musical score.
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I think you are missing the point here. Choose the best surgeon, both by experience and technique. You should not be concerned about the nuances of technique. Many surgeons cannot agree on them so what hope is there for you? Look at their before and after results, ask to speak to their patients and ask how many they do each month. This will give you a great idea where to go without worrying about the specifics of technique. Consider getting the work done under oral sedation and local anesthesia and removing 95% of the surgical risk. There are surgeons like myself that get long lasting and great results with this approach and compromise nothing. I personally prefer SMAS lifts and stay away from deep plane work. I think deep plane facelifts leave a somewhat unnatural smirk to the face.
What type of facelift is best for a 56 year old woman? It depends...
Facelifting, and facial cosmetic surgery in general, are true arts. The key to a beautiful, rested, and natural results is not a specific techique, vector, or piece of equipment. Instead, a surgeon with a true sense of the actual aging changes to be addressed, and a good vision of the shape that must be created, will choose from a variety of techniques.
I always enter facelift surgery with a specific plan of action to achieve the shape I am seeking. Due to unforseeable surprises in muscle quality, facial fat, tissue strength, and tissue elasticity, I find I often change the specific type of lift technique I use "on the inside".
So, rather than picking a surgeon on vectors and technique, choose on his demonstrated ability to draw from a wide variety of techniques to match the tissue qualities of each patient to predictably deliver consistent, predictable, pretty results.
Type of facelift recommended
Obviously we don't have a picture to render a more accurate opinion. In general, I am more comfortable with a SMAS lift combined with a platysmal muscle plicaton in the neck. The deep plane lift is not one that I perform. It may be advisable to look at a lot of before and after pictures prior to choosing you surgeon. Also a personal chemistry with your surgeon can be very helpful.
All the best,
Tal Raine MD FACS
The best type is the type that works. You have to evaluate the before and after photos of the surgeons and see what looks best to you. I would not concern yourself with the type as it is not the type but the surgeon that will get you the results. There are surgeons out there that will argue SMAS elevation vs. SMAS plication vs Deep Plane that they all will achieve the same results in different hands.
It all depends on what your surgeon feels comfortable with and what kind of results they obtain.
The name of the facelift isn't as important as the results that doctor gets
The exact name of the facelift isn't as important as the actual photos of many of that doctor's patients showing what kind of results they get. Each doctor is different and so are their results.
Personally, I use a SMAS lift with a directly vertical vector on the SMAS because I believe the cheek tissues descended vertically down, not at 45 or 60 degrees.
Since we are both in WA, please check the facelift and cheek and neck lift photos on my web site and see if you think there are differences from the other doctors you have already seen.
The best facelift is one that addresses individual needs
The trends in facelift today are away from deep plane procedures, and from extensive surgery on the SMAS as well. The idea had been longevity of results warrant the procedure, but current understanding is that the risk of deeper plane procedures and longer recovery may not be worth the potential of a longer lasting result.
Patients today have come to expect safe procedures with short scars if possible, substantial improvement, and a rapid recovery from a pleasant experience. The key again is individual care, many vectors as needed, support of the SMAS as gently as possible, restore volume where needed, and safe a rapid recovery.
Best of luck,
Peter E Johnson MD
Face lift options
It sounds like you are being very thorough and seeing several doctors, which is good because the choice of surgeon is more important than the choice of technique. In general, the deep plane version should produce good long-lasting results, though whether the results are better than less invasive approaches has not been proven. The risks of nerve injury may be greater with the deep plane, and there may be more swelling that takes longer to resolve. The vector is something that should be individualized. Most important in my opinion is to decide which procedure will give the best 3-dimensional result for a natural appreance.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.