Why Didn't My Facelift Work? (photo)

Hi Mommy123456,

I see what you are talking about.  In general, my philosophy is that facelifts are for patients who have sagging skin (skin hanging off the jawline and neck).  In your before photos, your jawline was not bad, your neck was not sagging, but the chin to neck angle was a bit blunted, but not sagging enough for anyone to notice, and your cheeks appear to have lost volume. 

Many women tell me that they always looked younger than their age, but at some point the started looking their actual age, which is what prompted them to seek some cosmetic facial procedure.

Actual Age versus Age of appearance

I think that patients who look ten years younger after a facelift often times look prematurely older by 10-15 years due to sagging of the neck and jawline.  So for your before photo, your chronologic age is 44, but you look in the 40-45 range, but you don't look 50-55.  By removing the significant sagging around the neck and jawline, can easily make that person look ten years younger, based on their appearance pre-surgery.  So if the 44 year old looked 50-55 because of jowling and sagging neck, then they may look 40-45 after surgery and really appreciate the improvement, and more like their actual age and maybe a bit younger with the slight swelling after surgery which gives the face artificial volume. 

Facelift will make a person look 10 years younger, right?

If you don't know their ages on the before and after photos, you would think that they do look 10 years younger.  But if you saw their actual age and then asked yourself, whether they look 10 years older than their actual age, then you may not feel that it accurate.  So with the 44 year old, who looked 55 because of jowling and neck sagging, that would mean they would need to go from looking 55 to 35, which is extremely rare.  We don't usually tell patients that they will look 20 years younger, the number you normally hear is 10 years, but that is based off their age appearance and not their actual age. 

As far as making someone look ten years younger, if we take it to an extreme, would performing a facelift on a 20 year old, make them look 10 years old?  Not likely, if anything, they would look exactly the same.  Their neck is perfect, their jawline is perfect, their cheeks are full and high.  If you are already at the top floor, how much higher can you go?  Definitely not another 10 floors up.

The older and the saggier the patient, the more dramatic the improvement.  If a person is aging well, and looks very close to their actual age, or better than their actual age, then the improvement may not be as great. 

So in your case, you were before surgery 44 and look about your age, you had a facial procedure which didn't make you look 34 as you were probably hoping for.  In order to actually attempt to do that, wouldn't it be helpful to look at younger photos of the person that the surgeon may be operating on for comparison.  In order make a natural improvement, to do that you would need to see what changes occurred to your face and try to work backwards from there.  In some cases the old photos do point the surgeon towards a cutting and lifting procedure, but what if the photos show something different, and the neck and jawline looked about the same as it did 10-15 years ago, but the mid-face and eye area looked fuller.  Would the surgeon then recommend something different or customized to that particular patient's face, or would they recommend their "blue-plate special." 

Fitness trend and athletic people
For my younger female patients who are athletic, I don't see much sagging of the face, but instead, I see loss of volume of the face.  The areas of volume loss tend to be the tear troughs (diagonal grooves from starting at the inside corners of the eyes, the temples, and under the cheekbones.  If you can find photos of yourself in your teenage years and early 20's, you may find that those areas were fuller.

I have also noticed a trend with so many fitness DVD's out their to get super lean and cut, that people in the before and after photos have amazing bodies, but often times their faces look drawn and gaunt, and perhaps a bit older looking, despite their lean physique.

 

Dr. Yang's Philosophy on Facial Aging
Lower third of the face (jawline/neck)
Sagging of the jawline and neck will definitely prematurely age a person.  Whatever their apparent age, if you add jowls and turkey neck to the same exact face, our brains will add 10 years to that person's estimated age.  We might think they are just a young looking 55 year old, but their neck gives away their age, when in fact they may only be 45.
Middle third of the face (Cheeks/lower eyelid)
I think that the mid-face or cheeks can make a person look drawn and tired, but not as aging as sagging skin of the jowls and neck.  Adding volume to the cheeks to make the cheek a single convex unit gives a less tired appearance.  Having a full high cheek with no shadows cutting diagonally across the cheek is a very youthful feature.  This doesn't mean that the face needs to be fat, but simply have a uniform curvature, without having a pillow face (overly plump face.) 

Upper third of the face (upper eyelid/brow)
Lastly is the upper eyelid and brow area.  I think this is actually the key area which can truly make a person look younger.  If the eyes look like they did when they were younger, then the person actually looks younger.  If you flip through a fashion magazine, and look at the model's eyes, in general, most of these young models have relatively flat eyebrows, with fullness between the eyebrow hair and the eyelid crease.  The eyebrows are rarely one pupil width higher above the upper lash line.  The skin below the eyebrow is reflective and curves with the eyelash line.  Traditional aggressive upper eyelid procedures remove loose skin, but this loose skin was originally part of the skin under the full brow.  This can make the upper eyelid crease look closer to the lower edge of the eyebrow and make the eyebrow look low.  This also shows too much eyelid as compared to younger photos of the patient themselves.  There are obviously exceptions for people with deep set eyes even when they are young, but for the rest of us, these general observations are true.

I will post a link the my upper eyelid page on my website.  I have additional before and after photos of facelifts and necklifts on my website which can be found, but I think the upper eyelid concept is more interesting.

Repositioning a flat cheek- Mid-facelift

The mid-facelift did reposition your cheeks higher as shown on your front after photo, but the main issue which was not addressed was a lack of volume.  Lifting a deflated cheek, still leaves the cheek deflated, but simply higher.  For people who have a full cheek and have a mid-facelift, they often will comment that they have a pumpkin face and the swelling seems to last up to 6 months before they look more normal.  People with thinner, more gaunt faces, may actually like their initial cheek result, since the swelling actually artificially gave the patient the volume that they were missing, but slowly as the volume diminishes, they feel like they look the same again.  To reiterate, the mid-facelift never promised to add volume to the face, only to reposition the existing cheek fat pad, slightly upwards and slightly backwards.  If volume loss was the actual issue, then facial fat transfer (fat grafting) or some volume restoration with fillers would actually be the more appropriate procedure to try to restore the younger appearance.

Neck improvement not noticed?

The neck angle appears slightly sharper, but it was not bad to begin with.  We notice subtle sagging of the our own necks, more than anyone else would even notice.  Some people's necks are really hanging, so their before and after results, would be very dramatic.  Your anterior necklift made your chin more defined, like a chin implant might make a person's chin more defined, but rarely do we say that a stronger chin looks 10 years younger.  We might say that the profile looks stronger, or for a person with a fat neck, it can make them look thinner, but looking younger for a person without hanging neck skin rarely happens.


Summary
I think that you did not have much actual skin sagging to make a significant difference using traditional facial rejuvenation strategies (Excision of sagging skin.)  The newer strategies is to add volume in the right locations on the face to create uniform contours on the face, which will in turn make the face look less drawn, reduce diagonally downward shadows and create a more uniform single cheek surface which will in turn lean to a younger appearance.

Often times for my younger patients, I will use small volumes of filler to treat isolated areas such as the tear troughs and smile lines to make their eyes look less tired.  The diagonal tear trough lines and smile line which both angle downwards, can make the face look saggy.  Both lines are parallel and downwards which makes the face look tired from the two diagonal shadows forming these two lines.

"Choose between your face or your butt"
One characteristic of young people, is that they have thin bodies and full faces.  This perfect combination changes as we age.  As the French actress Catherine Deneuve said, "After a certain age, you have to choose between your fanny and your face."  This means that women's faces mirrors their bodies, so people with fat bodies and fat faces can look younger on their face, but their figure is not great.  If their bodies are fit, then their faces are are too thin. 

Back then there was no way to add volume back to a thin face, so you could only choose to be thinner or fatter.  Now, with fillers and fat grafting, you can have a leaner body, and make up the difference in facial volume with these procedures.

Sorry to be long winded, but this is what I typically need to discuss during the initial consultation to educate the patient and create realistic expectation, when they think that a facelift will make them look 10 years younger, yet I think they already look better than their actual age.

 

Best,

Dr. Yang

In your before photo you don't appear to have significant sagging and I don't think a facelift was a suitable option for you.I think a facelift was too aggressive for you.

         I think that your aging changes are more subtle, which means your genetics are good and you take care of yourself.  At this point, fat grafting to the tear troughs, cheeks, and marionette lines could improve and rejuvenate your face without having to undergo a major surgery again.

IUt is very imprortant to manage patiets expectation.  Also, the plastic surgeon needs to sell the product he can deliver.  Clearly, you are not happy.  Looking at you photos i would not advised a midfacelift but possible a facelift which would have addressed both more aggressively.  You would not have noted a major change because your facial aging is minimal.

 

 

 

When reviewing your photos I agree that your improvments are sublte. In My practice young patients like yourself see real changes to their facial features that they would like to correct. Unfortunately such subtle changes are often not possible to improve enough that its worth having surgery for. I do see some improvements in your after photos but they are sublte and I can understand your dissapointment

When I see a younger patient like yourself I am always cautius to take a step back and evaluate what it is the patient is really unhappy about. For the younger group it is either:

 

1) Real and early aging. Lifting procedures can help here

 

2) No real signs of aging - Counseling and clear demonstration of how a procedure cant help is the ethical thing to do

 

3) The third category is you - you work out and have volume loss in the face as well as some underlying facial skeletal deficiency or changes

 

The third category is so easy to miss. You really have to study a patients face to catch it.  You can still achieve those results but it would mean additional procedures. At the very least make sure you consult with someone who can really see what your seeing and understands your desires.