In the seventies, Phyllis Diller defied gravity with her famous facelifts, exposing the common man to the world of plastic surgery. In reality, facelifts began much earlier at the turn of the century, when plastic surgeons would take out a small amount of skin from in front of the ears of the patients to get a more youthful appearance. The procedures were simple but did not demonstrate much longevity, as a result more complex techniques were created (which involved pulling the skin as well as the underlying muscles and fat) to provide more natural and durable results. But, as with everything else in life, history seems to repeat itself. As I cull through New York magazine, W magazine, and Allure, I often come across ads or descriptions for weekend facelifts with no bruising. What is this weekend facelift , you may be wondering? Well, this is a marketing tool for those offering a procedure quite similar to the ones offered by our long-forgotten colleagues, so many years ago. How can you understand what you are getting, when you go to a physician to rejuvenate your face?

First, lets understand the anatomy of the face, as well as the changes that occur with aging. Your face is like a building, an external facade is supported by an internal foundation and framework. Just like the buildings facade, your skin will be worn-out and weather beaten with age. But this is only half of the story, the internal foundation/framework of your face is a structure that plastic surgeons call the SubMusculoAponeurotic System - SMAS for short. The SMAS is a sheet of muscle and connective tissue that supports the facade/skin. It is what pulls your skin to create facial animation, as well as facial wrinkles. As time goes by, the SMAS will sag just like the foundation of a building. There is one anatomical difference between your face and that building I am describing – between the skin and the SMAS is a layer of fat that helps to soften your facial features and adds to your facial contour.

As you age and your skin is exposed to environmental factors (sun, cigarettes, weather), your skin is becoming thinner and loosing its elasticity. These skin changes, combined with the damage from constant facial animation is what results in the fine lines and wrinkles around your face. The deeper grooves and furrows around your mouth and eyes are the result of changes in the SMAS and fatty layers of the skin. Many patients come to me after loosing a large amount of weight, and although young, they present with a gaunt, haggard look as a result of loss of the fatty layer of tissue. SOME FAT IN YOUR FACE IS GOOD!

Now that we have an idea about the anatomy, lets lay down some basic rules of plastic surgery and facelifts.

1.  Any procedures that we, plastic surgeons, perform upon you, must look natural when we are done! This is the most overused cliché in the business, but what does it really mean? And more importantly how can we accomplish this? We all age the same way- some faster, some slower, but gravity and atrophy of your facial tissues happens in all of us. With this fact in mind, we must return the structures to their proper positions on your face. The most important example of this is the surgical treatment of the SMAS. Gravity and facial animation have conspired to force the SMAS layer to sag toward the floor and slightly in toward your mouth. It is this change in the SMAS that contributes most to the marionette line at the corners of your mouth. You can see the result of aging by taking a simple test – look in the mirror, note the border of your jawline, the marionette lines and the position of your cheek. Then give a big smile and place a finger on the highest point on your cheek to hold it in its new position and stop smiling. If you see a dramatic change in the jawline, marionette lines or cheek fullness, you are likely suffering from sagging of the SMAS. Now older surgical treatments for the SMAS involved pulling it toward your ears. Try this on yourself – pull your cheeks out toward your ears, and most likely you will see that wind tunnel look. That’s a no-no. In order to get a more natural restoration, it seems logical that the SMAS must be pulled in the same direction as your smile. Further, this lift must extend across your face, cheek and under the eyelid. This is the essence of the VERTICAL lift. I personally think that this is the only technique for anyone with significant signs of aging.
    
2. The skin will go wherever the underlying structures move it. For instance, if you rearrange the SMAS, the majority of the marionette lines will go away. This is true, but because of age-related changes, your skin will still require some help in removing any excess skin. This is where many physicians overdo it. The tighter you pull the skin, the more tension will be transmitted to the structures to which it is anchored. This distortion can result in wider scars, loss of skin with resultant scarring, as well as loss of hair both in front and behind your ears. The pulling on the ear can result in a distortion that plastic surgeons call “pixie-ear”. This is when the earlobe is pulled down and forward on the face. The little notch between the earlobe and the face is lost, and the scars are typically easier to see as well. This pulling can also result in shinier, glass-like skin, and enhance the windblown look.
   
   It is for these reasons that removal of any excess skin, must be done in a careful manner that does not apply too much tension to the skin or the surrounding structures.
    
3. Although the aging process is the same in all people, no two people age the same way. Be it genetics or environmental factors, everyone ages differently and will present to their plastic surgeon with different concerns. For some patients, it may be sagging of a single component of the face, for instance only the neck or midface. For others, their concerns may involve all facial structures. It is for this reason that facelifts must be tailored to each patient. Many physicians tag their facelifts with a specific moniker i.e. midface lift, platysmaplasty, neck lift. But the fact remains that regardless of the degree of sagging, the SMAS component should be VERTICAL, and the skin resection should be under moderate tension.
    
4. There has been much discussion about short-scar or limited scar facelifts. What is this all about? Once again, even though the key to a natural facelift is the rearrangement of the SMAS layer, excess skin needs to be removed. For some patients, the amount of excess skin is small. For those lucky patients, excess skin can be removed by making an incision around the ear, without the scar behind the ear. This is the Short scar facelift. For the remainder of patients, especially with excess skin in the neck, the excision of skin will require that the incision extend behind the ear and across to the hair on the back of the scalp. It is the scar that extends from the ear to the scalp that is most readily seen when you pull your hair back in a ponytail. In order to minimize this scar, I believe in placing the scar at the top of the ear so that it is less visible.
    
5. Some loss of fat (fat atrophy) in the face cannot be corrected by the vertical lift or skin tightening component of a facelift. The loss of fat can be corrected as a stand alone procedure or in conjunction with the face lift by transfer of fat from some other part of the body to the face. This technique is growing in acceptance, and has been highlighted often in the lay press as well as in plastic surgery journals. I have been a proponent of fat transfer for 10 years and have recently been awarded patents for my fat transfer techniques. My techniques for fat transfer are currently being developed by Angiotech Corporation in conjunction with Lipose Corporation and will be available to the public in January 2009.
    
6. Facelifts will not correct the fine lines and wrinkles of the face. I like to equate the facelift to a tailor removing excess material on a baggy pair of pants. The finer wrinkles still need to be ironed out. This can be done by chemical peels, dermabrasion or lasers resurfacing. Many of these procedures require daily maintenance. Although your plastic surgeon may be helpful with these treatments, quite often your cosmetic dermatologist is best at prescribing the correct skin maintenance formula for you. In an effort to create seemless care in my own practice, I have created a system of skincare, diet, exercise and surgery to treat the entire patient. Many physicians are focused on just getting the surgery performed without addressing the entire face. I have brought together the best nutritionists and aestheticians to create this overall skin program. It is this program that will be presented in my new book “ Beauty Bootcamp” due out in December 2008.