A nicely done facelift should not be noticeable. Other people should think the patient looks nice, and it should NEVER occur to others that the patient has had an operation. The paradox in my mind is that in order to accomplish that goal the surgeon needs to be MORE aggressive, not less. Why? Because in the old days the way a facelift was performed was to simply pull the skin back. But today, our understanding is that a youthful face is one that is full and has contours that an older face does not – and certainly that a pulled face can’t possibly have. Pulled skin only serves to obliterate fullness that would be appropriate in some places, and morph a face so that it looks operated.
A modern facelift is truly an exercise in sculpture with an understanding of what makes a person look youthful, as opposed to older. This has a lot to do with the atrophy of fat and soft tissues of the face that descend with time and need to be put back into the place they were located when the patient was younger. A youthful face should be full at the upper cheeks and more narrow below – like a triangle with one point facing down the center. As we age, the soft tissues of our mid face and cheek move a couple of centimeters down thereby creating more of a rectangle shaped face – or in the worst case scenario by inverting that triangle so that the widest part is at the bottom.
In order to make someone look better and younger, we need to reverse that trend by moving the soft tissues upwards, but not necessarily by pulling skin tighter. Today we understand that if you pull skin tighter, what you get is a pulled skin look, not a younger look.
Unfortunately, this means that when people want “just a little lift”, or when they go shopping for a “mini-lift” or “minimally invasive” procedure, they may get what they ask for, but not what they really want. Not if the point is to look better.
A well done facelift undermines the skin only because it is in the way of what we really want to gain access to and elevate, the fat and connective tissue that lies beneath the skin. Once we have that access, the soft tissues are elevated, liposuction of the neck may be performed, muscles can be tightened, and sometimes fat is actually added to the upper face. I recognize that this idea seems counterintuitive, but in keeping with my triangle analogy above, a full upper cheek is not a bad thing, it’s a youthful thing!
These operations take a lot longer than they used to, but the outcomes are far superior (in my opinion) than the old fashioned skin lift procedures of the 1970’s. Unfortunately, many plastic surgeons and so called “cosmetic surgeons” continue to do the procedures that way. I have many theories about why that is including the fact that it’s what people think they want. I know from my own experience that patients would much rather have a “mini facelift” that the real thing. It’s frustrating, and I try to combat it by making shorter incisions, but I still try to perform a pretty big operation through a relatively “small hole”. That’s why I have trademarked my own mini facelift operation the “Naturalift” SM. Still, for most people, I would much rather have the freedom to simply do the right thing. Patients who allow me to do that typically leave my office very happy that they did.