The Modern Face-lift: An Expert Interview With Sherrell J. Aston, MD

Pippa Wysong


December 22, 2009

Editor's Note:

Face-lifts are popular procedures, and recent years have seen changes in the approach to this surgery and what surgeons and patients alike should expect. Medscape's Pippa Wysong spoke to Sherrell J. Aston, MD, who offers his thoughts on the state of the art in face-lifts. Dr. Aston is Director and Chairman of the Department of Plastic Surgery at Manhattan Eye, Ear and Throat Hospital (MEETH) in New York, NY. He is also a Professor of Surgery at the New York University School of Medicine, New York, NY, and is certified by the American Board of Surgery (ABS) and the American Board of Plastic Surgery (ABPS).

Medscape: Can you start by giving Medscape readers an overview of the modern concept of a face-lift?

Dr. Aston: Today's face-lift is a highly individualized procedure designed for each patient. Face-lift involves repositioning the underlying foundation and restoring tissues to their original position, without stretching of the overlying skin. We address the muscles in the neck and along the jawline, and the fat and fascia in the cheek.

We are concerned with fat and/or tissue redistribution, and fat atrophy. Most patients need tissue repositioning to help create the contours of the face that we're trying to achieve. Some people lose facial fat volume as part of the aging process, but people in their early 40s and 50s usually need volume redistribution rather than volume addition. When people have loss of tissue volume in the face, we will add fat, which is taken from another part of the body.

Medscape: Some people associate face-lifts with a "face-lift look," or windblown appearance. What causes that?

Dr. Aston: Today, that appearance can be avoided. The stretched look of earlier face-lifts was a result of the skin being pulled tight. Tightening or repositioning of the underlying foundation contours the face, without the need for stretching the skin. Stretching facial skin does not give a face-lift result that's considered appropriate anymore. Having said that, there are surgeons who do just tighten the skin, which can lead to that windblown look.

Medscape: Should anything be done with the hairline?

Dr. Aston: The hairline in the front and back and the sideburn area should be left in their normal positions. If there is an alteration in the hairline, it really shows when a woman wears her hair up in a ponytail. Today, there should be no alteration of the hairline, and scars behind the ear should not be obvious.

Medscape: Which parts of the face are involved in face-lifts?

Dr. Aston: A face-lift means correcting the aging process from the corner of the eyes down to the collarbone. That includes the midface, cheeks, jawline, and the neck. A forehead/eyebrow lift takes care of sagging from the corner of the eye upward. Not all face-lift patients need a forehead lift. In some people the eyebrows maintain an adequate position without anything being done to them.

Medscape: Is there such a thing as a "minilift"?

Dr. Aston: A minilift is a term that has been coined by the media. What is usually meant by this term is a procedure that's intended to correct the cheek, midface, and jawline with a small incision. The so-called minilift does not do much to help with laxity and sagging skin in the neck.

Plastic surgeons today perform, for some patients, a "short-scar" face-lift in which incisions begin in the temporal area above the ear, follow the contour of the cartilage of the ear, and then curve around the earlobe. A full face-lift incision continues from the earlobe, up behind the ear, and then goes into the hair in a way that is not seen. A short-scar face-lift works for people who do not have significant sagging in the neck. Through this short incision, we perform very sophisticated work on the underlying foundation.

Medscape: Noninvasive and minimally invasive procedures. How effective are they?

Dr. Aston: There is currently a lot of discussion about noninvasive and minimally invasive face-lift procedures, but the results obtained with those kinds of procedures do not last very long.

Medscape: What are some examples of minimally or noninvasive procedures?

Dr. Aston: Noninvasive procedures are primarily injectable procedures, in which doctors put filler substances or fat in the face to try to lift it. Recently, I saw a fashion magazine article discussing lifting the face with onabotulinumtoxinA (Botox®) and fillers. That can't happen. You can add volume to the face with fillers, and there are people who benefit from fillers. OnabotulinumtoxinA can stop crows' feet and frown lines between the eyebrows, but onabotulinumtoxinA and fillers cannot actually lift the face.

Some fillers are absorbable and disappear after 3 or 4 months. There are intermediate fillers that last longer, and so-called permanent fillers. Generally, the permanent fillers have a high degree of complications: cysts; bumps; and irregularities. There are reports in the literature describing significant problems with permanent fillers.

Medscape: How long does it take for patients to return to normal activities after getting a face-lift?

Dr. Aston: Most people can return to full social and athletic activities 3 weeks after surgery, although there is still some swelling in the tissue.

Medscape: Is it better to do face-lifts on patients when they are young?

Dr. Aston: Patients should not have a face-lift until they have changes in the face that are a result of the aging process that they wish to have corrected. People observe changes in their faces differently. Some people see the early changes -- a little bit of jowl or a little bit of sagging in the midface that troubles them a great deal. That is why we do a lot of face-lifts on patients in their mid- to late 40s. There are people in their early 50s who don't need a face-lift; we send them home.

Age is not the determining factor for when one should have a face-lift. The primary factors linked to the aging process are genetics; lifestyle, such as a lot of sun exposure; weight gain or loss; and smoking. Those 4 things affect appearance and changes associated with aging in most people.

However, it is better to have a face-lift when the tissue of the individual is as good as it can be. The better the material that you have to work with, the better that it is going to look, and the longer that it is going to last. Ideally, you want to do the work when the collagen in the skin has not broken down much.

Medscape: How long does a face-lift last?

Dr. Aston: Once you have a face-lift, you will look better than nature intended for the rest of your life. Mind you, 10 years after surgery you're not going to look as good as 4 or 5 years after surgery because aging does continue, but you will look better than if you did not have the procedure.

Medscape: Can a face-lift ever fall?

Dr. Aston: Many patients ask that. No; a true face-lift cannot fall. The changes that you make by repositioning the underlying foundation and tightening the deeper-layer tissues in the face are secure.

Medscape: What about reports that some face-lifts do fall?

Dr. Aston: There have been some attempts to lift the face by placing individual sutures in the tissue in the face -- single loops, usually under local anesthesia. If you attempt to lift the face with 1, 2, or 3 sutures and a suture breaks, then obviously the tissue will fall down. It's well known that threadlift faces return almost completely to their original appearance in a very short period of time.

Medscape: What is a "lunchtime face-lift"?

Dr. Aston: The meaning varies, but it's been described as a procedure done with local anesthesia in the doctor's office during one's lunch break. There are nonphysicians who do some of these procedures with very bad results. It's a so-called face-lift. Usually there are little undermining and trimming of the skin. Plastic surgeons around the world agree that these quickie procedures with local anesthesia that are done in 45 minutes to an hour do not give the results that most patients want.

Medscape: What kind of anesthesia is required for face-lifts?

Dr. Aston: Face-lifts can be done with local anesthesia and intravenous (IV) sedation or general anesthesia, and both are effective. The extent of the procedure often determines which kind of anesthesia should be used. Some people undergo face-lifts that are much more involved than others, and what we do to the underlying foundation varies. Modern general anesthetics are short acting; patients can be awake within a few minutes of the procedure being completed.

Every patient gets local anesthesia injected into the tissue regardless of whether they are having general anesthesia or IV sedation. With IV sedation, you need to give the local anesthetic to numb the tissue. The type of anesthesia used depends on the surgeon, the planned procedure, the facility where there surgery is performed, and the desires of the patient.

Medscape: Stem cells are a hot topic in medicine. Do they have a role in face-lifts?

Dr. Aston: Right now, there is no such thing as a stem cell face-lift, although the hope is that stem cells can help rejuvenate tissues and fill in volume. Stem cells are obtained with liposuction. We frequently inject fat into different areas of the face to return fat that is atrophied, or to improve the contour of the jawline, or over the cheekbones to improve contour. Stem cells show promise for the future, and I anticipate that we'll do more with stem cells as part of facial rejuvenation in the years to come.

Medscape: Thanks very much for talking to Medscape today.