The Howard Lift: A Modern Facelift

Self-esteem, or more importantly, the lack of self-esteem is an expected occurrence in a society that pays a high premium on the physical attributes of the body and face. The premium that is placed on good looks is not debatable, it has been a well -documented fact for almost a century. The proof is found in the amount of money that is spent every year on cosmetics, weight loss schemes, hair care products, scar and wrinkle creams and the myriad of other commodities used to maintain an attractive, healthy body and a youthful face and neck.

The premium society exacts on us can affordably be paid with a healthy exercise program, a reasonable diet, a good skincare program including a sunblock, staying away from nicotine and in some cases, appropriately timed and well thought out plastic surgery.

The science behind the latest lotions and potions to attack facial wrinkles is a multi-billion-dollar industry. These products, all of which work if actually used on the face and not allowed to languish on the bathroom counter. They are a good investment realizing the limitations of what can be achieved in an aging face only using products applied to the skin. Improved texture-yes, fewer discolorations-yes, fewer fine wrinkles-yes, improved coloring-somewhat, improved stretch marks- not likely and tighter, lifted face and neck skin-never.

facelift

Dr. Paul Howard is board certified in plastic surgery and is one of the top facelift surgeons of the South. Dr. Howard also offers mini face lift, neck lift, eyelid surgery, rhinoplasty, brow lift, cheek augmentation, ear pinning surgery, and fat grafting to the face. Schedule your facelift consultation with Dr. Howard today 205-871-3361.

Once the effects of gravity are in full effect, it is the rare person who can reverse the sagging without a surgical procedure. The timing of that procedure will determine how much surgery is necessary; the earlier in the aging process, the less surgery.

As a general rule, when the lower eyelid dark crescents reveal themselves, the nasolabial folds deepen, marionette lines form between the corner of the mouth and the chin-jaw area and the once tight jawline is interrupted by “bubbles” of fat that represent cheek fat and skin sliding down toward the neck, then anti-gravity, lifting surgical procedures are necessary.

Facelifts, especially among baby boomers, have long been thought to be prohibitively expensive and thus available only to the few. Thus, plastic surgery is summarily dismissed as family and personal issues take precedence. Self-sacrifice becomes a way of life and self-esteem suffers, becoming very difficult to retrieve even with a successful diet and a perfect skincare regiment. The entire mass of skin and fat tissue from the lower lids to the jawline must be lifted, separately, which is the basis of the mid-face portion of the modern facelift.

What is a modern facelift? Modern is a deceptively simple word with many meanings. A modern facelift is new, fresh and up-to-date as well as novel and innovative. To create a modern facelift sounds complicated but is deceptively simple for the plastic surgeon with an open mind and open ears. Two of my mentors, Dr. John Kirklin and Dr. Ralph Millard, coming from different backgrounds and directions (cardiac surgery and plastic surgery), both taught that if you listen carefully, the patient will tell you what’s wrong and what they want from you as a doctor.

The modern facelift evolved from listening to patients with a completely open mind and blessed with a full toolbox of plastic surgery principles from which to choose and a creative disposition finding no limits to what is possible.

A background in chemistry and anatomy has helped base the modern facelift securely in the realm of medical science; just as Dr. Kirklin would have demanded and Dr. Millard has written in Principalization of Plastic Surgery.

The first patient requests for something new in facelift surgery was the most challenging and time consuming but had not been addressed in the plastic surgery literature in recent history. Not a single person wanted to undergo general anesthesia to have a facelift, regardless of who administered the anesthesia. Was it perceived danger, expense or the fact that general anesthesia requires a large volume of strong drugs that make people sick? From the patient’s viewpoint, it was all the above. From the plastic surgeon’s viewpoint, it is the wild fluctuations in blood pressure these strong drugs cause as well as bruising, swelling, hematomas and a longer recovery that occur with all general anesthetic protocols.

My unique use of three different and pharmacologically distinct local anesthetics was devised and in use today. The combination of local anesthetics burn less when injected, work quicker to make the face and neck numb and last longer reducing postoperative pain- all desirable traits. Each of the local anesthetics is augmented by epinephrine which helps to keep blood loss to a minimum.

Oral sedation was chosen for the smoothness of onset, the slower metabolism of the drugs and the minimal effect on blood pressure greatly reducing the risk of hematoma. The oral sedation can be adjusted as necessary during the procedure per the tolerances of the individual patient and the amount of sedation desired.

Patients requested for the modern operation to offer an equivalent result to other facelifts done under general anesthesia with incisions as short as possible. Initially, the short incisions sounded like a deal breaker but upon further consideration there are certain maneuvers concerned with the order and type of suturing that can shorten the incisions behind the ear. It was discovered that certain incisions in front of the ear served no purpose in making the results better and were dropped. While not exactly a “short scar” facelift, the modern facelift is definitely a “shorter scar” version of our previous facelifts.

All patients requested less swelling with less downtime and a quicker return to work and normal activities. Everyone wants this and all plastic surgeons try to accommodate this request with very little success unless they adulterate or simplify the facelift procedure to be less invasive compromising the result. We realized almost immediately that the swelling was much less about the operation as performed but was mostly a product of general anesthesia, regardless of the agents used to put the patient asleep or anesthesia provider-nurse or doctor. Changing from general to local anesthesia reduced our postoperative swelling, all other factors being equal, by at least 75%.

Even with improvements in swelling and down time with local anesthesia, more was needed as this was one of the more important requests. It was almost as important as cost. It was clear that the more so-called dead space that existed during the dissection of the face, the more hematomas, both large and small, and resultant swelling and bruising occurred. After the multi-vector, tightening of the SMAS, we began to use what is called progressive- tension- suturing which allows for maximal skin tightening with minimal dead space, minimal bruising and minimal tension on the skin closure helping reduce unwanted scarring and downtime.

This suturing technique may sound too good to be true but it is well known, but not for facelift surgery. The technique also allowed us to decrease the size of drains and the length of time they are necessary. Our drains are hand-made from 21-gauge butterfly needles and are removed in less than twenty-four hours as the dead space to be drained is minimal. These “micro-drains” require only hemovac tubes as the suction and drainage receptacle usually draining no more than a teaspoon of blood per side.

It is common for patients to inquire about the facelift and its effect on the mouth and perioral area. The answer is that the facelift, by itself, does not help rejuvenate the mouth. This was about the time fat grafting and Dr. Sidney Coleman burst on the plastic surgery scene. Using his new fat processing techniques, we were able to use a person’s own abdominal fat (or any fat for that matter) and inject the fat into the wrinkles and areas around the lips to rejuvenate, thinner, aging lips –permanently.

Although not a specific patient request, adding contour to the effacement (flattening) caused by tightening and elevation of the cheeks was a constant struggle. Fat injections in the cheek area answered a lot of plastic surgeon’s prayers. We now could offer rejuvenation in a permanent fashion to the cheeks, lips, peri-oral area, nasolabial folds and marionette lines with fat injections. Unlike many other modalities, fat injections can be revised easily and are considered permanent. Most patients request more fat rather than less.

The lower eyelids and their contribution to the mid-face aging process was all that was left to tackle even though it rarely was a request except by the most discerning of patients. The lowering of the thin eyelid skin from the effects of gravity onto the upper cheek with its intendant dark crescent circles and tear trough deformity could not be left unaddressed. This required lower eyelid blepharoplasty, cheek-lid blending, fat manipulation and sometimes fat grafting in the tear trough. This is most effective when done simultaneously with the modern facelift.

Today, our recommended surgical procedures, when indicated, for facial rejuvenation all fall under the rubric The Modern Facelift:

 Short scar facelift incisions with multivector SMAS plication, intraoperative open neck liposuction with jawline refinement, progressive tension suturing, micro-drains, fat injections to the cheeks, peri-oral, nasolabial folds, marionette lines, tear troughs and lower blepharoplasty with fat manipulation, septal closure, cheek-lid blending and temporary lower lid suture tightening. Anesthesia is multi-agent local anesthesia with oral sedation augmented with IM Toradol and clonidine to blunt the systemic effects of epinephrine. The price is under $10,000 all inclusive.

Realizing our increased life expectancy, more people question how long the modern facelift will last. This is what Dr. Millard called a crystal ball question. He had a crystal ball on his desk that he referred to the patients accentuating the complexity of predicting the unknown. He would then explain that the answer depended on you, the patient, more than the surgery performed. He also would explain that aging is a continuous, life long process and any further surgical procedure may depend on the patient’s tolerance for imperfection rather than an identifiable time frame.

When pressed he would usually say five years which seemed to please most people as a reasonable number. I tend to offer three years since my tolerance for imperfection is less than most and we have developed a number of inexpensive “tuck-up” procedures that address the aging issues that tend to re-occur more quickly than other aspects of normal aging regardless of the type and extent of the plastic surgery performed.

All requests by patients for further surgical refinements are encouraged will be considered so that the modern facelift remains “modern.” The last provision of the modern facelift is to continue listening to patients and follow their lead to avoid, at all costs, the “rut of routine.”

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Massaging After Facelift

Facial massage is a longstanding and proven method to aide in the healing process after facelift surgery. Surgeons instruct their post-operative patients to gently massage the facial skin with two goals in mind: smoothing of subcutaneous lumps, bumps and thickness from early swelling. Second, massaging away from incisions, especially around the eyes, is used as a “lymphatic drainage procedure” to decrease lymphatic stasis when incisions block the normal direction of lymphatic drainage.

It is also important for patients to massage the incisions around the ear when they are in the phase of scar deposition as the incisions begin to thicken at about 6 weeks. Massage as a form of touching helps during the first 6 months when many patients complain of hypersensitivity and shooting pains due to the normal process of nerve regeneration. Prolonged numbness can be disconcerting to some; massaging helps the psyche integrate the numb areas back into the normal body sensations so that the numb areas cease to feel separate from the remainder of the face.

Massage and wound care also engage the patient in their own recovery from surgery, giving them tasks that will make them take ownership of their recovery.

For the last 10 years, we have been doing extensive fat grafting with facelift procedures to address the effacement or flattening that occurs with all skin tightening procedures, especially in the cheek area. We also offer fat grafting in the lips, nasolabial and peri-oral region as there is very little that a standard facelift does to improve the peri-oral loss of fat with subsequent wrinkling. Attempting to tighten the cheeks enough to remove or affect the deepening nasolabial folds will not last and usually distorts the face in ways that are hard to camouflage. It should be an aphorism that you cannot lift the corner of the mouth by pulling of the lower face skin.

For the first 2 weeks post-operatively, the patient is asked NOT to massage at all so as not to affect the fat grafts. Usually, we extend the “no massage” time to 6 weeks unless a reason to massage the fat grafts arises—this is a rare occurrence. Massaging the fat grafts in the face prematurely will cause the grafts to dissolve away. It is also important to note that massaging the face while bruising is still present can cause the face to bruise and swell more.

We use standard marking pens to map the areas for fat grafting. Try as we may, it is difficult to remove these marks even with alcohol without having to rub hard enough to move the fat grafts once accurately injected. By the time that we start our staged suture removal, the marks are easier to remove with much less disruption of the fat grafts. Under no circumstances do we tell the patients to try and remove the markings. Patients are also instructed NOT to scrub their faces when washing, but gently pat the face to clean. Washing the face can mimic the massage-like pressure that we are trying to avoid during the healing process.

Visit Dr. Paul Howard’s Facelift Website

Endotracheal General Anesthesia & Facelift Surgery

Plastic surgeons have long known facelift surgery performed under general anesthesia requires a longer recovery due to the side effects from the general anesthesia administered during surgery. Addressing post-surgical facelift swelling has always been an important factor to most facelift surgeons. However, facelift surgeons have never figured out how to reduce it when the procedure is performed under general anesthesia. The face swells in recovery when the patient’s blood pressure goes up.

facelift swelling

Alabama facelift surgeon Dr. Paul Howard is board certified and is one of the top facelift surgeons of the South. Dr. Howard also offers mini face lift, neck lift, eyelid surgery, rhinoplasty, brow lift, cheek augmentation, ear pinning surgery, and fat grafting to the face. Schedule your facelift consultation with Dr. Howard today 205-871-3361.

General anesthesia is a state of reversible coma induced by intravenous drugs and inhalation anesthetic agents. The effects of the drugs and inhalation agents cause the entire body to become insensate, cannot feel pain, and have both amnesia and what is called, retrograde amnesia, so that the patient has no recollection of the surgical events or the preceding days in some instances.

While under the effects of the anesthetic drugs, the CRNA (Certified Registered Nurse Anesthetist) under the supervision of the MD Anesthesiologist, must control all bodily functions, mainly breathing and oxygenation, blood pressure and patient awareness. About one in twenty thousand patients experience awareness and pain even while under the effect of the anesthetic agents.

Very few patients die under general anesthesia (one in three hundred thousand). They are usually the highest risk patients who are ill and at the extreme of the age groups: either very young or very old. People “allergic” to an anesthetic agent or have a congenital disease that effects the metabolism of certain drugs is even rarer yet. Malignant Hyperthermia Syndrome is a reaction to certain anesthetic agents and is also very rare.

The anesthetic agents have improved incrementally over the last thirty years but have not improved the incidence of minor complications such as memory impairment (post-operative delirium), prolonged sleepiness, inability to urinate, sore throat, muscle aches, nausea and vomiting. Another complication which could be considered minor is swelling after head and neck surgical procedures, and sometimes whole-body edema.

Swelling is considered more of an expected sequella than a complication because it happens uniformly, especially in patients over fifty and those with high blood pressure.

The practice of administering anesthesia has changed dramatically over the last three decades. It used to be the convention, and still is in hospitals, for the MD Anesthesiologist to be present for the induction of anesthesia, including the securing of the airway, and for the emergence from and reversal of the anesthetic agents. It was assumed that these are the most dangerous parts of the “anesthetic flight”: likened to the take-off and landing of an airplane.

Now the take-off and landing must be safer as many office operating facilities do not require the presence of an MDA for general anesthetic procedures. This is true for virtually all the office-based operating facilities that provide cosmetic plastic surgery delivered under general anesthesia.

Alabama State Board of Medical Examiners and the Alabama State Board of Health-Division of Licensure and Certification require registration with the state and the practice of general anesthesia to be performed by competent licensed personnel working under a physician certified and licensed in the State of Alabama. There is no actual requirement for a CRNA or an MDA to preside over general office-based surgical anesthesia.

Fifteen years ago, unhappy with the way general anesthesia was being delivered without the presence of an anesthesiologist, we began working on the techniques used today in our practice to perform facial plastic surgery under specialized local anesthesia with oral sedation.

Two things became clear immediately: The patients were happier not suffering from the effects of general anesthesia and they had very little facial swelling and bruising causing their recovery to be much shorter and more comfortable. A second and equally important improvement was that the procedures are done in the office without the high OR and anesthesia fees charged for general anesthesia.

Local anesthesia is least likely to cause side effects. Local anesthesia with sedation requires much less of the strong medicines that shock the system and therefore is always preferred for older patients who may take a number of medicines that would interact with general anesthetic agents and who would take longer to emerge from general anesthesia sometimes requiring professional care for a day or two after surgery.

Younger patients, who usually have jobs and family commitments, simply prefer the cost and much shorter down times for return to normal activities.

Some discerning shoppers ask what kind of facelift can be done under local anesthesia, usually having been told only minor or skin-only facelifts can be done under local. The fact is that I do the same facelift I used to do when I used general anesthesia. In fact, the facelift I now do under local is much more intricate and modern than before as shown in our facelift gallery of photos at Continue reading

First Facelift

The term “first facelift” is showing up more and more frequently on Google searches these days. Although what the term means is intuitive, it is not a medical term that plastic surgeons frequently use. Medically speaking, the proper term is primary facelift but you can’t argue with a Google search.

Not particularly in tune with the “mind” of the internet, my assumption is that a first facelift is considered intrinsically different than secondary (second) or tertiary (third) facelifts. While there is some truth to the fact that first facelifts are performed differently than the others, there is no truth to the thought that a plastic surgeon can be an expert at firsts and not seconds or thirds. Although I am unaware of any statistics to the effect that at least half of the patients who have a first facelift before the age of 55, will also have at least a second as well as any number of touch-up procedures.

The importance of first facelifts is that any plastic surgical procedure including facelifts, eyelids, noses as well as cleft lip and palate achieve the best results the first time they are done;

Thus, the term first facelift. A good first facelift can lead to an even better second and even third. I truly was not aware that “first facelifts” were something people look for, or Google for, but I learn something about Google every day. With that said, I’m probably the best first face lifter around these parts.

Read more about top facelift surgeon Dr. Paul Howard in Birmingham, Alabama.

Facelift Swelling

The subject of facelift swelling is one that has driven a large part of my facelift procedures and practice over the last decade. It’s an easy subject to get your mind around because no one likes it, your reputation can depend on how much of it your patients have, once created it is hard to get rid of and regardless of how well patients are prepared for their surgery and the incumbent, yet evil swelling, they still feel like something is wrong when they have it.

For years all plastic surgeons thought that the swelling after a facelift under general anesthesia was a necessary evil and therefore spent little time trying to figure out what causes it and how to prevent it.

After years of failing to prevent swelling by doing small things that never worked like corticosteroids, drains, dressings, Vitamin K and dozens of other special medications and emollients. Being unwilling to accept failure, we started to question the basic tenets of doing a facelift. The most obvious and successful change was to stop doing general anesthesia for all facelifts. This was met with skepticism by many plastic surgeons that could not imagine operating on a patient for the hours necessary and have to deal with the anesthetic also. It was thought that the patients, usually a bit older than our average patient, wouldn’t or couldn’t tolerate the procedure “awake.” Concerns about the volume of anesthetic needed as it relates to toxicity and whether or not the entire face, neck and eyes could be rendered numb enough for surgery. All of these concerns quickly fell to the wayside; patients hated general anesthesia and the ability to anesthetize the face only required relearning all of the pharmacology of local anesthetics we learned in medical school. The only remaining question was whether or not the plastic surgeon (me) would exhibit patience in dealing with the conscious patient and subjugate the ease, comfort and lack of responsibility inherit in general anesthesia to the need and desire of the patient to have little or no swelling and a simpler, faster return to normal. The answer to the question for me was –absolutely.

From that point forward, we worked out the details of the sedation, the local anesthetic agents, monitoring and significantly changed the operation to accommodate the wishes of the patient which were primarily based on having minimal to no postoperative swelling. The accumulation of the techniques of anesthesia and its agents, sedation, operating room ambiance and the ability to perform a first-class and lasting facelift under these circumstances has led to what we call the Howard Lift procedures which include rejuvenating procedures for not only the face but the eyes, forehead, nose and neck. The Howard Lift is not necessarily a procedure but a new way to do facial procedures concentrating on minimal swelling leading to minimal downtime and a first-class, longstanding natural result.

Read more about facelift recovery.

Lifestyle Lift® FAQS & Fiction by Paul Howard, MD

Facelift Scar Comparison

Facelift Scar Comparison

How is the LSL better than other Facelifts?

The LSL is not a breakthrough procedure nor are any of the LSL techniques new in any way.  THE LSL is first and foremost a marketing company that hires physicians to do a version of the LSL.  In fact, their surgeons are not even required to do the LSL procedure.

How is the LSL different than other procedures?

The LSL is a version of the short-scar facelift procedure that was first described by others.  Included in the procedure is a so called SMAS plication which has been around for 20+ years and is one of many ways to tighten the deeper layers of the face.  The only possible advance the LSL offers is that it is performed under local anesthesia which has been available since the 1920’s.

Is the Lifestyle Lift® Cheaper?

The cost of the LSL procedure is different depending on where in the country one lives.  The fact is that the actual cost of the LSL is roughly equivalent to what most plastic surgeons charge especially when you consider the “fine print” procedures that are required on almost all patients.

Is there a difference in recovery from the LSL?

The rapidity of recovery depends more on the individual surgeon than the exact procedure performed.  Patient selection is probably the most important adjunct in recovery time and LSL patient selection is initially done by “consultationists” without even a medical degree.

Will I Bruise More?

One of the ways a plastic surgeon can decrease bruising is due to the technique chosen and in many cases whether or not the surgeon uses drains expeditiously. Part of the LSL marketing scheme brags about not using drains as if not using drains when indicated is somehow better.

Are the LSL Scars Better?

The short facelift scar pattern is pretty much the same for everyone.  The execution of the scar varies from surgeon to surgeon, but the scars don’t seem to do as well nor are they properly positioned in many of the LSL procedures (my personal experience). It is also easier to obtain good scarring with frequent follow-up and in-depth patient instruction which is not typical in practices that are volume driven like the LSL.

What is the Most Important Decision when Choosing a Facelift?

Most people believe that the most important aspect of achieving good results in facelift surgery is the choice of SURGEON and not the procedure or any number of other considerations.  It is interesting that the one thing that the LSL marketing scheme minimizes is the surgeon; such that the surgeon is the last person one meets in the process.  The consultationists and the people who collect the money seem much more important and meet the prospective patient well before the surgeon is chosen for you.

Read more about top facelift surgeon Dr. Paul Howard Birmingham, Alabama.

Call today to schedule your Facelift Consultation with Dr. Paul Howard

205-877-PAUL

Lifestyle Lift – The Small Print by Paul Howard, MD

It’s clear that the Liftstyle Lift ® (LSL) brand is a marketing juggernaut.  Cable, non-cable, internet, Debbie Boone is everywhere “lighting up my life.”  Their TV testimonials are uplifting by simply showing regular people with that blank stare pre-operatively and that smiling, happy visage after their LSL.  It is easy to see why there are so many lawsuits accusing this marketing company of being false and deceptive in their TV ads.  One of the oldest plastic surgery tricks to improve facial surgery results is to take the post-op photos of the patient smiling; smiling is the first and best natural rejuvenator lifting the sagging face without a single stitch.  Giving in to the “marketing police,” the LSL folks do add a few sentences in fine print at the bottom of the TV ad admitting that each patient had a litany of other procedures in addition to their LSL.  It is the other procedures in the small print that actually determine the quality of the result and are the subject of this article.

Over the time that I’ve been in practice, two things have actually vastly improved my facelifting results.  Recently, it has been the use of local anesthesia with sedation rather than general anesthesia.  The second improvement has been improvements in the neck contouring and the blending of the lower eyelid with the cheek as an adjunct to our version of the mid-face lift.  In the LSL marketing parlance these are called “neck firming” and “eyelid firming” procedures that really make a difference in the quality of the result, especially when the patient is not smiling.

Eyelid blending has always been a problem except in the extreme cases of facelift procedures done at deeper levels that allow for more tension on the SMAS and facial muscles with their fascia.  These operations are not an option for many people who cannot take 3-6 weeks out of their busy schedules to be swollen.

One of the integral causes of the dark circles and lower lid “crescent,” in addition to the weakening of the tissues that are meant to contain the lower lid fat allowing the fat pockets to bulge outward, is the dropping of the thin lower eyelid skin down onto the cheek accentuating the junction between the thin lid skin and the thicker cheek skin.  Lifting the midface necessarily raises the lid-cheek junction upward creating excess lid skin.  This is addressed surgically by making a lower lid incision through the muscle so that the lid-cheek junction at the orbital bone can be addressed directly.  Blending of the lid and cheek is done at the same time that the bulging fat is partially removed or simply cauterized.  The remaining tissue (septum) is cauterized to thicken it so that it can then be bolstered by dissolvable sutures.  The extra lid skin created is conservatively excised and a temporary muscle tightening stitch is placed to keep the lower lid from pulling down during the early phase of wound healing.

This description of surgical lid-cheek blending may seem highly technical to some.  For those less interested in details, the net result of the operation is depicted in the photos (note that the patient is not smiling, although she wishes she could!)

Eyelid Surgery Before & After by Dr. Paul S. Howard

Eyelid Surgery Before & After by Dr. Paul S. Howard

The basis of a good result in the lower eyelids as well as the neck is the performance of a proper mid-face lift with an aggressive approach to the jawline and jowls.  The LSL, when done well, can provide this platform to address the neck, lower eyelids as well as the cheek as a unit.  It is very rare to see a patient who has never had surgery that requires only a mid-face lift making these so called “firming” procedures an integral part of facial rejuvenation yet they only get a small print footnote in the marketing juggernaut that is the Lifestyle Lift®.

Dr. Paul S. Howard

Top Facelift Surgeon Birmingham Alabama