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 facial sagging without a surgical procedure. The timing of that face lift surgery, or mini facelift,  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 facelift 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 facial plastic surgery and its effect on the mouth and peri-oral 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 surgery (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.”

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

The Lifestyle Lift™ vs. The Howard Lift by Paul S. Howard, MD

Facelift Alabama

Plastic Surgeon Birmingham Alabama

The Lifestyle Lift™ (or LSL) continues to generate publicity, both good and bad, in the beauty business universe.  Ongoing lawsuits in the State of Florida brought by attorney general Pam Bondi as well as dueling articles in plastic surgery practice magazines explaining and dismissing the litigious nature of the LSL Company keep the spotlight on this controversial marketing company.  It is not known, the malpractice history of the LSL doctors, yet their history of suing and being sued regarding their trademarked name and aggressive marketing practices is well documented in public forums.  Let me be absolutely clear, LSL is not a facelift nor any kind or combination of surgical procedures.  Once again, the LSL is not a facelift.  The precise nature of the company is a little vague but we do know that it is a marketing juggernaut flooding the TV waves, radio and more recently the internet with a multi-million ($15 million or so) dollar ad campaign featuring the once popular Debbie Boone, daughter of teen idol Pat Boone of white-buckskin-shoe fame.

When one analyzes this expansive company it is easy to understand why there is a cottage industry of cases (patients) searching for plastic surgeons to re-do or correct the surgeries done under the auspices of this marketing company.  The LSL brand is metastasizing to every possible market as researched through their massive call bank in Troy, Michigan.  The major problem they are experiencing is the fact that they have grown rapidly, have roughly 90 doctors on the payroll nationwide, and it appears they are having one helluva time controlling the quality of their product.  Roughly 20% of their surgeons are actually board certified plastic surgeons.  As with any statistical analysis, there is a bell curve describing the quality of their surgeons.  It’s just the numbers are so large that the one’s with poor results number in the thousands every year.

The LSL marketing machine touts 3-4 facelifts a day (per doctor) and a procedure that only takes an hour to do.  When you consider that many of their surgeons are youthful, an hour facelift is improbable.  It seems that time is made-up by handling the incisions with haste.

Dr. Paul S. Howard

Regardless, Forrest Gump said it best, “Life’s like a box of chocolates, you never know what you’re gonna’ get.”  You can say same about the LSL.

In our efforts to separate what we do from LSL, we make a point of offering only one facelift per day performed entirely by a myself, a real board certified plastic surgeon with no consultationists, no fellows or residents involved with the personalized patient care.

As far as the facelift procedure itself, our Howard Lift has many commonalities with the LSL except it was developed from patient requests and follow-up over many years and not to satisfy a preconceived marketing plan.  Also, the Howard Lift is only the base procedure taking care of the cheeks and jawline.  Each patient receives a complete evaluation including the neck, eyelids, brow, and nose as needed.  A complete skin care evaluation with appropriate skin care including chemical peels and CO₂ laser resurfacing as indicated.  All of this is included at a cost comparable to the LSL except you know your board certified plastic surgeon and his entire staff prior to the day of surgery.  Follow-up is provided exclusively by myself and my staff so there are no covering physicians or strangers involved in your surgical care or follow-up.

For an in-depth explanation of our philosophy of practice and opinions on the surgical issues of the day, log-on to our web site www.thehowardlift.com and access our photo galleries and informative Faceliftology™ Blog.  The number one reason for unhappiness with a plastic surgical result is a lack of information and not being fully informed about your surgeon and his

Dr. Paul S. Howard is Board Certified by the American Board of Plastic Surgery.  To schedule a consultation with Dr. Howard to discuss your cosmetic surgery goals, please call 205-871-3361

*Faceliftology is a registered trademark, registered by Dr. Paul S. Howard, Plastic Surgeon Birmingham, Alabama.

*The LifeStyle Lift is a registered trademark, registered by Lifestyle Lift Holding, Inc. Michigan.

Count Dracula and the “Vampire Facelift™”

Vampire Stem Cell Face Lift

Count Vlad’s Castle in Romania. Dr. Paul S. Howard visited Romania several years ago to operate on orphaned children born with facial deformities.

Author Anne Rice benefited from the allure of the Vampire in pop culture where there has always been a certain interest in all things Romania.  From Count Vlad “the Impaler,” to the gypsy culture and even gymnast Nadia Comaneci have all fueled interest in the darkest of the former Eastern Bloc Soviet satellite countries.  Our fascination with Romanian people may stem from their unique Eastern European history.  The Romanian is proud of his Dacian ancestry making their culture and language more like that in Rome than their geographic neighbors which are Slavic countries such as Hungary, Serbia, Moldavia, and Bulgaria.

The myth that is Dracula has a basis in fact steeped in the history of Romania and the Dark Ages of Europe.  Vlad III, Prince of Wallachia, member of the House of Draculesti, known by the patronymic name Dracula was born in Transylvania in 1431.  The translation of the name Dracula comes from his father Vlad Dracula, meaning “dragon” or “devil.”  Vlad III was known in his adult life as the son of the devil.  It was only after his death in 1476 that he became known as tepes or “the spike,” alluding to his famous battles with the Islamic Turks and his father’s battles with the Boyer Family for the thrown of Wallachia.  Both the Boyers and the Turks were “spiked” or impaled as punishment and as a deterrent.  Thus, Vlad “The Impaler” was born.  It was left to the Irish author, Bram Stoker, to rekindle the Dracula legend as well as embellish it to include the Vampire myth in his 1899 gothic horror novel, Dracula.

The recent fascination with the Vampire myth was stoked by any number of books including those by Ann Rice and the TV series Vampire Chronicles.  It comes as no surprise that medical marketing would jump into the Vampire craze even though the institution of Vampire tales is beginning to wear thin even in pop culture.  We now have a non-surgeon entering the pop-culture marketplace with the so called “Vampire Facelift.”  The connection with vampires is interesting in that vampires are a Gothic myth with no factual basis much like the vampire Facelift™ is more of a New Age myth with no basis in fact.  The connection to Vampire culture is through the use of Platelet Rich Plasma (PRP) as an adjunct to the use of temporary foreign fillers (Juvederm™, Restylane™) to effect some sort of facial rejuvenation akin to the well-worn “Liquid Lift™.  Fillers plus PRP equals the Vampire Facelift™.

Platelet Rich Plasma is obtained by drawing blood from the patient’s arm (not the neck as in vampire-lore), and by processing the blood one obtains platelet poor plasma (PPP) and platelet rich plasma.  The most well-known use of PPP is “fibrin glue,” a soft tissue sealant used in many kinds of surgery.  PRP has a bewildering array of uses, but all of the known benefits come from the activation and stimulation of growth factors and cytokines.  These are necessary for cellular activity which benefits blood supply, healing and specifically the “take” of fat grafts mediated through the activation of stem cells.

Recently it has come to light that activated stem cells and PRP have a beneficial effect on aging skin causing increased collagen synthesis, may be helpful to increase elasticity and is believed to improve skin texture as well.

Platelet rich plasma, coming from blood, has many important functions, but none of these functions create volume nor “lift” tissues in any way.  Additionally, PRP is very easy to obtain from blood.  The actual skill involved is drawing the blood which is easily processed to PRP, is easy to activate with calcium and thrombin, and actually is a source of protein when swallowed (vampire’s diet).

Utilization of PRP is a useful adjunct for facial rejuvenation, but in and of itself has not shown to have much of a rejuvenating effect.  The addition of temporary fillers does not improve what is already known about the temporary volumizing effect of hyaluronic acid based fillers.  The two together serve to prove the uselessness of trademark laws as applied to medical science.

Dr. Paul Howard is Board Certified by the American Board of Plastic Surgery.

What the Hell is a Consultationist?

I, and many other who enjoy the English language, have been wondering which new words would be added to the lexicon of America.  These new words, or neologisms, are usually chosen by a group of exudate linguists to be included according to the extent of pervasiveness of their usage.  This begs an answer to today’s question: what the hell is a consultationist?

Upon checking Webster’s and Harper Collins dictionaries, no reference is made for the noun consultationist.  The closest reference is for consultation which we all know means an appointment or meeting to seek professional advice especially from doctors or lawyers.  It is through this prism that the term consultationist has come into my practice universe and the lexicon of plastic surgery.  Apparently in certain plastic surgery mass-marketing schemes, the number of patients seeking information is much greater than the doctors available to provide information thus leading to a new paradigm for plastic surgery practice by placing the here-to-fore unknown consultationist into the complex surgical information loop.  Naturally, not every plastic surgeon answers every contact for surgical information, but we all provide detailed information to our office staff who field those questions from the public.  The flow of accurate information through surgical surrogates called consultationists to the patient seems fraught with uncertainty proportional to the number of individual surgeons responsible for the information provided by surrogates.  The information provided, by necessity, must be wholly generic in nature as no one but the plastic surgeon can provide the necessary depth of knowledge and experience to provide anything approaching a real consultation.  These new plastic surgery mass-marketing schemes, in addition to spending millions of dollars on TV, radio, print, and internet, have actually added a layer of advertising bureaucracy as the information requests are funneled through a new layer of marketing specialists called consultationists.  These new patient calls have become “sales leads” rather than actual consultations.

This new marketing centered paradigm created a number of questions all of which surround the activities of the newly minted consultationist.  For instance, who are these people, how are they reimbursed, what is their background and training, and who decides what they say and who do they report to: the physicians, marketing director, or corporate management, or all of the above?  Is the protection and dissimulation of the brand primary or does accurate surgical information take precedence?  Regardless of the answers to these questions, the marketing consultationist has added an entirely new level of bureaucracy that can only be financially justified if information requests turn into actual doctor consultations.

Clearly it serves no purpose for any prospective patient to be denied a real consultation so the information flow through consultationists carries no more weight than any well-crafted patient directed web site.  The web site will certainly answer the single most important question at any consultation: who is your doctor?

It seems this one single question which would seemingly be the easiest to answer during any real consultation is usually the hardest question for a consultationist to answer generally depending on how many doctors are the recipients of this marketing service or sales lead.

I’m not sure I have been able to actually answer my initial question: What the hell is a consultationist?  My best research tells me a consultationist is but a cog in the marketing paradigm for certain large companies that endeavor to sell some kind of trademarked surgical procedure in some generic fashion.   The challenge is to maximize the marketing of the procedure, even if the procedure is not proprietary or in any way original.

The focus of the expert marketing must maximize the procedure and minimize the surgeon because each surgeon is an individual, but the procedure is universal and much more available as a marketing center piece.  This type of marketing plan when well executed can be enormously effective unless the “generic” surgeon pool is depleted or becomes technically antiquated and changes do not keep apace the market for facial rejuvenation.  Many of the predictable corporate problems are a result of the realities of size and success.  Time will be the arbiter regarding consultationists.  In the meantime, most of us plastic surgeons with integrity will try to muddle on without them.

Read more about top face lift surgeon Dr. Paul Howard and his minimal incision, quick recovery facelift.

Who is a Candidate for the One Week Facelift? by Paul S. Howard, MD

It is axiomatic that all facelifts are different and certainly one cannot recover from all facelifts in a single week.  What I wish to describe is the optimal situation from both the patient’s point-of-view and the surgical perspective.  Choosing the right patient with application of the correct facelift procedure under optimal anesthetic conditions will usually yield the quickest facelift recovery: one week from my perspective.

Who is the best candidate for the facelift procedure?  Ideally, the best candidates for facelift are women between 40 and 60, healthy, non-smokers, with the proper motivation and support.  More specifically our ideal patient is active and actually benefits from a return to normal activity in a week.  As with any surgical procedure, the difficulty and extent of deformity provided by the patient is important.  In the perfect world described here, our female patient has moderate aging of the cheeks with early marionette lines, somewhat deepened nasolabial folds and the presence of the “bubble” of cheek fat tissue obscuring the jawline.  Once these conditions exist, there is no amount of injecting or fillers that can camouflage or “lift” tissues to redefine the jawline.  Some skin elasticity remains as opposed to our older patients with “leather” skin, and a multitude of deep wrinkles indicated a total loss of elasticity.  Weathered skin is usually due to extensive sun exposure without sun-block, as well as environment toxins and smoking.  These older patients with skin elasticity problems are still candidates for facial rejuvenation, but the operations are more extensive and cannot be recovered in one week.  Minor aging of the neck can also be treated simultaneously and does not prolong our one week recovery.

We try to address as many skin quality problems as possible pre-operatively.  We prescribe the nightly use of a Retin-A, hydroquinone, steroid solution as well as a cleansing facial treatment pre-operatively if possible.  We frequently recommend lower blepharoplasty with our midface lift and thus recommend an eye exam prior to blepharoplasty in most cases.  Previous surgery for cataracts or glaucoma is noted as the post-operative incidence of swelling in the form of a chemosis is more likely in these patients and may take more than a week to resolve with prescription eye drops.

Optimal anesthetic conditions include the use of local anesthesia with sedation rather than general anesthesia.  The control of blood pressure within a narrow range of the pre-operative value is necessary to minimize swelling and bruising that is expected when emergence from general anesthesia is necessary.  Aspirin and NSAIDS are stopped 2 weeks pre-operatively, and Bromelein and Arnica are recommended peri-operatively.  The liberal use of ice on and around the eyes with constant head elevation, regional blocks for peri-orbital anesthesia, and minimal injections directly in the ultra-thin eyelid skin reduce the chances for injection bruising in the lids.

The most important discussion to lessen edema, bruising, and to expedite recovery within one week is the choice of the mid-facelift and the details of its performance.  Lapsing into technical jargon, our lift is a short-incision mini-lift with a multi-vector, progressive tension SMAS plication.  The combination of techniques results in an aggressive lift with a minimal of undermined skin resulting in minimal “dead space” to accumulate blood or fluid.  For this small area of undermined skin, we have further developed a system of “micro-drains” utilizing vacutainer tubes as the collection/suction mechanism.  These 21 gauge drains are effective for removing any possible fluid collections and are removed at 24 hours post-operatively.  These small drains are incorporated into 24 hour post-op compression dressing, and in most cases the patients don’t know they exist.  The light compression dressing is augmented with “rest-on foam” on the neck and adjacent to the peri-auricular incisions.  This foam is also removed at 24 hours and is replaced by an ace bandage to compress the dependent portion of the neck and to protect the ears, especially at night.  The neck compression is important to achieve our goal of one week to “street-ability.”

Incision care is of the utmost importance to achieve our goals.  Gentle cleansing using peroxide once a day with careful application of Aquafor, especially around and behind the ear where it is difficult to see and for the dissolvable lower eye-lid stitches.  If the lower led sutures are allowed to dry, they will become brittle and will not dissolve on schedule at about 5 days.  The nylon sutures about the ear and in the submental neck are removed at 5 days except for a few “key” sutures in areas of tension.  These key sutures are removed on day 7.

Lastly, a word or two on the general aspects of healing.  It should go without saying that a calm, smoke-free, supportive environment is important to have the mindset to heal uneventfully.  We request careful attention to the instructions provided to prepare for facelift surgery and the comfort to call at any time if any uncertainty arises.  All of the medications are provided for a reason and should be taken exactly as prescribed.  We will go over all of your medications in detail with you so there are no mis-understandings regarding when to resume them.  Controlled activity beginning post-operatively day one is important.  There will be three office visits during the first week and of course these are very important.  It is probably equally important for your mental recovery to parallel your physical recovery.  Although we aim for your physical facelift recovery to be well along at one week so that you can be in public, your recovery will continue for many weeks and months to total normality.  We use serial photography to allow you to follow your recovery visually, which in most cases, helps your physical recovery and state-of-mind as well.  You will receive copies of all photos as well as the constant reminder of your pre-op condition with a set of your before photos as well.

We believe that we are all “goal oriented” people and that goals for life as well as for recovery from surgery are important.  Our goal for you is a one week recovery and we will provide you all of the tools necessary to achieve this goal.

Read more about Alabama facelift surgeon Dr. Paul Howard plastic surgeon and view facelift before and after photos.

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Anesthesia for Facial Plastic Surgery

Facelift Alabama

Schedule your facelift consultation with Dr. Howard by calling 205-871-3361

There is a movement afoot to try to legislate safety in plastic surgery by controlling what we do rather than taking the more difficult route of controlling the credentials and training of practitioners.  State governments must find it less offensive to certain constituencies to legislate what we do and how we do it rather than more directly addressing the office surgical setting by requiring each and every practitioner to have a minimal amount of core training in the procedures legislators deem unsafe.  When non-professionals try to address concerns on medical safety it always appears that some group of doctors may be affected and their arguments always seem to be based on possible financial restraints or financial hardships that fully trained and credentialed doctors may not suffer.  The implications are that all doctors, regardless of training, are essentially equal.  No such assumptions are proffered for neurosurgeons or cardiac surgeons.  There is no legislation attempting to equalize specialty surgeons by defining what we do to make the entire group safer.  No one has proposed the idea that cardiologists, with little or no surgeon training, should be allowed to do open heart surgery as long as they operate in a safe manner and do the operations in approved facilities.  It would seem safer to address the training and credentials of those performing open heart surgery rather than restricting cardiologists to “simple” open heart cases.  This is much like restricting non-plastic surgeons to “simple” or low volume liposuction searching for a safety standard by “dumbing down” the operation and its possible complications.

In another way, many surgeons and non-surgeon administrators have convinced people that surgery is always safer when performed under general anesthesia with an anesthesiologist in attendance.  The fact is that almost all facial plastic surgical procedures done on adults for cosmetic reasons are safer when performed without general anesthesia, and its riskier counterparts, mask anesthesia and monitored anesthetic care.  The latter two are basically general anesthesia without the benefit of a secure airway and in facial cases, a difficulty in administering oxygen as needed.  It’s easy to declare that all patients need the most sophisticated and complex care in all circumstances with the assumption being that this is the safest way to proceed.  One aspect of plastic surgical complications that seems to be consistently overlooked is the general anesthetic contribution to all complications.  The fact that general anesthesia is related to complications is found in the surgical maxim that complication rates increase rather drastically after 2 hours under general anesthesia.  I don’t believe that operations longer than 2 hours are inherently more dangerous.  Many surgeons think that their meticulous technique, while sometimes slow, gives better results even though they may require hours longer under general anesthesia.  As a general rule, those surgeons who expedite the operation to decrease operative time are the safest.  The only way to further increase safety is to take the general anesthetic out of the picture.  Interestingly, using local anesthetics and regional blocks requires an entirely new skill set and, most importantly, it requires patience.  Adding sedation in the form of oral medication helps to make the experience more comfortable, but adds very little to the complication profile as these are the very same medications we use in our post-operative outpatient patients.  We have found that the intravenous use of medications such as versed and morphine creates large increases of medications with a short half-life and is more likely to cause nausea and vomiting.  Nausea is a much less common problem with oral medication especially if Phenergan or Zofran are used with the pre-operative oral medications.

In the past, the major complaint with local anesthesia with or without oral sedation is that it can burn when injected.  There are a number of techniques that surgeons can utilize to make the injections much less painful.  Almost all of these techniques require only a bit of patience from the plastic surgeon.  The most commonly used anesthetics are Xylocaine and Marcaine.  Due to the acidic pH of Xylocaine, most surgeons have for years added bicarbonate to decrease the “burn” when injected.  The problem with adding bicarbonate is that it decreases the ability of the Xylocaine to work as well and may require a larger volume of injection.  Knowing the details of Xylocaine led to a search for better anesthetics.  Our search led us to Paris, France where we discovered Septocaine.  We found that Septocaine has about the same complications and dosage profile as Xylocaine.  The difference with Septocaine is that it is less painful to inject, it tends to work faster, and provides what patients describe as a more “intense” numbness.  We have used Septocaine as a primary local anesthetic for over 10 years and I am sure it is more comfortable for the patients. The downside is that it is more expensive to use.  This is a small price to pay for patient comfort.  It is important to understand that the reason for all of this discussion is to make sure our facial plastic surgery  patients are comfortable, pain-free, and safe while having facelift surgery and eyelid surgery.

From a medical/surgical point of view there is a very specific and important reason to use local anesthetics and oral sedation rather than general anesthetics.  We are convinced that the vast majority of post-operative facial swelling after facelift surgery is caused by transient but significant changes in blood pressure during and immediately after surgery.  In fact, I believe most hematomas and swelling occur in the period of time after the procedure is finished during the period of time when the patient emerges from general anesthesia.  We believe that controlling the blood pressure at pre-operative levels throughout the operation and especially at the end has decreased swelling post-operatively dramatically.  Blood pressure control and the judicious use of epinephrine in our local anesthesia with complete patient monitoring has completely changed the first 24 hours after surgery – much less bruising, swelling, hematomas.

One might ask why everyone who does facelifts wouldn’t do it with these techniques.  The primary reason is probably the patience it requires and the fact each facelift should be done by itself each day.  This fact resulted in our “One Facelift a Day” promise.

Read more about top facelift surgeon Dr. Paul Howard and his no general anesthesia facelift.

The Stem Cell Revolution

The law of unintended consequences applies to President George W. Bush when he banned embryonic stem cell research.  The unintended consequence was the search for adult stem cells and the knowledge that there is an almost limitless amount of adult stem cells located in fat or adipose tissue.  This fact places plastic surgeons at the epicenter of the stem cell revolution.  Who better than a board certified plastic surgeon is in a position to obtain the necessary fat (liposuction) which is then processed to obtain adipose tissue derived stem cells?

These adipose derived stem cells can be utilized for a myriad of cosmetic and reconstructive procedures.  For our purposes, these all-purpose stem cells are the basis of all of our facial and skin rejuvenation procedures.  It is a well-documented fact that stem cells, when reintroduced into the face, causes any fat which is re-injected, to “take” better and as a secondary benefit the stem cells release a number of “growth factors” that improve  skin by reducing the visible signs of aging.

It is important to realize that you cannot share your stem cells with anyone else nor can you use stem cells from another person. The fat must be processed immediately and re-injected with the stem cells during the same operation as it is difficult to store adipose tissue for further use.  We have developed a “stem cell lab” within the confines of our sterile operating room.  The lab equipment costs little and only requires basic laboratory experience (such as the experience obtained with a B.S. in Chemistry).

Every medical breakthrough goes through stages.  First, there is disbelief followed by hyperbole.  The hyperbole stage is manifest by over hyping the benefits and the beginning of named procedures such as the “Stem Cell Lift” which basically does not exist.  Realistically, stem cells do not tighten skin or “lift” anything.  They are a great addition to volume enhancement by increasing the take of fat grafts and clearly stem cells cause your skin to rejuvenate by erasing age spots, increase skin thickness, and improve fine lines and wrinkles.  Most patients who have had our stem cell rejuvenation describe their skin as smoother and typically glowing.  Stem cell augmented fat transfer has become a staple in our rejuvenation procedures and at a minimal charge to the patient.

Read more about top facelift surgeon Dr. Paul Howard and view facelift before/after photos.

Looking Younger is Not a Sin

Having spent the majority of my life in big cities such as Atlanta, Miami and Paris, I was taken aback by the responses of women in smaller southern cities such as Birmingham, Montgomery or Mobile to the notion of facelift procedures.  I have on occasion related an anecdote about women in the South; if one asks a woman on the street in Miami or Paris “who is your doctor?,” the usual reply will get you the name of her plastic surgeon. The same question posed to a woman in Birmingham will get you the name of her gynecologist.  I have no particular problem with gynecologists but it does reflect a palpable difference regarding priorities in medical care. Likewise, there always exists a group of women who proudly notify their friends and family of their impending surgery and show their friends the results the moment the dressings are off.  A more common scenario in the South is that most women are very private in their personal affairs and only confide in their families and closest friends.  We are not talking about people of wealth as no one knows how or why celebrities and the wealthy choose their healthcare providers.  Judging from what we see on cable TV, the Michael Jacksons’ of the world as well as many aging models and TV stars should reconsider their choices of doctors, especially those who are fighting the aging process in an attempt to remain on the ‘’A’’ list.

The best example is the Hollywood penchant to completely overdo lip augmentation. The reason this is an issue is because “normal” people who inquire about lip enhancement look at celebrities, think they probably get the best plastic surgery, and assume that the comical, overdone lips are necessary for lip enhancement. Two bad assumptions are at work here: the first is that celebrities get the best plastic surgeons and the second is that enhanced lips should be huge and comical in appearance.  Good plastic surgeons can usually enhance lips in any of a number of ways achieving fullness, a very youthful pout and accentuation of youthful lip anatomy without the “bee-stung” comical lips that we see all too often. The choice to overdo any plastic surgical procedure is entirely up to the patient and not a part of plastic surgery itself.  There is an unknown in this process, which is the individual talent and taste of the plastic surgeon involved.  This is why it helps to see examples of the surgeons work in order to get some idea of how aggressive or exaggerated the work is. Surgeons will usually show pictures of work they consider exemplary so when viewing catalogs of photos it is good to evaluate each result carefully taking in to consideration your specific taste, even if the photos are of procedures you are not considering.

One of the most challenging operations for a plastic surgeon is rhinoplasty. This is why there are so many “challenged” noses out there in Hollywood.  It is a bit of a cliché to use the Jackson family as an example of rhinoplasty gone wrong but I’ll do it anyway.  I believe that at least one of the early iterations of Michael’s nose was an attractive change from his original ethnic nose into a slightly improved version.  I would surmise that it was an operation or two later that his final scar laden, next to nothing nose emerged was left of his original proboscis. Without the wonders of his handy, at home, hyperbaric oxygen chamber Michael may certainly have lost his nose in its entirety.  I suspect that the last twenty or so operations were not procedures chosen by his surgeon yet performed nonetheles.  The legacy of the Jackson family nasal nightmare should probably not be left with the surgeon but with the patients who are too famous, have too much money and succumbed to too much bad advice or a lack of good judgment.

Breasts have long been the subject of Hollywood photographers and celebrity magazines.  Ever since Janet Jackson’s infamous Super bowl wardrobe malfunction there seems a preoccupation with breasts, especially large ones. Many women seem to have attached their femininity to their cup size. The trend to larger breasts is exemplified by today’s Victoria Secret models that are not as anorectic as the models of the 80’s and 90’s.  In the real world outside of Hollywood women who consult for breast augmentation also want larger, fuller breasts but they also want “plausible deniability.”  That requires breasts large enough to be sexy but not quite so large that they could not conceivably be nature’s gift.

Plastic surgery and the “beauty business” as it is now called did not arise from the devil as a temptation to vanity but rather as a consequence of the very normal desire of human beings to appear physically attractive to each other. The process of aging tends to extinguish some of the physical attractiveness of youth.  Aging gracefully is the excuse given not to intervene with plastic surgery but our “grace” does not preclude spending billions of dollars on products for our hair, skin and nails.   Recently, plastic surgeons have become facile and more creative with the surgical interventions we recommend to treat the aging face.  Our operations tend to be less one-size-fits-all and are uniformly less invasive.  Surgeons now are utilizing more of our scientific educational background to apply the latest in biology to scientifically improve our results and to stay abreast the latest research and findings.

Those of us in facial and body enhancement business are as different as our patients. The best we can do individually is to provide up to date, non-biased information including our training and certifications to the table and provide honest, accurate photographs of our work so that patients may get an idea of our preferences and our aesthetic sensibilities.  The more factual information out there, the better chance the patient can find the right surgeon for the right problem.