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.”

Advertisements

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 facelift 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

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, eyelid surgery, rhinoplasty 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 facelift and mini facelift surgery 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 plastic surgery concentrating on minimal swelling leading to minimal downtime and a first-class, longstanding natural result.

Read more about facelift recovery.

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.

Unveiling the “Lifestyle Lift*” by Paul S. Howard, MD

The Truth about the marketing madness

One of the most disturbing aspects of medical care as practiced today is the unpleasant
marriage of medicine and industry creating what is known as the medical-industrial complex.  The medical-industrial complex is manifest in many ways including the extinction of the private, solo medical practitioner and the rise of things like copyrighted medical procedures.  In the not too distant past, most doctors were solo practitioners and thus provided the kind of medical care that made physicians respected and pillars of the community.  Among surgeons the attempt to copyright a surgical procedure is distasteful as the important surgeons we have known in our training taught surgery without taking credit or financially benefiting from their ideas and procedures, even if revolutionary in nature.  If an operation shows particular promise and represents a true advancement in medical care, it is usually submitted to a peer reviewed journal where its merits are debated among professionals in the field and either accepted for publication or not, depending on the originality of the idea and its ability to advance medical knowledge, but never for financial gain.

The recent introduction of the copyrighted named surgical procedure uncovers one of the weaknesses in trademark and copyright law as the procedure on which the trademark is licensed does not have to be in any way original except the name itself has to be unique.  The only reason to give an operation that is not original a trademarked name is for the purpose of marketing for financial gain.  Many less informed patients may believe that a trademarked name for a surgical procedure implies that the procedure, whether unique or not, is the most important aspect of patient care usually proven with a slick marketing plan.  It is clear that the “named” procedure is of minuscule importance when compared to the ability of the surgeon and whether the procedure is the correct one to treat the problem addressed.

The “Lifestyle Lift” is the latest marketing madness purposing a questionable procedure by marketing the name rather than the credentials of the physicians who perform the trademarked “Lifestyle Lift.”  I suspect that on occasion the “Lifestyle Lift” may actually provide a satisfactory result, if by luck the right patient sees the advertisement and gets a surgeon provided by the company, who performs the procedure resulting in a happy patient.  I get to see the results of the “Lifestyle Lift” and are asked to explain why such a well marketed operation did not accomplish the facial rejuvenation promised.  Many times, the patient dissatisfaction results from the limited improvement on the cheeks only while the neck, eyes and mouth, of equal importance, are not addressed with the “Lifestyle Lift.”   Most plastic surgeons find that addressing all of the aging issues usually allows the procedures to be “blended” together for optimal results.

Life Style Face Lift Revision Surgery

Alabama facelift specialist Dr. Paul Howard is a Board Certified Plastic Surgeon in Birmingham, Alabama. To schedule a consultation with Dr. Howard, call 205-871-3361.

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