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.

Stem Cells, Fat Grafting, & Facelifts

The facelift operation as practiced by Board Certified Plastic Surgeons continues to relentlessly evolve as surgical science and cell biology uncover new applications which can be utilized to improve our already outstanding results.  Responding to the wishes of our patients, operations have tended to become less invasive and shorter in duration with less swelling, bruising, and a much shorter down-time.  The short scar facelift has seen a resurgence with new and original methods of dealing with the SMAS, such as our progressive, multiple vector SMAS plication.  The blending of the improved mid-facelift with the lower eyelids and less invasive neck surgery when possible had been our idea of a modern facelift.  Due to the teachings of Sydney Coleman in New York City, we added structured fat grafting to our lips much improving the perioral area and enhancing the cheeks and what has been architecturally described as the facial “ogee.”  I believe fat grafting as now practiced was a huge step forward in facial rejuvenation completely replacing foreign body fillers such a Juvederm® and Restylane®.  In some circles, the efficacy of fat grafting is still questioned even as the evidence of graft takes in the 80-95% range are routinely described.  Over the last couple of years, the basic science of cell biology has given us new information on adipose biology and the nature of adult adipose derived stem cells.  The term “stem cell” occupies front page position in almost every modern women magazines.  Until recently, it has been unclear how this new information could be applied to Plastic Surgical science.

The evolution of stem cell biology including the fact that we could isolate stem cells from our own body fat seemed almost too good to be true.  Rather than throwing away the fat we obtain with liposuction, we can now take this fat, process it in the office, obtain stem cells, and then utilize the stem cells for improving fat graft take even further as well as adding growth factors to the fat grafts that have a beneficial effect on aging skin.  Body contouring with liposuction complimenting facial rejuvenation is truly a “scots” efficiency as Dr. Ralph Millard would say.  The beneficial effect of growth factors on healing and facial skin aging has been known for several years, but exactly how to utilize this knowledge never progressed after the discovery of its use as “fibrin glue.”  More recently, we have added platelet rich plasma (PRP) obtained by drawing blood at the onset of the surgical procedure, processing the blood to get PRP which adds large quantities of growth factors when added to fat and fat stem cells used for facial contouring and rejuvenation.  All of these biologic enhancements to fat grafting are obtained from the patient and therefore are autologous with no problem with rejection such as that which occurs with foreign body fillers.

To summarize our current facelift techniques, incisions are of the “short scar” variety, the SMAS is handled with progressive tension suturing in multiple vectors, micro-drains are used for 24 hours to reduce bruising, the glabella, cheeks, lips, chin, and perioral areas are enhanced by fat grafting augmented with stem cells and PRP.  Cost controls include doing the procedure in the office with local anesthetics and mild sedation.  The sum of these procedures we like to call the “Howard Lift” for lack of a more descriptive term.

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

How Smart is the Smart Lift?

The Smartlift™ facial surgery procedure is the latest trademarked surgery marketed directly to the patient as an answer to facial aging problems.  The Smartlift™ procedure differs significantly from the copyrighted or trademarked procedures in that the so-called Lifestyle Lift® is based on the aggressive marketing of a procedure (the Lifestyle Lift®) which only distinguishes itself by its simplicity leading to certain claims of reduced recovery and reduced operative times leading in some way to superior results.  The Smartlift™ is different in that the sales pitch has to do with technology rather than the marketing of a procedure.  The Smartlift™ is the facial rejuvenation procedure performed with the Cynosure® laser used for the laser assisted Smartlipo® procedure.  While the use of the Cynosure MPX® laser is accepted for liposuction, it is less accepted in the face and may be contra indicated when used to liquefy facial fat.

The Smartlift™ is the use of a laser underneath the surface of the skin (internally) as opposed to other laser platforms used on the surface of the skin (externally) resurfacing for fine lines and wrinkles.  The premise behind using a laser as an adjunct for facial rejuvenation is that due to the heat generated by the laser, facial skin contracts causing some small amount of skin tightening.  At the same time, the skin is heated and the laser emulsifies the facial fatty tissue violating the premise that you shouldn’t remove fat from the aging cheek.  The Smartlift™ is the procedure using the laser as described above to effect facial skin tightening with no actual surgical lifting performed.  Even with the addition of CO₂ fractionated laser to the external surface of the skin, the actual skin tightening is minimal.   With the aggressive attempt to tighten the facial skin by internal heating one runs the very real risk of removing facial fat excessively leading to a fairly dramatic skin laxity and worsening of the facial aging signs as well as severe skin contour deformities.

Dr. Paul Howard - Facelift Plastic Surgeon Birmingham, Alabama

The patient above is a 65-year-old woman 11 months after having the so-called Smartlift™ facial procedure on her sagging neck and aged jaw-line.  Additionally, she had upper and lower blepharoplasty.  She related her request for improvement in her aging face, neck, and eyelids after the Smartlift™ laser procedure.

The first challenge was to re-drape the skin of the neck which was no small feat due to effects of the laser on the submental fat and skin.  The jaw-line, cheeks, marionette lines, and nasolabial folds were addressed with a midface lift.  The cheeks were blended with the lower lids and the upper lids re-done.  Fat was liposuctioned from her abdomen, processed and enhanced with her stem cells to be injected in her nasolabial folds, lips, chin, and marionette lines.  Her neck continues to be a problem and has required several steroid injections to help soften the scarring caused by the Smartlift™ lift.  It has come to my attention that the Cynosure Corporation through its marketing people are now touting several other procedures based on the Smartlipo® laser with the addition of incisions in the mini-lift pattern as well as the full facelift incision pattern.  Succumbing to the philosophy that all of these procedures deserve a trademarked name, i.e. the mini-lift plus laser is the “Ultra mini-lift™,” the full facelift plus laser is the “Laser Smartlift™.”  I was surprised that the “Ultra Mini Smartlift” was kept out of the marketing “lift” bonanza.

Read more about Dr. Paul Howard and his popular Howard Lift Facelift in Birmingham, Alabama.

The Stem Cell Facelift – Fact or Fabrication

The Stem Cell Facelift - Fact or Fabrication Gargoyle of St. Severin in Paris, France – Photo taken by Dr. Paul Howard

If one were to internet search “stem cell facelift” or “non-surgical facelift” you get hundreds of search results describing outrageous claims of facial rejuvenation that exceed the results of “surgical facelifting.”  There will always be people following the holy grail of “non-surgical” procedures of all types.  These same people probably believe in gremlins, gargoyles, and the tooth fairy, all myths that get some play over the internet.  All good myths (and lies) seem credible because they were based initially on facts.  For instance, let’s look at the so-called “liquid lift” touted as some version of the “non-surgical facelift.”  Plastic surgeons have known and is replete in our literature that one aspect of facial aging is due to a loss of soft tissue (mainly fat) volume, no one who studies the aging process believes that simply addressing facial volume issues will in effect result in “lifting” of facial structures, i.e. the “liquid facelift.”  The proposition will always find an audience with those individuals who, for varied reasons, are frightened of surgery.  The proposition of volume lifting gets momentum as its practitioners recommend using one of today’s off the shelf fillers at $200-300 per milliliter.  It could take 30cc of filler to achieve the fullness necessary to claim the face is lifted.  This is a perfect example of utilizing a true discovery to develop a non-surgical marketing slogan such as the “liquid lift.”  If such a procedure actually worked, we could all take our marbles and go home as the answer to facial rejuvenation would be upon us.  As much as this would benefit the non-surgeon, it happens to be untrue, but still worth a try if you cannot do a proper facelift or obtain autologous fat as a facial filler rather than having a basically painless and simple surgical facelift.

The Stem Cell Face Lift is another of these stylized marketing slogans based on actual scientific discovery (stem cell biology) adulterated as some sort of magic bullet that “lifts” faces.  I think that the gargoyles protecting Notre Dame in Paris makes more sense than a stem cell “lifting” anything.  This is not to say stem cells don’t exist or that their discovery isn’t useful when applied to the biology fat grafting and actual facial skin rejuvenation.  An understanding of stem cell biology and how to isolate them from adipose tissue will probably become routine for all Plastic Surgeon’s in the near future.  Hopefully, as more and more is published on the subject of stem cells there will be fewer practitioners with a financial incentive to propagate the fantasy which is the “stem cell facelift.”  The final straw may be the fact that many of the non-surgeons are parlaying some knowledge of stem cell biology into a $20,000 procedure!

In the final analysis common sense dictates that stem cells are real and are a really important adjunct to my facial rejuvenation procedures, but by themselves cannot “lift” anything, particularly an aged face.

The Misunderstood Facelift

Facelift procedures have been a part of the plastic surgery lexicon since the early 1900’s. At that time, there were no board certifications, Teddy Roosevelt was President, the Great World Wars had yet to begin and antisepsis and anesthesia were in their infancy. Against this backdrop of medical history facelifts, eyelid surgery, and rhinoplasty were performed in doctor’s offices and in front of crowds of people for marketing purposes. Howard Crum, MD wrote of his experiences with live surgery demonstrations in front of “thousands” of rapt on-lookers as well as a number of psychologically disturbed voyeurs hoping to see some blood and maybe a mishap or two. Cosmetic surgery was done in hotel lobbies, at conferences, and in ballrooms to standing-room-only crowds punctuated with a police presence. The surgeons performing these dramatic operations were the “rock-star” doctors of the day carrying reputations about reproach. As the market for these surgeries expanded the number of unscrupulous practitioners increased dramatically. The unskilled and poorly trained surgeons were making a mockery of cosmetic surgery and in fact, became dangerous to the point where one such surgeon tried to make a patient taller by breaking her legs and resetting the normal bones. Unfortunately, the patient lost both of her extremities. Reputable surgeons responding to these rogue doctors tried to limit physician marketing seeing these advertisements as a way to circumvent the tried and true patient referral sources which tended to enrich doctors with good results at the expense of those whose results were not as good. Marketing expertise had taken the place of surgical expertise. Plastic surgical training programs began to spring-up across the country after WWI where the horrific injuries associated with “trench” warfare were shipped to England and the USA for reconstruction. The best surgeons were on the front lines of repairing war injuries and as far back as the 1920’s Sir Harold Gillies of England and New Zealand was of the early proponents of the so-called “cosmetic reconstruction.” That is, reconstructive surgery of the face with the ultimate goal being not only a good or reasonable appearance but an attractive face. Dr. Gillies and his famous trainee, Dr. Ralph Millard, wrote a textbook to this effect in 1954 and Dr. Millard continued to be the “poster child” for the relationship between reconstructive and cosmetic surgery. It sounds foolish and ignorant for a surgeon to claim some sort of providence in facial aesthetics yet offers no educational training or pertinent experience as a surgeon to back up their improvable claims of superiority in our field of plastic surgery. In fact, aesthetic considerations are so pervasive in the plastic surgery residency that almost every patient and every challenge, whether cosmetic or reconstructive, is evaluated under the prism of Drs. Gillies and Millard. We aspire to surpass the normal and attempt to achieve the “Ideal Beautiful Normal” (D. Ralph Millard, MD).

Trying to answer the question “who are the best cosmetic surgeons” is impossible because the question applies to each individual surgeon and not entire groups of surgeons. On a group basis, competence can only be determined by training and education, and subsequent board certification and not by marketing skill.

Dr. Howard has been a Top Facelift Plastic Surgeon for over 20 years.  To learn more, please visit his web sites:

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

Read more about Dr. Paul Howard’s popular short incision face lift with no general anesthesia.

The Mid-Facelift by Paul S. Howard, MD, FACS

Facial aging is complicated by genetics, environment, sun damage, smoking, and drinking.  There is not a single procedure that works for everyone, therefore it is important that individualized evaluation leads to an operation which is specific for that person.  The uniqueness of all faces as well as the patient’s desires may lead to a slightly different surgical approach for each individual.  Another way to say this is that the one-size-fits-all facelift has become antiquated.  To facilitate individualized care we prefer to look at each part of the face separately leading to a unique surgical treatment plan.

We divide the face into its component parts; forehead, eyes, midface, and neck with primary emphasis on the midface.  Midface aging is characterized by sagging of the facial soft tissues causing a deepening of the nasolabial folds, dark circles beneath the eyes, and the development of marionette lines from the corner of the mouth to the jaw line.  The jaw line becomes less defined as the sagging facial soft tissues drop below the mandible causing jaw line “bubble.”  In addition to the sagging soft tissues aging always involves a loss of volume and a loss skin elasticity.  It is the surgeon’s charge to address individual manifestations of aging for each component part of the face.  Elevating the soft tissues must be done and requires a specific vector or direction of elevation which may be unique for each face.  This maneuver defines the jaw line, improves the deep nasolabial folds, addresses the marionette lines, and elevates the lower eyelid skin.  This procedure is always required and must be performed accurately with minimal incisions.  Elevation of the cheek tissues is so important that it must be done under direct vision with the results being technique dependent.  The incisions are much less obvious than the old facelift scars.  While elevating the cheek and malar tissues some augmentation of the malar prominence (cheek bones) is achieved.  The need for additional volume can be affected by adding autogolous fat to the procedure.  As a rule of thumb, we rarely, if ever, remove fat from the midface but frequently add fat back to replace the soft tissues we lose over time.

The next issue to be addressed is the blending of the cheek elevation with the lower eyelids.  These procedures are typically done together; that is lower blepharoplasty and midface lift.  The elegance and effectiveness of the midface lift sets up the rejuvenation of the remaining parts of the face.

Dr. Paul Howard

Read more about Dr. Paul Howard’s minimal incision face lift with no general anesthesia.