The subject of facelift swelling is one that has driven a large part of my facelift procedures and practice over the last decade. It’s an easy subject to get your mind around because no one likes it, your reputation can depend on how much of it your patients have, once created it is hard to get rid of and regardless of how well patients are prepared for their surgery and the incumbent, yet evil swelling, they still feel like something is wrong when they have it.
For years all plastic surgeons thought that the swelling after a facelift under general anesthesia was a necessary evil and therefore spent little time trying to figure out what causes it and how to prevent it.
After years of failing to prevent swelling by doing small things that never worked like corticosteroids, drains, dressings, Vitamin K and dozens of other special medications and emollients. Being unwilling to accept failure, we started to question the basic tenets of doing a facelift. The most obvious and successful change was to stop doing general anesthesia for all facelifts. This was met with skepticism by many plastic surgeons that could not imagine operating on a patient for the hours necessary and have to deal with the anesthetic also. It was thought that the patients, usually a bit older than our average patient, wouldn’t or couldn’t tolerate the procedure “awake.” Concerns about the volume of anesthetic needed as it relates to toxicity and whether or not the entire face, neck and eyes could be rendered numb enough for surgery. All of these concerns quickly fell to the wayside; patients hated general anesthesia and the ability to anesthetize the face only required relearning all of the pharmacology of local anesthetics we learned in medical school. The only remaining question was whether or not the plastic surgeon (me) would exhibit patience in dealing with the conscious patient and subjugate the ease, comfort and lack of responsibility inherit in general anesthesia to the need and desire of the patient to have little or no swelling and a simpler, faster return to normal. The answer to the question for me was –absolutely.
From that point forward, we worked out the details of the sedation, the local anesthetic agents, monitoring and significantly changed the operation to accommodate the wishes of the patient which were primarily based on having minimal to no postoperative swelling. The accumulation of the techniques of anesthesia and its agents, sedation, operating room ambiance and the ability to perform a first-class and lasting facelift under these circumstances has led to what we call the Howard Lift procedures which include rejuvenating procedures for not only the face but the eyes, forehead, nose and neck. The Howard Lift is not necessarily a procedure but a new way to do facial procedures concentrating on minimal swelling leading to minimal downtime and a first-class, longstanding natural result.
Read more about facelift recovery.
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, eyelids, 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 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.
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.