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10 Key Facts You Should Know About Face Lift Surgery

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John Q. Cook, M.D.

Chicago 312-751-2112
Winnetka 847-446-7562

10 Facts About Face Lift Surgery

At its essence, facial rejuvenation surgery is the restoration of the dynamics and vitality that make youthful faces attractive. This section of the website concerns itself primarily with those operations that affect the upper cheek, the jaw border, and the neck.

In a simpler and less marketing-oriented era, these procedures were usually called face lifts and neck lifts, but now it seems each surgeon must come up with a catchy name that imbues the procedure with a sense of magic.  Many of these names focus on trivial issues such as the incision length or the mechanics of the “lift.” More important is the surgeon’s ability to achieve an understanding of how the three dimensional form of the face changes with the aging process and to develop a plan of restoration that is based on this understanding.  Most of the strange or disappointing results that occur after this type of surgery derive, in my opinion, from a fundamental failure of artistic conceptualization on the part of the surgeon.

This is incredibly powerful surgery in that it affects how others perceive us and even how we perceive ourselves.  I am humbled by the trust my patients place in me; that trust drives me to seek better understanding, better solutions.

  1. Facial rejuvenation surgery is a nuanced fusion of technique and artistic expression.
    The skills and sensibilities that are necessary to produce consistent high quality results in facial rejuvenation surgery require years of refinement.  Surgeons who shortcut this process do themselves and their patients a disservice.
    There is a remarkable beauty and complexity to the organization of the facial structures.  The surgeon should approach these structures with a respect that borders on reverence.  It is naive to think that the nuanced techniques necessary to address these structures can be easily mastered.   There is no endpoint in the process of technical refinement.  I believe that the surgeon learns something useful from each person that he cares for.  Every patient on whom he has performed surgery in the past contributes to the quality of the outcome of the current patient.
    Technique alone is sufficient for many kinds of surgery, but it is only the first step in facial rejuvenation surgery.  The amplifier of technique is artistic vision.  I am now going to say something that is a bit controversial.  As I look at articles in leading plastic surgery journals I am often struck by how horrible the “after” pictures of facelift patients appear!  The faces look different, but they don’t look better, and they certainly don’t look younger.  The surgeons who have written these articles often have impressive academic credentials and are technically proficient.  They haven’t harmed the faces in the way that a poorly-trained or disrespectful surgeon might do so, but the fact that they present these pictures as examples of their work makes me wonder about their artistic side.
    Artistic sensibility is inherent but can also be refined and strengthened with exercise.  Just as advanced practitioners of meditation techniques extend their perceptions, so can any artist who is involved in the creative process.  For each generation the artistic vocabulary changes, but the fundamental truth does not.  For plastic surgeons the first level of artistic visualization comes when the surgeon has internalized a vision of beautiful facial form.  The second more difficult level comes when he begins to understand the internal logic of each face and how it demands its own solution.
  2. Facial rejuvenation surgery requires an advanced understanding of the dynamics of facial aging and a highly individualized approach to each patient.
    Many of the less successful outcomes of facial rejuvenation surgery derive from a fundamental failure of diagnosis.  This surgery should not be about pulling the cheek skin back toward the ears and emptying out the fat from around the eyes.  The drawn, sunken look that results from this type of facelift and eyelid surgery cannot remotely be considered young or vital.  Then there are the various gadgets and threads that are supposed to tighten the skin.  This represents a conceptual step backward to a 1960’s concept of face lifting as a skin pulling or tightening procedure.
    When we age, the deeper structures of the cheek and neck descend in paths that are generally predictable, but with specific variations for each face.  An effective facelift should reverse this structural descent.   The goal should be to restore key curves of beauty and definition to their original position.   A face that has been restored in this manner will not look strange or different to the friends of the patient, because they have already seen that face before.
    An accurate diagnosis of facial aging must also include considerations of volume.  If bone structure provides a face with its defining foundation, and skin provides its surface, then fat provides its attractive soft curves.  In retrospect it is hard to understand why for so many decades surgeons focused exclusively on removing fat from the face rather than enhancing it .  All the while there were the Katherine Hepburns of the world who were noted to age remarkably well.  Just look at the cheeks of Katherine in her sixties and even her seventies!
    One of my patients who is now a convert to fat volume restoration suggested that part of the problem is that the word fat carries negative connotations for so many of us.  We do become increasingly efficient at storing fat in certain problem zones of the body as we age.  Those of us who have devoted countless hours at the gym to eliminate undesirable bulges across the waist or hips have a hard time believing that we would want to add fat anywhere.
    For many patients a loss of fullness in key zones such as the upper cheek, the jaw border, and the supporting regions of the lips precedes significant structural descent or loss of skin tone.  The best answer for these patients is often volume replacement and nothing more.
    I hope that this discussion makes it obvious why assembly line face lifts are certain to be a failure.. There is no “one size fits all” facelift.  The surgeon who is serious in his approach to facial rejuvenation must consider the interplay between three key variables: skin tone, deep structural descent, and volume loss.  For each patient and in different zones of the same patient’s face, the relative importance of these variables will be different.
  3. There is no single solution.
    An individualized approach to each patient requires individualized solutions.  One of the reasons that I find facial rejuvenation surgery so captivating is that you never stop learning from your patients.  The only practical limitation is one’s own perception and imagination.  The face is so nuanced, that you could spend a lifetime studying it and really just be at the beginning.  All of the subtleties of facial contour, motion, and tone demand the surgeon’s respect.
    I am helping my patients the most when I have a repertoire of face lift techniques.  This repertoire has grown with each passing year.
    Unfortunately we live in an era of hyper-aggressive marketing.  Some surgeons insult their patients’ intelligence by placing undue emphasis on one aspect of technique and implying that this will be the final solution to facial rejuvenation.  For example, some surgeons prattle on about short scar facelifts or s-lifts, as if these are remarkable innovations.  In fact, variations of these operations were described in the 1920’s and before.  As we have already seen, skin removal is often the least important element in facial rejuvenation, so to place the entire emphasis on where incisions are made really takes the focus away from what is truly important.  The first thing that anyone who is serious about facial rejuvenation will tell you is that each patient needs an incision that is appropriate for him or her.  For some patients, the scar will be quite short; for others it will be longer.  This does not lend itself to catchy phrases for marketing, but it is the truth.  Remember too that a short scar produced by an unskilled surgeon is usually much more noticeable than a longer scar produced by an expert.
  4. Facial rejuvenation is about much more than tightening the skin. It is about restoring facial structures and volume to the position of dynamic harmony.
    As a face ages it may present subtle miscues to those who observe it.  Patients often tell me on their initial consultation that even their best friends and spouses misperceive their attitudes and emotions.  People ask them, “Are you feeling tired?” or “Why are you so angry with me?”  when they are not feeling that way at all.
    When we look at a face, our eyes naturally scan specific regions that are rich in information, so that we can determine that individual’s state of mind.  These regions include the corners of the mouth and the zones around the eyes.  People who are particularly good scanners of this type of facial information are often said to be gifted at reading other people’s emotions.
    As facial structures drop and facial regions lose their curves and volume, the resting attitude of the face may assume a sad or angry posture.  The dynamics of facial expression are also altered.  It may become more difficult for the face to convey subtle nuances of emotion, and certain expressions may require greater effort than before.
    It is my firm belief that when facial rejuvenation surgery is properly performed, it moves the face closer to its unique signature or identity.  This may also produce a beneficial feedback mechanism in the people who perceive that face.
  5. Facial rejuvenation surgery should never produce a mask.
    The process that allows us to recognize a face is complex.  I believe that there are both static and dynamic components to facial identity.  Surgical and non-surgical treatments can alter these components for better and for worse.
    What is a bad facelift or bad Botox®?  We can find plenty of examples if we turn on the television or go to a charity benefit party in a big city.   There is something awry in the posture and motion of these faces.  Sometimes the effect can be quite disturbing.
    On the other hand, a face that has been skillfully rejuvenated will call out to others in a different way.  A properly rejuvenated face will look more vital, softer, healthier, and more expressive.  It should not look manipulated.  The first thought that will occur to a friend is that you look rested and full of energy.
    Let me better explain for you what I mean by static and dynamic facial identity, so that you will understand why it is important to consider them in any form of facial rejuvenation surgery.  Static facial identity is the equilibrium position of the face, the resting posture that the face assumes when we are not in a process of active expression.  You might say that this is the posture that the face assumes during a moment of pleasant relaxation.    It is also the posture of the face when one engages in various relaxation techniques or in meditation.  As we have already seen, the aging process frequently alters the position of static facial identity, so that it may not appear “rested” or relaxed to the outside observer.  This may create an undesirable feedback loop between a person and those she interacts with.  If the resting position of the face conveys the impression of fatigue or anger, then the response of the outside world may cause that person to move the face out of its position of relaxation.  It is my opinion that this maladaptive response can have undesirable consequences and lead to a person feeling less relaxed.
    Dynamic facial identity comes from signature patterns of facial motions.  Some of the motions may be compensatory.  As we age and our facial structures descend, it is natural for us to animate in ways that bring our brows, our cheeks, and our lips into the positions that they once occupied.  There is a paradox, in that what once occurred with maximum relaxation now requires an effort.
    The core of dynamic facial identity is not compensatory.  It is learned from our parents and those who are key to us when we are little.  It is developed to a degree by imitation as we begin to copy those whom we admire during our adolescence and teenage years.  It is really a complex layering of experience that orchestrates the motion of facial identity.
    The importance of the dynamic facial signature is demonstrated by an experience that is universal.  An individual walks toward us in a crowded airport.  Deep in her own thoughts, she has not made eye contact with us.  Is this our friend whom we have not seen for several years or someone who looks like her?  We call the friend’s name, and as her face animates there is either a flash of recognition or an embarrassment.  The moment that the face animates, we know for certain whether it is or is not our friend.  We could not describe precisely what has happened, but we have searched for our friend’s signature of dynamic facial motion.
    These observations have relevance to any patient considering facial rejuvenation of any sort, surgical or non-surgical.  The surgeon who chooses to do this work carries a responsibility.  He does not have the right to be oblivious to issues of facial motion and posture.  Rather than creating a mask that obscures our facial identity, he should amplify and restore that identity.
  6. In the overall analysis, volume is as important as structure.
    During their consultations patients often tell me that they feel that their faces have become increasingly harsh in appearance as they age.  It is as if something that gave the face a wonderful softness has been diminished.  What these patients have perceived quite accurately is that their faces are losing volume in key zones of beauty.  This has the effect of throwing the face out of balance.
    One of the first zones in which patients notice change is the upper cheek.  Just look back at your high school or college yearbook.  Look at the wonderful curves of the upper cheeks, even in relatively thin faces!
    Even in their thirties many people begin to lose the unbroken curves of their upper cheeks.  What was once a smooth curve becomes visually fragmented and hollow.  As the upper cheek loses its fullness, the structures of the lower eyelid are unmasked.   If a surgeon does not appreciate these issues he may compound the problem by performing an overly aggressive lower blepharoplasty.  If too much of the natural lower eyelid fat is removed, the lower eyelid structures are reduced to the level of the sunken upper cheek.  This gives the entire region a flat hollowed out look that simply cannot be considered rejuvenation.  In fact, the area is made less youthful in appearance by such injudicious maneuvers.
    One of the paradoxes of rejuvenation of the cheek-eyelid junction is that the addition of fat to the upper cheek reduces the need to remove fat from the lower eyelid.  In the vast majority of the lower eyelid surgeries that I perform I will do something to add volume to the upper cheek.  It helps to restore the “magic” to this key expressive area and allows me to avoid the creation of a hollow eye.
    The supporting zone around the lips and along the jaw border is also subject to volume loss, usually a little later than the upper cheek.  If this area is not addressed as part of an overall strategy of facial rejuvenation, the lips will look strangely out of balance when the cheek is lifted.  Just as with the cheek-eyelid junction, for decades many doctors really have focused on the wrong thing when it comes to the lips.  All that they could see were the creases and lip lines.   This led to extremely harsh methods of treatment- very deep dermabrasions, laser treatments, and chemical peels.  In order to have much of an effect, the treatment has to go so deep that the pigment structure of the skin is permanently altered.  I have seen many a “laser cripple” who can never leave home without a thick layer of makeup, to avoid detection of her “white moustache” of de-pigmented skin.
    A better answer for most people with lip volume loss is a combination of therapies.  Deep volume loss is addressed with fat transfer; issues closer to the surface are addressed with Restylane®, which is none other than the substance that naturally provides volume and resiliency to the deeper layers of the skin and tends to deplete with the aging process.  Gentler surface treatments can then be done to soften the remaining creases and wrinkles.
    Of course, the techniques that we use to restore volume to zones of the face can produce ridiculous results if the hand that does the injection is not linked to a mind that has judgment and experience and an eye with a good artistic sense.  I am absolutely baffled by some of the lips that have been created for certain people in the entertainment industry.  Lips are not supposed to look like cocktail sausages!
  7. Facial rejuvenation surgery can help to maintain the balance between a dynamic body and a vital face.
    At a health club where I work out I recently overheard a conversation between two women who were observing a friend as she ran around the track.   “Mary is working out a little too much.  Her face is starting to look terrible.”  This snippet of conversation points to a mean little paradox of healthy aging. Beyond a certain age, those of us who keep our bodies trim and fit tend to look gaunt and hollow in the face.  The very energy that we put into maintaining optimum fitness seems to rob our face of its vitality.
    Facial rejuvenation surgery really comes to the rescue in a situation like this in that it frees us from the necessity of choosing between a beautiful body and a vital facial appearance.  When volume and balance are restored in a face, harmony returns between face and body.
    In this sense, I believe that facial rejuvenation surgery can be an integral part of an overall plan for health and well being.  For many people facial rejuvenation removes a stumbling block on the road to fitness.  No longer does a person need to say, “When my clothes fit right, my face looks tired.”
    When the face is brought into harmony with one’s inner sense of vitality, a positive feedback cycle occurs that further encourages healthy habits.  This simple truth is the reason that I have maintained for many years that facial rejuvenation surgery, when artfully performed, can be part of a holistic approach to healthy living.
  8. Due diligence is an absolute necessity when you evaluate a plastic surgeon especially for facial rejuvenation.
    Medical marketing has exploded in the last decade, and this is particularly true in the field of cosmetic surgery.  There are good and bad points to this.  On the one hand, patients may be better aware of their range of choices than they were in the past.  It is easier to obtain relatively detailed information about various doctors on the internet, so that one can look beyond the immediate neighborhood when choosing a physician.  On the other hand, the doctor whose services you are buying may turn out to be very different than what he seems unless you really know what to look for.  Modern techniques of marketing can easily distract the patient away from meaningful credentials to meaningless ones. One of the most valuable services I can provide is to help the individual who is considering plastic surgery to distinguish between meaningful and meaningless credentials.
  9. The non-surgical facelift does not exist.
    I feel fortunate to practice in an unprecedented era of expanding possibilities for my patients.  We now have available a wide range of non-surgical options to soften and mitigate facial appearance:  everything from Botox® which selectively relaxes frown muscles, to an expanding array of fillers, to various therapies to improve the tone and texture of the skin.  I use these wonderful tools every day in my practice.  They fit in well with my emphasis on facial rejuvenation surgery, particularly for patients with early facial aging or for those with more advanced changes who don’t want surgery and are willing to settle for a more limited result.  I also use the adjunct techniques to fine tune and embellish my surgical results as part of a program of total facial rejuvenation.
    It disturbs me when certain practitioners imply that these adjunctive techniques can be combined in a way that will obtain results similar to those of surgical facial rejuvenation.  Those who make this assertion either lack honesty or at the very least insight.  Why is it that when I go to meetings in the United States and Europe and sit through hours of presentations, I never see results from these “non surgical” approaches that obtain a fraction of the power of a skillfully performed facelift?  Unfortunately, some doctors so believe their own marketing that they will give presentations where they sing the praises of their own work while the audience can’t tell the difference between the “before” and the “after” pictures.
  10. Optimum results occur when a top tier surgeon works with a team that is totally committed to patient care.
    The quality of your surgical experience is strongly influenced by the quality of the team that your surgeon has assembled to care for you before, during, and after surgery.   During your initial consultation you will have the opportunity to meet a number of these team members.  How they relate to you tells you much about the “soul” of the organization for which they work.  Look for people who provide you with a sense of   confidence, compassion, and service.   Avoid organizations that emanate a sense of the “hard sell.”
    The surgical experience has three distinct phases: the preparation phase, the surgical phase, and the healing phase.  A well-functioning team will extend your surgeon’s ability to optimize your care during each of these phases.
    The preparation phase begins with a detailed assessment of your overall state of health, nutrition, and fitness.  Patients who are fit and optimally nourished recover more quickly from surgery than those who are not.  We have found that the period leading up to surgery can be an invaluable “inflection point” for our patients.  The habits that we encourage in preparation for the surgery can stay with you after the surgery and provide as much benefit to you as the surgery itself!
    A great team is able to anticipate your needs and enhances your passage through the surgical experience in ways that pertain to a particular procedure, but which also relate to your distinct needs.  The simple, practical suggestions that they provide make the difference between a smooth recovery and one that can be frustrating.  Look for a team of individuals who are responsive and anticipatory during the preparation phase; these are the same individuals you will need to count on during your recovery.
    The surgical phase involves the operation itself.  It is the shortest and most intense phase of your surgical experience.  If you have followed my suggestions, you will have selected a leading surgeon to carry out the operation effectively and with artistic inspiration.  I know leading surgeons who operate in their own offices, in surgicenters, and in hospitals.  Regardless of the setting a truly leading surgeon will not allow for compromise in the quality of care.  It is not a trivial matter to put together a first rate surgical facility.  The team consists of recovery nurses, operating room nurses, surgical technicians, anesthesiologists and anesthetists.  How do you evaluate the quality of this team, since they may not be employed by your surgeon?  Look to section 7 of the companion piece, “Facial Rejuvenation Surgery – 10 Questions you should ask” that is available on this website.

The healing phase is significantly influenced by the quality of the team that cares for you.  For many years I have held to the principle that the critical first night after facial rejuvenation surgery needs the skills of a highly-experienced caregiver. In our practice you will spend the first night in a 5-star hotel in the same building as the surgicenters and care will be provided by an experienced caregiver.  This also allows for our clinical team to visit you the next morning in the comfort of the hotel room. Our goal is to provide you with a seamless continuity of care.  In the early weeks after surgery you will have frequent contact with the clinical team.  It is essential that every member of the team is imbued with the spirit of service and compassion.

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