This is a common question among people who are considering a facelift. When facelifts look “bad”, it’s usually because they look like facelifts instead of a face that exists naturally. In medicine we call these problems the “stigmata” of facelifts. As an Oculofacial Plastic Surgeon, I can tell you that it’s difficult to go out to an event – or even dinner -- without seeing at least one example that almost breaks my heart.
This is because the stigmata that screams, “I’ve had a facelift!” is almost always completely avoidable. Here are the problems I see most often:
1. A facelift was performed on significantly sun-damaged skin or skin that lost its collagen for other reasons, like smoking. This shouldn’t be done for two reasons. One is that there’s a disconnect between the perceived age of the skin and the perceived age that the contour is signaling. Also, the skin can get drapey looking once any swelling subsides. Thus, even if it’s subconscious, the observer is getting a what’s-wrong-with-this-picture message and that in turn stimulates a recoil reaction (it really does – there’s plenty of research on this). Second, and let’s be clear: a facelift will not pull the wrinkles out of your skin (at least not for long) even if it looks as though it should when you pull your face back with your fingers at home in the bathroom mirror. Wrinkles are from collagen loss in the skin and no amount of pulling can restore that. Collagen can be restored by other means, but that would not include a scalpel.
2. A facelift was performed without regard to the fact that significant volume had been lost in the face. This is a good part of why that “too tight” look exists or why a facelift can look like skin sitting right over a skeleton, the “Cruella de Vil” look. This can also result from the use of some outdated techniques. Arguably worse is when too much fat was injected, and it happened to “take” and the face looks disproportionate and like a chipmunk.
3. The person flexes their neck down and there’s that weird crease running up behind the angle of their jaw that just does not occur in nature. Again, poor technique.
4. The ears look strange. This can be what we call “pixie ears” (so very not as cute as it sounds) in which the surgeon has put too much traction on the skin and not enough anchoring underneath, causing the earlobes to pull down and almost disappear as they run into the jawline. Even more common is when the ears have been set too far forward and look pasted on. And even more common is a thick flap of skin right in front of the ear instead of that little dip that occurs in nature.
5. Easily visible scars. Everybody heals a little differently, but placement of the incision lines and a great deal of care in sewing those incisions closed is crucial. With rare exceptions, incision lines should be something noticeable only with a search. Furthermore, the incisions should be placed and closed so that the person with the facelift isn’t restricted regarding their hairstyle.
I do a significant amount of “revision work” in my practice on facelifts done elsewhere, and most of these problems at the very least can be improved. I would advise that seeing someone’s work tells you a lot more than their advertising, which can be woefully misleading. Also, the core specialties that are well-trained in doing facelifts are Oculofacial Plastic (or Oculoplastic) surgeons, ENT/Facial surgeons, and general Plastic surgeons. None of these specialties has a lock on technique, talent or most importantly, outcomes. (Some surgeons want to think their specialty does, but that’s just greedy, egotistical and political.) Your surgeon should come out of one of these three core specialties, but beyond that they should have the drive to keep up with this evolving field, the ethics not to cut corners or worry about their pocketbooks more than your well-being, a passion for their work and your result, and the artistic vision to know what your best version of yourself can look like and how to get there.
THE BIGGEST CONCERN ABOUT BOTOX: “I DON’T WANT MY FACE TO LOOK FROZEN”
This is a common – and certainly understandable – concern that newcomers to BoTox have expressed. Here’s the scoop:
For the majority of the muscles we treat, the aim is not to “freeze” the muscles but to relax them enough so that they don’t bulk up and create lines and furrows where they’re attached to the skin. Furthermore, we generally want to relax only those muscles that pull the face down and in (the sad, angry muscles), allowing the muscles that pull the face up and out (the happy ones) to stay strong and work unopposed.
There are some exceptions though. For instance, the muscle in your forehead (the frontalis) that raises your eyebrows and creates those horizontal furrows also happens to be the only muscle that keeps your eyebrows from sinking down to your kneecaps. Relax that muscle too much and you can look a bit Neanderthal-esque. An experienced doctor who knows what she’s doing will be able to find that “sweet spot” in terms of BoTox dosage and placement to relax the furrows without dropping the brow.
We can do some wonderful things with BoTox. If your doctor has an intimate knowledge of facial anatomy, a lot of experience and a truly aesthetic approach to the face, there never should be a compromise to your expressiveness. Also, find someone who is willing to take the time to assess your needs with you, explain their plan of treatment and follow up with you to make sure you’re happy with the result.
And remember, if you stumble into a bad treatment, it does wear off.
1.You have significant vertical “bands’ at your neck.These bands, sometimes called a “turkey wattle”, are the edges of a neck muscle (the platysma muscle). If the bands are very small, sometimes they can be kept at bay with BoTox, Pelleve or Ulthera, daily passive stretching of the neck or a combination of these; however, most of the time they require surgery to fix them definitively.
2. Your general facial shape looks as though it’s shifted from oval or heart-shaped to square over the years.This is gravity at work, and a good facelift will shift that contour change back so the fullness is through the midface and not hanging from your jawbone.3.Your skin is in good shape and it’s the falling of the lower face and neck that’s the problem, not wrinkles.No matter what misleading advertisements you may have seen, a facelift is not going to change your skin texture, at least not after the initial swelling has gone away. That’s what lights and lasers are for – shrinking and resurfacing the skin – and rebuilding collagen and elastin. Wrinkles occur from DNA changes in the skin along with breaking down of the collagen and elastin. Surgery with a scalpel won’t change the skin. A lift is exactly that – it will pick up what has fallen down, but it won’t alter the make-up of your skin.4.When you cup your hands under your chin (so the wrists meet), place your fingers on the sides of you face and then lift up gently, you look much better. Don’t worry about the wrinkles you push into being at the sides of your eyes. You’re pushing; a facelift is shaped from the inside out and nothing is pushed, so unless your skin has lost its elasticity (see above), a well-performed lift won’t leave you with more wrinkles there than you had before the lift (although a bad one certainly can).5.Generally, you’re at least 45 years old, and more likely over 50.Nothing is without exceptions, and genetics and lifestyle choices can always throw off the norms. That said, I’ve seen way too many women in their early 40’s (one was even 36!) who had been advised by plastic surgeons that they needed facelifts when all that was going on was some volume loss. On the other hand, I’ve seen a lot of women long past their forties who really needed facelifts, but they had been pumped up with fillers until they looked stuffed. (See my blog, Jowls: Facelift or Fillers?)If you think you might benefit from a facelift, look at these five indications and then have an evaluation by someone with the skill, the artistic vision and the integrity to advise you properly and make you your most beautiful. Click here to contact us for an evaluation appointment.
My father always said that getting older is much better than the alternative. To rephrase the sentiment, when my patients bemoan their advancing age (and this often starts in their thirties) I tell them that we all have a turn at being a particular age -- unless we don't, which is not a terrific option. One of my favorite axioms is from a good friend who opined that "old" is always 15 years older than your present age. Since my patients range in age from their mid-twenties to their mid-nineties, I can attest to the truth of that.
What most people are really concerned about are all the associations we have with aging, and usually that would be a slow decline into feebleness and drooling insensibility. The good news is that our whole paradigm around that picture has changed radically over the past few decades. There has been a shift even in the past 10 or 15 years. As I've often advised my patients, anyone who is a toddler right now may very well grow up thinking grandmothers can be a blast to spend time with -- not to mention, really hot-looking. I surely have a bunch of those in my practice and they are an inspiration to us all!
Here in Sarasota where people more often than not come to have a ball rather than to fade away as they get older, we have a perfect observatory for examining what is at work in aging fabulously versus not so fabulously. Let's start to take a look.
This is not a Pollyanna-ish thing, but acknowledging its importance is absolutely fundamental. On a physiologic level, things work a bit like this: If you routinely see the glass as half empty, not only are the endorphins ("happy" peptides that are secreted in the brain) not being secreted, but there's something else going on as well. Negative thoughts actually can place the body in a state of inflammation. This in turn causes aging of the cells in the body. Life is full of stressors for all of us. This can be anything from a careless remark that hurts to an entire range of family problems, a health issue or someone trying to destroy our life and/or our career. Remember that there are always things over which we have no control. We certainly have no control over what other people do. What we absolutely do have control over is how we respond to it. And this is where we have to be completely honest with ourselves and decide what that response is going to be. Given a perfectly normal period of anger or hurt, ultimately we have a choice between crawling under the bed and sucking our thumb, being mad at the world or dusting ourselves off and moving forward. Moving forward generally involves either attempting to rectify the situation or accepting it. Books are written on this, professionals are trained to help people with it and there is always at least someone who will be on your side. But ultimately, it's just really your call.
I remember during a particularly devastating time in my own life (I'm writing a book about it), I decided to take stock of it all. I bought one of those little journals with the blank pages. It had a muted pink linen cover with a beautiful botanical drawing on the front. This was to be my "grateful book". I began listing all the things for which I was grateful, even though I was feeling crushed by life at the time. Each entry was numbered: 1.I have a 3-digit IQ 2.I have the use of both arms 3.I have the use of both legs 4. There is a ceiling over my head 5.It is attached to a ceiling over a kitchen 6.In which there is a refrigerator 7.With food in it….You get the picture. Before I knew it, there were over a hundred items on that list. I just made it an exercise to review that list every morning. I pass this on because it was immensely helpful and so healing that it compelled one friend to say, "You're just like one of those Bozo the Clown toys. You get punched and then just pop up again." "Gee, Bozo the Clown," I replied, "I haven't had a compliment like that from a man in ages!"
That exercise was difficult at the time, but it was good medicine. More later.
To a certain extent – and within reason – that’s true. As you can well imagine, it’s certainly more likely that we’ll get a more youthful look with a more youthful patient. Regarding the longevity of the result, the more healthy the tissue on which we’re working, the more likely it is to retain the results of the surgery, and younger tissue often translates to more healthy tissue. Also, it has been shown that younger people generally tend to be happier with smaller levels of rejuvenation than older people are with even more dramatic levels of rejuvenation.
That being said, volume loss and sun-damaged skin are better treated with volume augmentation and lasers respectively than with a facelift. Both of these conditions tend to show up earlier than the conditions that are best treated with a facelift, those being the effects of gravity, accumulation of fat at the jowl areas, and stretching and shifting of connective tissues beneath the skin.
Remember too, that any invasive procedure will alter the anatomy somewhat. Structures are moved and stitched into a different position, and the nature of some of the operated tissue changes just by virtue of the natural healing process. So the fewer times someone has a lift over the course of their life, the lower the risk of complications.
Chronological age has less to do with age than individual genetics and lifestyle choices. I remember one day when I was operating, I had a 48 year old and a 64 year old back-to-back. The scrub nurse commented that even before the surgery, the 64 year old looked closer to 48 and the 48 year old looked closer to 64. The bottom line is that “how old” we look is becoming less and less a matter of numbers.
Lastly, make sure your doctor is someone whom you can trust to have your best interests in mind. A couple years ago I had a patient from out of town who had been told that she needed several things done including a facelift, and the fees came to well over $17,000. She was a beautiful, fit 36 year old with a slight genetic obliquity under her chin rather than the well-defined angle we associate with a young neck. She also had some early hooding at the upper lids and the beginning of some volume loss between her cheekbones and her nose. She had absolutely no indications for a facelift, much in keeping with most women that young. I gave her the contour she wanted at her neck, restored her upper lids and gave her some volume where she had lost it for way less than what she had been quoted and with much less invasiveness.
I have received many compliments on how smooth my skin is. Of course, that's our secret.
Thanks & Hugs,V.
There can be unfortunate results with any filler, but some of the same qualities that can make Radiesse more desirable for certain applications are the same ones that also can be problematic.
First, just to clarify things for those of you who may want a little background, the most commonly used fillers are hyaluronic acid-based. Hyaluronic acid (HA, sometimes referred to as hyaluronate) is a sugar that is found naturally in the body. There are various incarnations of this, most commonly Restylane, Perlane, Juvederm and the fairly new Belotero. Radiesse is made of calcium hydroxylapatite (CaHA), another compound found in the body in bone. Contrary to some Internet silliness that was floating around in the past, Radiesse will not “turn into bone”. It eventually breaks down into calcium and phosphate, substances that you take into your body every day.
Radiesse is an excellent filler in several ways. It’s relatively thick, so for any given amount of volume that’s administered, we just seem to get more fullness than with the hyaluronic acid fillers. Secondly, it’s a “biostimulator” in that it stimulates collagen quite actively. The hyaluronic acid fillers do that a bit, but not as much as Radiesse, which does that by design. Also, in most people it seems to last longer than the hyaluronic acid fillers.
As with any substance taken into the body, there are rare instances of a sensitivity to the product, but in all the injections I’ve done over the years (usually several each day), I’ve seen only one patient in which I suspected an allergy to Radiesse. Also, with anything injectable, strict attention must be paid to cleanliness to avoid the possibility of an infection and your doctor must be eminently well-versed in the minutiae of facial anatomy – and delicate in technique – to avoid injecting the product into a blood vessel or placing it so that it presses enough on one to cut off the blood supply.
But as for Radiesse in particular, it should never be injected into the lips as the movement of the muscle tends to form nodules. It also is, in my opinion, too thick to be injected into superficial wrinkles and is best used for contouring. The main problem I tend to see is overinjection or poor placement. The longevity that makes Radiesse such a great choice as a volumizer can make it especially frustrating when someone comes in with too much of it and/or poor technique as it can seem like an eternity waiting for it to break down and go away. With the hyaluronic acid fillers, a benign enzyme (hyaluronidase) can be injected with a satisfyinly rapid dissolution of the product.
My first encounter with a lovely patient of mine, her equally lovely friend and her father was where they had all been terribly overinjected by a well-trained individual who had gotten these patients to the point where I drove home in tears that evening, wondering how this could have been allowed to happen. The friend had been given Radiesse to the mid-cheeks to the point where it looked totally out of proportion and Perlane had been given to a depressed scar near the nose, creating an elevation where there had been a depression. I injected a little hyaluronidase to the elevation and it deflated rapidly, allowing me to fix the scar in a timely manner. But it was a waiting game with the Radiesse over a period of months with her and with the two other patients. So the bottom line here is that the advantage of Radiesse is that it tends to go further and last longer than most of the hyaluronic acid products, but it is less forgiving and requires, I believe, perhaps a more accurate “eye” along with considerable skill and experience for an optimal result.
Lastly, and I haven’t seen a whole lot written about this, but if you’re on Actonel (risedronate) for bone density, it may eat up your Radiesse. Medications such as Evista (raloxifene) have a different mechanism of action and won’t affect the Radiesse. Fosamax (alendronate) has the same mechanism of action as Actonel, but it just doesn’t seem to affect the Radiesse in my experience. I had a number of disappointed patients early on, who came back after about a month and said, “I thought you told me this would last longer…” and I gave away an awful lot of hyaluronic acid filler feeling like a horrible person, until the common denominator became clear.
Dear Dr. Barbour,
The two words Thank You cannot begin to express how grateful I am to you for all the TLC you have extended to me over the past several years.
As you well know, I underwent a botched lower lid surgery that left me with a large bag under each eye. After months of discussion with the surgeon who performed the procedure he did not offer me any correction procedure I was comfortable attempting. All trust and faith in him had totally diminished and I was exhausted from frustration and crying.
Totally deflated, frustrated and not wanting to look in the mirror, I went running; not walking to several of Sarasota’s self-professed best-of the-best in the plastic surgery field. At the suggestion of one of them I even traveled as far as Atlanta to consult with a renowned plastic surgeon. The “fix” offered by each and every one of the surgeons’ I consulted was to cut, cut, cut, cut, cut. Why didn’t it make sense to any one of them that after a cuttingly bad surgery experience I was not interested in going “under the knife” once again?
One day while speaking with a dear friend of mine, she mentioned she recently consulted with you about Botox, fillers, etc. She had you perform her procedures and was very happy with the results. Knowing my friend as I do, I knew she had done her homework before letting anyone touch her face. Note: I thought I had done my homework, too prior to my surgery. My friends’ looks greatly improved while mine continued to deteriorate. What did I have to lose by going to see you for a free consultation?
Feeling deflated, frustrated, looking tired and feeling ugly for the first time in my life, I was immediately comforted by the relaxing surroundings I found myself in when I entered your office. Oh so soothing and knowing you as I do now; a true reflection of your approach with your patients; relaxed and confident.
When I met you, I was immediately taken by your calming demeanor. You asked the right questions, answered my questions and above all you listened to me … what a novel concept! You were the first ocular plastic surgeon to offer me an alternative procedure. No cutting involved! The procedure, you felt confident, would improve (help correct) my bags and could done with a laser in your ever so immaculate surgery center located within your office. No scalpel, no stitches, no pain. I was convinced you were going to help reverse the life changing results of my botched surgery.
The rest as they say is history. The procedure was a breeze … good drugs! The compassionate care I received before, during and after, simply the best. But it’s the results of the procedure you performed that not only greatly improved my bags but did so much more than that. Once again I can look in the mirror without being mad at myself for making a really bad choice of surgeons to begin with, without feeling like I look tired all the time and worse … ugly.
You are still my go to plastic surgeon. The doctor I trust to give me Botox and fill my wrinkles and hollows. I respect you and admire you for the competent woman, artist and doctor you continue to be. Your sense of what is esthetically pleasing to your patients and the eye is amazing! It is my pleasure to say I know (of) you and trust you with my face. I will always highly recommend you to family and friends and even to strangers for that matter.
Please forgive the amount of time it has taken me to write this long overdue Thank You note. I am eternally grateful to you and your staff for all you have done for me over the years and look forward to all you will do for me in the years to come.
Keep your passion for what you do, stay as honest with all your patients as you have been with me. Promise to do your best as it’s all anyone can expect of you. My dear Dr. Barbour you are yet another reason I believe there are no coincidences in life, miracles happen and angels really do exist right here on earth.
Oculofacial Plastic Surgeon, Sarasota, Florida
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