5 Facial Plastic Surgeon Approved Alternatives to a Facelift – by John Kang MD

“5 Facial Plastic Surgeon Approved Alternatives to a Facelift”

There is no procedure out there that can best an artfully performed facelift surgery ideally designed for the patient’s unique anatomy and individual aging changes. Unfortunately many facelifts performed out there can still yield a cookie-cutter result where the outcome may look great in one individual and not so great in her friend, even when performed by the same surgeon. Worse yet are cases where patients prematurely go under the knife to prevent aging changes and end up regretting their decision due to loss of their natural essence or personae.

For those savvy, perceptive patients who fear less than an ideal result from a “cookie-cutter” facelift surgery; for those who wish to preempt the inevitable aging changes without prematurely undergoing a facelift surgery; for those who previously underwent a facelift surgery and wish update improvements without undergoing another surgery; for those who simply don’t have a week or longer to recover from a facelift surgery; for those who fear general anesthesia or even twilight sedation; for smokers who face greater risk of complications from undergoing facelift surgery; for those who can’t budget for a facelift surgery, there are finally time-tested, FDA approved alternatives to a traditional facelift surgery which Surgeons can provide to their patients. In this article I will be discussing some of the more popular alternatives offered at my clinic.

The five alternatives to facelift surgery I utilize in my office are Thermage, Ultherapy, Thread lifting, Fillers, and two “Mini Surgery” procedures consisting of 3-D volume restoration and re-contouring using fat transfer and lower eyelid fat bag removal using transconjunctival approach.

Very often these modalities are utilized in synergistic combinations for the individual patient’ s needs to achieve optimal outcome. The combination utilized are based on understanding of the individual patient’s inherent bony and soft tissue anatomical foundation and accurate analysis of the aging changes which have taken place. These aging changes can be usually correlated to patients age, ethnic background, and genetical and environmental factors.

Thermage and Ultherapy are both energy based lifting devices which work by sinking RF (Thermage) or Sonar (Ulthera) energy to heat up the collagen and tighten the connective tissue below the skin. These are ideal in those patients who feel the collagen in their soft tissues are getting too soft and gravitating downward, which can be felt even in early 30’s for some patients. Both machines have enough nuances that the Surgeon needs to be well versed in the optimal use of the machines and in whom to match with which machine. These machines are favorites as stand-alone procedure in patients who are in their 30’s to 50’s. Often they are used in conjunction with Botox and Fillers to achieve greater synergistic effect.

In patients from 40’s and up who note sagging of mid-face with steady deepening of the tear trough, nasolabial, and marionette line as well as appearance of the dreaded jowling and neck laxity, either Thermage or Ultherapy is recommended to tighten their native collagen in the soft tissue. But to achieve further lifting , thread lifting using either Silhouette Instalift or Novathread is recommended. The trick to a successful thread lifting is understanding the nuances of the mechanism and strength of the threads and creating proper vectors and anchors to create a subtle but definite and natural lift. After completion of one side, patient is brought up to a sitting position so patients can directly visualize and compare the lifted vs unlifted side as well as with their pre-operative pictures. Due to nearly no bruising and swelling, some patients resume their full activities and return to work or dine out on the same day. However we ask our patients to reserve a day or two to recover just in case they run into some swelling.

If the patient also has significant loss of facial volume beyond the reaches of a few tubes of Fillers, 3-D facial volume restoration and re-contouring with fat transfer is also recommended. In my clinic fat transfer is usually done under local anesthesia and due to nearly no bruising, recovery is usually no more than a few days. Likewise if a patient presents with lower eyelid puffiness which is severe enough to be seen even from across the room, lower eyelid surgery can be performed under local anesthesia with nearly no bruising, allowing recovery period to be no more than a few days to a week at most. Incorporating these two “Mini Surgical” procedures in my repertoire of alternatives to facelift surgery is imperative in my practice because in my opinion, the appearance of the fat bag under the eyes and loss of facial volume are truly the initial signs of aging changes visible in patients as early as late 20’s and early 30’s. Not a week passes by with patients coming in wishing some type of “lifting” surgery due to their “tired” and “gaunt” appearance when in reality, lower eyelid surgery is what they needed to rid of their tired look due to puffy eye bags and volume restoration and re-contouring with fat transfer is what they needed to rid of the gaunt and elongated look. This approach shares the same concept as the “liquid fit” using fillers that most patients are familiar with. But if a few 1cc tube of fillers can be helpful, imagine what 30cc or 40cc of fat transfer can do in terms of restoring the lost volume and re-sculpting and re-contouring the face back to much more youthful days. I feel the true sculpture in me is defined by what I can achieve with my fat transfer.

I will go through a few patient scenarios I have encountered in the past few months.

Patient #1 is a 61 year old female who came in wishing to look better a week before her daughter’s wedding. She had a very busy week ahead of her so not even a day to recover. She didn’t like the tear trough under her eyes as well as the ever worsening nasolabial line and jowling. Worst yet were the sunken in appearance of her cheek bone making her look tired. Her budget was very limited as most of her savings went to helping with her daughter’s wedding. After careful discussion, she underwent a 1.5 cc Radiesse injection to high light her cheek eminence as well as to fill out the hollowing of her cheeks. In essence the Radiesse was used to create a “liquid” lift. Another 1cc of Restylene was used to fill along the hollowing in the tear trough area as well over the nasolabial line which further provided an optical sense of mid-face lift. She was also given some Botox to smoothen the crow’s feet and frown lines; and, at the same time providing a slight lateral brow lift and thereby a subtle improvement to the lateral hooding of her upper eyes.

Patient #2 is a 55 year old CEO of a large real estate company. She was invited to a Gala event in Paris coming up in a few weeks and needed to look her best. She doesn’t believe in undergoing any form of lifting surgery but is willing to try anything else to improve her ever worsening facial and neck laxity and marionette line. After careful discussion, she underwent Ultherapy to her cheek and jawline, then her upper and lower neck, followed by her lower eyelid, brow and forehead. On the same day, she underwent Silhouette Instalift to lift her jawline and mid-face and soften her marionette line. Additional Novathreads were used to tighten her neck line. Finally 1.5cc of Radiesse was used to enhance her chin and 1cc of Restyene was used to further smoothen out her nasolabial and marionette line. On follow up phone call the following day, she was able to resume with her busy schedule and was quite satisfied with her outcome. She looks forward to all the picture taking sessions at the Gala in Paris.

Patient #3 is a 42 year old accountant who came in for a consultation to learn about the various face lifting procedures available to get rid of her tired and fatigued look. She was mentally more tired from hearing from friends and colleagues that she should smile more often because otherwise she looked cross and angry. She was previously a model with a well defined cheek bone and relatively strong jaw line. No jowling nor neck laxity was appreciated. Her eyes still showed plenty of sparkle with early sign of lateral hooding, but was more dominated by the severe puffiness in her lower eyelids. Upon further discussion, she has gone through nearly six month of personal issues and had lost close to seven pounds which consequently has made her cheek more sunken in, made more dramatic by her well defined cheek and jaw bones. Indeed upon her simply smiling, her lower eye muscle was able to tighten enough to push the puffy fat bags in while her smiling cheek provided more pleasant fullness to her otherwise hollowed out gaunt appearance. After careful discussion, she underwent the two “Mini-Surgical” procedures consisting of removal of lower eyelid fat bags via trans-conjunctival approach to rid of puffiness to her eyes followed by 35cc of fat transfer to various compartments of her face, previously harvested from her lower abdominal area. Both procedures were performed under local anesthesia in less than a few hours. She had minimal to no bruising but due to progressive swelling over the next few days, she was instructed to recover at home. Because she worked as a partner in a large CPA firm, she chose to work out of her home for the remainder of the week, but was able to resume her activities within a few days. When she returned back to work the following week, people noted she looked well rested from her much deserved vacation, but otherwise were clueless as to her actually undergoing her “Mini-Surgical” procedures.

Patient #4 is a 35 year old school teacher who noted that her round face was getting more wider and heavier, especially when taking pictures on her smartphone. She is careful with her diet and no weight gain is noted over the past few years. She knows she can never have a V line due to her full face, but would like to halt further widening of her face if not appear a bit more lifted and slimmer like she used to look a few years back. Upon further conversation, she grinds her teeth and wears a night guard. After careful discussion, she underwent Botox to reduce the Masseter muscle hypertrophy from her teeth grinding which is also therapeutic to minimize damage to her TM joint. In addition she underwent Ultherapy using both 3mm and 4.5 mm transducers to not only tighten the collagen in the soft tissue and fascia enveloping the muscle, but also reduce the generous fatty tissue in her subcutaneous tissue layer along the jaw line and cheek area. On her follow up visit she was ecstatically pleased with combination of subtle lift and narrowing of her facial frame from Ultherapy and narrowing of her jaw angle from reducing the bulk of her Masseter muscle using the Botox. She jokingly acknowledges “almost” seeing the V-line but most important, happy about not having to worry about posing behind her friends to make her face look smaller when taking selfies.

Patient#5 is a 64 year old waitress who still smokes close to a pack of cigarettes daily. She had lost most of her upper teeth many years ago with significant dental bone loss resulting in shortening and retrusion to her mid-face area. She has been wishing for some type of lifting procedure for many years, but has always been afraid to pull the trigger due to friends who looked for the worse in her eyes following their face lifting surgeries and her inability to quit smoking. She had a fixed budget and had to return to Philadelphia the same night. After careful discussion, she underwent lifting of her jawline, neck, and cheek using a combination of Sillhouette Instalift and PDO Novathreads. She underwent 40cc of fat transfer to all aspect of fat compartment in her face, with special attention to her temporal wasting and her mid face retrusion. Fat transfer allowed significant restoration of her soft tissue volume as well as restoring back to her youthful contour with greater anterior dimension which she had lost long time ago due to her premature dental extraction. The combined procedure took 3 hours and with almost no bruising and swelling, was safely able to return to Philadelphia on the same evening. On her follow up, between the thread lift and 3-D restoration of her facial contour, she felt she looked at least ten years younger and was quiet pleased with the outcome.

Patient #6 is a retired executive who had previously undergone two facelift surgeries, last one being more than 3 years ago. She is in her mid 70’s and still very active in many societies she belongs to. She wishes update lifting procedure but wants to avoid any surgeries and certainly avoid any anesthesia due to bad experience during recent hip replacement surgery. After careful discussion, she underwent Silhouette thread lifting to improve her jowling and nasolabial line. She underwent PDO Novathread lift to improve the persistent right side neck laxity and turkey waddle. Only the right side was lifted as the left side was satisfactory. In addition, 1cc of Restylene was used to further improve the nasolabial line and corner of the mouth on both sides. She immediately felt a few years younger and looked forward to meeting her friends at her 50th college reunion.

Patient #7 and #8 are couples from Boston in their 50’s who have been dropping by annually for the past five years to undergo “Couples” Thermage. After seeing their relatives in NYC, they drop by my office to receive their annual Thermage on their way home. They both feel that Thermage has helped to slow down the inevitable drooping of their face and neck. In their recent visit, in addition to the Thermage, wife received 1cc of Restylene to the temporal recession areas and another 1cc of Restylene to the Nasolabial line while the husband received Botox to smoothen out the strong glabellar frown lines. They are both pleased with the outcome and plan to drop by the following year.

Patient #9 is a 47 y.o. male patient who wishes facelift surgery to improve the fastooning around his malar mound. He is less concerned about the slight jowling and fullness under his chin, but he is really bothered by his malar mound which is worse in the mornings. Upon carful analysis, he has severe puffiness under his eyes which directly connects to his puffy malar mound. He has suffered from allergies and sinus issues most of his life, which worsens the lower eyelid and malar puffiness. After careful discussion, patient underwent transconjunctival lower eyelid surgery under local anesthesia to improve upon at least the medial half of the large fastooning. Once one side was finished, he was brought up to sitting up position to show the immediate improvement of the operated vs non-operative side. Although the patient would have benefited with pinching up of the skin under the eyes, he didn’t want any sign of undergoing surgery. In lieu of the pinch, the lower eyelid muscle was heated with Ellman RF unit through transconjunctival approach which tightened the muscle and to a degree, the overlying skin. PDO Novathreads were then deployed to tighten the soft tissue and skin around the puffy malar mounds. Only nominal amount of lift was achieved from the PDO threads, as discussed prior to the procedure with the patient. Nevertheless, he was over-all quite happy with near complete resolution of medial half of his fastooning and slight lifting and flattening of the puffiness over the malar mound, laterally. Even though he had no bruising, He was asked to recover at home for a few days due to the lower eyelid surgery and asked to minimize strenuous activities for a full week. On his follow up he was extremely pleased that natural improvement could be achieved without much down time and without having to undergo costly major lifting surgery which was recommended to him by several surgeons from prior consultations.

In conclusion, if these alternatives to a facelift surgery may be an option for you, please discuss with your Plastic Surgeon to see if you may be a good candidate for these procedures. Do remember that every procedure comes with benefits and risks as well as limitations and it would behoove you to find a Surgeon well versed in these techniques who can communicate to you how you can potentially benefit from the procedures with minimal to no downtime.