Self-perception and the face
This topic is worth a book-length discussion — perhaps even many of them. Hearing patients talk to me about their faces or bodies, you would think somebody replaced all the mirrors in their homes with fun-house mirrors. Their own perceptions of how they look differ wildly from mine. A woman with gorgeous breasts sees a flat chest. Someone with a beautiful face sees spinster lips. I sit with a lovely human being and look with her into a mirror; she describes a face that bears little resemblence to the one I (and the rest of the world) see.
People focus on minor imperfections and will see neon arrows pointing to them when walking past their reflection in storefront windows. If you go to a place where people congregate, like a bar, you will see people of both sexes making little pursing motions of their lips (model mouth), or tightening their jawline or cocking their heads in an attempt to improve the way they think that they look. Most of the time, the effort looks worse than one's natural face.
The worst accessory to this tale is the magnifying mirror. When age deteriates sight enough to make it difficult to focus on a close mirror, the magnifying mirror makes it possible to put on makeup without glasses. That's the good. The bad is that it makes every small blemish or wrinkle appear the size of a billboard. And the unfortunate wielder of the mirror thinks that everyone else can see the same things and as big. These imperfections are usually so small that they are uncorrectable. But they occupy more thought and concern than they should be worth. By magnifying the face, the mirror magnifies insecurities.
Every plastic surgeon or dermatologist sees patients whose faces are a sea of wrinkles and discoloration and who will point to one imperceptible wrinkle and tell how much it bothers them. Of course, people perceive others' faces as a whole, with almost no details; no one looks at another person and sees the individual concerns and imperfections that person may focus on in the mirror. I’m not sure I can tell you where any of my wife's moles or wrinkles are.
Invariably, my advice is to put the magnifying mirrors on a driveway and roll over them with a car.
The real problem with too much concern over perceived imperfections is that you try too hard to fix those specific issues, and multiple operations later, you have transformed something that only you had even noticed into something that everyone can see. It happens all the time.
There are countless reasons for people to be insecure about their appearance, from something someone said in the third grade, to a husband criticizing his wife. This is part of the human condition, and plastic surgeons and the like can help people considerably as long as the perceptions don’t drive irrational or headstrong decisions. Most patients are reasonable about what they want to achieve, and they are happy with their treatments and results.
The facelift is an operation that works — it's been done for 100 years, and the results can be extraordinary. I have been doing facial surgery and other treatments for 30 years with a great deal of satisfaction from patients and their families and friends. You will see a number of my patients on this website who have had surgery and look lovely. This is the only operation that removes the excess skin that forms with age on the face, and especially the neck. There is a place for "liquid facelifts," or filling the face with fat or other substances, but these only do one thing: they fill. At a certain point in time, smaller procedures just don't do as much as they did before, and you need to do something bigger.
However, as with any human endeavor, particularly those carried out for money, there is some bad that comes with the greater good. I have a real dislike of seeing some of the marketing and surgical results that I see in our community and nationwide. What follows is my attempt to explain the procedures as I have seen them, and discuss what they can and cannot do. These are rational, not magical, procedures based on biology. And, unfortunately, they are widely misunderstood.
One of the major problems in all cosmetic surgery of the face and neck is that the materials, mainly the skin, decline in quality with time. The difference between operating on someone young, late 30's-early 40’s, and someone over 60 is huge. Older skin, which has been battered by motion and sunlight, loses its elasticity; it doesn’t have any snap left. It’s like underwear with no elastic: you pull them up and they fall off. The problem is that this skin will not stretch and recover when it contracts, like a rubber band would. It will stretch, but instead of tightening when it contracts, it will wrinkle like a piece of cloth. This is a materials problem that surgery can only partially treat. This is why older people can look lovely with their necks at right angles, but still wrinkly when they look down, even after a face and necklift.
If you are about 55 or over, look at the skin of the front of your arm above where it creases when you flex your elbow. You will see no skin wrinkles when the arm is straight, but plenty when you flex. This is not “extra skin." This is a loss of elasticity, and surgery does not cure it. The same goes for crepey skin elsewhere on the face and body. Facelifts don’t change the skin. You have the same skin after as you did before, it’s just been rearranged a little.
Look at her neck. She does not have extra skin on her neck, she has inelastic skin. Elastic skin would not make folds and creases when looking down. Inelastic skin does. It’s like the differences between a rubber sheet and a piece of canvas.
Though surgery improves a neck like this to an extent it does not change the quality or elasticity of the skin. She will still have wrinkles when she looks down.
The tools of facelift surgery: The Pull Tool
When you pull back on the skin of your face in the bathroom mirror, you have essentially done a facelift. (Fingers do better.) It seems so easy, just substitute removing skin for fingers, and the face would look great. Unfortunately your fingers only are pulling for a few seconds; if you were to hold that pull on your face for days at a time, you would notice that the skin would stretch, and the small changes you see in the mirror go away. The same thing, worse actually, happens after surgery. Because the surgical tool of pulling and shortening skin is powerful, the temptation is to pull harder, which seems like a reasonable thing to do, but in fact is not. The more one pulls, the more tight, unnatural and odd the face looks — just look at some celebrity pictures. The pull tool absolutely works. It is usually a great success. But it can be overused, and unfortunately one sees this in blogs, on screen, and in public.
My mottos is "a little of this and a little of that." Using traction sensitively, and using other tools like small volume fills in the face, one can generate much softer and more natural results than in the past.
Though there are valid discussions and questions about the best way to do facelift surgery, it is important to realize that there are no secrets. There are no methods that one doctor knows that no one else does; no magic bullet to make a superior result. Some doctors try to brand their operations: the "Celebrity-Platinum-No-Down-Time-Facelift." This represents only marketing, and is not to be taken seriously.
In the past, facelifts were performed by just pulling on the skin. Some patients did well with this, but many looked pulled, tight and streaky. Almost all modern facelifts are done with some attention to the deeper layer of the face (called the SMAS in facelift-speak). This layer is adjacent to the muscles and is mainly used because it diffuses the traction to the skin and reduces the possibility for a pulled look, though it obviously does not eliminate this possibility. Anyone can look overdone with any technique.
This deep layer, the SMAS, has had almost everything done to it that one can imagine. I did invasive and complex SMAS flaps for many years until I realized that there was virtually no difference between that and a simpler suturing technique. Some plastic surgeons are passionate about the technique that they use, it is after all, what they are used to and what works in their hands. But within limits, the technique is not the most important factor for end results, the person it is used on is most important.
It’s not so much what you do, but who you do it on
Of course surgery needs to be done capably with technical skill and good judgement, but all other things being equal, cosmetic surgery works the best in the people who need it the least. Younger faces with elastic skin and good bone structure do wonderfully. Older faces with inelastic sun damaged skin and too much or too little fat don’t do as well. There are certain configurations of faces that are more difficult than others; for example the face that is skinny in back but is full in front and faces with “weaker” bone structure.
The neck is a key component of the facelift, and it has been approached innumerable ways. No one method is good for all necks. Some young necks with tight skin can be improved just by pulling from the sides. Some need more complex maneuvers to deal with fat, muscle bands and salivary glands. Some necks, particularly in older men do very well by just removing the extra neck skin, leaving a scar in the midline of the neck which usually heals quite well.
Twice the work gives 10% more result
The facelift can be a tedious operation, and it is tempting to take short cuts. These most often happen during the closure. Many people close the face rather coarsely, using staples behind the ear ("nobody looks there") and not doing careful trimming around the ear. Even so, many patients look acceptable. However the results of a facelift — or any craft — are dependent on many small details, which by themselves mean very little, but when taken all together make for a better result. Think of fine furniture; the details are what make it fine. Care with closure and the innumerable small details of the operation take time, but they add to the result. People DO look behind the ears, and wide scars and staple marks detract from the overall look.
What about all those people who have had surgery and look odd? What about celebrities who look terrible? Don’t they have the best doctors?
After seeing many well-known people in my office, and thinking about this question, I have decided that celebrities get exactly the same range of plastic surgery that everyone else gets, only their doctors get paid more and have more attitude. Celebrity patients put a great deal of stress on the doctor. A well-known person may have distinct (and sometimes irrational) concepts about what looks good, and browbeats the doctor into carrying them out. Whereas under normal circumstances, the doctor would just refuse these bad ideas. The pressures of public life, and just plain poor judgment, can cause celebrities to make disastrous decisions about their faces. Doctors are not well equipped to stand up to them, as the doctors can be influenced by the person's fortune and fame, and susceptible to the ego-stroking ("if this movie star want me to do her surgery, then I must really be good"). The doctor’s judgment thusly fails him as well, and he does on this person something that he would never do on a regular patient. And that's how a bad result is born.
Remember, when it comes to celebrity cosmetic surgeries, you're not going to register the good, natural results. But you certainly note the bad ones.
The facelift is an operation that relies on "tightening" and removing tissues, and looks fine if not done to excess. But if tightening and removing tissues are the only tools the doctor has, then those tools will get overused. Patients will get the same operation over and over again, and wind up looked pulled. Around Newport Beach, Beverly Hills — really, almost everywhere these days — it is very common to see patients who look odd, distorted and alien. And the reason is usually plain to see: they had too much pulling or it was done too many times. One can see streakiness of the skin, wrinkles that are pulled where they should not be, and "joker lines" which are sure signs that a facelift has been done. (See my article on "joker lines," or "cross-cheek depressions" as they are known, for more information)
I fix many post facelift deformities. These patients don’t always need further surgery, as some of these can be treated with fillers. But, of course, it is better if your doctor can avoid them. Sometimes the answer is not to do the third facelift.
I would like the reader to carry away two thoughts:
The first is that you don’t see the good results from facial surgery, you see the bad ones. For every person you see who looks obviously surgical, there are many more who just look good and unoperated and natural, which is the goal of successful cosmetic surgery.
The second is that people don't look odd from having had too little treatment. They look odd from having had too much. Sometimes surgeons, with the best of intentions, overuse the simple tools of surgery and do too much, or do the same thing too many times. Sometimes patients are fixated on an area of the face and don’t see the face as a whole.
The classic example is the patient who doesn’t like her nasolabial folds. That is all she sees. She will have surgeries until the fold looks better to her, but unfortunately the rest of the face will by then look terrifyingly worse and she will think she looks better. I don’t do procedures like this. I don’t do things that I think will make people look ridiculous, even though they might want it.