Facelift on the Cutting Edge w/ Dr. Sherrell Aston

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, a podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is Facelift on the Cutting Edge. We talk about facelift and neck lift quite a bit on the podcast. Dr. Bass, what do you have in store for us today?

Dr. Lawrence Bass (00:31):
We do discuss facelift from various aspects. Since it's the major reset for facial aging, most of what we've discussed represents my perspective on the facelift, and we've also had some experts to go back and forth over specific issues. What I'd like to do today is review the progress that facelifts have made over the past few decades and outline some of the current controversies and cutting edge techniques. To do that, I've asked my chairman and mentor in aesthetic plastic surgery, Dr. Sherrell Aston to join us for this episode. Dr. Aston is a professor of plastic surgery at New York University, a past president of the American Society for Aesthetic Plastic Surgery, and was the chair of plastic surgery at Manhattan Eye, Ear and Throat Hospital for 23 years. He also has run an international symposium that was for many years the largest aesthetic plastic surgery meeting in the world, and leaders in plastic surgery from all over the world would come to update their techniques by attending this meeting and listening to the lectures and watching the live surgery that was demonstrated at the meeting. Dr. Aston is also a host of the Plastic Surgery Show on Doctor Radio, and he really is an expert in particular on facelifting among his many other aesthetic plastic surgery skills and one of the most accomplished aesthetic plastic surgeons in the world today. So we're very fortunate to have him join us on the podcast. Dr. Aston, it's truly a pleasure to have you join us and to get a chance to discuss the intricacies of facelifting with you.

Dr. Sherrell Aston (02:38):
Thank you for that kind introduction, Dr. Bass, and it's a pleasure to be here with you and of the meetings that we produce, a cutting edge surgery symposium. You've been a part of that many times and shared your information with the world, and certainly you know that I respect your expertise, your judgment, your surgical skills, and all of the things that you've done to contribute to our specialty over the years. So it's a pleasure to be here on your podcast.

Doreen Wu (03:11):
Welcome Dr. Aston. Thank you for taking the time to join us today. So to start us off, what is the difference between a facelift and a neck lift or are they part of the same thing?

Dr. Sherrell Aston (03:22):
Yeah, well, most of the time a facelift and neck lift are going together. If plastic surgeons are talking to each other and we say facelift, unless a plastic surgeon defines that differently, and I'll tell you how, unless a plastic surgeon defines it differently, talking to his colleagues and I say a facelift, he would be assuming that you're going to be tightening the face, and that means from the corner of the eye down to the jaw area and under the mandible a bit. And you would assume that also includes the neck. If you said, I'm going to perform a short incision facelift, they'll lay public and often refers to that as a mini lift, then you know that you're only really lifting the face from the corner of the eye down to the jawline, but it doesn't change the neck. A great deal. It will change the neck some, but not to the extent if you're doing the facelift.

(04:20):
And it's really a matter of where the stitches are placed, facelift, the stitches if face and neck lift, which as I said most of the time goes together, the stitches go around the front of the ear, some way hidden in the creases or behind the cartilage of the ear, depending on the individual. Then they go under the ear, low back of the ear and up in the hair. If we are just doing the mini lift, the facelift portion, short scar facelift, if surgeon is talking to surgeon, then the stitches would stop at the earlobe but not go up behind the ear. So that's sort of the basic difference.

Doreen Wu (04:57):
And as we sit here today, what is the role of the facelift and neck lift on the aesthetic playing field?

Dr. Sherrell Aston (05:03):
Well, the facelift, facelift neck lift is a gold standard for facial rejuvenation. It lets you recontour the underlying foundation, which is the most important thing we do in changing the line foundation. Maybe we'll get to that in a little bit later and take away the extra skin. So it's a gold standard. And then we have complimentary things that we do in addition.

Doreen Wu (05:31):
What are some of the changes that you've seen over the last 40 years? How has the facelift gotten better?

Dr. Sherrell Aston (05:37):
Well, if we talk about the last 40 years, you have to remember that in the early seventies and even in the through to the early eighties, many times facelifts for many surgeons just meant lifting the skin. The underlying foundation was not really altered in a significant fashion. But then in the mid seventies, as some of us started developing, the techniques which are being used today changing the underlying foundation in terms of you know in lay public as SMAS, the platysma muscle. So we start changing the underlying foundation, taking away the extra skin, but rereally draping the extra skin, over a changed underlying foundation in the face, the cheeks and neck, the jawline altogether. And we were got away from that pull stretch look of just a face tightening procedure by pulling on the skin.

Doreen Wu (06:40):
What are some common treatments that are performed at the same time as a facelift?

Dr. Sherrell Aston (06:45):
Well, today with the facelift, of course we do eyelid surgery, brow lifts when we indicated, but let's just limit our comments right now to the face or the face to face and neck because we can talk about all those other areas for a long time. But today, we compliment our facelifts by adding autologous fat grafts. That means we take fat from various parts of body. Most often they would take fat from the medial thighs if the patient has it or from the abdomen. The fat that's taken from the medial thighs. Thighs tend to have the greatest survival rate and the abdomen being next. But we take that fat out with just a little syringe aspirate out fat. We prepare that fat in certain ways, which would take too much time to go into right now. And then we inject that fat into the areas of the face where a person has lost volume, the face has fat in different layers, if you will. There's a superficial fat layers in the face which give the contour of the face and the deep compartments of fat in the face in both the superficial and the deep lives of the fat become attenuated atrophy with a passage of time. And today, as part of facelift procedure, we restore that to make the faces look much, much better at complimenting all of the advanced procedures that we can do to the underlying smash portion of the phase or the underlying foundation.

Dr. Lawrence Bass (08:17):
And I think that's important that we're repositioning, but we want to shape the phase. We want to improve the quality of the skin that's aged and that adds to what we accomplish with the facelift itself. So multimodality approach brings a more complete correction and addresses more of the changes that have taken place over the decades of aging that led up to the facelift.

Dr. Sherrell Aston (08:48):
And let me just add to that if I could, because today we are doing radio frequency to make the quality of the skin better, FaceTite, AccuTite along with the facelift. And with doing that, with changing the underlying foundation, we can get an architectural rejuvenation, the face in terms of contour. And by adding the radiofrequency technology, we can get a anatomical biological rejuvenation of the skin itself. I know Dr. Bass does, I do almost every facelift adding to technology to make the skin quality better. Facelift takes away the extra skin, then we've got to make the skin better quality.

Doreen Wu (09:38):
Now let's talk about the results. How much improvement can I expect and how long will it take?

Dr. Sherrell Aston (09:44):
How long will the surgical procedure take or?

Doreen Wu (09:46):
My mistake. How long will it last? How long will the results last?

Dr. Sherrell Aston (09:50):
How long will it last? Well, the result will last forever. From the standpoint when you reset the clock on the face if you will, then you've reset that forever. You'll continue to age. But at 20 years after a facelift, you'll look better than nature than intended for you to look. You'll look better 20 years later than if you had not had the procedure. So it's essentially lasting forever. It's just the aging process continues unless you're unfortunate.

Dr. Lawrence Bass (10:22):
And so that's a key point that we're, we're setting the clock back. We never stops moving, but you'll never be as bad as you were before. And it's going to vary a little bit from person to person modulating the biology of the skin, the aging changes in the skin. As Dr. Aston mentioned, using radio frequency is going to improve your chances of getting longevity out of the facelift. And so again, this multimodality approach gives you benefits not only in your time zero results, but in what you're going to get out of the facelift in the long run.

Doreen Wu (11:05):
Now I'm curious, Dr. Astin, is there a preferred technique in your hands?

Dr. Sherrell Aston (11:10):
Well, I do different techniques. If we're talking about changing the underlying foundation, then I do different techniques according to the patient's anatomy. And you don't have to be a plastic surgeon to just think about the fact, and I'll look at 20 people you see today and decide in your mind if those faces all look to you like they should have the same facelift technique if they're going to have a facelift because the facial anatomy is different. The asymmetry of the face is quite significant in a huge percentage of people. There are some characteristics of facial asymmetry that nature repeats over and over and over, and we don't have to go into those right now, but it's definitely true, just like 89% of people in the world are right-handed. There's certain facial characteristics that are repeated over and over in the face. But the bottom line is I use a different technique according to the individual's facial architecture to try to give 'em more symmetry than nature had given them.

Dr. Lawrence Bass (12:13):
So let's talk in more detail about the technique used under the skin during the facelift. As you said, the old facelifts 1970s, even part of the 1980s were skin only, but almost all first time or primary facelifts performed today will include some measures to address the deeper tissues under the skin, the muscles and connective tissue or SMAS layer under the skin. So Dr. Aston, I think the biggest current controversy in facelift is the big divide selection of a SMAS technique versus a deep plane technique, or to put it in more proper language, a composite technique because that's really what the deep plane approach is. So for many of us, this is a long settled issue, but it's still widely discussed out there. Can you tell us your thoughts?

Dr. Sherrell Aston (13:14):
Absolutely. Dr. Bass, and thank you for asking that question. Well, listen, let's just tell our listeners this. Think about the layers of the face. The first thing layer you have is going to be the skin. Directly on the skin is the subcutaneous layer. That's a little fat layer right under the skin. And under that layer is the mass that Dr. Bass just referred to, which means superficial musculo apron neurotic system. And that system of fibrous networks, fibrous tissue, provides the connections of the underlying foundation to the skin and the muscles that move the face. So when you're small, it's the attachments that go from the SMAS up to the skin that move your skin as you animate. Now, once you go under the SMAS, you are in the deep plane. You can't, for practical reasons go deeper than under the SMAS because when you do that, you're right on top of the facial nerves and nerves that move the face.

(14:20):
So I essentially am in the deep plane with every single facelift I do because I'm under the SMAS, has to be an extreme arrest, a situation where you've got a secondary or a tertiary facelift, someone who's super thin, and there's no way to go into that plane without injuring facial nerves and nobody in their good judgment are going to do that. But primary facelifts and most secondary facelifts that I do today are in the deep plane. Now, the controversy today has really been stirred up into public's mind by social media because people talking about the deep plane without a true definition so people can understand what they're talking about. But let for sure factually, anatomically, anytime you are deep to the SMAS, anytime you've raised up the SMAS, you are in the deep plane and Dr. Bass referred to the composite facelift, and that actually means leaving a skin and muscle fat and the anterior portion of the face attached to the skin.

(15:37):
In my opinion, first of all, that is not regardless of what the internet says, regardless of what social media says, that is absolutely not a new technique developed by anybody who's practicing plastic surgery today. And that the deep plane was originally described by Dr. Tord Skoog who passed away many years ago. But in my opinion, when you do the deep plain technique that's social media advertised today, you're requiring the skin to hold up the underlying foundation. I always go under the skin, across the face as far as I think I should go, and then go also under the sma. We do different things with this SMAS. Once we have dissected that as a separate layup, you can think of that as like two pages in a book raise up the skin, and then you raise up the second layup when you go under the sma, how you rotate that second layer where you place the tissue that you've now undermined as surgeons would say to each other, how you place that undermined tissue will give a different shape in the face according to where you move your SMAS layer. And so we use it in different positions for different people to get the most elegant results for. Did you think that's a reasonable summary, Dr. Bass?

Dr. Lawrence Bass (17:14):
Yeah, I think that's an excellent summary. You're hearing it from the expert's expert, and I've thought about this a long time. Most plastic surgeons spend a lot of time thinking about exactly what they do in a facelift and exactly how they can make it better, exactly who should get which technique. And one of the big teachings today about facial aging is that every fat pad, the deep fat pads, the superficial fat pads, everything that makes our facial shape and position shrinks differently from the other parts and descends differently from the other parts. And so making a single vector of positioning for all of the tissues of the face as a rejuvenation maneuver seems intrinsically inadequate to me compared to looking at each component of the face and positioning that I think of it in a multiplane our way and the vector of where things move and how they're brought together in each zone of the face and neck at each layer of the face and neck is different. It's not all of those regions done the same way at the same time, and it's different from person to person.

Dr. Sherrell Aston (18:46):
I agree wholeheartedly. Dr. Bass and the vector of lifting of the underlying foundation is often different than the vector of draping the excise skin because with the skin, we want to maintain proper hairlines, et cetera. You can change the underlying foundation, put the skin back over top of it, different vector than you've changed the underlying foundation and it doesn't look like it's pulled and stretched, and you're not relying on that skin to hold up the fatty layer because you've already separated the fat from the skin anteriorly on the face. At least that has been my experience over the years that I've been doing this, and I'm pretty sure Dr. Bass, you do smash flaps when you think they're indicated and do different smash procedures. People in social media frequently who talk about SMAS flaps don't really have an appreciation of what you can do, contour the face. But if you look at the results that Dr. Bass produces, the results that I try to deliver, you can see a difference in terms of the face compared to someone who's just had everything pulled together as a composite.

Dr. Lawrence Bass (20:17):
Right, it's not just laxity, it's restoring youthful facial shape and that differential vector for each component. So I think it's clear and experienced surgeons would probably universally agree. There's not a single best technique that should just be cookie cutter applied to every patient that darkens your doorway. But there are a lot of variations in what's done with the sma. There are high SMAS techniques, extended SMAS techniques, the FAME technique, which Dr. Aston developed a finger assisted malar elevation, elevating the cheek soft tissues. People sometimes do things called strip SMASectomies, and there's also mass plications. So to the extent you can, because I've just listed a few of the more common, but not an exhaustive list of the options, share with me your mental algorithm of how you pick and put which patient with which technique, who really needs one approach versus the other.

Dr. Sherrell Aston (21:39):
Sure. Well, the high SMAS technique, well, first of all, each of those procedures you just talked about moves down the line foundation in a different way. The highest mask techniques allows you to take soft tissue up above the cheekbone, more towards the lateral canthus of the eye, and that lower temporal hollering that occurs and also lets you shape the cheekbone area itself. So when you evaluate the patient preoperatively, you say, where does this person need volume? And if you need it higher above the cheekbone as well as on the cheekbone, then a high SMAS is an excellent procedure. An extended smma procedure really has to do with how far anteriorly you release the sma. And there's some ligaments in the face where smma is attached called the masic ligament, zygomatic ligaments. So with the extended SMAS technique, you're going anteriorly, you're dividing those ligaments. Now, when I do a high SMAS, I take down the mater in zygomatic ligaments routinely because that's how you get the flap to move up, to give you the most volume that you can get out of the tissue you have, but an extended SMAS flap, it's the extension of your dissection, and then you can do with that tissue where you need it.

(23:10):
You can put it high, you can put it a level of zygomatic arch, the FAME procedure that I described in first in 1992, because the dissection goes into pre zygomatic space, if you will, and that's very anterior on the face. That procedure, it is limited in terms of the patients that I think are good candidates for it, and it is a composite lift technique that I described before, and therefore I think it's only good for certain anatomical patients. I also think it depends on the skin quality, but a SMAS flap technique gives me a better result. I compare my results with my results, my patients with my patients who've had the different techniques. I spent hours and hours sitting at the very desk where I am now studying the results of the techniques over the years. So I have a small group of patients where I do the fame procedure four.

(24:24):
But in those patients where I do the fame, I also do an extended SMAS dissection and I've got pictures showing and doing both, as I said, but, and then the SMASectomy means you're taking away some of the SMAS, you cut a strip of the SMAS out and people will have full faces. Or if you want to move the SMA to give certain contour in specific areas of the face, you can do that with a mastectomy. It's not a procedure that I do very often. I'm more likely do one of the others. And the SMAS Plication procedure is a procedure where you actually fold tissue over on itself, and it is a very good procedure. It's not a cop-out procedure at all that because you've not dissected under the SMAS to do that because in properly selected patients where you need fullness right along the zygoma, right along the jawbone, if you will, cheekbone, not jawbone the cheekbone, you'll get excellent results with a SMAS Plication.

(25:43):
But you also have to know it's not going to give you any fullness above the cheekbone. So you have to evaluate which technique you're going to use. Then I also do a procedure that I call a release SMAS Plication where I release the whole mass, take down the mass just like we talked about with a house mass and extended mask, but leave the tissue tissue attached at the zygomatic arch I implicate. And that is the most powerful of all the techniques that I can do to contour the upper face level. It gives an excellent result, it'll take people back to the cheeks that they had a much younger point in their life if they ever had it, because we can give patients with that technique results that they never had in their life.

Dr. Lawrence Bass (26:35):
So that's really a fantastic summary and an outstanding overview of some of the effects of all of these different techniques. And I hope that helps the listeners understand there's a lot of very technical detail in what's being done under the skin. Plastic surgeons spend a long stretch of years training and refining their techniques. And so there isn't a one single best technique branded technique names don't really convey the complexity of what surgeons are trying to accomplish underneath the skin to create the most beautiful face and the most rejuvenated face. And so a dialogue with your surgeon about what your aesthetic goals are, where you've seen changes in your face is probably more important than trying to learn enough about different techniques to direct your surgeon to perform a certain technique. It's really a partnership and you're counting on the surgeon for that technical expertise and you understand what the aesthetic goals are and what's causing you distress in your facial appearance. And the surgeon can work on the best options for reversing those changes.

Dr. Sherrell Aston (28:13):
Another point that I think is important to make Dr. Bass is the sense of aesthetics of the surgeon are also extremely important because a lot of people who would say they're technically competent to perform a certain procedure, but if their aesthetic judgment of what really looks good is not consistent with yours, then you might not be happy with the result. And we know we see some people even today that are overdone, sort of a simple word of saying it, but looking like they've had a facelift and people shouldn't look operated on when they have a facelift, they should look great but not operated on. So you need to make sure that the aesthetic judgment of your surgeon is consistent with your aesthetic judgment, right, Dr. Bass?

Dr. Lawrence Bass (29:06):
Absolutely. And we're both Park Avenue plastic surgeons. You are the quintessential Park Avenue plastic surgeon, so you're on the right podcast. This is the Park Avenue Plastic Surgery Class podcast. But in our environment, natural is king. It's key to preserve a natural look. No telltales, no signs of an operation. It's you the way your mom would recognize you way you look 10, 15 years ago. Not some altered you. Now, there are a couple of other issues in plastic surgery that we can sort through since we have Dr. Eston with us to share his expert perspective. There are some major variations in which skin incisions are used both in front of and behind the ear.

Doreen Wu (30:06):
Dr. Bass mentioned the incision in front of the ear. So I'm wondering, Dr. Aston, what is your preference for this? What are the options?

Dr. Sherrell Aston (30:14):
Well, it depends on the patient. First of all, let's say what is absolutely necessary, you have to have an incision that starts in the temporal hair, follows a contour of the upper portion of your ear, and somehow it gets down to your ear lobe. And when I say somehow, that means it either goes in a skin crease in front of the tragus, that little piece of cart that's sticking up when you put your finger in your ear, it's either got to go in front of that in the skin crease or around the inside edge of that so you don't see it. To me, the most important thing is the quality of the skin in the cheek and the quality of the skin on the tragus because if you look at people, look at yourself in the mirror, look at your relatives, you'll see that the skin on the tragus is often very delicate, maybe no texture at all.

(31:11):
It's just very smooth, almost looks like baby skin and the skin on the cheek that you're going to lift will have wrinkles and crinkles and that sort of stuff. If you make your incision behind the tragus in those patients, then when you take off your extra skin, you raise up the skin flap, you take away the extra skin, and you put that cheek skin on tragus, it will look odd. It'll catch the eye from a distance away. If the cheek skin is consistent with the skin on ETUs, then I put the incision around the back of the tragus so there's nothing going around the front of your ear in that little skin crease. But today we know how to make those incisions, whether it's in front of the tragus or around the back of the tragus in such a way that it's going to be hidden for all social reasons. And we can make them so that the incision when there's a lot of discussion before surgery, but I think it's not much of a discussion after surgery. You assume people heal well, as most people do.

Dr. Lawrence Bass (32:21):
Yeah, I think that's the incision everyone worries about because it's out where people can see it. The other incisions are much more hidden, but that's the incision that rarely gives a problem and heals beautifully and is usually, but as you can see, again, there's no one answer. Customization is key based on the individual patient's skin quality. Now, do you differ that for men and women or are there other changes in what you do when you're doing a lift for a man?

Dr. Sherrell Aston (32:59):
Sure. Well, there are few men who will have a significant amount of non hair bearing skin, no beard in front of the ear. There'll be a strip of good skin without whiskers. They whip through your finger. But the percentage of men who have that are small. Most men have their beard going right up to the tragus or very close to the trauss. And if you're doing a facelift on a man, you're sure going to get a few millimeters to much, much more of extra skin out. So I personally never put an incision behind the tragus on a man where a beard would go up on the tragus. Trying to shave the tragus is kind of difficult, but having hairs growing out of your tragus is not very good. So the majority of men, we use the skin crease in front of the ear and the majority of men who are requesting a facelift will have a skin crease in front of the ear. That's really perfect for hiding your stitches. Main thing is maintain the normal tragus. But other than that, I don't vary the incision between men and women at all.

Doreen Wu (34:10):
With regard to the incision at the back of the neck, do you go into the hairline or along the hairline?

Dr. Sherrell Aston (34:16):
I never go along the hairline. I put the incision behind the ear and it's, it's almost a small SS shape incision with the curve in it. But I go to the top of the ear, so there's only one centimeter of skin behind the ear that's not in the hair, and that one centimeter is where the ear attaches to the head. So I curve that incision so that I restore the hairline back to the original hairline that the patient has on the table. And in order to see the portion of the incision that's not in the hair, you have to pull the ear forward and look behind the ear. So I reestablished the hairline. I think today different people have different ideas about that, but today I think that that is a ponytail lift. You can wear your hair straight up on top of your head and you're not going to have it. You can put that incision in a man's hair. He can cut his hair if it's whatever usual short length he wants to, as long as that hairline doesn't have a step in it doesn't have a break in it, then it's not going to show.

Dr. Lawrence Bass (35:29):
And that's the artistry in planning the incision appropriately so that the hairline looks correct and keeps the scar out of the non hair bearing neck skin where it potentially could be more visible. So I think that's a hundred percent true, and I occasionally see a scar along the hairline not in it, and I wonder why that was done and do my level best if I'm doing a secondary lift to try to undo that if I'm able. Let me mention another variation though, that's getting a lot of attention. Mini lifts.

Doreen Wu (36:13):
Mini lifts are trending right now. So Dr. Aston, what are they and who are they best for?

Dr. Sherrell Aston (36:19):
Well, the mini lifts are what the plastic surgeons talking to each other or short incision facelifts that we mentioned a little bit earlier. That means you have the stitches around the ear, the front part of the ear behind the cartilage of the tragus down to the ear lobe. And that is a great procedure for the person who is coming along as many people are doing today when they have laxity that's limited to the face, the jawline from the corner of the eye down to the jawline and a little bit on the neck. If you have a little fat under the jawline, that sort of stuff, you can liposuction that out at the same time. But it is primarily a procedure that's meant to correct from the corner of your eye down to your jaw under the jawline, as I said, for a little bit to get rid of the jaw.

(37:10):
But it doesn't give you the changes that you need in the neck often. But it's a great procedure. We do a lot of what we call short scar facelifts. You do that, add some of the radiofrequency technology with it, compliment chain, skin quality, maybe do the radiofrequency on the skin of the neck and just do the short incision facelift. We do that often do to radiofrequency technology, improve the quality of the skin it gets with the Morpheus, gets subdermal, adipose, remodeling, tightening of the skin of the neck, short incision in the face. It's a shorter procedure on the operating tables, shorter procedure with recovery time. And so it's a very good procedure if the patient is a candidate for that.

Dr. Lawrence Bass (38:03):
Yeah, I mean, it's about the stage of aging. So for someone who hasn't aged enough to need the full facelift, but they say, I don't want to fool with things. I really want this to get cleaned up and let me stop thinking about it for a while. This is going to be a meaningful approach compared to doing more limited kind of treatments. I never approve of the concept of just pumping people up with filler and volume. Replacing lost volume is okay, but trying to chase laxity with volume is a big mistake because that's going to be unnatural. So for patients that are not at a stage, a later stage with a full lift, the mini lift can be a great solution, but it's going to really jump in there and make a change and make it durably in ways that a lot of non-invasive treatments will fail to do.

Dr. Sherrell Aston (39:12):
And Dr. Bass, okay, let me just add to that. Sure. Dr. Bass suggested this. There is no such thing as a filler facelift. It expands the face. It will not lift the face, but it expands the face. But the downside to that is that you get lymphatic obstruction from the fillers. And so as time goes on, when you put a lot of fillers in the face trying to lift it, then the tissues start to get thick from the cheek down to the nasolabial, fold the corner of the nose. And some people get that Howdy Doody look. Now, having said that, there's a lot of fillers used in my office, a lot of fillers used in Dr. Bass's office. I know because we believe in fillers properly used, but it's not a substitute for facelift. And we see more and more people today who have been overfilled.

(40:04):
There's actually a resurgence of facelifts today, people who recognize the fact that one, I should not have more filler because the shape of my face is beginning to change in a way that I never was before. As people have mentioned things to me, my mother, my sister says what's happening to their face? And we also see a lot of patients today who are good candidates for that short incision facelift or many facelift because they recognize what I've just said on friends, they've heard people talk about it, and they know that they can get a short incision lift, mini lift, as they may call it, mini lift. They'll get a better result, better contour, last longer, and turn out to be cheap in the long run if they care about the costs. So I suspect Dr. Bassett agrees that a short scar facelift in a proper patient, it's just a home run in terms of facial rejuvenation.

Dr. Lawrence Bass (41:07):
Absolutely. And as I said, replacing volume that's lost with filler is rational and aesthetically good, but just trying to make the filler do something it was never designed for is a big mistake. And also it's traumatic to tissues to inject. Too often surgeons know they would never do 20, 30 facelifts on a patient because that's too much for tissues to take. And I think a lot of folks feel that nonsurgical treatments have no limits in how many times or over how short an interval they can be repeated. And it's important to be safe and gentle with your tissues and not overdue treatments. Treatments are excellent and extraordinarily safe in aesthetic plastic surgery when they're done the way they're intended to be done and overdoing them, big mistake. And so trying to and run the facelift, and as Dr. Aston said, we both do quite a bit of nonsurgical treatments along with surgical options, but where they're appropriate.

(42:35):
So Dr. Aston, to me, the neck is always the sharpness of the jawline. The sharpness of the neck is always how a facelift really gets judged. That's really where it counts. And there's a lot of work going on trying to improve the results in the neck. And in fact, you just chaired a session at The Aesthetic Society annual meeting looking at some of these newer techniques. Some are very creative, some are very aggressive. What are the issues here and what do you think is coming for the neck based on some of the things that were presented during this panel that you moderated?

Dr. Sherrell Aston (43:22):
Sure. Dr. Bass, we've been talking about this mass in the face, we haven't talked about the platysma muscle in the neck and the platysma muscles is a broad, flat muscle that rises in deltoid and pectoral regions comes up above the collarbone across the neck up to the jawline, and it is the muscle that gets those cords on the neck as one ages. And just as we fix this mass in the neck, the SMAS and the platysma muscle are in continuity above the jawline. So when we're moving the SMAS and platysma majority of our face, we're moving them together. Now, there are some patients, and Dr. Bass is referring to a panel of chaired at The Aesthetic Society meeting on isolated neck procedures. And there are patients for whom we do isolated neck procedures, and that means contouring the jawline and contouring the neck according to the anatomy the patient presents with.

(44:25):
Sometimes patients will present with a lot of fat in the neck. If they have fat in the neck and loose skin, then we'll do radiofrequency technology. We use accu to face tighten the neck and liposuction the fat out. If the problem of the muscle cords in the neck or the muscle cords come off of the neck in an obtuse angle from under the chin, they don't have what we call a deep cervical metal angle. Then we have to fix the muscles themselves. And for many years, we have been fixing the muscle through incision under the chin and contouring the neck, giving a good chin, jawline neck without any of the incisions behind the neck. If there is fat under that muscle on the neck, then we have to remove that fat also. But you have to remove it appropriately so that you don't get a deep depression just under the chin.

(45:25):
So like the face, it's a matter of analyzing the issues. If the patient just wants their neck operated on, and it's consistent with the face because you have to remember, if you just fix the neck, you're getting a limited amount of change along the jawline in the neck. You can get a wonderful change in some of the jawline, the lower portion of the jawline. But anything really above the border of the mandible is not going to change a lot just by doing neck unless you do something in that area. And that is one of the places we can add the radiofrequency technology, just do a neck procedure. If there are people who are talking about doing procedures with removing the submandibular gland, which goes under the platysma muscle and removes the muscles, or excuse me, removes the gland, the submandibular gland, you can feel like an acorn under your jawline.

(46:27):
My impression of the results, I've seen that too many of those people have a hollow in their neck. They look great in the first six months and a year out. You can see a depression in the neck. I think the concept of trying to make everybody's neck look like the neck of a model who weighs 90 pounds and is anorexic, you'll see that kind of depression, but you'll also see that kind of depression in neck and people who've had so-called radical neck dissections for cancer procedures. So I leave the submandibular glands in place. I'd rather discuss it with the patient. There are procedures where you can put sutures under the skin of the neck and into the muscle and try to tighten the muscle in that way. The people who presented at the panel showed very good results with doing that. I think there's a select group of patients who are candidates for those kinds of muscle tightening procedures, but the people on our panel showed great results in their hands. So I think there are people who have an isolated neck problem and we fix them. And I've done many patients where all we did was the neck over the years. And there are just different ways to do that, just like there are different ways to fix their face.

Dr. Lawrence Bass (47:55):
We're starting to hear a mention of the deplane neck lift similar to the deplane facelift in some social media. So Dr. Aston, what does this about and what does it add to neck lifting, if anything?

Dr. Sherrell Aston (48:09):
Well, Dr. Bass, you're right. We are hearing a lot mentioning, and it comes up in social media now about deep plane neck lift. Well, that is about as nebulous a description as a deep plane facelift. I mean, because we don't know what they mean by deep plain neck lift. We have to assume that the people are talking about going under the platysma muscle in the neck, taking out the fat, and taking out the submandibular gland. There are many people that we have to remove fat from under the platysma muscle. There are no patients for whom I take out the submandibular gland. And the reason I don't do that is because the early results may look good, but the long-term results with moving the submandibular gland under the platysma muscle gives a depression in the side of the neck that frequently glossed over quickly in cases shown at meetings. But the anatomy of the neck can be overly operated and you wind up with the neck that's not consistent with the head sitting on top of it. So I think that when you're talking about deep plane and neck lift, there are few people who really can get an excellent contouring with specific kinds of problems on the neck. But just because someone mentions deep plane neck lift, don't think that's what you need.

Dr. Lawrence Bass (49:43):
And again, just as deep plane facelift is really not a new concept, doing things under the platysma muscle, if that's what they mean by deep plane, is not a new thing. Chasing either fat under the platysma along with fat that's over the platysma, which we do routinely, chasing sometimes some of the muscle prominence. I'm with you when it comes to the submandibular glands. I don't touch them surgically, but you can Botox the glands and get some, and I recently reviewed an article about that for the aesthetic surgery journal, but that technique is a way to safely chase it and reversibly chase it. So if you get in effect that's unwanted or overblown, you are not stuck with it.

Dr. Sherrell Aston (50:51):
Good way to deal with that. Dr. Bass, and I concur that these things we're talking about removing fat beneath the platysma muscle is not new.

Doreen Wu (51:02):
Well, this has certainly been an informative discussion. Before we wrap up Dr. Aston, what takeaways would you leave our listeners with when it comes to the facelift and the neck lift?

Dr. Sherrell Aston (51:12):
Well, the face and neck lift, as I said earlier, is a gold standard for facial rejuvenation. But today we have to complement that with contouring the face, using specific movements of the underlying foundation to give more youthful appearance and often give an appearance that's better than a patient originally had. We complement the results that we get with the facelift by changing the underlying foundation to give a more youthful architectural foundation. We complement the results we get with that, with modifying the quality of the skin by using technology that we didn't have before. I think that today's facelifts are the most elegant time in history of facelifts because we have the ancillary procedures. We didn't have studied the anatomy in great detail, and particularly with the autologous fat grafts to help contour the face. So I think it's important to know what facelift is all about. And if you talk to a surgeon, make sure that their aesthetic judgment's consistent with yours in terms of what you want to achieve, the shape face, the contours that you would like to see in your face. And if you do that in the hands of a surgeon with experience, you should be able to have a very nice result.

Doreen Wu (52:40):
Many important points phrased there. Dr. Bass, would you like to add any takeaways?

Dr. Lawrence Bass (52:45):
Well, mostly I'm reiterating what Dr. Aston just said, probably not quite as eloquently, but the facelift is the major reset for major skin laxity. There really is no meaningful substitute currently, and I don't see one on the horizon. I look at all kinds of new technologies and advanced research and where the facelift is not about to be obsolete. There's no one size fits all approach. Facelifting is about customizing many, many anatomic considerations to each individual patient's needs and their individual stage of aging. The techniques will vary based on those factors. There is no one best technique. So I think you can see from listening to Dr. Aston talk about everything that's happening with the facelift, that the facelift is on the move. It's continuing to undergo evolutionary change more than revolutionary change, but the procedure continues to get faster, easier, more complete in the correction and more natural. So basically, it's not your grandmother's facelift. Dr. Aston, I'd really like to thank you for joining us for this discussion of facelift. It's a favorite topic for both of us, and I can't think of anyone I'd rather discuss it with. Without a doubt, when it comes to facelift, you are the expert's expert, and I'm grateful to you for sharing your tremendous breadth and depth of experience with our listeners.

Dr. Sherrell Aston (54:34):
You're very kind, Dr. Bass. It's a pleasure to be here, and I look forward to many more discussions with you about facelift as we continue to do procedures that we really love doing and making patients happy with the results.

Doreen Wu (54:50):
I'll echo Dr. Bass and say thank you once again to Dr. Aston for sharing your perspective and technical expertise with all of us today. I could really sense the excitement of the cutting edge and facelift today from the discussion. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.