Facelifts and Finishing Touches: Common Additions to a Facelift to Minimize Recovery and Maximize Rejuvenation w/ Dr. Jason Bloom

Doreen Wu (00:00):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu I'm excited to be here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator, as well as our special guest facial plastic surgeon, Dr. Jason Bloom from Bryn Mawr, Pennsylvania. The title of today's episode is "Facelifts and Finishing Touches: Common Additions to a Facelift to Minimize Recovery and Maximize Rejuvenation." I finally made the decision to have a facelift slash neck lift, but now you're telling me that's not enough Dr. Bass, what else is needed, and why after the stress of making the decision to go ahead with surgery and picking the right surgeon for me? I don't want to think about a lot of other stuff.

Dr. Lawrence Bass (00:51):
There are a few considerations here, Doreen, the big decision is that it's time to go ahead. You see enough aging change that you'd like to go ahead with the facelift. And the other big decision is picking the surgeon. Who's a good fit for you. So once you've done that, each surgeon will have a standard approach and some adjunctive techniques that help her or him to get the best results and the least recovery. So you can get involved in these issues and ask the surgeon to lay out how they approach things. Or you can just leave it to their judgment and experience if you've seen some of their results and you like what they're doing, that's really the bottom line, depending on your stage of aging. When you proceed with the lift, there are other aspects of facial aging that may also need a fix. And I've said this before on the podcast, we we'd like life to be simple, where one thing goes wrong and one treatment fixes everything. But the reality is multiple things change as we age. And each one of those has its own focused treatment or procedure. So there are a number of things that the facelift either doesn't address or has very little impact on.

Doreen Wu (02:21):
Should I be chasing these additional things at the same time as a facelift?

Dr. Lawrence Bass (02:26):
It's typical and standard to address other aging changes on the face at the same time as the facelift, a good facelift surgeon will point these things out and you decide if they bother you enough to treat them at the same time.

Doreen Wu (02:42):
What are some examples of this?

Dr. Lawrence Bass (02:44):
So there are a few things that are very common or typical that I see that are surgically addressed at the same time as the facelift. One is wrinkles. If you have wrinkles like lipstick bleed lines on your upper lip, or even some wrinkling in the cheeks, these are not going to be eliminated by the facelift. We're not pulling you tight as a drum. That's distorting. That's exactly what we're trying to avoid. So those are treated with chemical peels or laser peels very frequently at the same time as a face lift and eyelid changes are another thing. You know, aging changes in the eyelids, that's the thinnest skin on our entire bodies. And that's one of the earliest parts of our face that shows aging changes. So most folks, once they've aged enough to need a facelift, if they haven't already addressed their eyelids, this might be the time. So I'll turn now to Dr. Bloom, who's graciously agreed to join us today and is a very experienced facelift surgeon and always has a very sensible approach to these things. So Dr. Bloom, what kinds of things do you see that people need to chase at the same time as a facelift?

Dr. Jason Bloom (04:13):
Well, you know, there's a couple things when I talk to a patient about facial, you know, and I say facial rejuvenation surgery. So whether that's addressing the jowls, the face, the neck but also as you said, the eyelids are also a huge portion of what we do. And I will say easily 85% of my facial rejuvenation surgeries, which include a face neck lift also includes something in the periocular area, whether it's upper or lower and or lower eyelids. Additionally, when I'm talking to patients, certainly some of our older patients, I say the face ages in three different ways. Number one, we get laxity in the muscle of the face. So, you know, you're starting to get some drooping, or in the neck, you start to see banding or laxity in the muscles. Number two, we see a volume loss.

Dr. Jason Bloom (05:17):
So whereas we lose volume in the mid face and some there's two kinds of volume loss or atrophy, or basically a repositioning of the fat. So the deeper fat in the face tends to atrophy or involute. And then the more superficial fat pads tend to droop. So we address the more superficial fat pads by repositioning them with surgery. But sometimes we need to add volume to the face with fat grafting, which is a common additional procedure that I do, to some of the deeper fat pads. And the last part of aging is the skin. As you mentioned, rhytids, this is when I say facial rejuvenation surgery, like a facelift surgery, face and neck. This is a surgery of the muscle and not of the skin. We are repositioning the muscular tissues and the deeper tissues to a more rejuvenated setting are in more rejuvenated area, but we're not pulling the skin tight. So rhytids or the skin texture needs to be addressed with, as you said, chemical peels or some kind of energy based laser or device to resurface those skin wrinkles.

Dr. Lawrence Bass (06:41):
You know, another thing that we used to do an awful lot of, I don't think we do quite as much now is brow lifting. And a lot of patients are surprised that their brow and tempolaris is not going to be picked up by the facelift. And that's partly because incisions have changed compared to facelifting in let's say the 1980s, when the incision typically went almost up to the coronal brow lift point.

Dr. Jason Bloom (07:12):
Yeah. I would say that I tend to do less brow lifting just because just in my experience, that procedure has not lasted super long in my hands. What I tend to do is if I'm looking at a brow lift, and the majority of the hood of the brow is lateral. And over the tempolaris muscle, like the muscle, when you bite your teeth down, you can feel, I will tend to do a temporal brow lift, which is easily accessible through an incision in the hairline. And I think that does a nice job in order to pick up the lateral or temporal aspect of the brow.

Dr. Lawrence Bass (07:59):
Now another type of lift that we're actually doing more of nowadays is lip lifting because as we age, the lip changes in a number of significant ways, including getting longer, and lip lift helps with that and with some other features. So is this what you found in your experience?

Dr. Jason Bloom (08:23):
Yeah, I have been doing more lip lifts than I ever have. Certainly I think it's kind of in Vogue right now. But yes, we do a modified kind of like Bullhorn upper lip lift and, and depending on the amount of tooth show that the patient wants and volume in the lip or red lip show, you can basically modify that based on the patient's wishes. I would say maybe every sixth facelift I'm doing, I'm adding some kind of lip lifting procedure.

Dr. Lawrence Bass (09:08):
And so that's important that there are a few aesthetic features that the lip lift addresses depending on the individual needs of the patient. It could be too long, a lip. It could be not enough tooth show, not enough for a million or the pink part of the lip showing. And all of those things can be adjusted to an extent with a lip lift. And this uses an incision as Dr. Bloom described. That's just underneath the nostrils at the top edge of the lip extending around the corner of the nostril sometimes to an extent, and through that incision, these adjustments can be made. So tell me what your thought process is in deciding whether a patient needs fat grafting along with the facelift. I mean, obviously we're going to get a degree of facial shaping with the facelift by repositioning those fat pads and muscles as you described. But sometimes that's just not enough.

Dr. Jason Bloom (10:15):
Yeah. I mean, I think the patients that are really volume deplete they tend to be good candidates for fat grafting, certainly another, when I'm talking to patients, another area that I tend to fat graft because it's not addressed during like even a facelift where you get some mid-face improvement is the temples. If they have a lot of temple hollowing, I'll tend to fat graft that. I did that today in the operating room with a patient who is getting a face/neck lift. Additionally, my preferred technique for lower eyelid surgery involves an incision through the eyelid to remove some of the fat. And then I do conservative fat removal there, and then I will fat graft around the eyes. And so when I do that, and I'm fat grafting already for lower eyelid surgery, I tend to add a little bit of fat in the cheeks to help position their cheek higher, little bit higher, to add some in the deep medial aspect of the face and or the temple, if they need to. And so if I'm already doing fat graft for the eyelid eyelid surgery, I will add some volume for the face.

Dr. Lawrence Bass (11:33):
Now we mentioned this earlier, when we were going over our notes for this session, that even though you get a number of other procedures or treatments done at the same time as the facelift, there may still be some need for maintenance treatments going forward. And that's an important thing for people to remember and plan for, to tell me why, why that is, why doesn't the face lift along with a chemical peel, an eyelid plasty, why doesn't that just cover it?

Dr. Jason Bloom (12:10):
Yeah, I mean, I can't tell you how many patients come in. And they think that once they have a facelift, that every one of their issues is taken care of and they won't need any treatments further, but, you know, I tell patients certainly a lot of what we do with neuromodulators and the upper face and the crow's feet it's to, I mean, that's due to the muscle action. So a facelift doesn't doesn't stop that. So we like keeping the face rejuvenated and keeping up with our neuromodulators and or fillers for fine lines or chemical peels or laser resurfacing and not just ongoing, but it'll also help maintain the results of their surgery for years later, you know, they just had a big outlay of money and time and downtime and all of this to have this procedure and they want to keep the results looking good. So just like you can't buy an expensive car and expect not to like update it every, you know, to take it in for servicing every so often. So what I say is you need to come in for your regular servicing of your face to keep it looking good, to keep it in tiptop condition and allow the procedure results to kind of maintain for the longest amount of time.

Dr. Lawrence Bass (13:43):
Yeah. I think that, I agree with all of that. That's absolutely true. There are just parts of the face, like the forehead that we're typically treating with Botox and other neuromodulators that the facelift is just not addressing we're expressly, trying not to pull really hard and distort the mouth. And so we still need some fillers in fold areas around the mouth and that fabric of the skin that's 50, 60, 70 years old with all the sun exposure needs some ongoing maintenance and that maintenance is exactly what's let the facelift age trickle up over the last 20 years. And that will, by the same token, allow the facelift procedure that you end up having to have more longevity and to allow you to have an overall much more completely rejuvenated appearance.

Doreen Wu (14:46):
Continuing the conversation of the doing the combined procedures. I'm curious, what are the advantages and disadvantages of doing these procedures in conjunction with the facelift?

Dr. Lawrence Bass (14:58):
Well, the big advantage of course, is you have one recovery and you don't have to go back to the operating room, have more anesthesia, have more time off work. So everyone would like to squeeze everything in at once.

Dr. Jason Bloom (15:14):
Yeah. I mean, I definitely agree. I mean, patients want to, if they have this big downtime and I tell them for a face neck lift, you're looking at around two weeks and that's, you know, at a minimum they want to have multiple things done. On the flip side. I mean, when we talk about disadvantages of including a lot of different procedures, it's time under anesthesia, it's longer cases. They do have potentially more downtime when all of these procedures start to build and add up on each other. Just a little bit more recovery is added. All of these things kind of add up. They're not without any disadvantages, but like I said, over 85% of my patients seeking facial rejuvenation surgery have some kind of combined adjunctive procedure.

Dr. Lawrence Bass (16:10):
And I think that's an important point. It's okay to group a bunch of these things together, but at some point it becomes too much for one day. There are also some procedures that we can't do quite as well if we do them in conjunction with a facelift. So the most common example that I run into is laser resurfacing. If we want to do laser resurfacing or a laser peel on the lipstick bleed lines, or the forehead lines, we can do that just as aggressively as we would if we were not doing a facelift, but if we're treating the full face with laser, we have to really modify how much laser exposure the skin gets over the areas of facial skin that are going to be undermined or elevated with the facelift surgery so that the healing can still proceed in a safe fashion.

Dr. Jason Bloom (17:10):
I totally agree with that. I tend to, even when I am doing lasers laser procedures in conjunction with with a facelift surgery, around the mouth, I tend to go still pretty, very aggressive doing fully ablative, but on the areas where we lift the skin laterally by the ears and jawline, I tend to doing fractional things and a much lighter one other thing I'll add about combined procedures. And you said there comes a time where it's just like too much during the day and you see this more than I do, because I'm just a facial plastic surgeon. But I mean, I've had people that come in and they want tummy tuck and lipo and the breast aug at the same time as a facial rejuvenation surgery. And I, you know, now we're talking massive amount of times in the operating room. I've never done like a super long, I've done cases like tummy tuck and a nose job or tummy tuck and with some, you know, plastic surgeons in my area, we've done some combined cases doing a body case and a face case, but anything we're talking a long case on the face neck and some kind of combined body surgery,

Dr. Jason Bloom (18:32):
we always split it up.

Dr. Lawrence Bass (18:34):
Yeah. That's important safety. We want everybody to look amazing, but safety has to come first. And when you get to some of these body procedures, there's much more metabolic impact to the body surgeries. The face surgery, even combined with a number of additional procedures or treatments on the face does not have a lot of metabolic impact or stress on the body, but the body procedures do. And so there are really important limitations based on safety when you're trying to do those combined procedures.

Doreen Wu (19:20):
Both of you briefly touched upon recovery times in your discussion earlier. I wanted to ask, what are some of the techniques that are reducing the recovery time associated with the facelift?

Dr. Lawrence Bass (19:30):
Well, in my practice, I typically put, instead of just a small amount of local anesthesia with epinephrine for vasoconstriction, I use a more dilute local anesthesia, more like the tumescent anesthesia we use for liposuction and this facilitates dissection, and also helps minimize blood loss. And one of the other things we've been doing recently, that's had a lot of attention for plastic surgeons is the use of tranexamic acid which helps the body's ability to clot and has reduced swelling and bruising in almost every plastic surgery procedure that we do. So that's had a big impact on recovery time for my patients.

Dr. Jason Bloom (20:23):
I will a hundred percent agree with both of those things. I tend to tumesce the face and neck when I'm doing these procedures. So putting a little bit more of a dilute anesthesia, and then I put tranexamic acid. Now there's multiple different ways to do it. And actually in aesthetic surgery journal open forum, my fellow two years ago wrote a an interesting analysis of all tranexamic acid cases in cosmetic surgery. And I'm presenting some of this data next week at the facial plastics meeting. But interestingly you can actually hang it up and give it IV. What I tend to do is I mix the tranexamic acid into my tumescent fluid, as well as my local anesthetic. And it works exceedingly well. It is really been a game changer in my practice.

Dr. Jason Bloom (21:25):
The one other thing that I will say is that I don't use drains in my face neck lift surgery. So I use a fibrin sealant it's called Artiss, which is FDA approved for rhytidectomy or facelift surgery. And I tend to spray this fibrin sealant into the neck and lateral face. And well certainly nothing's gonna prevent an expanding hematoma or bleeding that you would need to evacuate, but it does help with you know, helping bleeding and helping the tissues kind of stick down in the neck and the recovery.

Dr. Lawrence Bass (22:10):
Yeah. And it's interesting because I've been using the TXA or tranexamic acid in the two medicine fluid in the same fashion. And I just think the potential it puts the medicine where it needs to be without with a minimum issue of any systemic effect. But I think all of these approaches, as you said, are not going to prevent a surgical bleed, that bleeding that's big enough to require a trip back to the operating room. But what it's done for us is to critically telescope down the period of bruising, swelling recovery, that takes people away from their job, away from their social activities. It doesn't make it zero, but it makes it considerably shorter than it was historically. And in our busy, modern life in the 21st century, that's critical when people are deciding whether they can go ahead with a procedure or not.

Doreen Wu (23:19):
Before we conclude, I would like to ask both of you to share some key takeaways for our listeners, Dr. Bass, would you like to start us off?

Dr. Lawrence Bass (23:27):
Sure. I think the key thing is to pick a surgeon you're comfortable working with. You like their artistry and the style of their lift, aesthetically, the way it looks to you more than whether they use one technique or another, that's really important that there's a good match in that regard. And my second piece of advice is don't leave an obvious aging feature untreated that you'll be back in a few months having another operation. You know, if you look at an aging feature and say, "I can live with that as it progresses for the next five years," okay, there's no rush to treat it today, but you know, if when you're lifted, you're going to be looking at the saggy eyelid skin, or you're going to be looking at the lipstick or bleed lines. And you're going to be back in three months doing another procedure. You may as well just get it done and not have to make another trip back to the operating room.

Dr. Jason Bloom (24:31):
I cannot stress how important that is. You know I will say, I always like to have the patients lead the consult in the sense that my first question always to them is what's bothering you. And so when I hear what's bothering them, they're talking about their jowls and their neck. I will then make a suggestion as to, okay, well, I think the facelift is, and a neck lift is the right option here. But I will also interject if I think something could also be addressed at the same time and maybe they don't overtly say it, but I say to them, "if we're doing this surgery, I think it would be beneficial to address your eyelids at the same time. I think you have enough aging there," and they usually say in most cases, "oh, you know, those are bothering me too. It makes enough sense that while we're going there for this procedure to bundle that together." And actually, not that I have to, but I will say that if patients do book multiple procedures at the same time, like if they're booking their face, neck, and eyelids, I tend to work with the price and make it more reasonable for them to do all the cases together at the same time.

Dr. Lawrence Bass (25:56):
Well, Dr. Bloom, thank you for joining us on this podcast. I think you've given our listeners a lot of very useful advice from an experienced and wise surgeon on how to think about the entire face rather than just a single procedure. And we appreciate your joining us and sharing your wisdom.

Dr. Jason Bloom (26:21):
Well, thank you so much for having me again. It's always wonderful talking to both of you.

Doreen Wu (26:25):
Thank you, Dr. Bloom for taking the time to share insight and expertise with us, and thank you to our listeners for joining us today, to hear about the common procedures and techniques that are helping to maximize facial rejuvenation in conjunction with a facelift. I hope you found this episode as informative and fascinating as I did. If you think of other exciting developments or trends in plastic surgery that you would like us to discuss in upcoming episodes, please reach out via email or Instagram. We'll see you next time. This is Doreen Wu, thanking you for joining Dr. Bass, Dr. Bloom, and me for this discussion of additional procedures, commonly performed simultaneously with a facelift or neck lift. Be sure to tune in next time. And don't forget to subscribe to our podcast, to stay up to date with all of the exciting content that is coming your way.

Speaker 4 (27:12):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.