Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662
Facelift: State of the Art
26 February 2003 (online)
When I was asked to serve as guest editor of this issue of Seminars in Plastic Surgery, it was originally conceived as a collection of chapters on procedures to rejuvenate the forehead, eyes, face, neck, and perioral area. As such, I was faced with the arguably impossible task of deciding what procedures were state of the art for the treatment of each area. After a short period of consideration it became obvious to me that I did not know and could not choose. I was then struck with the idea of narrowing the scope of the project to a comparative analysis of the major schools of thought on facelift technique. Why not ask acknowledged experts to act as advocates for their adopted technique, to tell us how and why it works, and to provide case studies to photographically back up their claim? The readers could then review and decide for themselves what makes the most sense, what is most practical, and which produces the "best" result. This is, in fact, the theme behind the volume you are holding.
The challenge put to the authors was to describe the conceptual basis behind their technique, to review its evolution, and to provide an overview of the technical steps in its performance. In the technical description they were asked to discuss patient evaluation, their basic incision plan, treatment of the midface, and what they do in the neck and with the platysma. Space allowing, the authors were invited to discuss what they felt were the advantages of their approach over other commonly advocated procedures.
The authors were asked to include two case studies showing the benefits of their technique for readers to evaluate. Each case was to be shown in three (anteroposterior [AP], oblique, and lateral) well-matched views. Patients selected as case studies were not to be smiling in any of these three views in either the before or after photos. A fourth AP smiling view could be shown if the author wished, but in such case the patient was to be smiling in both the before and the after view, and the smiles were to be well matched. In addition, a before-and-after AP smiling photo pair could be shown only if a well-matched before-and-after AP pair in repose was included. Other photographic guidelines given to each author included the following
After photos were to have been taken at least 6 months after the procedure and preferably 9 to 12 months or more. Authors were asked not to select any patient in whom scars were immature (red) regardless of how many months postoperative they were, as these patients arguably could be assumed not to be completely healed. Authors were asked not to crop the ear and preauricular area out of the before and after photos so that readers could evaluate the author's placement of incisions and management of the preauricular area. If the ear is not included in the before or after photos, authors were asked to select a different case. Authors were asked to select cases in which the patient's hair was off the preauricular areas in all photos. If hair was obscuring any part of the preauricular incision, authors were asked to select a different case. Authors were asked to select cases in which lighting and photographic technique in the before and after photos were comparable. If there was a significant difference in lighting or photographic technique, another case was to be selected. Authors were asked to select cases in which makeup was comparable to the extent possible. Photographic backgrounds were to be comparable and were not to be changed or manipulated in any way, as background color, type, and shadows (or lack of them) are useful in evaluating the photographic technique. Authors were asked to include a description of other procedures performed (blepharoplasties, forehead lift, lip augmentation, facial implants, etc.) and to specify how many months postop the "after" photos were taken. Authors were asked to select patients who have not undergone ancillary treatments such as full-face laser resurfacing, fat injections, Botox injections, collagen injections, skin peels, or other procedures that might negate a fair comparison. Authors were asked not to mix photos from several photographic sessions in the "before" and "after" sets. If a complete three-view set (AP, oblique, and lateral), all taken at the same time, was not available, another case was to be selected.
Space allowed us to include two chapters likely to be of interest to readers, although technically not descriptions of specific facelift techniques. These include an excellent chapter of male facelift by Garth Fisher and a chapter on "maintenance facelifts" for younger patients.
In the course of preparation of this issue I was reminded that it is all too easy for one to become lost in technical details, dazzled by evocative illustrations, or swayed by the articulate writer or outspoken advocate of a given technique. Just how are practicing plastic surgeons currently performing facelifts, and why are they using the techniques that they do? It is hard to know for certain, but Matarasso, Elkwood, Rankin, and Elkowitz provided valuable information in their survey of 3800 members of the American Society of Plastic Surgeons published in the October 2000 issue of Plastic and Reconstructive Surgery. Seventy-four percent of their respondents performed some sort of superficial musculoaponeurotic system (SMAS) procedure, claiming its safety and effectiveness as at least part of the reason for their decision to do so. Fifteen percent performed a more traditional skin-only procedure. Nine percent performed a "deep-plane" procedure, and 2% used a subperiosteal technique. A similar overall breakdown was seen in an informal show of hands of approximately 500 surgeons at the Baker-Gordon-Stuzin-Baker Symposium in Miami last year. In this admittedly unscientific survey a slightly higher percentage of surgeons were using a subperiosteal technique however, and less than 1% stated they were currently using a "composite" or deep-plane procedure. This was a notable change from similar surveys in years past in which the latter two techniques were being used by a slightly larger group.
It is probably obvious, but should nonetheless be noted, that not all schools of thought on facelift technique are represented in this volume. Assembling a group of expert plastic surgeons is a lot like herding cats, and chapters on several techniques unfortunately could not be included. Information on these techniques must be obtained elsewhere by the interested surgeon. It is my opinion, however, that this does not diminish the value of this remarkable, first of its kind, side-by-side comparison of current and up-to-date information on this fascinating and always challenging surgical procedure.
I would like to express my heartfelt thanks to the authors for the time and effort they put into writing their chapters and assembling related materials. I know from my own experience that many hours away from family, friends, and personal pursuits outside their practices were involved and that these can never be recaptured. I do not know of too many industries in which "trade secrets" are so openly shared, and I am proud to be part of a profession in which we so willingly help each other learn to do better.
I would also like to thank my coeditor, Tue Dinh, as well as Lydia Bebczuk and the staff at Thieme, without whom this issue would not have been possible. Thank you all for your cooperation, support, and hard work.
Well, here it is. Assembled for your consideration is the collected wisdom and life's work of some of the most talented, creative, accomplished, respected, and honored members of our profession. It is my sincerest wish that this issue of Seminars in Plastic Surgery will assist you in your continuing efforts to provide your patients with the very best care possible. It is also my hope that you will treasure this important information as much as I do.
Timothy J. Marten M.D., FACS
Guest Editor 1
It has been my pleasure to collaborate with Dr. Timothy Marten on this outstanding issue of Seminars in Plastic Surgery. It is through his efforts, along with the contributions of the authors, that this special issue came to fruition. This issue echoes the saying "Variety is the spice of life." The many distinguished authors who contributed these chapters use different techniques for the purpose of facial rejuvenation. They all have excellent results.
My comments are directed primarily toward the (relatively) younger plastic surgeons who, like myself, recently started this wonderful and sometimes puzzling journey into the field of facial rejuvenation. After reading these chapters, one may wonder which technique to use. It is my belief that a plastic surgeon needs to master one technique of rhytidectomy (perhaps the one learned during his or her training) to achieve consistent, safe, and favorable outcomes. Then, he or she can learn one or two variations to gradually incorporate into the chosen procedure. Thus, the techniques can be modified and improved as needed over time.
Again, my many thanks to Dr. Marten and all the authors, as well as Lydia Bebczuk, Dr. Larry Hollier, and Dr. Saleh Shenaq for their tremendous efforts.
Tue A. Dinh M.D.
Guest Editor 2