Facelift Surgery Before and After
Chicago’s Plastic Surgeon Philosophy
Chicago surgeon Dr. Shah’s philosophy on face and necklift is mated to making a series of natural changes to the face. His goal is to restore a person’s appearance rather than to change it. Many of his patients will bring a picture of how they used to look and a frank and honest discussion takes place on how various approaches will help approach this goal. Dr. Shah uses the lastest in techniques (he’s help develop a facelift approach coveted around the world), technology (like to see yourself in 3D and the use of endoscopic techniques), and therapies (nutraceuticals, lasers, radio frequncy) to create a unique plan for each patient seeking to look like their former self.
His technique is based on the scientific data he helped discover, which includes the discovery of the platysma muscle’s extension into the face, the knowledge of what the best locations are in the face to secure it to, and the discovery of an anatomic landmark making the remarkably complex procedure safer for the patient.
Dr. Shah’s Approach
Surgeons perform facelift surgery the same way. A survey by the Aesthetic Plastic Surgery Society found that over 95% of its members performed SMAS only lifts. The SMAS is a covering of the face which surgeons use to pull on it in an attempt to produce changes to the face.
While SMAS lifts have been around since the 1970’s, many surgeons express frustrations with the limits in which it can change the face naturally. Surgeons who use this technique will try and pull the SMAS tissue and secure it. However, often at three months after the procedure, the patients will complain that they look exactly the same. Sometimes surgeons will attempt to pull more skin in an attempt to lift the face, however, patients will now have a pulled skin look, but not like more youthful.
I have learned a better method of rejuvenating the face, which is called CPMS. CPMS stands for Complete Platysma Muscular Suspension from a colleague of mine Dr. David Rosenberg in NYC.
If you look at an anatomy text book, it demonstrates that the platysma muscle is a neck only muscle. However, Dr. Rosenberg’s and my experience have demonstrated that this is not accurate. The platysma muscle actually has a significant facial component.
The significance of this anatomic finding can not be overstated. This finding demonstrates that many surgeons have been lifting the wrong tissue for the last 35 years. Dr. Shah proposes that the method of effectively rejuvenating the face is repositioning of the platysma muscle.
There are many benefits of this approach including a natural embryolgic glide plane. Beneath the platsymal muscle there are very few if any blood vessels. This allows the muscle to slide back to a more youthful position. The benefit of this lift is that it is a “true” facelift and that results are natural but will demonstrate improvement in both face and neck of the aging process.
Why don’t other surgeons utilize this technique?
The face has one of the most complex areas of anatomy in the body with many important structures. Most surgeons are hesitant to utilize more complex methods because of inadequate anatomic knowledge or experience in sophisticated techniques. This technique is a new concept which is only performed by 2 surgeons in the world.
What makes Dr. Shah different
One of the advantages of this technique is that it helps eliminate the “windblown” or “plastic look after a facelift. Some surgeons rely on pulling the skin tight in order to achieve a lift. Unfortunately, pulling skin tight is based on a false premise that a youthful face is back and tight. If you look at a young face, there is a roundness and soft quality. Repositioning the deeper tissue allows for rejuvenation of the face. Another advantage of this technique is a rapid recovery. Most patients feel comfortable in public within 5 to 12 days after the procedure.
Facial Aging Curve
The facial aging curve is a guide for patients to understand how various techniques can reverse aging. Aging is a constant process and this model helps us understand its process.
What Causes Aging?
Aging isn’t just as simple as something falling down or gravity. Aging is a multifactorial process which can affect every cell in our body. So it seems to make sense that addressing aging needs to look at all factors contributing. Let’s take a look at aging layer by layer: NEEDS DIAGRAM
- Skin- The skin of the face can become lax with age. The skin loses collagen and its quality is overall thinner with age. A face and neck-lift can address the excess skin issue by removing excess skin. The skin itself often needs to be resurfaced with a laser to help it have more collagen.
- Fat- We lose fat over time and some of the fat descends into areas where it no longer was present such as the jowls and neck. Dr. Shah addresses this issue by sculpting the excess fat with liposuction techniques with microcannulas, facetite and other modalities. For descended fat, he can reposition the fat to help the face appear in a more ideal location. For patients missing fat and volume, fat grafting and nanofat grafting can help restore a youthful countenance. Fillers and fat can be used to replenish the face.
- Muscle- Muscle is the one layer often failed to be addressed by most facelifts. Dr. Shah’s approach involves lifting the muscle of the face and neck rather than the SMAS. The advantages of lifting the muscle is that a more natural contour can be created and avoids the overly pulled look seen with excessive skin removal.
- Bone- We lose bone over time. Don’t think so. Ever wonder how an archealogist can tell the difference between an 80 year old and 24 year old skull. So how does one replace bone? In some cases the use of anatomically accurate implants can help. This is done on a case by case basis.
Deep Neck-Lift in Chicago, IL
What is a deep neck-lift?
A deep neck-lift is when mere liposuction will not be sufficient to contour the neck and deeper structures are addressed.
Let’s learn about the structures in the neck:
Skin- excessive skin is usually either excised or tightened using RF technology such as Facetite
Subcutaneous fat- This is the area addressed by traditional neck liposuction as well as kybella and coolsculpting. This area can be a contributing factor but is not the only one.
Platysma muscle- Most patients don’t have an issue with the thickness of the muscle but its separation. This muscle can constituted with surgery
Deep fat- The fat deep to the platysmal muscle also known as subplatysmal fat is a factor in fullness in necks. Too much fat here can lead to a persistently full neck. Deep neck contouring requires advanced anatomy of the face and neck
Anterior belly of digastric muscle- This muscle can lead to fullness along the border of the medial and lateral. neck. This is often missed as a source of fullness and can be seen with deeper inspection of the neck
Submandibular gland excess- The gland that is responsible for saliva can also in some cases lead to an overly full neck. Typically a portion of the gland is removed. This is used in select cases.
Why doesn’t every surgeon perform a deep neck-lift?
It requires advanced anatomy of the neck. Most ignore this areas completely. Dr. Shah has written 3 landmark articles on facial anatomy and teaches an anatomy course at University of Chicago. He is an expert.
Does every patient need a deep neck-lift?
This area is important to be recognized. Dr. Shah will account for this area in your consultation and discuss whether or not this area should be addressed.
Is recovery longer with a deep neck-lift?
Not necessarily. Most patients can realize their goals earlier but this approach requires more work.
Can I have a deep neck lift instead of losing weight?
Surgery should not be a substitute for weight loss. Patients should be at their ideal weight prior.
Since Dr. Shah lifts up the deeper layers of the face, tension is placed here rather than on the skin. This leads to improved cosmesis of facial scars. In addition, he hides much of the scar along the hair and natural creases of the face so that little scarring is visibly present. Finally, he uses meticulous technique in closing scars. Although it takes longer, Dr. Shah prefers a two-layered closure on the facelift skin to promote optimal healing. To read more about facelift scarring, click here.
Facial Analysis Chicago
Face analysis, particularly aging face analysis, can help demonstrate some of the areas which can be improved in aging face surgery. Dr. Shah analyzes each face to determine areas that can be treated.
Face Analysis and in particular aging face analysis can help demonstrate some of the areas which can be improved in aging face surgery.
With youth our faces will have the appearance of an inverted pyramid. As we age, our faces tend to become more bottom heavy and appear shaped more like a pyramid or rectangle. If you take a recognizable attractive face (not a patient of Dr. Shah’s) and change its appearance via computer manipulation to demonstrate this, you can see that the face becomes less attractive as well as appearing aged.
Part of the reason this occurs is a combination of factors including descent of facial tissues as a result of loss of elasticity and gravity and volumetric loss. Maintenance of youth will involve restoring the balance in the face by analyzying the root cause of the aging process for each individual patient.
As we age, portions of our face and neck have distinct anatomic names, helping patients communicate about what they would like changed. There are many classification systems out there which help determine how severe the aging process is.
Facial anatomy plays an important role in both analysis and the underlying cause of the facial aging. A simplified version of external points on the face are illustrated to facilitate communication.
Understanding the anatomy of aging can be a useful tool to see what areas of your face may or may not need improvement.
Eyebrow position is usually considered the key landmark in determining the aesthetic configuration of the upper third of the face. The medial end of the eyebrow should have a club-head configuration and should be in line with a vertical line drawn through the ala of the nose. It arches superolaterally above the supraorbital rim to its apex between vertical lines drawn from the lateral limbus and lateral canthus.
What are some of the important terms to know in facelift anatomy?
Nasolabial crease (sulcus)- facial line b/t upper lip and cheek
Nasolabial fold- bulging fat pad and skin lateral to NLC, caused by attenuation of the zygomatic retaining ligaments causing malar soft tissues to migrate downward along zygomaticus creating a bulge along NLC
Malar fat pad- triangular fat pad with base along NLC and in younger people with apex at zygoma
Modiolus – corner of the mouth
Marionette lines- inferior extensions of the nasolabial crease below the mouth, otherwise known as NLC below commissure
Witch’s chin deformity- a droopy chin from aging, otherwise known as ptosis of the integumentary and muscular tissues of the mentum
Jowls- ovoid masses of fibrofatty tissues subcutaneous tissue immediately adjacent and lateral to inferior extremity of the nasolabial crease
Knowing several structures on the surface of the face will help improve understanding of the aging terminology.
1- Eye-Cheek Junction- This is a critical area in evaluating the aging face. Ideally this area is a smooth transition from the eye to the cheek.
2- Tragus- Part of the ear which is located on the face. In facelift surgery, an incision can be made behind this part of the ear (retrotragal) or in front of this part (pretragal)
3- Zygomatic Insertion Point- Location of the origin of zygomaticus major muscle determined by P Miller, S Smith, AR Shah (yes that is Dr. Shah). Serves also as a useful point to help identify platysma muscle location within the face.
4- Malar fat pad- Location of fat pad in face
5- Nasolabial fold- A fold which may become more prominent with aging. Note, that every person has a nasolabial fold and that its elimination will look unnatural
6- White part of the lip- As we age this part of the lip looks longer and the red lips become thinner.
7- Mandibular angle- Good bone structure may help lead to improved jawline and neckline
8- Marionette line- Lines along inferior lip which may become more prominent with aging.
9- Jowl- The jowl below the jawline can be improved with liposuction, the part above the jaw in the face is generally not recommended for liposuction.
10- Chin projection- A more prominent chin can help with providing more definition to the neck
11- Submandibular glands- In some patients, these glands may be prominent on the side view of the neck. They are generally not recommended to be removed for aesthetic purposes as they provide almost 80% of saliva.
12- Hyoid bone- A critical bone in the neck which helps determine how much of an L can be created in the neck.
13- Sternocleidomastoid muscle- A neck muscle who is typically much more prominent in men and should not be removed for aesthetic purposes.
There are differences between our faces and necks which will limit how much improvement we can see in a facelift. Much of this difference has to do with innate structures in our neck such as the chin and a bone in our neck called the hyoid bone. You can feel this part of your neck because if you stick your tongue out the bottom of the tongue will move this portion of the neck forward.
Facelift Recovery Time
Every patient has a different amount of downtime after a facelift. Many patients are able to resume normal activities after 7-10 days.
Facelift Frequently asked questions
Every patient has a different amount of downtime after a facelift. Many patients are able to resume normal activities after 7-10 days.
A face-lift fee can be quoted by seeing Dr. Shah in person or sending a front, side, and oblique photograph of the face and neck.
1. He is one of two surgeons in the country who discovered the significance of the platysma muscle in facelifting. As such he slides the muscle backwards and repositions, creating a more lasting lift. He secures his lift in fixed anchor points which was described in a recent scientific article.
2. He does not use surgical drains. Surgical drains can be painful and cause infections. By using a revolutionary new technique, he is able to circumvent the use of drains leading to earlier recovery.
3. Well concealed incisions- By putting the tension on the deeper structures which have been lifted, Dr. Shah’s technique avoids tension on the skin of the face. This allows for the maximal amount of cosmesis along facial scars.
4. Not just younger but “gorgeouser”. Dr. Shah’s techniques allow for patients to not just look younger but actually more attractive. He restores balance to the face by putting emphasis on the cheekbones, giving the face a more overall attractive contour.
5. Advancements- Dr. Shah has written 3 landmark papers on face-lifts and face-lift anatomy, making him a foremost expert on creating a better and safer face-lift.
The sun should be avoided for several reasons. First of all, excessive sunlight on fresh, healing scars may cause hyperpigmentation, or darkening of the healing areas. Secondly, excessive sunlight may create increased swelling. Finally, the sun will damage the skin on a long term basis, creating deeper lines and a more leathery appearance to the skin.
Although many patients describe enjoying a nice glow after the sun, it is not recommended by ANY plastic surgeons or dermatologists. The simplest way to slow the aging process is to wear daily sunblock spF 15 or higher.
The youngest age of a patient for a face-lift I will perform is 40. The determining factors for a facelift are the inherent skin elasticity and the root cause of the aging factor in the patient. Some patients at 40 will benefit from a maintenance lift. In patients who are upset about their neck line, generally speaking 40 to 45 is the age where most patients will benefit from a lift and liposuction rather than liposuction alone. This is mainly due to skin elasticity. In some patients, particularly in African American and Asian patients, the skin may have excellent elasticity well into the 50’s. For some of these patients, liposuction and neck sculpting alone may be an option rather than a face-lift.
I take a different approach than most surgeons when addressing the neck. I am not a big proponent of liposuction, particularly in the central neck. There are several reasons for this. First of all, I have seen many patients with persistent lumpiness in their neck after central liposuction. I think that most patients will have some slight textural unevenness to their necks after any procedure, but persistent lumpiness is not a desirable feature for my patients.
Second of all, I don’t know if standard liposuction is actually that effective. There are two types of fat in the neck. There is a more loose fat which is less fibrous. This fat is amenable to liposuction. Some patients also have a denser more fibrous fat which is much more resistant to liposuction techniques. In addition, there are certain locations which are not safe to liposuction in the central neck. All liposuction is superficial to the platysma muscle. But in some patients, all of the fat is located deep to the platysma muscle. This fat must be addressed with another technique or the neck will not have enough definition postoperatively.
It depends on the surgeon and the technique. I do not change hairlines by placing my incision and vector of pull to account for the additional skin. The standard approach for a face-lift is to make an incision straight up 5 cm above the ear. The main problem with this incision is that it can change the position of the temporal tuft. In addition, this incision does not serve a purpose. I am not sure the advantage of having an incision superiorly along the scalp. The incidence of hematoma is much higher in these patients. In addition, in a face-lift procedure, the big question is how much skin did my surgeon remove WITHOUT tension. This will let the patient know how effective his or her lift is. If there is a large amount of skin removed, the hairline will shift in patients with excessive superior component to the lift. I perform a variety of incisions, but the key component is to maintain hairline position. Surgeons who have a straight line back into the scalp will shift the hairline, creating an obvious sign of a lift.
Drains are placed to remove excessive fluid after a lift. If a face-lift takes more than three hours, a drain may be placed. I generally avoid drains for several reasons. First of all, I am able to perform a complete lift in a period of time where a drain is not necessary. Second of all, drains can be uncomfortable. I use a compressive dressing to help prevent fluid from accumulating.
A short answer is typically no. Most of the time, the patient needs the lift repeated. The reason for this is that one of the potential causes of wider scars can be too much tension on the incision line. If the lift is repeated, the skin incision will have less tension and the scar will have a better chance of healing appropriately.
The key concept in facial rejuvenation is to properly analyze the face and determine the most effective way of rejuvenation. Some patients in the early 40’s may benefit from a face-lift, depending on the position of the deeper tissue. A common misconception is that a little lift is safer and less invasive than a larger lift. Some of the mini lifts offered rely solely on excision of skin without actually lifting the deeper tissue. A common occurrence after this type of lift is wide scars from large amounts of tension on the skin, ineffective lifting, and surprisingly an unnatural appearance. The unnatural appearance occurs because the skin is stretched with too much tension, creating a pulled look. It is important to realize that a youthful face looks plump and with a taut neck rather than looking stretched or pulled.
None of materials Dr. Shah uses are metallic and will not effect x rays / airport scanners. Dr. Shah does not use non-absorbable (permanent) sutures for the suspension in face-lifts.
Dr. Shah does not use permanent sutures in the face. A permanent suture can lead to infection if it becomes impregnated with bacteria. In addition, a truly effective lift does not rely on a suture to suspend on the face. Repositioning of the deeper tissue will allow the newly positioned tissue to heal in a better place, obliterating the need for a permanent suture. Natural healing is far more effective than reliance on permanent sutures.
Dr. Shah does not use staples in aging face. He believes that staples can lead to “step-off” deformity where the hairline is not matched up properly.
Most patients can exercise 2 weeks after lift with the exception of skiing/horseback riding. Any exercise where the pull is felt on the neck should be avoided even at the 2 week mark.
Caffeine can raise blood pressure and thin blood which can delay healing. It should be avoided 4 days before a procedure and 4 days after.
Alcohol thins blood and therefore can delay healing and lead to more swelling postoperative after a face-lift. It should be discontinued one week prior and one week after.
Scars go through different phases of healing. Scars are considered mature at 6 months to a year after a procedure.
Healing of a scar is dependent on individual healing characteristics. A key to favorable scarring is location of scarring, size of scar, color of scar and texture of scar. By designing a face-lift with the scar hidden throughout the hairline, in a small crease in front of the ear, behind the tragus, behind the ear, and hidden in the hair again, it is difficult to see the scar. In order to maximize the healing of the scar, closing the scar in a precise manner is critical.
Dr. Shah does not believe in the use of staples since it can lead to mismatched tissue postoperatively. In order to help minimize discoloration of the scar after a face-lift, Dr. Shah recommends use of daily sunscreen (UVA and UVB), found in many moisturizers, and avoidance of direct sunlight on scars for 6 months. Even sunlight on a bruise can lead to discoloration. Some individuals have a propensity to develop thicker scars called keloids or hypertrophic scars. It is critical that patients have close follow ups with Dr. Shah in order to maximize the healing potential of each patient. Patients with keloids and hypertrophic scars can be treated with steroid injections and silicone sheeting.
Lifts lasting are dependent on elasticity of tissue, adherence to lifestyle changes, including avoiding smoking and sun.
All scars are visible. However, ideally, the scar can be hidden to a fine line so it is difficult to see.
Dr. Shah hides scars in hairline but uses hair sparing technique to conceal scars.
Typically face-lifts are not painful procedures. Most patients are able to take Extra Strength Tylenol the next day. However, every patient is different and sensation of pain is difficult.
A hematoma is a large collection of blood which can accumulate after a face-lift. Generally speaking, most hematomas are a result of patients being on blood thinners or elevated blood pressure. Dr. Shah advocates patients follow a strict preoperative regimen to minimize chance of hematoma formation. In addition, patients with a history of high blood pressure should monitor their blood pressure closely to ensure that it is under control.
Some patients seeking facelifts are seen as young as the early 40’s. Patients as old as 85 years of age have had lifts performed. Vanity has no age.
The goal of a Facelift is to reposition deeper tissue in an effort to give more definition to the jawline, neckline and change the appearance of the facial shape from a pyramid to an inverted V. Lines can be a result of aging to skin, which is addressed by a skin rejuvenation procedure not a facelift. Some lines are a result of excess skin, which can be repositioned during a lift.
I don’t believe a traditional facelift is a great procedure either for rejuvenation. I think a modification of a deep plane technique, termed, CPMS, has worked well for me. A facelift does not fix every problem in facial aging, but can serve as a foundation which works in conjunction with other techniques.
Minilift has no place in plastic surgery. A classic minilift procedure is where skin is lifted and removed. Unfortunately this procedure is ineffective in facial rejuvenation. Some surgeons use the terms minilift interchangeably with short scar facelifts. Short scar facelifts can be effective in specific patients depending on the degree of skin laxity.
Typically liposuction is not a desirable procedure in the face. Sometimes in patients with extra fullness in the cheek, the buccal fat can be removed in an effort to give more definition to the face.
Parotid glands are necessary for salivation (spit) in the face. Their removal for aesthetic purposes is not recommended. Some patients with large parotid glands actually may have large masseter muscles. In that case, botox may help in certain cases. I would recommend a patient with a large parotid gland to have an otolaryngologist explore additional causes of bilateral enlargement.
Dr. Shah does not believe in removal of submandibular glands for aesthetic purposes. Submandibular glands provide a necessary function in creating saliva. In addition, a motor nerve of the face courses through the glands, making their removal risky.
I have not seen effective lift long term looking results or impressive results. In addition, the premise of all midface lifts is to lift the cheek pad and hold it in place with either a suture or a absorbable device and skin is removed from the lower lid. Unfortunately, when these lifts descend over time, the lower lid can be pulled down with it. Dr. Shah prefers the use of volumetric rejuvenation of the cheek area in an effort to lift the nasolabial fold. Most faces and malar areas flatten over time. When this flattens, The nasolabial fold can become more pronounced. By adding volume into the face, the malar area is improved, softening the nasolabial fold.
Removal of wrinkles is not a primary goal of facelifts. The name rhytidectomy is misleading. It means to excise wrinkles. A lift is designed to lift and reposition deeper tissues. In this process some lines may soften. Many lines seen in the face may be a result of aging in the skin. A common analogy is seen in that of cowhide and leather, with cowhide representing young skin and leather representing older skin. If you stretch leather, you will never recreate cowhide. Similarly, if you stretch aged skin, you can never transform it to young skin. Microscopically, there are changes seen in the skin which can show dramatic changes to the skin. A skin rejuvenation procedure may be needed to work in conjunction with a lift which helps to rejuvenate the skin.
MACS lift is essentially a form of a mini-lift where the lift is lifted by purse string suture and attached to the periosteum of the zygoma. I performed a study examining various anchor points and have found that this is indeed a good anchor point. I do not think this technique makes much sense to me from a theoretical standpoint and have seen patients postoperatively who have had MACS lifts performed. Changes created with this lift are subtle and unnatural in my opinion. I advocate elevation and repositioning of deeper tissue and have found results to look more aesthetically pleasing.
Fat transfer has a role, as does the concept of addition of volume in facial rejuvenation in surgery. It can work well in conjunction with surgical procedures to help rejuvenate a face in most patients rather than as the solution.
Yes. Chicago surgeon Dr. Shah is certified by both boards.
About Chicago’s Dr. Shah.
Dr. Shah is a double board certified facial plastic surgeon who has written over 50 scientific articles including three landmark articles about facial anatomy revolutionizing the way plastic surgery is performed. Chicago surgeon Dr. Shah specializes in Facelift and takes an analytical approach to patient recovery after the procedure. Based in Chicago, IL; Dr. Shah is not only recognized as one of the top plastics surgeons not only in the city of Chicago, but in the world.