THE "VERTICAL MIDFACE LIFT"
The bad news is, we cannot stop aging. The good news is, we have many methods of treatment that can solve most of the appearance problems associated with age.
Dr. Binder has lectured around the world sharing his philosophy and techniques, which have earned him international acclaim. He has taught hundreds of other surgeons, as well as the public at large, about the significance of the aging process, what it means, and how it should logically be treated.
We cannot do anything about the passage of time, but there are many physical signs of aging that can be reversed by facial rejuvenation procedures. Facelift surgery is highly effective in correcting the underlying soft tissue and imbalanced features that are caused by aging and exacerbated by over-exposure to sun, rapid weight loss, alcohol intake, smoking or other abuses. Such signs of aging include wrinkles, pouch-like bags under the eyes, sagging skin, drooping eyebrows, eyelid hooding, jowls and "turkey gobbler" chin and neck.
The goal of the modern day facelift is to restore a youthful look to the face. The term facelift is really a misnomer, as the operation combines lifting and sculpting the face and neck regions in one procedure. Midface lift or necklift can either be done separately or at different times. This is less common than performing the complete facelift procedure, which includes both the midface and neck areas. Another procedure, which removes excessive fat or folds of the neck under the chin, is frequently performed as part of a rhytidectomy. This is called submental lipectomy.
As the skin begins to sag and fatty tissue layers are lost, imperfections in the contour of the face become very noticeable. Additional procedures can be performed to support or augment both the bony and soft tissue structures of the face. Flattening at the level of the cheekbones can be improved through placement of midfacial implants. Implants may also be used to enhance the contour of the chin and improve the jaw and neckline.
Contemporary facelift surgery differs vastly from the older stretch and tighten procedure, which ten years ago, ignored important principles of aging and facial structure. The older methods, which dealt only with the skin and not its underlying structure, attempted to correct wrinkling and sagging skin by pulling the face as tightly and flatly as possible. This method often resulted in a very unnatural, mask-like or flattened appearance that did not last. Today, revolutionary facelift techniques focus on creating dramatic, yet solid, long-lasting changes that are natural in appearance. They correct underlying skeletal structural deficiencies and effectively reposition and contour the underlying muscle layer and skin. For these reasons, the surgeon must have the necessary training to understand and effectively deal with the anatomy and underlying structures of the face.
Facelift surgery is performed on both men and women, and corrective procedures vary from person to person. While one individual may need a complete face and neck lift, another may only require elevation of sagging eyebrows or fat removal from the lower eyelids. Another may need only correction of an early double chin. A person whose facial appearance is very weather-beaten may also require a chemical peel or laser resurfacing. Someone else may require all of these procedures to maximize the outcome of the facial rejuvenation process. This is the basis for the "multi-level approach" to facial rejuvenation.
PROBLEMS OF AGING
The aging process is a result of losing deep and superficial adipose (fat) tissue.
The processes involved are:
Volume loss has its most significant impact on how youthful someone appears. If we look at figure (xx), we see a span of 40 years separating the mother and daughter. Volume loss is the most significant factor in the facial aging process and visually, the most striking. What is missing is the amount and volume of fat and soft tissue in the face that causes the face to appear older. This process occurs early and plays the greatest role in the aging process. The bone structure is still there, only the camouflage has disappeared.
We can also look at the aging process as a young inflated beach ball (FIG XX) compared to the older beach ball that gradually deflates over time. Leonardo Da Vinci was able to depict this process in his famous painting Age Confronting Youth. (See photo). We see similar changes in athletes such as marathon runners and weight lifters. They frequently have significant loss of fatty tissue of the face that produces a gauntness or a hollowing out of the cheeks and midface, causing them to look much older than their real age.
As an example, (insert photograph) the patient in the photograph demonstrates how facial contouring procedures provided the foundation in combating the aging process. This patient was unable to undergo facelift at this time. However, using just a chin and midfacial implant, we were able to enhance her appearance and reduce the effects of the aging process for over seven years. Note that a facelift was not done in this seven year postoperative photograph. The longevity derived from these procedures clearly shows how the enhanced structure and support provided by the implants holds up and stops the soft tissues of the face from falling. They add volume and set up the foundation for a better facelift result in the future.
Other signs of aging produced by weakening and sagging of the facial muscles are formation of jowls along the mid-jaw, skin hanging under the chin (turkey gobbler deformity) and the formation and deepening of the nasolabial folds and marionette grooves. These are conditions that are best and more definitively corrected with the facelift procedure.
THE MULTI-LEVEL APPROACH TO FACELIFT
It has been said that facial aging is easy to recognize, but difficult to define. Most agree that there is no one best method for facial rejuvenation. All patients present different types of problems unique to each individual facial structure. Therefore, I have developed the multi-level concept of facelift surgery to treat all patients with different bone structure and skin type.
I developed my philosophy and approach to facelift surgery focusing on treating patients who were not considered ideal candidates. I felt an obligation to provide a superior facelift result for each and every patient, no matter what the preoperative or underlying circumstances. Early on, I understood that I would have to apply multiple techniques to accomplish superior results in this group of patients. "If I could achieve a successful result in the less-than-ideal circumstance, then I would be able to achieve not only good, but consistently great results in the rest of the population who were considered better candidates for facelift surgery."
GOALS: The primary goal begins with correctly analyzing and understanding the deficiencies or deformities present in the anatomy of each individual patient and isolate these problems that may be present. By analyzing and treating the aging face, we have to understand why facial structure is so important and the rationale for the type of facelift or facial rejuvenation procedure we choose. This will determine how we can logically approach the problems of aging in order to select the most appropriate procedure or procedures for each patient.
The rationale for the multi-level concept in facial rejuvenation is that the skin, subcutaneous tissues, deep fat and soft tissues all atrophy and sag at different rates and at different levels, but in predictable patterns. The aging process occurs at all levels including skin, subcutaneous tissue, the SMAS and the deep fat and soft tissues. All of these anatomical levels have a significant role in the aging process and determine the procedures we choose to perform in order to reverse the aging process. Therefore, facial rejuvenation procedures must account for Structure, Volume (presence or absence) and Vector (how the downward distribution of soft tissues are displaced).
EMPHASIS ON STRUCTURE AND SUPPORT:
An emphasis on structure and support answers the following questions:
Our contemporary definitions of facial beauty stress the principles that:
The four primary components of facial beauty are:
Youth is characterized by a fullness in the cheeks and lips with the absence of wrinkles or blemishes occurring on the skin. This is a constant in defining beauty. The definitions of beauty and youth become inseparable and an extremely important concept for the surgeon to realize.
The multi-level approach is a logical three-dimensional understanding of the aging process that recognizes and treats all of its components.
THE LEVELS OF FACELIFT:
I have developed a versatile independent array of techniques with the flexibility to provide options that effectively treat most patients with different problems. This provides the ability to design a logical course of the best treatment options for each and every patient and targets the problem to ensure the best possible outcome.
THE FACELIFT PROCEDURE
The facelift procedure is divided into 2 components: the Midface component and the Neck component.
THE VERTICAL MIDFACELIFT: WHAT IS IT? WHAT IS ITS SIGNIFICANCE?
The Vertical MidfaceLift is going to prevent the pulled look. Many patients are apprehensive about undergoing a facelift because they have seen so many patients that are either too pulled or appear unnatural after facelift surgery. This has caused much concern and many patients try to avoid a surgical solution. Patients often chose a temporary fix or more minor procedures that unfortunately have limited longevity. To avoid these problems, the surgeon must accomplish a vertical lifting or elevation of the midface. Hence, the term Vertical Midface Lift. This process lifts the deeper soft tissues, fat and jowls. Lifting these tissues must be done in a way that just doesn’t pull the face. Rather, the surgeon must have the experience needed to access the areas of the face which will enable him to elevate and anatomically relocate the midfacial soft tissues and the jowl vertically upward and back to where they were years before. This is what will ensure no distortion of expressive features. The surgeon must realize that it is not only the skin that has dropped, but the deeper elements of the soft tissues which form the jowls have also dropped. The soft tissues must be relocated upward and suspended at a higher location. That is the most effective way to treat this type of problem. My facelift procedures utilize the vertical midface lift as the gold standard to effectively withstand the test of time.
In order to successfully elevate the face, the deeper SMAS-type of facelift procedures are performed. The facelift is now designed to relocate and recontour the soft tissue and muscle layers of the face. It must also redistribute, smooth out, and remove the excess skin from the face and neck. The facelift operation usually takes between 3 1/2 to 4 1/2 hours to perform. Incisions, which will heal into flat, nearly invisible scars, are made in unobtrusive areas such as inside the hairline and/or in natural depressions around the ears. Usually, the incision for facelift surgery begins in the hair near the temple and continues in from the front of the ear, around the earlobe, behind the ear and into the hair in order to prevent easy detection. At the temporal area, the incision is carried below the hairline so that the hair can always be worn in any desirable fashion.
In choosing from a variety of facelift techniques and applying these techniques individually to each patient, the surgeon must have an in depth understanding of the anatomy of the face. This ability to perform these procedures safely and efficiently with minimal down time directly correlates with the degree of training and qualifications of the surgeon.
OTHER FACELIFT PROCEDURES THAT CAN BE PERFORMED.
* Short Scar – Short Flap FaceLift: Recently a short scar or short flap technique for younger patients has been proposed. The indications for this procedure are for younger patients to treat early development of the jowl. This is a limited approach and does not have similar benefit in terms of the long term results obtained with the vertical midface lift.
* Subperiosteal Midface lift: This procedure has also been highly advertised as one with invisible scars. This procedure is performed for cheek elevation when the neck and jowls do not need lifting. The indications for this procedure are also designed for younger patients. The scars are usually above or in the hairline. An incision may also be made intraorally, similar to performing a mid face implant procedure. The procedure is performed usually in conjunction with an endoscopic forehead lift.
* Liposuction of the MidFace and Buccal Fat Removal: Liposuction of the jowl or nasolabial folds may cause problems in soft tissue irregularities. One seldom encounters fat within this area. The problem is a redundancy of tissue that gathers within these areas, rather than an accumulation of fat. Dr. Binder maintains that the tissues need to be lifted, rather than removed, In other cases, fat can be trimmed successfully and safely during the facelift procedure.
BUCCAL FAT REMOVAL: Removal of the buccal fat is what created the waif look in the early part of the 1990’s. Since then, we have eliminated this look from the spectrum of being aesthetically desirable. The entire basis for one looking younger is to maintain a fullness of the face. I perform buccal fat excision in select cases, and reserve this procedure in patients with very thick skin, wide moon-like faces, patients of Asian decent and those having an exceptionally amorphous face. In these types of patients, buccal fat excision can be used to contour the face in conjunction with the use of facial implants. However, as I have maintained throughout the years in my articles and lectures about facial contouring, I would be extremely cautious performing buccal fat removal in patients who have thin skin, a thin face, or prominent bone structure. It should also be noted that some of the negative effects of buccal fat removal may not be seen for 10 to 15 years, when the natural fat reducing effects of the aging process start to chart their own course and accentuate the loss of fat removed. Once removed, the buccal fat is difficult to correct.
* Radiofrequency Devices: Radiofrequency devices have been introduced recently. Heating the skin via radiofrequency or by most any energy source will result in edema to the skin that makes it appear less wrinkled. I have found the results of such treatments to be short lived and advocate them only if the patient understands the limitations of these procedures.
* THE THREAD LIFT: The media quickly picks up on new plastic surgery procedures and people very often hop on the bandwagon. This procedure which uses sutures to suspend the face has been embraced by various cosmetic doctors who may or may not be surgically oriented. It is not without complications. After my thorough review of the results of this technique, so far, I am unimpressed. I will reserve judgment until a more a double blind study is published showing long term follow up with discernable results.
B. THE NECK:
Is there excessively loose skin? Is there excess laxity and loose-hanging muscle below the chin? Or is it a combination of all of the above? Correctly diagnosing the pathology is essential for choosing the most appropriate technique.
1. THE SUBMENTAL PROCEDURE ("CORSET PLATYSMAPLASTY"): In time, the platysmal muscle falls and drags the skin down with it. This is what causes the bands to develop over the anterior or front part of the neck. We provide a more ideal neck contour by utilizing this muscle. We actually isolate, relocate, and use the muscle to produce a supportive neck sling so that it reinforces the neck rather than merely pulling the skin.
There are a few options for neck lifting. To be effective, they all involve treating the redundancy of the platysma muscle in one form or another. In cases of minimal redundancy, the neck may be approached through an incision under the chin. The muscles can be sutured together and the neck contour improved. In many cases, what might appear as fullness or excessive fat, particularly in the "turkey gobbler deformity", might actually have very little fat present. In these cases, it is important that fat NOT be removed. The presence of a layer of fat under the skin is essential for smoother and more youthful quality to the neck skin.
2. THE BIDIRECTIONAL NECK LIFT: In cases where there are larger degrees of redundancy, we do not merely isolate or tie the muscles together. We actually produce a muscular sling from a bidirectional approach. In the midline, under the chin (the submental area), the muscle is isolated from the skin and underlying tissue and then rotated in an upward direction where the muscle is reinforced at a new location and a muscular sling is created. This improves the contour over the lower part of the neck in the more central locations of the neck. The platysma muscle is also isolated from the back of the neck and advanced backward, repositioned and resuspended as an extension of the SMAS component of the facelift. This upper part of the platsyma procedure creates a well-defined jaw neck even in the most difficult cases.
Having the opportunity to follow my patients for over 10 to 15 years, this bidirectional playtsma method has proven to provide the longest lasting results in neck lifting than any other type of procedure.
3. SUBMENTAL LIPOSUCTION: In younger patients who have enough elasticity of the skin and/or a specific area of excess fat, liposuction have proven to be an excellent modality to sculpting the neck. After a certain age, however, liposuction can cause negative effects. Some of us need that cushion under the skin to insure that the it looks healthy and vibrant. Excessive fat removal, particularly in older, thinner patients, with a sagging of the muscle, can cause a depressed area under the chin which is referred to as a "cobra" neck deformity (a common occurrence from excessive liposuction of the face or direct removal of the submental fat. (In photo xx, we illustrate the need for the removal of submental fat. In this case submental fat removal was performed in conjunction with the neck lift to elevate and relocate the jowl and excessively heavy neck tissues as well as define the jaw neck line.
Dressings and a custom pressure wrap are applied immediately following surgery to reduce the natural swelling and inflammation. A small, thin tube may be placed in the back of the ear to allow drainage of any blood collecting under the skin.
A full set of postoperative instructions is accessible on our web site. Attentive follow-up care by the surgeon is essential to ensure rapid healing. One can expect about a week of initial recovery time, during which most swelling and discoloration will decrease. The remaining swelling and bruising can be expected to subside over several weeks, along with any feelings of tightness or numbness.
How Long Will a Facelift Last?
Plastic surgery of the face corrects visible signs of aging, but it does not stop the process. The degree of improvement and duration of the results are based to a large extent on your own individual aging process. This is affected by age, heredity, health, sun exposure, diet, exercise, alcohol intake, smoking and other habits. However, the better care you take of yourself, the longer the results will last. In general, a face and neck lift should effectively correct the visible signs of aging for five to ten years. Although no surgery can permanently prevent aging, a person will always look better in the years to come than if the procedure were not done at all.
POSTOPERATIVE QUESTIONS THAT MUST BE ANSWERED
Every patient and surgeon must draw conclusions when the postoperative moment of truth arrives. These questions must address the objectives of surgery.
I have been able to conclude that only a diversification of techniques applied to multiple levels of the face will have the ability to attain enhanced results and prolonged longevity that patients should expect.
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Beverly Hills, California 90212