The Diva Lift: Facelift for Full Figured Females

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In this day and age, it is a bit disgusting that some surgeons go out and makes a minor change to a procedure that has been around for a century and “invents” some new miracle procedure.  There are bunches of these types of docs out there.

I recently detailed some of my work that involved modifications of traditional facelifts in patients with high body mass index (BMI) in an article in Cosmetic Surgery Times.  The Body Mass Index is a formula that gives a number based on the height and weight of the patient.  Overweight patients (full figured) present many differences when compared to the average facelift patient.  This magazine goes out to cosmetic surgeons from multiple specialties and frequently details new or innovative approaches to cosmetic surgery.  The editor, Teresa McNulty, and I discussed a modified facelift that I was performing on full figured women with great results.  She was impressed with my surgical results and suggested the name of the article be the “Diva Lift”.  So there, that is how the name came about and not as a self anointed marketing ploy on my behalf.

What is the “Diva Lift”?

First of all, the word Diva, until the past decade when it became descriptive of any star female singer, was commonly used to describe full figured opera singers.  Facelift surgery is a very large part of my cosmetic facial surgery practice and one of my favorite procedures.  I enjoy facelift surgery because I think it is the most dramatic cosmetic surgery procedure that exists for several reasons.  First of all, you can hide mediocre surgery on boobs, bellies and buts, but you can’t hide facial surgery.  Secondly, as we age, big changes occur in our cheeks, face and neck that cannot be disguised with clothing.  Another important thing about facelift surgery is it is probably the most noticed surgery as patients look at their face daily more than any other body part and those we interact with see our face more than other parts of our body.  Facelift is the ultimate rejuvenation procedure.  Patients simply feel bad when their face ages and feel better when it is firm and tight.

 Facelift patients come in all size, shapes and genders and unlike some operations, no two are the same.  Also many surgeons perform different variations of facelift surgery.  Like anything else, there is a right way and wrong way to perform facelift surgery.  Many surgeons perform time tested “textbook facelift surgery” while others get lazy and adopt shortcuts that affect the results and longevity.  Worst is the current rage of “minimally invasive facelifts” that are merely marketing ploys of corporate franchises.  These lifts claim to be revolutionary or miraculous and lure patients with promises of maximum results with minimum downtime and cost.  Note to consumers!  You get what you pay for.  I don’t mean this only in terms of cost (because some of these miracle lifts cost more than my larger lifts) but in terms of recovery.  If a patient over 40 years desires comprehensive facial rejuvenation that will last over 10 years, then they need a longer recovery.  Two weeks of recovery is not too much to endure to reverse decades of aging and skin sagging.  To truly address the deep tissues of the front of the neck and cheeks, incisions must be made under the chin and in front of and behind the ears.  These incisions are well hidden and almost unnoticeable when performed by experienced surgeons.  These trendy “minimally invasive” facelifts only use a smaller incision in front of the ear and this severely limits the effect of the lift.  When you perform facelift surgery correctly and comprehensively, it requires tightening of the neck muscles under the chin (called the platysma muscle).  It also requires tightening of the deep layers of the cheeks (known as the SMAS which stands for superficial musculoaponeurotic system) with numerous sutures for a secure and lasting result.  Finally, the incision behind the ear (which is hidden in the hair) is absolutely imperative to truly address the excess skin of the chin, face and neck.  When a surgeon shortcuts any of these incisions or approaches, the patient gets short changed.  The result will simply be less dramatic and for sure will be less long lasting.  A three to five day recovery may sound like a great thing, but it is a short cut.  To address all the important structures, a recovery closer to two weeks is necessary.  Most facelifts with short recoveries will unfortunately also have short results and will begin to relapse within the first 2 years.

The “Diva Lift” (and I must admit that I hate to “name” a facelift is far from a short cut.  In fact, it is a more aggressive facelift because these overweight patients have more fat and skin and need more surgery to obtain a natural and long lasting result.

 

How is the “Diva Lift” different from conventional facelifts?

 

The main differences of the “Diva Lift” are modifications of traditional facelifts to address the excess fat and skin.  The first difference is that these procedures require a higher level of liposuction of the superficial and deep fat when compared to a normal weight patient.  Also, deep fat accumulations are addressed under the chin and the front of the neck.  By reducing or sculpting this deep neck fat, the surgeon can obtain a much more defined neck after the facelift compared to facelifts that don’t involve this deep fat. After the superficial and deep fat are reduced or removed, the neck muscles in the front of the neck (platysma) are tightened.  The “Diva Lift” also involves a higher level of “liposculpture” where instead of just removing the fat under the skin; it is sculpted to provide youthful contours of the jaw line, jowls and neck.  Full figure patients also have much more fat in their cheeks and neck and the “Diva Lift” specifically address this to a greater level than the conventional facelift.

Besides the deep fat in the neck, the way that the deep tissues of the cheeks are managed is critical in larger patients.  In many patients, a common surgical technique called “plication” involves tightening the deep fat and tissues in the cheeks by folding them over.  In a thinner patient this technique may be desirable as it add some facial volume, whereas in the full figure patient the goal is to reduce some of the cheek volume.  With this in mind, the “Diva Lift” involves a more comprehensive method of treating the deep tissues in the cheeks called “SMASectomy”.  Instead of folding the tissue over on itself like plication surgery, some of the deep tissue is actually removed which not only tightens but slims the face, which is very important in this type of patient.  In the “Diva Lift”, much more time is spent dealing with fat excess than in the conventional facelift.  Also important in this type of lift is the tightening of the backside of the neck muscles (posterior platysma).  Many surgeons omit this step and again, it improves the result and longevity of the lift.  Why doesn’t every surgeon do all of this?  The answer is simple.  It takes time and expertise to competently perform these procedures and some surgeons don’t want to devote the time or do not have the surgical expertise.  The “Diva Lift” is not a facelift for beginning or inexperienced surgeons.

The last step of the “Diva Lift” that varies from conventional facelifts is the excess skin management and incision patterns.  Since the full figured patient has more skin than the average patient, incisions must be slightly larger (but still well hidden) and performed in a certain manner so there is no bunching of the tissue.  These incisions are specially designed as not to be noticeable or make big changes in the patient’s hairline, specifically the sideburn region and the hairline behind the ear.

So, the “Diva Lift” is not a smaller, but rather a larger type of facelift.  It embodies a little more aggressive treatment at each step of the facelift when compared to the average facelift.  It definitely requires more work on the part of the surgeon and perhaps a few more days of recovery for the patient, but the results are worth it.

Some surgeons may read this and say “this is nothing new and Dr. Niamtu is merely doing a larger facelift”.  In some ways they are correct, but it is not simply a larger facelift.  It is a combination of procedures that must be addressed in a specific way with careful attention to details as the full figured facelift patient requires a different type of surgery.  I am the first to admit that I have not invented or discovered anything new.  I have merely modified common facelift techniques to better serve the full figured patient and have obtained impressive results with this technique that have been natural appearing and long lasting.

There may be nothing new under the sun, but there are surely ways to innovate existing procedures to better benefit selected patient populations.

To find out more about facelift surgery by Dr. Niamtu in Richmond, Virginia visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

www.lovethatface.com

The Liquid Facelift: there’s a sucker born every minute!

 

P.T. Barnum, the great circus promoter is frequently quoted as saying “there is a sucker born every minute”.  I am sure he would be quite amused by the new amazing miraculous “Liquid Facelift”!

In this day and age, the best way to promote one’s agenda is to “invent” a really sexy sounding facelift.  First you need an unusual name so the media can key in on it and it will make patients think it is new.  Next, you need to make it sound like it is some new “miracle” that has displaced previous technology.  Finally, you need to make it sound really desirable.  The best way to do this is to tell people that it is non surgical and has little or no recovery.  If someone can put these three things together and find someone in the media to promote it, they will frequently get their 15 minutes of fame.  In the best case scenario the entire hype concept will really take off and the “miracle procedure” will fill the appointment book of the promoting doctor and he or she will frequently franchise their technique to teach other doctors this gift to humanity.  It all goes great guns……………..until…………..well until the other doctors, the public and the media find out four things.

1.  It is really not a new technique, only a hyped repackaged version of procedures that have been around for decades.
2. It is very expensive; it has more recovery that promoted.
3. It is really not a facelift and the results in the average patient are disappointing
4. It doesn’t work.

When all of these factors fall into place, and they always do, many patients are left disappointed and with skinny wallets in the wake of disappointment. 

We have seen this many, many times!  Do names like the Contour Thread Lift, Thermage, The Life Style Lift sound familiar?  I am not sure which is sadder, the fact that so many doctors try to make something out of nothing for personal gain or publicity or the fact that the poor public is so gullible and easily parted from their hard earned cash.  To me, this is much like the weight loss or diet industry.  It is a well established fact based on science and physiology that if you restrict caloric input and exercise you will lose weight.  That simple, no magic!  Yet as I was typing this blog, a commercial came across about the Cookie Diet.   All you have to do is eat these yummy cookies and the weight will fall off!  Please! This should be illegal, but I am sure thousands of gullible people will try the cookie diet and that it will soon fade into obscurity that the thousand diets before.  Will the public ever learn?  If it sounds too good to be true, is it true?

Back to the liquid facelift.  What this procedure really is, is filler injection.  Yep, filler injection, Restylane, Juvederm, the same stuff that thousands of docs do every day.  The liquid facelift is nothing more than a mega filler injection session.  Instead of just filler in the lips or smile lines, it goes in the midface, the jowls, and other place.  Nothing new as most of us that inject filler inject it in these areas when requested.  So, please consider several things.

1. The liquid facelift is not a facelift.
2. The liquid facelift is filler injection.
3. Fillers laser up to a year in the best scenario.
4. Fillers are extremely expensive and a liquid facelift can use up $5-8,000 of filler in 20 minutes.
5. Most people that need a facelift have excess skin and loose muscle.  The liquid facelift does not tighten the skin or muscle; it just fills up hollow spaces.  This is fine, but is it worth it for a year of looking better.
6. A facelift can last 10-20 years, and yes, it required surgery and 2 weeks of recovery.  So what, if you want a real facelift with real facelift results, have a real facelift.
7. All the filler in the world won’t tighten up turkey gobbler skin on the under the chin and under the neck.

 

Is there anything good about the liquid facelift?  Sure, fillers are great and even though I do almost 100 facelifts a year, I am one of the busiest filler injectors in my state.  Fillers are great, but they are not a facelift and should never be used in conjunction with the word “facelift”.

If P.T. Barnum were still alive and if he was a doctor, I bet he would be a big proponent of the liquid facelift.

To find out more about Dr. Niamtu or cosmetic facial surgery in Richmond, Virginia, visit www.lovethatface.com.

 

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

www.lovethatface.com

The First Face Transplant in the USA

Dr. Niamtu with Dr. Maria Siemionow 

There are a lot of disadvantages of lecturing all over the world in terms of travel, inconvenience and time away from home, but this is greatly outweighed by the advantages of making friends with special people.  While serving as the co-chair of the American Academy of Cosmetic Surgery meeting in Phoenix in 2007 one of my duties was to procure world class experts to discuss topics of interest for cosmetic surgery.  This had been right around the time of the French performing the world’s first face transplant.  I became aware of Dr. Maria Siemionow, a transplant surgeon from the Cleveland Clinic.  I was thrilled when Maria agreed to be the featured speaker for our meeting which led to a friendship.  This was several years ago and she detailed her work with animal models in preparation for the first U.S. transplant.  It was pretty fascinating as an incredible amount of work from all walks of medicine are needed to coordinate such an undertaking.  On the surgical side there are transplant, vascular, plastic, ENT, maxillofacial, craniofacial and other surgeons.  On the medical side there are numerous specialties that deal with the host and donor rejection issues and there are psychologists that counsel the patient, families, etc.  More work than you would ever imagine.  Most people think that the work is what happens in the operating room for 20 plus hours of surgery, but that may be the easy part.

This is a very emotional issue with incredible medical ethical implications.  There is much less emotion when transplanting tendons in the knee, corneas in eye or even heart transplants, as these organs are hidden and do not express emotion.  Ethicists do not accept this type of surgery for cosmetic reasons, but rather as last ditch efforts to correct deformities so horrific that the patient has no chance of a normal life in their current state.  The lady in France was mauled by dogs, the patient in Cleveland was a victim of severe trauma.  These unfortunate patients are disfigured to the point of being unable to cope with the isolation of not being able to leave their home.

Think about the psychological ramifications of this type of surgery.  The recipient patient may resemble the deceased donor.  What about the relatives of the donor possibly seeing someone with a new face that resembles their deceased loved ones?  What about the recipient patient knowing that their face is part of someone who is not living?  None of this is to be taken lightly.  Many problems exist with tissue rejection as human immune systems vigorously reject foreign tissue and patients must undergo extensive pharmacologic treatment including massive steroid doses.  The treatment can be worse than the cure.  This is not a procedure where you simply go have an operation and simply heal.  This is not a facelift, this is a face transplant.  There are good possibilities that many of the functions of the transplanted face will not work.  The muscles may not move, the new face may be expressionless.  No taste, no smell, no feeling.  In effect the new face may be a living mask, but to the recipient it may be the only possible option to appear human, just as a donor heart may be the only chance a patient with heart disease has to live. 

Also the fact exists that the entire transplant may fail and the patient could be more disfigured than they were before the surgery, or they could become so sick from the medical treatment they could die.  Again, there are many considerations with this type of surgery.

What will the future hold?  If we can work out the rejection problems, it could be possible that these procedures could be predictable.  If that happens, replacing missing facial anatomy may be a possibility.  On the other hand, as cloning and stem cell research develop, we may be able to “grow” new anatomy and the entire transplant situation may go down in history as weird science.  In any event, it is a very situation that challenges all aspects of medical and human ethics.  In the movie “Face Off” John Travolta and Nicholas Cage exchanged faces seemingly as simple as putting on a Halloween mask.  This technology may never happen but if it does where does it stop?  Assuming it became an extremely predictable, would an older patient ethically be able to have a younger face transplanted?

All of this makes for deep thinking and undoubtedly will be the plot of more movies and books.  Maria Siemionow and her team deserve the greatest respect for their unfaltering research and work leading to this historic event.  I am honored to have her as a friend.  Time will tell how society views the process.

To find out about cosmetic facial surgery in Richmond, Virginia visit  www.lovethatface.com

 

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

www.lovethatface.com

Minimally Invasive Cosmetic Facial Surgery: Is Less Really More?

 In this day and age of sensational media coverage for cosmetic surgery it can be difficult to sort the wheat from the chaff in terms of what is good and what is hype.  There is no doubt that many things in cosmetic surgery have gotten easier.  The average hospital stay for a facelift 3o years ago was 4.5 days, now, my facelift patients are home by 4PM on the same day of their surgery.  The anesthesia is also easier.  Most patients don’t need intubated general anesthesia and do well with light IV sedation.  We also have new, technologically advanced instrumentation such as endoscopic surgery.  So from this standpoint, cosmetic surgery is easier.

Minimally invasive surgical procedures have also found a place in the pop culture of cosmetic surgery.  It seems every time we turn on the TV or pick up a magazine we are force fed some new miracle procedure that gives facelift results with minimal everything.  Minimal downtime, minimal scars, minimal price, minimal anesthesia and maximum result.  One should wonder how so many “minimals” can equal a maximum.  Do you ever wonder “do these minimally invasive procedures really give the same result and longevity as the traditional approaches?”  These are questions you need to ask or you can be quickly separated from you hard earned cash.

Let’s take facelifts for example.  It is quite fashionable for some surgeons to market their “miracle” facelift.  They will tell you that it is a new technique that few others know how to perform.  They will tell you that the scars are much smaller than traditional facelifts and that it can be done in an hour, with local anesthesia and no bandages and you can go to work the next day.  Now, doesn’t this sound too good to be true?  If these procedures really do exist, how come all surgeons don’t offer them?  How can you get the same result with 1/2 of the incision?  Can you really get the same results?  Will the results last as long as a traditional procedure?  These are things that many patients fail to question and end up with suboptimal results when compared to a traditional procedure.  Or the result looks pretty good for a while and within a year or so, the sagging jowls and neck skin have returned.  Also beware of the before and after pictures of these miracle surgeons.  They frequently position the head and neck to make the post operative result look better.  Also, it is important to know how long after surgery the picture was taken.  A picture taken at 3 weeks may look very different (and better) than one taken at one year.

Facelift surgery is over a century old.  Most every configuration of facelift procedures have been tried, retried and repackaged as a new procedure since the 1920’s.  To adequately correct significant aging in the neck, cheeks and jowls, most surgeons will agree that an incision in front and behind the ears is required.  There is no doubt that in younger patients a more conservative procedure can be performed.  Patients with minimal neck aging and jowling can be adequately treated with only an incision in front of the ear.  This is not a contemporary innovation; in fact this procedure was well described in the plastic surgery literature in 1927.  Back then, surgeons knew that this procedure was not one for advanced aging and same holds true today.  If you take a patient with significant neck and jowl aging and perform an anterior only incision, you will get some improvement and it will last for a while, but you won’t get maximum improvement and it won’t last nearly as long as facelifts that are made with incisions in front of and behind the ear.

It is not that I don’t ever do a front only incision facelift as once in a while I do.  I reserve these “half facelifts” for young patients that just don’t have much aging.  Although I perform 2-3 facelifts a week, I only do a handful of the limited incision facelifts per year.  I have many more patients that ask for them, but in reality they are not conservative candidates and will be unhappy with the results down the road.  Many patients ask for the more conservative “weekend” facelift” but after they hear the pluses and minuses of result and longevity, they most often opt for the more traditional procedure.  I can then offer them a better result that will last longer.

Most patients that present for facelifts are in the range of 45 on up.  It is not unreasonable to have an incision in front and behind the ear to reverse a half century of aging.  Although proponents of tiny incision facelifts would like you to think that the incisions are a problem, it boils down to about 3-4 inches of incision behind the ear.  This allows more ability to tighten the neck skin and the incisions are hidden in the hairline.  Having this incision only increases the healing by several days, but in my opinion can double the longevity. 

There are also times when a patient presents for a conservative facelift and I turn them away.  The reason is that they have more aging than a conservative lift will correct and the result will be compromised and it will reflect on my reputation.  Since my practice is limited to cosmetic surgery of the head and neck, my work is visible.  A bad breast, belly or butt result can be hidden with clothes, but my result is my reputation.  Fortunately, most patients will opt for the correct procedure once they find out the true details.  I have reoperated many times on patients that fell for some “miracle” lift procedure only to be disappointed.  Another situation that exists (that most surgeons learn early on) is that when a patient gets a short cut procedure, they frequently get a short cut result.  Even though the surgeon and staff have explained to the patient that their result will be less than a traditional procedure and even though the patient signs consents detailing that, some patients soon forget that they had the short cut procedure.  They notice that their result is not as tight as their friends or does not last as long and then they become unhappy.  The bottom line here?  Conservative or short cut procedures are fine for some patients.  Those patients include minimal to moderate aging or patients that need a bigger procedure but have medical problems that prohibit more advanced procedures.  Fact.  You get what you pay for.  A patient with significant jowl and neck aging that gets a short cut procedure (no matter how cool it sounds) will not get the same or lasting result as traditional procedures.  No two facelift patients or no two facelifts are the same.  Each patient presents with unique aging and anatomy and the surgeon has much less ability to correct these unique areas with the limited incision procedures.  A few more inches of incision can make a world of difference for the final result.  It is kind of like the ski vests that some people wear in the winter.  They are lighter because they have no sleeves, and there may be some advantages, but if you have to go out into really cold weather, you are better off with the traditional winter coat.

Although I may sound negative, there is nothing wrong with the small incision facelifts.  They are fine for patients with minimal aging, but most patients present for facelift surgery simply need more.  Some doctors push these procedures because they don’t have the training to do the more comprehensive procedures.  Some doctors push these procedures because they don’t have the training to use IV or general anesthesia.  Some doctors push these procedures because they don’t have an accredited surgery center to do the more involved lifts.  And some doctors push these procedures because they have a place in the cosmetic practice, but not as a “do all, end all” option, and this is a fair choice.

 

Believe me; surgeons want easy procedures just as much as patients.  If there is ever an easy procedure that can truly replace traditional facelift surgery no one will continue to do it the “old way”.  Just like you don’t see people driving horses to work!  The combustion engine was such a tremendous advantage, it supplanted previous transportation.  Same thing with facelift surgery.  If a procedure is developed that produces the same result and longevity as traditional facelift surgery, it will push traditional facelift surgery by the way side.  Also, every surgeon will do it, not just a few.  It will be like the discovery of penicillin; all doctors will embrace the new technology.  Finally, this will be on the front page of all major publications and probably warrant a Nobel  prize.  It won’t be limited to some handful of surgeons with a big marketing budget.

Less can be more I suppose, but most of us would not think of this as an advantage.  You are rarely happy when you get a tiny serving of food, a carwash that leaves dirt on your car, a house painter that misses spots, etc.  In most cases, “less is less”.  The same goes for cosmetic surgery, so let the buyer beware.  Make your choices carefully and research what you may be missing when you opt for a conservative approach to surgery that is usually performed otherwise.  Sometimes it may provide advantages, and sometimes it may provide disadvantages.  And remember what your parents told you when you were young, “if it sounds too good to be true it probably is.”  No tiny procedure will rival the results and longevity of a traditional facelift and for sure, no laser, IPL, smart or dumb lipo, or thread will even come close.  A good general rule is to wait a year to try any new cosmetic surgery miracle that debuts on Oprah or the Today show as we have seen a bunch come and go.

 

Joe Niamtu, III DMD