Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Do I Need a Full Facelift?

I can’t tell you how many times that I (and every cosmetic surgeon) hear that question.  I think that the word “facelift” has more meanings to people than any other word in cosmetic surgery.  People ask about a “full facelift”, “half facelift”, “neck lift” and so on.  This can be very confusing to patients and some may forego treatment because of preconceived notions that are not true.

A “facelift” by definition is a procedure called rhytidectomy.  A rhytid is a wrinkle and “ectomy” means to surgically remove, so technically it refers to a surgical procedure with incisions removes skin to tighten wrinkles.  A traditional facelift includes hidden incisions in front of and behind the ear.  The skin is then separated from the underlying tissues and the deep layers are tightened.  Then the skin is pulled in a natural direction and the excess is removed.  Traditionally, the platysma (muscles in the central neck) are also tightened.

A traditional facelift does very little (or nothing) for the central oval of the face (brow, central forehead, eyes, nose and mouth).  It also does very little, if anything for tissues above the nostrils.  So, a “facelift” is more for the jowls and neck, in fact, all about the jowls and neck. Now you know what a facelift really is!

The “wrinkle” in this description (yes, pun intended) is that not all surgeons do the same surgery the same way.  Some surgeons omit the platysma procedure.  Personally I think that is short changing the patient, although very young patients may not need a platysmaplasty.  Also, some surgeons “invent” shortcut facelift procedures where they omit the incision behind the ear.  I am always leery about someone who takes a procedure that is 100 years old and puts his or her name on it, or even worse, a corporate name.  Again, facelift surgery has been around for a century and all the tricks have been attempted and abandoned because a short cut in surgery almost always translates to a short cut in result and longevity.  Some surgeons try to avoid several inches of incision behind the ear and end up doing a procedure that will begin to relapse in several years.  These types of shortcuts always claim easy surgery with fast recovery.  Remember, in cosmetic surgery, you always get what you pay for….not in terms of money, but in terms of recovery.  The cosmetic consumer should always be cautious about any surgery that deviates significantly from the standard of care in technique.  Just because something is new, does not make it better.  Obviously, we do make advancements in materials and techniques, but if and when that happens, it becomes widely adapted and the norm.  Any patient that is looking at a “new” or “miracle” procedure should ask the surgeon to see 20 pictures of patients that had this procedure by same surgeon and the pictures should be 1-2 years after the procedure.  If a surgeon can’t show you that (for any procedure) you better think closely about getting surgery that is different from the way most surgeons do it.  Cosmetic surgery patients often get the short end of the stick from hype delivered by companies, media and surgeons.  If it sounds too good to be true, it is!  If someone invents a new and radical improved facelift procedure, it won’t be in TV ads, it will be front page news.

So, back to the“facelift” definition.  Much of the confusion about the definition of the word comes from a patient’s experience.  A patient may have “rhytidectomy” but also have a brow lift, eyelid surgery, cheek implants, chin implant, laser skin resurfacing, etc.  So when this patient tells someone they had a “facelift” the listener may assume that a facelift includes all that additional surgery.  They would be wrong!  Rremember, a facelift primarily addresses the jowls and neck.  The patient merely had other procedures along with their facelift.  When you get your engine tuned up, it may include a wheel alignment at the same time, but technically, an wheel alignment is not part of a tune up.

The best way to keep this all simple is to divide the face into 4 segments:

  • Upper face
  • Midface
  • Lower face and neck
  • Face and neck skin

Each of these regions concerns separate cosmetic procedures to address the aging in that area and the facelift concerns the third item on the list.  Also facelifts come in three sizes; small, medium and large.  It is basically the same procedure in different versions.  Patients in their early 40’s may need a small lift, while patients with more aging need bigger versions of the same operation.

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

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


February 27, 2012 Posted by | Cosmetic Facial Surgery Consultation, Cosmetic Surgery Education, Facelift Surgery | , , , , , | Leave a comment

Minimally Invasive Facelift: Counterpoint

I was recently asked by a major cosmetic publication to discuss my feelings on minimally invasive facelifts.  Although I think they are a possible option for younger patients, I believe they are over used on patients that actually require a more comprehensive facelift and therefore lead to many unhappy patients that are left with a lesser result, all in an effort to attempt to shave a few days off of recovery.  The following represents my thoughts on this issue.

Facelift surgery has been around it its current form for about 100 years.  During that time, virtually every permutation of the procedure has been attempted; some with success, some without.

In today’s fast moving cosmetic market, companies, media, surgeons and patients eagerly await “new advances” for devices and procedures.  We all want a simpler means of obtaining similar results but sometimes the cart gets in front of the horse.

Let me preface this discussion by saying that the best facelift technique is the one that works well in the hands of the specific surgeon, provides good results with low complications and most importantly, happy patients.  This means that there are many ways to approach lower face and neck aging.  I have a large facial surgical practice and my patients expect dramatic results.  Many of them have already had negative experiences with minimally invasive facelifts and are very frustrated.  This patient will only be happy with a comprehensive facelift.  Having said that, my good friend down the street is a dermatologist and performs only minimally invasive facelifts with local anesthesia.  His patients are also happy and that procedure works fine in his office with his patients.  So, we are both doing the right thing.

Also, I must point out that there are many renowned cosmetic surgeons that are staunch advocates of minimally invasive facelifts, so they obviously work well for these people. I consider a minimally invasive facelift (also called short scar facelift) to be a lift with an only a preauricular incision that terminates at the mastoid region with no posterior auricular and scalp incision.  These lifts are also usually performed without midline platysmaplasty and frequently utilize variations of purse string sutures.

 Expressing my feelings on minimally invasive facelifts may be discounted by short scar advocates, but I can back up what I say in my series of almost 700 facelift procedures over the past 12 years.  Is 700 facelifts a big number?  For some surgeons it is not as they have partners, fellows, interns, etc. that may do a big part of each procedure.  In my office, it is me alone, every cut and every stitch, so my 700 may be more experience than someone else who has done 1,500.

The remainder of this article will deal with why I personally, don’t favor minimally invasive facelifts. It is not that I never do a short scar facelift, but my parameters are only for young individuals with minimal aging.  This means patients with early jowling and almost minimal neck laxity.   I perform an average of two facelifts each week.  Last year I performed almost 80 facelifts and of these, only two were short scar lifts, so it represents 2.5% of my yearly lifts. 

There are many reasons that I don’t favor these lifts but the primary reason is that I am thoroughly convinced that even younger patients need a larger lift.  I have a policy when I perform a short scar lift that during the procedure if I ascertain that the patient will be better served with a traditional lift, I have their permission to convert to a conventional pre and post auricular procedure.  I have changed to the larger lift in mid surgery numerous times and have been glad I did as even patients that did not exhibit significant neck laxity actually had impressive skin excess as evidenced when the posterior auricular incision was completed .

I think there are many reasons that short scar facelifts have become fashionable.  Number one, there are a lot of different specialties that now perform cosmetic facial surgery including facelift surgery.  Some of these practitioners did not have training in larger lifts and therefore feel comfortable with the smaller variety of lift.  Similar to this, some surgeons do not have the ability or the facility to utilize IV anesthesia or general anesthesia and the minimally invasive lift can be performed with local anesthesia.  This is all fine and well, again safe surgery with good outcomes and happy patients is the bottom line.

Another reason for the increased popularity of these lifts is the significant media hype that is so pervasive in our society today.  Many consumers equate “new” with better.  This is an area where I begin to have problems with the promotion of these small lifts.  I can’t turn on my TV without seeing ads for what I call “franchise facelifts”.  These are corporate entities include franchised physicians and the targeted marketing drives patients to these surgeons. My problem is not with the surgeons but rather with the franchise. This type of lift is promoted as “new” and “revolutionary” and catch phrases such as “takes about an hour”, “no bandages”, “drive home from office after  your lift” and “go back to work in several days”.  I take great umbrage to these statements and the way they are presented.  First of all, short scar facelifts with purse string sutures are not new and have been done for almost a century as evidenced by the diagram from a 1927 French textbook (figure 1). 

       This figure from a 1927 textbook shows the same procedure being performed by some doctors and advertised on TV as “new” and “revolutionary”. 


Secondly, the before and after images shown in these commercials and accompanying literature are not standardized and the results appear more dramatic than they really are.  The old trick of taking the pre facelift picture with the chin tucked in and no flash, then taking the post facelift picture with the chin extended and using a flash is a well known means of manipulating an actual result. Also, if you look at the fine print, some of the patients also had platysmaplasty and simultaneous laser skin resurfacing, hence the minimally invasive theory goes out the window.  I think this form of marketing is unethical and I (as well as many colleagues) have retreated unhappy patients that underwent “franchise” facelifts.  These patients feel betrayed as they were promised a maximum result with minimum surgery and they still have laxity.  They paid more than I charge for a traditional facelift and now have to have a second surgery to get the result they could have gotten in the first place if they had an age appropriate facelift.  Buyer beware!

The other reason that I think these lifts have become popular is that some surgeons get lazy.  I realize that I am going to take some torpedoes with this statement, but I think it is true.  A traditional facelift (pre and post auricular incisions, platysmaplasty and SMAS treatment) is a lot of work.  If you are the sole surgeon and do it correctly, it is an intense procedure.  I have seen numerous colleagues slowly back off from the traditional procedure.  First they omit platysmaplasty and maybe do less with the SMAS, next they eliminate the posterior incision and pretty soon they are only doing short scar lifts without platysmaplasty.  Most say they get the same results, but I personally question this.  I too have gone through phases in my career where I attempted to eliminate platysmaplasty and posterior incisions, but I have consistently gone back to basics because I felt I had better, longer lasting results.  Some readers may say “well, maybe he is not proficient with the short scar techniques”.  Fair question, but I think my experience trumps that.

 As many surgeons have become much more conservative in their approach to facelift surgery, I have become more aggressive and can clinically justify my decisions.

My biggest problem with short scar facelifts is the lack of a post auricular incision that extends into the scalp.  To me, this is the most important vector to truly manage significant cervical and submental skin laxity.  Any sacrifice in this vector will affect the surgeons ability to tighten the neck.  I realize that with some short scar procedures proponents advocate a more vertical flap tension to compensate, but again, no one can convince me that this is as effective as the traditional  posteriolateral vector used with post auricular incisions.  In reality, all facelift incisions should be engineered to be perpendicular to the vector of pull for skin excess and thus the traditional 10 o’clock and 2 o’clock vectors are in my mind, superior. 

My second big problem with short scar lifts is that many surgeons omit platysmaplasty.  I abandoned this myself for several years and saw less dramatic necks that developed banding within several years.  This led me to resume with even more aggressive submentoplasty and all of my rhytidectomy patients receive simultaneous platysmaplasty.  I do not perform submental liposuction as the first step, but rather perform a subcutaneous scissor dissection with care to leave adequate submental and cervical fat attached to the dermis.  I then, prefer to perform “open” liposuction where I can actually see what I am removing or sculpting.  I am fairly aggressive with this liposuction as I like to see the actual platysma muscle.  I then perform a midline plication with 2-0 braided nylon sutures from the mandibular border at least to the thyroid cartilage if not below.  I place 5-7 sutures and this not only tightens the neck, but also elevates the submental tissues and allows for the best cervicomental angle possible.  I generally do not remove subplatysmal fat unless grossly excessive as this contributes to a central depression.  If the patient has microgenia, a silicone chin implant is frequently inserted.  I am always amazed by the amount of excess skin present after aggressive platysmaplasty and submentoplasty.  I am thoroughly convinced that this skin excess would not be as impressive without platysmaplasty and would be more prone to early relapse.

As I stated earlier I am not a fan of purse string sutures.  I think that suspending the SMAS with one or two sutures leaves too much room for laxity. My average preauricular flap dissection is 6-8 cm and I perform a SMASectomy that is closed with five to eight 2-0 braided nylon sutures. These sutures secure the distal SMASectomy incision to the fixed SMAS over the parotid and begin at the malar region and extend into the superior cervical area below the mandibular border.  I am convinced that this repair is solid, addresses multiple SMAS vectors and will not relapse when patients turn their head or sneeze in the early post op period. Although some surgeon do not advocate significant skin removal, I typically remove 3-6 cm of skin on older patients.

The problem with trying to redistribute posterior skin in short scar procedures without a post auricular incision is the significant mastoid skin bunching that occurs and takes months to resolve.  Where does it go?  It is not magic, it flattens out with time (sometimes a long time) but there is still excess skin present, it is just redistributed.  My answer is to remove it in the first place.

In conclusion, there exists a trend to perform less invasive facelift surgery, primarily to decrease recovery time and make the surgeons life more simple.  I do believe that these short scar lifts are appropriate on some patients but at the same time feel that the do not comprehensively address the average facelift patient (fifth decade and beyond).  I feel that these smaller lifts are over rated and too often performed on patients that should have had a larger lift.  I can back this up by the revision facelifts that I do on patients that should have had a larger lift in the first place.  In terms of recovery, my average patient is suitable for work in two weeks.  That may be a long time for some surgeons and patients, but I tell my patients that to take two weeks off to reverse a half century of aging is really not a bad deal.

I fully realize that many surgeons will disagree with me and as previously stated, if their smaller procedure works better in their hands and they have lasting results with happy patients, then we are all winners.  I do things the way I do because my experience has shown that in my hands a more aggressive lift produces more natural and longer lasting results.  To each his own.  I believe there is a time for minimally invasive facelift, but it is not “most of the time”.  I feel that using these smaller procedures on the average facelift patient is a short cut facelift and the patient will have short cut results.  When patients ask me about “lunchtime facelifts” I tell them they will last till “dinner time”.  Patients get what they pay for.  Not in terms of money, but in terms of recovery.  Facelifts that heal in a week or less are simply not comprehensive enough to compete with traditional facelift procedures.


Tight, natural and long-lasting results are very predictable with traditional facelift surgery.  Unfortunately, there are surgeons that would attempt to perform  a minimally invasive lift on the above patient.  It is simply not possible to obtain the results and longevity with minimally invasive procedures.


To learn more about facelift surgery and other cosmetic facial surgery procedures by Dr. Joe Niamtu in Richmond, Virginia visit www.lovethatface.com 

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

March 10, 2011 Posted by | Facelift Surgery, Minimally Invasive Cosmetic Facial Surgery, minimally invasive facelift, New Cosmetic Surgery Technology | , , | Leave a comment

Dr. Niamtu Recent Featured Cosmetic Facial Surgery Patient

Name: Brenda Michaels

Age: 61

See a video of Brenda Discussing her Surgery

Procedures Performed:

  • Facelift
  • Upper and lower eyelid surgery


I am a recent widow.  I have two sons and two beautiful daughter-in-laws, and three adorable grandchildren, ages three, five, and seven.


Self employed- buying and selling plastic raw materials.


I enjoy hiking, gardening, reading and playing my piano.

Why you wanted to have cosmetic surgery:

I had wanted a facelift for a number of years as time continued to take a toll on my neck and face.  For me, my neck was the deciding factor in my decision to have a facelift.

Why did you choose Dr. Niamtu:

When I found Dr. Niamtu’s website, I was most impressed with the amount of information that was given about cosmetic facial procedures and I just knew that he was the doctor that I wanted to perform my facelift.

What were you hoping to achieve with the surgery:

I wanted to achieve a more youthful looking face and neck and Dr. Niamtu gave me that.

How did you like the results:

I am most pleased with my facelift.

What advice would you give other women considering cosmetic facial surgery:

Several of my friends have told me that they wouldn’t want to spend the money for cosmetic surgery or put themselves through the surgery and recovery.  Certainly having cosmetic surgery is a very personal decision, but for me the results were worth it all.  I “love my face” and for any woman considering cosmetic facial surgery I would say “Go for It!”

Any special thoughts on your experience:

I feel that I was blessed to have found Dr. Niamtu and to have him perform my surgery.

Comments from Dr. Niamtu:

I think I have the greatest patients in the world and feel very lucky to do what I do for a living.  It just keeps getting better!









To find out more about cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia, visit


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

November 25, 2010 Posted by | Cosmetic Eyelid Surgery, Cosmetic Facial Surgery Consultation, Eyelid Surgery, Facelift Surgery | , , , | Leave a comment

Dear Dr. Joe, what do you think about the MACS facelift?

Sometimes routine questions that I receive on my web page make interesting reading and I occasionally post these in my blog.  This following is an actual question and answer concerning the MACS facelift technique.

Question:   Dear Dr. Joe, I am 46 years old and getting my mother’s neck.  What do you think about the MACS lift?  Where can I see before and after pictures of your facelift results?


Answer:   Thank you Annie,

If you go to lovethatface.com on each procedure page, there is a Mona Lisa Icon and if you click that you will see hundreds of pictures of procedures.  I believe I have about 16,000 pictures on the site.

The inventor of the MACS lift (Dr. Alexis Verpaele) is a friend of mine and we have lectured together in the US.  Personally I do not agree with that procedure for the vast majority of my patients.  I think it is a shortcut procedure that does not address all the aging changes comprehensively and is a bit of a fad.  It is not a bad procedure for minor aging, but, in my opinion not comprehensive enough for more advanced aging.  When a surgeon tries to do facelift surgery without an incision behind the ear, there is a compromise.  It limits the amount the neck can be tightened and also presents fewer options for the direction of the skin pull, which can give an unnatural appearance.  Also this procedure does not comprehensively address the anterior neck and platysma.  I believe using a posterior ear incision (with the front incision of course) and performing platysmaplasty is the gold standard for the most natural, long-lasting and tightest lifts.  Many surgeons are searching for and easier facelift, i.e., Lifestyle Lift, Quick Lift, Liquid Facelift, etc.  Again, I personally believe they are all compromises of what we know has worked well for years.  Much of it, in many cases is just marketing hype.
There are many prominent surgeons that like these lifts and may get good results on younger patients.  I too, will perform and abbreviated lift on patients with minimal aging, but out of about 80 facelifts that I perform each year, only several are the “short cut” variety.  Basically, facelifts come in small, medium and large.  For patients requiring a small lift any of these “new” lifts will suffice and I also do them, but in my experience, most people need more.
Consults are free, come and see us.

Dr. Joe

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

November 9, 2010 Posted by | Facelift Surgery, Minimally Invasive Cosmetic Facial Surgery, minimally invasive facelift | , , | Leave a comment

The Diva Lift: Got Curves?Facelift for Full Figured Females

Dr. Niamtu Diva Lift

Click above to view article

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.  Full-figured or plus sized patients 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.

Why is there a  need for the “Diva Lift”

For 13 years, I have had patients (mostly female) that presented to my practice for facelift consultation that were turned away from other plastic surgery practices because they were “over weight”.  They were told to lose 50-75 pounds and come back for surgery.  This is, in my opinion, a surgeon turning away a patient because the surgeon is not sure how to treat them, or is not energetic enough to perform a technically difficult facelift, or simply does not think they can get a predictable result.  Don’t get me wrong, there are in fact sensible reasons not to operate on over weight patients if they are not healthy, but being over weight is not a contraindication to facelift surgery for the healthy patient.

As I began to see more of these “rejected” full-figured patients, I began to think about why this group was being denied facelift surgery and how could it be done to be safe, effective and with natural results.  I began performing facelift surgery on these patients, but with numerous modifications from my conventional facelift technique.  Immediately it became apparent that these full-figured facelift patients had extremely impressive results.  They were among my best before and after cases.  The more I did, the more I refined my technique for this type of patient and the results became better and better.

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.  A surgeon can hide mediocre surgery on boobs, bellies and butts, 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?

Like average facelifts, the Diva Lift can be performed on healthy patients with IV sedation in the accredited ambulatory office surgery center. 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.  The fat cannot be simply removed or an unnatural contour will result.  Instead, the fat is sculpted to gently taper from the cheeks to the neck.  Enough fat is removed to slim the face and neck, but not to look unnatural.

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 tissues (know as SMAS)  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 have  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.

After surgery, the patient wears a partial facial bandage for the first 24 hours and generally does not wear any dressings after this time.  Since full-figured patients may have a higher incidence of blood clots, the patient is encouraged to walk and move around as soon as possible after the procedure.  They are also prescribed compression stockings which help reduce blood clots.

As some overweight patients have medical problems such as high blood pressure, diabetes, and other problems that could affect anesthesia safety this class of patient must be very carefully screened with medical and anesthesia consultation.  For the healthy full figured patient, they are treated exactly the same as the low BMI patient.

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


October 26, 2009 Posted by | Facelift Surgery, New Cosmetic Surgery Technology | , , , | Leave a comment

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 http://www.lovethatface.com.


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


June 16, 2009 Posted by | Facelift Surgery, Minimally Invasive Cosmetic Facial Surgery, minimally invasive facelift, New Cosmetic Surgery Technology | , , , | Leave a comment

The First Face Transplant in the USA

blogsiemionowDr. 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


December 19, 2008 Posted by | Can Cosmetic Facial Surgery Change Your Life?, Cosmetic Facial Surgery Consultation, Face Transplants, Facelift Surgery | Leave a comment

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

February 27, 2008 Posted by | Facelift Surgery, Minimally Invasive Cosmetic Facial Surgery, minimally invasive facelift | , , , , | 1 Comment