Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.

This image shows an actual surgery patient of Dr. Niamtu.  The aging midface (left) is rejuvenated by lower eyelid surgery and cheek implants (right).


Facial aging is an interesting multi factorial phenomenon.  Many things contribute to an aged midface including sun damage to skin, atrophic and gravitational changes to fat, muscle and bone.  Two of the biggest things that make us look old and tired occur in the lower eyelids and cheeks.

The lower eyelids can undergo aging changes as early as the third decade.  The skin becomes crinkly and sags, fat can protrude from around the eyeball and produce sausage shaped fat bags on the lower eyelids.  This protruding fat also causes a shadow from overhead light which contributes to the dreaded “dark circles” under the lower lids.  In addition, due to the aforementioned changes, the “tear trough” (technically the nasojugal groove) becomes accentuated.  This produces a deep grove under the eye from the side of the nose across the cheek.

Extremely related to midface aging is volume loss in the midface.  Young patients have full, plump and rounded cheeks.  This good fat in good places produces a smooth, continuous contour under the eyes and around the cheeks.  Gravitational and atrophic aging changes causes volume loss in the cheeks and gives us a drawn, gaunt and hollow appearance.  This is also very related to the lower eyelid aging as the lower lids are the upper cheeks.  The combination of aging produce an old and tired look and the only means to address this aging comprehensively is to address both the lower eyelids and cheeks at the same time.  I find it rare that patients with lower eyelid aging don’t need attention to the cheeks (midface).  I would say that 95% of my lower lid patients that are over 40 would benefit from simultaneous midface augmentation.  Fortunately, many of these patients understand this and combing procedures.

My approach to the healthy lower lid is pretty simple.  I remove conservative fat with a laser incision from the inside of the lid (transconjunctival blepharoplasty).  This means no external scar and no bleeding due to the laser.  No bleeding means faster surgery and recovery with less bruising and pain.  I am always very careful to only recontour the excess fat as not to produce further volume loss.  The second step of lower eyelid rejuvenation is addressing the aging skin of the lower lids.  Although some surgeons still cut off lower eyelid skin, I think that is a bad idea.  It only stretches the skin; it does nothing for rejuvenating the skin.  The skin will return to its normal wrinkling in a short time.  More of a problem is the fact removing skin from the lower eyelid can also contribute to lower eyelid malposition.  Due to the scarring that can occur inside the lower lid, the eyelid can be pulled down which looks unnatural and can cause problems.

To truly rejuvenate the lower eyelid skin, it needs to be resurfaced.  I prefer CO2 laser resurfacing or chemical peeling.  These modalities actually remove wrinkles and brown spots and makes new, younger skin. That is truly rejuvenation!

Since the aging does not stop at the lower lid, this is an excellent time to also address the midface.  The patient is already sedated and will be taking a week off of work, so why not be comprehensive with the rejuvenation?   My most common method of augmenting the aging midface is the use of silicone cheek implants. (Click here to view a video about cheek implants and facial aging)There are many reasons that I like cheek implants.  Among them is the fact that they are inserted from the inside of the mouth so there is not visible scar.  They are held to the cheekbone with a micro screw, so they are permanent, but they can be changed or removed in 30 minutes if the patient desires.  Not many things in cosmetic surgery are permanent but reversible!

By placing cheek implants, the youthful contour of the midface is reestablished and many times the tear troughs and even the nasolabial folds are also improved.  Alternatively, the cheeks and tear troughs can be volumized with injectable fillers.  This is non-surgical and is also reversible.  The downside of midface filler augmentation is that it is a temporary fix.

Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.  If a patient seeks lower eyelid rejuvenation and the surgeon does not discuss the midface aging, a second opinion may be in order.

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


Joe Niamtu, III DMD

December 6, 2011 Posted by | cheek implants, Cosmetic Eyelid Surgery, Eyelid Surgery, minimally invasive facelift | , , , , , , , | 4 Comments

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

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 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

Evolence: A New Breed of Fillers


Recently, new wrinkle filler called Evolence has been getting a lot of attention, especially after Demi Moore and other Hollywood types have admitted using it.

This is an exciting time in cosmetic surgery as many new and effective products have become available.  As the minimally invasive revolution continues, patients find it difficult to take precious time away from work or play and want significant lasting results with minor recovery.  Enter Evolence!

Evolence is new to the United States after recent FDA approval, but is the number one filler in Israel and has been used outside of the US for ten years.

What sets Evolence apart from other wrinkle fillers is its unique collagen composition.  While most of the other popular fillers are made of synthetic substances, Evolence is the first all natural filler.  It is made from porcine tendon which has the closest structure to human collagen and has been used for decades in heart valves, skin grafts and other medical and surgical products.  Although collagen fillers are not new, they fell out of favor due to two things.  One was that patients were allergic to the older bovine collagen fillers.  Evolence has a unique proprietary process of removing the allergic components of collagen and no allergy testing is required!  This is a huge and new step for injectable collagen fillers.  The other drawback of previous collagen fillers was that although they did a good job, they simply did not last.  Evolence has a patented Glymatrix technology which is a sophisticated cross linking process that extends the length of the filler for up to or over a year.  I can speak personally to this filler.  I was chosen to be one of the teaching staff for Evolence and attended an injection training session in January of 2008 in the Cayman Islands.  The meeting was off shore as new fillers that are not FDA approved cannot be injected on US soil.  The instructors were offered free filler, so I had my smile lines injected.  As I type this blog entry it is exactly one year later and my filler is still present.

The main difference between Evolence (the new collagen) and other fillers is that Evolence actually becomes part of your tissue.  It is collagen and is designed to replace the collagen we lose due to aging.  When injected, instead of being recognized as a foreign body (like most fillers) it is recognized as collagen and the body integrates it into the natural surrounding tissue and even grows blood vessels into it.  It also causes the body to produce some new collagen which can add to the result.  Pretty cool.

Perhaps the biggest advantages of Evolence is the fact that since collagen has many special properties, there is less swelling, pain and bruising with Evolence.  It is great for the patient who wants treated but has a big party in several days.

Right now Evolence is only FDA approved for the nasolabial folds (smile lines) but an new product called Evolence Breeze will be available for lip injections and is used very successfully in other countries.

Since new fillers seem to come and go every month (Artefil went out of business last in December 2008 ) it is critical for surgeons and patients to critically evaluate all new products before recommending them to patients.  Having had Evolence treatment on my own smile lines as well as using it on my patients, I can say that this product is a welcome addition to the armamentarium of cosmetic surgery providers that utilize injectable wrinkle fillers on their patients.  To find out more about Evolence visit www.evolence.com and for more information about cosmetic facial surgery by Dr. Niamtu in Richmond, Virginia visit www.lovethatface.com


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


January 21, 2009 Posted by | Lip and Wrinkle Fillers, minimally invasive facelift | , , , | 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