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 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