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Face it: Time for a Lift?

Sometimes creams, peels and injections aren't enough

Around the time that a Long Beach X-ray technician turned 50, she began seeing her dermatologist twice a year for strategic poking and plumping. A couple of dozen units of the neurotoxin Botox to reduce the furrows in her forehead and the crow’s feet around her eyes, a syringe or two of the filler Juvederm to pad the parentheses, or nasolabial folds, that led from the corners of her nose to her lips.

A few years later, she saw deeper effects of gravity’s downward pull, particularly on the lower half of her face. “The sides of my cheeks seemed to be drooping,” she says. “I didn’t have a defined jawline and there was loosening in the neck.”

In September she decided it was time for a more aggressive intervention.  
“I work out five days a week,” says the technician (who didn’t want her real name used for privacy issues). “I was happy with my body, but not my face.”

At 55, she had a lower facelift and neck lift, performed by Dr. Eugene Elliott, a Stanford-trained plastic surgeon at Coast Memorial Medical Center in Fountain Valley.  When she went home the next day she took with her antibiotics, painkillers and strict instructions to ice her face every 20 minutes and not to lie flat for three weeks. Today, two months after the $12,000 surgery, she says she is thrilled with the results.

“I’d do it again in a heartbeat,” she says. “I didn’t have a facelift because I wanted to look younger; I just wanted to look refreshed and well-rested and I do. The best thing is that nobody knows I had anything done.”

“I’d do it again in a heartbeat,” is a phrase that a 60-year-old social worker in Irvine also utters when she talks about the lower facelift and neck lift she had in March with Rami Batniji, a Newport Beach board-certified plastic surgeon and ear, nose and throat physician. Like the X-ray technician, this social worker had twice-annual Botox and dermal fillers for several years before she turned to surgery. “People started telling me more frequently that I looked tired,” she says. “There was a disconnect between how I felt – which was young, active and energetic – and how I appeared to the outside world.” The moment Dr. Batniji took off her bandages some 48 hours after the procedure, “I was like, ‘Wow!” says the social worker, who also spoke on condition of anonymity. “It was transformational.”

For years we’ve been hearing that injectables, laser resurfacing and non-surgical tightening, smoothing and lifting treatments would make the facelift obsolete. But anyone who has been thinking she can spend her facelift fund on a new Tesla might want to delay a trip to the car dealership.

Yes, national statistics from the American Society of Plastic Surgeons show a 4 percent decline in the number of facelifts being performed in 2014 vs. 2013, while minimally invasive treatments have been climbing steadily. In 2014, just over 128,000 women and men went under the surgeon’s knife for a facelift in the United States, a fraction of the nearly 14 million visits to physicians’ offices for minimally invasive cosmetic procedures. Plastic surgeons in Orange County and Los Angeles, however, report that they aren’t experiencing any drop in surgical procedures. Instead non-surgical fixes are proving to be a gateway treatment to a facelift a few years or a couple of decades down the road, as Sue’s and theses stories illustrate.

“Because of the more conservative office-based modalities like Botox and fillers, patients are coming into the office earlier, in their 30s and 40s,” says Elliott, “and they’re becoming aware of how their face is changing over time and how interventions can help preserve a
youthful look.”

The First Line of Defense
There are many tools in the toolbox of noninvasive treatments. Botox and its competitors Dysport and Xeomin immobilize the muscles that cause expressive or dynamic lines – smoothing out the parallel lines between the brows and softening forehead furrows and crow’s feet. Injected into the corners of the lips, Botox can give a lift to a smile that’s migrating south. Dermal fillers, such as Juvederm and Restylane, replace the collagen and fat we lose as we age. Batniji says that strategically injecting a wrinkle filler into the temples can give the appearance of a subtle brow lift while a few cubic centimeters skillfully placed in hollow tear troughs can erase shadows, forestalling the need for eyelid surgery.

The new filler Voluma, approved by the FDA in October 2013 to correct volume loss and sagging in the cheeks, is seen by some doctors as a game changer. Voluma has been shown to last up to two years, about twice as long as other fillers (and at $1,000 to $1,200 a syringe, it’s about twice as pricey, too). “Voluma isn’t just about addressing cheeks that are volume-deficient,” says Batniji, who trains other physicians in administering the filler. “Used in small amounts it can also define the cheek and give it a beautiful contour.”

While fillers pad wrinkles and folds, resurfacing treatments, in the form of chemical peels or lasers, can help whisk away fine lines, improve skin tone and uneven pigmentation, and prompt the skin to produce more collagen. Skin tightening without the scalpel has long been the holy grail of anti-aging, and two energy-based devices claim they can deliver results. Thermage uses radiofrequency energy to heat the inner layers of the skin and stimulate the formation of new collagen, while Ulthera does the same with ultrasound energy. The treatments are expensive, uncomfortable and, on anyone with more than minimal skin laxity, pretty ineffective. The technician says she tried Thermage at her dermatologist’s office several years ago. “I wouldn’t recommend it to anyone,” she says. “It cost $1,800, was really painful and didn’t do a thing.”

It’s difficult to predict who will respond well to these energy treatments, even in patients who may seem like ideal candidates. “I’ve done at least 5,000 Ulthera treatments,” says Dr. Leslie Baumann, a prominent Miami dermatologist. “And 90 percent are happy with the results. But that still leaves 500 unhappy patients.”

One new treatment that some doctors, among them Baumann, are calling a breakthrough is Kybella, an injectable solution that has been FDA-approved to treat under-the-chin fat.
“I love, love, love Kybella,” says Baumann, who was involved in its research trials. “It’s going to replace liposuction when it comes to dissolving a double chin.” Kybella, in the hands of a skilled practitioner, can also produce a sharper jawline. Several rounds of injections, done a month apart, are required, and the cost runs from $4,000 to $10,000.

Nonsurgical treatments can help people delay facelifts until well into middle age. (Roughly two-thirds of people who have facelifts are 55 or older and one-third are between 40 and 54, with a tiny fraction of facelift patients under 40.) Seldom is a facelift performed on a virgin face that hasn’t experienced some kind of noninvasive treatment. The rare exceptions are likely to be men, who represent fewer than 1 in 10 people who have facelifts. “Men might go straight to a facelift,” says Dr. Gregory Evans, the chair of the department of plastic surgery at the UC Irvine. “They tend to wait a little longer on anything that involves seeing a doctor.”

When Gravity Catches Up …
The gene pool we inherit plays a big role in how we age, as do lifestyle habits like smoking and sun exposure, but at some point we all look into the mirror and find our wrinkles and folds deepening, the bags under our eyes becoming more pronounced, while our jaw line turns squiggly and we see the creeping gobble, gobble of a turkey neck.

“The bottom line,” says Evans, “is that when we get significantly more sagging skin, baggy eyes and loss of volume, nonsurgical options are not going to take care of what needs to be done to make someone look more youthful. That’s when moving on to something more invasive will get you the best overall result.”
Dr. Tanya Kormeili is a UCLA dermatologist who says she frequently refers patients to plastic surgeons on the hospital’s team. “Not everything can be corrected without surgery,” she says. “When people have a significant amount of loose skin and they want to achieve a correction of 90 to 100 percent, then they really do need surgery. The analogy I use is if you bought a size 8 dress and you wear a size 4, you can iron the dress, you can put shoulder pads it in, but at the end of the day you have to take it in.”

Dr. Leif Rogers, a Beverly Hills plastic surgeon who offers a full menu of surgical and nonsurgical procedures, says that when patients tell him they absolutely want to avoid the knife, he suggests they lower their expectations and raise their budget. They won’t get the same tightening as they would with a facelift, but they can maintain a fresh appearance with a steady menu of energy treatments, fillers and resurfacing treatments.

“But,” he cautions, “it will end up costing you four times as much.” And, with a lower facelift and neck lift carrying a price tag of $20,000 to $25,000 in Rogers’ practice, that can easily approach six figures.

Most plastic surgeons will tell you they don’t see noninvasive anti-aging procedures as supplanting surgery or vice versa. Rather, the two protocols complement each other.  Facelift techniques have changed, and results are more natural than the overly taut wind-tunnel look of previous decades, thanks in large part to a combination approach to restoring the youthful face. “We used to take fat out a lot more than we do now,” says Evans. “Today the approach is to reposition and readjust things and use fillers to augment fat loss.”

Elliott points out the mid-face facelift, or tightening of the cheek area, is pretty much a thing of the past. “That’s a procedure that was very popular until about seven to 10 years ago, and then it fell out of favor,” he says. “It didn’t seem to enhance appearance as much as a lower face lift and a neck lift.” Instead, Elliott might inject fat or Voluma during a facelift to pad the seperation between the cheek and lower eyelid that contributes to an aging appearance.

Going back to the facelift fund, you might want to allot some extra money for post-surgery treatments. That’s right: Looking young in your 50s and beyond means ongoing interventions with injectables and the occasional peel or laser treatment even after you’ve gone under the knife. Julie Loats, 69, had a lower facelift when she was 60. While she still feels good about her neck, a few years ago she felt she needed some spot treatments elsewhere – like around her lips and cheeks and brows. Research on RealSelf.com, a site where people share their experiences with cosmetic surgery and other procedures, led her to Dr. Lorrie Klein, a dermatologist in Laguna Niguel. She now sees Klein a couple of times a year for some wrinkle fillers and Botox. Loats, a retired social services manager, says she pays for her beauty upkeep with the money she earns teaching Silver Sneakers senior fitness classes at a local gym. “I plan on keeping it up as long as I can,” she says.

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