Facelift Revisions

patient 2 pre-operative composite facelift

“The Do-Over” - Revising Previous Facelifts

Shouldn't your facelift age well?

After all, you've invested time, effort and considerable resources to rejuvenate your features and update your look. You'd certainly like the new image in your mirror to last months, if not years. But what happens when your long-term expectations are met only by short-term results?

The truth is, the same facelift procedures that yield fabulous new profiles right after surgery can fade and distort before your next birthday. You may be wondering how this can happen, given the technological advances in all of plastic surgery.

The reality is that the most popular techniques, which have been done for years, are falling woefully short over time. I know. I used to do them. I see the results every day both in my office and everywhere I go. An early pleasing result frequently gives way to that “facelifted” look that everyone would rather avoid.

And disappointments continue with the “minimally invasive” procedures currently being promoted, simply because so little is done. I believe that anyone who is unhappy with a previous facelift would surely want to get it corrected if they knew that it could be easily done, and if they knew who to go to.

Why Facelift Patients Are Often Dissatisfied

Each year I meet hundreds of men and women who want me to give them back the faces of their youth. Many are visiting a cosmetic surgeon for the first time. They have thought long and hard about how lifting their wrinkling skin and sagging features might also elevate their confidence and restore their self-esteem. They are anxious to match the vision they see in the mirror with the young and vibrant person they feel they still are inside. I am excited to help them.

Many people who come to me, however, aren't so optimistic. They once had the same enthusiasm for a plastic surgeon's scalpel and skill as every facelift newcomer. But they have seen the immediate, meticulous results of their surgeon's work fade over time.

Perhaps you recognize it in your own face: there's no longer the youthful harmony you enjoyed right after surgery. Instead, your lower cheeks and jawline remain tight while other areas, such as your upper cheeks and forehead, continue to fall. You see the pulls and tensions across your face, and often notice the look of a “pulled mouth.”

The area under your eyes takes on a hollow, even gaunt look, leaving you with a classic mask-like appearance. The natural reaction is to blame the surgeon. But most cosmetic surgeons are extremely capable of bringing home a beautiful, youthful contour that satisfies your vision and refreshes your looks. Blame the technique, not the surgeon.

It was not the surgeon, but the traditional old-fashioned technique that led to your current appearance.

The beauty of the Composite Facelift is that we can apply the same principles to correcting facial distortions as we do to prevent them in the first place. During this surgery, we manipulate the skin and underlying tissues to improve an earlier outcome in the same way we initially rejuvenate the face.

The Composite reverses the progressive downward movement of the cheek fat and muscle by returning them to their original position. In doing so, the procedure not only corrects the imbalance of the face but also eliminates the windswept nature of those lower cheeks.

Secondly, the Composite corrects the gaunt or hollow eye created during a previous surgery by repositioning the remaining orbital fat so the eye socket has the necessary padding.

Thirdly, the Composite corrects the bulges of the croissant-shaped ridge we call the malar crescent by lifting and moving the lower eyelid muscle up toward the eye, bringing with it the malar fat that creates the higher cheek mass.

I have been able to help the majority of patients who have come to me unhappy about the long-term results of previous facial surgery. Whether they have been through one operation or many, I am happy say that they enjoy a beautiful, longer lasting result after revision surgery.

My philosophy is that I will never agree to do revision surgery unless I can assure the patient of significant improvement.

Surgery is never 100% perfect, and the need for small touch-ups is always possible.

Patients understand this, and the limitations of surgery, if they have been sufficiently educated and have asked all the right questions.

Facial Distortions Tell the Story

As mentioned earlier, there are three distinctive signs that your facelift is not aging well: the lateral sweep, hollow eye, and malar crescent. It may be months, perhaps even years, before you see any of these, but when they occur, they distort the image you've spent thousands to restore.

These four women all show similar signs of an aging conventional facelift.

As the unsupported soft tissues of the upper face continue to age, the lateral sweep of the cheeks appears. Hollow eyes and malar crescents are also developing.

The most obvious problem associated with a standard facelift is an expression that I coined for an article I wrote in 1998, and what surgeons now commonly refer to as a lateral sweep.

Problem – The Lateral Sweep

It's the distinctive swept back or stretched appearance between the corners of the mouth and the earlobes that tell friends and family you've definitely had some work done.

Often one sees actual lines or redirected wrinkles from the mouth to the earlobe, curving down and then up, ending at the facelift incision in front of the ear. The look will be especially pronounced if you have dry, sun-damaged skin.

This tautness occurs because the surgeon only lifted the lower cheeks and jawline laterally (toward the ear) and did not lift the upper cheeks and lower eyelids vertically (toward the eye).

The forehead is often left untouched as well. The initial results can be stunning, but as time goes by, the upper face continues falling, in contrast to the lower face, which stays taut. The fat of the cheek (“malar fat”) is not supported in a vertical direction and soon starts heading south as well.

Problem – The Hollow Eye

The hollow eye is a sunken or concave appearance of the eye socket. It's often associated with a traditional procedure because the surgeon has removed undereye fat pads (the standard blepharoplasty) to eliminate the characteristic puffiness of an aging face.

As we grow older, our eyelids undergo predictable changes. The skin becomes thinner, leaving the skeletal structure more pronounced and leading to a wider and deeper under-eye space. This usually begins in your 40s; the bony anatomy not seen in youth now shows up.

In a standard facelift, surgeons typically perform a separate upper and lower eyelid lift or bypass the eye entirely. Even though restoring this area is key to achieving a soft, harmonious look, removing the fat alone often creates an even more abrupt transition between the soft lower eyelid tissue and cheekbone.

The practice of removing the lower eyelid fat began in 1928 in France, and is still commonly done today. I did it myself for years. But without the necessary padding, the skin may eventually collapse into a concave appearance.

Conventional blepharoplasty led to a hollow eye and scleral show.
patient 20 eyes post op

After Composite correction

In the “septal reset” portion of the Composite Facelift, I correct this gaunt appearance by going beneath the lower eyelid, retrieving more fat and its cover (the septum), and spreading it over the hollow space onto to the cheekbone. I have never seen a hollow lower eyelid that could not be corrected, even when the earlier procedure removed a lot of fat. An added bonus is that repositioning the eyelid muscle during the cheek lift gives a thicker cover to this area.

This is a good example of how all of the elements of the Composite Lift work together to rejuvenate the face. I perform a septal reset routinely in all first-time facelifts.

Left: After conventional procedure.
Right: Ten years after the Composite, the eyelid and cheek
anatomy still appears youthful.

The malar crescent, obvious as a
conventional facelift aged.

Smooth contour of the upper cheek
restored with the Composite.

Problem -
The Malar Crescent

A little known part of your facial anatomy, the malar crescent is the lower border of your lower eyelid muscle (the orbicularis oculi). In younger people, it is barely noticeable. But as many individuals age, especially beyond their 40s, the crescent can become an obvious, unattractive fullness along the upper cheekbone.

A traditional facelift not only fails to address this bulge, but the procedure can actually make it worse.

By not repositioning the lower eyelid muscle upwards, the surgeon virtually guarantees that if this mound is beginning to appear, it will eventually become worse. Additionally, if the fat under the eye was not preserved, and a hollow eye is also developing, the malar crescent will be even more prominent.

patient 19 progression of muscle changes under eyes

Before conventional After conventional After Composite

Upper photos: The lower eyelid muscle has been drawn in.
Note no change in position between “before” and “after” a conventional facelift.
Note the improvement after the Composite Facelift.

Considered together, these two markers are noticeable reminders of cosmetic surgery. The maneuver I described for remedying the lateral sweep and the hollow eye also eliminates the malar crescent. Since the cheek lift elevates the whole muscle mass of the lower eyelid and cheek and secures it to the orbital bone, the results are not only dramatic, but long-lasting.

Left Images: After conventional and before Composite procedure.
Right Images: After the Composite

I now see ten-year follow-up patients with a stable high cheek mass. If you go through surgery, you deserve a great longlasting result. You want something worth your time and expense.

Other Telltale Signs of Surgery

There are a number of distortions that scream “facelift surgery!” that aren't necessarily the result of the aging of a facelift, but are caused by the technique that was used.

Before and After Composite Lift

Problem -
Earlobe Displacement

Everyone seems to know that it is the ear that often betrays a facelift.

Pulled-down earlobes may happen at the time of the original procedure, or can develop with time. The most dramatic of these distortions has been called “the pixie ear.”

The natural contour of the earlobe can usually be restored, but this is often difficult. Often the earlobe is not distorted, but simply pulled forward, another tip-off that a facelift has been done.

Problem – The Pulled Down Eyelid

It is not uncommon to see the lower eyelid pulled down, or to notice a different level when comparing the two eyelids.

Left: Several years following a conventional procedure, this patient shows a pulled-down lid.
Right: Two years after correction of her lower lids.

patient 24 eyes
Side-by-side comparison of the left eye
before and after revision.

patient 23 eyes

Top: Before eyelid surgery.
Center: After complications from a conventional procedure performed elsewhere.
Bottom: After reconstructive eyelid revision surgery.

There are several reasons this may occur. The most common is when too much skin or too much fat has been removed, and the lower eyelid reveals too much sclera (white of the eye). This appearance is called "scleral show" and is not only unsightly, but can lead to dryness of the eye, requiring drops and ointment.

Anytime a surgeon, even an expert, operates on the lower eyelid, there is a possibility that scleral show can occur. The surgeon must be prepared to correct it—usually not a complicated operation.

Many people with “round eyes” inherently have a degree of scleral show before surgery. As always, expectations of the end result of your procedure must be discussed with your surgeon. Today, a surgeon can control the eyelid level pretty well, but on occasion a more severe scleral show will require a more complicated correction.

patient 26 eyes pre op patient 26 eyes post op
Left: Three previous blepharoplasties left this woman with downward sloping eyelid corners.
Right: After correction.

Without question, the eyelid is the most complicated and often least predictable part of facial rejuvenation.

Left: This gentleman had facelift and eyelid surgery 13 years previous.
Right: Two years after a secondary Composite Facelift and eyelid correction.

Problem – Post-Op Neck Deformities

The neck is frequently omitted in primary facelifts, or often a more limited neck procedure is done.

Even in the best hands, necks can pose problems following surgery. Because the neck changes appearance with every movement of your body and face, a true evaluation of the static neck is never possible. (There is a saying that men extend their neck while shaving, so they think they always look young, while women see their neck while looking down in their makeup mirror, and think they always look old. I believe there is some truth to that theory.)

Typically, there may be either too much, not enough, or uneven removal of fat from the neck. Overly defatted necks are impossible to totally correct.

jowls pre op corrected jowls

Left: Overcorrected neck Right: Composite revision

Excess fat is easier to correct.

Left: Undercorrected neck Right: Composite revision

neck cords pre op neck cords post op

Left: “Cords” formed by the platysma muscle. Right: Revised with the Composite Facelift.

Uneven areas of fat will be seen as abnormal even to the casual observer. The front edges of the platysma muscle may be visible as unsightly cords or bands. Cords and excess fat appear normal in the unoperated face, but become very obvious in the facelifted patient when not addressed.

Left: Another example of neck cords.
Right: The Composite improved the neck,
corrected the lateral sweep, and lifted the lower eyelid.

Incisions made in front of the hairline are virtually impossible to hide with revision surgery.

Problem – Unsightly Incisions

Ideally, all facelift incisions should be placed in areas where they are difficult to see. This is not always possible, but every attempt is made to hide telltale scars.

Your individual skin type will affect the appearance of healed scars. Often scars are more noticeable because the skin remains a different color, and some skin types heal with some spread to the scar regardless of what surgery is done.

The placement of a facelift incision around the ears differs according to the individual surgeon.

These photos show why I prefer to make the incision behind the tragus.
Right: The same ear after the Composite revision.

I prefer the incision to curl inside the tragus, the cartilage in front of the opening of the ear, for both women and men. There are surgeons who put the incision in front, thinking it heals better there. I have found that in the event of poor healing, or infection, or too much tension, a scar in front becomes impossible to camouflage, even with makeup. Unsightly scars can usually be improved when the revision surgery is done.

In some patients there may be wide areas of scarring from skin loss around the ears or neck. This was seen more frequently years ago when we didn't know that smokers were at risk for poor healing. We now know that nicotine causes diminished blood flow to the skin. Too much tension, or even pressure from a collection of blood under the skin, can cause wide areas of skin to die if the blood supply is already compromised. While it is impossible to remove all such scarring, improvements can be made, even doing a little bit at a time over a number of months.