Internationally recognized for his facelift revisions, Dr. Hamra can:
- Correct the distortions from previous surgery
- Correct the three distinctive signs of aging
- Restore the look of youthful anatomy
- Create long-lasting results
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?
An Aging Conventional Facelift
Youthful look restored
by the Composite Facelift
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 to perform the surgery.
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 Same Principles Apply
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.
This photograph shows an aging conventional facelift.
Please click on the image or the arrows to see the rest of the story.
Because the elements of anatomy of the midface (and forehead) were not corrected in the original surgery, they have continued to move downward with age.
The Composite reverses the progressive downward movement of the tissues of the midface (particularly the cheek fat) by returning them to their original position.
For this patient, the aging of her conventional facelift is most obvious in the under-eye area.
She has developed a hollowness under her eyes...
...and a bulge called the malar crescent.
The Composite corrects 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.'
The Composite also 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.
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."
- Sam T. Hamra, MD
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.
Click on the image or the arrows to advance though the sequence.
Problem – The Lateral Sweep
This tautness occurs because the surgeon only lifted the lower cheeks and jawline laterally...
...and did not lift the upper cheeks and lower eyelids vertically (toward the eye).
Problem – The Lateral Sweep
The cheek skin and fat can relax in time, while the jawline remains taut. When this happens, the difference in tensions reveals itself as the lateral sweep.
Problem – The Lateral Sweep
The cheek skin and fat can relax in time, while the jawline remains taut. When this happens, the difference in tensions reveals itself as the lateral sweep.
With time, the sweep becomes more and more noticable.
Problem – The Lateral Sweep
The forehead is often left untouched as well in a conventional facelift.
While the initial results can be stunning, as the upper face continues to fall with time, additional problems can surface.
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.
Traditional blepharoplasty (left) removes most undereye fat. The composite blepharoplasty (right) repositions the fat to create a smooth undereye contour.
Problem – The Hollow Eye
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.
Fixing the Hollow Eye
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.
This image shows how a conventional blepharoplasty led to a hollow eye.
Fixing the Hollow Eye
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 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.
The image shows the results after the composite correction.
Fixing the Hollow Eye
Top Image: After conventional procedure.
Fixing the Hollow Eye
Top Image: After conventional procedure.
Bottom Image: Ten years after the Composite, the eyelid and cheek anatomy still appear youthful.
Problem – The Malar Crescent
A little known part of your facial anatomy, the malar crescent is the lower border of the 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.
This image shows the malar crescent, made more obvious as a conventional facelift aged.
Problem – The Malar Crescent
The lower image shows that the smooth contour of the upper cheek has been restored with the Composite.
Problem – The Malar Crescent
After conventional and before Composite procedure.
Problem – The Malar Crescent
After the Composite Facelift.
Before
conventional
After
conventional
After
Composite
We have drawn on the lower eyelid muscle (orbicularis oculi) in the top row of these photographs. You can see that the conventional facelift did not change the position of the lower edge of this muscle. By not repositioning the lower eyelid muscle upwards, the surgeon virtually guarantees that if the malar crescent 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.
Note the youthful contour achieved when the muscle is repositioned vertically with the Composite Facelift.
Considered together, these two markers (hollow eye and malar crescent) 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.
I now see ten-year follow-up patients with a stable high cheek mass. If you go through surgery, you deserve a great long-lasting 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.
Problem – Earlobe Displacement
Everyone seems to know the ear often betrays a facelift. Pulled-down earlobes may happen at the time of the original procedure, or can develop with time. The most dramatic distortion has been called “the pixie ear.”
Natural contour can usually be restored, but this is often difficult. The earlobe is often not distorted, but simply pulled forward — a tip-off to a facelift.
Click the images or arrows to see how these distortions can be repaired.
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 – 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 – Earlobe Displacement
This "pixie ear" distortion has been corrected and a more natural contour of the earlobe has been restored in this patient.
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.
Several years following a conventional procedure, this patient shows a pulled-down lid.
Problem – The Pulled Down Eyelid
Two years after correction of her lower lids.
Problem – The Pulled Down Eyelid
Side-by-side comparison of the left eye before and after revision.
Problem – The Pulled Down Eyelid
Before eyelid surgery.
Problem – The Pulled Down Eyelid
After complications from a conventional procedure performed elsewhere.
Problem – The Pulled Down Eyelid
After reconstructive eyelid revision surgery.
Problem – The Pulled Down Eyelid
Three previous blepharoplasties left this woman with downward sloping eyelid corners.
Problem – The Pulled Down Eyelid
After correction.
Why Are Eyelids Such A Problem?
There are several reasons these types of eyelid problems 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.
Two years after a secondary Composite Facelift and eyelid correction.
This gentleman had facelift & eyelid surgery 13 years earlier.
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.
Without question, the eyelid is the most complicated and often least predictable part of facial rejuvenation.
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.
Top Image: Overcorrected neck.
Problem – Post-Op Neck Deformities
Lower Image: After Composite revision.
Problem – Post-Op Neck Deformities
Under-corrected neck.
Problem – Post-Op Neck Deformities
After Composite revision.
Problem – Post-Op Neck Deformities
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.
Upper Image: “Cords” formed by the platysma muscle.
Problem – Post-Op Neck Deformities
Lower Image: Revised with the Composite Facelift.
Problem – Post-Op Neck Deformities
Another example of neck cords.
Problem – Post-Op Neck Deformities
The Composite improved the neck, corrected the lateral sweep, and lifted the lower eyelid.
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.
Incisions made in front of the hairline as seen here are virtually impossible to hide with revision surgery.
Problem – Unsightly Incisions
The placement of a facelift incision around the ears differs according to the individual surgeon.
There are surgeons who put the incision in front, thinking it heals better there (as shown in this photograph).
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.
Problem – Unsightly Incisions
I prefer the incision to curl inside the tragus, the cartilage in front of the opening of the ear, for both women and men.
Unsightly scars around the ears can usually be improved when the revision surgery is done, as shown here.
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.
Please visit our Facelift Revision Gallery page for additional
before and after photographs of these procedures.