Fillers, the Liquid facelift and "Puffy Face" Syndrome

Everything evolves. When cosmetic fillers were first used, we applied them to the problems of wrinkles - and they worked pretty well. Then we used them to enhance lips, and then to enhance cheekbones, and to smooth out jawlines...and the list of uses kept on growing.

This ever-increasing use of fillers has directly led to the concept of the "liquid facelift", which is simply the use of a significant volume of injectable filler agents to add volume to the face. When done appropriately, and done well - the technique can look good, restoring the lost contours of youth, at least for a time, until the costly products are absorbed by the body. But like anything, it can be overdone. And quite expensive.

Hype alert: the liquid facelift technique is not really "just like a regular facelift", despite the marketing hype of some websites. The two methods work totally differently. Let's review some of the basic differences:

- In a surgical facelift, you remove excess neck and cheek skin. Not possible with the liquid facelift technique, which works by inflation.

- In a surgical facelift, you can tighten the neck muscles and re-suspend the SMAS layer (the fibro-fatty anatomic layer between the skin and the muscles). Not possible with the liquid technique.

- Traditional facelifts (with the exception of those that use fat grafting techniques) work by tightening tissue planes. This can sometimes cause a flattening effect on soft-tissue facial curvature.

- The liquid techniques work by inflation or "re-volumizing", and can add fullness to areas that would otherwise be difficult to correct. Traditional facelifts can sometimes shift soft tissue fullness by re-distributing or lifting tissues, but they don't add new volume.

- Surgical facelifts typically have an effect of 8 to 10 years, on average. Injectable products, even the newer, longer-lasting ones, last 1-2 years at most.

So, the two procedures are not directly comparable. Don't be fooled - choose the right procedure for your particular needs. If you have a lot of lax skin, get a surgical facelift. If you have loss of facial volume issues with minimal skin laxity, then you might be a candidate for re-volumizing with fillers. Your plastic surgeon can advise you.

I'm also starting to see patients who have been over-treated with the facial fillers. It used to be just the lip area - but now it's the entire face that is involved. Since there isn't an official name for this, I'll call it "puffy-face syndrome". Features of "Puffy face syndrome" that I've seen include:
- generalized swollen or bloated look to the face, due to the over-injection of filler agents, which is out of keeping with the pre-procedure appearance;
- excessive fullness in some or all of the injected areas: brow, cheekbones, paranasal and perioral areas;
- obliteration of normal naso-labial creases.

Interestingly, many of the patients that I feel are over-injected seem to be somewhat addicted to their filler treatments. When I tell them "no, you really don't need any more volume" - they react with shock and disbelief!

So, while I think that facial fillers are useful, they are but one option among many for the treatment of facial aging. Too much filler can lead to Puffy Face Syndrome! This is another example of how aesthetic judgement is important.

Thread Lifts Don't Work

For those of you who are unfamiliar with the term, the Thread Lift was a much-hyped procedure in which a special type of barbed suture would be placed under the skin, to draw the loose facial tissue upward. The idea was to get a facelift-like lift, without actually doing a real facelift. It sounded so promising - just have a few of these magic threads inserted into your cheeks during your lunch break - and voila! - a younger looking you. A number of companies make and promote these barbed sutures, under a variety of trade names.

Well, as we've said before - when you do less, you get less.
Here's some more evidence: in this month's issue of Archives of Facial Plastic Surgery, a study looked at how well the thread lift procedure held up over a two year follow-up period. The answer: not good.

The authors evaluated the results of 33 patients who underwent a thread-lift procedure alone or in combination with other facial rejuvenation procedures to the brow, midface, jowl, and neck. Long-term aesthetic results were evaluated by 4 independent, blinded surgeons.

The thread lift group had a much smaller degree of improvement than the groups that were treated with standard procedures. Furthermore, any early improvement from the thread lift had vanished by the end of the two year study period.

The authors concluded that the short-term improvement of the threat lift was largely attributed to "post-procedural edema and inflammation" (swelling). After evaluating the thread lift extensively, they've decided to abandon it, stating "Given these findings, as well as the measurable risk of adverse events and patient discomfort, we cannot justify further use of this procedure for facial rejuvenation."

Take home lesson: there is no substitute for a properly-performed facelift for facial rejuvenation. Don't waste your time & money on thread lifts.

Twins Facelift study

New, in this month's issue of the Plastic & Reconstructive Surgery journal, is the 10-year update on the famous twins study, originally devised by Dr. Bernard Alpert at UCSF.

In this study, 2 sets of identical twins underwent facelift procedures, by four master surgeons, all using different facelift techniques. The goal was to see which facelift technique worked better.

For those of you who like the details, the surgeons and their techniques were:
Dr. Jack Owsley -- multi-vector SMAS-platysma facelift with neck liposuction,
Dr. Dan Baker -- SMAS-ectomy with anterior platysmaplasty,
Dr. Sam Hamra -- composite / deep-plane facelift with anterior platysmaplasty,
Dr. Oscar Ramirez -- subperisoteal facelift with anterior platysmaplasty.

(N.B. platysmaplasty is a necklift operation, done with an incision beneath the chin area, tightening the neck muscles together in the middle.)

Drs. Baker and Hamra were assigned the first set of twins, while Drs. Owsley and Ramirez worked with the second set of twins.

So, which facelift method was the best?

Well - the answer is not that easy. All four of the twins looked good. All four of the twins, at 10 years out, looked better than they did pre-operatively. So, great surgeons can probably get great results, even if they use somewhat different operative techniques to achieve that result.

Studying the pictures, however, my personal preference was for the results by Dr. Owsley and Dr. Baker. To my eye, these looked the most natural, and the most aesthetically pleasing. This did my heart good - as I use Dr. Owsley's technique almost exclusively for major facelifts. (Disclosure: I did my facelift Fellowship with Dr. Owsley, learning the technique from him personally, over the course of a year.)

Of interest to me was that the Owsley technique gave a nice result in the neck, without having to open the neck surgically using a platysmaplasty. Also, both Dr. Baker's and Dr. Owsley's methods gave excellent correction of jowls and lower facial laxity, and I felt that these methods "aged" better than the other two methods.

Of course, this is a comparison of only 4 patients, not a large, randomized prospective study...nevertheless, it's fascinating stuff for those of us interested in facelifts!

Mini-facelifts

Ahh...the allure of the "mini" procedure. It sounds so pleasant, with its implications of short recovery and a less invasive nature, so...cute.

Take for example, the "mini-facelift". It's been marketed under all sorts of clever names: the quick-lift, the mini-lift, the S lift, the life style lift, Dr. X's own lift - but they are basically all pretty similar. Use pretty standard incisions - sometimes a little shortened in length, and do only a little "work under the hood" - and call it a day.

Less involved surgery, of course, means less swelling and a quicker recovery. But it also leads to lesser results - and that's my point here. The results of a mini-facelift are simply not the same as a properly done full facelift. Think "minimal facelift". When you do less surgery, you usually get less of a result.

While mini-facelifts can work, and I certainly perform them in carefully selected patients, I think they are best suited to:
1) people that have had a previous standard facelift a few years ago, and now just need a little touch-up,
2) people with early aging changes in the cheek and jawline areas, but who still have an excellent neckline.

Wel'll talk more about facelifts in future posts. Have a nice weekend!