Many patients who are unhappy with a facelift come seeking more surgery. The problem is that they often already look like they have had too much surgery. So how do you make someone who looks like he/she has had too much surgery look LESS operated on by doing more surgery?! That’s the challenge and that’s why I find the field of secondary or redo or revision facelifts so interesting. To be honest, it is not always possible to make an operated face look less operated. But frequently it is possible and these patients tend to be enormously grateful. By relieving excessive tension, correcting distortions, redraping the skin in more natural directions, adding small amounts of fat, and correcting the previously uncorrected areas, frequently the face and be brought back into harmony. And that is enormously gratifying.
Patients pursue revision of a previous facelift (also known as a secondary facelift) for a variety of reasons:
Patients tend not to use the word disharmony but I am using it here to describe the situation where a facelift has been performed and it just does not look right. Sometimes the face looks unnatural, or weird, or operated on. In some cases, the cheeks have been addressed but not the neck, leading to disharmony between those two areas and a bizarre look. In other cases, the skin has been redraped in unusual directions. For example, it is common to see the neck creases pulled up on to the cheeks, again resulting in a look that is not quite right.
Most plastic surgeons perform fat grafting to the face at the time of facelifting. Unfortunately, like any good thing, it can be overdone leading to a puffy, over-filled face. In other cases, the face is not overfilled in general but there are areas, such as the lower eyelid, where the fat grafting was overdone or the fat is not exactly in the correct place. Imprecise fat grafting to the lower eyelid can result in lumps and unusual contours.
The incisions for a facelift should be completely invisible. If scars are apparent or in some cases, unsightly, patients will often come for a secondary, or revision, facelift.
Some patients who complain of a botched facelift or as facelift gone wrong, are upset with the distortions of the ear and hairline that goes with an amateurish facelift. If the sideburn has been pulled too high, the result is a very aging look because of the bald area where the sideburn should be. The same is true behind the ear. The ear itself can be distorted by a facelift; most commonly, the lobule is pulled down and forward because the cheek was trimmed with insufficient care. Lastly, some patients notice that the front of the ear looks bizarre because the tragus in front of the ear has been amputated or distorted so that the public can look right into the center of the ear canal.
In some cases, patients say they are not happy with their facelifts but in reality the face is acceptable but the face needs a browlift, or eyelid surgery or a chin implant or setback of the ears (otoplasty). In other patients who complain that they do not like their facelift, the problem is the nose. The nose tends to elongate with aging in many people and the plunging tip of an elongated nose is often what really makes the patient unhappy.
And of course there are patients who are happy with their first procedure but time has passed and they are ready for a secondary procedure.
40’s: The JOWL decade. Patients who seek improvement in the appearance of the aging face in their 40’s are most frequently interested in elimination of early jowls. Of course, aging changes vary tremendously between patients of different skin types, bone structures, genetics, ethnic groups etc., but the earliest correctable sign of facial aging, not including the eyelids, is frequently the appearance of jowls, or at least the sagging of the lower cheek, even if there is not yet an actual jowl. The skin elasticity in these patients is usually of good quality and surgical correction is usually excellent.
50’s-60’s: The JOWL and NECK decades. Patients seeking an improvement in the appearance of the aging face in their 50’s and 60’s have often developed both changes along the jawline (jowls) and changes in the neck. The other category of patients in this time period is the re-do or revision facelift patient; that is, the patient who had a facelift procedure previously and returns either because of dissatisfaction or because the aging changes have progressed. Skin elasticity in this age group is still good and the results are usually excellent.
70s-80’s: The JOWL and NECK and DEFLATION decades. Patients seeking improvement in the 70s and 80s often have the triad of jowls, changes in the neck and deflation (fat loss) in certain areas. As mentioned above, the other category of patients in this age group are those who have had previous procedures. Patients in the 70s-80s often require elimination of the jowls, improvement of neck laxity, and replenishing of facial fat with fat grafting. Different facial shapes age differently: The thin face tends to lose fat and require fat grafting. The heavier face tends to sag more than the thin face, and may not require the fat grafting that the thinner face might. The results in this age group are also gratifying although the skin quality is not as good as younger patients and some residual excess skin is often seen under the chin when the swelling has resolved. This age group is also extremely pleased with facelifting.
Dr. Thorne is the Editor-in-Chief and the author of several chapters in Grabb and Smith's PLASTIC SURGERY, 7th Edition.
