Hello and welcome! We have prepared an exciting session for you. Before we begin, we want to remind you that the material shown here is the property of ASPS or the presenters. Copying or distributing the content in these presentations without specific consent from ASPS is prohibited, including screenshots, photography, live streaming and video recordings. Also, please note that this session has a corresponding forum discussion taking place right now on the PSTN 23 conference platform. If you have questions for our faculty, please feel free to submit them there. Please note that chat records may be recorded. Thank you for your participation and enjoy! Welcome to the Basic Facelift Getting on Base 2.0. I'm Deb Johnson from Sacramento and joining me are Jim Zins of the Cleveland Clinic and Brian Boyd of Rolling Hills in Southern California. We spoke to you last year about getting started with facelifting and we were asked to reprise our talks, adding in some new information and some tricks of our trade. We will each present a short video and then the three of us will get together for a lively roundtable discussion on facial rejuvenation that we hope you'll enjoy. And we hope you gain some tips for your own practice. I'd like to start with how to assess a patient seeking facial improvement. You first need to know what the patient's drivers are. Do they look older than they feel? Are they competing with younger people in the workforce? Are they trying to feel more confident? Do they have a big event coming up in which they want to look their best? I always ask a patient, what bothers you most about your face? I think listening to the patient's concerns steers you in your recommendations. Not everyone wants or can afford everything that you might have to offer. I'm a big believer in if it isn't broken, don't fix it. So if a patient isn't bothered by certain aspects of their aging face, I don't insist they consider the whole enchilada. There's nothing wrong with doing things piecemeal. If you and the patient are in sync and your results are good, he or she may well come back for further procedures in the future. Be sure and point out what you notice in the patient's anatomy. Document any asymmetries because the patient may not notice them preoperatively, but they will for sure notice them after your surgery. Note any static or dynamic wrinkles, any shadows, any bulges, laxity of the skin of the cheek or neck, and of the upper lip. Note the quality of the skin in terms of Fitzpatrick type, thinness, dryness, oiliness, sun damage, hyperpigmentation. Discuss, frankly, the limitations of the patient's anatomy. Someone with a full, round face will never achieve an angular look, even with liposuction or buccal fat pad removal. Someone with a very fat neck will likely never achieve a sharp cervical-mental angle. Someone with thin, sun-damaged skin is at higher risk for wound healing problems and will likely experience some rebound of skin laxity after surgery. I always warn them they may need a touch-up after a year. I discuss with patients that everyone heals a bit differently. Some have more inflammation, some have more pain, some have more obvious scars. The bottom line is to under-promise and do your best to over-deliver. Refuse to operate on patients with unreasonable expectations because they will only make your life miserable. If a patient wants only a neck lift, for example, be specific about what that procedure can improve. Have the patient look in a mirror as you demonstrate where she will note improvements. Point out that a neck lift will have no effect above the corners of the mouth and will not improve the cheeks, eyes, or brow. If you add in fat grafting, laser treatment, chemical peeling, etc., discuss the limitations of those ancillary services. I basically fat graft all my facial rejuvenation patients unless they reject it, but I tell them the take of grafted fat varies from person to person and the final results won't be visible for three to four months. If the improvement in their lips or nasolabial folds isn't as good as they'd hope, then I suggest hyaluronic acid fillers along with giving them the cost and the longevity of those treatments. Don't rush to surgery without taking a holistic view of the patient. If the patient's results would be enhanced or improved by preoperative skin care, then by all means suggest that. Topical therapies, laser treatments, or peels may well improve the skin quality and enhance your results, making it longer lasting. If weight loss is possible and desirable, discuss this frankly with the patient and wait until he or she has achieved that goal. After surgery, suggest ongoing skin care for your patient. I tell my patients I want to protect their investment, and to do that requires good ongoing skin care and sun protection. Providing the patient with a postoperative facial, makeup advice, a light peel, or a microneedling treatment can make them feel pampered, and they'll also be more likely to suggest your expertise to their friends and family. Send the patient copies of their pre- and post-op digital images via a HIPAA compliant portal, but only post them online if the patient has given you specific written permission. Watermark any of your posted photos so they can't be lifted for use by another website. Now, let's go to the OR and discuss more tips about facial rejuvenation. So what are other things that we need to think about for patient safety during face lifting? One is prevention of DVT and pulmonary embolism. It's rare in face lifting, but we want to treat everybody like there's a high risk, and so use of intravenous sedation rather than a general anesthetic, and putting sequential compression devices on the patient, keeping the patient warm and comfortable, are really important. So what are the things we worry about in face lifting? What's the most common risk? Common question. Certainly, hematoma is always listed as the most common risk. Relatively rare, anyway, about 2% if you look at meta-analyses, but we want to try and prevent it. So, you know, you've all been taught careful hemostasis, second look, making sure that you are very careful with your dissection, using some epinephrine in your local anesthesia to try and constrict the blood vessels. Some people have used quilting sutures, some people have used the netting kind of sutures, and so one of the things that I've found is the use of TXA, a super game changer. It's 10 mils with 1,000 milligrams. You mix it into your local anesthetic. Some people give it IV, some people use it topically on pledges, but just mixing it in with your local. As you can see here, we've got a bowl of our local, which is quarter percent lidocaine with epinephrine with 10 mils of TXA. We'll use that to kind of to mess the skin of the face. Gives us good anesthesia as well as good bleeding control, minimizing inflammation and bruising as well. So you can see when we're draping, we want to keep the hair out of the surgery zone. So we use a little autoclave tape just to hold the hair out, and then place some drapes on that tape by securing it with a little stapler. And that keeps our area nice and clean. An important adjunct to any facelift surgery is fat transfer. If the patient has adequate fat in their neck, you can harvest that to use in the face. If they don't have adequate fat in the neck, then harvesting from the abdomen is a good solution. So we're going to numb this up and take a little fat from her tummy, centrifuge it down, and put it into her perioral area. To harvest the fat, we use a 10cc syringe and a one and a half millimeter fat harvesting cannula with a blunt tip. So we're just going to collect a couple of syringes of fat to use for the fat transfer. So we put the fat into the centrifuge, and we're going to spit it at 3,000 rpm for three minutes. We're going to transfer the fat. You can see she's got marionette lines, a mental crease, thin upper and lower lips, and wrinkled earlobes. So we'll be transferring fat into all of those areas to try and pump them out. So with two syringes of fat, we've got a total of nine cc's of solid fat, which we put into one cc syringes using a blunt tip needle, making insertion sites using an 18 gauge. And twisting the blunt tip just gently will help you maneuver it right into the position you want. And then just putting small aliquots of fat. And where exactly are you trying to put it in respect to the marionette line? Just beneath and on the edges to feather it just a little bit. And then we'll just turn our needle and go right along the vermilion border to augment the lower lip. So we've put some fat into the upper and lower lip. We're just going to put a little bit in this area where she's got some transverse wrinkles and a little bit of a rabbit line to try and improve the quality of that skin. So not really to add volume, but just to put some better tissue underneath the skin. Why do you prefer to do this at the beginning rather than the end of the neck lift? Because I think once you're at the end, things are swollen and it's harder to see how it's going to look. I like to do it at the beginning just because these aren't areas where I'm going to dissect per se. But I want to be able to see the contours as well as possible without having it too swollen. So now we're going to open the neck. I do like to open necks because I think I have more control. I know a lot of people can do a nice platysmal tightening without opening the neck, but in my hands I like to be able to see it. So we're just going to make a small transverse incision and elevate the skin off the platysma. Take out any sub-platysmal fat and repair the muscles. Go ahead and run this down to as far as we can. And then we'll be dividing the platysma transversally distally to try and prevent recurrent banding. So now you can see we've sewn the platysma back together from the mentum down to the ankle. And we're going to be dividing the platysma distally. So what you want to do is go three or four centimeters up to the side. And you can check to see that it's divided by using your finger to feel the edge of it, which is good. And then we're going to do the other side. So I do a lot of neckless. Probably two-thirds to three-quarters of my facial rejuvenation are neckless rather than faceless. The other quarter or third are faceless. A lot of women hate their neck, and that's where they tend to show age earliest. So a lot of women say, my upper face doesn't bother me, but I don't like my neck. I want to have my jawline tightened and my neck tightened. So a necklift incision starts in the posterior hairline. And you do a little bit of a curvy linear incision back here up to the level of the tragus in the postauricular sulcus. And then preauricular, posttracal, up to the sideburn, and then just a little bit around the sideburn. And then we're going to dissect a little bit distal to the posterior incision and down to the jaw. One of the places that we're worried about, you want to be careful about the marginal mandibular. Marginal mandibular nerve comes from here down to insert on the undersurface of the depressor anguli oris. 80% of the time it's above the jawline, 20% below. But it's important for you to stay subcutaneous because if you're getting deep in these tissue areas, there's a chance you could injure that nerve. The buccal branches are coming out this way. Usually they're not at any risk in a necklift, but in a facelift where you're dissecting up to the malar eminence, again, being subcutaneous to protect those. And then the zygomatic and frontal branch. Frontal branch starts from half a centimeter below the tragus to a centimeter lateral to the eyebrow. And it's superficial in this area, so we have to be careful here. If you're going above the zygomatic arch, you know that's where it transitions from deep to just under the temporal parietal fascia. So you want to be careful in that area staying subcutaneous or right on the deep temporal fascia to protect that nerve and avoid injuring the paralyzing the frontalis muscle. So we're going to inject this with our termicit solution. Again, which is quarter percent lidocaine with one to 400,000 epinephrine with a thousand milligrams of TXA added. Okay, that was about 50 cc's. So it's nice to keep the sideburn out of the way with little clippies. We buy these at the five and dime and sterilize them. And you can just use that to hold. If they're out of place, it makes it cleaner. And we put a little roll in the ear, preventing any getting in the ear canal. I like to put the posterior incision along the hairline edge, something I learned from Tim Martin. It does make a little more visible scar, but with a careful closure, it's quite acceptable. And then you don't shift the hairline, you don't lose any hair. Most of these women that we're operating on have thin hair, so you want to preserve as much hair as possible. Also makes the vector better for treating the neck, because you're having a tightening in this direction rather than vertically and changing the animation lines to an odd angle, which gives you a telltale sign that you've had a facelift or a neck lift. We're going to elevate the skin just between the subcutaneous fat. You can see the demarcation between the subcutaneous fat and the fascia. And you just carefully dissect along there. And we just stop the bleeders as we encounter them to keep a clean field so it's easy for visualization. So the other nerve we worry about is the great auricular nerve. So at about halfway through, I convert to scissor dissection. You want to be gentle with the skin. The skin is quite thin, so you don't want to be yanking on it. You don't want to be grasping with hooks in the area of the flap that you're not going to be removing. And I put my finger behind. The skin is sticky in the early part, in the periauricular area. There's a little more fibrous tissue, so you'll feel that stickiness as you're cutting. And then you'll come to a point where the cutting gets quite a bit easier because you're more in the loose areolar plane. And at that point, you can convert from directly seeing and cutting to putting in the larger scissors and elevating with a little cutting push action. Not work in a deep hole. Just try to get a broad swath opened up. So push, cut, push, cut. You want the tips of your scissors to blanch the skin a little bit, so you don't want to be deep like this. You want to be up so you can see your tips. That means you're in the subcutaneous space and you're safe. If you can't see your tips, back out, start over. And I'm working through there. And you kind of feel your scissors, make sure there's nothing holding you. We're just going to put a gauze in there for hemostasis, and then we're going to move up to the top. We're using the small scissors just to get things going. If this were a male patient, how would you have changed that incision, or would you? Usually in men, you're moving the beard posteriorly. So you can put it post-tragal, but then you have to make sure that the skin that you're placing over the tragus has had the follicles removed from underneath. So you debride the follicles to try and prevent that beard growth on the tragus. Sometimes men have a very demarcated line pre-tragally, and if that's the case, it would still look very natural to have a pre-tragal incision line. And then you don't have to worry about changing the beard so much. You do have to warn men that you're shifting their beard backwards, so they'll have to shave a little closer to their ear and a little posterior to their ear. What about men that have long sideburns? If men like to wear long sideburns, then I still do a sideburn incision, but you sort of decide. I'm usually doing it at the top of the helix, and then they can grow their sideburn overlying the scar, and that tends to camouflage the scar as well, so that's a good thing. The troublesome patient is the one that doesn't have a sideburn, doesn't wear a beard, has male pattern baldness. Those are much harder to hide your incision lines, so in that case, sometimes you won't do the transverse incision. You'll do more of a max-type lift to minimize the appearance of the scars. So nothing can be super cookie cutter, because you have to tailor it to the patient and their particular anatomy. Again, doing this under direct vision with finger pressure behind, getting past the adherent portion of the skin, lift the tips up. Again, doing the cut and push, you want to dissect a bit beyond your incision. That makes when you turn the skin a bit to elevate it, you don't get a dart or a pucker. Dissecting down over the jawline, your marginal mandibular is going to be in this area, so you want to just be careful there, make sure you're staying subcutaneous, and just meeting your submental incision here. Are you trying to release that mandibular ligament? I am. I'm getting into that area, so this is where you want to be careful, but if you want to release the mandibular ligament, just put a little gauze in there just to give it a little more time for hemostasis. Let's turn on the lighted retractor. Your choice of bovie versus bipolar? I've just always used the bovie. I've never seen it cause an issue. I know some people do use bipolar to try and minimize risk of nerve injury. I sort of trained using the bovie and I've stuck with it. I haven't seen nerve injuries, so bipolar to me is just a little bit more cumbersome. It will be super easy, we're very used to it. As you can see, pretty nice bloodless field with the TXA. It's been a real game changer because it makes things very easy to visualize and gives you a nice clean field, very little bruising, very little swelling. In a thin patient, I'm going to do platysmal placation. If she was heavier and had thicker tissue, I might do a smasectomy to reduce the volume, but I think in someone like this who's quite thin, you want to maintain as much volume as you can so we're just going to placate her platysma. In a neck lift I placate along a line that is parallel to this preauricular line and extending into the depth of the neck. So we're going to start down here as far as our dissection goes and come up to the zygomatic arch parallel to that preauricular line. So I just draw another pen for the other side. Just draw a line so that you can see it up to the arch. If we were instead doing a facelift we would have dissected from this point probably in her I would go a hair sparing incision up into the temple. If she had a lot of hair we would extend it up this way into the temporal hair and then we would be dissecting to the malar eminence and placating along that zygomatic arch from the malar eminence back. So an L-shaped placation rather than a straight line. We're again going to use the 40PDS. As you can see the bottom of the location there you start in front of that and your vector for suture placement is the angle of the mandible or the jawline. So you want to have your distal bite more distal than your lateral bite. And then we're just going to sort of see where it wants to go. We pull along that angle and then grasp the posterior tissue. Let's see how far it'll come forward. You can get a bite about a centimeter and a half behind. And then I'm going to placate this using a running horizontal mattress suture. About a centimeter above where we were previously. And then usually at the lobule level I'll tack to the mastoid fascia back here to get a nice secure anchoring point. And then we're going to convert to the preauricular so that we don't pull too hard on the lobule and change its position. And then when we get to our finishing point you want to come into the little cleft you've created, leave a loop, come back into that little cleft, and then tie this down. And when you do that you can see you bury your knot so then it's not going to be palpable to the patient. And you always want to feel make sure you don't feel it. If you do feel it you can put another suture to kind of evert over the top of it. So your extent of the section anteriorly so we've dissected along this line down to the zygomatic ligament across to the midline. When you do your placation you can see how that bunches up the skin here. So you need to do just a little bit more releasing there. Now we don't see her nerve. You know we know it's would be here back to here so it's around in here but we've conducted it. So if you do happen to injure the nerve you just want to repair it with a 7-0 suture. Usually that will heal it. It will come back. Rarely you can get some permanent numbness to that area to the ear from injuring the nerve. And then we're going to re-drape our skin. So we want our skin to be taut but not tight. We're just going to lay it the way we want it to go. And you can see you can get a fair amount of skin out without too much tension. An instrument I like to use is this clamp it's called the Desumcio. Named after Dr. Desumcio from Brazil. Has some prongs on one end that you set on the edge of the of the incision and place this over the top so you can get a nice positioning. So you place it at the top of the ear lay the skin back and just set it and then leave that there. Grab it about halfway down and again set it and then you can mark your incision line and remove that amount of skin. And then I do like to use drains for 24 hours. Even with the TXA I think it getting any little weeping blood out helps reduce the bruising and makes healing faster. I just bring the drain out through the bottom of the incision. I know some people come up here or some people go distal. And the hole starts about here so I put it about halfway from the black dot to the hole just so you're getting some suction back closer to your incision line because that's where it will tend to pool. And the reason for doing this is because you want to make sure that you don't get too much some suction back closer to your incision line because that's where it will tend to pool. And the reason for curving that posterior incision is to lengthen the incision line a little bit to prevent bowstringing and because it will as it heals it will turn into a straight line but it will have a little more give. It won't be as obvious. And then closing the skin with a horizontal half buried fibro nylon so that the suture is exiting in the hair and not on the non-hair-bearing skin so that you don't get any suture tracks that are visible. So you can see we've now closed posterior neck with the horizontal half buried mattresses. Now we're going to close the sideburn area to some sanding. Again putting this at the edge. Just bring that up. I'm just drawing a line moving up to our point. And again closing from the corner to prevent dog ears. Okay now that we've set the tension of the sideburn and the posterior ear we want to set the lobule. One of the big concerns in facelifting is development of pixie ears so if you take all the tension at these two points and then just set the lobule where it wants to lay then you don't have any tension on it. So you just feel where the edge of the earlobe is and kind of mark that. And then we cut with the scissors down close to that mark. Bring the lobule out and just take a peek. See how it's sitting. It wants to be just a little bit distal. So when you've got the edge of your lobule exactly where you want it. So to set it you put one suture down a little deeper into the sturdier tissue under the skin edge. And then we're going to lay the skin over the front of the ear and just trim it where it wants to lie. See that right at the tragus just barely a little tiny bit to remove. Curves around here. If this skin here is quite thick or fatty you can trim it just a little bit. You want to be careful. You don't want to devascularize it but just to make it a little less bulky over the tragus. Her skin's quite thin so it's not a real big deal. And behind the ear just lay the skin where it wants to be. And then along that little curve of the ear. And then closing the subcutaneous tissue behind the ear you want to catch the perichondrium on the ear. That'll give you a better hold of the suture line against the ear so it won't drift down and become more visible. And the assistant can give you just a little bit of traction. How'd it go? It went great. You did marvelous. Okay just gonna get your bandage on and then get you to the recovery room. I'm going to ask you to close your eyes for a moment because we're going to put a little bit of netting netting over your head and then we'll make an opening in the netting for your eyes but I just want you to keep your eyes closed for a sec. This is a number seven size netting. Your assistant picks up. So keep your eyes closed and pull down. Okay, this one's a little generous. You need about 15 inches. I always tell patients they're going to look a little smurfy or look like a q-tip. But it's only for one day. The good news is they're totally unrecognizable. Okay, keep going, keep going. Hello, my name is Brian Boyd. This presentation will concern the description of a basic facelift which relies on a plication technique. Like many procedures in plastic surgery, patient selection is very important in order to get a good result. The patient should be assessed for bone structure, jowl formation, neck laxity, cheek creases and all of these things can be corrected by a facelift. However, beware the soccer ball face where the patient's face is completely round with a fair amount of adipose tissue. Here, even with a wonderful facelift technique, the results may not be spectacular. As for any procedure, the patient must be optimized for surgery. He or she should stop smoking at least a month ahead of time. Hypertension should be controlled and all medical conditions should be completely optimized. I personally don't indulge in skin treatments for the patient preoperatively, but others do. I don't think it affects the results, however. I perform most facelifts under local anesthetic with oral sedation. However, if you wish, you can utilize an anesthesiologist to give IV sedation or even a general anesthetic. I feel that there's less bleeding under local anesthetic and the patient recovers much quicker. The patient's hair can be a considerable nuisance during a facelift and so by wrapping the hair in a coban bandage such as you see here, the stray hairs will generally stay out of the way during the closure of the wounds. Furthermore, the coban bandage can be prepped together with the patient's face. For infiltration, I used a mixture consisting of 50 ml of 1% xylitol and 1% xylitol. of 1% xylocaine and 1 of 100,000 pounds epinephrine mixed with 200 ml of normal saline with an added 500 milligrams of TXA. TXA really does reduce bleeding and oozing during the procedure. I prefer pre-hairline incisions in the temporal area because incisions within the scalp can lead to a retrusion of the temporal hairline. In order to hide the incisions, however, I would recommend a beveling incision from the hair-bearing area towards the non-hair-bearing area in such a way as to divide a number of the hair follicles. Thus, when the wound is put back together again and sutured, these hairs will grow through the hairless flap and so disguise the location of the scar. There's a big debate about whether one should place the facial incisions retrotragal or pretragal. I don't have really strong feelings about this, but I do believe there's nothing quite like a normal tragus. Attempts to reconstruct it with a retrotragal incision can be quite good, but sometimes they can be somewhat disastrous. Here, for example, is the scar resulting from pretragal incisions and I don't think you could really match the appearance of the tragus here by carrying out a flap or a reconstruction of the tragus. In the postauricular zone, the incision will pass around the attachment of the lobe of the ear and then on to the back of the ear to some extent before passing into the postauricular hairline, again at the junction between the scalp and the hairless skin immediately inferior to it. The purpose of passing up onto the back of the ear is to make this a very wide flap rather than a narrow pointy one, so that there's going to be no degree of ischemia during the healing process. Once again, as the incision passes down the back of the scalp, the beveled incision is used from the hair-bearing area to the non-hair-bearing area in order to cut a number of hair follicles in such a way that when the wound is closed, those hairs will grow through the scar and hide it from view. In marking the extent of the dissection, I always start by marking the anterior aspect of the patient's jowl. The reason for this is that there are ligaments which pass from the underlying smass to the skin and it's these ligaments that form the anterior aspect of the jowl and indeed cause the jowl to form. I make it a point of dissecting over this area so as to divide these ligaments and allow the jowl to be obliterated during the facelift. The jowl marking that I've just described will now be incorporated in the marking which defines the extent of the dissection. Please note that the extent of the dissection passes way down into the neck, five or six centimeters below the mandible itself. The purpose of the placation is not so much to do a lift but to rather shrink-wrap the mass so as to tighten the face and neck in a diffuse manner. The suture that I prefer for the placation is a Quill 20 PDO. This absorbable suture is two-ended, a fixed point in the middle and has numerous barbs. This allows it to be tightened and locked with every single suture and it allows you to see the effect on the SMAS as the suture is going in. This diagram is a rough representation of the placation technique but you'll see it much better in the video which will follow in a few moments. Most of the tension of the closure will be taken on the SMAS, not on the skin. This video will illustrate some of the details of the facelift. Dissection starts in the preauricular area using a 15-bladed scalpel. The junctional areas between hair-bearing skin and hairless skin are treated with a beveled cut which cuts some of the hair follicles, permitting future hairs to grow through the scar, hiding it from view. You'll notice here there seems to be a sort of white membrane on which we are dissecting. This is really just the scar of a previous facelift. It is also visible in the postauricular zone where dissection proceeds also with a 15-blade. Once the platysma muscle is reached, the blade is abandoned and the facelift scissors were employed to continue the dissection. The dissection passes anterior to the jowl so as to disrupt the pre-jowl ligaments and allow the jowl to be flattened by the pre-jowl ligaments. And allow the jowl to be flattened by the plication which will take place later. This is a widespread extensive dissection and not by any means a mini lift. It is the sort of dissection that is quite extensive for somebody purely under local but they tolerate it very well. In the preauricular area at the level of the zygomatic arch, the temporalis fascia is exposed. The PDO suture is then inserted into this fascia and brought out through the smas before being used to weave down through the smas in a line parallel to the posterior border of the ascending ramus of the mandible. These continuous sutures are locked by each pull since there are barbs on the suture. It passes all the way down to a point five centimeters below the angle of the mandible and then passes upwards anterior to its path of descent taking small bites all the way. Once in the preauricular zone once more it passes outwards towards the jowl area and then backwards to the preauricular zone again before passing out to the mid-cheek and then back again once more. The other end of the suture also has a needle on it and that is also used to placate the smas possibly emphasizing the posterior aspect of the platysma and pulling it back to the mastoid fascia in the process. In this way the entire exposed surface of the smas and the platysma are subject to this weave or this placation. With the result that the surface area shrinks. When the suturing is complete, the suture is simply trimmed flush with the dissection. It's very important that there are no knots, since patients who have subcutaneous facelifts do not like the feel of knots under the skin. I almost always use drains on facelifting patients. Here we see a Penrose, which has been split into two, with one arm going into the neck and one going up into the face. This is used with a pressure dressing. The tension of this facelift is taken up by the plication and the weaving sutures. You can see the skin redundancy as a result of that taking place. There should be very little tension on the skin closure. It only remains to establish the line of pull, and this is determined on the basis of what looks best. The Zins marker is used in order to make pilot cuts into the skin. So as to affix key staples in the preauricular zone, as well as in the postauricular zone. It only remains to excise the redundant skin and fit it to the existing wound. Care should be taken at the earlobe so that the skin of the face does not pull down and create a pixie ear. In fact, the skin below the earlobe should be pulled up tight against the earlobe to prevent this happening. Here is a photograph of that particular patient a year later, and you will immediately notice that she's got a fairly good result from the jowls and the line of the mandible. But I'd like to point out that if you look at a periocular area pre and post-op, there's been an improvement there, although nothing specifically was done to improve it. Also, there's a fullness of the cheek on the operative side, although no fat grafting was employed. I try to keep the closure as simple as possible. Basically, along the hairline, I use staples. This applies to the preauricular as well as the postauricular area. 6-O-proline is used in the cheek skin anterior to the ear. While 4-O-chromic catgut is used in the postauricular sulcus. As I mentioned, the drains previously. The sulcus is an important area because there's a potential dead space in the sulcus. On the right here, we can see a cross-section of the ear with a dead space in the postauricular area. On the right here, we can see a cross-section of the ear with the ear incision and the facelift skin coming together. If they're just sutured, then there will be a large dead space beneath them where fluid can collect and where the wound can get an infection and break down. A 4-O-chromic catgut suture is used to suture these wounds together. But in addition to catching the two skin margins, the suture also grabs the deep tissues of the mastoid fascia and the ear cartilage right at the base of the sulcus so that when the knot is tied, the whole thing socks in and eliminates the dead space. Usually, 3 or 4 of these sutures are sufficient to eliminate the dead space behind the ear. And because these sutures are absorbable, they probably will not need removal. If you're using passive drainage like I do with a Penrose drain, you're obliged to put a pressure dressing on postoperatively. Otherwise, the drain will not work. If you're using a suction drain, it is not so important. I have a problem with suction drains in that they often leave a ridge in the neck or the face, which takes a long time to disappear. So I prefer these soft Penrose drains, which you can easily remove, and you can direct them into different parts of the face. 24 to 48 hours later, I would remove this head dressing, remove the drains, and put the patient into a Velcro-type dressing like this, which she can take off by herself, wash her hair, and so on. The patient will shampoo on day 3, and she'll wear this as much as possible for about a month so as to avoid any edema or swelling in the neck region. I'd like to present a few cases to illustrate one or two points with regard to this facelift. This is a 60-year-old lady who was concerned about her neck and jowls, and she was very pleased with the result. Although the neck and jowls have certainly been improved, the patient was particularly happy with her midface, which seems to have had a volume augmentation without ever having fat grafting or anything specifically done to the midface. Even her eyes and periorbital areas have been improved, although she had no blepharoplasty or any work done around the eyes. This 58-year-old lady had a very bad neck, so bad, in fact, that she wore polar necks to hide it from view. After the surgery, she was able to wear a low-cut dress and was very proud of the shape of her neck. It's fairly obvious on the AP view, but it's even more obvious when one looks at the oblique shot or, in fact, the lateral view. The patient's face has been transformed by this operation. This patient was 61 years of age at the time of her facelift, and I only show her for one reason alone, and that is to draw your attention to her midface. Although, again, she did not receive fat grafting or nothing specifically was done to the midface, apart from what you've already seen, you notice she's achieved this OG curve here, which she did not have preoperatively. Again, fat was not injected. We could have done a little bit better with the neck, but overall the patient was extremely pleased with the result. Finally, this is one of the older patients. This patient was 72 years of age at the time of her facelift. Her main complaint was facial wrinkling and jowls. Also, she had a bit of a problem with her neck, but again, using the same technique with little or no variation and with no surgery elsewhere, no fat grafting, the patient got a very nice view from the anterior aspect, and she was also very pleased with the lateral view, where we cleaned up a lot of facial wrinkles and smoothed out the jowls, giving her a very nice jawline. The oblique view shows the same thing. The patient was very happy with this result, again achieved by a simple plication technique, as described here. In conclusion, then, this is a very basic facelift. It is a subcutaneous dissection. It involves plication of the SMAS. It does not involve any deep dissections, deep, plain facelifting, or any situation where the facial nerve would be at risk, and yet the results are very acceptable. For the young surgeon starting off in practice, I would heartily recommend this method as a starting point, and from there, he or she can branch out into modifications or extensions at their own discretion. Thank you very much. I'm Jim Zins, and I'm going to talk with you today about the basic facelift operation, getting on base, hitting singles, doubles, and triples, not going for home runs, but delivering a consistent result each and every time. I have no disclosure. What I'd like to do is briefly review some principles of facial aging, certain maneuvers during the procedure which will improve your surgical results. Then I'd like to review briefly the anatomy of the facelift operation with emphasis on its three-dimensionality. Then I'd like to categorize the facelift procedures for you, and finally put this all together and at least theoretically review what may or may not work with regard to certain facelift operations. Principle number one, bulges are associated with underlying soft tissue laxity and creases with ligamentous or pseudoligamentous attachments. This is perhaps easiest to understand in the malar soft tissue area where the malar soft tissue deflates and moves inferiorly and medially until it reaches the crease or the nasolabial crease where we have ligamentous or pseudoligamentous attachments to the deeper soft tissue. But this is also true in the lower eyelid where laxity of the septum orbitale results in the bulge, and the crease is caused by attachments of the orbicularis retaining ligament. Principle number two, ligamentous release allows mobilization of the soft tissue laxity distal to the retaining ligament attachments. This is perhaps easiest to understand in the midface. Here in the midface, we see the major zygomatic cutaneous ligament. We need to cut this zygomatic cutaneous ligament if we are to be able to mobilize the soft tissue distal or medial to it. Now, don't get me wrong. We can mobilize this medial soft tissue by cutting the ligament at any level of this chain link fence. We can do it in the subperiosteal plane. We can do it in the subsmaus plane, or we can do it in the subcutaneous plane and still mobilize that soft tissue. Now, there exists a series of retaining ligaments in both the forehead and in the midface, which are extremely important when we start talking about facelift surgery. These retaining ligaments form a T with the apex of that T being the major zygomatic cutaneous ligaments. Lateral to this, we see minor zygomatic cutaneous ligaments. From the apex of that T, the ligaments extend vertically down as masseteric cutaneous ligaments, stout superiorly but flimsy inferiorly, coalescing to form the mandibular cutaneous ligament. Principle number three, release, mobilization, and repositioning without undue tension is most effective long-term means of soft tissue repositioning. Now, what do I mean? I mean that it is not the sutures, the permanent sutures, that hold the result in place. It's really the scar that forms from this mobilized soft tissue. Therefore, undue tension is most important to allow for a minimum amount of creep or relapse. Principle number four, the laxity of facial aging is best treated where that laxity is greatest. Now, this is easiest to understand in a direct brow lift. What's the most easy way to elevate the brow? It's a direct brow lift. One centimeter of excision leads to one centimeter of elevation. But this is also true with the platysma where it's most medial, most lax medially, and this is where I think it is most important to be addressed. So here we've opened the platysma in the midline. We see abundant sub-platysmal fat, which we will address. We'll talk about this in depth in just a few slides. Principle number five, neck skin has a unique ability to contract once it's released from its underlying platysma muscle. Now, we learned this a long time ago from liposuction procedures. When we do liposuction in the neck, we remove very, very little fat. The reason we get the correct, the dramatic correction that we get is because of release of the attachments from the platysma to the skin. This allows the skin with its unique ability to contract over volume without removal of skin. Case in point, here we see this patient before and after procedure. No facelift was performed, but we see a very significant improvement in the neck area. This was done through a submental incision only. Fat was removed from the superficial surface of the platysma, the platysma was opened, sub-platysmal fat was removed, and the platysma was tightened. We can do everything that we do in a standard neck facelift through a submental incision except remove skin. Principle number six, the appearance of deflation is an integral part of facial aging, and this is best addressed by a facelift combined with fat transfer. This has become an integral part of facelift surgery. It's not merely the removal of soft tissue, skin and soft tissue and fat, it's also adding volume to the face. A case in point, patient who underwent a brow lift and a facelift surgery with fat grafting to the malar area, the nasolabial folds and the lateral orbits. This is before and one year after surgery. Again, volume improvement in the face has enhanced the surgical result. Principle number seven, central facial aging is the most difficult area to treat and therefore it requires ancillary techniques for correction such as fat grafting and aggressive peeling techniques. In this before and after picture, we see significant improvement in the central face. The combination of the facelift combined with resurfacing with the phenolcrotonoyl peel is an extremely powerful and unrecognized modality. This leads to significant improvement in the surgical result when we combine the two modalities. There exists a very important subcleavage plane in the midface. And through this subcleavage plane between the deep fascia and the superficial fascia pass some very important structures, including the muscles of facial expression, the retaining ligaments, and the distal facial nerve branches. And these facial nerve branches pass through this sub-smash cleavage plane at very distinct points. So facial nerve branches exit the parotid gland deep to the parotid masseteric fascia. They stay deep to the parotid masseteric fascia until they approach the retaining ligaments. And when they approach the retaining ligaments, they pass through this sub-smash cleavage plane to innervate the muscles of facial expression predominantly on their deep surface. Therefore, the facial nerve branches are most likely to be injured when they pass through this sub-smash cleavage plane. But they are relatively out of harm's way until they release those retaining ligaments. The muscles of facial expression are superficial structures. And therefore, they are by and large innervated on their deep surface. So dissection on the superficial surface of the muscles of facial expression is entirely safe. This is true for all the muscles except for Major League Baseball, mentalis levator labii superioris, and the buccinator muscle, which are deeper muscles of facial expression. So once we get to the retaining ligaments, we then go superficial on the muscles of facial expression because this is a safe plane. All sub-smash procedures and all super-smash procedures follow that plane. They go superficial to the muscles of facial expression once they release the major zygomatic cutaneous ligament. So here we are in surgery. The ear is at 6 o'clock. The major zygomatic cutaneous ligament is at 12 o'clock. You see scissors pointed under this. The major zygomatic cutaneous ligament will be cut. And then immediately distal to that ligament will be the zygomaticus major muscle. So in sub-smash procedures, we're going to do a limited subcutaneous dissection. We then go sub-smash until we get to the retaining ligaments. Once we get to the retaining ligaments, we go superficial. This takes us superficial to the muscles of facial expression of zygomaticus major. And we then continue this dissection in the subcutaneous plane. In a super-smash operation, we never violate the smash. We stay superficial to the smash. As we extend distally, we come to the zygomaticus major muscle and, again, continue distally in that superficial plane. So we're safe from facial nerve injury. Here we are back in the cadaver laboratory. Each clip represented a zygomatic cutaneous or masseteric cutaneous ligaments. And you can see in this cadaver, the ligaments are very sparse. We see the zygomaticus major at 5 o'clock. And here we see a very flimsy masseteric cutaneous ligaments. The clips around the masseteric cutaneous ligaments herald the location of the zygomatic branches of the facial nerve. And here we've colored them. There's zygomaticus major at 12 o'clock. But we see two branches, a deep branch and a superficial branch of the zygomatic branch of the facial nerve coursing deep to the zygomaticus major. The reason this is important is important not only in sub-smash surgery, but also in super-smash surgery. Because in the mid-face, especially in thin patients, it's extremely easy to inadvertently violate that thin surface. Violate that thin smash. Over the zygomatic arch, the frontal branch of the facial nerve passes over this middle third. And it's generally two to four branches crossing over the zygomatic arch. The nerves are actually deeper than one generally expects. It's deep to the smash. But as you see here, it is also deep to the parotid masseteric fascia, or the parotid temporal fascia as described by Fritz Barton. But once that nerve passes over the zygomatic arch, deep to the parotid masseteric fascia, it passes into the imnominate fascia, which is a fusion between the superficial and deep fascia. And this is where it's most likely to be injured, one to two centimeters above the zygomatic arch. So again, the nerve is deep to parotid masseteric fascia as it crosses over the zygomatic arch. But one to two centimeters above the arch, it passes from the deep fascia into the imnominate fascia, which is a fusion of the superficial and deep fascia, and is here that is most likely to be injured. Again, back in the cadaver laboratory, and we can see here four different branches crossing the zygomatic arch in its middle third, deep to the parotid masseteric fascia. Putting this all together, as we dissect from the preauricular area, we're over the parotid gland. This is a safe area. Once we go beyond the anterior border of the parotid gland, the nerves are still deep to the parotid masseteric fascia. So we're superficial to those branches, whether we're in a subcutaneous or a subsmass plane. We then come to the ligaments of the face and at the level of the retaining ligaments, the nerves are gonna pass from the parotid masseteric fascia to the subsmass plane, is here where they can potentially be injured. So we pass superficial to the zygomaticus major muscle at this point, staying in a subcutaneous plane. We have basically two facelift variants. We have the subsmass variant and we have the suprassmass variant. The subsmass variants all follow the same plane of dissection. They initially start in a subcutaneous limited dissection. They then go subsmass until they reach the zygomaticus major muscle, at which point they come superficial or subcutaneous. Suprasmass operations are basically subcutaneous operations. We then address the smass from its superficial surface. This is a lateral smassectomy, the smass placation, the max or the ESP facelift of Heflin. So what are these operations doing? They're all doing the same thing. They are vertically shortening the smass and in shortening the smass, they are passively bringing facial fat and platysmal fat back up into the face. So here we're doing an extended smass, but again, what's happening is we're taking the smass, we're elevating the smass in a posterior vertical direction. And in doing this, we're passively repositioning facial fat and fat from the platysma back into the face. So the smass is acting as a vehicle to reposition facial fat. So all modern facelift procedures practice release of the retaining ligaments. That is the zygomatic cutaneous ligaments and the upper masseteric cutaneous ligaments, and to a certain degree, the superficial release of the zygomaticus major. And again, this can be done at any level of the chain link fronts. We can do this, we can release the retaining ligaments of the smass or we can release them superficial in the subcutaneous plane and still mobilize distal soft tissue. Here we're doing a smass plication. We're taking two forceps. We're demonstrating the laxity in the smass. We're going to plicate the smass, sewing loose distal smass to fixed proximal smass in a vertical and superior and lateral direction. This is a key suture placed vertically to elevate the soft tissue into the malar complex. They will continue down with plication sutures, suturing loose distal SMAS to proximal fixed SMAS. So why open the neck? It gives us direct access to submental superficial fat, as well as direct access to the intermediate layer, including the subplatysmal fat, anterior belly of digastric muscles, and the submandibular gland. It also allows us to tighten the platysma where it is most lax, and that is centrally. So why not open the neck? Well, it takes extra time in the operating room, and the literature shows that it is associated with enhanced complications. But the risk of complications, I think, is far outweighed by the improvement we get with our surgical results. So, submental approach, submental incision. We join the two lateral subcutaneous dissections in the neck. We defat the platysma in the superficial plane under direct vision, open the platysma, defat conservatively, treat the digastric muscles and the submandibular gland if necessary. So here we are in surgery, submental incision, the platysma is opened, subplatysmal fat is demonstrated, this way conservatively resected, and then the platysma closed. The extent of subcutaneous undermining in the neck, joining the two lateral dissections, again from the lateral view, and then closure. So we finished our cheek work, we finished our platysmal work, our neck work. We are now using, closing the facelift side. Single suture is placed at the top of the ear with only minimal amount of tension. No tension is placed on skin removal in the neck area. Tension placed on neck skin will cause bad scars at best and skin slough at worst. So we want the incisions to kiss once we've completed our skin excision. This incision in the temple area is made just posterior to the anterior temporal hairline, in this way it is well disguised and is a better incision than the anterior temporal incision. This clamp is a clamp that I've modified from the DiEssenzio clamp and use this to mark the skin excess. Very helpful. Again, only skin excess is removed. There is no tension placed on this skin closure. This is not what's causing the improvement in the surgical results. Only the excess skin is removed. Again, skin tailored. We will then close in two layers. Skin excision completed. So neck variants. We have fat necks. In fat necks, wide skin undermining is extremely important. And defatting both above and below the platysma in the sub-platysmal plane and the superficial plane. Fat necks always have extra fat in the sub-platysmal plane. Problem with this operation is contour irregularity if meticulous care is not taken. Thin necks. Avoid ovary section of fat both in the superficial and deep in the sub-platysmal plane. The most common problem I have in these patients is recurrent platysmal bands. And then the massive weight loss patient is another category. Significant skin excess. Again, wide skin undermining in the neck and distal to the nasolabial fold is critical. And again, expect some relapse in these cases. So a few before and afters. This is a patient three years after facelift, extended SMAS, endoscopic brow lift, perioral phenolcrotonoyl peel for the perioral area. Again, getting significant tightening in that central component. Profile view, the same patient, three years post-operatively. Fat neck before and after, one year post-operatively. Front view. Profile view. Again, demonstrating the importance of meticulous defatting both above and below the platysma in order to get the neck contour that we like. And finally, the patient with significant skin excess. Here, dissection beyond the nasolabial fold and beyond the marionette lines I find is important to getting the surgical result we're looking for. And again, profile view, two years post-operatively. So, avoiding complications. Since I've been using bipolar cautery instead of unipolar cautery, I have much less problems with neuropraxia. Raise the blood pressure to normal or supernormal levels at the time of closure. Use a so-called second look technique. By that I mean, do the first side, first cheek side, do the cheek side on the second side, do your submental incision, your submental work, and then and only then come back and close the first side and then close the second side. This will allow maximum amount of time between injection of local with epinephrine and minimizing the likelihood of epinephrine rebound. And then finally, use TXA mixed with your local anesthesia. This has been a godsend for me. So, tranexemic acid has changed my surgical life. I now mix tranexemic acid, as you see here, two cc's of TXA and 100 cc's of local anesthesia. This leads to dramatic reduction in operating time and drying up time. TXA has been added to our local anesthesia, one milligram per cc. We have completed both sides of the facelift and now we are coming back to dry up at our second look on the left side. We've completed closure of the left side and we are now on the right side of the facelift, again about to start our closure. We have done no drying up on the right side. So again, TXA has been a dramatic change for my face-up surgery practice. I used to spend 15, 20 minutes each side drying up. Now, I spend two to three minutes. Really, a dramatic reduction in bleeding at time of closure. Also, reduction in edema and less drainage. And then finally, to enhance your result, use of the hemostatic net as described by Aresvald. This has been shown to reduce hematoma, to help with draping of the skin, and to reduce post-operative edema. Pre-op patient after massive weight loss, you can see the skin excess in the neck, dramatic amount of skin excess in the neck. Again, applying the hemostatic net after surgery, leaving this in for 48 hours, removing the sutures at 48 hours, allows us to get that kind of result. I thank you for your patience. Hey, I'd like to welcome you all to our roundtable discussion on basic facelift, getting on base. This is our second year of doing this. And the three of us, Jim Zins, Brian Boyd, and myself, Deborah Johnson, are gonna have a little bit of a roundtable discussion to talk about some things that are important to basic facelifting. And so we hope you'll enjoy it. And I'm gonna start off by asking you to, when a patient comes in for a consultation for facial rejuvenation, and you've evaluated them, how do you talk to them about setting realistic expectations of what you can achieve? Go ahead, Brian. Um, it's always very difficult because people have all kinds of notions about what a facelift will do. If a patient comes into me and does not have any jowls or does not have a bad neck or a wrinkly face, I realize that they're not probably gonna get a good result from a facelift. And I'm more likely to try to persuade them to take some other form of therapy, like a peel or injectables and so on. But if I think that they're suitable for a facelift, then I would tell them, quite frankly, that the best things that a facelift will do for them will be to improve the jowls and improve the neck. The cheek area or the nasolabial folds may be improved in the short term, but basically they're not really improved in the long term. And they can be treated in some other way by an injectables or fat injection or something like that. So I like to get that knowledge to them right early on. Also, I'd like to tell them, although they will feel them very, very tight immediately following a facelift and everything will be very, very firm, things will loosen up, but they will not go back to the way they were to start with. So setting realistic expectations, very important. One of the reasons that I've always liked this operation is because the patients who come in are generally well-educated. They're mature, generally women in my practice. Matter of fact, the patients get older with the doctor, so they're getting older and older, but they come in pretty well-informed. They're intelligent, they've thought about this. The average patient coming in to see me for a facelift has been thinking about this for a minimum of five years. So I don't have to talk them into any operation. They've already basically decided they're gonna have the surgery before they come in to see me. So basically what I do is first I ask them what their concerns are. Most often, this is very specific, and they'll address, as Brian says, they'll look at the lower face, the jowl, the neck area. Occasionally, they will be very nebulous and they won't define the problem. Those patients are the patients that you may have more difficulty with. The patient who comes in and is well-grounded is going to do very well post-operatively. That patient who comes in is haphazard, is teary-eyed, et cetera, those are the patients you really have to worry about and perhaps have at least a second consultation or perhaps tell them that you're really not the right doctor to do the operation. So again, setting the expectations in facelift surgery, in my experience, is not terribly difficult. I have a long discussion with them, basically a question and answer. I go through and I really start the discussion by saying, listen, this is a big deal. This is a significant investment in time and effort and emotion. Most, very large majority of patients are very happy with the result, but you have to give me two weeks out of your life. So that's basically how I set the stage. And then of course, I go through the complications fairly in fair depth. Yeah, good. Yeah, I think it is important to get to know the patient, to get an idea of their level of understanding. To me, a lot of patients are basically fearful of looking weird after the surgery. You know, they see celebrities or whatever that have had too much done, and they're frightened by that. And, you know, I always tell them, you know, you never recognize good plastic surgery, you only recognize bad plastic surgery. So, you know, my goal is to make them look rested and refreshed, but not pulled tight, not too different from their basic way that they look, because I think that it does, people wanna look like themselves, they just wanna look better. And, you know, there are those patients that kind of make the hair on the back of your neck stand up because they aren't very realistic. And, you know, as Jim said, I think it's really important to either, you know, if you can't get that patient on the same wavelength as you is to just say, I'm sorry, I'm not the person that can help you because I don't think I have the skills or, you know, the qualifications to get you where you wanna go. And it's better, you know, particularly for a young plastic surgeon, it's better to let those people go by and deal with those patients that you really have a good rapport with and that you think have realistic expectations. And then you can work through, you know, any issues, even if you have complications, you can work through those issues because that's an educated patient. So when a patient comes to you for facial rejuvenation, do you, you know, after your examination, do you give them an idea of what you think the best options are for them? You know, for instance, if a patient comes in and says, I hate my neck, do you mostly focus on their neck or do you say, well, you know, we can, you know, we'll improve your neck, but really you need some other things. You know, I had one former partner who thought everybody needed a brow lift. So I, you know, I think that some people upsell and I don't know how you guys deal with that. I tend to only do, you know, I'm a big believer in if it isn't broken, don't fix it. So if something doesn't bother the patient, I leave it alone. But I will sometimes say, you know, you would get probably a better result from a full facelift or including a blepharoplasty rather than just dealing with your neck. But, you know, it depends on the patient's financial situation and time away from work and, you know, investment in the recuperative process, et cetera. How do you guys decide what to recommend to patients? Jim? Well, I start from head to toe, again, starting the discussion by asking them what bothers them. In your hypothetical patient who comes in and says they just have a problem with the neck, we can address the neck alone. But then of course I say, you know, the neck is a neck and the face is a face. And, you know, most patients who come in say they're just concerned about the neck, but then they, you know, you finish the conversation, they say, well, you're also gonna take care of this too. You know, the jowl area, lower face too. We say, no, the neck is a neck and the face is a face, one. Two, if they come and say they're just gonna want their neck and they have significant facial aging, you know, of course I point out to them, we can't just do the neck because we're gonna create a lateral sweep and we're gonna create folds and things that aren't going to look good. So that's the first thing. First of all, to define exactly what their concern is. And then I will go ahead and point out the other anatomic imperfections for full disclosure. So they just want their lower face done, but they have significant lower lid bags. I say, well, your best result, as you said, your best result would be to do the facelift as we've discussed, but also you have to realize you have lower lid bags and that would improve things. So I don't try to upsell, but I do point out the other problems, the brow position, the problems in the upper and lower lids, et cetera. The one thing, the skeletal problems, I think I do emphasize. So if someone comes in with significant sagittal microgenia and or vertical microgenia, and this is gonna really compromise the operation, then I'm a little bit more emphatic and say, listen, the result is certainly gonna be far superior if we do add a chin implant or a genioplasty to the facelift operation. So there are some specific anatomic deformities that I would hit a little harder and be a little bit more emphatic on including during the surgery. Similarly, they've got deep perioral wrinkles. Listen, those wrinkles, the coarse wrinkles in the cheek are gonna get better, but those wrinkles around the mouth are not. So you really do need to add resurfacing to your operation if you're gonna get improvement in that area. You made a really good point there, Jim, about genioplasty or chin implant. If a patient has microgenia, I would definitely recommend a chin implant. I don't do many osteotomies, but I would definitely recommend it because the result of that is so dramatic and so beneficial that even if the results of the facelift are not great, then they're happy with the chin. You know what I'm saying? It's a really good thing to do if they need it. Now, if they don't need it, of course, you would never suggest it. The other thing is a lot of patients come in and they're concerned about the neck, as you mentioned. Sometimes they say, I'd like a neck lift, thinking that that's somehow gonna be much less expensive than having a facelift or a much lesser operation. I don't do many isolated neck lifts. I would probably do neck and jowl lift or a facelift, basically, and I would tell them that really, what you're asking for is a facelift here. I mean, we're not doing your brow, we're not doing your eyelids, maybe, but we're doing the face. We're doing the jowls, we're doing the neck. I rarely just do a neck lift in isolation, occasionally, but quite rarely. Yeah, Brian, I would just add to that. The anterior-only approach to the neck, which is an operation which I do through a submental incision only with no pre-auricular or post-auricular incision, you should have that in your armamentarium. There are some patients who are not gonna be able to do a facelift or a true neck lift for cost reasons, for time reasons, for age reasons, but they'll either walk out of the office with no operation or you could offer them an operation which is somewhat of a compromise. So again, that anterior approach with no incision in the front of the ear or behind the ear is a good operation for the proper patient. I would expand on that, Jim. That's a very good point, and it's quite valid. I'd expand that, and the elderly gentleman with the kind of webbing of the neck, an anterior direct excisional neck lift, I found to be well-received, very easy to do under local anesthetic, and I've done it on a number of physicians, actually, and it's been a really good thing to do. Males only, I would not do it on a female. Yeah, and I would just add, that's a good point, Brian. I would also add to that, but that is not a bad thing to keep in your back pocket for that patient with massive, who has a facelift with massive weight loss. Those patients with really very, very significant excess skin in the neck will come back with residual or recurrence early on, and you can offer them that, even women, a small operation to correct residual deformity without having to go back and having the problem of doing a facelift and having to charge them room fee, technical fee, et cetera. So that's all something to think about. Yeah, I think the anterior approach, I sort of call it a submentalplasty, is valid in patients with good skin quality, because you do have to depend on the skin to re-drape, and if they have a lot of laxity, then you really have to do the lateral incisions to get that excess skin out. But I agree, and in older men, I think that doing a direct excision of that excess skin, I usually do with a little Z-plasty at the angle just to break that up, works very well and is very gratifying to male patients, because it's an easy fix and doesn't cost a lot of money. Yeah, you have to do a Z-plasty. Again, for the audience, you have to do a Z-plasty, or else you're gonna get a neck contracture and hypertrophic scar. That sets the subicromental angle, but that Z-plasty, you've got to think about that Z-plasty a little bit. It's not a regular 60 degree Z-plasty, otherwise you'd get an oblique line on the neck. You have to do a 45 degree Z-plasty in order to get a transverse central limb on that Z-plasty. Just a small point. Yeah, that's a good point. You design the Z so that that central limb lies in the new cervical mental angle. Great, great. So if a patient comes in and you think that they're a really good candidate, but they're a smoker, they use tobacco, either they're a cigarette smoker or they're a vapor, they chew Nicorette gum, some use of nicotine in their system, how do you counsel them? Do you operate on them with having them sign off that if they have a complication, it's not your fault? Or do you insist that they stop smoking? And what's your timeframe for all of that? Go ahead, Brian. To be quite honest, I've not really had that problem very often, but if I were to have that problem, I would ask them to stop smoking for a month. I'm not sure about doing a cotinine test. I think it takes a couple of days to come back and they can always start smoking immediately after the surgery to get them through the stress of having the surgery. So I would try to build up some trust. I didn't mention earlier, but I would see all facelift patients, at least twice before surgery, first time for a general discussion, and then a second time to get into the details and the consent and photographs and all that kind of stuff. But if I didn't trust the patient, then I'd try not to operate on them. But even if I trusted them and they'd stop smoking, I would be a bit more limited in the extent of my undermining and the extent of the devascularization of tissues and so on, keep my flaps nice and thick and be very, very, very conservative about the facelift and tell them that I was about to do so as well. Yeah, like Brian said, this is becoming a rarer and rarer problem because less and less people smoke. But faced with that situation, again, the re-study from many, many years ago from the early 80s showed a 12 times incidence of skin slough in patients who are active smokers. So this is a real problem. So if you identify someone who is a smoker, the dictum is, as Brian said, one month. That data does not come from facelift surgery. That data comes from free flap breast microsurgery. So taking that data and applying that directly to the face, I think is a big jump. That being said, what I tell the patient is, the longer the hiatus between your cessation of smoking and the operation, the safer the procedure. Nobody can tell you when an active smoker or a former smoker or a former smoker becomes a non-smoker as far as the relative risk is concerned. So the greater the hiatus, the better. That being said, there's also a very interesting study came from University of Maine, which showed that former smokers are very often likely to lie to you. So they tell you they stopped smoking when they really haven't. So that brings in the question of the urine cotinine test just for, and what they did in that study was they did a urine cotinine test early on, and then they repeated urine cotinine the day of surgery, even though that result was not gonna come. And they found that former smokers were much more likely to be less honest than non-smokers. So now getting to the operation, we have the former smoker, we don't know when that former smoker, the risk becomes less, but certainly as I've outlined, but what I would do is just what Brian said, you do a smaller operation, less undermining, or a deep plane facelift, which is gonna give you better blood supply to your skin flaps, and you tell that patient to expect a lesser result. Yeah, I think that's right. I think you need to, for a young plastic surgeon, you need to tailor the operation, not only to the patient's anatomy, but to their comorbidities. And so we've all had a patient who had some sort of healing problem, and they do torture you for weeks on end until it's finally over. And when you're young, you wanna try and get on base every time. You don't wanna strike out. So I think avoiding smokers or assuring that that patient is not smoking by doing a urine cotinine on the morning of surgery and canceling them if they're positive, I think is very prudent because you'll sleep better at night and you won't have all those wringing hands patients, why do I have these wounds that are taking forever to heal up? Because you do learn from those patients, but it's a painful learning process. Oh, and one other point, Deb, stopping smoking, I had a patient like this a number of years ago, came in with a significant, former smoker stopped smoking, came in with a significant post-racial skin slough, couldn't understand it. Well, the son was a lot smarter than I was. He said, dad, didn't you continue to use the patch? So he had stopped smoking three months before, but he was using the patch. Right. And no, I wasn't smart enough to tell him to stop. Yeah, I think it is important to, if they're using a patch or Nicorette gum or some such, it's all still risky. And I think the thing that we need to be aware of now is the popularity of vaping because they don't get that cigarette smell to them. So sometimes when they're in your office, you can't recognize that they're a smoker, but they are getting a lot of nicotine in their system. So I always particularly ask about vaping, whether they're doing that. You know, on the flip side, do you guys have any opinion about patients who use marijuana? You know, here in California, marijuana is legal. And so, you know, we, you smell it on the street all the time. And I think there is a fair percentage of the population that does use marijuana with some regularity. Do you think that that creates any risk for your facelift flaps? Well, I don't know about that. I have to pass on that. I don't, I'm not well-versed in that. I don't know about you, Deb, but I didn't inhale in my youth, you know. You and Bill Clinton. So my knowledge, my knowledge is not great about how it's taken. But I do understand that sometimes they roll it with tobacco and make a spliff out of it and smoke it as a cigarette. So it could be a problem if they're using it with tobacco. I think if they consume it without tobacco, I don't think there's any particular risk with it, but don't call me. Yeah, I think, to me, I think the biggest risk is if they're coughing, you know, because if you're increasing your intra-abdominal pressure coughing and that's raising the blood pressure in your face, I think you're a little more risk for increased bruising, perhaps hematoma formation. So I try to get them to avoid smoking and if they need it to go to edibles just so that they're not coughing. So how do you deal with a diabetic patient? Do you have, do you do anything in particular to try and minimize complications in someone with diabetes? No, I would treat them the same way. I think I would be more concerned with, you know, their comorbidities, associated comorbidities, but if they're merely diabetics and they have no significant comorbidities, vascular disease, et cetera, I would treat them like a normal patient aside from, you know, handling, you know, their diabetes medications. I would get anesthesia to help me with that. Yeah, I do like to make sure that their A1C is below seven. Yeah, that's a good point. Studies have shown that that's important. So I do always test for that. I don't know, Brian, do you do that or do you just- As long as they're well controlled. I mean, obviously I would not clear a diabetic for surgery myself. In fact, most patients I have cleared by their primary care physician or their cardiologist or the endocrinologist or whatever, whoever they're seeing. And I would not clear them myself until they'd been seen by that individual and the diabetes was under control. Having said that, I would tend to be a little conservative rather like in a smoker in doing the surgery. And how about patients that are overweight? Somebody with a BMI, you know, in the high 20s, 30s, how do you counsel them? How do you decide when weight loss prior to surgery is appropriate and request that? Or do you just discuss with them the limitations of their result based on their obesity? Obesity is a huge problem. Whatever surgery you're doing, you know, whether you're doing a free flap or you're doing a facelift, it doesn't matter. The results are not as good. You know, it's really difficult to deal with it. People are obese. Generally their face is gonna be round, moon-shaped and it's like a soccer ball. I mean, it's round. And if you pull the skin tight, it's still gonna be round. It's not gonna change very much. There's no prominences there to pull against and to define. And I generally try to avoid operating on obese patients in terms of facelifts. I try to, maybe they may need a submental lipectomy or something like that, but I try to avoid it, generally speaking. I've not been happy with the results. Yeah, aside from, you know, doing a hemoglobin A1C as you suggested, Deb, and aside from other comorbidities, you know, I think it really depends on the architecture of the face. You know, that patient that Brian described obviously is not gonna get a very good result. Now, another subpopulation that we're dealing with more often now, I think, is that patient who has undergone, who was formerly obese, has had either taken medication or has had gastric bypass type surgery, weight loss surgery, and presents with massive weight loss and significant skin excess and facial aging well beyond their age. Those patients are also technically very difficult. It's very interesting, recently looked at this. And if you look at a number of papers published on body contouring after massive weight loss, there are almost a thousand in the plastic surgery literature. The number of papers on facelift after massive weight loss, there are about four. And one of the reasons that there's so few is, of course, numbers, unless people are, you know, the facelift is the last operation done generally after body contouring after massive weight loss. But also the results are so less than ideal. So patient, I think doctors, plastic surgeons are averse to showing results which are less than ideal. So again, those are difficult patients. Those are patients who are going to have some relapse after surgery that you're going to have to deal with one way or another. So again, results are compromised. For those interested, one of those four papers was written by Jim Zins here, and it's an excellent paper on that subject. One of the issues is being able to, you know, again, set that expectation. So if you see someone who has that really lax skin, either severe sun damage or massive weight loss, educating them preoperatively that there will be some relapse, they may need to touch up, figuring out, you know, what's going to be the financial aspect of that and what's going to be the timeframe of that to do it. Yeah, Tom Musto, a number of years ago, wrote a paper on the two-stage, basically the two-stage facelift to deal exactly with that problem, realizing that that patient is going to need a touch up in the early, you know, earlier than, sooner rather than later. But, you know, again, that's touchy because, you know, again, you don't want to scare that patient off yet. You do want to set the expectation. So that's a little bit of a fine line to walk, I think. Also, it seems redundant, but I should say this, that you're not going to get away with any kind of limited incision on a person with a massive weight loss. In my experience, the incisions almost meet at the back of the neck. You know, you have to get rid of the dog ears. You've got to get out a huge amount of skin and you just cannot do it through a limited incision. Yeah, and, you know, again, just amplifying that facelift alone is generally not going to be adequate. You're going to need to add ancillary procedures. You need to do fat grafting. Although in my experience, the fat in these patients is not very helpful. There are older patients and they don't do very well with fat grafting, but you also can do such things as submalar implants, et cetera, but you need to do more than just a phase often. So in terms of your actual surgical technique, how do you feel, how do you deal with, you know, the periorricular space? Do you do a pre-tragal, post-tragal incision? How do you deal with the hairline? Do you do a hair-sparing incision or an incision within the hair? Jim? I think you are going to tailor that individually to each patient. In that patient with heavy skin, heavy periorricular skin, but a well-defined tragus, I will make a pre-tragal incision because I won't be able to recreate that very fine tragus that heavy skin into the periorricular area. So pre-tragal or post-tragal depends on the skin quality, skin thickness, et cetera. With regard to the post-auricular incision, I basically never do a short scar facelift. I think a short scar facelift biomechanically is poorly designed. You tend to need to pull the skin in a vertical direction and you will create dog ears if there's any significant skin excess in the neck. And I've had to revise other plastic surgeons' facelift results because of that. So I always make a post-auricular incision. You're really trading a post-auricular incision for a pre-temporal incision when you do a short scar. So a short scar is not in my armamentarium. Regarding the rest of the post-auricular incision, I will follow the posterior hairline in a patient with significant skin excess in the neck because otherwise I'm gonna create a step off. In that patient, again, anatomic variance, in that patient with a short distance between the post-auricular sulcus and a posterior hairline, those patients I will take the incision into the posterior hairline. So I'll design the incisions depending on the anatomy of the patient, the peculiarities of the patient. I spent most of my life doing retro-tracheal incision. I now do pre-tracheal incisions 90% of the time. The only time I would do a retro-tracheal incision is when the patient's already had a facelift and there's already a scar there. Then I would just redo it. Because you get some good results from going retro-tracheal but there's a hell of a lot of bad results out there. And it's really a dead giveaway for somebody who's had a facelift. So I find that the pre-tracheal incision seems to heal extremely well in most people. And I go with that. In terms of the temporal hairline, I go in front of the temporal hairline. I don't go into the temporal hair because I don't like the retrusion of the hairline which can occur usually after a couple of facelifts, it has to be said. But when you get that hairline moving backwards because you've resected scalp, it's not a good look. So I go in front of the hairline, cutting obliquely through the hair follicles so that they will regrow through the scar, of course. And then- Yeah, go ahead. I do something just a little bit different which I think is helpful. Rather than going at the anterior hairline which again can be a telltale sign of the facelift. Not always, but you can get it. And once you get that scar, it's impossible to deal with. So I actually go several millimeters, maybe five millimeters posterior to the anterior hairline so the scar lies within the temporal hairline, but I don't lengthen the distance between the lateral brow and the temporal hairline. Now, the problem with that is that you then are not taking out, you're not getting any correction in the temporal region. So you have to add, if you're going to do that and the patient has significant temporal laxity hooding, you've got to add a lateral brow to that operation. So I think that's a helpful point. Yeah, I think the important thing, I do do a retrotragal incision, but I think it's really critical to not have any tension on that incision. So that, so I, you know, I fix the preauricular and the postauricular incision first and then set the lobule, make sure there's no tension on the lobule and then just lay the skin over the preauricular area and mark it with no tension at all. Because I think if you've got tension on that repair, it's going to pull that scar forward, it's going to pull the whole cartilage forward and it's going to be a telltale sign that, that of a bad facelift. So I think being really attentive to having minimal tension on your skin, letting your, you know, whatever you're doing with the SMAS, do the heavy lifting and then just re-draping the skin so that there's no tension. Reduces your risk of, you know, having weird healing lines, weird contours and also reduces your risk of healing difficulties, minimizing that tension on the skin. Yeah, that's a very good point. So at the end of the operation, when you resect that skin, the skin edges should be kissing. There should be absolutely no tension. You know, Joel Feldman a number of years ago would say, you basically have to take no skin out of the neck at all. Now, I think he recanted that later in his career, but basically just releasing the skin from the platysma, letting your platysma, your platysmaplasty and your SMAS do the work and having those skin edges. So the skin is not the vehicle to get the correction as Deb says so nicely. You made a good point, Jim, there about that. People don't realize this, but you're actually one of the few people that made the point that in the post-auricular area, that area of skin there can be very narrow if there's an anterior displaced hairline. And you can have a very narrow flap going up there, which can necrose and you get delayed healing behind the ear. And what you do, what you suggest, it was a very good idea, you go into the hair post-auricular to make it wider. Another way of making it wider, which you can add to that, is going up on the back of the concha a little bit as you come around the ear, go up on the back of the concha, not just in the sulcus, but up on the concha a little bit and then across so that you have a really wide postauricular flap, which has got a really good blood supply. You know, and then a final point about that postauricular flap, keep that postauricular flap thick as possible. It can even be a fasciocutaneous flap because that great auricular nerve is coming right up to the center of the lobule. So you have a lot of room between your postauricular flap and that great auricular nerve. So keep that flap as thick as you can. This idea that thick flaps are parasitic, you know, that got some laboratory evidence, but that doesn't work in facelifts. Facelifts need, you know, thicker flaps or healthier flaps. Yeah, I think that's an important point is to make sure that that postauricular, you know, the sulcus incision stays hidden. So coming up onto the concha, I always like to anchor that to the perichondrium to prevent that incision from sliding southward and being seen behind the ear once the patient heals. I think that's a bad stigmata of facelifting as well. So as far as trying to prevent hematoma formation, hematoma formation, what are you all doing? Are you using TXA? Are you using progressive tension sutures? Are you using a hemostatic net? How do you all work on preventing hematoma? Go ahead, Brian. I must say that TXA, transezymic acid, has revolutionized facelifting for me. I put this into the infusion and into the local injection that I give, and I can tell you the formula later, but it really seems to make a huge difference, you know, injecting that stuff in there. And it's totally benign as far as I know, and it really does reduce the amount of bleeding. So I would say that's one of the most important. And the other thing I would say, I do quite a lot of facelifts just under local anesthetic with oral sedation. And this is not a weekend lift or some minor facelift. I do the full thing under local in probably 80% of cases, not all cases, some people will not go for it, but that way the blood pressure stays pretty even. You don't have all these ups and downs where you have the King Kong awakening following a general anesthetic, and you're trying to get the patient off the chandelier. I mean, they stayed calm and collected. They get off the table, you put the bandage on their head with them sitting in a stool or a chair. I mean, it's just so much easier if they'll go for having a local anesthetic. Yeah, so hematoma has become, I think in modern face of surgery, becoming less and less of a problem. The incidence of hematoma in the literature, when they quote double digit figures, that's old data. I would say the average incidence of hematoma now really is in the low single digits. My hematoma rate is probably about 1%. I haven't had hematoma in several years. And the reason is because we've gotten very good at preventing them. So here's my take on it. One, I agree entirely with Brian regarding TXA. I put TXA in my local anesthetic, injected my local anesthetics, two milligrams of T, two cc's of TXA and a hundred cc's of a half percent xylocaine with epi. Now it doesn't really help me in my dissection. I don't really see a lot of change in the bleeding in my dissection. But when I go to close, it is remarkably dry. It is unbelievably dry. So it has saved me tremendous. It has changed my life as it's changed Brian's. It saves me, I would spend 15, 20 minutes drying up each side of the facelift and now I spend two to three minutes. So there's, so it definitely reduces intraoperative, intraoperative time. The data doesn't, we don't have data that really shows that it reduces hematoma but it certainly does reduce intraoperative time. I think it reduces swelling and it reduces drain out, but it does do those things. That's well-documented in the literature. So that's number one. Number two, practice the second look technique. So what I do is I do the first side of the facelift, the SMEAS first side, left side. Then I do the right side. Then I do the submental incision and do my submental work. And then, and only then, after I've done all of that, do I come back to close. So there's been a maximum amount of time between injection local with epi and closure so that I'm reducing the likelihood of epinephrine rebound because epinephrine rebound, in my experience, has been the most common reason, most common reason for hematoma. Then finally, the other thing is raise the blood pressure to normal or supernormal levels at the time of closure. That also I think is very important in reducing the incidence of hematoma. And then finally, again, the literature clearly shows this, postoperative hypertension is associated with increased incidence of hematoma complications. So you have to keep that blood pressure. Now, the number used to be below 140. There's gonna be an article coming out from Fouad Nahai, an ASJ, showing that when the pressure is kept below 120, that's even more effective. So really, the lower the blood pressure post-op, the better. Clonidine, clonidine's also been suggested for many years, initially described by Dan Baker, preoperatively to reduce blood pressure and prevent hematoma in males. Clonidine, I've found, makes it very difficult for the anesthesiologist to manage the pressure in surgery. So actually, I don't use clonidine anymore. So again, second look procedure, TXA. Oh, and then finally, the hemostatic net. So the hemostatic net, I've been using recently. I haven't used it for years. TXA, I've used for over five years, and we have a huge experience. The hemostatic net, I'm a believer in the hemostatic net. I use the hemostatic net on all patients now. And again, Arsvold's shown that this reduces hematoma. It also reduces edema, and it helps re-drape the skin. So again, this is something that I think everybody should be looking at. So when you do your hemostatic, are you doing it in the way that Arsvold does, or are you doing individual sutures? And how long do you leave those in? And how do you prepare the patient for those? Okay, no, that's good. I think that's an important question. Well, the first thing is, you can sort of tiptoe into the water here. If you want, you can do what was suggested in a recent ASJ article, and that is just start with three sutures. One suture at the cervical mental angle, one suture at the gonial angle, another suture below the gonial angle on the other side. Start with a mini, that mini. Now that doesn't help you re-drape the skin. So that's how you can get started, making sure you're okay with it. Then start using it just in the neck, because that's really where most of the hematomas, in my experience, occur. They occur in the neck. And it's a running suture. Arsvold's using a 6-0 on a huge needle. I use actually a 4-0 nylon running suture with multiple rows in the neck. And you know what? I just tell the patient, you're gonna have some sutures that I'm gonna take out at 48 hours. I always take them out at 48 hours. I don't see in any longer than 48 hours. I haven't had any patients with hypopigmentation or hyperpigmentation, but that has been reported. So again, the way to get started, easy to start. Start using it just in the neck, and just tell, hey, you're gonna have some sutures in there. I'm gonna take them out in 48 hours. So I take them out then. Then the next question is, do you use drains or do you not? You can start by using a drain, and then when you're comfortable, get rid of the drain. So you get rid of the drain, that's a big plus for the patient. Yeah, I think also the use of TXA, I mean, I put drains in everybody, but the amount of drainage, as you mentioned, is far less. Patients will come back the following day to have their drains removed, and there's like maybe a teaspoon in their drain overnight. So it really has reduced the amount of drainage. And I feel like it reduces the kind of inflammation. Patients look normal faster, I think, when I use TXA, and that's been a big help. But I like your idea of using the net to kind of re-drape the skin, similar to how we do progressive tension in a tummy tuck. It does allow you to position things and to take the tension off the incision line and place it throughout the dissection so that you're re-draping, reducing tension, reducing inflammation, reducing dead space. All of that's gonna be helpful for your result. Yeah, that's the exact point. It's exactly the same principle as progressive tension sutures. Right. If you leave drains in for a long time though, particularly suction drains, and then you take them out, they can leave a ridge which can take months and months to go away. Yes, that's true. Yeah, that's what I'm gonna get about. A lot of reason I use Penrose and I use a kind of a bulky, slightly pressure dressing. But I suppose if you take them out at 24 hours, then you don't get that. Is that fair to say? Yes. So there's been a push of late for opening the neck and being more aggressive in the neck. People are taking out submandibular glands, digastric muscles, subplatysmal fat. How do you deal with the neck in those situations? Are those maneuvers that you think are important to have in your armamentarium? How aggressive are you in the submental space? I mean, take it. Well, I always open the neck. So I always use a submental incision. Again, my patient population is probably average to 60 years old. I do lots of 60 year olds, 70 year olds, and some 80 year olds. They all have bad necks. So I always open the neck. And I almost always do a through and through the section from the lateral approach and then join that subcutaneous section and then join that subcutaneous section through the submental incision. Then I open the platysma. Fat necks always have significant subplatysmal fat. So if you've got a fat neck, I think you really are obligated to open the neck and open the platysma. And then you remove subplatysmal fat, flush with the digastrics, not to over-resect it in that interdigastric triangle. And then if the digastric muscle, anterior belly is bulging, I shave it and selectively remove the gland only after a significant discussion with the patient. Most patients in my practice decline removing the gland, but the gland, if it's not removed, can be a problem post-operatively. You have to point it out. And the only way I know to improve that problem is by partial gland removal. Nothing else works. Yeah, I take a slightly different view. It's interesting. I rarely open the neck, but you have to, as you say, open it. If somebody has a fatty neck and you have to remove fat, then I would open the neck and do exactly as you described. I've not done the glands. I just feel that that's perhaps a little bit aggressive for the patients that I have, and I don't think they would agree to it. But as I say, only about 20%. I have a different patient population. I don't have many obese patients coming to see me. Yeah, I do like to open the neck because I think that from a lateral dissection, you can't really get that cleaned up enough. In my hands, I need to directly visualize it and bring those platysmal edges back together. I think that's the only way you can get rid of the central platysmal bands is by dividing it transversely centrally. I don't take out the submandibular gland basically because I think the literature shows a high hematoma rate. Even I think Brian Mendelsohn has a lot of experience, and he had like a, I don't know, it was a 10% hematoma rate from his gland resection. But one thing I've found to be helpful, I always point it out to the patient if they have a prominent gland beforehand, and then postoperatively, I've injected them with Botox because that'll shrink that gland up, and that's been helpful in some patients to reduce the volume of the gland and reduce the perception of the bulk of the gland doing a little Botox. And if it's a patient that comes in for Botox for their glabellar lines, and you can inject their gland as well, that's an easy just overtime fix that is very acceptable to the patient. Is it permanent? Joel Feldman a while ago when I was practicing, and again, a great facelift surgeon said he heard a lot of people talk about injecting the gland, he never saw a before and after photograph of it. It'd be interesting to look at consecutive patients with Botox into the gland and see if we could document, if we really could document improvement. Deb, what dose would you inject into each gland, and how long would the effect last? Usually I'll put in between five and 10 units in each gland, and it'll last for six months. You can't either? You can't. Yeah, not too bad. So how do you feel about fat grafting? Is fat grafting now a routine part of your facial rejuvenation or only in selected patients? Go ahead, Brian. I rarely do it. I do it occasionally when somebody has a great deal of tissue loss from the zygomatic areas, particularly of very bad nasolabial folds. Those are the areas that I would do some fat grafting. The way I do a facelift seems to push the tissues up into the zygomatic areas, so it's not routinely necessary. In selected cases, yeah, I would do it. Yeah, of course. So I fat graft almost everybody unless they specifically don't want it. I always tell them if I'm taking fat out of their neck, I might as well use it elsewhere in their face. But I think, again, it's usually thinner patients with some deflation, and I think adding some volume back. I'm not as aggressive with volume as some of our colleagues are. I usually am limited to eight to 15 cc's total, not putting in a huge amount of volume, but I think adding fat back into the nasolabial folds, into the cheek sometimes. Earlobes, I think, are a nice place to fat graft because that's very, a telltale sign. They got a nice, smooth face, and then they got wrinkly earlobes. So I think adding some fat to the earlobes at the time of the facelift is a nice fix. Also, you know, eight to 10 cc's of fat is actually quite a lot of fat because you think of a unit of voluma for $1,000 or whatever it is, that makes quite a big difference to a cheekbone if you inject that. So if you're injecting eight to 10 units around the face, that's quite significant. Yeah, well, you assume you're gonna be losing, you know, a quarter to half of it anyway. So I think that we've talked about a lot of things, but I think this is probably as much as our audience will be able to handle. And I appreciate your videos. I think they're very educational, and I think our audience is gonna appreciate looking over your videos and appreciate this round table discussion. And hopefully, if things go well, we might be back again for 3.0 in the future. You never know. All right. For this wonderful discussion. Bye-bye.

facelift techniques

facial rejuvenation

plastic surgery

patient assessment

surgical options

hematoma prevention

tranexamic acid

fat grafting

neck management

muscle adjustment

patient demographics

pre-surgical consults

lifestyle factors

companion procedures

modern facelift surgery