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Composit approach tackles facelift flaws


Dr. Hamra
Colorado Springs, Colo. — We've all seen celebrities — and countless everyday patients — who suffer from "the facelifted look." Its telltale signs include swept-back cheeks whose tension is aesthetically at odds with other areas, such as those around the eyes, which project a hollowed-out look often caused by overzealous fat removal.

According to Sam T. Hamra, M.D., F.A.C.S., such problems are not the fault of surgeons, but of the traditional techniques they have used. He is assistant clinical professor of plastic surgery, University of Texas Southwestern Medical Center.

"After a conventional facelift is done," he says, "people may look good for six months or a year. But then the jawline stays rather tight, and the cheek area starts coming down. Then you'll have the 'swept' look, called the lateral sweep.

The way to correct that is to take the whole face apart — "you undermine and totally redo the complete facelift," he says.

Called the composite facelift approach, Dr. Hamra's method includes moving tissues in a superior medial direction on the cheek rather than the singular lateral direction traditionally used in subcutaneous lifts, SMAS lifts, and malar fat techniques. The composite facelift achieves a lift that is multidirectional and oblique — toward the eye and ear rather than the ear alone. Such movement of the cheek, Dr. Hamra says, returns the aging eyelid muscle and cheek fat to their original positions and prevents pulling toward the ear.

He employs a homespun analogy to describe his approach to patients:

"If a woman who wears size six inherits her mother's dress and it's a size 12, you don't just alter it. You have to take it apart and make a new dress out of the same fabric. It's the same thing on a secondary facelift. You take everything apart — the neck, the cheek, the lower eyes, and the forehead. And then you redo it in the correct direction," Dr. Hamra says.

As for guidelines, he says, "once you undermine everything, then you simply have to reattach it with the correct amount of tension."

Experience helps guide Determining the amount of tension is largely a matter of experience.

"You don't measure in the same tension as you would with a skin lift," Dr. Hamra says. "You must apply enough tension to reposition the muscles and fat of the cheek in the correct direction — toward the eye rather than the ear."

In addition, he says that on any secondary facelift, "the neck usually has to be redone because you want a complete facial rejuvenation when you're finished. That's done by analyzing what's going on and then trying to achieve a much improved neck contour."

Likewise, physicians must keep in mind that frequently, facelifted patients' earlobes have been pulled down.

"The scars that are frequently in front of the tragus, which may be acceptable or not, are going to be better if they're inside the tragus." he says.

"The vast majority of women who've had a facelift and eyelid procedure have not had a forehead lift, which must be done so every composite facelift will ensure the harmony that must exist after surgery by making the forehead, cheeks, jawline, and neck all harmoniously changed," Dr. Hamra adds.

High foreheads In the forehead area, 40 percent of patients' foreheads are too high to permit a coronal lift.

With such patients, he says, "you want to lower their hairline and make their forehead more narrow. So in these women you put the incision right at the hairline, then narrow it down anywhere from three-eighths of an inch to one inch."


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