Ancillary procedures make all the difference in facial rejuvenation

When patients say, "I want a facelift," they usually mean, "I want to look younger and more refreshed." Southern California cosmetic surgeon Ronald Strahan, M.D., relies increasingly less on facelifts alone to address that request and instead grants his patients' wish for rejuvenation with a combination of procedures.

"Most women who come in want a neck that looks tight and feels tight, so I perform an aggressive neck operation, and then the position of the brow dictates if I do a small incision forehead lift. Then I evaluate the midface," says Dr. Strahan, who started his career as a board-certified otolaryngologist.

When evaluating a patient for rejuvenation of the aging face, he examines all of the characteristics and layers of the face. The goal, he says, is to create facial harmony for an age-appropriate appearance. As a result, he relies more on the ancillary procedures of blepharoplasty, rhinoplasty, skin resurfacing and soft tissue expansion (STE) and less on aggressive techniques of facelifting to produce that result.

"I usually ask the patient for a picture of when they were about 30 or 35 years old, which is the age of optimal physical appearance, and this gives me a clear idea of their ideal version of themselves," Dr. Strahan says.

MIDFACE FINDINGS Today, Dr. Strahan rarely performs a facelift operation alone because of findings from his recent study that suggest patients have a much higher degree of satisfaction with the treatment of the aging face when some additional change to the midface is provided.

In a retrospective study conducted by Dr. Strahan and his colleague, Catherine J. Hwang, M.D., the charts of 430 of his facelift patients who had at least 10 years' follow-up were reviewed to compare the results of patients having SMAS techniques with the results of patients having deep-plane techniques.

As he expected, forehead and necklift patient satisfaction was well over 90 percent; however, the long-term satisfaction rate with the facelift part of treatment of the aging face was disappointing.

The revision rate two years postoperatively was 13 percent for the SMAS technique group and 8 percent for the deep-plane technique group. At 10 years after surgery, the patient satisfaction rate for both groups had plummeted to 50 percent. Of those who were dissatisfied, 80 percent were unhappy specifically with the midface outcome.

"This shows that the forehead lift is a good operation and the necklift is a good operation, and no matter what technique is employed in the midface, it's really a mediocre operation," Dr. Strahan says.

All of the patients evaluated also had ancillary procedures. Most had either blepharoplasty or rhinoplasty or soft tissue expansion (STE) — either hard implants, fat transfer or nonautologous injectable fillers, or skin rejuvenation or a combination of those procedures.

"Fortunately, I had enough data to go back and cross-reference these cases to see if the ancillary procedures affected the patient's perception of their overall experience," Dr. Strahan says.