Revision surgery and dissatisfaction are like peanut butter and jelly. While they certainly exist independently, one is often associated with the other. Rhytidectomy is unique among revision procedures because it's not always coupled with a problem or dissatisfaction. The aging process prompts a particular contingent of facelift patients to present years after their primary surgery requesting more of the same.
"These patients feel they have enjoyed a worthwhile benefit from their original investment, but find that aging has again caught up with them and they would now like to enjoy a similar — or enhanced — benefit again," says Washington, cosmetic and plastic surgeon J. William Little, M.D.
Of course, there are other rhytidectomy patients, as well. Another contingent of facelift revision candidates presents much earlier — typically within a year or two of their original procedure. Comprising three groups, these patients are fundamentally unhappy.The first (and largest) group represents patients who are disappointed with the final rejuvenation result and feel that they still show areas of aging that they had assumed would be eliminated, Dr. Little says. The second group, considerably smaller than the first, is typically angry instead of disappointed, and while these patients may also harbor markers of continued aging, theirs is no longer a look of natural aging. "They appear unnatural, or 'surgical,'" Dr. Little says.
Finally, the third (and smallest) group shows clear evidence of a surgical complication. This can include visible scarring of the face, distortion of an eyelid or interference with the normal movement of the face.
PICKING PLANES While he has performed facelifting in all three planes of the face, Dr. Little says he now prefers to work mainly in the superficial, subcutaneous plane.
"I find this method the most powerful for controlling the architecture or shape of the final outcome," he says. "This is true for both the primary and the secondary facelift, where shape-based results are equally important.
"My basic facelift frees the skin widely from the entire face, up to the corner of the mouth, such that the underlying soft tissues may then be re-elevated in a strict vertical direction and reshaped without restraint," he says. This is accomplished by fine, rapidly absorbable 5-0 vicryl sutures without the traditional tension associated with facelifts.
"The results are long-lasting precisely because tension is avoided. The skin is then re-draped and tailored in a predominantly vertical direction over the re-sculpted soft-tissue base, again without tension," Dr. Little says.
In cases where the patient is displeased with the outcome, Dr. Little says the re-operative surgeon should have extensive experience and confidence in correcting the concerns of the unhappy patient. "It must be understood that the patient's tolerance for further disappointment is now essentially depleted," he says.
EXPERIENCE COUNTS When extensive experience in facelift revision surgery is sought, Neil Gordon, M.D., is often considered the "go-to" guy. He is a clinical assistant professor of surgery at Yale University School of Medicine, New Haven, Conn., and the director of head and neck aesthetic surgery and coordinator of education in facial plastic and reconstructive surgery in the section of otolaryngology, department of surgery. He has been referred to by an iconic fashion and beauty magazine as the surgeon to seek for those who are "over-pulled or underwhelmed."
Dr. Gordon's practice is dedicated strictly to facial surgery, and 35 percent of the procedures he performs are revisions. He stresses the importance of avoiding skin tension at all costs in rhytidectomy.
"In people who have had facelifts, in most situations, the skin has already been tightened, so the technique that is essential in revisions has to be one that can mobilize or move droopy soft tissue back into place without using the skin as the mechanism of the lifting," he says. "These people have had their skin tightened once, and if they were overdone, they have had their skin tightened too much, so anything that would tighten their skin further would worsen the problem."