The Importance of Subtle Results in Facelift Surgery

March 14th, 2019 | Categories: Facelift

Thanksgiving has come and gone, which means it’s been nearly four months since our beloved permanent makeup artist, Debbie Miller, had her facelift revision surgery. My experience with Debbie’s facial rejuvenation has been really easy and pleasantly challenging all at once. On one hand, D.M. exudes natural beauty and amazing bone structure. A starting point like Debbie’s can make any plastic surgeon look like a magician. But there were unexpected challenges as well. A history of prior surgery added an important variable and challenges, as did a career that demands persistent downward gaze, as did her lifelong sun exposure and fair European skin.

All this amounted to an elaborate and carefully crafted surgical plan, somewhat prolonged recovery, and the need for adjunctive treatments like laser peel, stem cell grafting, habit changes, and correction of a previous surgeon’s work. The result? Even though we are not even close to the finish line, nobody can “tell” that she’s had work done, yet she just looks more refreshed, refined, and balanced. That’s the art of plastic surgery: it sometimes takes a lot more work to generate a subtler result. Anyone can ‘pull things tight’, but a real artist must work hard to reverse age-associated changes and revise imperfect surgical results in a way that appears very natural. I love when people tell Debbie that “she looks amazing!” “Did she do something to her hair?” “Something looks different, but I can’t put my finger on it…”

I’d like to start from the top and describe the steps taken to achieve her perfectly subtle change. The pictures are very premature (2 months out), but you can already see the changes.


Before, there was an eyebrow asymmetry, with the left brow appearing higher than the right. The peak of the brows was at or just slightly above the orbital rim, and made the eyes look deep-set and tired. With a skin-only browlift and scars hidden in the hairline, I was able to balance the brow position and raise the eyebrows to a more attractive and youthful position. Fat grating to the temples effaced some of the hollowing that occurs naturally with facial aging and weight loss.


Before, there were dark shadows and asymmetric creases under the eyelids, and the outside corners of the eyes were rounded. A gentle combination of fat transfer to the lower lids, nasolabial folds, and cheeks and surgical tightening of the outer corner of the eyelids (canthopexy) contributes to an important softening of these cosmetically significant features. Botox injection to the crow’s feet and lower outer eyelids enhanced the result even further. CO2 resurfacing further improved skin tone evenness, pore size, fine lines, and tightness.


A telltale sign of a facelift is the “pixie ear” deformity, when visible scarring and tethering of the earlobe attracts the eye to an abnormal appearing structure. During facelift revision, I take the time to re-create the normal anatomic relationship between the ear and the skin, hiding a well-concealed scar in a naturally occurring shadow and taking all tension off the earlobe. The scar on the left is ten years old, and on the right is 10 weeks old- and it already looks better. With time, I expect this scar to fade away almost completely.


The secret to a beautiful facelift is the necklift. The secret to a great necklift is a linear shadow between the earlobe and chin, and elimination of visible vertical bands on the frontal view. The after photo is a bit premature, as swelling in the neck can take as long as 6 months to resolve, and this is only 2 months later. Also, many of the fine lines of the lower neck and chest are pulled vertically, and these also take time to disappear. Multiple CO2 sessions may be necessary to eliminate these lines entire, but the overall shape of the neck is already perceptibly longer and more sensuous. There are no longer visible platysmal bands, and a combination of liposuction of the jowls and fat transfer to the pre-jowl sulcus (marionette lines) makes the entire lower 1/3 of the face more continuous and youthful. CO2 also helps with this as does the midface lift that was performed.


While I am a bit uneasy sharing early postoperative results, there is no question in my mind that Debbie’s story and early results demonstrate an important principle: it is possible to have a facelift and enjoy the results without “looking done”. I take special care to create nearly invisible scars placed in strategic positions. I take no shortcuts to help you achieve the results you desire and while it may take 6-12 months for you to be “before-and-after ready”, there’s no doubt you’ll be presentable in 3-4 months. As I’ve mentioned in a previous blog, it’s so important to address the face as a whole. In isolation, browlifts, midfacelifts, and necklifts can be underwhelming. When all of the above are addressed in concert the results can be magical.

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