Today, we’re gonna be talking about facelift versus neck lift with fat transfer of the cheeks. The area, the place where we need to start when we talk about this is we need to talk about the aging face. You know, why does anybody need a facelift? Why does anybody need a neck lift? Well, as we age, we lose collagen and we lose volume in the face. The collagen is a supporting tissue of the face. So, as the collagen weakens, we end up getting descended fat pads. The chief fat pad that descends is called the malar fat pad that’s on the cheek.
So, as we age, our cheeks kind of drop down, you know. So, when the cheek drops down, now the skin of the nasolabial fold gets loose. Now, the jawline gets loose. And that’s all due to the descent of the malar fat pad. You know, also when we lose collagen, the texture of the skin also gets worse. Now, the other thing is the compartments of the face, the volume of the face, the fat compartments in the face, those compartments shrink also as we age. So, as we’re young, we have a round, youthful face, short eyelids. And as we age, we get a flatter face and longer lid to cheek because the cheek is falling down.
So, those are the things we’re kind of dealing with when we talk about the aging face. The same thing happens to the neck. The connective tissue gets loose, and instead of having a nice sharp angle of the neck, we start to get more of a slope, and then extra volume and things in the neck. So, these are the things we’re trying to deal with when we’re thinking about a facelift or a neck lift. Now, essentially, you know, the strength is in the connective tissue. There’s no strength in the skin. You know, skin is an elastic, stretchable object so we could move, so we can have a child. You know, if skin was tight, you know, the stomach wouldn’t stretch and things, you know, for a baby. We wouldn’t be able to move and be so flexible. So, the skin has to be flexible, but the deep tissues, the connective tissues on the layer of fascia above the muscle is really the area of strength. We can call this the SMAS in the face, and we call it the platysmal fascia in the neck, which is really one continuous plane and things like that.
So, when we do a neck lift or a facelift, we wanna suspend the strong supporting tissues, which is the fascia layer, and not really relying on skin to do a facelift. If you rely on skin to do a facelift or a neck lift, it will not last because skin will stretch. If you pull the skin too tight, you get all the funny wrinkles and lines in the face that then give away that you’ve had surgery. What we’re trying to do is use those deep tissues, make a supporting foundation, and then just take away the extra skin and let the skin lay on the face naturally so then we get a natural look. We get better scars. We don’t get this fake, pulled, overdrawn facelift kind of look. So, that’s the idea, you know, of what we’re dealing with when we’re thinking about, you know, a facelift or a neck lift.
Now, essentially, a facelift, you know, is a neck lift and a facelift together. A neck lift is just half of the facelift. So, the neck lift, we’re just dealing with everything from the chin down. And so, it’s half of the facelift so you have half of the amount of scar. The facelift, we’re dealing with, you know, everything from really the side of the eyes, almost up to the top of the eyes, the rim, down through the face and through the neck.
Now, with the facelift, we’re gonna make a scar some place into the hairline or in front of the hairline, come to the ear, around the back of the ear, and then back into the hairline behind the ear. With the neck lift, we’re just gonna make an incision really from the ear, from the earlobe, back behind the ear, and into the hairline. So, the neck lift scar is really the scar behind the ear. The facelift scar is the scar in front of the ear and behind the ear. So, those are the different things of the scar.
Now, because of, you know, what we’re dealing with, the neck lift, the only thing we can improve is really below the angle of the jaw so we can improve the neck below it, but we don’t really improve the jaw and we certainly don’t improve the face. With the facelift, we’re gonna raise the cheek back up. We’re going to improve the jawline and improve the nasolabial fold and improve the neck. So, those are the differences between.
Now, with a facelift, we’re making that incision again in front of the ear, around the ear, behind the ear, lifting the skin away from the supporting fascia and things below. And once we lift that skin away, what we’re gonna do is we’re gonna use sutures to take that distended fat pad and pull it back up to the cheek where it’s supposed to be. So, that enhances the cheek and enhances more of a round face instead of a flat aged face. So, that’s what we’re doing there.
When we pull the cheek up, we pull the jawline. When we pull the cheek up, the nasolabial fold is pulled up, and that improves. Now, for the neck, what we’re doing is we’re taking some of the fascia, that fascial supporting system in the neck, and then placating it up this way, so now we’re tightening the neck that way. So, that’s what we’re doing for the neck lift. So, the facelift is really twice the operation of the neck lift.
So, I want you to get the idea of what’s doing what. And again, the key thing is that a natural facelift to support the lift is really the fascia below the skin, not the skin. We can do little skin facelifts, but the skin will look too stretched and it will never last. What will last is the deep tissues. So, that’s the idea. I mean, this is similar to a breast lift. If you just tighten the skin on a breast lift, it will not last. If you take the deep tissues, if you use the sutures to support the breast tissue against the chest wall and tie that to the muscle fascia, that will be a lift that will last year after year.
So, it’s the same idea. Skin has no strength, will not last. The supporting tissue has strength and will last. Now, the fat transfer, the idea of that is to build up the cheek. So, with a facelift, we’re actually taking the real fat pad and moving it back up. With the fat transfer of cheek, we’re just kind of cheating and adding to that area to give the appearance of the real fat pad. So, we’re adding volume that we take fat from someplace else, the stomach or the leg, and adding volume to the cheek to give the same effect, but we’re not actually moving the proper tissue.
So, when we add, when we do fat transfer of the cheek, we do improve the cheek, but we don’t improve the nasolabial fold unless you put fat in the nasolabial fold. We don’t improve the jawline unless you put fat in the jawline and hide these things. So, the fat transfer is more hiding the changes of aging. The facelift is trying to correct the changes of aging.
Now, you can do a facelift and a fat transfer together and then get the effects of both, but that’s kind of the idea of the one, you know, versus the other. So, this is kind of the…I’m trying to give you the idea of what’s being done. Now, so far as the recovery, the recovery between the two surgeries is very similar. Facelifts or neck lifts are not generally very painful procedures. They’re procedures that are more swelling and throbbing than knife pain.
Initially, in the first 48 hours, just swollen like a balloon and you can’t get out and do anything. Usually, people are in the house for a week or 10 days after a facelift or a neck lift before the swelling goes down and things look reasonable, still swollen but reasonable. It really takes two or three months for all the swelling, you know, down to see the perfect result from the facelift.
If you’re off of work, you know, a minimum of a week, maybe 10 days off of work would be better, maybe 14, but a week would probably be the minimum off that you need from work and things like that. You can’t exercise and jump around after the facelift because you get bleeding and things into the facelift, stretch the scars, scars open or something like that. So, you have to take it easy for maybe two to three weeks before you’re back out doing things and things like that. But the facelift generally is not a very terrible recovery, not super painful, more swelling. You know, some people in pain meds in one or two days, and that’s pretty much it on that pain of the facelift.
Now, the complications. The big complication of neck lifts or facelifts is nerve injury. When you lift the skin up to expose the fascia, the nerves of the face are exposed. The facial nerve kind of comes out in an area behind the ear, near the mastoid, and it kind of covers the face like this. So, we have one nerve going up to the eyebrow, three nerves in the middle, and then one nerve to the jaw. When you do the neck lift, the only nerve at risk is really the nerve on the jaw. Now, if that nerve got injured, the smiling would be affected on one side. You only smile, you know, unilaterally with one side not moving and things like that. So, that would be the marginal mandibular, and that would be the problem there.
With the facelift, you have the risk for that same nerve, the marginal mandibular on the jaw, and the nerve, you know, on the forehead. So, if the forehead nerve was injured, you know, you couldn’t raise the eyebrow. So, one eyebrow would raise and one wouldn’t. So, the facelift has more risk of nerve injury because you just lifted more skin and exposed more nerve, but the neck lift also has risk for nerve injury. So, those are, like, the primary risk and things like that.
Now, a smoker who has bad blood vessels, bad blood supply has risk for the skin dying when you lift the skin. Nonsmoker, very, very rare to have any skin death and flap death and things like that. Infection in the facelift or neck lift is very rare. I’ve never seen an infection with a neck lift or a facelift, and it can happen but the blood supply to the face is so good. It’s very rare to have problems with infection.
Hematoma under the flap, when you raise the flap, now if it bleeds underneath, it will be like a balloon full of blood. Now, that’s just gonna happen when somebody’s blood pressure goes up, when they’re too active, when they’re jumping and things shortly after surgery. Once it heals and it’s solid, you know, there’s no risk for…you know, no more risk than anybody else for having a hematoma and things in the face.
Sensation problems to the neck, some of the superficial nerves to the neck can be injured with the facelift. So, you might have problems with sensation and things around the ear. And I think these are the complications, you know, you have to consider with the neck and the facelift. Now, let’s look at some pictures to kind of talk about what we just said. The top picture is a facelift and this is a before and after. The bottom picture is a neck lift with fat transfer to the cheeks and lower lid, and this is a before and this is an after.
Now, what we did again, describing the scar. The scar of the facelift, you know, comes either at the anterior hairline or in the hairline, in front of the ear, and then goes around the ear. You can either have a scar in front of the ear or a scar that goes behind this area here. This is called the tragus. I generally put the scar here and go behind the tragus, then around the earlobe, behind the ear, and then into the hairline. The reason why you go behind the tragus because, whenever you break up a scar, it becomes more difficult to see. It looks more natural. If there’s a lot of straight line going here, it’s more obvious that you had a facelift. If you hide the scar on here, it’s very difficult to tell.
So, if you see after, you know, we kind of tried not to disturb the ear, disturb the tragus, but the scar is physically here. Yeah. And it’s very difficult to see the scar and it heals very well because you’ve broken the scar up in that area around the tragus. I think that’s kind of an important thing. The other thing that’s important with the facelift is not deforming the ear. A lot of times, when people have the facelift, the ears are deformed. And when the ear is deformed, it’s kind of a giveaway that you had a facelift. You might have a pixie ear with a ear so down and pulled too much. You might have an ear that moves more of the front, moves more to the back, the angle of the ear changes and things like that. And that is kind of a dead giveaway for a facelift. So, the key is the ear before, the ear after should be exactly the same. The scar should be difficult to see. That is kind of the key to a natural facelift.
One of the things that’s key to natural facelift is the skin is smooth. We don’t have sweat lines, pulled lines, wrinkles going up and down in odd directions. Everything should be natural and smooth. And this happens, those pulled lines happen when people try to do a skin facelift, where they’re relying on the skin to get rejuvenation, which never works. So, this is what we’re talking about with the facelift.
Now, if you look at the length between the lid and the cheek, it’s much longer before and much shorter after because we’ve actually used the sutures to reposition the cheek pad, the cheek fat pad back up to the cheek. As we age, that cheek fat pad falls down, now we pull it back up. And when we do that, we improve the nasolabial fold. When we do that, we improve the jawline. If you look at the jawline before, it’s more redundant skin here, you know, more of a marionette lines, more of a loopy skin here without [inaudible 00:13:33]. Here now, the angle of the jaw, the jaw and the angle of the jaw looks more straight and more youthful. So, that’s the real advantage of a facelift versus the neck lift with fat transfer of the cheek because, as you can see, the loose skin here in the angle of the jaw, because of the descended fat pad, is still there after when you do a neck lift because a neck lift does not correct the fat pad.
Now, we’ve hidden, you can see that the fat pad is lost here. We’ve added the fat pad with the fat transfer and got a younger looking face, but it did not improve the jawline. The advantage of the facelift is we’ve moved the tissue up to improve the cheek but also we improve the jawline. So, this is a shortcoming of the neck lift. It does not improve the loose skin on the jaw. Now, the angle of the neck where there’s no really angle of the neck, this just goes straight line from the chin to the neck.
We do have the angle of the neck restored from the neck lift but it doesn’t help that loose skin on that marionette area, the jowling, doesn’t help this jowling in the area of the mandible. So, that’s one of the main differences between the facelift and the neck lift. And again, if you look at the redundant skin in the nasolabial fold which improved with the facelift, this little flap of skin here with the fat transfer and the neck lift is not really significantly changed. That’s, again, because we did not elevate the fat pad and make the real correction, we did a masking by adding volume. So, we didn’t really correct the descent. We just covered it up with the fat.
So, those are the differences, you know, that we’re gonna see with the facelift and the neck lift. So, the advantages of the facelift are an improving jawline because of the resuspension of the fat pad, and also an improvement on the nasolabial fold because of the reposition of the fat pad. Remember, the fat transfer of the face is more of a masking than actually a real correction. Now, here’s what we did with the fat transfer to the face, and we kind of see before we have a hollow cheek. You can’t even see really where the cheek…there’s no cheek bulge at all, you know, from the eyelid down.
If you look at the length of the eyelid, the eyelid starts here that you can see here. It’s very long. Now the eyelid is very short. So, the incision we made for this neck lift just starts right at the earlobe, goes behind the earlobe, and into the hairline. There is no incision in the front of the ear. Again, the incision is here, right at the earlobe, behind the ear, into the hairline. There is no incision in front of the ear. So, that’s an advantage of the neck lift. There’s no incision in front of the ear. So, deform the ears, less likely. Giveaways and things like that are less likely. But when we’re doing that, now, the fat transfer to the face is really what’s creating the cheek and giving that rejuvenation and the youth look to the cheek.
So, both of these people have great results and look much younger than they did before the surgery, but there are differences. Everything has a yin and a yang. Again, the major advantage is the jawline with the facelift and nasolabial fold. With the fat transfer, we don’t have the scar in front of the ear. So, those are the things we think about, you know, with facelift versus neck lift with fat transfer to the cheek.
Now, just to kind redo the fat transfer of the cheek, I mean, the fat transfer of the face, here are just some example again of a patient who have fat transfer to the face. Now, this is a young person who really doesn’t need a facelift, but has lost some of the cheek, and the face is too flat and square. The nasolabial folds are too full. The eyelid is, again, if you look, the eyelid is very long. The distance between the lid and the cheek is very long. Now, when we’ve done the fat transfer, we’ve rounded the face, the face of youth. Babies are round. Young people have round faces. Old people have straight faces. So, we’ve added the fat in the cheeks to give the curve of the face. If you look at the length of the eyelid, now the eyelid is maybe half as long as it was before.
The skin also gets better. Remember fat has stem cells, so all the plasma facelifts, vampire facelifts, the fat does that even better. So, the texture of the skin gets better with the fat. And again, you can see the cheek hollow, no real projection of the cheek. And now, the nice projection of the cheek. See the cheek as opposed to before. This face is just younger than that face. So, that’s what we’re thinking about and that’s what we’re doing when we’re doing a fat transfer alone to the face.
So, now we see the three different things, we saw a facelift without a fat transfer. We saw a neck lift with fat transfer of the cheeks, and now just the fat transfer of the cheek by itself. All three after pictures look younger than the before pictures. All these are good procedures. They can be used separately. They can be used together. They each have their advantages, they each have their disadvantages, and this is just trying to explain to you what’s doing what.
I hope you like this video, and my goal is to just make more and more videos because I get a lot of feedback in the office that people enjoy them and they find them educational. Take care. This is actually the Super Bowl weekend for New England and the Falcons, and we’ll see how that works out. Take care.