By Elizabeth Morgan, MD PhD FACS
“Can it be done in the office?” and “Do I need a face lift?” are two common questions that cosmetic surgery patients ask us.
Today, short-acting general anesthetics and advanced monitoring make general anesthesia very safe, safer than intravenous sedation — one reason that anesthesiologists prefer this approach. Indeed the dangers of sedation without airway control are such that the American Society of Plastic Surgeons requires members to restrict its use to accredited out-patient surgery centers. But most people dislike the cost of a surgery center, as well as the recovery from general anesthesia, and avoid it if possible.
What can a plastic surgeon today offer the patient who wants the lower cost and faster recovery of a procedure done in the office with local anesthesia, perhaps with one or two light sedative pills at most?
Surprisingly we can offer a lot of safe office operations. This isn’t just our ingenuity but our response to patients wanting solutions to a wider range of cosmetic issues. Today I can safely offer my patients 50 such procedures with continuous monitoring of pulse, blood pressure and pulse oxygenation to ensure the surgery is in fact safe.
Such operations include small-volume liposuction, small-volume fat transfers, lip lifts, lip implants, buccal fat reductions, face lift revisions, skin-only tummy tucks, ear lobe repairs and reductions, chin implants, elbow lifts, buttock lifts, upper lid lifts, lower lid lifts, correction of nipple eversion and inversion, labiaplasties, brow lifts, alar nose reduction, ear setbacks, implant exchanges and much more.
Not every patient or problem is suited for local anesthesia surgery, but what can be done is remarkable. Incremental advances in our understanding of local anesthetics and cosmetic surgery have expanded our patients’ options while making these procedures almost painless.
Indeed the pain from many of these operations is much less than for filler, Botox or Kybella injections. For instance, pain from local anesthesia for a lip lift (see Figure 1 A and B) is two spot skin injections or four seconds, compared to the severe pain from Kybella fat injection of the neck (see Figure 2 A and B),which lasts five minutes. This is 75 fold less pain!
Indeed the ease and recovery from such procedures makes patients want all cosmetic surgery done this way. The day may come — but it’s not here yet. Why not? Office surgery should take not much more than two hours for patient comfort, cannot be safely done in a hypertensive or hyper-anxious patient or if there is a risk of fluid shifts, unexpected bleeding, unsafe levels of local anesthetic or damage to vital structures. Major surgery with these risks belong in an accredited surgery center.
Although mini-face lifts can be done in the office, surgery tends to be limited and results less durable. So far in my practice, an in-office mini-face lift seems a poorer choice than a well-done standard face lift in a surgery center, which will typically produce good to outstanding durable results with a low risk of complications. (See Figure 3A and B.)
This leads to the question — what is a standard face lift? It is a ‘bespoke’ or ‘designer’ lift, based on the patient’s facial changes and the available techniques. Here is how that approach is evolving.
From the early 1910s to 1968, face lifts just tightened skin. By the late 1960s, all of the neck skin and much of the facial skin was being raised off the deep layers beneath. Results could be good but were unpredictable.
In 1968, Tord Skoog, a Norwegian plastic surgeon, introduced his deep layer face lift. By raising and tightening the deep layer of the face — a fascial layer he called the submusculo-aponeurotic system (SMAS) — he improved face lift results and durability. But the SMAS flap was often fragile and hard to suture. Facial nerves travel under the SMAS and could be injured. So face lifting branched in two directions, less and more. Which approach a modern plastic surgeon uses depends on her/his assessment of risk and of the patient’s needs.
Doing less led to SMAS excision or plication — tightening with SMAS without lifting it. Nerve injuries were rarer, and results were very good. This then led to the ‘mini-lift,’ which uses a short incision in front of the ear to tighten just the SMAS. The results are less durable and eventually led to ‘suture’ and ‘thread’ lifts, a recurring ‘face lift’ fad with little durability.
Doing more led to sub-periosteal face lifts, which lifted the facial tissues off the bone, now largely replaced by the composite face lift championed by Dr. Hamra. This procedure leaves the skin attached to the SMAS and extends further into the mid-cheek and lifts the lower lid and brow as well. Results can be superb, but the extent of surgery, longer recovery and greater risk led many surgeons to only incorporate elements of this lift into their face lifts, as needed.
Meanwhile back in the lab, plastic surgeons were dissecting cadaver faces to understand facial aging. Why do our faces age differently from those of all other animals? Faces of the dog and cat, mandrill and camel do not sag as ours do. (See Figure 3.) Here’s what we learned.
First we learned that aging causes loss of facial fat, deflating the face. The advent of fillers, fat injections and soft solid silicone implants allows us to restore some of this youthful facial fullness. But this is only part of a fascinating story.
Another part is that our muscles of facial expression differentiate us from other animals. These muscles lie in the SMAS, kept in place with ligaments that attach skin and SMAS to bone beneath along a line going from lateral brow to angle of the jaw. These ligaments separate the mobile, expressive front of our face from the immobile sides.
In front of each ligament is a ‘potential space,’ a glide plane that allows the muscles to move. We move them constantly! This repetitive motion plus aging and sun damage will stretch the skin, subcutaneous fat and SMAS, causing them all to bulge out over the ligaments, forming the jowls, facial folds, saggy cheeks and bulgy lower lids of “age.”
Further, aging causes thinning, weakening and absorption of tissue in every layer of the face, from skin and fat to periosteum and bone. By our mid-20s, signs of aging are seen in Caucasian women. Because of men’s thicker tissues, these changes are seen later, in the early 30s. Those with even thicker facial tissues have even later visible signs of aging, as is evident in many Americans of Asian and African descent.
But no worries for early agers, right? Now that we know the anatomy in detail, can’t we just tighten those SMAS tissues around the ligaments? Not so fast! The nerves lie in the ligaments. Releasing ligaments can cut those nerves.
But our new knowledge does provide an answer. We now know how to find the glide planes between the ligaments — these are safe spaces where SMAS and skin can be tightened away from ligaments and nerves. This approach provides a limited dissection, less risky composite face lift, an approach being incorporated in face lifts today — yet another important incremental step forward.
Meanwhile, plastic surgeons and others are exploring another avenue: stem cells and other biotechnology to rejuvenate aging tissues. The ultimate irony for plastic surgeons would be if our own research leads to pills, creams or safe injections that restore the face to a youthful appearance permanently without surgery, injections or implants.
While we await this Fountain of Youth, we have ever better face lifts and a panoply of office procedures to offer our patients. It’s astonishing progress from the introduction of general anesthesia in 1844 and local anesthesia in 1888!