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BackTable / ENT / Article
Facelift Surgery vs Alternatives: Helping Patients Find the Right Fit
Julia Casazza • Updated Jun 26, 2024 • 31 hits
Rhytidectomy, commonly referred to as “facelift,” is one of the oldest and most popular facial cosmetic procedures. Contemporary surgical and sedation techniques enable facial plastic surgeons to perform this procedure in-office for patients that meet specific criteria. Nonetheless, not all patients need or are ready to commit to a facelift. Facial plastic surgeon Dr. Demitri Arnaoutakis provides some expert advice on youth-enhancing facial cosmetic procedures, including the role of alternatives to facelift surgery.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Before performing any cosmetic procedure, surgeons should investigate patients’ medical history and goals to counsel on the most appropriate options.
• Explaining the necessary preparation and downtime associated with a given procedure helps patients select the option best suited to their needs.
• A facelift isn’t the only option for a tighter, more youthful face. Microneedling, fillers, neuromodulator injections, and radiofrequency-assisted lipolysis are all nonsurgical alternatives that produce similar (but shorter-lasting) results.
• Patients with cardiac history or significant anxiety regarding their procedure should undergo their facelift in the operating room, not the office.
Table of Contents
(1) Pre-Operative Counseling for Facial Cosmetic Procedures
(2) Non-Invasive & Minimally Invasive Alternatives to Facelift
(3) Facelift Surgery in the Office vs the Operating Room
Pre-Operative Counseling for Facial Cosmetic Procedures
Pre-operative counseling focuses on patient goals, medical history, and an understanding of the desired procedure(s). Asking patients about their problem areas on an intake questionnaire, then again while the patient is looking in a mirror, helps the surgeon conceptualize the patient’s goals. As with any surgical consultation, surgeons should investigate the patient’s medical history, medication list, smoking status, and surgical history (including non-surgical cosmetic procedures such as polydioxanone/“PDO” threads, or injectables).
After data is collected, the surgeon formulates an assessment and recommends surgical and/or nonsurgical options. Walking through a given procedure’s post-operative course day by day can help the patient understand whether that procedure is appropriate for his or her desires and lifestyle.
[Dr. Gopi Shah]
I think that's great. All right. Let's get into our clinical topic today. We're talking about in-office facelifts. I want to just start with the basics. How do these patients present to you? Do they all know that they want a facelift or do they even realize that that's what they need? How does that sort of initial visit go?
[Dr. Demetri Arnaoutakis]
Yes. In my consultations, obviously, the patients come in. Obviously, we have our intake form and they write at the top, what's the reason for the visit? Sometimes they'll just write “deep plane facelift.” Sometimes they'll write “my jowls are bothering me” or “my eyelids” or “my neck.” As we get to know each other, what I usually do is just hand them a mirror. I also have a stool and a mirror in my office where we sometimes we'll just sit in front of it and the patients will point to things that they're self-conscious about.
Then once they've made everything clear, I'll do my assessment and sort of talk with them what I think is best. A facelift isn't for everyone, right? There's downtime, there's cost, there's, the stigma, perhaps the scars around your ears and whatnot. Some people are like, look, doc, there's no chance I'm ever doing that. What other options do you have? Obviously I do some minimally invasive type facial rejuvenation procedures as well. I have to basically, give them all their options.
Then they decide what's best for them and they break it down, whether it's their financial reasons or scarring or downtime. Then we just decide, what's best for that patient. Then, after that point, if I can get a feel for what they're leaning towards, and then I'll probably give them a more thorough explanation of that route and give them, a day one, a day two after a facelift. If truthfully they're interested in a facelift, then we just walk them down basically every day of their recovery from day 1 to day 10 or 14 or so. I think that gives them a more realistic idea of what to expect.
[Dr. Gopi Shah]
Are there certain questions that are always part of your history?
[Dr. Demetri Arnaoutakis]
Yes. In this day and age, there's so many different types of injections and non-surgical treatments. For example, there's something called PDO threads. They're sold as a “quick facelift” if you will. They don't last very long. They're these barbed wires, basically, that go underneath the skin into the dermis and SMAS and then try to lift up your jowls and nasolabial folds. Anyway, if someone's done that six months ago and you're going into surgery, you would like to know that you're going to run into that barbed wire when you're elevating the deep plane lift. Yes, there are certain things I'd like to know about what they've done to their face and neck in the past.
[Dr. Gopi Shah]
You'll go through prior procedures, filler or other sort of non-surgical or injectable or another—
[Dr. Demetri Arnaoutakis]
Yes, injectables. It falls into one big category there. Then of course their medical history as well. Any cardiac issues, we definitely want to have them have medical clearance if there's anything concerning in their medical history. Have them get EKGs, chest x-rays, blood work, and a clearance letter from their primary or their cardiologist, or whatever it may be.
[Dr. Gopi Shah]
If the patient's a smoker, for example, how do you counsel them with a history of smoking? Do you try to have them stop perioperative? Is that even reasonable or is it just setting the expectations with that risk?
[Dr. Demetri Arnaoutakis]
Yes. I think in the past that would have been a hard no for a lot of surgeons to just not operate on. I think now, I think there's certainly been a trend towards, okay, they can safely undergo a face procedure, especially a deep plane facelift, there's better vascular supply to the skin dermis area.
I would encourage, and I think a lot of plastic surgeons do this as well, is to have them undergo hyperbaric oxygen. Certainly several sessions after the procedure, that just obviously increases oxygen delivery to the tissues. I baseline have all my facelift patients at least do one session postoperatively. For smokers, we would have them do at least probably five or six just to be safe.
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Non-Invasive & Minimally Invasive Alternatives to Facelift
In the right patient population, non-surgical alternatives to the facelift produce results similar to the surgery itself, including tighter skin and fewer deep lines. These treatments can be ideal for patients in their twenties through forties who aren’t ready for a surgical fix but want to alter their appearance.
Non-invasive options include microneedling, radiofrequency microneedling, neuromodulator injection, and fillers. Microneedling, which can be accompanied by heat, stimulates dermal collagen production. Neuromodulators, such as Botox, paralyze the muscles of facial expression to prevent or reduce wrinkle formation. Fillers change the contour of a patient’s face; however, Dr. Arnaoutakis advises against “liquid facelifts,” in which multiple vials of hyaluronic acid are injected into a patient’s face, as results last only six to nine months.
Radiofrequency-assisted lipolysis is a minimally invasive option that removes fat, leaving the patient with a tighter-appearing face. In this procedure, small incisions are made in the patient’s face, into which a radiofrequency probe is inserted (Dr. Arnaoutakis uses FaceTite technology). The probe then uses heat energy to promote coagulation of adipocytes. The entire procedure takes less than an hour, and nitrous oxide plus Valium suffices for sedation.
[Dr. Gopi Shah]
Okay. We keep throwing around facelifts and non-surgical and surgical. Can you just organize it for me? Tell me first about sort of the non-surgical facelift options and then plastics is such a language, right? If you don't know the vocabulary and the language, it's hard to know. When we talk about traditional versus NAS versus deep, can you just go through first non-surgical and then organize the surgical for me?
[Dr. Demetri Arnaoutakis]
Yes, for sure. I think within the non-surgical there's, you can say sort of non-invasive and minimally invasive. Something non-invasive would be like microneedling or radio frequency microneedling. Radiofrequency microneedling is basically where I have this platform where 24 needles come out, they penetrate the skin and they're delivering radio frequency energy into the papillary and the reticular dermis. Basically, that is promoting new collagen formation, which of course, as you know is going to help sort of improve the texture of the skin. You get some skin tightening as well.
We usually do three sessions, you space them out a month apart because that's the time period it takes for the collagen to rebuild and you'll see some nice improvements, mostly in the quality and the texture of the skin. I tell patients, your pores will improve. Again, the texture and the quality of the skin, you will see a little bit of improvement in the laxity. Botox and fillers, I would say fall within a non-invasive category as well. Botox are neuromodulators, which we use for frown lines and forehead lines and crow's feet that have other causes as well, especially reconstructive patients need facial reanimation, some types of kinesis issues, and you can do Botox to help alleviate that.
Then fillers or hyaluronic acid. We already have hyaluronic acid on the skin surface. Basically, you're providing volume to a patient in areas where they're a little depleted. I know there's been tons of marketing as far as a liquid facelift if you will. I'm not a huge proponent of that. I just think sometimes that people can look overdone and fake and you're injecting five, six syringes, that adds up financially and, it's only going to last six, nine months.
[Dr. Gopi Shah]
Just to clarify the liquid facelift. Is that part of your HA fillers or is that different?
[Dr. Demetri Arnaoutakis]
Yes, that's HA fillers.
[Dr. Gopi Shah]
That's it. Got it.
[Dr. Demetri Arnaoutakis]
Or it could be something called Sculptra. It could be Sculptra or Radiesse. There's different types of fillers. Now that I do so many deep plane facelifts that I'm more a proponent of something that I know is going to last, probably 10-plus years, it'll really give them the result they're looking for. Then they really won't have to be injecting their faces with all of these fillers and such. To each their own. Some people just, that's the route they want to go.
Then I think a step up in our totem pole is minimally invasive procedures. We have something it's called radiofrequency-assisted lipolysis. What I do is I make tiny access or port sites underneath each lobule and then right underneath the chin and the cemental crease. I basically use a 15-blade to make a tiny nick in the skin. Then it's enough space to allow the probe, but in this case, the device is called FaceTite, T-I-T-E is how they market it. Anyway, the probe goes underneath the skin and is delivering again, energy that is supposed to cause coagulation to the adipocytes and the subcutaneous tissue and the subcutaneous fat and also promote skin type.
Now that can work very well for some patients, usually for patients in their 20s, 30s, early 40s, what we refer to as these gap patients. They're in between the injections and they're not perhaps quite ready for a neck lift or a for facelift. This is a procedure that I do in my office under local anesthesia. We provide perhaps, four milligrams of Valium. We have, Tramadol, if they need, or extra-strength Tylenol. We have Pro-Nox, which is laughing gas, and that really provides for a very comfortable setting.
Facelift Surgery in the Office vs the Operating Room
The ideal candidate for an in-office facelift is a younger individual with no serious medical history and limited anxiety regarding the procedure. Cardiac concerns or excessive worry over the procedure are indications for an OR procedure. Dr. Arnaoutakis uses IV propofol, Pro-Nox, and Valium for procedural sedation. Even when in the OR, general anesthesia is rarely needed.
[Dr. Gopi Shah]
That's interesting. Okay. You mentioned some local anesthetics and you mentioned Pro-Nox and tramadol. Do you have to have like a special sedation license or do you have a sedation nurse?
[Dr. Demetri Arnaoutakis]
Pro-Nox, it's just like a 30-second onset and then it goes away in like in a minute so it's very short, very short acting, and with Tramadol, that's just a tablet. So that's just like prescribing someone narco or whatever. Technically anybody-- not anyone but as a physician you can do that in your office. I am in the process of building actually from ground up a new office with a surgery center attached to it and I'm working with a company to help me get it credentialed.
It would be a Quad-A SF credentialing and in that facility we are able to do obviously local anesthesia. You can do IV so I truly do the majority of my facelifts under IV anesthesia, so Propofol drip, and I have a board-certified anesthesiologist there who's a little strength medication So I would never do that just in the office I have obviously an anesthesiologist they're doing but that's I rarely maybe once a year do a facelift under general anesthesia 99.9% of the time it's under Propofol.
…
[Dr. Gopi Shah]
Okay. Then in terms of when we talk about in-office facelifts, I would think that pretty much all your non-surgical so the non-invasive and minimally evasive RFA fillers all that can be done in the office. In terms of the surgical, are all of these on the table for in the office too? What procedures can you do and how do you decide?
[Dr. Demetri Arnaoutakis]
Obviously that's where it takes into their medical history, it's really important. If someone's had a cardiac history, then I'm certainly not, I'm going to be doing anything in the office. If it's someone maybe in their mid-40s who they're very fit, they don't take any medications, in that case, I would say they could be a candidate for doing this under Valium and local anesthesia. We obviously have monitors and we're monitoring their vitals throughout the procedure but in that case could be very safe. Again, the patient avoids going through anesthesia. It's not like there's no risk with obviously going under general anesthesia or even Propofol. This sometimes could be even safer for them.
Podcast Contributors
Dr. Demetri Arnaoutakis
Dr. Demetri Arnaoutakis is a facial plastic surgeon in Tampa Bay, Florida and Beverly Hills, California.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, September 5). Ep. 127 – In-Office Facelifts [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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