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Aesthet Surg J
Aesthet Surg J
asj
Aesthetic Surgery Journal
1090-820X
1527-330X
Oxford University Press US

39024417
10.1093/asj/sjae158
sjae158
Editorial
AcademicSubjects/MED00987
Asj/4
There Is No Facelift for All Seasons
Nahai Foad MD, FACS
Dr Foad Nahai is an adjunct professor, Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA, USA, and is an editor emeritus for Aesthetic Surgery Journal.

Corresponding Author: Dr Foad Nahai, 875 Johnson Ferry Road NE, Atlanta, GA 30304, USA. E-mail: nahaimd@aol.com; Twitter: @nahaidr
10 2024
18 7 2024
18 7 2024
44 10 11271129
12 7 2024
19 8 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.
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pmc“Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.”

–––Sir William Osler1

No two faces are alike, age the same, deflate the same, or have the same morphology. Why perform the same operation on every face? There is no “facelift for all seasons”! Of course, I say this metaphorically, meaning there is no one facelift procedure universally the best for every face.

Facelifts date back well over 120 years to the early decades of the 20th century when the pioneers of aesthetic surgery began by removing strips of skin in front of the ear or in the temporal area.2 From skin excision the procedure evolved into skin undermining plus skin excision, relying on skin tension for the result. This so-called “skin lift” lasted well into the 1960s and early 1970s when Skoog3 initiated the “modern facelift” by including what he referred to as the “buccal fascia,” later termed the “superficial musculoaponeurotic system” (SMAS), into the procedure. His seminal publication was followed in 1976 by Mitz and Peyronie's description of the SMAS.4 Manipulation of the SMAS in some form or other became the “gold standard” for facelifts and remains so to this day.

Mark Lemmon and Sam Hamra in 19805 published their experience with the “Skoog rhytidectomy,” and in 1990 Hamra expanded on Skoog's concept, publishing his seminal work on the “deep plane facelift.”6 A few years later Hamra, in an effort to achieve more mid-face elevation, modified his procedure and called it the “composite lift.”7 The late 1990s and the turn of this century saw many modifications of the “SMAS lift” by thought leaders such as Connell,8 Tom Baker, Stuzin,9 Barton,10 Owsley,11 Marten,12 Aston,13 Warren,14 and Dan Baker, who introduced the less-invasive “SMASectomy”15 and popularized the short or limited scar facelift.16 Tonnard and Verpaele's “MACS lift”17 combined the short scar facelift with SMAS purse string plication and suspension. We have continued to witness further alterations in SMAS management recently as described by Jacono,18 Talei,19 and Grotting.20 The currently popular facelift techniques are referred to as “deep plane facelift,” while bearing only modest resemblance to the original deep plane lift described by Hamra.6 The term “deep plane” has become a social media buzzword, a marketing tool.

In 1992 we saw the simultaneous introduction of endoscopic procedures in aesthetic surgery by Vasconez21 and Isse.22 This was followed by our application of endoscopy to facial aesthetic surgery including the neck.23,24 Endoscopic techniques reduced scars and gained popularity. Saltz published a large series in 2012,25 and recently combined endoscopic and open techniques to enhance results.26 More recently Chia published his large series on the “ponytail lift,” expanding the applications of endoscopic techniques with and without open techniques.27

With all these options, which is best, lasts longer, and is safe? Some, but not all, authors would argue that their approach or modification is the best, but there is no evidence that one facelift procedure is better than another. On the contrary there are several studies reporting little or no difference in the quality of the results between techniques. In a “classic twins” study by Alpert et al, 4 surgeons each performed their own technique on 2 sets of identical twins who were followed for 10 years.28 The study showed only minor differences in results at 10 years. In another study on monozygotic twins, Antell and Orseck29 reported on 8 consecutive sets of twins, comparing skin only, conventional SMAS flap, SMAS plication, and SMASectomy, with a mean follow-up of 23 months; they concluded that “no one facelift technique performed in this study produced a superior result as compared with another.” In a prospective randomized split-face study on 21 patients, Ivey et al30 compared SMASectomy or conventional SMAS lift on one side with extended SMAS or composite facelift on the opposite side of the face, reporting no differences and similar outcomes at 1 year. Adamson retrospectively compared SMAS plication to deep plane SMAS and reported only minimal differences.31 Becker, in a similar larger retrospective review, reported no difference between SMAS plication and deep plane SMAS lifts.32

More recently, in a review of evidence-based, case-based comparisons of modern facelifts, Avashia et al concluded “there is no ‘best’ technique.”33 A 15-year review of practice patterns in facelift based on tracer data from the American Board of Plastic Surgery by Stein et al reported that the most common techniques were SMAS plication (40%), SMAS flaps (35%), and SMASectomy (22%).34

Although the literature confirms the contention that there is no facelift for all seasons, all the techniques described have 5 steps in common:

All require incisions in the scalp and face

All entail some skin undermining

All include SMAS manipulation

All include volume management

All include ancillary procedures

These 5 steps and the concepts behind them contribute to the safety, quality, and longevity of the result. Each procedure should be custom made or tailored to the individual, based on the extent of aging, deflation, skin quality, facial morphology, and hairlines. I call this a “bespoke facelift.” Each of the 5 steps may not contribute equally for every face. One or more steps may play the major role in contributing to the final result.

Finally, longevity in an academic career has taught me that good results are based more on the surgeon’s experience, technical ability, and judgment rather than on any particular technique. After over 4 decades of interest in and experience with facial rejuvenation, not only is there no facelift for all seasons, I venture to suggest there is no best facelift.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.
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