Unhappy After a Facelift? What a Revision Can (and Can't) Fix

Announcer (00:02):
You're listening to Alabama the Beautiful.

Kirstin (00:05):
I'm Kirstin Jarvis and I'm here with Alabama Cosmetic Surgeons, Dr. James Koehler and Dr. Vincent Gardner. Hey, Dr. Koehler and Dr. Gardner.

Dr. Koehler (00:13):
Hello.

Dr. Gardner (00:14):
Hey, Kirstin.

Kirstin (00:15):
Hey. So today we're going to talk about the revision facelift. The hardest consult is one where someone's already had a facelift and they're sitting across from you unhappy. Let's talk about what the conversation looks like and what is actually fixable.

Dr. Koehler (00:33):
Yeah. Well, it's kind of a complicated question there because there's a lot of different reasons that people come in for a secondary facelift. Sometimes it's a patient who had a facelift but they've never really been happy with it. And those people may be a little different story. It could be they just had really high expectations or maybe they thought the procedure was going to do things for them that it didn't do, which sometimes is just a communication thing. So for example, they may have got a mini facelift and they thought it was going to address more issues than it really did where maybe it was the wrong procedure for that patient. And so that's one of the reasons they may not have got a good result. And this is a common thing that I hear some people equate the term facelift with make me look younger.

(01:29):
They think that's the procedure. Just give me the make me look younger procedure, but they use the word facelift and it actually happened. I was injecting Botox just yesterday on a patient and she says, "Well, I really don't like these fine lines around my eyes and I've been doing the Botox. It helps, but it's still not going away." And she goes, "Well, I guess that's just I need a facelift." I'm like, "Well, no, a facelift doesn't really do that for ... It doesn't treat that. " But the reason I bring that up is that we need to make sure we communicate what a facelift really does, which for surgeons when we talk about a facelift, we're talking about mainly the lower face and especially the neck, those two things. And we will see some improvement in the cheek, but sometimes we have to do actually a designated mid-face type of procedure, which is called a mid-face lift.

(02:19):
But usually a facelift, depending on the type of facelift, will address the cheek to a certain extent, lower face and neck, but it doesn't do anything for your brow. It doesn't really do anything for your eyelids. Those are separate procedures. So there's brow lifting, upper eyelid surgery, lower eyelid surgery, and then there's other adjunctive procedures like fat grafting and laser resurfacing. They all do different things and they all help you make you look more youthful. But if the patient comes in and says, "Well, I want a facelift and their interpretation is make me look younger." Well, then we got to make sure that we're talking apples and apples here. So that's one conversation. And then the other is just a person who had a facelift. And again, this is another misconception. It's like, "Well, I already had a facelift and it's been 10 years or however many years and why do I need to have another?" Well, you're 10 years older and a facelift doesn't freeze you in time.

(03:15):
And that's something I always try to tell people. It's like, yeah, we'll be able to turn back the clock, but then the clock continues to tick. So depending on what your expectations are, just realize you continue to age. And an important thing too there is the age in which you do a facelift. So if you do a facelift and let's say you're 50, your skin elasticity is better and the result that you get is going to, in a sense, I guess maybe last a little longer than if you get a facelift when you're 70 where the skin elasticity is not as good and the aging process kind of accelerates. I always say it's a bell curve. As you get older, the difference between somebody who goes from 50 to 60 is not the same as somebody who goes from 70 to 80. Usually we see accelerated aging in the face as we get older.

(04:04):
So anyhow, the point is that nothing is permanent. It will change. And so those are some of the points of discussion that we have to have as what is the reason that you're in there for? And if it's because they're unhappy with the original surgery, then we got to identify what those things are and how do we go about correcting that.

Kirstin (04:23):
We've heard from people in the past that think maybe they don't love their results because they're so early in their healing process. How long does it actually take for swelling to fully resolve or a patient to show their full results versus just a bad result in unfinished healing?

Dr. Koehler (04:44):
Yeah, that's a big distinction. And unfortunately there's good and bad with ... There's groups out there, like you can be on a Facebook group or other things and it can be very useful that people share their recovery and what they went through because sometimes that's the part that's missed and people don't understand one week you're healed, like it's a process, but people also need to understand that it's different for every patient. So I have in my own practice, I'll have some people, when I see them at a week, I'm like, "Oh my gosh, you could go out in public and you look great." No bruising, very minimal swelling, all that kind of stuff. And then other people will have more significant bruising and maybe they even have a little bit of fullness in the temporal region because they didn't do a brow lift and they probably should have done a brow lift as well.

(05:37):
So that may take a little longer to resolve. The facelift result, I mean, you're really looking at about six months and maybe even there might be a little residual swelling after that. But I usually tell people at six weeks, you're going to be looking really good. You'll be able to go out into public and people who don't know you shouldn't know you had something done, but there may be still some little residual signs or some residual swelling that can take longer. And also something we need to talk about, it's not a common occurrence, but these things happen, especially with deep plain facelifting. We are working near the facial nerve and the facial nerve is what moves the muscles of your face and that nerve doesn't take a joke very well. So if it gets bruised up in surgery or maybe from the cautery, the heat of the cautery damages the nerve to a certain extent, that nerve can take a little holiday and it takes a little break and it can sometimes take eight weeks or 12 weeks for something like that to resolve.

(06:36):
And so there could be some noticeable asymmetries or things that will ultimately resolve, but it can take some time and that's frustrating. And it's rare occurrence, those types of things, but they do happen and any surgeon that does this at any frequency has had it happen to them. And so every patient's different. Not everybody has a look great in one week. Some people are bruised and swollen and your anatomy is different too. Some people, we have to be a lot more aggressive in the procedure to get the result that we want. Maybe we have to really debulk the muscles in the neck and take out the glands and all that and it can create more swelling. And again, the pain can be different from patient to patient. It's just no two people are exactly the same. So it's helpful to compare when you compare yourself to somebody else, but you shouldn't stress.

(07:24):
I had a lady in that was in today for a follow-up and she looks great. She's not where she's going to be. She's only two weeks out from surgery, but she's got some swelling still and she's thinking she should be ahead of it. I'm like, "You're right where you need to be. This is good." But she said, "Well, I saw a lady on Facebook that had..." And I'm like, "Well, I mean, you're not far from..." It's pretty good where she's at. It's not bad, but she's comparing herself to somebody else and it's a different patient. Somebody else has got more swelling than you. So you have to trust your doctor in that process and you shouldn't be judging your result at three weeks and four weeks and five weeks. It's really more at the three to six month mark where you're going to see realistically.

(08:11):
And one area, sometimes we have some firmness under the neck here and some residual swelling that just takes a little bit longer. So even though they have a good chinneck contour, it's still fuller than it's going to be in the final result.

Kirstin (08:23):
Okay. When you look at a face that someone says is not delivering or didn't deliver, what are you checking for first?

Dr. Koehler (08:33):
The one thing that I'm really looking at is like when I look at the procedure, like are the incisions well designed? Does it appear to be a well done facelift? I don't know what they look like before, quite frankly. And sometimes you see what people look like before and you're like, "Oh my God, that's a home run." When I look at what they looked like before, but if you don't have the benefit of seeing where they are before, you might be like, "Oh yeah, you've got some residual laxity." Meanwhile, you look at their picture from their other doctor, their neck went from their chin straight to their chest. I mean, it might be a great result. So sometimes it's expectations like what they realistically ... And that's what I really need to determine is like is the result, like does it appear that it was a well done surgery and maybe this is an issue with their tissues or maybe they needed other procedures in conjunction with what they had to get the kind of result they were thinking they needed.

(09:22):
Or if it wasn't, maybe there was an area where they could have taken out the gland and it would've given them a better jawline and that was not done. So that's something that maybe we can do in the revision or maybe the muscles of the neck, they weren't tightened enough there and so we still have some muscle sagging there. The skin has to be looked at independently too because skin quality is a big factor. A facelift doesn't change your skin quality. It does lift the tissues. We're lifting that deeper layer, but they may need laser resurfacing or other things. It doesn't fix poor skin elasticity. That's something that you can't fix with a facelift. So yeah, a lot of factors go into what I'm looking at and sometimes you do see a poorly executed face, like the incisions were not placed ideally, they're visible and some things we can fix with a revision facelift and some things are like maybe not easily correctable.

Kirstin (10:19):
Are there technique level mistakes that you can spot on people?

Dr. Koehler (10:24):
I mean, a common one actually when Joe Biden was president, I saw several pictures of his going, "Oh, look at his pixie ear deformity" on Instagram. And a Pixie ear deformity is sometimes where the, let's say you put too much tension on the skin and what happens is as the skin kind of retracts back and then the ear lobe gets kind of stretched out and it looks like a little pixie ear. Sometimes you'll see things like that where that's like a technical thing or you sometimes see that where maybe somebody had a second facelift and they tried to get it tighter and there really wasn't enough to pull there. And anyhow, they overtightened it and it relapsed and pulled the ear down. So yeah, too much skin removal, things like that.

Kirstin (11:07):
So you're telling me all of the theories on social media about Joe Biden having a clone out there was really-

Dr. Koehler (11:16):
I'm not going down that route. His clone got a bad facelift. That's what happened. I don't know. But I think as a surgeon, and sometimes those things are not necessarily easily picked up by the average person. And surgeons, we look at things and so I can sometimes spot a facelift leg. I'm like, "Oh yeah, facelift." Whereas the average person would have no idea, but we know what we're looking at. And again, there's a difference between what the surgeon and maybe the patient can identify with because sometimes patients identify things and this happens with not just facelift surgery, all types of surgery where patients, we see this all the time, they have a procedure and then they look at themselves and they look at themselves in ways that they've never looked at before. And what they're actually doing is noticing things because they're paying attention. So with breast surgery, it's like, well, my one nipple sits a litle bit higher than the other.

(12:12):
And they're like, "Oh, it was never like that before." And then you look at the picture and you're like, "Yeah, it's always been like that. " Or with facelift surgery, people will be like, "I think you lowered my right ear. My right ear is lower than my left." And we pull up their picture, it's like you're not symmetric. Yeah, your right ear is always sad, a little bit lower. So my point is patients can notice all these subtle things, but other people really don't notice. You might look at people all the time that one ear might sit a little bit lower than the other, but you've never noticed it. But if I point it out to you, you'd be like, "Oh yeah, I guess it does sit a little lower." As surgeons were trained to look at, we know the telltale signs of facelifting surgery.

(12:49):
So yeah, we can pick up subtle signs that you're like, "Oh yeah, that's a facelift." But an average person may not pick up on that.

Kirstin (12:55):
Well, the conspiracy theorist will, but I've never met a conspiracy theorist that is also a surgeon. So there's that.

Dr. Koehler (13:04):
There's one to my right there, two over. I'm just kidding. There you go.

Kirstin (13:12):
Yes, Dr. Gardner. See, now all the people, they had side by side pictures being like, "This is not actually Joe Biden. Look at his ear lobes." There we go. That's why.

Dr. Gardner (13:21):
It's his robot.

Kirstin (13:23):
Yeah. All right, the professional take on that. All right. How often is the issue of not the actual surgery itself, but just a mismatch between what someone wanted and what they're actually a candidate for?

Dr. Koehler (13:38):
I mean, it's just a mix. It happens all the time. That's where the discussion really needs to come in because there's things that a patient can't change. So if they naturally have really good bone structure, like already a good jawbone, well, it makes it a whole lot easier to get a well-defined jawline surgically. Whereas somebody who doesn't, unless they're willing to do things like a chin implant or some other things to help accentuate that, their underlying anatomy limits the result in terms of what they're wanting to achieve. So building the expectations, really understanding what procedures do what. And I think from a patient perspective, that's where it's like you got to be brutally honest with your surgeon. So sometimes people go into it and they're like, "Well, all I can really afford is the facelift. So that's all I really want to do. " But meanwhile, they're telling you things in the consultation that bother them.

(14:31):
And it's like, again, we get back to that whole issue, like a facelift doesn't address some of those things you're concerned with. So it's fine. We can still maybe just do your facelift and it will still be fine, but realize it's not going to affect. For instance, if you've got lots of wrinkled sun damaged skin. A facelift, when you reposition those tissues and kind of tighten things, yes, some of those wrinkles and lines will be, the deeper creases will be improved because everything has been tightened, but at the end of the day, the skin quality is still the same. And so there's photo damaged skin, maybe fine lines and wrinkles. Well, a facelift's not going to crack that. That's going to require resurfacing. So just again, having discussions, being honest with your surgeon about what really bothers you and realize, be open to the discussion of what it's going to take to get you where you want to be.

Kirstin (15:19):
Okay. Let's talk about how revision actually works. Walk us through what's different about doing surgery on tissue that's new, like virgin tissue, I guess, versus somebody who's already been operated on.

Dr. Koehler (15:33):
Well, what I do is I pull out my magic wand and no, it's different. So operating on a virgin face and one that hasn't had a bunch of filler and other things done, from a surgeon's perspective, it's a much more predictable operation. The anatomy is where it's supposed to be. It's like when you do the dissection, the tissue planes, unless you're a surgeon, this won't make a lot of sense to you, but like how the tissue planes elevate is just much easier. It opens up. It happens the way it's supposed to and everything's much more predictable. When you go into an operated phase, even if you had the surgeon's prior operative note, which to me is, I mean, I guess it's kind of helpful to kind maybe know which technique was done, but it's still like you don't know. And so you're walking into potential scar tissue, altered anatomy, things maybe not 100% being where they're supposed to be and like we don't know if part of the gland was removed or not.

(16:33):
And so we're going to be looking around trying to do all the things. And so anyhow, the point is it's a slower dissection. There can be increased risk for things like skin loss or nerve injuries in reoperated patients. It's more challenging. So revision facelift surgery, I mean, I just did a lady last, was it last week or two weeks ago, two weeks ago, it was our third facelift and we got a great result. So I mean, you can get great results on revision facelifts, but the patient needs to, again, understand that there are more risks involved. It's a more complicated surgery and it may take a little longer operative time-wise, but it's doable, just it has some issues associated with it.

Kirstin (17:14):
So is recovery the same as the first time facelift or is it different the second or third time around?

Dr. Koehler (17:24):
I don't know. I think recoveries vary because sometimes some of the things that I'm doing now both from an anesthesia technique point and some of the medications we use can really result in decreased bruising and swelling. So depending on how long they had it done before, they might have less swelling. But I mean, I would typically say a reoperated case because of increased operative time, maybe more tissue manipulation. I mean, it might be more swollen, but it varies. It varies.

Kirstin (17:56):
Are there results, like if somebody's coming to you for a revision, is there a point where the kindest thing you can tell someone is this as good as it gets or is there always room for improvement?

Dr. Koehler (18:09):
Sometimes people maybe are only seeking a little bit of improvement. They're not happy with where they are that they want to get to that next level and it still could be achievable. So even though they might have higher expectations, it still might be a patient we would operate on, but if they're like, "I will not be happy unless I achieve X." And you're like, the chances of me getting to that are pretty low, that might be a better one for us to just say, maybe we don't do the surgery because sometimes the expectations are high. And I just feel in the world we live in where every highlight reel is on Instagram and every great result is on Instagram and that's wonderful to see that what's possible, but not every result is a highlight reel. Again, it comes down to bone structure, tissue quality, blood supply, all sorts of things.

(19:04):
So the results can vary from patient to patient and sometimes if the expectations are just not there, they're really, really high, it's sometimes best just to say like, "Look, that's the best you can do. " I often say little saying of mine, it was not my saying, another surgeon said this to me a lot many years ago, but he'd say, "The enemy of good is better." You might have a good result, but you're still not happy, but trying to achieve better can result in complications. So sometimes you're just better to accept a really good result. Now, if you've got a bad result, that's a different story. Maybe we're willing to accept the risk of another surgery or other procedures to get it to look to where it's not people on the street looking at you going, "Oh my gosh, what happened to you? " If you got that kind of a result from surgery, well then yes.I mean, I think it's worthwhile to see what we can do to improve it, but every case is different.

Kirstin (20:03):
So when you talk about skin and volume and bone structure, at what point are you really no longer fixing a bad facelift? When is it that you're just managing aging now? Is there a point that it's too far, too late?

Dr. Koehler (20:18):
To do a facelift?

Kirstin (20:19):
Yeah.

Dr. Koehler (20:20):
Well, I know I did an 80-year-old last year. I mean, she actually had her 80th birthday, I think, a couple months after I did her facelift.

Kirstin (20:27):
She looks good.

Dr. Koehler (20:29):
Yeah, she was ecstatic. I mean, so there's not an age, you have to be healthy. I turned down people in their 50s from a facelift because their health is too poor and I'm not going to do a facelift on them. So it's not an age thing. But again, if we're doing a facelift on an 80-year-old versus a facelift on a 50-year-old, and given that their health is totally fine, tissue quality and everything is different, so the expectation needs to be a little different. So on an 80-year-old, maybe a year or two after that facelift, we're going to see a little bit of relapse there. It's not going to ... Again, we don't fix you in time, but the skin elasticity is not as good. So you might see a little different end result on that 80-year-old versus a 50-year-old. So it's just all building the expectations with the anatomy they have.

Kirstin (21:15):
What's the single biggest mistake people make when they're shopping for their second surgeon?

Dr. Koehler (21:21):
I don't know. I think if you're going to get a revision facelift, you want to see somebody that they have expertise in facelift surgery, they do it frequently enough and they have enough results to show you, this is what I can do because revision surgery is more challenging. And the only thing I would say, and I touched on it already, is that be open to the discussion that when surgeons are suggesting other things, a patient shouldn't feel like, "Oh, I feel like my doctor's trying to upsell me a bunch of procedures." I think a lot of times if you've got a lot of experience doing this surgery, I try to look at every patient like, "Okay, if this is my family member, what would I recommend for them?" And people may want other things. They may want more than what I recommend and sometimes I'm like, "Yeah, no, you can do that".

(22:10):
But I'm just saying baseline, this would be the minimum thing that I would do. But some people are like, "No, I only want a facelift," but they really have big bags under their eyelid or something. And you're like, "Look, if we do this bottom part where we don't do that, it's not going to look balanced. It's not going to look ... It'll look operated." Yeah, just be open to the discussion of all of that stuff and seek out an experienced surgeon.

Kirstin (22:34):
Okay. Do you have a burning question for Dr. Koehler, Dr. Gardner, or me? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you. Now go back to making Alabama beautiful.

Dr. Koehler (22:49):
Thanks, Kirstin.

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Got a question? Leave us a voicemail at alabamathebeautifulpodcast.com. To learn more about Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.