Why the Fancy Name of Your Face Lift Surgery Doesn’t Matter

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:11):
Hey, Dr. Koehler.

Dr. Koehler (00:13):
Hey, Kirstin.

Kirstin (00:15):
You want to know what we're talking about today?

Dr. Koehler (00:18):
Please tell me. What are we talking about?

Kirstin (00:20):
We are talking about all the different buzzy names for facelifts and the things that people make up and come up with that are probably the same exact thing as something else.

Dr. Koehler (00:33):
Unless it's the Koehler lift, right. Then that's totally different.

Kirstin (00:37):
We weren't going to talk about that yet.

Dr. Koehler (00:38):
Oh, okay. Yeah,

Kirstin (00:40):
That's still under wraps. The trademark hasn't come through.

Dr. Koehler (00:44):
Okay, good.

Kirstin (00:46):
Okay, so there are so many types of facelifts out there.

Dr. Koehler (00:51):
Yep.

Kirstin (00:52):
I'm going to talk about some. You ready?

Dr. Koehler (00:56):
Sure.

Kirstin (00:57):
All the names for facelifts out there are rhytidectomy facelift, facial rhytidectomy, cervicofacial rhytidectomy, SMAS facelift, deep plane facelift mini facelift, short scar facelift, S lift, weakened facelift, mid facelift. I can't even get through 'em all. There's still a whole half of a list to go, thread lifts, max fifts, composite facelift. I don't even know if I said those correctly. Which of those are real?

Dr. Koehler (01:23):
Well, they're all real. Not all of 'em are real good, but they're all real. There's been a real evolution of the techniques for facelift. Many years ago when it was first, facelifting was first being played with, it was a skin only really just removing a little skin and tightening the side of the face. And now we're at a place where we're really going into the deeper structures and repositioning tissues in a different way. So there's been an evolution that has occurred, but along the way there's been lots of spinoffs, some of it from a marketing perspective, but some of it just from a people trying to create less invasive potentially ways of achieving results.

(02:21):
Yeah. Well, there's really kind of, lemme back up, there's sort of two things. There's the evolution of facelift, and along the way, like I said, there's different spinoffs where people try to do maybe a less invasive version of the technique. And then there's another subset of that, which is where it's the marketing component of surgery where people try to trademark names that sound catchy, that are really, you can't trademark a surgery, but you can trademark a name. And then, so for instance, if the lifestyle lift or something like that, I can't market and say I do the lifestyle lift because that's trademarked, but if I pay the company that does the lifestyle lift, then I could use that term and do that surgery. Now, some of these trademark procedures have certain requirements. If you want to be a doctor for some of these lunchtime facelift things, you have to do the procedure, for instance, under oral sedation or IV sedation, not general anesthesia. And the procedure needs to be performed in a certain period of time.

(03:36):
And so there's certain requirements that they've used as part of their marketing thing. But the actual surgery itself, you can't trademark a surgery. If somebody said, okay, this is how we do the lifestyle lift, I could do that exact same surgery and I just can't call it a lifestyle lift. But that being said, a lot of those catchy marketing kind of facelifts, just like a lot of things, it comes down to the doctor. There's some good surgeons that can do some really good surgery even with these sort of less invasive procedures. But ultimately, in my opinion, there's sort of a handful of those procedures on that list that are really the workhorses of facelift surgery.

Kirstin (04:26):
All right. Out of that list that we just kind of ran through, are there any that are different from each other? Are they all actually the same thing? Or like a SMAS facelift, a deep plane facelift, mini facelift? Are those all different?

Dr. Koehler (04:41):
Yeah, they're all different.

Kirstin (04:42):
Okay. Let's talk about it.

Dr. Koehler (04:43):
Well, yeah, they're different and it does start to get a little bit confusing until you really understand the anatomy. But I will just say this, that of the list that you gave me, there were several of them, like a SMASectomy, the composite face lift, a deep plane face lift. I mean, there's a bunch of them on there that are, I would say that these are kind of commonplace workhorse type surgical facelifts. The SMASectomy is probably the one that most people train, they're trained to do in residency and in fellowship, almost every surgeon knows how to do a SMASectomy. And that is really when I started doing facelift surgery, that was a big part of, I did a lateral SMAtectomy, and there's a lot of people that argue that you can get just as good a results with a lateral SMASectomy as you can with a deep plane facelift.

(05:47):
And I can mean that's an interesting discussion amongst surgeons. But yeah, a composite facelift that's been around since the eighties and the surgeon that developed that, it is really, in essence, it's a deep plane facelift with some nuances. And now again, this would be a surgeon's discussion, but it's is a deep plane type of facelift where we're going into the deeper structures, releasing the ligaments of the face, repositioning those deeper structures. So yeah, they're good procedures. I think the deeper plain facelifts are facelifts that definitely come with more experienced surgeons that understand the anatomy, whereas like a SMASectomy, although you may understand the anatomy, the SMASectomy is a procedure that it's definitely a safer operation, although if not done well, it can have its own set of problems. But the deep plane face left definitely requires a different understanding of the anatomy. And I think the biggest thing to understand is that it really oftentimes comes down to the surgeon's hands or their abilities because even you take two doctors that say, well, we both do deep plane facelift, well, they may both do deep plane facelifting, but there can be significant little subtle differences on how they do their deep plane facelift. It's not like a cookie cutter. You have to do these five things, and that makes it a deep plane. There's a lot of variations in this. And even just the artistic part of the procedure, which vector do I reposition the face? One surgeon may reposition it more vertically, one may position it more horizontally. And these are the artistic things that the surgeon and their experience. And that's why you could get two different results from two surgeons that both did a deep plane facelift. So

Kirstin (08:01):
Are names like QuickLift and Swift Lift, are those just clever branding or do they actually represent different approaches?

Dr. Koehler (08:11):
Again, it's trademarking a name, and those are kind of types of mini facelifts. And unfortunately, I'm not a huge fan of mini facelifts. I think there is a place maybe for a mini facelift in let's say younger patients, maybe in their forties that have some laxity that don't have a lot of jowling, but would like to see some tightening. I'm not saying it's a bad procedure. It doesn't give the same kind of benefits that you can get from some of the other procedures like a lateral SMASectomy or a deep plane facelift. I think there's also sometimes a perception issue. People are inclined to feel that somehow if it's minimal or minimally invasive or mini or any of those terms are used in the procedure, that somehow that implies a safer procedure with less risk and less problems and complications. And maybe in some cases that could be partially true, but like thread lifts, I'm definitely an anti thread lift person.

(09:15):
I've seen the evolution of threads and unfortunately, I think thread lifts just tend to fall into the hands of people who don't really know how to do facelift surgeries or don't do facelift surgeries, but want to offer people those non-surgical procedures. Because lots of people want the results of a facelift they just don't want to have a surgery. And the problem is those threads, I mean, the original ones were pulled off the market and people had threads extruding out of their face, and there were permanent sutures. And when they smiled, you could see all these lines from where the threads were. And I mean, it's like they weren't benign. I mean, they had problems. And so even though it was not a true surgical procedure, they had complications enough to where they ended up getting taken off the market. So again, mini facelifts in the right patient with the right surgeon, I have absolutely seen some really nice results from some of these mini facelifts, quick lifts, all that kind of stuff in good surgeon's hands, and right, patient selection, it can be good.

Kirstin (10:20):
Since there are so many names and buzzwords and things out there, if someone was researching facelifts, what should they pay attention to beyond the buzzwords?

Dr. Koehler (10:31):
Well, I think beyond the buzzwords is really doctor reputation, looking at their results. Those are the kinds of things. I know some really good surgeons that now do deep plane facelifts that earlier on in their career were not doing deep plane facelifts and had very happy patients and got great results. And so you don't necessarily, and unfortunately right now the deep plane is the buzzword. There were other things like maybe QuickLift had its moment and lifestyle lift had its moment, but now everybody wants the deep plane facelift. And so just because somebody says they do deep plane facelifts, as I mentioned, there can be significant differences in the actual, how you execute that procedure. So really it's a matter of looking at the doctor's work and maybe looking at reviews and patient testimonials and then going and visiting and seeing your comfort level with that doctor.

(11:24):
But yeah, it's hard. And it would be the same for any other surgery, like rhinoplasty. You can do a closed rhinoplasty or an open rhinoplasty, and that means the incisions are all on inside the nose, it's closed, and if you make an incision on the outside, it's open. But then there's a whole bunch of different ways that you can do that nose surgery. And so if somebody says, well I do an open rhinoplasty? I mean, it really doesn't mean that much. It means, okay that the incisions here, but the rest of it could be done completely differently by four different doctors. So it really kind of comes down to if you kind of like the work that you see that doctor does then, and they've been doing it for a significant period of time, and you have that confidence in their ability, then those are the kinds of things you got to look at.

Kirstin (12:19):
Alright. Well, let's talk about you and your technique. How have your facelifts changed over the years?

Dr. Koehler (12:27):
Yeah, they've changed a lot over the years. And it's interesting that some of the people that I teach courses with, it's like every year when we meet to teach a course, we've all made little adjustments and it's never stagnant. In fact, every year it might be, oh, I used to suture it this way and now I do this. And I think it's partly because we're all seeking to get that perfect result. And there's parts of our procedures that we find, okay, this gives us a consistently good result. But sometimes in certain patients, maybe we don't get as good of outcome in certain areas. And so we're always looking to finesse and make that a little bit better. So even amongst all these people that I highly respect that are great surgeons, it's like they're excellent surgeons, but if you ask 'em how they were doing it three years ago, they've changed it.

(13:20):
And so I don't know what to tell you there, except for when I first started, it was probably more of a SMASectomy type of a procedure. But I also used to do a very aggressive neck work, and I used to do a lot of skin undermining. And as a result, I always ended up putting drains in the neck because I was doing a lot of, I was pretty aggressive in the neck to get good neck and jawline contour. And so now it's kind of flipped. I do a deep plane, which is actually less skin undermining in a lot of ways. And I do a preservation deep plane facelift, which means there's even less skin undermining. So I don't do nearly as much skin dissection, but I'm doing some more aggressive things in the deeper layers. But as a result, with the evolution in this deep plane facelifting, it is a procedure that requires more skill.

(14:17):
And even though it is in many ways more aggressive, if, I don't even know if that's the right word, but it's more involved, the recovery on these patients is actually quicker than some of the procedures that we were, I mean, like a SMASectomy, I've seen better quicker recoveries than the SMASectomy procedures. So yeah, I think in the long term, the results have gotten better and the recovery's gotten better. We've gotten rid of drains and a procedure that continues to evolve. I mean, facelift again from eighties, nineties, two thousands, and where we are now, it continues to change. And surgeons expertise, the knowledge that comes from the advances that multiple surgeons from multiple specialties bring has made the procedure safer and better with time.

Kirstin (15:18):
Were you facelifting in the eighties?

Dr. Koehler (15:21):
No, but I was in the, definitely was around in the eighties, eighties were a great time. You weren't even born yet.

Kirstin (15:26):
Yeah, I wouldn't know about that.

Dr. Koehler (15:28):
No. But the eighties were good. I liked the eighties a lot.

Kirstin (15:32):
Is there anything that you do subtly or just small tweaks that you make during a facelift that people wouldn't know about but make a big difference?

Dr. Koehler (15:44):
Well, I mean, I don't know that it's anything totally unique to me, but I think the things that you hear people doing submandibular gland work where we sort of shave down the hanging part of the gland, that's something that I actually wrote a publication on with my partner surgical that I was in practice with. We were doing it probably not, well, I wasn't doing it very often, but it was something that we did on occasions to help people, especially if they had a really heavy necks to try to get 'em a better contour. And we wrote a paper on it in 2005, and back then not a lot of people were doing it. And even then it was kind of one of those procedures that it would make you a little anxious because it takes a little bit of surgical skill to do that. It can get a little bloody and stuff.

(16:42):
But nowadays, we've got some advanced techniques on how we can do it, and it's actually very safe and it can be done well. And so those are little finesse things that can help us get better neck contours. And that's not something that every surgeon does, although I'll say now, it's definitely way more popular because we've been teaching the courses and people want to learn how to do that because it can help enhance jawlines. As we get older, parts of that gland that are sitting in the floor of the mouth kind of drop down. And even though you can tighten the muscle, sometimes even after you tighten everything up, you can kind of see a little bulge in the neck, and that's the gland. And so we don't take the gland out completely. We just kind of take out the part that's hanging down.

Kirstin (17:25):
All right. Let's talk real quick about male facelifts. Is there anything about doing a facelift on a man that's different than on a woman? Or thicker skin or facial hair or anything that makes it more challenging?

Dr. Koehler (17:41):
Yeah. Well, definitely male facelifts tend to bleed a lot more than women. And a lot of it is because they do have beard hair, and the blood supply is more robust, that dermal plexus that supplies to allow all this hair to grow. So definitely the rate of hematomas where we have to maybe take a patient back to the operating room because they have some bleeding is much higher. Well, not much higher, but it's higher in men for sure. So sometimes we'll do, we're more likely to put a drain in a male patient, or we'll do some netting that sometimes you'll see, I dunno if you've seen pictures of where people put these sort of, it looks like hell raiser, but they've got sutures on the outside of the skin that just have it all netted down. It's called a hemostatic net. And that hemostatic net is just to prevent blood from accumulating.

(18:35):
And those sutures stay under the skin for or on the outside of the skin for just a few days, and then you take 'em out. It doesn't leave any permanent marks or anything like that, but it just helps prevent blood accumulation under the skin. So that's something that is often considered more common if you're dealing with a male patient because they're more prone to have some bleeding issues and the male patient to get a good chin neck contour. Sometimes the heavier neck, we may have to be a little more aggressive with maybe taking out some of the, or shaving down some of the muscles in the neck to kind of help get our contour the way we want it. But really, the principles are similar, but also in men, because they have beard hair, we have to place our incisions a little different in front of the ear, because if you were to do a facelift on me, if I put that incision in the crease of my ear and then I pull this back, now all of a sudden I got, well, I already have enough hair growing on my ear, but I don't want it growing on my tragus too.

(19:41):
So for men, we will put that incision a little bit in front of the ear so that we're not repositioning beard hair onto an area that normally would not have hair. And then incision, I think closure, we close it meticulously for men and women. But the difference is most women, well, some women wear their hair short or pulled back. So the incision placement and the closure is always important. But in men, most men wear their hair short or they don't even have very thick hair. So we have to really pay attention to that closure because it's not like, oh, they can wear their hair down or it's harder to conceal it.

Kirstin (20:23):
Do you have to do things differently maybe like for example, in the upper face to avoid giving men an overly done look? I know we kind of talked about it before in another podcast, but don't you do something differently up here that way their brows are a little bit heavier. Women want the lifted brow.

Dr. Koehler (20:42):
Well, yeah. If you just look at men in general, men, they don't arched brows and they don't have brows that are really raised up. And so yes, you can do a brow lift on a man, but you don't want to create a big arched brow, and you don't want to create an over elevated brow. That feminizes the upper face. And there's no question that we talked about it before. I've seen pictures of Kenny Rogers, his neck looks fine, but the eyelids and stuff, to me, his brows were always low. I think they look higher. And I mean, it's a personal taste. I think it feminizes the face. I don't think it makes it masculine.

Kirstin (21:33):
All right. I just got an idea for a podcast.

Dr. Koehler (21:35):
Okay, good.

Kirstin (21:36):
We'll talk about it later. I forgot to talk about the lift and fill philosophy. So we kind of, were going to talk about volume loss and how the idea of volume loss has changed over the years, but sometimes I know everybody comes in here, I need filler under my eyes. I need filler here. I need filler there. A lot of that is thanks to social media, but sometimes you recommend fat instead, especially with facelifts, right?

Dr. Koehler (22:04):
Oh, always. Fat is definitely the best filler. It's your own body. What we're going to have that stays is going to be there hopefully for quite a long time. You'll see some of it resorb, but what does stay will last a long time. Definitely, it isn't just pulling things tight. It does involve adding volume in the places that need it, and fat is just a great, great filler. So yes, we recommend that on a lot of faces. Some patients just, they're not maybe as interested in doing fat, and I don't know, sometimes people have fears about that they're going to come out with fat faces. I mean, that's just not the case. I mean, the fat is a finesse thing. It's really not a, if you made that the main part of the procedure, I think you'd just be disappointed if you said, I just want to go in and get fat, facial fat grafting. I mean, I think most people would be like, oh, I was really hoping to get a lot more out of it. It's going to benefit you, but it's kind of a icing on the cake kind of thing.

Kirstin (23:03):
It's not a BBL for your face.

Dr. Koehler (23:05):
No.

Kirstin (23:08):
Okay. Do you have anything else to add?

Dr. Koehler (23:14):
I feel like we've talked about a lot of this stuff before. It's important stuff.

Kirstin (23:19):
Yeah.

Dr. Koehler (23:20):
Yeah. I got nothing.

Kirstin (23:21):
All right. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at Alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (23:35):
Thanks, Kristen.

Kirstin (23:35):
Go back to making Alabama beautiful.

Dr. Koehler (23:37):
I'm on it.

Announcer (23:41):
Got a question for Dr. Koehler? Leave us a voicemail at Alabamathebeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and 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, theaxis.io.