MIRABELLA
NEED A LIFT?
In plastic surgeons’ offices across America, one scenario gets played out day after day: a well-tended woman in her late forties or early fifties has a consult. This is not her first time under the knife. When her eyes began to sag in her late thirties or early forties, she had an eye lift. Now, a decade later, her eyes crinkle again, her forehead droops. She wants a brow lift. “But if I pull her brow up, she can’t close her eyes,” says Thomas Romo, M.D., chief of facial plastic and reconstructive surgery at New York’s Lenox Hill Hospital. “Her doctor whacked too much skin out of her lids.” Surgery is, consequently, out of the question, or must be far more conservative. “Now that women are getting procedures so much younger and living so much longer, planning is more important than ever,” Romo says. “I mean, taking a thirty-somthing woman and giving her a fifty-year eyelid problem? Horrible!”
By now, everyone has heard (or seen) such a horror story, just as we’ve all known someone who emerged from the operating room like a Venus on the half shell, a subtly but-gloriously-rejuvenated version of herself. Anyone who daydreams about plastic surgery, of course, envisions an outcome similar to the latter scenario. And while there are no guarantees in elective operations, doctors say the right procedures, in the right sequence, and performed by the right physician, are the keys to success.
In their thirties and early forties, women often still choose an eye lift as a first procedure: not only is it a kinder, gender operation, but “90 to 95 percent of the time, the eyes are the first to go,” says Bernard Markowitz, M.D., associate professor of plastic surgery at UCLA. But most surgeons no longer cut large slices out of the upper lids (and none from the lower lids) of these patients because they have not yet developed enough sagging, and that approach can create a drooping look to the lower lid as the face ages. These days, doctors remove fat pads from the inside of the lower lids, or by taking out some of the upper-lid skin and laser resurfacing the area to erase crow’s feet.
Of course, surgeons may not touch the eyes at all, opting instead to give patients a brow lift. “You have to make sure you're offering the right procedure for the diagnosis,” says Romo. “If she has excess lid skin, she should have an eye lift. If she has a brow that's fallen, giving the illusion of droopy eyes, she should have a brow lift.”
One way surgeons make this diagnosis is to feel the brow and see if it rests above, on, or below the bone—anything below would indicate a dropped brow. An “open” brow lift, in which a surgeon makes an incision in the scalp from ear to ear, lifting and tightening skin, is the gold standard. However, this is a more involved procedure with significant recovery time. Younger women may not be psychologically ready for such a radical operation. A compromise may be the newer, less invasive endoscopic brow lift, in which several small incisions are made in the scalp, and an endoscope is used to raise the brow, anchoring it to the skull with titanium tacks. There’s a shorter recovery time and less trauma to patients. But this, too, is an imperfect method with inconsistent results. “A young woman who needs a brow lift, I’ll do it endoscopically, because the tissues are firm and a less invasive approach can be effective,” says David Hidalgo, M.D., chief of plastic surgery at New York’s Memorial Sloan-Kettering Hospital. “A sixty-five-year-old has more to correct and the tissues aren’t as good, so I’ll use the open technique.”
In general, surgeons recommend that younger, first time patients undergo procedures for features that have always bothered them and that have been exacerbated by subtle aging. “Of the thirty-somethings I see for eye lifts, it’s mostly women who have always had sleepy eyes,” says Thomas Loeb, M.D., a plastic surgeon in New York. Liposuction to remove a double chin that has started to jiggle a bit more alarmingly is both a popular first procedure and wise planning, says Romo. “A young person still has skin that will snap back after liposuction. But a woman older than forty-five will need to cut some skin out, too, or she’ll have a turkey neck.” If a weak chin is contributing to a prematurely sagging neck and jowl, Romo suggests a very thin chin implant, or “a thin Gore-Tex wafer,” as he likes to call it in front of skittish patients. “Since it sits on the chin bone, underneath the skin, it won’t be affected by later surgery or aging,” he says.
Injectables—such as Botox, collagen, and fat—for forehead furrows, nasolabial folds, and lip lines are another typical entree into cosmetic surgery. Botox and collagen offer temporary solutions and are safe for patients of all ages. But whether more permanent plumpers— such as fat, Alloderm (skin harvested from cadavers, stripped of cells, and used like an implant), and Soft Form (Teflon implants that get inserted in lips and nasolabial folds)—are compatible with later face-lifts is still somewhat under debate. For instance, many doctors believe that the skin on the lower section of the face moves during a face-lift and that any prior implants might then create strange bumps under the skin. Thus, as injectables become permanent—Romo is currently working with an experimental form of Alloderm, which could work like collagen that doesn’t wear off—patients need to be more cautious about procedures that don’t replace a face-lift (nothing does), but do rule it out.
By the time women reach their late forties and fifties, they begin to see more serious signs of aging—lines deepen into wrinkles, the brow falls, jowls form, nasolabial folds and marionette lines (from the corner of the mouth to the chin) develop, and the neck gets loose and corded-looking. They also start to undergo more serious procedures like face-lifts and laser resurfacing. Surgeons divide the face into three sections: the upper, from the hairline to the eyebrow; the middle, from the eyes to the corner of the jaw; and the lower, from the jaw to the clavicle. And while most people think a face-lift tightens the whole face, in truth, it affects only the middle and lower portions. A brow or eye lift rejuvenates the upper area. An operation often called a “minilift” affects the middle portion only. Again, patients must be careful that their “cure” matches their diagnosis, and that the operation doesn’t alleviate aging in one area of the face only to highlight it in another. “I usually don’t do minilifts because patients don’t get enough benefit,” says Markowitz. “You get an unbalanced look, with tightness in your cheek but a loose neck and forehead. You’re creating deformities rather than harmony.”
To tighten and smooth fine lines, patients also frequently need laser resurfacing. “Otherwise, it’s like trying to make an alligator bag smooth by pulling on it,” says Romo. Carbon dioxide laser resurfacing, and the lengthy healing process that accompanies it, remains the most effective laser procedure. “We hoped the [newer] erbium laser would have the same effects as the carbon dioxide laser but with faster healing,” says Alan Matarasso, M.D., associate clinical professor of plastic surgery at New York’s Albert Einstein College of Medicine. “But the latest studies show it may not be as effective.”
Once women have spent so much time and money ridding themselves of wrinkles, the new concern is: How long will this last? “It is not like a stitch drops and the whole thing falls back down,” says Loeb. “But the clock does keep going.” The speed of that clock depends upon the same factors as always: sun exposure, cigarette smoking, rapid weight loss and gain, genetics, and age. For example, a woman who has a brow or eye lift at forty will probably be set for ten to fifteen years. A woman who has a brow lift in her fifties might find it lasts half as long. Women age more drastically after menopause, and surgery doesn’t stop that—which means that women who start young and get hooked on surgery could find themselves going in for (several) repeat procedures.
How long will a lift last? “It’s not like a stitch drops one day and the whole thing falls back down,” says Dr. Thomas Loeb.
The idea of numerous trips to the surgeon calls to mind society matrons so yanked they look as though they’re experiencing extreme G-force. To ease the mind of patients who worry about looking artificial, surgeons use computer imaging to help them visualize changes, emphasizing, however, that the images are guides and not guarantees.
Some procedures, in fact, are meant to change features: nose jobs, some facial implants, a type of face-life called a subperiosteal (where tissues are actually detached from the bone and lifted), and an eye lift called a canthopexy (it’s what Jocelyne Wildenstein did to her eyes—enough said). Women who undergo these operations should be sure radical alteration is what they're after—and a good doctor would not push them on patients looking to merely alleviate aging.
Of course, finding a good doctor can be the biggest challenge of all. The best resource is word of mouth from friends and beauty professionals such as hair stylists or facialists. Make sure the doctor is a board-certified plastic surgeon (call the American Board of Medical Specialties at 800-776-2378), although dermatologists can often be more experienced at procedures like laser resurfacing. Cosmetic surgery is very lucrative, since it’s usually not covered by insurance. According to the American Society of Plastic and Reconstructive Surgeons, examples of national average surgical fees in 1997 were $2,905 for eye lifts and $4,783 for face-lifts, not including anesthesia, operating room, medical photographs, nurses, and medication—and these fees are much lower than those in major cities. Remember, any doctor can legally perform surgery, therefore profitability can make it appealing to less qualified physicians looking to ease managed care’s pinch. So before a doctor picks up a scalpel, make sure he’s not cutting corners.