In previous chapters, Dr. Howard Tobin has reviewed a number of options that are available for patients considering facial rejuvenation. How does a patient decide what options are best? There is no one answer for everyone, and this is where a personal consultation is often necessary.

In making a decision, there are three basic steps that need to be taken:

1. Defining the goals of surgery.
2. Evaluating risks and recovery
3. Considering the cost of surgery.

Let’s discuss each of these in turn.

GOALS OF SURGERY

While patients often come in for consultation saying they just “want to look better,” most people have some idea of what is bothering them about their appearance. For example, some patients say that they have noticed their neck sagging, or perhaps their main concern is their brow or forehead. If their concern is localized to certain areas, then the surgical plan should focus on that area. There is no reason to consider eyelid surgery, if a patient has no problem around the eyes.

On the other hand, patients must realize that there is no single universal operation that will correct everything. If the entire face is sagging and the patient seeks maximum improvement, then a combination of procedures will be needed. Our general approach to this is what we call a “full face rejuvenation.” It consists of a combination of a forehead or brow lift, traditional lower facelift and blepharoplasty — a rather formidable combination, but one that provides the best overall rejuvenation.

We feel that it is essential to get the input of our patients before making specific recommendations. While often patients assume that because of our experience, we can look at a patient and determine the best course of action, in truth, cosmetic surgery is primarily intended to help patients feel better about their own looks. Unless we know what is troubling you, it is difficult to make specific recommendation. Remember, while it is important how you look to others, of far greater importance is how you look to yourself.

RISK AND RECOVERY

Assuming that one is looking for a full and balanced rejuvenation of the entire face, there are still choices that must be made. Every procedure has risk and every procedure requires time for healing and recovery. It stands to reason that, the more you do, the longer it will take to recover, and the more risk you must take. For that reason, some patients may have to temper their desire for the best possible result with their inability to take the required time for recovery, or their unwillingness to accept certain risks that go with a given procedure. For example, if the patient is seeking improvement of the entire face, he or she may choose to substitute an endoscopic forehead lift instead of an extended subperiosteal coronal lift. While the later may give a somewhat stronger lift, the endoscopic lift allows for quicker recovery.

ENDOSCOPIC SURGERY

Quick recovery is one reason why the endoscopic forehead lift is proving so popular. This operation allows significant rejuvenation of the forehead and brow while avoiding the long incisions that are required for subperiosteal or coronal lifts. Granted, it will not provide the same result that a subperiosteal lift does, or even an open coronal lift, but, for many patients, the quick recovery and lack of long incisions make it a valid alternative.

There are other situations where a simple procedure can be substituted for a more extensive operation Examples include choosing neck liposuction or necklift instead of a facelift. While there are always limitations to the effectiveness of the simpler procedure, these options often deserve consideration. Unfortunately, patients sometimes are lulled into thinking that there is a simple operation that will do the same thing as a more extensive procedure. This is rarely the case, in spite of glowing reports of new procedures that appear regularly in the lay press.

Deciding between techniques available for upper face rejuvenation can be especially difficult. Options include eyelid surgery (blepharoplasty), endoscopic forehead lifting and the more comprehensive extended subperiosteal coronal lift. Here we will focus on choosing between the later two options.

DECIDING BETWEEN A SUBPERIOSTEAL AND ENDOSCOPIC LIFT

Both the subperiosteal lift and the endoscopic brow lift are operations designed to lift the forehead and brow, but beyond that, there are major differences between the techniques.

The endoscopic brow lift is a modern technique that evolved from the older traditional coronal or forehead lift. Instead of using an incision across the top of the head, a series of small incisions are made just above the hairline, with an additional small incision at the top of the head. These incisions vary from less than a half to one inch in length. Using lighted telescopes and a small videocamera, the forehead, temple and brow tissue is separated from the underlying bone, elevated upward and backward, and fixed by sutures that hold the tissue in place. The primary effect is to raise and stabilize the brow to minimize forehead wrinkling and sagging. There is also some elevation of the temple tissues and very slight elevation of the corner of the eye.

The subperiosteal lift also developed from the older coronal lift, but in this case, the development was in a different direction. Instead of moving in a more conservative direction, this operation takes a more aggressive approach involving downward dissection into the mid and upper face. Not only are the brow and forehead elevated and supported, but also the soft tissue of the mid face is addressed. There is even some improvement down to the jaw line. There is distinct improvement around the corner of the eye and over the cheekbone area.

The advantage of the endoscopic operation is primarily related to the low risk of complications, and the fact that recovery is usually prompt. The subperiosteal lift on the other hand can result in longer recovery. While experience has reduced the risk of complications with this operation, there still does remain some added risk of nerve damage that can cause weakness of the forehead muscles.

COST

And now a word about that unpleasant subject — money! Nothing worthwhile in life is free, and cosmetic surgery is no exception. The bigger the operation, the higher the cost. While it is certainly true that combining several procedures will lead to cost savings in the form of reduced surgical, operating and anesthesia fees, still, the ideal program may remain beyond the means of some patients. Here again, a simpler operation may do the trick, even if the overall result may not be quite as good.

THE BOTTOM LINE

As you can see, the decision can be quite difficult. For patients who want the best and are willing to sacrifice to achieve it, we will usually begin by considering a traditional facelift and eyelid surgery. This is often combined with other adjuncts such as chin or cheekbone augmentation or perhaps laser resurfacing, which is discussed below. If this seems too much, then the next step is to try to focus on what concerns you the most. When the upper face is of most concern, our first recommendation may well be a subperiosteal lift

A detailed consultation is certainly the first step, and if you do some homework before the appointment, you will gain even more. This book can be of help to you in considering options. It will aid you in your thinking and assist you in choosing the proper questions to ask during your consultation.