Facelift Marketing Hype: Fact or Fiction?

Monique Ramsey (00:04):
Welcome everyone. Today we're sitting down with the man of a thousand faces, and actually it's probably literally more than a thousand faces.

Dr. Brahme (00:11):
Yeah, probably.

Monique Ramsey (00:12):
And what does that mean? What do I mean when I'm saying that? I mean Dr. Johan Brahme, who's going to be here on the podcast today, who's been with our center for 20 years, and so we're having this lovely milestone, but he's been perfecting the art of facelifts over 30 years. And so I want him to kind of cut through the marketing hype. There's a lot of stuff out there, especially with social media. So we're going to break down what really matters when it comes to facelift techniques and let's dive into how they are for men versus women. I know Dr. Brahme, you do a lot of facelifts on men. First of all, welcome. Thanks for coming on.

Dr. Brahme (00:53):
My pleasure.

Monique Ramsey (00:54):
We're going to find out why that even matters, why male facelifts might be slightly different. Let's go into the pros and cons of each of the techniques. So let's start first with the mini facelift. And everybody, I can tell you, every listener right now, they're thinking, I want a mini, I don't need a full facelift. Right? I can have a mini. And so when they come to you, who is the mini facelift appropriate for and who not?

Dr. Brahme (01:23):
Before we go into who's good for what, let's go into what the different kinds of facelifts are. And there are probably as many facelifts as there are plastic surgeons because everybody develops their own little tweak on the facelift operation. But what you really want to talk about is what's the depth of the facelift? A mini facelift is usually just tightening the skin a little bit. It's about a two hour operation, and you don't do any really work on the deeper structures. So it's just a little skin nip and tuck. and it looks nice, it looks nice for a shorter period of time because you're only relying on the skin to keep that nice tightness that you have achieved right after surgery. But the fact is that after a year or two, the skin relaxes. It can be a good operation for somebody who's young, and I'm talking in their thirties and forties, who just wants to look a little bit smoother and really doesn't have a serious aging concern with wrinkles and sagging and so on and so forth.

(02:41):
So that's the mini facelift that can often be done just under local anesthesia with a little bit of sedation. And like I said, it doesn't last all that long. The standard facelift that most, I would say probably 80% of people are doing is a SMAS facelift. The SMAS stands for superficial musculoaponeurotic system, and it is the connective tissue that lives deep to the skin and the fat, and it is a very strong layer. And if you tighten that layer, you tighten the skin along with it and you'll see that you'll have a ton of extra skin that you don't need. And it's nice because the tension of the operation is not on the skin. It's on the deeper structures, so it looks more natural. It is more long lasting. And finally, what's along the news cycle right now is a deep plane facelift.

(03:41):
And the deep plane facelift goes one step even deeper than the SMAS facelift. And really the difference is not that great. It's a longer recovery, it's a deeper plane. It is more swelling, and most importantly, it has a higher risk of nerve damage. Now, there are two kinds of nerves in the face. There is the sensory nerves which provide sensation and feeling to the face, and then there's the motor nerve which supplies animation. And those nerves, the motor nerves live deeper, and so they are at higher risk with a deep plane facelift. So those are the three different basic types. They're based on how deep in the layers of your face you go and how long they last. And a good facelift should last about 10 to 12 years, maybe 15. As a patient, when you come and see a doctor, a plastic surgeons for a facelift, you want to see a lot of pictures. You want to make sure that the patient looks like themselves and that you like the pictures. That's really the important thing. And how you get to that point probably doesn't matter very much. It's much more important the aesthetics and the experience of the facelift surgeon rather than what kind of facelift they do.

Monique Ramsey (05:10):
I would think that all of us are so different. Part of what you're looking for, I would think in a facelift surgeon, or at least if you're a surgeon themselves and thinking, if I'm going to go have a facelift who's going to do my surgery? I want somebody who's done a thousand of them. I mean, we did some quick napkin math and we figured conservatively you've done over 1200 facelifts. So in that time, well, we can count these things.

Dr. Brahme (05:37):
Yeah, I know we are very good at that.

Monique Ramsey (05:42):
Data, data, data. With all that though, I would think there's certain times that you approach it and you're like, we're going to do the standard facelift. And you get in there and you're like, oh, okay. How do I want to tackle this particular facial anatomy or something. And do you find that it's very routine or do you find that every so often having some experience has helped you?

Dr. Brahme (06:07):
Oh, the experience is crucial in facelift surgery because it's a very delicate surgery. You're operating on the face and there are nerves and blood vessels and various structures that you have to be very careful not to injure. The thing about having experience is where you can go quickly and where you have to be careful. For example, all the nerves run under the muscle and they run in an organized fashion, so they're predictable where you're going to find them. For the experienced facelift surgeon, a facelift should take about three and a half hours. But then there are a lot of ancillary operations that we do because like you say, everybody's different. Everybody has different concerns. Facial aging is not just about loose skin and sagging skin. It's about volume loss. It's about, for example, the upper lip grows and thins out, so you see predictable things in every aging person. It's just some aging slightly different ways. Their brow may be falling or extra skin bags under the eyes. Everybody ages a little bit differently, but it is pretty predictable. So what you want to do is you want to map out a game plan for that patient. What combination of procedures will give the most pleasing result? I think that experience is a very important thing, much more important than which kind of facelift you do. And there are lots of proprietary facelift, the short scar facelift, the La Jolla facelift, the Quick Facelift, the Scarless Facelift.

Monique Ramsey (07:51):
There's a lot, a lot of buzzwords out there.

Dr. Brahme (07:53):
A lot of buzzwords. Basically it's the layer of the tissues that you manipulate and how you do that and how it turns out in real life.

Monique Ramsey (08:05):
You can call whatever you want.

Dr. Brahme (08:06):
There are no cookie cutter facial surgeries. These are all tailored to the patient, what they want, what their problem is. That's the hallmark of good surgeries, combining the right operations, doing them well and experience.

Monique Ramsey (08:24):
So in those 30 years, I would think that you see things come and go, right? Things come and different techniques go, and it's sort of like you're saying then really the tried and true sometimes is the best way.

Dr. Brahme (08:38):
Yeah, or things evolve in your personal technique over the years because you find that this works really well and is long lasting. So for example, the neck, there are probably 50 ways that people have approached the neck and the neck muscles to smooth these two lines here, which are the ends of a muscle, and then to tighten them. And everybody has their own little way of making the neck as nice as they can. So those are things that you want to look at in the before and after pictures.

Monique Ramsey (09:12):
Now, are there certain techniques over the years where you're like, I just don't want to do that. It's not worth it for whatever reason, or maybe like a natural result, or I think patients are always thinking, I don't want to look like I'm sticking my head out of a car window and having that really pulled thing. How do you address those fears and have there been any techniques that you've tried and thought, no, that's not really the best.

Dr. Brahme (09:38):
There are things that are a little tricky, some that I don't do. There is a gland that sits, a salivary gland that sits under the muscle there. Well, it also sits near a lot of nerves and there are a lot of blood vessels there. Sometimes people trim that little gland and it's pretty high risk. You can have some significant bleeding and actually life-threatening complications from that. So that's not for the faint of heart. The other is removing fat. You want to be extremely careful in removing fat when you're operating on somebody who's say in their fifties, sixties, and so on, because we are going to lose fat as we get older. And sometimes those resections and removal of fat ends up really not looking natural. I've seen people who have had all the fat removed from their neck and it looks strange. It doesn't look natural and tightening the skin too much to where people have that wind blown look. So that's why I say, you really got to look at all the photos. We have hundreds of photos here of patients that I've done, so you can see that they look fine afterwards. They look like themselves.

Monique Ramsey (10:54):
Yeah, I think that's what the goal is for most of us, I think rather than coming in and saying, yeah, I want the lifestyle lift or whatever some of these things are that we've heard from way back, and it's like, does it matter what it's called or does it matter that I

Dr. Brahme (11:08):
How you look.

Monique Ramsey (11:08):
How I look and

Dr. Brahme (11:09):
Yeah, what are the results?

Monique Ramsey (11:11):
I like my result? Exactly. And however the doctor gets me there. So do you find that you have to adjust your approach for somebody who's maybe lost a lot of weight because we are seeing people who, with Ozempic or any of the different branded or non-branded kinds of skinny shots out there, people talk about Ozempic face. Well, I feel like anytime somebody loses a lot of weight, they're going to have lack skin. So in the face, do you approach that differently?

Dr. Brahme (11:41):
You're usually surprised at how much extra skin that people have. A lot of these weight loss patients are fairly young, so their skin has good elasticity. So the face is usually the last thing to go. I mean, the breasts, there's a ton of extra skin, the abdomen, the thighs, and so on. The face is not as much involved because the skin is thicker, the skin has better elasticity. So you can see somebody who's lost a ton of weight, like a hundred pounds, 150 pounds, and their face looks pretty good. But I had somebody the other week and she said, I do this, she'd lost 85 pounds, she said, I do this all the time. I said, well, maybe it's time to do something then if that is what you do.

Monique Ramsey (12:30):
If you keep pulling on your jowls.

Dr. Brahme (12:31):
It's going to look better. You have to be cognizant that there's going to be a lot more skin to be removed. So you have to fit that geometrically, make it look natural, but it's very satisfying. So I'm doing a patient, I think it's next week, and she's 29 and she lost 85 pounds and we've done her breasts, we've done her tummy, and this is what she now is focusing on. And people say she's 29 and she's going to have a facelift? It's not about the age. It's about the condition of the skin and the aging and how patients see themselves.

Monique Ramsey (13:12):
Everybody's completely different in how they're going to if you're losing 85 pounds, and this is something that bothers her.

Dr. Brahme (13:18):
There's been a lot written recently in the Glamor magazines about people having facelifts at a younger age in their forties, and I think that's actually a very good idea because they will look better for longer if you say, well, I'm going to wait till I'm 70 to have a facelift. Well, why would you do that? Do you want to look aged for a while and then have a big transition, or do you want to have a gradual improvement that lasts over time? And I had a facelift about nine years ago and nobody said that to me, and it was one of the best things I've ever done. And also it's good because I can talk to the patients from a patient's point of view how it was for me.

Monique Ramsey (14:04):
Yeah. Now, speaking of men and men having facelifts, Dr. Brahme, you have a lot of male patients, and how are men different? How is their anatomy different than a woman, and what are the things a man needs to look for when they're looking into doing a facial rejuvenation?

Dr. Brahme (14:23):
First of all, men have bigger faces, much bigger faces. I mean, probably 30% bigger than women, and men have more hypertension, they bleed more, they swell more, they bruise more. So the recovery is a little bit longer for a man, but not much. You just basically have to look at the hair growth and see where you put the incisions because men are going to, in some cases, lose some hair, male pattern baldness. And so you don't want to put scars up in the hairline up here because eventually that may be visible. So you have to settle in for a longer operation. Male facelifts usually take four, four and a half hours. But anatomically, their structures are thicker, they hold sutures better, so they have a really, really good results. But men also don't want to look different. You have to be very careful not to feminize men, for example.

(15:27):
Lifting the lip because a lip has grown long is a very feminizing procedure. And so I really don't do that much in men unless it's very blatant. In terms of fat grafting, you want to put the fat in a little different anatomic position than you do in women. But men lose fat as well, so you have to not be overly enthusiastic about removing fat and more judicious about putting fat back in. Anatomically, we all have the same nerves, we all have the same skin, we all have the same structures. It's just some considerations in men that you really want to be cognizant of and talk to your patients about it, especially shaving, for example. When you tighten the neck, you may find yourself shaving behind the ear a little bit, so you may want to do laser hair removal just to cure that problem.

Monique Ramsey (16:23):
Now, how do you manage if a patient has a complication after surgery? Like if they have some nerve injury or scarring isn't quite going the way we would all want. Because how people scar, it's sort of a little bit of an unknown. You do your best work on the table, but then their body takes over. What do you do in the cases where something isn't going perfectly?

Dr. Brahme (16:47):
Well, first of all, facelifts have very low complication rates, very low. Bleeding is less than 1%. I have never seen an infection in a face because the blood supply is so strong. So the major three complications would be nerve injury, bleeding or wound problems. Those are the major three. Wound problems are rare, thank God, because the face, again has such good blood supply that the incisions tend to heal. In some of my patients, you can't even see that incision after a month. Most patients scarring is not a big issue with facelift surgery. That being said, some patients will have scarring, whether it is from sin skin, whether they're smokers, whether they have other underlying diseases, and the skin is very thin. Those patients can have some healing problems. Fortunately, they're not usually serious and they heal fine. The one thing that you have to be aware of and be very judicious with is doing other ancillary procedures. For example, doing lasers at the same time or chemical peels at the same time because you're lifting up the skin and the structures to tighten them. And then if you injure the skin from the surface area by doing lasers and so on, you can cause a burn and you can have some bad wound complications. I've certainly seen that. Nerve injuries, I've never had a permanent nerve injury. I've had a few that were temporary. They almost always come back. It can take a couple of months. They always come back in my hands.

Monique Ramsey (18:34):
That's good. And I think that if anybody out there is listening and you've had a facelift that kind of at the beginning, you're kind of numb. And this is why it doesn't hurt very much.

Dr. Brahme (18:43):
I mean, I was pretty numb for a year.

Monique Ramsey (18:46):
Yeah, me too.

Dr. Brahme (18:47):
And then it's sort of normalized and doesn't bother me, doesn't bother me at all. It's a very easy recovery actually for most patients.

Monique Ramsey (18:56):
So if somebody's thinking, let's say somebody has a texture problem with their skin, so you're going to lift and make things look really great, but maybe they're a candidate for dermabrasion. I know, do you still do dermabrasion? And if you do it, where are the places and do you do it at the same time as a facelift?

Dr. Brahme (19:15):
Yeah, so I certainly do everything that needs to happen in the face, I do it one sitting because it's silly to have to go back. And as long as they're healthy and can tolerate that, we do it all. In terms of dermabrasion, yes, I do dermabrasion a lot, and especially around the mouth. The wrinkles around the mouth are very deep. The skin is very thick, and so you can really make a huge change with dermabrasion around the mouth. And everybody hates what they call the smoker's lines, and those is taking an eraser and just getting rid of them. It's marvelous.

Monique Ramsey (19:52):
You talked about the lip lift and maybe sometimes the chin implant, and we didn't really talk about eyes. And so what percentage of facelifts that you do involve either upper or lower or both?

Dr. Brahme (20:06):
I would say probably 50%. Eyelid structures age, just like the rest of the face. And when you look at the eyes or the orbital area, you have to look at the position of the brow. You have to look and see how much extra skin there is, if there are fat pads that need to be trimmed and so on. So doing upper and lower eyes takes about an hour and a half. That's something that we often do when we're doing a facelift as well, because the whole face ages. I tell people, yeah, your face is going to look great, but in five years you're going to need to do your eyes, so why not just do it at the same time?

Monique Ramsey (20:43):
And have everything kind of get refreshed.

Dr. Brahme (20:45):
Have everything done. Yeah.

Monique Ramsey (20:48):
So Dr. Brahme over 1200 facelifts, what would your advice be to somebody who's thinking about facial rejuvenation with a facelift, whether it's a mini or if it's whatever kind.

Dr. Brahme (21:05):
Or whatever.

Monique Ramsey (21:06):
Yeah, right. There's too many. But what would your advice be to them on how to find the right surgeon?

Dr. Brahme (21:12):
This is a very good question because I think it's really key. The public needs to be a little bit educated. So you want to go to a board certified specialist, and there are boards that are recognized by the American Board of Medical Specialties. Plastic Surgery is a board that's recognized. Facial plastic surgery is a board that's recognized, and these are examinations and levels of achievement in education that are challenging to get to. And so that's the first thing. Some people say, I'm a board certified cosmetic surgeon. There's no such thing. There's no board of cosmetic surgery. You can pay $500 to the board and get your board certification. So it doesn't mean anything in terms of education or competency. So the boards that you want to look for are plastic surgery or facial plastic surgery. And then I tell people, you have to make sure that the facility that they operate is board certified, that you have the highest safety record, that you use anesthesiologist, although many nurse anesthetists are very competent, but the highest level of service in anesthesia is a board certified anesthesiologist. And all our anesthesiologists are board certified. You have to look at the pictures, like I keep emphasizing, what do they look like? Do you like the pictures? If you don't like the pictures probably is not the right fit for you. And then finally, once you've checked all the basics, it comes down to the personality. Did you click with this person? Do you think this person could do a good job for you? Or if something happens, do you think this person will stay with you and get you through the process? So I think that it is both an educational thing, an experience thing, and also a personal thing. How well do you fit?

Monique Ramsey (23:19):
I think the buzzwords out there in terms of all these different trademarked facelift things that can sound sexy and sound important and sound fabulous, but the proof is in the pudding in the photos, right?

Dr. Brahme (23:35):
Absolutely. I think all these proprietary names, they're sort of confusing. I get people coming into me and say, well, what about the S lift? I said, I dunno what the S lift is. And there are probably dozens of S lifts and they're all different. The basic surgery is the same. It's what you do underneath the skin.

Monique Ramsey (23:57):
If you're listening today and you've found it to be an interesting topic, we'll put in the show notes, we'll put links to the gallery so you can see all the different facelifts that Dr. Brahme has done, the thousands of them. We don't have every case on the website because not everybody wants to have their face up there. But of our very kind patients, we have very kind patients who allow us to use their photos on the website. And then we have another group of patients who don't want to be on the website, but they'll let you see their before and afters when you come in for your consultation.

Dr. Brahme (24:30):
We have many more pictures in the office than we do on the website because people are more comfortable to have their picture up in the office rather than out floating on the internet.

Monique Ramsey (24:41):
Well, thanks Dr. Brahme, and thanks for being our man of a thousand faces or 1,200, and we're looking forward to the next time we have you on the podcast. And thanks all of you for listening today. Thanks. Bye-bye.

Dr. Brahme (24:57):
Thanks. It was a pleasure. See you soon, Monique.

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