Subtlety is the new standard in cosmetic surgery. Stars and everyday clients alike are embracing advanced facelift techniques that deliver natural, refined results without obvious signs of enhancement. Dr. Mike Roskies, a double fellowship-trained facial plastic surgeon, shares insights on the growing demand for “undetectable” lifts and the procedures shaping this modern aesthetic era. —Noa Nichol
Could you explain the “Ponytail Lift” and what makes it a popular choice among patients seeking a refreshed look without drastic changes?
The “Ponytail Lift” is one form of endoscopic facelift that has been trademarked and popularized by a surgeon in the U.S. Some other surgeons will market it as a “scarless” facelift. The goal of this surgery is to mimic the look one gets when making a tight ponytail. So, as you can imagine, much of the outcome is centred on the upper face including the brow and upper eyelids.
The biggest upside to the technique, and one that I’ve adopted for my patients, is that placing an incision very high up on the face (hidden in the temple hairline) creates a vertical vector of lifting which is the most natural and durable direction to lift a face.
The downsides of the technique are that it cannot remove very much skin in a natural way and can lead to temporary and unnatural bunching of the skin at the temples. Additionally, it won’t treat the neck unless you add incisions under the chin and behind the ears (which many surgeons will do, but it won’t be part of their “scarless” approach).
I’m not a huge fan of the endoscopic lift at this point as I think more details need to be worked out. It’s a fair technique for patients with mild aging who really wish to address the upper third of their face.
The mini facelift and deep plane facelift each offer unique benefits. For someone unsure of which option suits them, what are the key differences, and how do you guide patients in making this choice?
The term “mini” lift is another layperson marketing term used by surgeons to mean one of three things: 1. Less dissection 2. Less recovery or 3. Shorter scars.
When I first started, I also used the term mini-lift which was really a short-scar deep plane facelift. If a surgeon is doing less dissection and promising less recovery, you’re going to sacrifice the result. Many patients will ask me to keep scars shorter but still get them the same result and my answer to them is “you’d never get on a plane and ask the pilot who usually flies at 35,000 feet to fly at 20,000 today”.
I would encourage people looking into surgery to understand the medical terms rather than the layperson terms so that they know exactly what their surgeon is referring to. Avoid marketing terms at all costs.
A deep plane facelift goes underneath the connective sheath of muscle that envelops the whole face from temple down to the neck. By going “deep” to this plane, we can release ligaments and reposition the face and neck as one composite structure. It leads to more natural looking results. Since the 1990s, the deep plane facelift has rivalled traditional techniques and with the advent of social media, it has become the preferred method of lifting faces. Surgeons can argue about technique at conferences until they’re blue in the face, but the proof is in the “before and afters” and the deep plane has emerged victorious.
The concept of undetectable work is becoming more prominent. What are some of the techniques or advancements that have helped make facelifts appear more natural and unnoticeable?
For me, the way to keep things undetectable is simple: have a plan.
The reason why we focus on celebrity plastic surgery is because it’s sometimes just too obvious. I think the reason for this is that many celebrities don’t have the luxury of significant downtime and so they try to pack in many treatments when they’re not shooting or on tour.
The approach to the face in the surgery suite or medspa should be the same as how we approach our bodies in the gym. First, find someone you trust to guide you. Second, define your goals and timelines. Third, build over time.
The undetectable celebrities like Christina Aguilera have been out of the spotlight for some time now. This has allowed her to do things over time without the challenge of a deadline.
Next, make sure you work out the entire structure. It’s hard for people to conceptualize this, but more surgery sometimes means a more natural outcome. It’s why you work out your chest and your biceps at the same time too. When the lower face looks young from a great lift, but the eyes and brows are still aged, something is off. Treating the face as one holistic structure is so important to achieving natural results that are undetectable.
The last part is finding the tools you need to accomplish goals 1-4. This is where facelift surgeons have made the biggest impact in the last 10 years. We’ve come to understand that it matters much less how you take the face apart and much more how you put it back together. Reversing the aging process by repositioning the face more vertically (a “vertical vector” lift) has a much more natural outcome that improves not just the midface but also the neck. This is where the aesthetic eye of the surgeon is so important.
Your research has shown that the limited delamination deep plane face and necklift can yield effective results with fewer complications. Could you elaborate on the benefits of this technique and what patients can expect from it?
Sure! I was part of a group of surgeons from around the world who came together to create a modification of the deep plane facelift called the “Preservation Face and Necklift”. One of the senior authors remarked how it has been the single most important change in his technique over the last 20 years.
By releasing less skin (“delaminating”) to get access to the muscle, we are seeing two major benefits: less complications and more powerful lifting.
As far as complications, while we still remove all the skin required to treat the face and neck, we now reposition much more muscle to the extent that it gets tucked close to the incision line. The space between the incision line and the muscle is called “dead space”. Dead space is where bad things can happen; we can see skin death or the accumulation of fluid under the skin. The limited delamination lift reduces the amount of dead space by half. Our study of 4000 patients showed significantly less complications as a result.
The second and most surprising part of the new technique is that we’re seeing lifts that hold for longer. This is because we’re harnessing the power of the skin-muscle attachments called septa that are now kept intact. This has lead to less relapse of tissue and a much lower revision rate as shown in our study.
What factors do you consider when assessing a patient’s facial structure to create a custom facelift approach that maintains natural expression and longevity?
We have patients send in photos prior to seeing me and it’s at this point that we assess their candidacy for consultation. I’m generally reviewing their past medical history and looking at non-surgical and surgical procedures that may interfere with my surgery. From an anatomical standpoint, I’m mostly assessing if the degree of aging change would warrant a significant intervention. If the changes aren’t advanced enough, we generally will ask patients to wait.
But this is only half the story. The main challenge is assessing our patients’ expectations for surgery. This is what the consultation is for. I have already decided your anatomy is a fit for surgery, but are you? Because our faces make up our identity, facelift surgery is a truly emotional journey. I want to make sure that the trust you feel in me during the consultation will last even if there’s a bump in the road. Put in other words, if you take my hand and we dive into the deep end together, you have to trust that I will guide you back to shore.
Because in the end beauty isn’t just about what your face looks like. It’s an entire predisposition that starts from the inside. I want to make sure both the inside and the outside will align.
With many patients moving away from fillers, what do you see as the main advantages of facelifts over temporary fillers, especially for long-term aesthetics?
The aging process was one thought to be the result of loss of fat in our face. Enter: dermal fillers. The overfilling of faces to compensate for soft tissue descent with gravity was an issue not because we were using the wrong solution, but because we didn’t well-define the problem.
Filler has its time and place and can be an immediate and gratifying treatment when used by expert hands attached to a good aesthetic eye. We know short-term fillers last longer than originally suspected and adding filler on top of more filler can lead to medical and aesthetic risks.
Aging is actually a multi-pronged process that we summarize with the “4Ds”: deflation of fat, descent of muscle, deterioration of skin and degeneration of bone.
The most natural solutions address most of these “Ds”.
The use of fillers, fat grafting and other volumizers are very helpful to add contours and shadows to a face. Facelifting changes the foundation.
Facelifts reposition tissue that has descended down with time. We solve the problem of aging by simply reversing the vector of aging.
How do you address patients’ concerns about recovery time, scarring, and the overall healing process associated with facelifts?
The way to address concerns is to talk about them openly. I have made a concerted effort to post all phases of the facelift journey through my patients’ stories online. The reason why there is fear about facelift surgery is because it was a secretive (sometimes illegal) procedure done behind closed doors in the past. The equivalent today is surgeons who post only a before and after photo online once their patient is fully healed. They skip the essential aspects of recovery that are both physical and emotional.
It may not be for everyone. In fact, I’ve had some patients cancel surgery after seeing these videos. I look at it as a gift for both of us. I want qualified candidates who are prepared for big surgery. If you follow me online, you’ll see that recovery happens quickly before your eyes, scarring is almost imperceptible at the end and the healing process can be a beautiful aspect in the journey.
Social media has brought cosmetic enhancements into the spotlight. Do you find that patients are influenced by trends, and if so, how do you help them make choices that will age gracefully over time?
I think social media has been a double-edged sword when it comes to marketing cosmetic enhancements. It has certainly helped generate interest in the field of facelift surgery and has lowered the barrier to entry for some. Additionally, it has enabled patients to be more educated than ever when it comes to their procedure of interest. I love having more concrete conversations about surgical plans with my patients now.
The downsides are that trends can absolutely influence decision-making. I simply will never perform an operation that makes you look like less of a human (i.e. “cat eye” surgery). Imagine being a 70 year old woman with grandkids who once had that surgery at the age of 30? Additionally, patients sometimes get bogged down by terminology (see all of the above). I think it matters less how your surgeon gets you to where you want to go, more so where they actually get you. There are talented surgeons around the world using hundreds of techniques. The best one is the technique that your surgeon uses most effectively to generate the results that you like.
As someone with extensive experience and research in facial plastic surgery, what emerging trends or techniques are you most excited about for the future of facelifts and rejuvenation procedures?
The biggest paradigm shift in facelift surgery has been a new focus on beautifying goals in addition to rejuvenating ones. In the past, most people would come to improve their necks and jowls, but today, especially in the younger demographic, people are looking for more.
They’re tired of nonsurgical treatments that don’t achieve their goals or make them look different in a not so subtle way. The trend towards surgery as a more holistic way of approaching surgery is I think one that will stay for good.
We can now add subtle procedures to face and necklifting like brows and lips that add nuanced beauty on top. It’s like adding color to the newly created canvas. The surgeons who can use technique and artistry together to create this beauty are the ones leading the shift into the future.
I am also excited about the push towards more natural outcomes. It’s boring to say, but it’s true. The best plastic surgery is the one no one notices. I often have patients come back months later in follow up who focus on the minutiae of the result, but when we take photos and compare to their pre-op, there’s a “wow” moment and the rest doesn’t matter. We often forget how far we’ve come because the results still look like them.
Lastly, I think that as our techniques have improved, the focus should also stay on safety. It’s not sexy, but it’s so important. Preservation lifting is a safer procedure that minimizes complications. It’s no wonder it’s being used by thousands of surgeons worldwide. I’m really proud to have played a small role in that. Because ultimately, we’re physicians pushing the limits of cosmetic surgery and the people who will benefit the most are our patients.
share:
Be the first to comment