Facelifts: Can They Turn Back Time? with James Zins, MD

Podcast Transcript

John Horton:

Hello and welcome to another Health Essentials Podcast. I'm John Horton, your host.

My great-grandfather used to talk about looking in the mirror and being shocked at the old face he saw staring back. It's a reality of aging that hits us all at some point. And when that day comes, you may think about getting a facelift. This surgical procedure smooths out wrinkles and tightens saggy skin to turn back the clock in your appearance. It sounds tempting, right? Well, today, we're going to learn more about this surgery and what it can and can't do for you.

We're joined by Dr. James Zins, Emeritus Chair and Section Head of Cosmetic Surgery at Cleveland Clinic. He's one of the many medical experts who pop into our weekly podcast to answer your health questions. So with that, let's see what options are available to change the face you see in the mirror.

Welcome to the podcast, Dr. Zins. Thanks for stopping by to chat.

Dr. James Zins:

Well, John, thanks for having me. I think it's going to be a lot of fun.

John Horton:

It definitely will. Before I talk with any of our Cleveland Clinic doctors, I always watch their bio video online, and I was really struck by how you talked about being instantly drawn to facial aesthetic surgery right at the start of your career. What was the attraction for you?

Dr. James Zins:

Well, John, you're right. I was always interested from the very, very early days of my residency. In residency, when our mentors were doing facelift surgery, most of the residents would run the other way because they knew that they were just going to be able to stand there, and they're going to watch and really not participate fully. I always gravitated to those cases because I really had an interest in 1), the facial anatomy, but 2), it's a very happy field. Patients are happy.

Really, I like dealing with older women. The reason being is they tend to be intelligent. They tend to know what they want. They research the topic. They come in. You don't have to sell them anything because most of them have already made up their mind what they want to do, and all you need to do is to explain to them in detail what the experience is going to be like, and they make their decision.

So it really is … it's a happy field. You're dealing with a clientele, which is a very, very good clientele, and the rewards are great. You see them right away.

John Horton:

Well, it sounds like you're the perfect person to answer any questions we have about facelifts, and we've got a few of them. So let's start with a real basic one: Why should someone consider a facelift?

Dr. James Zins:

Well, I think consideration for a facelift is multifactorial. There's lots of reasons people do it. The most common comment that I get is, "I look in the mirror and I don't recognize that person." Or "I'm tired of people telling me that I look sad, or I look tired." Those are some of the most common comments that I hear.

The other, also very common, is — look, there's age discrimination out there, whether you want to admit it or not. Younger people are at an advantage. So it's very common for women to come in to me and say, "Listen, I'm in the workplace. I'm working with younger people and I want to make sure that I look the part so that I can maintain my professional position." So also from a professional standpoint, that's a more and more common comment that I'm hearing.

Now, the best patients are those patients who come in for reasons such as that, they want to do this for themselves. That patient that comes in is teary-eyed, they've just lost a significant other, a spouse, and they want to change their life — a facelift is not going to change their life. It's not going to change their inherent being. So those patients are ones that really … probably it's a better idea to talk with them in-depth, defer things until emotional stability is established.

John Horton:

Now, you had mentioned women coming in a lot for it, but I take it that the fellas also get this done?

Dr. James Zins:

Yeah, well, I think if you read the lay press, they say more and more men are having facial cosmetic surgery. And I think that may be true in other practices, may be true on the East Coast, the West Coast. In my practice, it's still, I would say, probably 20 women to each man.

John Horton:

Is there a best age to get a facelift? Can you be too young or too old for one?

Dr. James Zins:

We need to be careful with the term because a “facelift” means many, many things. We can do very minimal surgery, and we call it a facelift, or we can do more extensive surgery depending on the degree of aging and the problems that have arisen.

For example, in a younger patient in perhaps their 40s, the patient comes in, and they're most concerned about the neck. The rest of the face looks quite good. We can limit the surgery to a small incision under their chin and accomplish a significant improvement in the neck and the jawline without incisions in front of the ear, behind the ear, and without a more extensive procedure.

On the other hand, if the patient comes in having spent a lot of time outside, deep wrinkles, a lot of skin excess, or that patient has lost a significant amount of weight, those patients need more extensive surgery. So the degree of surgery really is dictated by the degree of facial aging.

In addition to a facelift, very commonly, the face ages globally, so the eyes are aging, the forehead's aging. So we may suggest ancillary procedures, additional procedures, in addition to the facelift. So again, there's a grade of facelift from a very minimal procedure to a more complex procedure depending on the degree of aging.

John Horton:

So, depending upon when you come in, it sounds like if you come in early when the effects of aging have not hit quite as hard, that's where people always talk about the nips and the tucks, and you can just have little adjustments made here and there, and if you wait until you're much older, it sounds like it's got to be a little bit more of an overhaul that gets done?

Dr. James Zins:

Yeah, John, that's a very good point, and I agree with that. The patient comes in and says, "Well, should I wait for another five years?" Actually, the sooner the procedure is done once aging has occurred, the longer lasting it tends to be and the more natural it tends to be.

So that patient who comes in, as I mentioned earlier — severe sun damage, lots of skin excess, the neophyte — the young plastic surgeon might say, "Oh, this is a great patient to operate on." No, because that patient to the effect is not going to be long-lasting. That rubber band has been stretched out and is no longer elastic. So we tighten the skin, but the recurrence of facial aging or the wrinkles are going to occur much, much sooner than in someone who is younger. The skin is elastic. We take out a modest amount of skin, we tighten the muscle, we perhaps add facial fat. That's going to be a much more long-lasting operation, and a happier patient.

John Horton:

Yeah, and you had mentioned, too, that it just looks more natural. I think anyone who follows any of these entertainment journals or whatever, you see where stars get worked on, and it's a massive overhaul, and it looks almost too dramatic. Whereas, some people just have little things done here and there, and you don't really notice. They just seem to stay forever young.

Dr. James Zins:

Yeah, there's several reasons for that, I think. One is the patient just had too much surgery, too many facelifts. That's one. The other is that the patient came when they're older, lots of skin excess, and then, the skin excess is in multiple directions. It's not just in the neck area, but it's also in the face area, and we have to pull the skin in an uncompromising way so that we create wrinkles that don't look natural.

John Horton:

Dr. Zins, are there certain things like bone structure, or I think you've mentioned, skin condition, that make someone a good or bad candidate for a successful facelift?

Dr. James Zins:

John, very good point. The bony foundation, the bony skeleton, really is extremely important because that's what supports the soft tissue. So those patients who have a prominent chin, have good projection of the cheekbones, that supports the soft tissue very well. Conversely, the patient with a weak chin, doesn't support the soft tissue as well. So those patients really are not going to have as good a result.

On the other hand, what we can do is we can add to that bone structure. So a chin implant, or what we call a genioplasty, to advance the chin will definitely help that patient. Also, cheekbones — we can add either add fat grafting to those patients or, actually cheek implants, again to improve the bone structure. So the way to think about it is the facial bone structure really is the foundation for which we work, and then we're going to re-drape the skin and the soft tissue over that foundation.

Other things: A long neck is very helpful in making the face look attractive; conversely, a short, square face, is more difficult to work on than that an angular face in a long neck patient.

John Horton:

So if somebody doesn't have that great foundation, does that mean you're probably not likely, or you shouldn't, get a facelift, or is it just you might have to look at some other things being done, too?

Dr. James Zins:

No, I think we have to look at the bony foundation in addition to the skin and soft tissue, and we alter that foundation at the time of surgery to improve the foundation to give us a better structure on which to re-drape skin and soft tissue.

John Horton:

Can you tell us a little bit about what actually happens during a facelift procedure?

Dr. James Zins:

Sure. Facelift surgery, depending on the extent of the surgery, can be as simple, as I said, as making a small incision under the chin then we can address the cheek area, again in younger patients, by what we call short scar facelift, where we make the incision just in front of the ear and behind the tragus. And then, the classic operation is an incision both in front of the ear and then behind the ear and into the hairline and incision into the hair-bearing temple area. That's the classic incision. So again, a variety of incisions depending on a degree of facial aging and what the patient is willing to endure.

John Horton:

And then, after you make those incisions, is it just a matter of tightening, I'm just … pulling it up, like you're pulling up sheets on your bed to get the wrinkles out?

Dr. James Zins:

No, modern facelift surgery is more than just tightening the skin. Modern facelift surgery involves taking out the loose skin, but also addressing what we call the SMAS, which is the structure of the soft tissue deep to the skin, tightening that structure. So the way to think about this is we tighten the tissue underneath the skin, the SMAS, so that we don't put a lot of tension on the skin itself, adding to a longer lasting facelift, 1), and 2), adding to better scar healing. That's important. So the incisions are relatively small, but the work that we do underneath can be fairly significant.

So skin soft tissue, SMAS operation, adding volume to the face. Again, the early facelift was just skin tightening procedure. Today, modern facelift surgery is more than skin tightening; we're also adding volume. The way to think about this is very often, especially in patients with faces like yours and mine, thin, long faces, we tend to look as we get older like we've lost volume in the face. Very often, a patient will come in and say, "Oh, you lost weight." No, you haven't lost weight. It's just that you have the appearance of volume loss in your face.

So part of the surgery is not only tightening the skin, but also adding volume to the face. And that volume can be added by a fat injection, by fat transfer, by implants, as I've mentioned to you, are ways to do that. So it's both adding volume, as well as tightening skin and soft tissue.

John Horton:

And it sounds like that's changed over the years — there's been a little bit of an evolution in facelifts.

Dr. James Zins:

Yeah. Well, the SMAS, that structure, which I mentioned under the skin, which is just on top of the muscle, that SMAS has been around and identified since the 70s, but means of addressing SMAS has varied over time.

John Horton:

Now, do things like eyelid surgery and brow lift surgery fall under the facelift umbrella, or are those completely different?

Dr. James Zins:

Well, again, as I mentioned, very often, the face ages globally, so it doesn't age in one space. So again, the brow may descend, upper eyelid skin excess may appear, in addition to jowls and laxity in the cheek and the neck area.

Generally, the first things we start to see in facial aging — and we may see this as early as the late 30s — is some laxity in the neck area. Also, in the late 30s or early 40s, you may see a little bit of skin excess in the upper lids. So those are early signs of facial aging. And then, as we get into our 40s, the face starts to — what I call, masculinize a bit — so instead of that nice oval, youthful face with tight cheeks, what we're seeing is, we're starting to see masculinization, or squaring off with the lower face. That's perhaps in the 40s and the 50s. Then, deeper lines start to appear in the 60s.

So the candidate for a facelift really probably starts as early as the 40s, and then goes up really into the 80s.

John Horton:

If you come in for a facelift, how big of a surgery is this? Is this just an outpatient thing? Is it something where you're staying over, or is it just quick and easy?

Dr. James Zins:

Good question. Again, this depends on how much aging there is and how much surgery we plan. We may want to do a very minor procedure, addressing the neck only, or we may want to do an intermediate procedure where we're injecting the cheek only with the incision in front of the ear. Or the patient has more facial aging, then we're going to make the incision. We're going to do surgery, which involves a more aggressive approach. So that's really dictated by the degree of facial aging and how much surgery the patient is willing to undergo.

For example, the patient comes in with the neckline, which doesn't look ideal because there's extra fat and loose skin. I can address that through an incision under the chin, but that's going to just address the neck and the jawline. Now, if the patient says to me, "Well, that's all that I'm concerned about. That surgery to address other areas is more aggressive than I want to be.” Or "It's going to take too much time to recover." Or "I can't afford it, and I'd be very happy if we just do what you've described to me, address the neck and the jawline," we can do that with a relatively minor procedure.

On the other hand, the patient comes in and brings in the picture from their graduation from high school, and you're 60 years old, then there's going to be more work.

So again, to the degree of aging, but that generally correlates with the age as well. So, someone who we're going to limit the surgery to under the chin, that's going to be a patient in their 40s and in their 50s. When you get into the 60s and the 70s, again, there's probably going to be more facial aging that's going to require more surgery.

John Horton:

What does the recovery process look like? Are you all bandaged up for a little bit? Is it something where it's just a few days and it goes away? What happens in the days and weeks after the procedure?

Dr. James Zins:

Most surgeons are doing facelift surgery as an outpatient, or they're having you stay locally at a hotel nearby or their own surgery center. Relatively few patients today are being admitted to the hospital. That's sort of yesteryear. We generally don't do that anymore. It's really not necessary.

Generally, what I do is a soft dressing around the chin and the head, which we leave on just overnight, and then we see the patient the next day. I see all of my patients the next day to make certain that there haven't been any untoward effects of the surgery. There's been no untoward bleeding, bruising, swelling that needs to be addressed. I see all those patients the next day even though they go home. The bandages come off. If we've used a drain, the drain may come out at that time.

There are newer techniques that we are now using to avoid the use of drains. I'm getting a little complicated for this discussion, this podcast, but we use a hemostatic net, which now can avoid the use of drains. So that's also a plus. So things continue to get better and better as we go on.

But if we do a classic facelift, then recovery, I tell the patient it's going to be about two weeks. Not because they're in pain for two weeks, but just because they're going to bruise, and they're going to swell. Generally, what I tell my patients is if they've had a traditional facelift with the incisions as I've described, and a fair amount of work, the first night's going to be tough. The afternoon of the third day is what we call hump day. That's when everybody magically starts to feel better, the afternoon of the third day. And then, from day three to day 10 or day 14, they're really just recovering from bruising and swelling. So they're able to go about their business at home, but they're probably going to want to have some time off.

I tell the patients, again, with a standard facelift, with incision in front of the ear, a significant amount of work, you're probably going to want to take off 10 days to two weeks.

John Horton:

And I'm guessing that scarring has got to be pretty minimal. People are doing this for improved looks for the most part. So I'm guessing you don't even see those over time.

Dr. James Zins:

Yeah, John, I think you're right. A well-executed facelift, those scars really should be minimal. Almost right after the surgery, the scars are minimal. Now, there can be untoward problems with healing, rarely. Some of that is technically related on how the surgery was done, and some of that just is the patient's healing. But generally, the scars are very well concealed almost immediately after surgery.

John Horton:

Now, a big question that I think everyone wonders: How long do facelifts last? What's the warranty on these?

Dr. James Zins:

I think the two most common questions that I'm asked, 1), how long is the facelift going to last, and 2) am I too old or too young to have the facelift surgery? Again, the longevity of the facelift depends on the degree of facial aging and how elastic that skin is. If that skin is relatively elastic and the patient is young, the results are going to last for a long time. It'll last for 10 years.

Now, again, it's not like turning on the faucet that you all of a sudden start to age. Again, the skin has a property called creep. We put a certain amount of tension on that skin, and that skin gradually relaxes over time. The skin will relax over time, so there's going to be some recurrence of facial aging. The younger the patient, the more elastic the skin, the better the bone structure, the longer lasting the facelift surgery, given surgical expertise. So I think that's important.

The older patient, or that patient comes in for a secondary facelift, where that skin elasticity at age 70 is not nearly as good, that's not going to last quite as long as the first operation.

John Horton:

So if you come in earlier, what's just a basic time frame you're looking at versus older?

Dr. James Zins:

Again, the patients tend to get old with a doctor. My average patient is probably 50 years old, 60 years old. I do a lot of patient facelifts in their 70s, and we've done a number in the 80s. But I would say in my practice, the average age is probably late 50s to 60. Others are going to be younger.

So I think you're a facelift candidate probably in your 40s, perhaps less surgery needed, and then again, 50, 60, 70, even 80 years old. I haven't operated on anyone 90 years old yet though.

John Horton:

As far as how long they last, if you do it early then, you're probably looking at maybe getting 10 years or so out of it versus later.

Dr. James Zins:

Again, some patients are very finicky. Some patients notice every wrinkle. They get that 10X mirror out and look at every wrinkle, so they come in a little bit earlier. Others are probably not quite as finicky, so they'll be coming in later to ask for secondary procedures. I tell the patients, again, about 10 years.

The other thing that they very often will ask me is, "Well, am I going to look worse because I had the surgery?" No, you're never going to look as aged as you did when you came in. There's going to be long-lasting results from then on. So if you have a bad neck, you come in, the neck is done, that neck is never going to look as bad as it did before.

John Horton:

Now, you mentioned people being sensitive even after they get it, and then they start noticing wrinkles coming back. Can you get multiple facelifts if you want to keep up that fight against Father Time?

Dr. James Zins:

My mother had three facelifts.

John Horton:

Wow. All right, so we know you can get at least that many.

Dr. James Zins:

Again, but you can have too many facelifts. But certainly, a secondary facelift is very common. Perhaps 10 years after the first facelift, a secondary facelift is very common. Also, when that patient comes in with facial aging, it may be a secondary facelift is not the best thing to do. Maybe what they need is more volume than they need skin tightening. So maybe we're going to inject new fat grafting rather than a facelift. Or we may address other parts of the face. But certainly, a secondary facelift is quite common.

John Horton:

So if you're thinking of getting a facelift, what's the process to get started? What kind of questions should you absolutely ask your doctor ahead of the procedure?

Dr. James Zins:

Well, I think the first thing you should do is do your homework. Research the procedure. Talk with your friends and family, especially those who've had the procedure done. Talk with them about whom they've seen and whom they were happy with and who've had good results. The most common reason for patients to come see me is because I've operated on friends or family members. So that's a very good gauge of picking the right plastic surgeon. So that's the first thing, you want to pick the right plastic surgeon.

Then, of course, you want to have an in-depth consultation. That consultation in my office is going to take a half hour to 45 minutes reviewing before and after pictures with the patients, going over the risks and complications. Now, we haven't talked at all about risks and complications, but that's a very important part of a surgery, because no matter how careful we are, no matter how good a plastic surgeon he or she is, everybody has complications. So the patient has to understand the risk. This is not like getting your nails done. This is real surgery. So we have to talk about that in-depth.

Review before and after pictures. Don't show the patients just the best results. Show the patients a wide variety of pictures so that they have an understanding of what can and what cannot be accomplished. If they come in, and they look at these pictures in my before and after album, and they tell me they don't see a difference, well, maybe they should see another doctor. Again, the best thing you can do is say no to that patient you don't connect with. I think that's very important.

And then, they have to have confidence in the doctor. They come into the office, or into the procedure area, getting ready for their surgery, everything happens just as we have discussed, that's very self-fulfilling. That makes it a very easy experience for the patient and for me.

John Horton:

You had mentioned risks and complications, so let's address those. What are some things that can happen that maybe aren't in the plans?

Dr. James Zins:

Yeah, hematoma is probably the most common reason for early re-operation after facelift surgery. That incidence really should be in single digits — should be in the 1% to 2% to 3%. So again, rare, but that's the most common reason to have to go back for a second operation early on after facelift surgery.

There are a number of things we do to prevent that, to keep that number down very low. One is high blood pressure needs to be controlled. We need to have the patient off all types of blood thinners, including the aspirin and the NSAIDs. We use techniques during surgery to minimize that likelihood. We have special medicines to reduce bleeding, which we now use. And then, we have techniques that we do at the end of surgery to minimize that.

But hematoma really needs to be discussed because if that happens, that's an emergency. That's an inconvenience for me. That's an inconvenience for the patient. But that needs to be taken care of because as long as that's taken care of, then there's no long-term problems. Short term, those patients tend to get a little bit more swollen and their recovery is a little bit longer, but there's no long-term problem.

Infection is extremely rare for the same reason that the bleeding can occur. Blood supply of the face is very good. Good blood supply prevents infection. The face is very vascular, so the likelihood of infection is extremely small. Of course, we give the patient antibiotics preoperatively and during surgery to minimize that.

Scarring: Again, bad scarring is very unusual. Problems with healing can result in bad scarring, and that's most common in active smokers. Very, very few patients of mine are smokers. But active smoking can have a very deleterious effect on healing, and we can have significant problems. So patients must stop active smoking, we say, for a minimum of four weeks, but there's no hard date on that number. What I tell the patient is the longer the interval between cessation of smoking and your surgery, the safer it is.

Nerve injury is another risk. Again, extremely rare, probably in a 10th of a percent, but that's also a known complication, facial nerve injury.

Those are some of the common things that we talk about. So we go over all this in the office in great detail because an informed patient is a good patient.

John Horton:

Well, and it sounds like, too, that people should really talk to their doctor because, as I understand, these procedures are really tailored very individually to how your face is, and what your needs are. No two surgeries are exactly the same. Everything's going to be a little different. So get the game plan early as to what's going to happen specifically to you.

Dr. James Zins:

I can describe it fairly straightforward for the patient. The patient with a fat face has certain issues that we have to deal with in surgery. That patient with a thin face has other issues we have to deal with in surgery. That patient that has lost a lot of weight, those patients need to be addressed differently. And that patient with a poor bone structure needs to be addressed differently. So there are grades or stats of various ways that we can look at the patient and explain to them what they need.

John Horton:

Well, Dr. Zins, I feel like we've looked at this from all angles now, but before we say goodbye, is there anything we missed regarding what people should know if they're thinking about getting a facelift?

Dr. James Zins:

Yeah, I think again, that that patient should be motivated. That patient who comes into the office is positive. They've done their research. They're enthusiastic about the surgery. They're not hesitant. Those patients are good patients. Those are patients who are going to do well emotionally and surgery-wise after surgery.

That patient who comes in who is very hesitant, comes in for two or three consultations, those are patients that we have to be wary of. We're better off telling those patients, "Well, maybe you want to wait and think about it and come back when you're a little bit more sure how you'd like to proceed."

John Horton:

Great advice. I appreciate you making the time to come in and chat with us today, and I learned a lot.

Dr. James Zins:

Well, John, thanks. Thanks for having me. We had a lot of fun. You have a good day.

John Horton:

Facelifts aren't for everyone, and there's a lot to consider before moving ahead with the surgery in search of a younger look. Talk to your healthcare provider about your options.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.