A renowned plastic surgeon with more than 30 years of experience, Pittsburgh plastic surgeon Leo R. McCafferty, MD specializes in facial rejuvenation, including facelifts, eye surgery and everything in between. Here, he fills us in on what to know before considering facelift surgery, and the combination treatments that are trending right now.
How have facelifts evolved over time?
“I presented on the history of facelifts at the Northeastern Society of Plastic Surgeons’ conference in the late fall of 2019, and the procedure has been described in the medical literature as far back as the mid-1800s and most likely performed in some fashion even earlier. It’s kind of amazing that facelifts started simply and then became very complicated, and have since returned to something that is less-invasive. There was a time where the face was completely taken apart and then put back together, and the results weren’t necessarily any better. Today’s facelift involves not only the skin, but also the underlying tissues, and typically a little less ‘taking apart’ if you will, and results that are better, safer and long-lasting.”
There are so many techniques now, and many doctors have trademarked their own versions of the facelift. How can patients find out what’s best for them?
“When it comes to facelifts, one shoe doesn’t fit all, and there are lots of different techniques out there that have different names, which can make it confusing for the patient. Naturally they want to research it on their own, or watch YouTube videos on a specific type of facelift, and that often creates more confusion. It’s important to get a professional consultation and then a second opinion—sometimes a third even—and try to listen to the experts rather than place too much emphasis on the internet.”
Who is a good candidate for a facelift?
“Every patient is different and has to be analyzed for their specific issues and concerns. What is it that bothers them, and can the doctor marry their skill with the patient’s desire for improvement. What we try to teach residents in training is that every case is different and you have to figure out which patient will benefit from which procedure. There’s no gold-standard technique either: There has been study after study after study, and not one shows one type of facelift is better than the other. In my experience, the patients who often have the best results are those who don’t wait too long to have the facelift done. It’s not so much the patient’s chronological age, but more so the ‘age’ of the environmental sun damage on their face. In most instances, a patient having a facelift in the late 60s will have a better, longer lasting result than having it done in the late 70s.”
How young is too young for a facelift?
“It’s not so much the age, it’s the look. We do see a number of patients in their 40s who have just begun to notice a little laxity in their lower face or a little wisp of extra skin in their neck, and they want to catch it before it gets too bad. Some of those patients might be ready for a facelift, but the vast majority are not. The better recommendation is often to encourage them to adopt some better skin-care habits and begin some nonsurgical or noninvasive treatments. Then they may be a candidate 10 years later. For those in their 40s who are ready, they get a great result because of the quality of their skin. I like to use this analogy: The facial skin, as we age, is almost like an elastic waistband that gradually loses its elasticity over time. A brand-new elastic band will look tight, whether it’s pulled tight or in a free, lax state, but when it’s older it’s very lax in both states. The younger patient has more structural resilience in their skin to hold things in place, so within reason, younger patients can do better with facelifts than slightly older.”
How much of the loss of elasticity is due to genetics versus sun damage?
“I think it’s a combination, but you know, it’s interesting. If any one of us were to stand in front of the mirror when we get out of the shower and put the backside of our hand next to our backside, the quality of the skin on our backside, which hasn’t seen the sun, is infinitely better than the backside of our hand. Even in patients who have a genetic predisposition to aging and sun damage, the quality of the skin on the areas that don’t see the sun is better. It’s a simple test we all can do. The sun plays a big role, but it’s also wind, pollution, smoking, diet—they all play a role. Staying well-hydrated is important, too, as water is the best moisturizer for the skin.”
I know a facelift won’t improve some signs of sun damage like fine lines and discoloration. As a result, how often are you pairing facelift surgery with lasers, fillers, etc?
“I trained in Miami and at the time, the Baker Gordon peel preceded any of the laser treatments. Then in the late 80s, the CO2 lasers and then other types of lasers came onboard to help with skin resurfacing. I have gone full circle, and now pair a lot of my facelifts with the phenol peel which is a modification of the Baker Gordon peel. It works exceedingly well and doesn’t have the safety issues, protection protocols and higher costs that accompany laser treatments. Some doctors will disagree, but the concept of resurfacing the skin is the same, it’s just the application tool used that’s different.”
Can you perform a peel at the same time as the surgery?
“I like to apply the peel at the same time as the procedure, but not on areas of the face that we’ve undermined. A very common area to place it is around the mouth on the ‘smoker lines,’ or vertical lip lines that many people have, even if they’ve never smoked. Or the lines around the eyes.”
Does combining the two extend the downtime?
“No, the downtime is not extended and is the same as it is for performing the facelift alone: Typically, you’ll have the facelift sutures removed within a week and by this time the peeled area will also be healed. Somewhere between a week and two weeks, you can be out and about wearing normal makeup, and no one will know. A chemical peel will not add to that timeline. The peeled area may be a little pink, but it’s easy to cover with light makeup, nothing heavy. If the patient needs other parts of their face peeled, I usually recommend they have the facelift first so the canvas is essentially tightened, and then the peel can be placed several months later. This staged approach would mean more downtime.”
What about pairing a facelift with a blepharoplasty (eyelid surgery)? Is that common?
“Most people come in complaining that they look tired or sad, and more often than not, that comes from the eyes—heavy upper eyelids and/or bagginess under the eyes. Because of this, I’d say in 90 percent of facelift cases, we’re addressing the eyes in some way.”
And what about fat-grafting? That’s a popular complementary procedure to a facelift too, right?
“Yes, I do this in about 95-percent of cases. In addition to the laxity of the skin and underlying tissue, we know from scientific studies that the face loses volume. Even an overweight, elderly person can still look deflated and gaunt in the face because of this aging process. The idea is restoring a more youthful facial shape without making the patient look operated on or ‘puffed up’ and adding fat back into certain areas of the face can help us achieve this in a natural-looking way. Nobody wants to look like they’ve had a facelift.”