What do you think? Facelift/neck lift? Fillers and Botox or fat transfer?

Dr. Dean Kane Q & A.

Q. I'm 43 but feel like I'm 23. The past few years I've noticed less volume, for the record I think I already have a thin face. The upper eyelids stand out along with the tear trough. My dermatologist told me no on the face/neck lift but I submitted my photos to a plastic surgeon. He also said I wasn't a candidate for the lifts. He suggested an upper eyelid surgery and fat transfer! I don't want to spend thousands on that if in a few years I will need a facelift. Please help with your opinions. Thank you!

​A. Thanks for sharing your photos! You will notice that your best appearing presentation are the photos in which your cheeks are the most prominent and your jawline is most angular. This is due to a "heart-shape", convex presentation where there are more highlights then shadows.
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​You, like many patients may achieve these features with facelifting options, injectibles, peels and laser. Each has its own advantages and disadvantages, onset and duration, recovery and cost. Your personal needs must be evaluated with a well experienced, Board Certified Plastic Surgeon or Facial ENT Surgeon that provides all options so they are not biased based on a lack of skill level.
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​I have many patients choose fillers, retinoids, peels / lasers when they won't consider surgery, have the funds or recovery time for surgery.  Others, recognize the advantages of surgery to reduce / lift the jowls, widen and fill the upper cheek and redrape the lax skin while maintaining a thinner facial appearance and obtaining a longer duration of results.
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​Both of these and other combinations are options you will determine with a trusting physician.
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​I hope this has helped! All the best!

Which filler would you recommend and which is more effective between Botox, Dysport, and Xeomin?

Dr. Dean Kane Q & A. 

Q. Right now in my life for being 43 years old I feel great and I think I look pretty good but, of course, we all have things we"d like to change. The thing that bothers me most is the tear trough area, and the upper eyelid. I know in the near future I will be getting an upper and lower eyelid lift, along with a face/neck lift. Until then can I get a filler that will last in the tear trough area, and botox/dysport in the upper eyelid area to lift a little. Is this possible without surgery?

A.  ​​​​Every patient is unique. Your bony and soft tissues, their symmetry and aging, your personal and perceived appearance and how it bothers you are just a few of the factors to review with a well experienced, Board Certified Plastic Surgeon or Facial ENT Surgeon who offers ALL these and other options.

​Since the effects of aging, weathering, sun-damage, ethnic background affects everyone differently, you may consider filler for the tear trough and Botox for the brow elevation and / or stage your surgery at this time when healing is better, scars will usually be smaller and skin elasticity is at its best.
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​Consider more than one well experienced, Board Certified surgeons for evaluation as you may find that their Botox and Filler skills as well as their surgical skills and results will vary.
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​One consideration come to mind and that is you may wish to have the upper and lower lids improved at the same time. Using access gained by both incisions, a mid-face lift may rejuvenate your cheeks, eliminate the tear trough, possibly elevate your jowls and bring you a longer duration of satisfaction.
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​If you are a candidate for a short scar face lift (or MACS lift and other named procedures) you may improve the jowling and upper neck while younger and gain more youthful appearing years.
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​Regarding which Fillers or Muscle Relaxers; the options are getting so numerous that each filler or muscle relaxers have their own peculiar niche of use.
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​I happen to like Botox in the brow area for precision and Dysport in the lips for a softer relaxation.

​Hyaluronic Gel fillers such as the Restylane Family or Juvederm Family each have their nuances. Depending on each gels production and artificial molecular linking will determine:

1. ​their duration,
2. ​their projection,
3. ​their volumization (ie. water attraction).

​This determines where they provide the best "fill" you desire.
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​Noting your tear trough example, some injectors have only superficial injector skills and will inject immediately under or within the skin (ie. dermis). Others, may feel comfortable injecting under the deeper muscles of the cheek next to the bone with a variety of techniques.

1. ​You may wish to use Restylane or Juvederm superficially but it has the side-effect of radiating a "tindel" bluish coloration or lumpiness on eyelid skin.
2. ​Silk in this location superficially may swell the tissues too much.
3. ​I achieve my best appearance under and over the deep muscles of the cheek with a more linked, longer duration filler such as Voluma or Perlane.

Yes, the possibilities are endless today and so you must find and trust a surgeon with a lot of experience using each option selected for your anatomy, concerns and budget.

​I hope this has been helpful. All the best!

Which technique, high SMAS or lateral SMASectomy, provides the most improvement or lift of the cheeks?

Question from  North Carolina, NC: When choosing between two different surgeons, each with a different preferred surgical technique, which will provide the best lift of the cheeks: high SMAS or lateral SMASectomy? I am NOT interested in fillers or fat transfer to augment the cheek area but would rather have a lift that will address the cheeks. Thank you!

Answer from Dr. Dean Kane, Board Certified Plastic Surgeon from Baltimore:  
​I LOVE facelifts because of the uniqueness of every patient and the variation of the anatomy! 
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​If fillers and fat grafting is left out of the equation, a Midface Lift is your best option to lift and fill the cheeks. As I perform them, a lower eyelid incision is made and depending on the tissues to be lifted, the cheek will be suspended straight up to the inferior orbital rim.
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​As you have found out there are different proponents for many SMAS lift variations. Some say imbricate at a medium or high cheek plane; some say lift and suspend in front and behind the ear; some say pull tight, cut off the excess and sew to the opposing edge. 
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​For maximum advancement of the jowl to the cheek deficit, I find a high SMAS imbrication is very straight forward and best option to achieve a youthful appearance. It also lifts the jowl, the platysma and the attached neck soft tissues.
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​For maximum jowl and neck elevation from the facelift incision, a SMAS elevation and advancement in front of and behind the ear works well.
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​Lateral SMASectomy similarly lifts the jowl and tightens the soft tissue upward and outward but excises the redundant tissue which can be used to augment the cheek. 
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​I find that SMAS lifting will not fully address the youthful medial upper cheek; ie., the nasal half of the cheek "apple" just below the eyes. I therefore perform fat grafting from any liposuctioned fat I have contoured from the jowls, jawline and neck. You may also consider fillers such as Voluma. 
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This of course only addresses one of many decisions made for customizing a facelift to the individual patients face and neck.
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​​This was a great question. I hope I was helpful.