How Not To End Up With a Super Obvious Facelift

Speaker 1 (00:02):
You are listening to Alabama, the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis. 

Dr. Koehler (00:10):
Well, I'm Dr. James Koehler and welcome to our show. How are you, Kirstin? 

Kirstin (00:16):
Hey, Dr. Koehler, 

Dr. Koehler (00:19):
What you got for me today? 

Kirstin (00:21):
Well, we are going to talk about one of the cosmetic procedures that you are most known for, the facelift. 

Dr. Koehler (00:28):
Okay. Yeah. I love facelifts. 

Kirstin (00:31):
Yeah, you're pretty good at it, huh? 

Dr. Koehler (00:33):
Well, I dunno. I keep trying. I keep getting better. 

Kirstin (00:37):
Okay, so I do have a question for you. If you see somebody who has obviously had a facelift, what's wrong? 

Dr. Koehler (00:48):
Well, if it's obvious, it's wrong. So I will tell you actually a story. I was nominated for an award. This is, I don't know, was it five years ago or something like that? I don't know. We were in Beverly Hills, and that was the year that they had all the fires in Malibu. And my wife and I were staying in a hotel in Beverly Hills, and all the local people from Malibu were checking into the hotels with their dogs and cats and everything else. They were all having to be evacuated from their homes. So we were sitting in the lobby and it was some really interesting people watching. But yeah, I spent quite a bit of time seeing some less than ideal facelift results, so that's what passed the time. But yeah, no, I think the thing about a facelift is now for a trained professional, I think, yeah, you can notice these things, but for a layperson, it shouldn't be obvious. That would be the one thing. Now, granted, if you've got somebody who looked a certain way and now they look different, I mean, it will be obvious and it just depends on at what stage in their aging they chose to do that. I mean, if you waited until you have big turkey neck and then it's gone, I mean, people are going to notice. But the point being, if you met somebody you'd never met before who didn't know what you looked like before, it shouldn't be obvious to that person. 

Kirstin (02:16):
Is there a correct age that you should aim for to get a facelift? 

Dr. Koehler (02:21):
There's not really a correct age. I mean, it really depends on the person. Some people will do a facelift, they're late forties. I'd say the majority of people are typically between 55 and 65. But people get that done older than that and younger than that. And it really depends on a lot of things. It depends on just your biologic, aging. I mean, you look at the people you graduated from high school with and there's going to be people in your class, they're going to be like, oh my God, you never change. And other people are like, oh, I can't believe how old he looks, or whatever. So we all biologically will age a little differently. And then there's environmental factors if you have an outside job versus an inside job, if you're a smoker or not, you're nutrition. So there's all these things that impact how we age. And so there isn't an age or an ideal age, and some people don't want to wait until it gets really bad. But you asked me earlier about what makes it an obvious facelift or what makes it a bad facelift. And sometimes people have these wind swept looks where their face is pulled too tight. That's kind of one of the common giveaways, or the incisions are not well done and they're a little bit more noticeable. 

Kirstin (03:37):
So do you make your incisions in such a way that they're easily hidden? 

Dr. Koehler (03:43):
Yeah, I mean the goal for anybody doing the surgery is to make the incisions hidden as possible. It can be harder for some people than others. So when we do male facelifts, a lot of men wear their hair short. And so being able to conceal a scar is a lot more difficult. And then there's some other issues that come into male face lifting. Typically for women, we're going to put that incision sort of in the crease of the ear and in men, because they shave, if we lift skin and move it back, and we put that sort of right in the sulcus of the ear, it pulls hair into that area. And then now they can't really shave the tragus of their ear. So that's why we will in men, sometimes we'll put it in front, and so that also it can be a more noticeable incision. But if it's closed really well and the person has good healing, then yeah, it can be very well concealed. 

Kirstin (04:36):
So are there certain techniques that you use for a facelift for certain people versus other people? Or do you just go with one basic technique for yourself? 

Dr. Koehler (04:48):
I'd say the basic technique is where I'm at now with my face lifting. The technique is pretty much the same for every person, but it doesn't mean that it's done the same. The technique is the same, but the vector pull might be different. The amount of pull might be different, how much deeper tissues we're removing in the neck. So sometimes we have to remove deep fat in the neck. Sometimes we have to remove part of the salivary gland as part of the surgery. So those things vary from patient to patient. And certainly there are a number of different facelift techniques out there, like a lot. And it actually can be very confusing to the public when they're starting to try to learn about facelifts. 

Kirstin (05:31):
And I'm sure since you've started cosmetic surgery, you've improved your technique along the way. Are there certain things that you do that you just know, like I am always going to, I know you've mentioned in lecture before, you're always going to take out that gland underneath the chin. 

Dr. Koehler (05:48):
No, I don't always take out the gland, but it is something that is an important part for some of the heavy necks, yes, in some people there are indications to pretty much remove that. But yeah, the technique has evolved. We're really trying to maximize the results for the patient, and we're really working towards trying to minimize the recovery and the stigma of we want to get those natural looks with the least recovery and the least risk. And so that's where the evolution in the technique is, is that there are certain things that we do that we know can give people better results, but sometimes they also give them more recovery. And so trying to find that right balance is where the secret is. 

Kirstin (06:28):
Okay. Give me the basics of your facelift. How's it done? 

Dr. Koehler (06:35):
Well, before I give you the basics of my facelift, let me just say, because I mentioned there's a lot of different ways of doing facelifts. And right now on social media, the big buzz is deep plane facelifts. And as far as I'm concerned, when I go on the internet, everybody apparently does a deep plane facelift, although I don't believe that. But that's the buzzword these days. And the reason, well, deep plane facelift, which is not a new concept. I mean, it really was developed in the nineties. A surgeon, Dr. Sam Hammer really was kind of one of the first people to really popularize deep plane facelift. It's changed, the techniques changed a little bit since he described it, but pretty much it was a deep, deep plane facelift. But the reason that it's maybe taken a long time to catch on is that doing deep plane facelift requires a higher skill level than doing some other facelift techniques. 

(07:36)
And it takes surgeons years to develop these skills. It's an evolution of every surgeon's technique. And I don't think anybody comes out and just jumps into doing deep plane facelifts. They start with things that are a little less risky, and they slowly evolve and advance their technique to where they're doing these. And so right now, again, it's a buzzword, but I can tell you that some really awesome facelift surgeons that I know, some of which now do deep plane facelifts, but if you talk to them 10 years ago, they weren't doing deep plane facelifts, and they were still getting outstanding results. So the results you get, if you look at before and afters of your surgeon and you talk to your surgeon, I wouldn't get bound down like, oh, I need to get a deep plane facelift. You just need a good doctor that does a good facelift. 

(08:24)
And whether it's a deep plane or not, there's academic discussions to be had, but there's doctors that are very skilled that do less aggressive facelifts that get great results. So back to your question, deep, plane face lifting is what I do. I do a deep plane facelift. The incisions for most of these full, lower face and neck lifts are the same. And the incision begins in the temporal hair tuft, and it extends into the sulcus of the ear, and it goes back around the backside of the ear into the hairline. And so that's the incisions. And then there's also one other incision that's about an inch, inch and a half underneath the chin. And through those incisions, all the work is done and in a deep plane facelift and deep neck lift. So for the deep neck lift, that's where in certain patients will take out some of the fat that's underneath the platysma muscle, which is a muscle that runs from your chest all the way into your face. 

(09:22)
We really don't use that muscle for really much of anything, but it's there. But deep to that muscle is where nerves and arteries and scary things live. And so you have to be skilled to take out fat and other structures in that layer. That's where the glands live, is in that deeper layer. And so like I mentioned, sometimes you have a salivary gland that sits here. And as we get older, that gland can descend, and especially in some thinner patients, like you can visually see a bulge in their neck. And yes, you can tighten and lift things, but some patients, if you don't trim or shave that little part of the gland down, they still can have that noticeable bulge. So that's the deep neck work, taking out deeper fat, maybe the glands tightening up the muscles of the neck. And then there's the deep facelift, which is the incisions around the ear where we're now going beneath some of the muscles of the face or into that layer where the muscles of the face are and the facial nerve, and we're elevating that and re-suspending it. 

(10:26)
So it's not about trying to tighten the skin. In fact, you'd be shocked at how little skin is actually removed in facelift surgery. In fact, that's the opposite of what you want to do if you try tightening the skin on the outside. That's what gives people that weird pulled appearance. And we don't want that. We want it natural. So we're actually lifting the layer where the muscles of the face are. And the reason that deep face lifting is a little more challenging is that's also where the nerves, the facial nerve lives, and that's the nerve that actually supplies those muscles that move your face. So all the facial expression you make, and if that nerve gets injured, which sometimes can get temporarily bruised and occasionally very rarely permanent injury, but if that nerve gets bruised, it can affect the movement of your face. And so that's why deep plane facelift is not, I would say, done by every person that does facelifts. 

Kirstin (11:22):
So if you have a patient inquiring about a facelift, our surgery coordinators upon initial phone call always want to make sure that they tell patients when they're going to look good, when they're going to feel good and when they can do stuff. So can you tell our audience, when our patients can expect to look good, feel good, and do stuff.

Dr. Koehler (11:42):
I'd say typical is four to six weeks. That's look good, feel good, do stuff. Now, some people, it's much quicker than I have people that even two and three weeks are looking pretty darn good and could be out in public and might have a little bit of bruising, a little bit of swelling, but they could get out and function. And for people who maybe didn't know them, they'd be totally fine. Now, people that knew them, that might be a little more obvious, but four to six weeks. But bruising is usually gone. And a lot of times people don't really have as much bruising as you'd think, but bruising is typically two to three weeks. And then by three to four weeks, a lot of the swelling is gone. And certainly by six weeks, most people are definitely, you get out and be social, you're not going to see your final result takes several months for all the swelling, particularly if we do some of that deep neck work, people can be swollen up under the chin for several months. 

Kirstin (12:40):
So when people use jargon like I got a full facelift or a lower facelift or a mini facelift, is there a difference between any of those surgeries? 

Dr. Koehler (12:53):
Yeah. Well, this is where people can get very confused very quickly. So mini facelifts, typically a mini facelift is a procedure that oftentimes is marketed as a lunchtime lift, but it's not a lunchtime lift. I mean, you can get it done over lunch maybe, but it's like, there's a recovery. But the difference, a mini facelift is for somebody who really doesn't need a whole lot of lifting, they may not have much laxity at all in their neck, and the incision starts in the hairline, goes in front of the ear, but a lot of times it just goes barely back behind the ear and then it stops. And most of the time, they're not doing that deep neck work. They're just tightening up that deeper layer. It's called the SMAS. They're maybe putting some stitches in to tighten it up and closing it up. And yes, you can get some tightening that way. 

(13:42)
I'm not a big fan of mini facelifts. I feel like if you're going to do it, do it right and get a good result. But a mini facelift might if you're a younger patient and you're not really wanting to have that recovery. It's not a bad option, but there's a time and a place for every procedure, let me just say that, and a mini facelift on maybe a 40 early fifties, sure, you could do that. But when you start fifties and sixties, you probably are looking at a full lower face and neck lift. And that's really referring to the incisions I mentioned before around the ears and under the chin. And what it refers to is it's going to tighten really the lower face and the neck. So we call it a full lower face and neck lift. It does nothing for your midface, your forehead, your eyelids. And so we break it up. It's separate procedures. So I think if patients come in and they say that to their doctor, I oftentimes want to clarify that with patients. I'm like, well, let's talk about that. What areas are you looking at improving? And if they start saying, oh, I want my brows higher, okay, well, that's a different procedure. I mean, we can do it at the time of a facelift, but that's not a facelift. That's a brow lift. 

Kirstin (14:50):
So that was going to be my next question was about doing a brow lift or a facelift, but you got that. So I know you are very much not about suggesting surgeries that a patient doesn't ask for. Is that one case where you would kind of approach things a little bit differently if they were a candidate, if their results would be a lot better if they had a brow lift in conjunction with their facelift, you would suggest that during a consultation. 

Dr. Koehler (15:18):
So yeah, a patient comes in, I don't like to be offering a bunch of other procedures that they didn't ask for. I don't want them to leave here going, well, I wasn't bothered with my eyelids and he talked about my eyelids. But truthfully, when it comes to the face, and a lot of times it's kind of getting permission from the patient to say, look, is it all right if I talk about all the areas of your face, just so I can explain to you where the benefits will be? But there are circumstances where combining certain procedures really gives a better result. And I did an article for a magazine, a few, maybe it was a year or two ago, about facelifts. And in that article I talked about that, which was sometimes there's this perception in the public that, oh, if I do brow lift, cheek lift, eyelids, facelift, that's going to be too much surgery. 

(16:05)
That's going to look overdone. And actually, sometimes it's actually the opposite of what you think. Sometimes if you get this lower part looking good and the tops not matching the bottom, then all of a sudden it's just not looking right. So the curtains need to match the carpet. I mean, that's just whatever. But there are things that I do and I will suggest to patients, but we're certainly not going to pressure people into doing things they don't want to do. But they do need to understand that because what we don't want is get it all done, and then they're disappointed because they thought, oh, I thought a facelift was going to correct this. No, it doesn't. 

Kirstin (16:41):
Well, my opinion on that is cosmetic surgery is an investment. If you're going to spend the money on surgery, do the whole thing, do what is going to get the best results. 

Dr. Koehler (16:55):
And sometimes you don't necessarily have to do everything at once. There are times where I'm like, okay, look, we can start with this, but realize that at some point you're going to probably want to do these other things. And sometimes that makes sense for people recovery wise or whatever the reason is. And they're like, yeah, I do plan to do these other things, but just not altogether. 

Kirstin (17:14):
Are there things that patients come in thinking they need a facelift, but it's really not going to address the things that they're concerned about, such as loss of volume or fine lines? Are there things that a facelift wouldn't necessarily fix? 

Dr. Koehler (17:30):
Yeah, no, actually, that's probably the biggest misconception. And you touched on it right there, which, well, the volume loss is one thing. We'll talk, I can talk about that. But skin texture and tone, fine lines and wrinkles. A facelift does not really address that. A facelift is repositioning the muscles, that deeper layer of your face and repositioning the skin to get rid of jowling, sagging, neck, deep nasal labial folds, marionette lines. Those things are what we're lifting to improve. But the actual texture of your skin, that's actually a function of the skin. And so really to address the skin, especially if there's problems with the skin, texture, tone, fine lines and wrinkles, that's like CO2 laser skin resurfacing. It's a chemical peel, it's photo rejuvenation. There's a lot of microneedling. There's a lot of different options there, depending on the level of photoaging that's there. 

(18:24)
But the point is that that's where I need to educate people. Like, Hey, by the way, you've got a lot of sun damage skin. The facelift is not going to help all these other things. So if we want to do this, we don't have to do it at the same time, but you may want to address this with these other options. So yeah, that's really where our job comes into educate people and make sure we, patients need to be clear about what they really want to see fixed, and they need to communicate that to their doctor pretty clearly. So that's where the communication comes in. 

Kirstin (18:55):
Beautiful. You touched on it earlier. Tell me about this SMAS. Why is it so important? 

Dr. Koehler (19:00):
The SMAS? Is that how you say it? 

Kirstin (19:04):
SMAS, SMES? I know that. I don't like it. I saw it one time in a video.  

Dr. Koehler (19:10):
Yeah. Yeah. Well, it's just an abbreviation that stands for the superficial musculoaponeurotic system. And so it's the layer deep to the skin that was described many years ago. And in fact, there's a big debate of whether or not that layer even anatomically exists, but that's not for this podcast. But basically it is a deeper layer. It's the layer sort of just above where the nerves reside and where the deep facial nerve is kind of, it's deeper to that layer. And so when we do deep plane face lifting, we're lifting that SMAS and repositioning it. But there's techniques where people call it like a SMASectomy, where instead of lifting that layer and repositioning it, we're just taking a strip of it out and then using sutures to tighten it. And again, these techniques are all still very good techniques, and you can see some awesome before and after results of patients that have not had deep plane facelifts that just got a really good facelift with a SMASectomy or other technique. 

Kirstin (20:16):
Are there times where you would do a neck lift only not in conjunction with the facelift? 

Dr. Koehler (20:21):
Yeah. 

Kirstin (20:22):
Like what kind of patient would you do that on? 

Dr. Koehler (20:24):
So if a person does not have, jowling has a pretty good jaw contour, but really they've just got fullness in their neck. Now, if it's a weight related thing, then weight loss is obviously indicated there. But sometimes people just carry some extra fat in their neck, and we can, even if their weight is decent and they don't need to lose weight, we can remove some of that deeper fat, sometimes the gland and tighten the muscle. So that's a neck lift or a deep neck lift. 

Kirstin (20:55):
Are there things that we can do in our younger years to try and hold off the need for a facelift, or how can I delay? 

Dr. Koehler (21:03):
I wish I could help you, Kirstin. I wish I could tell it's too late now. How old are you now?

Kirstin (21:07):
<laugh> 

Dr. Koehler (21:07):
Well, I mean, there's a lot of things you can do. I mean, the things that a lot of dermatologists will tell you all the time is sunscreen, sunscreen, sunscreen. Stay out of the sun, protect your skin, because the sun will age your face significantly. So some people are like, I look better tanned. Well, you may when you're younger, but you might not like it much when you're older. So protecting your skin from the sun healthy diet, that's also a good thing. I do think there's maintenance type things like doing Botox to prevent the dynamic lines, which then ultimately can form permanent creases. So things like Botox, skin treatments like microneedling can be beneficial to help stimulate and keep collagen formation. Just having a good skincare regimen using a Retin A as you get a little bit older can help kind of give your skin a healthy glow. 

(22:06)
So there's a lot of things that you can do that are basic, but realize that these are maintenance things. This would be the equivalent of like, okay, if you want your car to look really good, you can't take a car that's all beat up and wash it and make it look good. At that point, it's too late. But if you've taken care of it along the way and you've protected it and done all the nice things that you're supposed to do, then yeah. I mean, you might be able to stave off some of the surgical things, but really the sagging and descent of the tissues, which ultimately leads to when we look at doing facelifts, there's not any exercise. I've seen all kinds of crazy things along. There's not an exercise or thing that you can do. It's just, it's some of it that's genetics, and it's just how we age. 

Kirstin (22:51):
Well, one thing that I think is awesome is that TikTok has made, maybe Instagram too, have made skincare cool. We love watching people wash their face. We love watching people do their skincare. Sunscreen is cool now. I love it. 

Dr. Koehler (23:08):
Yeah.

Kirstin (23:08):
We're going to look young forever. 

Dr. Koehler (23:10):
Perfect. Preserved in time. 

Kirstin (23:12):
<laugh>

Dr. Koehler (23:12):
Well, speaking of which, you know what, I just thought of a topic here. You've made me think about it. But a common question that I get is, if I get a facelift, how long will it last? You cannot preserve a, it's not like we don't petrify you. You're going to continue to age. So sometimes people ask me, how long will a facelift last? And I'm like, well, 24 hours. You continue to age from the day that you have the surgery. And what I like to tell people is that my hope is that in 10 years time, you're still going to be looking better than if you had not done this procedure. But by no means are you going to like even two years out, you're not going to look exactly like you did maybe the first six months out from your surgery. Now, it depends. The younger you are when you do a facelift, and this is where age does come into play, so you have better skin elasticity when you're 50 than you are when you're 70. 

Kirstin (24:18):
And if listeners want to see any of your before and afters for facelifts, neck lifts, brow lifts, they're on our website and our Instagram. 

Dr. Koehler (24:27):
Yeah.

Kirstin (24:27):
Good place to go check it out.

Dr. Koehler (24:30):
Yes. 

Kirstin (24:32):
All right. Thanks Dr. Koehler. Go back to making Alabama Beautiful. 

Dr. Koehler (24:37):
Alright, thank you. 

Speaker 1 (24:42):
Got a question for Dr. Koehler? Leave us a voicemail at Alabama the Beautiful podcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to eastern shore cosmetic surgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the Beautiful is a production of The Axis, THE AXIS.io.