When Facelifts Go Wrong (& How to Fix!) Explained by a Facial Plastic Surgeon

[00:00:00]I see more patients in my consultation clinic for revision facelift surgery than most people realize and in almost every case the problem is avoidable. Hi, I'm Dr. Amir Karam. I'm a board-certified facial plastic surgeon with over 20 years experience helping people look as young as they feel.

[00:00:16]Today, I'm going to break down the reasons people end up needing a second facelift, which is something no one wants when it's done prematurely. A well-executed facelift properly done should last 10 to 15 years. You shouldn't be looking for another surgeon within a year or two. And yet, I see it all the time in my consultation clinics.

[00:00:38]Many patients who still have jowling, neck laxity, they might even look pulled and unnatural and they come to me to fix these issues. These situations fall under four distinct categories.

[00:00:50]Understanding them will change how you think about surgery whether you or somebody you know has already had it or just starting to consider it. And by the way, if you like videos like this and want to see more, make sure you subscribe to this channel. Let's get into it.

[00:01:06]>> [music] >> The first category is what I call the under-corrected patient. Now, this is somebody who had a facelift, but the surgeon simply didn't do enough or go far enough. Now, my standard for a well-done facelift is clear. I really aim and hope that by the end of the surgery and by the time healing has happened, there's no jowling, the neck has had a meaningful improvement depending on where it started from. In my practice, the face should also look extremely natural and there should be a significant improvement over the before and after. That's to me the standard of a good facial rejuvenation outcome. When that endpoint is not reached, the patient isn't happy and they're often back in a consultation room within a year or two trying to find somebody or the surgeon who did the procedure for them in the first place who can finish the job. This is never done on purpose.

[00:01:56]I've never met a surgeon that, you know, chooses to do this. Everyone's got the best intentions when they have a patient on the table and they're doing this uh surgery for them. So, even though it's not on purpose, it may be a function of the technique that was used or the surgeon's comfort level and experience didn't allow for a full correction. Now, what does this look like? Often times this is somebody who still has laxity along the jawline, you know, the quote-unquote jowls where part of the cheek is hanging over the jawline.

[00:02:25]That's the definition of a jowl. Or maybe the neck is not fully corrected.

[00:02:29]There's still quite a bit of laxity left in that area and the patient knows it and they can see it every time they look in the mirror and that leaves them feeling dissatisfied. I'll give you an example. So, tomorrow I'm doing a series of consultations and I always pre-examine the consultation photographs, etc. and their histories before we go into it. And there's at least two or three patients in there that have had facelifts done within 2 years. And when you look at their photos, they still have laxity over their jawline, they still have quite a bit of laxity in their neck. And these are patients that literally just went through the process, but they're still having the same issues they had before.

[00:03:06]They've never even reached a place where they felt completely rejuvenated. And that is something that's objective. It's not the person who perceives it. It's not the person who's being too picky, which we'll talk about later. This is a person who objectively has room for improvement. The good news is this is totally correctable. So, this is actually one of the better outcomes to have when it comes to revision surgery.

[00:03:30]There's really nothing to lose here other than the fact that you have to go through another recovery, you have to go through the expense of it, etc. But uh you can get to where you want to get to by seeking the help of a surgeon that is capable of finishing the job. So, this to me is a completion surgery and if it's done right, you can have an excellent, long-lasting result and get back to where you wanted to be when you first set out.

[00:03:54]The second category, this is slightly different and it's also very common. The patient who had a facelift but only part of their face was addressed. So, what I mean by that is maybe they come out looking like they have an amazing neck, very well done, but the mid-face was never lifted or maybe there's hollowing in the face or maybe the corners of the brow, the upper third of the face is still lax, but then they have a tight lower half of the face. So, in this case, the face looks unnatural. It looks different than what a human's face looks like because remember, this is a key point, when you're younger, everything is young. When you're older, everything is older. So, by addressing only part of the face, it ends up looking a little strange and that strangeness makes everyone, including the patient, realize that something is not quite right and that often times it's blamed on plastic surgery, right? I mean, that's the first obvious accusation is the person doesn't look like a normal human, therefore they've had plastic surgery. That's not something most people want to walk around looking like. So, in this case, some parts are youthful and some parts are old and that looks unnatural. Now, I I think of a gosh, a number of cases of uh scenarios like this and nowadays I don't perform, you know, isolated procedures like lateral brow lifts and things like that, but when I was doing them, I would get a lot of patients who would come to me who had a facelift and then this part of the face, say the upper third of the face, mid-face and lateral brow, was drooping still and it just didn't look right, right? There's like a ridge of of bunch tissue in this area. I would go and I'd do a lateral brow lift, sometimes a mid-face lift, etc. to complete the outcome and as a result, you know, the patient's ultimately happy when the other components get addressed.

[00:05:36]Everyone's got a different approach to this, but sometimes the surgeons and the patient advocate for kind of this piecemeal approach. Like, let's just do the facelift now, later we'll come and do your eyes or later we'll come and do the fat transfer, etc. And then in the meanwhile the person's walking around having this kind of disconnected-looking outcome. In our practice, we generally recommend getting whatever needs to be done done at the same time, although there's exceptions depending on the degree of aging in those other areas.

[00:06:01]But ultimately, if you need it, it's cleaner and better to get it all addressed together. But again, the good news is, like the under-corrected patient, this one is correctable at any point postoperatively. It doesn't matter, you know, if you do it 6 months later, a year later, 3 months later, you can go back and finish what you intended to finish the first time. And by the way, if you want deeper weekly insights on procedures, skin care, aging well, all these different topics related to just all-around rejuvenation, I have a newsletter that I write, the Dr. Karen POV, and it's delivered free to your inbox. So, the link is in the description. Make sure you sign up for that.

[00:06:42]Now let's talk about the third category.

[00:06:43]This is the hardest to talk about and the hardest to fix. Now these are patients who had a facelift and now they look unnatural. They don't look like themselves anymore. They look like they've been operated on. Many times it's things like the corners of the mouth have been pulled sideways. It's the kind of wind-swept look, and when they talk, things just look tight and they don't, you know, move the right way. This usually happens when the surgeon has either removed too much skin, pulled in the wrong direction, the wrong vector, etc. Lifting in the right direction is everything in a facelift operation. The wrong vector creates that telltale wind-swept, pulled, you know, type of an outcome. Now, how do we correct this? So, if somebody comes to me 5 to 10 years after they've had that original facelift, and now they want a secondary or revision, I can totally address that. With the right vector, this vertical orientation, adding some fat transfer, etc., we can often bring naturalness back to the face, generally.

[00:07:37]But what happens if somebody comes too soon after their original surgery?

[00:07:42]Unfortunately, we have to ask them to wait in many cases like this because what happens is if the person was pulled, a lot of skin was removed in a horizontal fashion, then when we lift the face vertically, we literally run out of skin to be able to close that region safely because the lift going upward separates that space and there's not a lot of room to bring it together without risking having very unsightly or pulled-looking scars. So, in these cases, revising too early creates more problems than it solves. So, I look at these as a very case-by-case situation.

[00:08:13]Um there have been scenarios where we operated a little bit sooner just because there was, you know, some flexibility in that, but there's a lot of scenarios where I simply have to tell the person we have to come back and wait. The hardest situations of all are when the face has also been heavily overfilled. This can be either with fat or with filler on top of a distorted facelift, and that's when things become truly complex. In fact, I just talked to a patient yesterday about this who really, you know, sadly had spent the last 10, 15 years filling her face full of filler, beautiful woman, wanting to look like she did when she was in her 30s, and now she's, you know, 10 years, 15 years later looking very round, and there's no way to get her back to that level. So, even with a properly done lift, we can't exactly get a person back to that because those those tissues are going to harbor all that volume and you can't get rid of it. So, less is more, don't do too much. Those days are over where we're, you know, really thinking that more volume is the right answer.

[00:09:09]done a lot of videos on what you should do or not do before getting a facelift.

[00:09:16]So, make sure you check out those videos as well as you're navigating through this journey for yourself.

[00:09:22]>> [music] >> This one may surprise you. Some of the patients who come to me asking about a revision surgery don't actually need it.

[00:09:31]After evaluating them, I feel like they've had a great result, a meaningful correction, a real improvement above baseline. But somewhere along the way they fixated on something small. Maybe there's a little bit of laxity, maybe there's a little bit of fullness under the neck, maybe things aren't as tight as they can be. Sometimes people have this feeling that they should be literally as tight as a mannequin almost, you know, and they do this to their face and say, "Hey, there's there's stuff here. Like, this should not be here." Well, actually it should be there because it's soft tissue and you move your face in a lot of different directions and you need that extra bit of compliance in the in the system and the tissues to be able to accommodate a full head turn in one direction or up or down or whatever it is. So, the fact that things aren't as tight as they are in the first month or two really starts to bother these particular category of patients. They're convinced that they need to go back under the knife to tighten more. Here's the reality. No facelift makes you as tight as a drum forever and it shouldn't because that's not what human faces look like. There is a biology to this whole thing, too.

[00:10:34]There's some soft softening over time, which is normal. There's a swelling that goes down, which is normal and expected.

[00:10:39]But, also depending on what type of tissue you bring to the table, you know, for example, patients who they're in their 60s or 70s, even 50s sometimes, with really sun-damaged skin. I mean, I'm talking crepey, thin, sun-damaged skin that really has very little elasticity to it. Patients like that, no matter how tight you pull them, no matter how good the facelift is, when they turn their head down, they're going to get a bunch of little lines, you know, across their neck. They're going to go down like this. They're going to see some stuff because the soft tissue you can't change. You can't change the skin quality. That's why I always talk about how important it is to take care of your skin both before and after, you know, surgery because if you don't have youthful-looking skin, sometimes that is the thing that you fixate on after surgery and you blame it on the surgery.

[00:11:26]Now, in these situations, I want to be clear, it doesn't mean that the surgery has failed and what I do in these scenarios is I always look at the before and after and really try to, you know, understand what's what. But if I come to the conclusion that that was a successful looking surgery, then what is usually going on is that there is an expectation disconnect between what the patient expected and what the surgery could do or what the surgeon could prepare the patient for. So, it's so important to set these expectations up front. For example, patients who've had long-standing grooves in the corners of their mouth. You get rid of the marionette folds by lifting the cheeks, but there's always a little groove here.

[00:12:06]It doesn't go away completely. Patients can fixate on that and they think it's because you didn't pull tight enough.

[00:12:10]Well, the reality is you got to explain some things like that are not going to get better all the way as a result of surgery. So, knowing that up front allows you to just know what to expect and that's such an important part of this entire journey with a surgeon. We always have this saying, it's basically if you talk about it before surgery, it's an explanation. If you talk about it after surgery, it's an excuse. So, I really, really do take that to heart and I try very hard for my own patients to set expectations where I think there might be some limitations, etc. And sometimes it sounds like I'm delivering bad news, but I'd rather under promise and over deliver than the the other situation. So, that conversation about what things are going to be corrected, what the results are going to look like at a year, 5 years, 10 years has to happen before surgery, not after. And trust me when I say this, I say no to a lot of patients on a very regular basis for a number of different reasons. I don't know, maybe 30, 40% of the incoming consultation inquiries we say no to. This is one of the categories where we would say no to somebody. If I get a chance to talk to them, I try to um explain to them, you know, the fact that they had a great outcome, they shouldn't, you know, whatever and really doing the the other surgeon a favor by doing that and also the patient a favor if they can they can buy into it because the scary thing is a second operation in a person who doesn't need it can lead to enormous amount of potential problems. I mean, you open up a ton of canned of worms that you can take a lovely result and truly, truly ruin it. So, for anyone who's watching this, you know, pick your battles. Listen to your surgeon. If you need another opinion, get another opinion, but it's got to be with somebody you trust because sometimes people will just tell you what you want to hear and then go in and operate on you. And it's not because they have bad intentions, but maybe they really do think they can help you, but these things all have risks in this category especially. It's better to leave things alone, especially when they're minor.

[00:13:55]Minor laxity, etc. That's all just part of the normal aging process. You still look a lot better than you did before the surgery. So, selecting who's actually a candidate for revision and having the integrity to tell someone they look great when they think they don't is one of the most important parts of the whole process. You need a surgeon you can trust enough to tell you no. And that includes your own surgeon. And I'm grateful anytime a patient who comes to me with exactly these concerns and they really listen to me when I if I felt that there was an opportunity to make things better, I always would. And if I feel like it's a it's a bad idea to go forward and I say no, when they trust me and they, you know, they take my advice, I'm so grateful that they have that much faith in my judgment and know that I have their best interest in mind. And that's the feeling you want to have towards your surgeon. All right, folks, that covers it. So, if you want honest conversations like this where I tell you what actually works, my opinions, what doesn't work, how to age well without regret, make sure you subscribe to this channel. And if you're thinking about surgery, drop your questions in the comments below. I'll take a look and read them. More info on my surgical practice in the link in the description, which is also where you can sign up [music] for the Dr. Karam POV newsletter. I'm Dr. Amir Karam and I'll see you in the next video. [music] >> [music] >> Mhm.