Endoscopic “Ponytail” Facelift

Regardless of age, if you’re starting to notice sagging jowls, loose neck tissues and deflating apples of the cheeks and you’d like to restore a refreshed appearance, then a ponytail facelift may be the perfect option for you. Patients with moderate to severe tissue sagging are likely best served by the more complete facelift, Dr. Rad’s signature deep plane “sub-SMAS” technique. But a ponytail facelift is a good option as a refresh rather than an overhaul.

Yes and no: surgical ponytail facelift is needed when non-surgical treatments have reached their limit of efficacy. While fillers are effective in restoring volume and lifting tissues to some degree (the “liquid facelift”), patients who don’t want to have more volume added to their faces benefit from ponytail facelift.

The facelift will involve more incisions, a much longer surgical time, and a longer recovery time. Compared to the ponytail technique facelift which involves only a single incision behind each ear and can be completed in under an hour. The traditional facelift procedure will also carry a much longer recovery time then the minimally invasive Ponytail Technique Face Lift. While both procedures will leave you looking younger, a traditional facelift will involve more areas of the face including the cheeks, jowls, eyes, and in most cases, the neck. Another main difference between the two is that the ponytail technique is better suited for men and women who are in their late twenties to late thirties and the full facelift is better suited for patients who are a bit older and have loose drooping facial skin.

Facelift procedures require anesthesia to ensure patients’ comfort and safety during surgery. The choice of anesthesia depends on various factors, including surgeon preference, the extent of the procedure, the patient’s health status (presence of heart, lung, kidney or endocrine illnesses), and patients’ preference. The 3 most common types of anesthesia used for facelift surgeries are:

1. General Anesthesia (GA)

Patients are asleep and are unaware during the surgery. During GA, the anesthesia team administers a combination of anesthetics to optimize the depth of anesthesia while minimizing side effects. This usually involves propofol for quick induction, and inhaled gas anesthetic for stable maintenance, and an array of anti- medicines to reduce nausea side effects, the most common issue with GA.

In terms of what patients experience, your last memory of the process is rolling into the OR, and then the next memory is waking up in the recovery room. You feel nothing or experience nothing of surgery. Dr. Rad’s anesthesia teams are exceptionally skilled in ensuring comfort and safety. Patients do not experience “waking up” episodes, nor do they have any memory of the procedure.

GA involves administering intravenous medications and inhaled anesthetic to induce sleep and keep the patient pain-free throughout the procedure. This involves an airway tube (“endotracheal tube”) which serves two purposes: (i) to deliver the inhaled anesthetic which gives long lasting anesthesia, and (ii) protects your windpipe preventing any fluids, secretions or phlegm from getting into your lungs which can cause a pneumonia or airways spasm/constriction (“laryngospasm”). Without protection of your airway, such as with IV sedation only, the risk of airway/lung problems is higher.

Patients awaken quickly because the depth of anesthesia is not nearly as deep as required for other types of surgery (think liver, kidney or heart surgery). Within 15-20 minutes you are awake enough to remove the airway tube, and then you are rolling to recovery. Typically patients stay for a couple or a few hours in recovery before going home.

This type of anesthesia is needed when deep plane face and neck lift with deep neck sculpting (gland reduction) is being done.

Dr. Rad advises not thinking of GA as “being on a breathing machine” or being dangerous. Rather, the anesthesia machine is supporting your natural breathing and protecting your airway. In fact, GA is for comfort and safety. In the hands of a board certified anesthesiologist (with whom Dr. Rad always works) in the safest possible environment (accredited hospital-based surgery centers) GA is very safe, in fact it is much safer than the cumulative risk of driving a car every day.

2. IV Sedation with Local Anesthesia

In some cases, combining sedation with local anesthesia (injected numbing medicine) is used. In this case, patients often receive propofol for the IV anesthetic to induce sedation and which helps them relax and feel drowsy during the procedure. While the patient is not fully unconscious with this approach, they are generally not aware of the surgery and experience little to no discomfort.

This does not involve the inhaled anesthetic as in GA, and does not require an airway tube. You are breathing on your own and the anesthesiologist will maintain your level of anesthesia with propofol and other IV medicines. Oxygenation is supported with supplemental oxygen.

Patients may be a candidate for this type of anesthesia for shorter procedures and neck lift that does not involve deep neck sculpting.

3. Local Anesthesia Only

This type of anesthesia is the simplest of all, and involves injecting numbing medicine throughout the tissues to be lifted. Dr. Rad uses local anesthetics routinely in the office and this does not require going to an OR.

We start with applying topical numbing which dulls sensation, then injected numbing medicine is given while you are awake.

Patients are candidates for this approach when undergoing in-office mini-face lifts, upper blepharoplasty, buccal fat reduction and direct brow lifts.

Overall, the choice between these types of anesthesia will be discussed during the pre-operative consultation with the surgeon. The surgeon will consider the patient’s medical history, the complexity of the procedure, and the patient’s preference when deciding on the appropriate anesthesia.

You may hear that the safest plastic surgeons have “operating privileges” at major hospitals. “Operating privileges” allow surgeons to perform surgery at that hospital, and they are granted following a 6-month process of evaluating a surgeon’s background.

Dr. Rad’s credentials have rigorously been vetted by the top hospitals in DC and northern Virginia, specifically Sibley Hospital (DC), Inova Fairfax Hospital and Fair Oaks Hospital (northern VA), and George Washington University Hospital (DC). This means that his training, board certification and safety record meet the high standards of these top hospitals in DC and northern Virginia.

Proper skin care is critically important as your tissues will be inflamed after surgery. “Inflammation” is a common term that is commonly associated with harmful internal processes. However, inflammation is a normal process whereby the immune system is activated to heal tissue trauma caused by surgery. This is a normal part of healing. However, too much inflammation can be harmful and so we must be sure to avoid anything that can irritate your skin or worsen inflammation.

It is important to use the right products immediately after surgery. Dr. Rad recommends avoiding products that have stimulatory ingredients such as retinols and using gentle skin care with products that have high concentrations of antioxidants to calm and soothe inflamed skin. Drs. Sherber and Rad recommend the following curated, science-backed products for daily use after facelift surgery (you may order products online or ask our staff for these products from our Boutique). Products are at different price points but we have vetted these products for their high quality ingredients and calming formulations for optimal facelift healing.

• Cleanser: use a high quality oil-based cleanser. Drs. Sherber and Rad recommend Eve Lom Gel Balm Cleanser or Sturm Facial Cleanser. Follow the instructional video on the website. Massage a grape-sized amount of balm or 2 pumps of foam onto dry skin for 60 seconds, then enter the shower. Apply a warm/moist muslin cloth to your face for 30 seconds, repeat twice more, then buff your skin on the last application.
• Incision Care: La Mer The Concentrate
• Face and Neck Care: Sturm Face Cream (fragrance free, best for sensitive skin), Creme de la Mer (contains fragrance), Augustinus Bader The Rich Cream for dry skin (fragrance free), Augustinus Bader The Cream for oily skin (fragrance free), or Caudalie Premier Cru (contains fragrance)
• Eyelid Care: using a separate eye cream such as Sturm Eye Cream, La Mer Eye Concentrate, Augustinus Bader Eye Cream, or Caudalie Eye Cream for eyelids is important to prevent milia, small bumps that can develop when using thick face creams or ointments.
• Lip Care: Sturm Lip Balm, La Mer Lip Balm