Revision Facelift

Dr. Rad’s eye is trained to evaluate a face both holistically and at the smallest details, and revision facelift requires careful planning. It’s important to provide the surgical records from your prior facelift so that Dr. Rad can understand where you started (your pre-operative photos), what surgical methods were used and the details of how your facial anatomy was changed (the operative report), your “final” results (post-operative photos), and any problems that may have occurred after surgery (the clinical notes during recovery). Prior to consulting with Dr. Rad you must request all records from prior surgery, most importantly your pre-op and post-op photos, operative reports and clinical notes. We also request photos of your face from prior decades starting in your teen years through to your current age.

Patients who are healthy, non-smokers, and who have reasonable goals and whose anatomy is favorable for correction (this depends largely on Dr. Rad’s assessment) may be good candidates for revision rhytidectomy procedures. You should be clear on the reasons for which you seek revision facelift as there are many motivations, most often being quite personal.

Dr. Rad has extensive experience in treating patients who have many reasons to have a corrective facelift.

• Patients Seeking to Correct Scars, Distortions or Other Problems after Facelift - “I had a prior facelift and have unsightly scars and asymmetries. Can I have a successful revision facelift to correct these issues?” Facelift surgery is not without risk. Complications can occur and correcting scars or complications from prior facelift procedures is a common reason patients seek revision and these can be the most challenging circumstances. Skin tension on healing incisions lead to telltale signs of having had facelift: Unsightly or poorly placed scars around the ears – facelift scars placed straight in front of the ear can be much more visible than when meticulously placed along the natural curvatures of the ear. Asymmetry in facial contours and volume – if one side is pulled up more than the other, or inherent facial asymmetries weren’t accounted for in the initial facelift, then these can draw attention. “Pixie ear” deformity – the earlobe is pulled from too much tension on the incision line which elongates the earlobe and results in a visible scar with odd shaped earlobes. “Joker’s smile deformity” – the corners of the mouth are stretched and a windswept facial appearance results from over pulling facial skin; this is most common from skin-only facelifts (which should never be done). “Ear canal show” – too much tension pulling on the tragus cartilage (the small cartilage in the front/center of the ear) forward showing inside the ear canal, and others. Scars don’t heal well when closed under tension, and they tend to widen and become very visible. Sometimes odd scar patterns can make improvement challenging. These include “stair step” or “zig zag” hairlines behind the ear, or loss of the sideburn from poor scar placement, which are difficult to correct. One must be so careful in selecting a facelift surgeon because, in inexperienced hands, many telltale signs of prior poor facelifting can become apparent. The good news is that, when facial anatomy hasn’t been significantly altered for the worst, most of the time Dr. Rad is able to improve the facelift result and with excellent results.
• Improving upon an inadequate prior facelift result is a common reason why patients seek Dr. Rad’s expertise, not necessarily because there was a complication, but because their first result fell short of expectations. The two most common scenarios in which Dr. Rad consults with patients who have had prior facelifts performed elsewhere, the results of which were unsatisfactory, are the following: 1) A patient who had an in-office mini-facelift performed elsewhere, usually awake and under local anesthetic, commonly an “S-lift” or “Short Scar Mini-Lift,” and results did not match up to expectation. 2) In these situations, the limited results should not have been a surprise because the deeper structures and more central areas (nasolabial folds and marionette lines) were not addressed, nor did the lift impact the areas around the mouth, chin and jowls, and sagging in these areas persisted. Dr. Rad often corrects these suboptimal results by deep plane lift to address laxity and deep lines around the mouth. 3) A patient who had a skin-only facelift from which some improvement was seen initially but then disappeared after swelling resolved over months. Skin-only facelifts refer to the tightening of the skin layer. 4) Despite the claimed “advantages” of using local anesthetic and relatively easy recovery, the reality is that skin-only lifting is never a good idea, because skin does NOT have the strength to hold lifted tissues and, when tensioned, skin stretches out quickly. This explains why patients note that their results disappear quickly. 5) Dr. Rad has extensive experience addressing these shortcomings of skin-only tightening or otherwise unsatisfactory results of prior facelifts done elsewhere. Although corrective surgery often is more nuanced and challenging, patients who find themselves in these circumstances often can have a second chance to achieve better results.

Safety is Dr. Rad’s highest priority and he takes many steps to ensure patient safety. If general anesthesia is needed, then, for safety reasons, your surgery will be done in the safest environment, which is an Ambulatory Surgery Center that is part of a hospital campus. There, Dr. Rad works with a board-certified anesthesiologist and large team of experienced surgical nursing staff, which offer an unparalleled level of safety. Dr. Rad has tremendous depth of experience in facelift surgery, and so risks of complications are very low. He also focuses on minimizing tissue trauma, and so risk of tissue damage is very low.

All in all, risks are extremely low in the right hands, right environment and with the right surgeon and team. Think of this as “driving the safest car on the safest road with no traffic” where you know you’ll get from point A to point B without worrying about a terrible car accident.

Experience is crucial. In the spirit of the “10,000 hour rule,” your surgeon should be very experienced, and talented technically and artistically, which comes with doing many facelift surgeries.

How can you know how experienced a surgeon is? In general, the most skilled surgeons not only have basic requirements of training at exceptional institutions and certification by the American Board of Plastic Surgery, but they are also at least a decade out from finishing his or her training.

The literature is clear that less experienced junior surgeons are more prone to making errors than more experienced surgeons.

Experience is represented by multiple factors: how many before and after images are shown to you, how much information on facelift is presented online, and how expertly your surgeon explains the procedure and rationale to you during consultation.

Publications in scientific journals also indicate vetted expertise. Your surgeon should be able to demonstrate evidence of facelift expertise by showing multiple results of facelifts generally, and of facelifts in patients with similar anatomy and concerns as yours. A lack of evidence indicates lack of experience, which indicates lack of expertise.

Motor nerves, called “facial nerve branches” stimulate the muscles that move the face, and injury to these nerves is rare. Temporary stunning of facial nerve branches occurs in about 2% of cases which is in line with the average for the best facelift surgeons in the world. Keep in mind that stunning means that the nerve function comes back, and in Dr. Rad’s experience, all patients who have had temporary nerve stunning have had 100% return of nerve function. Permanent nerve injury is practically zero, and we say “practically” because in skilled hands one can be sure that it doesn’t happen, whereas in unskilled hands it can. Dr. Rad’s rate of permanent nerve injury is in fact zero.

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.

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.

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

In Dr. Rad’s DC practice, the cost for facial aesthetic lifts starts at $18,000+ for targeted in office “mini lift”, $29,000+ for more advanced face and neck lifts, (“deep plane” or ponytail methods), $49,000+ for surgeries combining other procedures (blepharoplasty, brow lift, fat grafting, etc.), $75,000+ for complex anatomy, corrective work and up to $150,000 for extensive facial surgery requiring multiple operations (such as adding rhinoplasty, facial bone augmentation or shaping, custom facial implants, etc.). Note that pricing is customized for each patient and these guidelines do not necessarily apply uniformly. Also keep in mind these are approximate ranges and total cost depends on multiple factors: your unique anatomy, goals, complexity of the procedures, recommended techniques, whether corrective work is needed, in-office or hospital-based operating facility, and combining multiple procedures (increasing concessions apply for multiple procedures).

Although you may receive varying cost estimates from other practices, keep in mind that your surgeon’s education and training, plastic surgery board certification, his/her experience (at least 8 years of experience after residency is recommended), and the “X” factor of aesthetic artistry and surgical skill (i.e., talent) of your surgeon are important factors in pricing. Dr. Rad’s goal for every patient is to achieve nuanced and natural results with minimal recovery, and we have mechanisms in place to bring your goals in financial reach.

Dr. Rad strives to deliver the best facelift Washington, DC has to offer. To find out more about facial cosmetic surgery and our financing options, schedule your consultation by contacting our office today.