Avoiding the Unfavorable Facelift Result

February 28, 2017

Happy 2017 Readers!  Last month, we explored the phenomena of overfilled facial features.  I discovered that it stimulated conversation about a new problem that we’re seeing with the rise in facial fillers being injected.  However, we didn’t discuss something important and closely related:  The Unfavorable Facelift Result.

Every facelift patient I see voices the same concerns.  They say that so-and-so’s facelift looks “weird” or “unnatural”.  This often leads to the belief that they don’t want anyone to tell that they’ve had anything done.  While hiding surgical scars and achieving harmony are high on the list of operative goals, you do want something done, and you want that something to make you look younger!

So what is it that makes patients look bizarre after a facelift?  There are 4 major culprits:  1. Excessive skin tension.  2. An unartistic vector of pull.  3. Tethering of the muscles of facial expression.  4. Corrective disharmony between facial features.




When the patient is laying on the table, it is very tempting to take out a lot of skin.  Many a great surgeon has redraped the skin and taken out a lot of it, and on the table the patient looked like they were in their 30s.  The surgeon patted himself on the back and thought that he’d “hit a home run”.  However, as the patient healed, the earlobe pulled down, the scars widened, and wrinkles that formerly looked natural were now “windswept”.  Avoiding undue tension on the skin is an important part of obtaining a nice result.  Don’t ask me how I know!




As the face ages, the soft tissues descend with gravity.  Therefore, it would seem intuitive and natural the restoring the face’s youthful shape would be pulling those tissues upward.  However, it is technically more straightforward and easy to pull the soft tissues lateral, towards the ear.  The problem with this is that it leads to flattening of the facial features and sometimes the creation of a cross cheek depression.  Pulling the facial fascia in an upward direction more accurately restores the patient’s youthful appearance.




All of our anatomical study up until 2009 was on the anatomy of the face in cadavers or during live dissection in the operating room.  In 2009, it occurred to me that we were missing the point – the face is a dynamic, fluid structure.  Facial expression is an overlooked part of youth and facial beauty.  I realized that we should focus not just on this static anatomy, but on dynamic anatomy.  Using ultrasound, we demonstrated that the fascial fascia and the muscles that control facial expression move around a great deal in ways we never previously recognized.  Tethering these muscles with poorly-placed sutures creates some of the weird smiles we see after facelift surgery.




On an almost daily basis, patients tell me that they just want their neck done or just want their face done.  It’s understandable – they don’t want all of that expense, pain, recovery time, and with all of the bad results, it’s natural to assume doing less would lead to a better outcome. However, many strange outcomes you see are actually not bad facelifts.  Often, the patient has had a good facelift result, but their neck and upper face remain in an aged position, or their eyes are undercorrected.  This leads to disharmony, which your brain interprets as “strange”.  It’s sometimes best to do it all and turn back the clock on your entire face.  The caveat to this is the male patient.  I frequently find that male patients just need conservative upper eyelid surgery and a good necklift.


I hope that this editorial spurs your intellectual curiosity.  If you’re considering facial rejuvenation, keep some of these points in mind to further a good conversation with your plastic surgeon.  We love informed patients!

The Importance of Precision Facial Filling

December 28, 2016

Go to any cocktail party or benefit and you see them: Overfilled faces. Many women have lips and cheeks that are too big and clearly overinjected. It wasn’t supposed to be this way. Just 10 years ago, the problem was that faces were overpulled, flattened, and had bizarre earlobe deformities. When hyaluronic acid fillers and fat injections came to the forefront, it was felt that restoring volume was what was missing from facial rejuvenation. These volumizers were billed as a cure to the bizarre appearances you were seeing around town. However, we seem to have traded one set of deformities for another.

Why is this going on? There are many contributing factors, there are 3 things you should know as a patient considering fat or fillers: 1. The Foundation of Facial Anatomy. 2. Fillers are not a Cure All. 3. Respecting the Harmony of Youthful Faces. Precision facial filling is a catch-all term I use to describe the artistic and anatomically-accurate use of fat and fillers. Although plastic surgeons have the best background to accomplish this, any good dermatologist, nurse injector, or aesthetician can learn these principles and get really nice results.

The Foundation of Facial Anatomy

Doctors are busy. These days, you’re lucky to get 30 minutes of a doctor’s time. Because of this insane time crunch that doctors are under, we don’t go back to basics. Anatomy is the foundation of everything that we do. Ten years ago, I was the anatomical research fellow in the Department of Plastic Surgery at UT Southwestern in Dallas, Texas. At the time, it was the mecca of aesthetic surgery, with some of the world’s most renowned plastic surgeons. We discovered that the body’s fat was compartmentalized by fascial membranes which originate from the bone and deep tissues and insert into the skin. Previously, ligaments had been noted here and there, but until we used a special dye stain and microscopic dissection techniques, we didn’t see these membranes. This anatomy underlies the way the face looks, why you have creases in certain areas, and contributes to the way in which the face ages. An understanding of these anatomical nuances allows the surgeon to inject a little bit here and a little bit there to achieve the desired volume and contour, instead of having to randomly inject large lumps of fat or filler haphazardly.

Fillers Are Not a Cure All

In plastic surgery, the best results are typically obtained when more than one solution is thrown at the problem. Facial fillers are no different. When doctors try to erase every line with filler, they are going to have to use a lot. This is expensive, and leads to overfilled features. Fillers work best when they are injected deep and superficial, in lines and around them, and then combined with facelift surgery. Throwing ever more volume into the fat compartments doesn’t restore their youthful tension – that requires surgery.

Respecting the Harmony of Youthful Faces

If you look at a young face, it is full. Cheek and forehead highlights are round and glowing. As we age, those youthful contours flatten and dim. It makes sense that restoring this volume is an important part of facial rejuvenation. However, when fat and fillers are overinjected, instead of obtaining a nice contour, cheek contours are fat and blunted. When lips are overfilled, you see less and less of the upper teeth; upper tooth show is a huge part of looking young. These undefined looks aren’t pleasing to the eye, and it’s why you have a negative reaction when you see someone whose face has been overfilled.

As doctors, nurses, and aestheticians inject more and more filler, we are seeing more of these unfortunate results. As a patient, if you are armed with information, you can speak more intelligently with your doctor and work together to achieve the result you desire. An informed patient is a good patient, and that’s something we all want!

Yours Truly,
Daniel A. Hatef, M. D.