A facelift's effectiveness is significantly limited by the underlying health and quality of the skin and deeper facial tissues; therefore, prioritizing skin improvement and preserving deeper structures is crucial for achieving optimal, youthful results.
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I'm here in Miami
and uh it's Thursday but I forgot my
lesson of the day Wednesday yesterday
Wednesday was our uh consult day and
we call it hump day hell day whatever
you want to call it I saw probably 45 46
people uh mostly new consult some old
consults coming back in to just talk
about things and again there was a theme
that popped up there's always a pattern
and I saw several patients yesterday
with really bad skin coming in for
facelands and they're lovely people so I
don't mean to insult their skin but they
had really bad skin and they're going
for a facelift and this is important
because face lifting is meant to make us
look more refreshed youthful and younger
and it's done by lifting sometimes we
add some volume to the face to brighten
the face as well but the number one most
important thing or the biggest most
important organ we have that we use in
face lifting is the tegument or the skin
and that's all this stuff
so uh what's the the purpose of lifting
if you're gonna still have bad skin
you're still going to throw Shadows
you're still not going to have that
bright appearance to you and
realistically really limited your result
so uh with these patients I try to
explain to them what's happening in
their skin and why it's important to
brighten it so with aging we see The
Superficial part of the skin can get sun
damaged and we're all familiar with that
because we see it on everyone's face
what we don't realize is that there are
several layers deep to that that
actually affect how that superficial
layer looks and that's different for the
eyes than it is for the cheeks than it
is for the lips the tissue layers are a
little different so to walk you through
it superficially we need to fix Vina's
face Vina Nevis and on your right so uh
Venus face is a good example so superficially
superficially
when you get sun damage you can get
separate keratosis you can get uh little
sun spots you can get a bunch of
different things the most common that we
see that's concerning is form or a
variety of melasma melasma is
superficial skin pigmentation and
melasma can happen from sun damage in
areas up over here especially around the
cheeks very common it can happen from
lasering which is like sun damage on
crack so if you laser someone who has
pigmentary issues it's just like putting
them in the Sun and accelerating it and
you get it from hormonal changes as well
when you go through hormonal changes
rapidly the pigment and the skin gets
more reactive for some reason so you do
see that it's up regulated so for
melasma or superficial pigmentation we
can treat patients with chemical peels
with lasers those are aggressive ways to
get it off if it's skin that's sensitive
and gonna react things like that might
just make it worse so we just give
people creams creams that can light new
creams they can calm the skin there's a
bunch of different things you can use
creams that can make the skin look
younger Retin-A is a common one that
people use for better skin turnovers the
skin turnover goes faster and you your
skin peels off faster it also allows
better depth of penetration of the
different creams that you put on that's
why people use it but you don't want to
use Retin-A on sensitive areas like here
or around the under eye so it becomes limiting
limiting
now that's it uh nothing's working and
you're Asian and you've got bad melasma
and you want to know what else to do
well there was a study done amongst
Asians uh using tranexamic acid txa this
is a an IV medication or oral medication
that we use for women who have heavy
menstruation heavy periods to help them
form blood clots and we've also found
that it helps with melasma so if
somebody takes melasma with recalcitrant
or resistant melasma where about one to
three months just depending on how long
you want to put them on it you can
lighten the large majority of these
people who don't lighten otherwise so
that's the melasma
there are the fine wrinkles and texture
and things like that and for those
things you have
Retin-A also you have CO2 lasers or
erbium yag lasers which are fractionated
lasers which help superficial texture by
ablating the surface that means it
explodes water and ablates the surface
they also can go a little bit deeper and
cause coagulative necrosis or other deep
damages in the dermis to tell your body
to remodel and make new collagen
other than just burning things off and
then you have radio frequency radio
frequency there are a lot of different
types and I'll talk about that totally
separately because it's confusing to
doctors and to patients all the
different types of radio frequency but
radio frequency can be used
superficially to stimulate the skin like
microneedling it can be used deep to
melt fat and it can use just in the
middle to go and thicken the dermis or
help the dermis get healthier
so what is below the skin we've got the
epidermis we've got the dermis under it
we've got more important layers as well
and the one right under it is called the
smash the smash is The Superficial
musculoponeurotic system this has its
own thick hydratory layer that's
interspersed with fat molecules
and a bunch of hyaluronic acid and fluid
amongst other tissue and then when you
go deep to it you have some mimetic
musculature so smiling muscles that it
wraps around so this mask kind of covers
all that but what I'm talking about is
the thick part of the smash that you
have on top of the orbicularis Ora's
muscle or the thick part that you have
going over the zygomatic is complex and
down into the Buckle you also have your
fat pads in the face and there are the
granular fat pads which we call the
superficial mail art pad or the law of
fat pads that you see around the zygoma
and then you have your buccal fat pad
which is totally different
and they contribute to appearance of
skin in different ways so this mass is
very very important if this Mass becomes
deflated or damaged in someone's face it
can start to make the whole face look
darker it is what is probably the most
responsible for the hydratory potential
or the cushiony appearance of your face
when you get rid of it the face starts
to throw Shadows everywhere not just
where it's folding so the smash is super
important I do see patients who come in
and they have an exaggerated appearance
to their face because their smash is
shrunken that could be because they have
Scleroderma and they've had multiple
bouts of fibrotic reactions in their
face where the smash just shrinks down
it could be from dissolver and filler
meaning they got overfilled and the skin
got damaged over time and the smash is
really where a lot of the filler stays
and when you dissolve it you have all
these microcystic little areas that have
expanded and it collapsed in an
exaggerated fashion after you dissolve
and that doesn't recuperate so well in
the mid face and I have I did see two
patients like that yesterday who didn't
understand why they look darker but when
I told them their timeline matched up
and that's exactly what happened I saw
two other patients who had had deflation
in the smash or the fat from repeat
radio frequencies and the type of radio
frequencies you have are the wand based
ones which generally you don't want to
put in the face you don't want to put
acutite in the face or face tight
melt the fat layers and melt the smash
you're going to shrink them people
imagine that you tighten these layers
concentrically and you get a lift out of
it realistically that's not happening
you're microwaving them and you're
shrinking them and reducing their
thickness so the support for the skin
over time ends up going down it's not
shrinking and tightening like you think
you do get some fibrosis and contracture
and density in that area because you
scarred it down that's where the
tightening comes from so it's important
to be cautious when we're doing these
deeper types of radio frequencies or
heat based treatments in the face or
repeats based treatments in the face
because even if you're not melting the fat
fat
you have to remember the smashes there
and even if you're not melting the smash
you're going to cause a fibrotic
reaction there and eventually it's going
to sclerosis it's going to scar down and
that's very very common and it's common
amongst people who do over aggressive
single treatments or are over aggressive
by doing multiple treatments so you have
to be cautious how many heat treatments
you're doing even CO2 laser when it's
overdone can do that so
the layers deep to the epidermis and
dermis which is what we consider the
integument are just as important to the
appearance of it
you have to keep them intact and it's
impossible to replace them we can't go
and replace a damaged smash we can't go
replace lost fat in the face we'd have
to take fat from somewhere else and try
to replace it so we have to be cautious
and make sure we keep this our entire
lives or you end up like these ladies in
my office who are getting darker or
getting older and accelerated with raids
and they don't know exactly what's
happening so what do I offer them when I
see this deflation I recognize the
deflation in the face when it's caused
from Smash or fat deflation it's a
different type of darkness and collapse
I tell them they could do nanofat PRP if
you take nanofat and PRP and inject it
back into the dermis subdermis and a
smash you'll actually get a surprising
amount of Rejuvenation in those areas
and patients skin just turns brighter a
lot of that is from the return of
hydratory potential of the face where
the face like a sponge starts to inflate again
again
that's decently easy to treat the hard
one is when there's damage with age or
sun or lasers to the dermis and you get
that dry appearance to it that's really
hard to rejuvenate I still use nanofab
PRP for that but what I do recommend
that's very easy is to do micro needling
micro needling uh is touted for collagen
production it doesn't really produce
much collagen what micro needling by
itself or micro needling with PRP is
good for is stimulating the skin and I
like to tell patients to go do it maybe
three four times a year and what happens
is they needle the skin the skin gets
pissed off or stimulated your immune
system wakes up comes and tries to heal
the area and in doing so uh hydrates it
more aggressively so now chronically dry
skin becomes more hydrated
people use oils hyaluronic acids and
Retin-A and these things can have a
positive or negative effect just based
on your skin type you never know micro
needling unlikely has any negative skin
type negative skin reaction the
micro needling RF or radio frequency is
totally different so not the same kind
so the message in the end of all this is
if you're in the position where you're
trying to go get a facelift because you
want your face to look brighter nicer
and younger you first need to focus
yourself on improvements in the skin
quality and you need to be religious
about that that's why I always send my
patients to Jen Hollander first go see I
said go see her start getting uh going
on a skin regimen make your skin
brighter and I'm not when I'm talking
about skin I'm never just looking at the
outer skin I'm looking at what's under
the skin too because I recognize it I've
seen it so many times so I look for
deflation and I look for darkness and I
look for different things that you see
over time that happen again with age
with filling and dissolving or that
happen with heat based therapies or
repeat bouts of scarring again like
Scleroderma and those kind of autoimmune
issues where you get rapid dehydration
and skin quality changes so you have to
treat all of these when you are looking
at the aging face so it's not just one
level of skin integument you have your
smash you have have your fat below that
there's the mimetic muscles below that
there's fat pads again and you need all
of them the medic muscles The Smiling
muscles in the face do not function
properly when they are bogged down with
a lot of fluid like filler or silicone
and they don't function well when
they're denuded when they're stripped
down if somebody overheat treats or over
dissolves the muscles start to work a
little weird they they contract too much
or they relax too much it doesn't
function well and when you get rid of
the buccal fat pad that's an entirely
different one that I just touched upon
the buccal fat pad is a support
structure for this part of the face so
when you get rid of the buccal fat pad
in some people you start to see collapse
here and it's a whole other type of
Darkness that you see in people where
they start to get indentations here in
front of the pre-gel fold is what I call
it or the marionettes as it comes down
so all these things are important you
can't replace them so this is more you
know it's a message for like young
people especially don't think that you
could just keep doing heat treatments
over time and it's going to be healthy
and have no problem problem these things
can slowly damage you they slowly just
think about it they just slowly
microwave your face and you keep eating
it too much or if you get too much
filler you've expanded it now you've
damaged your tissue and somebody's gonna
go try to dissolve you and the dissolver
is gonna now deflate you so much because
you are over expanded already so take it
easy on all this stuff and don't think
we can fix it because we can't fix everything
everything
happy Thursday for the Wednesday message
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