Dr. Altman s Current Approach to Facelifts. February 9, 2016

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1 Dr. Altman s Current Approach to Facelifts February 9, 2016 Dr. Altman has been performing facelifts for close to thirty years. Over that time period his technique and philosophy have evolved into his current approach to managing the rejuvenation of the face and neck. Earlier in his career, the facelift procedure was performed under a general anesthetic which took 5 to 7 hours to perform. In addition to lifting the skin and deeper tissues from the sides, the muscle in the anterior or midline of the neck was often sutured together from side to side creating a corset. Patients undergoing this procedure frequently spent one night in a hospital or at a facility with nursing. Although the risk was small, and the likelihood remote, any bleeding or swelling over the anterior neck could result in an emergency airway situation. In addition, this approach could cause contour irregularities that are difficult to correct. With this technique, patient swelling often lasts a number of weeks. On occasion, there is a tendency to over pull the face initially, although with time, as tissue relaxes, the results can be very good. Prior Technique Lateral face and neck flaps & platysma midline neck surgery (Neck stitching drawn in blue is internal)

2 Over a period of time, Dr. Altman decided that maybe he could get the same or better results leaving out the anterior neck portion and planning a second smaller step. Currently, the facelift procedure is performed with the intention of performing two smaller, less invasive procedures separated by about one year. This staging approach is different than that which is routinely performed in the community. Typically, the initial operation is performed under relatively light intravenous sedation, not general anesthetic. The sedation is administered by an anesthesiologist. With this technique, the patient is deeply sedated only during the brief periods when Dr. Altman is administering the local anesthetic. After this time, the patient is comfortable, and even able to stretch or move if necessary. This operation usually takes just less than 4 hours, about 1 ½ to 2 hours on either side of the face. Typically, there is no anterior or midline surgery on the neck muscles. Sometimes a small amount of liposuction is necessary. Dr. Altman s belief is that most of the hanging skin and muscles in the anterior midline neck can be gently pulled to the sides, without suturing them together in the midline, thus avoiding the time and risk of midline surgery. In his current technique, there is a tendency to pull the tissue only enough to look excellent and refreshed, understanding that there may be tendency to stretch over time. Dr. Altman recommends a smaller second stage or step at 12 months to complete the process. This second procedure is usually performed under a local anesthetic but sedation is available from an anesthesiologist if requested. The second stage typically takes about 3 hours or less. Typically, the patient can go home with a spouse or a friend, not requiring specialized nursing. The net result, of two smaller stages, gives results which Dr. Altman feels are comparable or better than one more aggressive procedure, with less risk and downtime. This planned two- stage procedure should not be confused however, with minimal or risk free surgery. All of the risks, including bleeding, infection, lost motion, or sensation can occur, but less than with more aggressive dissection techniques. With the two stage procedure the pricing has been set up so that the patient pays for about 2/3 to 3/4 of the entire cost in the first stage, and if s/he chooses to go ahead with the recommended second smaller stage pays the remaining 1/3 to 1/4 (quotes are individualized). Advocacy for this approach to face- lifting is not to say that the other more traditional way is wrong, it is not Dr. Altman s method of choice for most of his patients. His interest in approaching aging is a more conservative manner over the years is based on his experience with hundreds of facelifts.

3 Please feel free to discuss this in person with the doctor. Dr. Altman s Current Technique Lateral flaps only Comparison of single step versus two stage facelift One stage Two stage Comments 5 to 8 hours 3 to 4 hours General anesthetic breathing tube Incisions on the sides of face and under the chin Intravenous sedation or local anesthetic Incisions on the sides of the face only Sedation is performed by an anesthesiologist in either scenario (disclosure) In patients with very complicated neck structures the procedure which

4 Hospital or nursing facility Time period to look good typically several weeks to months Risk to airway or irregularities in the anterior neck - possible Risk to facial nerve injury: low Home Time period to look good typically a few days to a week Risk to airway or irregularities in the anterior neck - none Risk to facial nerve injury: very low addresses the muscles under the chin may be able to accomplish more, with more risk, albeit rare, life threatening airway complications The two stage technique accomplishes about 75 to 80 percent improvement in the first stage and about 25 to 30 percent in the second stage. Advantage: one step Disadvantage: two steps Each step in the planned two stage technique is less invasive Costs $15,000 women, $20,000 men Costs divided into two parts $11, and $3, Costs vary by patient and procedure these are estimates Patient Signature Date: Additional Discussions: Regardless of technique the precision placement of incisions, preserving the hairline, positioning scars so they are least visible, and maintain the appearance of the ear, are most important goals of the surgery, often overlooked in consultations. The placement of incisions above and below the ear is the same regardless of technique. More to follow Modern facial rejuvenation involves more that repositioning the tissue of the face. Most patients benefit from filler to correct volume deficiencies correction typically involves the use of dermal fillers placed anywhere from 1 week (out of town patients) to several weeks after

5 surgery. Most patients benefit from procedures that improve skin texture and fine wrinkles. Patients who are able to have medical aesthetician skin treatments, and fractionated CO 2 laser resurfacing of the face will improve overall appearance. For individuals planning special occasions, the timing of Botox several weeks prior to the event is also very helpful. More to follow Long- term follow- up. Regardless of techniques used for facial rejuvenation, aging continues. Most patients are candidates for repeating the entire process in 10 to 15 years. Each person, including their anatomy, their expectations, and their needs are so different that this discussion needs to be individualized. More to follow Who make the best candidates? The best candidates are individuals who have looser skin, narrower faces, and good bone structure. Individuals with rounder fuller faces, and neck have the blessing of looking and younger, but may be more difficult to improve. On occasion, Dr. Altman may recommend that some individuals are better candidates not to have surgery, or possibly not best suited with the techniques he offers. This is a conversation to be held with the doctor as it is very individualized. More to follow