Journal of Plastic and Reconstructive
Surgery
Background: Selecting the “correct”
face lift technique has always been a difficult
decision for the plastic surgeon. A technique that
provides optimal aesthetics for one patient may
not provide the same result for another. The complexity
of comparing these different results on patients
with different facial features further confounds
one’s ability to decide on a given technique.
Even identical twins are often treated more appropriately
with a different technique from one twin to the
other because the character and severity of facial
aging may differ between them. By comparing different
superficial musculoaponeurotic system techniques
on “less different” people (identical
twins), perhaps the ideal technique may be determined.
Methods: Between November of 1997 and April of 1999,
eight sets of twins underwent face lift surgery
by the senior author (D.E.A.), using one of four
techniques. The charts and photographs of the eight
consecutive pairs of twins (16 patients) were reviewed
retrospectively.
Results: No one face lift technique performed
in this study produced a superior result as compared
with another when performed on the appropriate patient.
Conclusion: There exists no face lift technique
suitable for every patient. As the current literature
suggests, there is no one “best” face
lift technique of those studied. (Plast. Reconstr.
Surg. 120: 1667, 2007.)
The question “Which face lift technique is
best?” is nearly as old as the operation itself.
This question becomes more difficult to answer than
ever before, given the vast array of tech-niques
for facialplasty, and the variable effect of gravity
and other environmental effects on the skin and
the deeper structures of the face. A more effective
comparison of these techniques may be obtained by
decreasing the number of variables between the patients.
By using identical twins as the subjects and one
surgeon to perform his choice of one of four techniques
most commonly used in his practice, a more controlled
comparison is offered. Although many other excellent
techniques for facialplasty are currently in wide
use today, this study compares the four techniques
most commonly used by the senior author (D.E.A.)
during the time period in which the procedures were
performed.
PATIENTS AND METHODS
Between November of 1997 and April of 1999, eight
consecutive pairs of identical twins (16 patients)
underwent facialplasty in an office surgery setting.
Preoperative genetic analysis 1 was pe-formed to
ensure that the twins were monozygotic (identical)
rather than dizygotic (fraternal) twins. Seven sets
of twins were female and one set was male. The twins
were operated on the same day and in the order of
their birth sequence. The patients ranged in age
from 48 to 77 years, with a mean age of 60 years.
The choice of facialplasty technique was based
on the patient’s anatomical findings at consultation
and at surgery. Because of these differences, in
some cases a different technique was used on one
twin than on the other. The facialplasty techniques
usedin this study were as follows: no superficial
muscu-loaponeurotic system (SMAS) or skin only (four
patients), conventional SMAS flap (dissection carried
just anterior to the parotid gland) (two patients),
SMASectomy as described by Baker,2 (six patients),
and SMAS plication (four patients). Adjuvant procedures,
when performed, were performed on both twins. Interestingly,
twins usually decide to have the same adjuvant procedures
to retain their similar appearance. These procedures
include one or more of the following: brow lift,
blepharoplasty, and buccal fat pad excision.
Follow-up photographs (of the same hemi-face view
from twin to twin) were obtained 13 to 60 months
after surgery (mean, 23 months). The preoperative
and postoperative results were evaluated by four
plastic surgeons blinded to the type of face lift
and to the nature of the ancillary procedures. The
face was divided into three anatomical areas for
evaluation: the cervicomental angle, the jawline,
and the nasolabial fold. Each anatomical area was
scored separately and graded as follows: 1, no improvement
(poor); 2, mild improvement (fair); 3, moderate
improvement (good); 4, marked improvement (excellent);
and 5, perfect result. The average score by the
evaluators for each anatomical region was added
to achieve the total score (range, 3 to 15: 3, no
improvement (poor); 4 to 6, mild improvement (fair);
7 to 10, moderate improvement (good); 11 to 14,
marked improvement (excel-lent); and 15, perfect
result). Complications were noted and analyzed.
RESULTS
Table 1 summarizes the face lift results. At follow-up,
seven of the patients (44 percent) were found to
have an excellent result, four (25 percent) had
a good result, and five (31 percent) were found
to have a fair result. No patients had an outcome
with a poor result or a perfect result. One of two
patients (50 percent) who had a conventional SMAS
flap operation had an excellent result. In the SMASectomy
group (n =6), two (33 percent) had excellent results,
one (17 percent) had a good result, and three (50
percent) had a fair result. In the plication group
(n = 4), two (50 percent) had excellent results,
one (25 percent) had a good result, and one (25
percent) had a fair result. In the skin-only group
(n = 4), two (50 percent) had an excellent result,
one (25 percent) had a good result, and one (25
percent) had a fair result. The patient with the
lowest average score (4.25) had a skin-only lift
that was evaluated at 18 months postoperatively.
Clinical examples of excellent, good, and fair results
are shown in Figures 1 through 6.
The anatomical region that showed the best long-term
improvement was the cervicomental angle (average,
3.42). The anatomical region that showed the least
long-term improvement was the nasolabial fold (average,
2.45), similar to the find-ings by Hamra.4
Two patients (4a and 6a) (13 percent) had a small
neck hematoma that was percutaneously evacuated
on the seventh and eighth postoperative days, respectively.
Neither patient suffered long-term problems from
the hematoma. There were no patients who suffered
a skin slough or facial nerve weakness in this study.
DISCUSSION
 |
 |
| Fig. 1. Patient 5a (left) preoperatively
and (right) 22 months postoperatively. |
Fig. 2. (Left) Preoperative view of
patient 5b, a 59-year-old woman with a long
history of sun exposure. Note the advanced signs
of aging as compared with her twin, shown in
Figure 1. (Right) Postoperative view at 22 months. |
In 2005, over 150,000 face lifts were performed
in the United States. This represents an increase
of 52 percent of the number of face lifts per-formed
in the year 1997. Along with the increase in the
number of procedures, there is also an increase
in the number of the type of facialplasty techniques.
Since the original work of Mitz and Peyronie on
the SMAS, many excellent techniques in managing
the SMAS have been described. Today, many of these
techniques are com-monly used. In a recent study
by Matarasso et al., of 570 plastic surgeons surveyed,
18 percent dissected the SMAS over the parotid,
23 percent imbricated the SMAS, 15 percent performed
a SMASectomy, and 15 percent performed a
 |
 |
| Fig. 3. Patient 8a (left) preoperatively
and (right) 18 months postoperatively. |
Fig. 4. Patient 8b (left) preoperatively
and (right) 18 months postoperatively. |
skin only procedure. In addition, 8 percent performed
a deep/composite dissection, 16 percent performed
an extended SMAS flap dissection, and 5 percent
performed a subperiosteal and/or an endoscopic lift.
When considering the options, one must realize that
facial rejuvenation requires a complete analysis
of the topographic changes that occur in the aging
face. A careful selection of facialplasty technique
and adjuvant procedures should be chosen to provide
the patient with a harmonious result.
Using monozygotic twins as the subjects of study,
major anatomical differences between patients are
removed, allowing the comparison of SMAS techniques
to be more accurate. It is important to obtain genetic
marker analysis to ensure that the twins are indeed
monozygotic rather than dizygotic. Monozygotic twins
typically maintain their similar features throughout
life, as opposed to dizygotic twins, who can vary
greatly in appearance. However, it is not to say
that even monozygotic twins age in a similar fashion.
Environmental factors including cigarette smoking,
sun exposure, and undue stress can cause one twin
to age more than the other 8 (Fig. 7).
 |
 |
| Fig. 5. Patient 3a (left) preoperatively
and (right) 16 months postoperatively. |
Fig. 6. Patient 3b (left) preoperatively
and (right) 16 months postoperatively. |
Not only does the aging process differ between
twins and nontwins, but it may also differ between
the right and left sides of the face. One upper
eyelid may have more excess skin than the other
or one facial half may demonstrate more soft-tissue
ptosis and sun damage. These findings are evident
on analysis of split-face preoperative photographs
(Fig. 8). In our patients with these findings, the
same face lift technique was used on both sides.
However, one could argue to use a different technique
on one side of the face than the other to ultimately
provide a more symmetric face and a better overall
result.
The results of our study essentially showed no
difference between the face lift techniques on analysis
of the postoperative results. Previous studies comparing
superficial plane techniques have shown similar
results.9–11 Despite these findings, it is
impossible to draw any firm conclusion for several
reasons. The patients in this study were not randomized
to one technique or another. The senior author carefully
chose one technique over the other based on the
subject’s physical findings and his own experience.
By choosing a technique based on the severity of
aging, a selection bias is inherently present. In
addition, no statistical analysis was performed
because of the small number of patients enrolled
in the study, and a type II error (not being able
to show a difference when there actually is a difference)
is possible given the small number of subjects.
There are currently many twins that have recently
undergone facialplasty that have less than 1 year
of follow-up that will be evaluated in the future.
This increase in number will help—but not completely—eliminate
a type II error. Finally, the subjective nature
of evaluating cosmetic results allows for error.
 |
 |
| Fig. 7. (Left) Twin with a 30-pack-year
history of cigarette smoking. Note the advanced
signs of aging as compared with her nonsmoking
twin (right). |
Fig. 8. Patient 5b. (Left) Mirrored
image of the right side of the face. (Right)
Mirrored image of the left side of the face. |
The deep plane techniques were not evaluated in
this study but certainly have been used with great
success. In addition, specific maneuvers to improve
the lid-cheek junction were not used. As we are
all aware, there exists much debate over the superiority
of superficial versus deep plane techniques. Presently,
both authors use both superficial and deep plane
techniques and operations to improve the lid-cheek
junction but are careful not to use an aggressive
procedure where a more conservative approach is
warranted.
CONCLUSIONS
The clinical results of four of the superficial
plane face lift techniques are similar when performed
on the routine patient presenting for facial rejuvenation.
As newer techniques evolve, one should evaluate
the results over the long term. Many techniques
demonstrate improvement over the short term but
provide little or no improvement compared with the
proven techniques over time.
ACKNOWLEDGMENTS
The authors thank Eva M. Taczanowski, P.A.-C., and
Viralkumar Patel, M.D., for assistance in the preparation
of this article.
DISCLOSURE
Neither of the authors has a financial interest
in any of the products, devices, or drugs mentioned
in this article.
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