A recent study published in JAMA Facial Plastic Surgery made some headlines with "surprising" results of one surgeon's cosmetic rejuvenative surgical procedures and how they made almost no impact on the patients' attractiveness and minimal impact on how youthful they looked. While the results may have surprised the general public, they were less shocking to experienced plastic surgeons who, like me, reviewed this article in detail. In conversations with colleagues, including several members of the American Society for Aesthetic Plastic Surgery, a few key elements stood out.
This study reviews the impact of one person's surgeries in restoring youthfulness or creating attractiveness. His results may, or may not, be reflective of the specialty. The paper is replete with the myriad statistical techniques used in evaluation, but no images of the surgical results.
The majority of the patients in this study underwent periorbital surgery (upper lid, blepharoplasty, lower lid blepharoplasty and browlifts). Recent objective studies of the aging process and reassessment of classic surgical techniques have changed conceptual and hence, surgical paradigms.
Standard blepharoplasty (eyelid surgery) used to make eyes round and hollow as a result of excessive fat and skin removal. However, longitudinal and cohort studies have shown that these traits mimic the aging process rather than reverse it. Similarly studies have shown that young attractive women have low brows and that in many women, they tend to elevate with age.* So it is not surprising that periorbital surgery had a limited rejuvenative effect, and, in many cases, an aging effect in many patients reviewed in this study.
That the surgeries performed had even a less effect on the patients studied is also not surprising. "Lifts" -- browlifts, eyelifts, facelifts, in the best case scenario, are designed to bring the patients appearance to where it was years before. Those whose facial morphology was deemed attractive or unattractive prior to the "lift" will, at best, only return to that state.
Facial attractiveness is determined by the shape and proportions of parts, and how they relate one to another. It is the balance of facial features (nose, chin, cheeks, jawline) that is important. Operations that change the size and shape of these features are those that can alter attractiveness. The size and shape of these features is dictated by their skeletal components. Hence the primary determinant of facial appearance is the facial skeleton. And the operations that have the most significant impact on facial appearance are those that manipulate the skeleton. These include rhinoplasty (nasal bones), cheek bone, chin and jaw implants.
In short, facelifts, browlifts and eyelid surgeries alter the way that the skin and musculature sit on the skeleton, but they do not alter the bone structure that builds the foundation for symmetry in the first place. They can help patients to appear younger, but cannot reasonably be expected to change their objective level of attractiveness. For patients who are happy with their underlying facial structure and are looking to regain some of the key attributes of their youth, these procedures can be an ideal solution.
Of course, choosing the right surgeon is just as important as choosing the right procedure. Because conventional brow, eye and facelifts only allow the surgeon to remove or tighten facial tissues, producing a look that may be better but is often unnatural and exaggerated. We have all seen victims of this type of cosmetic surgery -- people who look perpetually surprised from brows raised too high; whose eyes are strangely round and hollow from excess skin and neck fat removal; whose necks appear uneven or pulled too taut; or whose lower eyelids merge unnaturally with overly flat and windswept cheeks. These patients often end up seeking revisional cosmetic surgery procedures with different surgeons.
When evaluating potential plastic surgeons, remember that plastic surgeons board-certified by the American Board of Plastic Surgery® go through prolonged specific training, examinations and requirements for recertification for their surgery to select the correct operations to make you look younger or better, rather than not.
* Matros E, Garcia JA, Yaremchuk,MJ. Changes in eyebrow shape and position with aging. Plast Reconstr Surg 124:1296-1301, 2009.)