Drs. Jones and Lo attempt to objectively assess the longevity of a primary face lift in white female patients.1 Although the authors discount the assessment of perceived age as a valid method, my referenced study provided the first objective evidence that facial rejuvenation surgery lives up to its billing.2 As the authors correctly point out, no other technique or product can make this claim, distinguishing surgical treatment from all alternatives. My study prospectively evaluated 71 consecutive male and female face-lift patients (Fig. 1), primary and secondary, who met strict inclusion criteria (minimum 6-month follow-up, no makeup or jewelry, no subsequent procedures including fillers and botulinum toxin, and photographic consent). The inclusion rate was 68 percent. Interestingly, the average benefit in apparent age as judged by independent observers, 6.0 years, was almost exactly half the mean reduction reported by patients themselves, which was 11.9 years.3
Unfortunately, the authors’ conclusions are undermined by the fact that their 50 study patients were not consecutive and represented only 2.9 percent of their total number of face-lift patients, well below the 80 percent benchmark for evidence-based medicine.4 This important limitation is not addressed by the authors. It is not clear how and when (before or after measurements?) their 50 patients were chosen for inclusion. Even the most valid scoring device cannot compensate for an unrepresentative sample. To suggest that their photographs may not have been truly representative because patients with greater degrees of facial aging did not provide consent speaks to the authors’ intent to showcase their most dramatic results. Examples that include typical results are preferred.2
There are no control patients, making this a retrospective case series. Only two raters were used for one subjective assessment and five for another, including a plastic surgeon and several nurses, who cannot be considered independent. Three different face-lift techniques, featuring different neck treatments, and patients who underwent subsequent surgical procedures during the study period, including repeated face lifts, were included, introducing confounding factors that challenge long-term data interpretation.
The oral commissure is very sensitive to the tone of the lip elevators and depressors (note the slight preoperative smile in the authors’ Figs. 3 and 4), and the measured changes are small, on the order of several degrees. The same is true for differences in jowl position and jowl angle. Some or all of these changes may be within the margin of error. Control patients, sufficient sample sizes, and sizable treatment effects are needed. The legend to the authors’ Figure 6 alludes to a comparison of short- and long-term results. Such a comparison cannot be made from a single lateral view and a single frontal view. The cervicomental angle “relapse” labeled on the left photograph appears to be an error.
These face lifts were no doubt performed along with other facial cosmetic procedures that may have contributed to a more youthful appearance unrelated to improvement of the jowls or cervicomental angle. Several of the patients have clearly had blepharoplasties, and some of the long-term photographs show lighter skin pigmentation, possibly as a result of facial peels. Any use of fillers needs to be disclosed because these injections can smooth nasolabial creases and marionette lines (Fig. 1). Treatment of the jowls and neckline is only one facet of modern surgical rejuvenation. Indeed, many other physical traits affect apparent age (and therefore subjective scoring), including facial volume, skin smoothness and lack of blemishes, periorbital skin tone, tear troughs, nasolabial creases, and no doubt other factors that we may not yet fully appreciate (facial volume was only generally recognized as important within the past decade). How does one assign a relative importance to these parameters, even if they could be reliably measured? Moreover, how does one assess the overall effect, which is the culmination of so many factors?
We have at our disposal the ideal measuring device, the human brain, which has evolved a large area of gray matter devoted to facial recognition, so important to our daily interactions, and which remains (at least at the time of this writing) unsurpassed as a computer processor. Individual variations are managed by using a sufficiently large sample size to provide a normal distribution of responses and to ensure interrater reliability. In my study that incorporated two groups totaling 198 age raters, the apparent age of control patients differed by less than 1 year on average, and the interrater reliability was 0.995, attesting to the precision of this “measuring device.” Only by objectively evaluating our results can we move on to a higher level of understanding and possibly sort out which techniques work best. It is refreshing to see facial cosmetic surgery submitted to scientific inquiry.
The patient provided written consent for the use of her images.
The author has no financial interest to declare in relation to the content of this communication. No outside funding was received.
Eric Swanson, M.D.
11413 Ash Street
Leawood, Kan. 66211
1. Jones BM, Lo SJ. How long does a face lift last? Objective and subjective measurements over a 5-year period. Plast Reconstr Surg. 2012;130:1317–1327
2. Swanson E. Objective assessment of change in apparent age after facial rejuvenation surgery. J Plast Reconstr Aesthet Surg. 2011;64:1124–1131
3. Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast Reconstr Surg. 2011;127:823–834
4. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Therapy. In: Evidence-Based Medicine. 20002nd ed Toronto Churchill Livingstone:105–154
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