In 2000, Matarasso et al. performed an American Society of Plastic Surgeons (ASPS) member survey describing face lift practice patterns including operative techniques, perioperative care, and common complications.1 Although much has changed in the cosmetic marketplace since that survey, no similar study has been performed since. Therefore, we have attempted to repeat Matarasso et al.’s survey1 and contrast the findings between the two. We hoped to (1) define current face lift practices, (2) compare current practices with the previous report and delineate any significant changes, and (3) compare current practices to evidence-based data when available.
This study utilized a descriptive survey to assess face lift techniques, perioperative management, complications, and concomitant procedures of ASPS members (see Document, Supplemental Digital Content 1, which shows a sample of the descriptive survey that was distributed to half of current ASPS members, https://links.lww.com/PRS/F51). The survey design paralleled that of Matarasso et al.’s study1 from 2000, with additional questions to account for interval surgical advances. The study was reviewed by the Cleveland Clinic institutional review board, which concluded that informed consent was not required for participation. The survey was distributed electronically to half of current ASPS members (2271 individuals) by email. No means of compensation were provided. The survey was sent a total of five times between July and September of 2020.
Results of the questionnaire were collected electronically and anonymously. Statistical analysis was performed using Microsoft Excel (Microsoft Corp., Redmond, Wash.). Pearson chi-square test was performed to evaluate trends among different demographic groups. A value of p < 0.05 was considered statistically significant.
A total of 251 responses (11 percent response rate) were collected. With 251 responses, this study has a ±5 percent margin of error at a 95 percent confidence level.
With regard to duration in practice and practice type, the current survey represented a well-distributed cross-section of plastic surgeons. Ninety-four percent of current respondents had been in practice for more than 5 years, with the largest group (62.55 percent) having practiced for more than 20 years. The current number of respondents in practice greater than 20 years was nearly double the number in Matarasso et al.’s study (33 percent of respondents). Currently, the most common practice type reported was solo private practice (51 percent), followed by group practice (27.5 percent) and academic practice (8 percent). Overall, practice types closely corresponded to those reported in Matarasso et al.’s previous study with the age of practitioners in solo private practice, group practice, or hospital-based practice having remained roughly the same.
Half of current respondents spent at least 75 percent of their time performing aesthetic surgery with 20 percent performing exclusively aesthetic surgery. The majority of current respondents (60 percent) performed at least 12 face lifts per year, with 6 percent of respondents having performed more than 50 face lifts per year. Similar to Matarasso et al.’s study, there seems to be a positive correlation between years in practice and the number of face lifts performed in the prior year. The only current respondents who performed more than 50 face lifts (n = 12) had been practicing for over 20 years.
With regard to superficial musculoaponeurotic system (SMAS) management in the current survey, approximately three quarters of respondents manipulated the SMAS without undermining. The remaining quarter utilized a subSMAS technique. The most common technique was plication (45 percent). Comparatively, respondents in Matarasso et al.’s survey were evenly divided between supraSMAS and subSMAS techniques. The overall trend has been an increase in supraSMAS techniques, particularly in SMAS plication over the past 20 years (Fig. 1). In both studies, “safety” was the most common reason why respondents utilized their preferred SMAS approach (54 percent currently; 63 percent previously).
When asked how they have altered their technique since starting practice, the most common response (38 percent) was “less extensive SMAS dissection,” followed by “no change” (24 percent) and “more extensive SMAS dissection” (22 percent). This contrasts with Matarasso et al.’s findings, where “more extensive dissection” was the most common change (30 percent), followed by “less extensive dissection” (24 percent) and “no change” (24 percent).
When treating patients with deep or prominent nasolabial folds, the most common method in the current study was fat grafting (43 percent). In contradistinction to Matarasso et al.’s survey, where 53 percent of respondents performed more extensive skin dissection, only 10 percent of current respondents chose this response. Notably, every current respondent who performed a more aggressive dissection had been practicing for more than 20 years.
When treating massive-weight-loss patients, 43 percent of current respondents did not change their technique, 35 percent performed a more extensive skin dissection, and 30 percent utilized a higher volume of fat grafting. The previous survey did not address face lift surgery in the massive-weight-loss patient.
Neck Lift Technique
Respondents were asked multiple questions regarding the treatment of submental fat, the use of a submental incision, and how they addressed the platysma. When addressing submental fat, there appears to be a shift from direct excision to liposuction (Fig. 2). Twenty percent of current respondents did not use a submental incision at the time of face lift, which was markedly higher than the previous survey (4 percent). When means of addressing the platysma in the two studies were compared (Fig. 3), the majority in both surveys plicated the platysma in the midline (69 percent currently; 75 percent previously). There did not appear to be differences in the treatment of the platysma based on years of experience or practice type.
With regard to the treatment of ptotic submandibular glands, most respondents in both surveys did not perform gland excision. Previously, 3 percent of respondents performed partial gland excision, which increased to 8 percent of current respondents. Respondents who plicate the gland have become less common (47 percent previously; 25 percent currently). No treatment remained a common practice (45 percent previously; 61 percent currently).
Fat transfer was not addressed in the previous study since it had not yet become common practice. Currently, however, 40 percent of respondents performed fat grafting in at least 50 percent of their face lifts, whereas one quarter of respondents performed fat grafting in less than 10 percent of their face lifts (Fig. 4). Fat grafting volumes and the areas injected are detailed in Figure 5 and Table 1.
Table 1. -
Preferred Locations of Fat Grafting during Face Lift*
*Multiple choices were allowed.
Although not addressed in the previous survey, current respondents were asked to identify the most common adjunct procedures performed at the time of face lift surgery (Fig. 6). Although partial face laser resurfacing and chemical peeling were the most common adjunct procedures performed, specific types of energy-based devices and chemical peeling agents were not identified.
Average face lift duration does not appear to have changed since the previous study. The most common “average duration” among current respondents was 3 to 4 hours (42 percent). In both surveys, 90 percent of respondents take between 2 and 5 hours to complete their face lift. There were no differences in the average duration between experience groups or practice types (academic versus private).
When an active smoker presents for face lift surgery, 88 percent of current respondents will not operate. Comparatively, 53 percent of previous respondents would operate on patients who smoke up until the day of surgery. Of current respondents who will operate on active smokers, 60 percent perform less extensive skin undermining, 30 percent do not alter their operation, and 10 percent perform a deep plane or composite face lift. Overall, 7 percent of current respondents require preoperative urine cotinine tests in patients who report a recent smoking history. Of those current respondents who would operate on active smokers, the majority (86 percent) have been in practice more than 20 years. These surgeons, however, still represent the considerable minority (12 percent) within their experience demographic. This is a decrease from Matarasso et al.’s study, in which 61 percent of more experienced surgeons would operate on active smokers.
There appears to be a decided move from intravenous sedation toward general anesthesia over the past 20 years (50 percent previously; 79 percent currently). Regarding the current use of local anesthetic, the most common types were lidocaine with epinephrine (45 percent) and tumescent fluid with epinephrine (45 percent), followed by lidocaine with epinephrine and tranexamic acid (8 percent) and lidocaine without epinephrine (2 percent).
Two-thirds of current respondents do not use any ancillary techniques to minimize bleeding or drainage. Twenty-two percent utilize tranexamic acid to minimize bleeding and drainage, 11 percent utilize tissue sealants, and 2 percent utilize quilting sutures. Of those respondents who utilize tranexamic acid, roughly equal proportions of respondents administer the medication through intravenous, subcutaneous infiltration, and topical routes.
There was a significant decrease in the number of respondents who provided no form of deep vein thrombosis prophylaxis (68 percent previously; 33 percent currently). Types of deep vein thrombosis prophylaxis are illustrated in Figure 7.
Overall, 91 percent of current respondents administered some form of antimicrobial prophylaxis compared to 72 percent in the Matarasso et al. study. In the current study, 39 percent gave antibiotics preoperatively, 15 percent gave them preoperatively and intraoperatively, and 37 percent gave them preoperatively, intraoperatively, and postoperatively.
Among current respondents, the most common complication requiring operative intervention was hematoma (51 percent), followed by scar revision (11 percent). Other responses included recurrent skin laxity (4 percent), residual submental fullness (3 percent), skin loss (3 percent), undercorrection (3 percent), and undertreated nasolabial folds (1 percent). As Matarasso et al.’s study asked respondents to review medical records and report the incidence of local, systemic, and nerve-related complications, a direct comparison between the studies is not possible.
Recent authors have attempted to define face lift outcomes more clearly through large-scale database analysis of perioperative data, risk factors, and complications. One such study reviewed over 11,000 face lift patients based on insurance claims,2 and a more recent study reviewed the outcomes of 13,346 face lifts performed by ASPS members.3 A recent member survey has delineated the use of fat grafting in face lift surgery.4 Still, no one has repeated Matarasso et al.’s original 2000 ASPS member survey in two decades. In replicating Matarasso et al.’s previous study, we have attempted to define the current face lift practice patterns of ASPS members and identify significant changes over the past 20 years.
The respondents to our survey were significantly older than those who answered the survey 20 years ago, which may explain why the type of surgical practice has changed little over the past two decades and why a significant portion of respondents remained in solo private practice. This contrasts with virtually all other medical and surgical specialties.5 It appears that plastic surgery may represent the last bastion of solo private practice in the United States.
There appears to be a general increase in use of supraSMAS, rather than subSMAS, techniques over the past two decades. The debate regarding the superiority of one face lift technique over another is an ongoing one. Attempts to compare various procedures have been numerous, but definitive answers elusive. Although one publication has demonstrated improved results with the deep plane technique,6 the preponderance of studies fails to find significant differences in long-term results between techniques.7–13 Barriers include the subjective nature of the result, varying technical expertise, and, as identical twin studies have demonstrated, excellent results can be obtained with a variety of different techniques.14,15
Compared to the original survey study, a significant change was noted in the approach to the patient with deep nasolabial folds, a common problem seen specifically in the massive-weight-loss population. The majority of respondents in our survey rely on more aggressive fat transfer rather than more extensive undermining which was the preferred technical approach in the original survey. This approach is consistent with the current treatment of the massive-weight-loss patient with deep nasolabial folds, which includes more aggressive fat transfer and longer postauricular incisions.16–20 It should also be noted that undermining beyond the nasolabial fold interrupts the third arcade of cheek blood supply, potentially increasing wound healing problems.21,22
Currently, ASPS members appear to have become less aggressive with their approach to the anterior neck. Although both survey groups treat superficial fat, current respondents less frequently open the platysma and treat subplatysmal fat. Furthermore, a significantly larger portion of current respondents rarely utilize a submental incision during face lift surgery. This trend stands in contrast to what is suggested by the plastic surgery literature and national meetings. Long-term reviews by Rohrich and Stuzin have recommended addressing the platysma through a submental incision in virtually all primary face lift patients.23,24 Feldman’s experience is similar.25,26 Finally, during the discussion at a recent ASPS face lift panel, panelists were asked how often they opened the neck through a submental incision. Hamra, Little, and Stuzin reported opening the neck anteriorly 100 percent of the time, whereas Tonnard reported opening the neck in only 30 percent of his cases.27
While there is a consensus in the literature that partial submandibular gland resection represents the best means of correcting the visible submandibular gland,25,28–33 this procedure is performed by only a small minority of ASPS members. Their hesitancy to perform the procedure may rest with concern regarding the potential complications, including marginal mandibular nerve injury, sialocele, and hematoma with airway compromise.30 To avoid these potential complications altogether, Rohrich et al. have recommended refraining from gland resection and instead performing intraglandular injection of 10 units of botulinum toxin during surgery, with repeated injections 6 to 8 weeks postoperatively to cause glandular atrophy.34 Results of such treatment have not been widely documented, however.
Although not addressed in the Matarasso et al. survey, resurfacing has become a common adjunct during face lift surgery. A sizable portion of respondents utilize full-face resurfacing at the time of face lift. The literature documents the safety and efficacy of combining face lift surgery and full-face resurfacing with traditional carbon dioxide, fractionated carbon dioxide, and erbium lasers.35–39 To minimize complications when resurfacing undermined skin, the following measures have been suggested: (1) reduce the extent of skin undermining, (2) progressively reduce the laser energy or peel strength from proximal (central face) to distal flap, and (3) resurface only thick healthy flaps.
Significantly fewer members in the recent review operate on active smokers compared to the 2000 survey. When operating on active smokers, 70 percent of members alter their operation. This is consistent with the literature, which suggests that reducing skin undermining, performing a composite lift, reducing tension on the closure, and minimizing the length of the postauricular incision are means of reducing complications in those patients with a recent smoking history.40 Given that the literature documents as much as a 12-fold increase in skin slough41 and histologic evidence of vascular occlusive disease in skin of smokers,42 the recommendation to defer surgery for a minimum of 4 weeks following abstinence from tobacco is most appropriate.43 This recommendation is based on free flap breast reconstruction, however, rather than on direct face lift data.
A number of issues regarding smoking remain unclear. The above data reflect the risk of skin complications only. It is also known that active smokers have a higher incidence of systemic as well as local complications. Furthermore, whether a former smoker’s complication rate approached that of a nonsmoker has yet to be determined. Finally, former smokers are more likely to be deceitful than nonsmokers regarding smoking cessation. Therefore, a preoperative urine cotinine test is advisable when considering operating on recent smokers.44
Techniques to reduce hematoma incidence in face lift surgery have been well-studied. Although a majority of respondents used no additional means to gain hemostasis, nearly one in four currently used tranexamic acid either intravenously, topically, or mixed with local anesthetic. Tranexamic acid is receiving increasing attention in the plastic surgery literature as a means of reducing operative time, intraoperative bleeding, postoperative ecchymosis, and hematoma. Current data supporting its use in face lift surgery are predominantly subjective, and validated supportive data are sparse. The optimal route of administration (i.e., intravenous, topical, or local infiltration) is unclear, although each route has its proponents.45–48 Other means of reducing seroma and hematoma, including tissue sealants and quilting sutures, are practiced by a small percentage of current ASPS members. Both internal and external quilting sutures are effective in reducing hematoma incidence following face lift surgery.49–51 Although the data supporting the use of tissue adhesives in reducing seroma rate are strong, the ability of tissue adhesives to prevent hematoma is equivocal.52–57
Although the percentage of members not using deep vein thrombosis/pulmonary embolism prophylaxis decreased significantly from 2000 to 2020, it remains surprising that nearly one-third of respondents do not utilize intermittent compression devices or other means of prophylaxis. The literature consistently documents a low incidence of symptomatic deep vein thrombosis in this patient population, which approaches zero when conscious sedation rather than general anesthesia, is used.58–60 However, given that the majority of respondents report a face lift surgery duration of more than 2 hours and that the majority of patients undergo general anesthesia, Caprini scores of 3 or higher are nearly universal. Therefore, mechanical prophylaxis should be recommended.
Although the reported incidence of postoperative infections is less than 1 percent in large retrospective reviews,3,61,62 an increasing majority of respondents utilize prophylactic antibiotics. While the duration of surgery is an indication for preoperative antimicrobial prophylaxis, there is no clear indication for postoperative prophylaxis.63 Despite this, one-third of the survey respondents continued antimicrobial prophylaxis postoperatively.
The strengths and limitations of this study include those inherent to all large-scale surveys. Although the response rate (11 percent) was less than ideal, it is similar to that of previous ASPS face lift surveys.1,4 Furthermore, a nonresponder analysis found that more than 20 percent of surveyed surgeons who practice predominantly aesthetic surgery responded, and general demographics of ASPS members, nonresponders, and responders are comparable (see Document, Supplemental Digital Content 2, which shows the nonresponder analysis, https://links.lww.com/PRS/F52).
Our respondents are disproportionally composed of surgeons in practice for more than 20 years. Thus, other experience demographics were relatively small and likely underpowered to detect a difference between age groups. Finally, techniques in face lift surgery are often nuanced and tailored to individual patient needs. Therefore, categorical questions may miss subtle differences between respondents. Nevertheless, we have successfully captured an overarching view of general practice patterns among ASPS members.
Despite the enthusiasm generated through franchised face lift efforts, social media feeds, and the marketing of mini face lift alternatives, ASPS members’ basic approach to the face lift operation has not changed dramatically. Adjuncts to the operation, however, have been positive, including fat grafting techniques, concomitant use of resurfacing, and means of minimizing blood loss with tranexamic acid. In certain instances—particularly in regard to deep vein thrombosis/pulmonary embolism prophylaxis, antimicrobial prophylaxis, and smoking cessation—respondents are not following evidence-based guidelines for perioperative care. Finally, common complications of operating plastic surgeons appear to coincide with published retrospective reviews.
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