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  William J. Binder, M.D., F.A.C.S.
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  Beverly Hills, CA 90212
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We cannot do anything about the passage of time, but there are many physical signs of aging that can be reversed by facial rejuvenation procedures. The goal of the modern day facelift is to restore a youthful look to the face.

Facelift surgery is performed on both men and women, and corrective procedures vary from person to person. While one individual may need a complete face and neck lift, another may only require elevation of sagging eyebrows or fat removal from the lower eyelids. Another may need only correction of an early double chin. A person whose facial appearance is very weather-beaten may also require a chemical peel or laser resurfacing. Someone else may require all of these procedures to maximize the outcome of the facial rejuvenation process. This is the basis for the "multi-level approach" to facial rejuvenation. (seeThe Multi-level Approach)

Problems of Aging

The aging process is a result of losing deep and superficial adipose (fat) tissue.

The processes involved are:

arrow image  A decrease in thickness and elasticity causing the skin to relax and sag.

arrow image  soft tissues caving in causes depressions to occur in the face

arrow image  Volume loss of the lips. The lips become thinner and shorter (in both the vertical and horizontal dimension)

arrow image  Increased depth of the facial folds and wrinkling of the skin.

Facelift surgery is highly effective in correcting the underlying soft tissue and imbalanced features that are caused by aging and exacerbated by over-exposure to sun, rapid weight loss, alcohol intake, smoking or other abuses. Such signs of aging include wrinkles, pouch-like bags under the eyes, sagging skin, drooping eyebrows, eyelid hooding, jowls and "turkey gobbler" chin and neck.

The term facelift is really a misnomer, as the operation combines lifting and sculpting the face and neck regions in one procedure. Midface lift or necklift can be done at different times but this is less common than performing the complete facelift procedure. Another procedure, which removes excessive fat or folds of the neck under the chin, is frequently performed as part of a rhytidectomy. This is called submentallipectomy.

As the skin begins to sag and fatty tissue layers are lost, imperfections in the contour of the face become very noticeable. Additional procedures can be performed to support or augment both the bony and soft tissue structures of the face. Flattening at the level of the cheekbones can be improved through placement of midfacial implants. Implants may also be used to enhance the contour of the chin and improve the jaw and neckline.(seeFacelift with Facial Implants and/or other procedures

Face and Neck Lift Procedure

Contemporary facelift surgery differs vastly older methods which dealt only with the skin and not its underlying structure and attempted to correct wrinkling and sagging skin by pulling the face as tightly and flatly as possible. This method often resulted in a very unnatural, mask-like or flattened appearance that did not last.

Today, revolutionary facelift techniques focus on creating dramatic, yet solid, long-lasting changes that are natural in appearance. They correct underlying skeletal structural deficiencies and effectively reposition and contour the underlying muscle layer and skin. For these reasons, the surgeon must have the necessary training to understand and effectively deal with the anatomy and underlying structures of the face.
The facelift procedure is divided into 2 components: the Midface component and the Neck component.

The Vertical Midface lift

The surgeon must realize that it is not only the skin that has dropped, but the deeper elements of soft tissue which form the jowls have also dropped. The soft tissues must be relocated upward and suspended at a higher location. With the Vertical MidfaceLift, Dr. Binder accesses the areas of the face which will enable him to elevate and anatomically relocate the midfacial soft tissues and the jowl vertically upward and back to where they were years before. The process allows him to lift the deeper soft tissues, fat and jowls in a way that doesn’t pull the face. This approach is designed to prevent distortion of expressive features and hold up over time.

In order to successfully elevate the face, deep SMAS-type of facelift procedures are performed to relocate and re-contour the soft tissue and muscle layers of the face. It must also redistribute, smooth out, and remove the excess skin from the face and neck.

The facelift operation usually takes between 3 1/2 to 4 1/2 hours to perform. Incisions, which will heal into flat, nearly invisible scars, are made in unobtrusive areas such as inside the hairline and/or in natural depressions around the ears. Usually, the incision for facelift surgery begins in the hair near the temple and continues in from the front of the ear, around the earlobe, behind the ear and into the hair in order to prevent easy detection. At the temporal area, the incision is carried below the hairline so that the hair can always be worn in any desirable fashion.

In choosing from a variety of facelift techniques and applying these techniques individually to each patient, the surgeon must have an in depth understanding of the anatomy of the face. This ability to perform these procedures safely and efficiently with minimal down time directly correlates with the degree of training and qualifications of the surgeon.

Neck Lift and Submental Procedures

There are a number of issues to consider when evaluating a patient for cosmetic surgery around the neck.Is there excessively loose skin? Is there excess laxity and loose-hanging muscle below the chin (submental)? Or is it a combination of all of the above? Correctly diagnosing the pathology is essential for choosing the most appropriate technique.

1. The Submental Procedure ("Corset Platysmaplasty")

ThePlatysma Muscle is a broad sheet of muscle arising from the pectoral (chest) and deltoid (shoulder) muscles and rises over the collarbone (clavicle), proceeding upward in a slanting manner along sides of the neck.  Over time, the platysmal muscle falls and drags the skin down with it. This is what causes the bands to develop over the anterior or front part of the neck. 

With the corset platysmaplasty, Dr. Binder will isolate, relocate, and use the muscle to produce a supportive neck sling so that it reinforces the neck rather than merely pulling the skin.
There are several options for neck lifting. To be effective, they all involve treating the redundancy of the platysma muscle in one form or another. In cases of minimal redundancy, the neck may be approached through an incision under the chin. The muscles can be sutured together and the neck contour improved. In many cases, what might appear as fullness or excessive fat, particularly in the "turkey gobbler deformity", might actually have very little fat present. In these cases, it is important NOT to remove fat. The presence of a layer of fat under the skin is essential for smoother and more youthful quality to the neck skin.

2. The Bidirectional Neck Lift

In cases where there are larger degrees of redundancy, Dr. Binder does not merely isolate or tie the muscles together. Instead he works to produce a muscular sling from a bidirectional approach. In the midline, under the chin (the submental area), the muscle is isolated from the skin and underlying tissue and then rotated in an upward direction where the muscle is reinforced at a new location and a muscular sling is created. This improves the contour over the lower part of the neck in the more central locations of the neck. The platysma muscle is also isolated from the back of the neck and advanced backward, repositioned and resuspended as an extension of the SMAS component of the facelift. This upper part of the platsyma procedure creates a well-defined jaw neck even in the most difficult cases.

Following a number of patients over a 10 to 15 year period following this surgery, Dr. Binder believes the bidirectional playtsma method has proven to provide the longest lasting results in neck lifting than any other type of procedure.

3. Submental Liposuction 

For younger patients who have enough elasticity of the skin and/or have a specific area of excess fat, liposuction have proven to be an excellent modality to sculpting the neck. For older patients, however, liposuction can remove that cushion under the skin that insures the neck looks healthy and vibrant. Excessive fat removal, particularly in older, thinner patients, with a sagging of the muscle, can cause a depressed area under the chin which is referred to as a "cobra" neck deformity.

William J. Binder, M.D., F.A.C.S.
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Dr. Binder pioneered the "facial contouring" approach to facelift surgery that utilizes a 3-dimensional perspective to balance facial contours and underlying structure.
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