4 Procedures That Will Change the Way You Think About Face Lift Surgery

Laura Cain (00:07):
You are listening to The La Jolla Cosmetic Podcast.

Monique Ramsey (00:14):
I got my Spotify wrapped the other day, and if you guys are on Spotify, you see what summarized, what you've listened to over the year. And so I was thinking about that with our podcast. What have we talked about this year? We've talked about a lot. And so I really wanted to do this compilation episode to talk about some of the really exciting treatments and technologies that we have for the face, what we've covered this year, and just sort of bring them back up to the surface and to your attention so you can kind of consider this your LJC podcast wrapped for 2023. So what are we going to talk about? I want to talk about some things that make some really big impacts. And first, so we're going to talk about eyelids. We're going to talk about Ellacor, which is a new technology that we're super excited about, and so we have some great procedures for the neck, and Dr. Salazar and Dr. Brahme are going to talk about two really cool approaches to deal with the neck. But first, let's do the eyes. I think the eyes are one of the best things you can do to look more refreshed. It doesn't break the bank. It's a pretty quick recovery. And so let's hear from Dr. Riedler, our facial plastic surgeon on the amazing results you can get with eyelid surgery.

Dr. Riedler (01:30):
So often patients come to me for eyelid surgery because they are starting to notice age-related changes in their eyelids that make them look either tired, old or sad when they don't feel tired, old or sad. And so eyelid surgery can treat various issues in the upper and lower eyelids, such as loose or sagging skin that might create folds or wrinkles and make the upper eyelids appear kind of heavy fatty deposits that might make the upper and lower eyelids look puffy under eye bags and just excess skin and wrinkles.

Monique Ramsey (02:16):
What causes eyes to look older? Tired. Is it just that extra amount of skin or the puffiness or all of the above?

Dr. Riedler (02:23):
Well, it really varies from person to person. Every patient is going to have different age-related changes that can be changes in the skin fat muscle and or bone that cause these changes in the appearance. So it's always a very individualized treatment. And so evaluating each person's specific changes is important, but generally the excess skin or sagging skin is very commonly an issue, especially in the upper eyelids. That can be just because the skin is losing elasticity, but it can also actually be related to the eyebrow drooping and then causing the excess upper eyelids skin to kind of fold over itself. And then fat can be an issue in the upper and lower eyelids. More commonly in the lower eyelids, there's a hammock called the orbital septum in the lower eyelids that holds the fat in your eye socket. And so as that weakens with age, the fat in your eye socket can start to bulge out and then that can make your lower eyelids look really puffy.

Monique Ramsey (03:43):
Oh,

Dr. Riedler (03:44):
That can also happen usually to a lesser extent in the upper eyelids as well.

Monique Ramsey (03:50):
Now you mentioned the brow. How would somebody know if I pulled up on my own brow or if you're at home and you're trying to do your own diagnosis, how would you know if a brow lift would be more appropriate or the eyes or do you sometimes do a combination?

Dr. Riedler (04:07):
Yeah, so patients with concerns about the upper eyelids might be a good candidate for a brow lift or an upper eyelid surgery or both? It depends on a few different things that I look at during the consultation. One of those is just the brow position. So the normal brow position is either at or above the brow bone. So if the brows position below the brow bone, that indicates that you'd probably benefit from a brow lift. And then other things that I look for are, there's something called connel sign, which is in upper eyelid skin fold that extends beyond the eyelid into the crow's feet area. And that's a sign that your brows are drooping and that excess skin would actually be best treated with a brow lift. That doesn't mean that you wouldn't benefit from upper eyelid surgery as well, but when the excess skin extends that far, typically a brow lift would be beneficial as well.

Monique Ramsey (05:11):
Because a brow lift, isn't the incision sort of from ear to ear like a headband, or could it be just the temples or,

Dr. Riedler (05:18):
Well, yeah, so that's another complex topic as well.

Monique Ramsey (05:22):
Sorry.

Dr. Riedler (05:23):
No, it's okay. There are a lot of different techniques for brow lift and it can be from ear to ear or it could be endoscopic with a few small incisions in the scalp, or it could be a temporal brow lift that involves incisions kind of on the side of the scalp to lift more of the lateral or the side part of the brow.

Monique Ramsey (05:45):
Okay. So sorry to derail us over to brows, but I just thought that that was sort of interesting. So now, where are the incisions made for an eyelid lift?

Dr. Riedler (05:55):
So for the upper eyelids, the incisions made within the natural eyelid crease, and for the lower eyelid, the incision can either be made just below the lower lash line, which is also well hidden, or it can even be made on the inside of the lower eyelid if skin removal isn't required. But all of the incisions for eyelid surgery are designed so that the scars are well hidden in the natural creases.

Monique Ramsey (06:21):
And so if you're doing the incision on the inside of the lower eye, that means you're not taking out skin. It's more about the fat and the muscles.

Dr. Riedler (06:30):
Typically, that's more about the fat and the muscles. Exactly.

Monique Ramsey (06:35):
So how long does it take maybe for those scars to heal and be not noticeable?

Dr. Riedler (06:43):
So the sutures are in place for typically about a week, and then the incisions will be kind of pink for up to six months maybe. But typically I would say within about four weeks or so, they're not very noticeable.

Monique Ramsey (07:04):
What's the usual age of someone who's thinking about having their eyes done?

Dr. Riedler (07:10):
So I've seen patients really all ages from their twenties to their nineties, but I would say the average age is probably in their fifties. The eyelids and the brow area tend to be one of the areas that ages earliest, and so it tends to be patients who maybe aren't as concerned about their lower face yet, but their upper face is starting to bother them sooner.

Monique Ramsey (07:43):
Now, if you do this when you're younger, let's say you had this done in your 34, 34 years old, you get your eyes done. Is this something that you would have to maybe repeat again later in life?

Dr. Riedler (07:55):
So yeah, eyelid surgery can be repeated later in life. The results, they don't go away, but everybody continues to age. So depending on how you age after surgery and what age you were at the initial surgery, I would say if you're 34, there's a decent chance that you might be looking to have another eyelid surgery later in life. Just depends on the patient.

Monique Ramsey (08:22):
Now, if the problem that the patient is having is just, let's say hollowing under the eyes or dark circles, could you just get filler to fix that?

Dr. Riedler (08:33):
So that's a good question and a common question. It depends on the specific problem. So dark circles can be either from the fact that you have a lot of blood vessels under thin skin in your lower eyelids, and that unfortunately can't really be fixed surgically or with filler. The best treatment for that is under eye concealer, but if the dark circles are related to Halloween, that's causing shadowing, then filler may be a good option. If there's a bulge from fat pouching out and then that causes a depression below it with Halloween and darkening there, really surgery is going to be a better option. I mean, sometimes a little bit of filler can be placed there to smooth the transition between the lid in the cheek, but it really just depends on the specific findings in each individual patient.

Monique Ramsey (09:37):
Now, how long does eyelid surgery take?

Dr. Riedler (09:41):
So it takes one to two hours depending on which eyelids are being treated or if all of the eyelids are being treated.

Monique Ramsey (09:49):
And what would somebody look like immediately after surgery?

Dr. Riedler (09:54):
So immediately after surgery, there's some sutures in place, and then generally you're going to have swelling and a little bit of bruising for I would say at least a week. And then the sutures come out, the swelling does take some time to go away. I would say you'll look swollen for about two weeks, and then by three or four weeks you're going to have a little bit of residual swelling, but when people look at you, they won't necessarily notice it.

Monique Ramsey (10:26):
Oh, you would probably notice it more on yourself than

Dr. Riedler (10:29):
Yeah. Definitely,

Monique Ramsey (10:30):
Than somebody else. Now, what other procedures could be combined with eyelid surgery?

Dr. Riedler (10:37):
Brow lift is a common one. As we discussed earlier, sometimes upper eyelid concerns are best addressed with upper eyelid surgery or brow lift for both. So that's a really common one. Fat transfer is another adjunct procedure that can be very helpful to restore a youthful appearance in patients who have hollowing of the upper or the lower eyelids. And then faces don't age in an isolated manner. So often patients with eyelid aging have other signs of facial aging that they may wish to improve. And so eyelid surgery can be combined with any of the other aging face procedures that we perform, like brow lift, facelift, neck lift, lip lift, fat transfer, and skin resurfacing.

Monique Ramsey (11:26):
Yeah. Oh, I was just about to ask about laser. So do you ever have where you would do their eyelid lift and then also laser around the eyes at the same time?

Dr. Riedler (11:38):
Yeah, so often we combine skin resurfacing laser treatments with eyelid surgery because the thin skin of the lower eyelid, especially the texture changes with age. And so laser resurfacing can be very helpful to improve the skin texture in addition to treating the excess skin and fat.

Monique Ramsey (12:01):
So we have a new nonsurgical treatment, which is actually an eye drop, an eye drop that you just drop into your eyes that helps your eyes look more open and it's called UPNEEQ. How does that work?

Dr. Riedler (12:15):
That actually works by activating one of the eyelid elevator muscles in your upper eyelid and you drop it in your eye and it activates that muscle to contract and lift your upper eyelid a few millimeters and makes your eye look more open.

Monique Ramsey (12:36):
So that's kind of fun.

Dr. Riedler (12:37):
Yeah, I mean, yeah, it is because it's just an instant result, which is kind of exciting.

Monique Ramsey (12:44):
And it's, from what I've read, it's safe for everybody pretty much. Pretty much everybody can use it, which is nice. So for a temporary little lift.

Dr. Riedler (12:53):
Yeah, for a temporary, yeah, it lasts about maybe eight hours or so.

Monique Ramsey (12:57):
Yeah, so we put all of our prices on our website and for eyelid surgery, the range is about seven to $10,000. And we have lots of financing options, and I think not everybody realizes that financing is really normal in our industry. A lot of patients don't know that or prospective patients, but that is a way to sort of have your cake and eat it too, be able to have your eyelids surgery and then pay over time while you're enjoying the results of it. And our finance team is amazing at helping to figure out what's the best option for you. Now, does insurance ever cover eyelid surgery?

Dr. Riedler (13:40):
No, insurance does not cover cosmetic surgery. Lower eyelid surgery is almost always considered cosmetic and not covered by insurance. In some cases, if the upper eyelids are so heavy that they block your vision insurance may cover upper eyelid surgery when it's done after specific testing and with somebody in your insurance network who does that surgery.

Monique Ramsey (14:08):
Okay. So the last question is, is it possible to have a virtual consultation or do you see everybody in person or is it up to the patient?

Dr. Riedler (14:22):
Yeah, I mean, it's up to the patients. So I always like to see patients in person before surgery and even really before we schedule the surgery, because with a lot of facial procedures, especially eyelid surgery, nasal surgery, it's really important to see in person and feel and really evaluate the anatomy. But a virtual consultation, especially for patients who might not locally is always a great option as a first step too.

Monique Ramsey (15:02):
So next up we're going to talk about Ellacor, and we had one of the international experts about this new technology and procedure, Dr. Jason Pozner. He came on with Dr. Johann Brahme in our practice, and they talked about this technology and device and what it does and why it's different than anything else out there. So Dr. Pozner, can you just kind of help our audience understand what is Ellacor and how it works?

Dr. Pozner (15:37):
Sure. So I think when people hear about a lot of technology, I think they get very confused because a lot of these things sound alike, and when you start to describe something, they're like, oh, well, that's the same as so-and-so, and this is a uniquely different device than the other devices out there. And we'll talk about the FDA approval on this a little bit because it's a little different than what we use it for. So when we talk about devices that are needling devices, and I understand you guys have a morpheus device and we have that and a couple of other different ones. So those are needles that go into the skin to help create a little burn zone of energy that creates some secondary tightening. And those are insulated generally where the tip is exposed, but those are solid needles. So you're putting a solid needle in, and when you put a solid needle in, well, the hole closes up right away and you rely on the skin inflammation to help tighten.

(16:36)
So this is a uniquely different device in which it's a hollow needle, and basically you're taking out a small punch of skin with each needle incursion into the skin. And they did a very nice study. This device was designed in Mass General by the two founders were Rox Anderson, who's one of the famous dermatologists inventing fractional lasers and CoolSculpting. And most of the things that we use today, and Jay Austin, who is a plastic surgeon and chairman of the department at Mass Genera;. And Rox did an early study where they looked at different size holes and they kind of looked at, well, what's a hole that's going to cause a scar and what's a hole that's going to not cause a scar? And they kind of came to the conclusion that when the hole was over half a millimeter, the potential for scarring was higher than it was under half a millimeter. So they designed these needles, they're about four tenths of a millimeter on four 10 microns around the size of a 22 gauge needle that we use all the time in medicine, and they take out little punches. So if you could imagine if you had some cleats on your feet that were hollow and you walked on the golf course and every time you did, you took out a piece of the golf course, that's how device works, and it's just very rapid and in use, it looks like a sewing machine.

Monique Ramsey (17:54):
And how much excess skin can it remove?

Dr. Pozner (17:58):
So currently the device has different settings on it, and I've been using the maximum setting on it for everybody. I think that's good. And they were limited a little bit by the FDA, and this might change later as we get more experience with this device. So I'm a cutting edge guy. I like new technology as Dr. Brahme if he took on this technology. So I think all the kinks aren't completely worked out with this in that I think we have a lot to learn, but currently the max setting is 8%. So that's what I set the device at is 8% of the skin surface area being removed. So when I did a face and neck today, I took out 24,000 cores of their face.

Monique Ramsey (18:42):
Wow.

Dr. Pozner (18:43):
That's a lot. Maxed out the tip.

Monique Ramsey (18:46):
And that was for the face and neck together.

Dr. Pozner (18:48):
I did the face and neck. Now the FDA approval is for the face, not the neck yet. So when we do the neck, it's off label just like Botox. It was approved for this area, but we used it everywhere else. So that's well within our legality and in our practice to be able to use it on any area. In fact, we've used it off the face on some arms and legs as well.

Monique Ramsey (19:09):
I was about to say my mind is going crazy with where else we can go. And Dr. Pozner, what kind of patient would benefit the most from this treatment? Is there an age range or men, women, everybody.

Dr. Pozner (19:23):
I think we're still identifying best patient, but if you would ask me, it's someone who is not yet ready for a facelift. So early forties, mid forties, maybe early fifties. Although the FDA studies were in very older patients were a lot of wrinkles and they saw some significant results. One of the other groups that we've been very interested in using it on and we've treated a bunch of these patients is those patients who've had a facelift and complain of a little laxity because usually the jowl area, and no matter how much you pull them, they're going to end up with a little bit of redundancy there in the future. And if you pull 'em so tight that it's gone, then they look like the joker and you don't want those patients in your practice. And also neck laxity, everyone seems to over time get a little recurrence. So we've done a bunch of post facelift patients to see if we can improve them as well. So I think that's the two groups. But again, in my mind of fantasy with this, I would start treating everybody at 30 and you get one a year, so you'd never need a facelift.

Monique Ramsey (20:24):
There you go. Now, Dr. Brahme, how did the Ellacor technology catch your attention and what made you really be the champion to bring it to La Jolla Cosmetic for our patients?

Dr. Brahme (20:36):
Well, we see so many things come through the noninvasive treatments, and some of them are good and some of they're bad, and some of these machines are gathering dust in closets, very expensive machines gathering dust in closets. But when I heard about this, I thought this is something that is so needed in a zone that is so difficult to treat and it just has so many potential uses. And like Dr. Pozner said, the lower face here, no matter how tight you make people when they come back at six months or a year, this is the area that they don't like. And I had had a patient just I think the day before or something like that who I'd been spending weeks talking to about this area and she wanted a facelift or she wanted maybe some laser or something. And then the rep came in for Ellacor and I said, you are the patient for this.

(21:41)
And she was actually there the first day she was a training patient. And she is so thrilled because this, like Dr. Pozner said, I think that as a standalone procedure in the early patient who's not ready for a facelift, but who has some little stuff there that they want to get rid of, and then also for the patient who is coming back a year after and saying, oh, I love it, but God, can we do something here? And now we can. And Dr. Pozner has a lot more experience with this than I do, but I am shocked at how well patients heal. And these little hollow needles really don't leave a scar. They really don't leave a scar.

Monique Ramsey (22:31):
It's amazing.

Dr. Brahme (22:32):
And so I was so on board with this from looking at the micrographs that they have. They have pathology samples that show that there's no damage. And what really bothers me about RF technology, heating technology, laser technology is that it is an injury to the skin and that you rely on the scarring afterwards to really give the effect in more pigmented patients, you have a higher risk of hyperpigmentation and all that kind of stuff. But with this, it is removal. Yeah, there's some scarring, and I think that you see the permanent result a little bit down the line, but it's removal and there's no injury, no chemical injury, no thermal injury. I thought it was beautiful, and I was really excited that we were going to be one of the first practices in the country together.

Monique Ramsey (23:40):
The first neck procedure that I think I want to bring up to everybody's attention is sort of an old procedure that's new. Again, it's especially attractive to men who don't always want to have a facelift, but they want to look younger. And our surgeons are among just a few in southern California who do this procedure, and it's called a TZ plasty. So I'll let Dr. Salazar explain.

Dr. Salazar (24:09):
A TZplasty, it's I would say, the most powerful or the ultimate weapon against that neck Turkey gobbler deformity. Why? Because you're literally addressing it on site. You're really taking care of the problem, right where the problem is, and you're directly wedging or excising the tissue where the problem is.

Monique Ramsey (24:37):
Now the name TZ plasty, does it have anything to do with the shape of the incision or where is it getting this name?

Dr. Salazar (24:46):
T for Turkey?

Monique Ramsey (24:47):
No.

Dr. Salazar (24:47):
No, it's exactly as you're pointing out. It's related to the shape of the incision. So you excise you, and I'll go into details in a little bit, but you basically excise it and close it, so you excise it in a T weight with your incisions looking like a T, but then you perform something that in plastic surgery is called a Z plasty. So you excise it as a T, close it as a Z, and that's where the name comes from. So if you want me, I can tell you why or why in the world you have to excise it that way and then close it in the other way. And what is a Z plasty and all those things. We can go into those details, but only if you want,

Monique Ramsey (25:27):
Well, I'm kind of a dork about this stuff. I love it.

Dr. Salazar (25:31):
No, I think

Monique Ramsey (25:32):
We can do it as a bonus. If you're a subscriber, you can get this extra information,

Dr. Salazar (25:37):
Right? Exactly. Exactly. So here we go. Let me explain to you a little bit how well, you know what, before we go into that detail, let me tell you about the classic patient that wants to have this done. Because there is, I mean, I would say we all think about it. There's not a single patient. I'd say that it's above the age of 45 or 50 that has never said, oh my God, what am I going to do with this? I need to do something. And then probably people just forget about it or they don't take that step or they don't care that much about that. But I would say for the TZplasty, the classic patient tends to be a male patient, tends to be a patient in after the age of 50 that has developed loose skin over here. Sometimes the rest of the face looks fine and looks young, but what am I going to do to this?

(26:39)
How do I get rid of just this? And classic statement is, I want to get rid of this, but I don't want face a neck lift, but I don't want those incisions. I don't want for anybody to see that I have an incision around my ear in the back of my ear when I go to the club with my friends and no, just take care of this and no other incisions, please, what do you have to offer me? What about a little bit of liposuction? Could that take care of it? And then at that point in time you realize that the tissue is hanging, that if it would be like a big thick neck with a lot of fat, well maybe let's go ahead and start addressing that fat with liposuction. But most of the time it's just that loose skin that's hanging there sometimes with a little bit of fat.

(27:29)
Sometimes the muscles, the platysma muscle that's over here has been separated. Sometimes it hasn't, but it's just this. And so that's the classic patient that can really benefit the most out of this technique. So we take advantage of the fact that we all have this submental crease, so a crease a line underneath your chin, we all have it. Why? Because we all have a little bit of fat, does not need to be too much, and that generates that little crease. So that portion, the T of the incision, the horizontal part, we already have it. And if not, and I don't know if you know this, Monique, but I mean that's the most common place in your body to have a scar not related to surgery. It's here and in your forehead. So underneath the chin, if you look at people out of a hundred people, you're going to find many, many scars already there.

(28:26)
So we're not adding a lot, right, because either you already have the scar when you've fell and trip while you were running or you were riding a bike. And if not, then we already have a crease there. So that's the top of the T. Then we have the vertical portion of the T. It's going to be an incision that's going to be running up and down, and it's limited. It goes from that crease to pretty much, if you want to think about this, like the adam's apple, just for people to imagine that, and that's going to be the vertical part of the T. Once we do the excision, we want, and I know you know this, but let me share it with all the audience. You want tension, but at the same time, you don't want too much tension because too much tension leads to scarring problems.

(29:14)
Too much tension leads to wounds that don't heal well, and sometimes to the development of problematic scars that you don't want. So as Zplasty, it's a maneuver, it's a technique and plastic surgery in which we break the scar from a straight line and then we turn it into a small Z. And by doing that, we've decrease the amount of tension. So when I say we want tension, it's because why? Because with tension, if patients would have tension already in the neck, they wouldn't be asking for this surgery. And so that's why we want the tension, but we don't want too much tension because then we would have problems with scarring. So you excise it as a T, and then you close it as a Z. And then there's a recent modification of this technique in which calls for a very tiny, a very tiny incision, horizontal incision at the level of the atoms apple, to make it even better. So if you think about, it's still called the TZ plasty because it looks like a T, but it's like one of those special font Ts that the T has a little, right, a little horizontal at the

Monique Ramsey (30:23):
Has a little tail or something.

Dr. Salazar (30:24):
Like a little tail at the bottom with a little style. So that's for patients to understand that they're going to have an incision underneath the chin, a vertical incision from the chin down to the level of the atom's apple and a very small, tiny incision underneath over here at the level of the Adam's apple and man, have an incision really right here, right where everybody can see it. So let me point out too, I mean, our audience that are actually looking at the podcast, the ones that are listening to it, you can't see this, but if you look into the video, I can assure you that if I had a TZplasty, you can't see it right now. You can see my chin. You hardly be able to see my atom's apple. So where all the incisions and everything's going to be, you can't see it in a regular social conversation. Of course, if I would be doing that and lifting my head, then

Monique Ramsey (31:20):
You're getting your teeth cleaned at the dentist.

Dr. Salazar (31:23):
That's correct. That's correct. So if you do that, you can definitely are going to be able to find some of those incisions. But let me tell you, those incisions heal really, really well, and they don't become an issue later down the road. We also follow the patients frequently. We would treat those scars and everything. And the way we normally do, as you know, we follow our patients very closely. But that scar, it doesn't turn into a big issue. It doesn't turn into a problem. Patients are not conscious about it. Once it heals that a year has gone by, as a matter of fact, it looks fantastic. Even after two months, it's hard for you to find it. And during a normal conversation, you can basically see it unless you start going underneath and analyzing the patient. And so patients actually tolerated very, very well, and they're very happy after, I mean, the day after surgery, they start saying, my God, I can already see the result. The family member there that's taking care of them. Immediately they say like, whoa, it's impressive.

Monique Ramsey (32:29):
Yeah. Now, when you're doing this procedure, are you treating the skin and the muscle underneath the skin, or is this more the person who's just got that extra skin?

Dr. Salazar (32:42):
So the great part about this is that it gives us direct access to the territory that normally with other procedures, you're dressing from far away. So when we make that incision and we excise that tissue, then we get access to the platysma muscles that are right there. We get access to the fat that's underneath the skin. So if we feel the need to remove some of the fat, if we see the need to tighten those muscles, if we sometimes underneath those muscles, it's called sub platysmal fat underneath the muscles, you can also have some fat. So you can also remove some of that fat if there's a need for that. So all of a sudden you have all these possibilities that you can address while removing the Turkey gobbler. So you remove that excess skin, and then you have access to all these other different structures that you can also improve while you're there.

Monique Ramsey (33:44):
So the final procedure that I want you all to know about is the neck lift. And you might think, okay, what's different about the neck lift? That's been around a while, but there's two approaches. When you're not liking your neck, most people will hold their hands to the either side of their neck and they pull back, they pull backwards, and there certainly is a way to take that skin from behind. But what about the bands? People will get those cords that kind of come down the front of the neck. And so how do we deal with that? And that's actually its own little procedure called a submental, platysma plasty. And so Dr. Brahme is going to talk a little bit about how to address the neck from the back, but also from those bands and getting rid of those two chords.

Dr. Brahme (34:37):
Thank you. And hi, Monique. I do a lot of neck and face surgery. The neck is usually the one thing that men come in for facial complaints. And then women, it's also high on the batting order. And before Zoom it was called the turkey neck. And that is something that is a predictable sign of aging. As our collagen gets looser and our skin gets more stretchy and we lose fat, which is one of the signs of aging. And so you see all the little bands in the neck, and what many people see is loose skin sort of in the central neck, and sometimes they see two parallel bands going from the chin down to the chest, and those are the edges of the neck muscles, and they attention for a smooth neck. So I see a lot. And over my 20 years in practice, let's see, how long has it been? 1992, almost 30 years in practice, many things have come and gone, but the neck is really where most of the advances, the significant advances in facial surgery has been.

Monique Ramsey (36:02):
So if we're talking about turkey neck almost is sort of the extra double chin maybe or the extra skin that sort of hangs down, but then the sort of the cords that almost people see. So that's the muscle. Is it just that because we've lost fat that we're noticing the muscle? Or does the muscle somehow change as we age?

Dr. Brahme (36:25):
Well, the muscle does change a little bit, and the overlying fat layer gets thinner, so you see more of it. But the real culprit is the skin, because as we age and with sun damage and constant stretching and changes in collagen and so on, the skin just doesn't spring back. And for many young people who come in with a heavy neck, we talk about liposuction to get rid of the fat layers, but then you have to make sure that you assess the skin. So you suck out the fat, then what is the skin going to do? And the skin is everything in plastic surgery, whether it's breast or body or face, the skin is everything. And if it has good elasticity, maybe it'll be good with just some minor changes. But if there's less elasticity, then you need to tighten things.

Monique Ramsey (37:23):
And when you tighten things, where are the scars? Where do you make the incisions?

Dr. Brahme (37:29):
Well, I tell people we're talking about the neck now, but the neck is connected to the face and it's connected at the jawline. And so it is virtually impossible to do just a neck lift for the best result. You really have to work along the jawline. And the skin from the jawline gathers sort of in front of the lower part of the ear, and the skin from the neck gathers behind the ear. So the incision usually goes up along the inside, the ear on the front, and then in the crease of the ear behind the back and out into the scalp. And then we also make an incision right under the chin in that little crease that everybody has. And we work on the muscles through that incision so that you can get a nice, smooth central neck and get rid of those bands that we talked about.

Monique Ramsey (38:26):
And what are you actually doing to those muscles? Are you shortening them or how do you make those sort of disappear?

Dr. Brahme (38:32):
Good question. So since there two muscles, one on each side of the neck, and you have those two bands running down the center of the neck, what we do is that we stitch up the muscle, we sort of lace them up like a shoe from down deep in the neck up to the chin. And then what we do is through the incision around the ear, we mobilize the neck muscles. That is, we sort of free it up and then we pull it behind the ear and anchor it there. And when you put that stitch in, you just get an incredible jawline. The nurses always go, oh, that looks so good.

Monique Ramsey (39:18):
So you're sort of suspending it back behind.

Dr. Brahme (39:20):
Right. Exactly. We're tightening it, giving it that youthful tightening.

Monique Ramsey (39:25):
And how long could that last?

Dr. Brahme (39:28):
I usually tell people that barring any illnesses or major weight changes and things like that, about 10, 12 years, something like that, I'm starting to see some of my patients from earlier on now. And the nice thing is that once they've had the surgery, a, they know what it's about and they know what the recovery is about. So there's less fear. But also if you do this, and I prefer to do this in younger people, I don't like to wait until the skin gets really bad. So if you do it in young people, you can really get a smooth result and you really set the hands of time back and you will look better 10 years down the line than you would have had you done nothing.

Monique Ramsey (40:24):
So that's our La Jolla Cosmetic Podcast wrapped for 2023. Some of our fun procedures that you might not know anything about or you might've known a little bit about him. And so if any of these procedures sound interesting to you, we do free consultations, we'd be happy to see you. We also do consultations from afar, so if you don't live in the area, we have a lot of patients who travel, so we can do a Zoom consult. But we'd love to see you. We hope you have a really happy holiday season.

Laura Cain (40:57):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego Freeway in the XiMed building on the Scripps Memorial Hospital campus. To learn more, go to lj csc.com or follow the team on Instagram at ljcsc. The La Jolla Cosmetic Podcast is a production of the Axis, THE AXIS.io.