Facelift surgeries have a history spanning around 100 years. Over this time period, facelift procedures have evolved to become safer, more effective, natural-looking, cost-efficient, and easily accessible. However, there are still challenges that need to be addressed, limitations to overcome, and complications to prevent in facelift surgeries.
In the year 2010, after completing my specialization training at Hacettepe University, I began my advanced fellowship at the Cleveland Clinic. Dr. James Edward Zins, my mentor, was a prominent figure in the field of facelift surgeries. He was known for performing 100-120 facelift surgeries annually, having authored hundreds of scientific papers, and possessing both wealth and humility. He was a true academic in the realm of plastic surgery.
We were utilizing a surgical technique known as Extended SMAS, which involves operating in the deeper layers of the face. In 2010, this technique was only used by a small fraction of plastic surgeons in the United States. Many surgeons avoided it due to the perceived risks of damaging nerves, muscles, and salivary glands. Most preferred safer and simpler superficial techniques. However, Extended SMAS often produced more lasting and effective results compared to traditional techniques.
Dr. Zins was a master of this technique, but he had no intention of keeping this privilege to himself. He aimed to map the facial nerve anatomy in the deeper layers of the face and understand the relationships between nerves and surrounding structures in potential injury areas.
In 2010, he sent me and my colleague Mo Alghoul to a cadaver lab to map the zygomatic area. We dissected cadavers from various ages and ethnic groups. The zygomatic area is perhaps one of the most complex regions in terms of nerve-muscle-ligament relationships. We mapped nerve pathways in relation to nearby muscles and supporting ligaments. We documented the variability of this area's anatomy between individuals and even between the left and right halves of the same face. Mo Alghoul presented this study at the American Society of Plastic Surgeons Congress the following year, where it received the "best cosmetic paper" award. It was later published in PRS, the highest-impact scientific journal in the field of plastic surgery.
Citation: Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the Sub-SMAS danger zone, authored by Mohammed Alghoul, Ozan Bitik, Jennifer McBride, James E Zins (Plast Reconstr Surg 2013 Feb;131(2):245e-252e. doi: 10.1097/PRS.0b013e3182789c5c).
In subsequent years, Dr. Zins and his fellows conducted similar studies in other areas of the face, including the frontal, mandibular, and buccal regions. The primary goal of these studies was to create a roadmap for safe surgical dissections, meticulously identifying danger zones that surgeons should be cautious of, down to millimetric precision.
As of 2011, I had read almost everything written in the scientific literature about facelifts up to that time. Upon completing my advanced specialization and returning to Turkey, I began performing surgeries using the Extended SMAS technique. Through careful selection and sharing of meticulously chosen articles, I started achieving "high-level" results in my own surgeries. Within the first year of my individual practice, I had amassed over 10 before-and-after photos that could be considered very good. I knew what I was doing, and I was certainly able to achieve good outcomes.
The issue was that I couldn't achieve the same level of results in every patient. On the operating table, every patient appeared equally well. However, during the 3-6 month follow-up appointments, I noticed that after performing surgery using the same technique on two patients within the same week, one could return with very good results while the other might have only average results. We had a significant problem with "consistency."
Some patients were also losing the surgical results much earlier than expected. It didn't take long for me to realize that these problems weren't unique to me; they were shared by surgeons worldwide performing similar procedures. Interestingly though, no one seemed to talk about early relapse at conferences. There was very little information in the scientific literature about unsuccessful outcomes, early relapses, the instability of techniques, and even complication rates (which is still the case).
In facelift surgeries, we were surgically releasing all the retaining ligaments that anchor the facial soft tissues to the skeleton. This was necessary to adequately mobilize the face, and the success of the surgery depended on it. After releasing all these ligaments, we would reposition the face and secure the soft tissue to soft tissue using sutures. While this classic method worked well in some patients, it was inadequate in others (especially in those with heavy facial structures and lower tissue quality). Experienced surgeons were avoiding operating on patients in this group, considering them poor candidates.
Some surgeons attempted to reconstruct the facial retaining ligaments based on similar observations. An Australian plastic surgeon named Brian Mendelson had written articles on this topic, but his technique was deemed risky, which might explain its limited acceptance.
When looking at the map indicating the danger zones of the face that I mentioned earlier, we could also see safe zones where nerves didn't pass through. However, we hadn't previously looked at these visuals from this perspective. By utilizing the safe zones identified by the facial retaining ligaments in our previous work, I could systematically repair them.
In 2013, I began repairing the ligaments I had released during surgery. Over time, these repairs became systematic and extended beyond the boundaries previously described by Mendelson. I analyzed a total of almost 300 patients, both those operated on using this technique and those who weren't. In the group where I repaired the ligaments, the rate of deterioration in early postoperative results had decreased from 5.76% to 0.53%. Additionally, we didn't observe a significant increase in complication rates. Depending on the scope of the procedure, we did observe temporary nerve weaknesses in about 8% of cases, but this rate was similar to that in previously published series. This technique almost eliminated the problem of early relapse after facelift surgery. This study was published in ASJ, the highest-impact factor journal in aesthetic surgery, thus entering the medical literature.
Citation: Bitik O. SUB-SMAS Reconstruction of Retaining Ligaments. Aesthet Surg J. 2022 May 5:sjac117. doi: 10.1093/asj/sjac117. PMID: 35512707
Even in scientific circles, changing habits and entrenched ideas isn't easy. Some colleagues claim they don't see early relapse after facelift surgeries. Others, on the contrary, state that more than half of the patients lose their results within a year and that relapse is a natural outcome of facelift surgery. Currently, no one knows the true frequency of early relapse after facelift surgeries.
With the goal of compiling existing knowledge and exposing prevailing ignorance, I designed a meta-analysis. My colleagues and I gathered, categorized, and analyzed all published facelift articles (over 1300) in the literature. Only 4.4% of every 100 articles discussed relapse. This means that in the majority of studies (96%), early relapse was completely overlooked, a result surgeons preferred not to discuss. However, relapse had been identified in all studies that sought to observe it, with rates ranging from 1% to 50%. We found an average of 2.2% in the literature, but the true frequency is much higher. For instance, in some mini-lift techniques where nearly every case resulted in relapse, series of 1000 cases were published without any relapse-related data. Moreover, no diagnostic criteria for "early relapse" had been established. We were the first to define these criteria, which have yet to gain general acceptance, but there's no alternative. Sometimes a problem is so disregarded in scientific literature that you need to present the issue as a problem using numbers to make people realize its significance. This was exactly what we did.
Citation: Kucukguven A, Galandarova A, Bitik O. A Systematic Review and Meta-Analysis of Early Relapse After Facelift. Aesthetic Plast Surg. 2022 May 9. doi: 10.1007/s00266-022-02894-8.
Another contribution I made to the scientific landscape of facelifts is my study in which I described a technique that relocates the buccal fat pad beneath the SMAS layer. Beneath our facial bones lies a deep fat tissue system that extends from the temple to the cheek, known as the Bichat fat system, named after the anatomist who described it. Perhaps its most significant part, clinically speaking, is the cheek extension. The other term for this extension is the buccal fat pad. This pad, which has its own artery, behaves almost like an independent organ. As we age, the tissues that hold this pad in place loosen, the pad herniates, and it sags. The buccal fat pad is extracted in a procedure called "buccal lipectomy."
A surgeon named Alan Matarasso from New York was extracting this herniated pad through the mouth for patients undergoing facelifts. When the buccal fat pad is large and herniated, if not addressed, it can lead to contour deformities post-surgery. Furthermore, it can act like a buffer/spring inside the cheek, potentially causing early postoperative sagging.
In traditional facelifts, the buccal fat pad remains invisible. Even in sub-SMAS techniques, to assess and address the buccal fat pad, you need to release all the masseteric retaining ligaments around it. As this step is one of the most challenging in sub-SMAS dissection, even surgeons performing this dissection may not encounter the buccal fat pad routinely. As I mentioned at the beginning, you cannot adequately mobilize the face without releasing all retaining ligaments, which is essential for achieving a successful outcome. In extended SMAS dissection, I release all masseteric ligaments, and the buccal fat pad naturally presents itself during the surgery.
In 2013, I began thoroughly releasing this fat pad during surgery and repositioning it like an implant in areas of facial volume deficit. With this technique, I can achieve greater volume transfer than what's possible with a standard facelift. We achieved a remarkable solution, especially for patients with volume loss under the cheekbone. We analyzed patients we applied this technique to, confirming with MRIs that the transferred fat pads maintained their position and original volume. This provided us with an autologous tissue option to use instead of cheek implants. And all of this without the need for an additional incision inside the mouth.
This study was also published in ASJ, the highest-impact factor journal in aesthetic surgery.
Citation: Bitik O. Sub-SMAS Transposition of the Buccal Fat Pad. Aesthet Surg J. 2020 Mar 23;40(4):NP114-NP122. doi: 10.1093/asj/sjz129.
In the field of facelift surgery, besides the four scientific publications that have already made their way into the scientific literature, I have also developed various other "active" projects. These include those I've presented at various national and international conferences, as well as those in the stages of data collection, writing, and publication.
• Intraorbital Fixation Mid-facelift (Published in ASJ!)
• Double-Level SMAS Plication
• Sub-Platysmal Fat Split: A versatile approach strategy to deep neck sculpting
• Endoscopic Forehead Lift: How does it fail? How it shouldn’t.
I've been sharing patient visuals related to these active projects on my Instagram account for quite some time. However, the process of scientific publication is a completely different matter, of course.
After these studies are published, I will continue to write the second or third parts of this article. Even this article has become quite lengthy. I hope you haven't become bored while reading it.
As of today, I have a total of 45 scientific articles indexed in SCI/SCIE. To describe all of them would require another blog.
It's not only about facial rejuvenation, but also about any medical field: take a look at the scientific background of the physician who will be taking care of you.
What was scientific integrity?
Scientific integrity was dedication; it was love.
Stay with love,
Stay beautiful,
O.B.