Patients continually look for less obvious facelift techniques. The scarless facelift may be the answer, but is the term misleading to your patients? The scarless facelift refers to a facial rejuvenation procedure in which incisional scars are minimized by using endoscopic techniques. Because the incisions are extremely small and placed in hidden areas behind the ears and hairline, the term scarless facelift has become popular for this technique. Endoscopy is indeed an exciting advancement, eliminating the need for long incisions and offering faster healing time with fewer side effects than traditional facelifts. However, the term scarless can be misleading for patients. Clarification and communication between physicians and patients regarding facelift expectations is more important than ever.

In patient consultations, I emphasize that visible scarring is always a risk in any procedure. Although scars from endoscopic facelifts are hidden and minimal, they are scars nonetheless. In fact, side effects such as small patches of alopecia may occur in as many as 25% of endoscopic procedures. Any incision, no matter how tiny or hidden, carries some degree so scarring risk. Secondly, I review less invasive alternatives with the patient, such as Botox, lasers, and the new brow suspension procedure. These alternatives may, in some cases, produce the patients’ desired effect without incisions. The next step is determining exactly what the patient has in mind by seeking a scarless facelift. All procedures have different levels of risk, and some individual expectations for facelifts can be met by less invasive procedures.

Rejuvenating the Face

The benefit of endoscopy in facial rejuvenation is the ability to lift the forehead, midface, and neck without removing skin. The combination endoforehead-endomidface lift is appealing to younger patients who are beginning to show signs of sagging brow and forehead, but with whom a traditional facelift would be an extreme measure. Since the technique is particularly demanding and is operator- and instrument–dependent, a comprehensive evaluation is vital to determine the right combination of techniques. Many surgeons prefer tailoring to a patient’s specific needs by building on a foundation of existing procedures, and at the same time combining all applicable treatments for each individual. For patients up to the age of 50, many surgeons tend to use a combination of Botox, laser, and/or full endoscopic technique without skin incisions. For patients over 50, who require a more radical facial rejuvenation, many physicians combine endoscopic techniques of the central oval of the face (forehead, midface, and chin) with the standard cervicofacial rhytidectomy at the jaw line and neck with some skin and muscle incisions.

In younger patients, however, the option of using Botox, laser, autologous fat transfer, or a combination of all three, is preferable. These often give the patient lifted and tightened skin with less risk of scarring. Even the fine needle tip to administer Botox does not eliminate the risk of scarring. Thus, even with the least invasive alternatives, it is not wise to promise the patient a completely scarless facelift. Strategic injections of Botox, still the simplest, least expensive, yet highly effective method of achieving a minimally invasive lift, are commonly done in the office.

In addition to Botox, laser resurfacing also offers minimally invasive options with impressive results in removing lines, tightening the skin, and generally causing an overall lifted look. The 1064 nm laser is the least invasive. The erbium and CO2 lasers go deeper, but are respectively more invasive. All three lasers function in the same way, causing a tightening of the collagen fibers of the dermis, which results in a lifting effect. All of these modalities play a role, and are most effective when used in combination, such as laser with a forehead lift or laser with Botox.

For patients who have a significant loss of elasticity in the underlying muscle tissues, Botox and lasers are less useful. In these cases, it is necessary to rely on the endoscopic facelift to rejuvenate the face. It is possible to achieve the effects of a full, open facelift with an endoscopic forehead lift, and endoscopic mid-facelift, endoscopic insertion of implants, endoscopic neck lift, or a combination of any of the above procedures.

Lifting the Brow

In contrast to the brow lift, a new procedure called brow suspension is also an option for a hidden scar alternative. This surgical procedure is less intensive than the endoscopic brow lift and CO2 laser. The brow suspension technique is based on the fact that when the patient is lying down, the brow takes a higher position because the downward pull of gravity is eliminated. The brow suspension technique secures the eyebrow in the position. It is simple, safe and easy to perform with consistent satisfactory results, and it could postpone major facial rejuvenation procedures for several years.

The eyebrow suspension method is as follows: make two 1-mm incisions within the eyebrow, then two other incisions within the hairline, directly above the eyebrow incisions. Using a catheter, tunnel underneath the skin between the incisions in the eyebrow and the ones in the hairline. Thread sutures through the tunnel connecting the incisions and secure them to hold the eyebrows in place.

Brow suspension is more appropriate for younger patients who want to slow a minimal drop in the brow. Instead of being a definitive treatment for a sagging brow, it is a temporary lift that helps postpone a major facelift. The results of brow suspension usually last for 1 to 6 years, and the procedure can be repeated easily a few years later. The less invasive brow suspension involves fewer and less extensive incisions, but it has less permanent results than the endoscopic brow lift.

Simon Ourian, MD, is cofounder of a laser and aesthetic surgery center in Beverly Hills, CA, and a member of Plastic Surgery Products’ editorial advisory board.

Medical Journal – Discrete Techniques (PDF)