Dr. Little’s Techniques
Secondary Surgery after Prior Facial Rejuvenation
Secondary facelift or eyelid surgery, or repeat surgery following previous operation(s) by another surgeon(s), represents a large portion of Dr. Little’s practice. Patients presenting to the office after prior surgery fall into four categories.
The Happy Group
One such group, who typically had their surgery some five to ten years before, has remained generally pleased with their initial overall result, but now feels that aging has again caught up with them, at least in their facial appearance. They are now, therefore, interested in recapturing the earlier benefit they enjoyed (or more) and are happy to learn of newer philosophies and techniques (such as structural fat grafting) that are now available to bring enhanced improvements over their original result.
The Disappointed Groups
Sadly, the other three groups typically (but not always) present to the office much earlier, say a year or two after their surgery, and share–in common–disappointment or even profound unhappiness with their surgical experience. The largest of these groups consists of patients who feel they did not receive an adequate or hoped-for benefit from their surgical investment, leaving them with continued signs of aging they had assumed would be reversed. Most often these disappointments fall into the group of aging stigmata that remain most difficult for plastic surgeons to eliminate—those that fall most forward in the face, near the nose, mouth, and chin. Here, persistence of the “jowl complex” leaves uncorrected “bitterness folds” at the corner of the mouth or longer “marionette lines” that extend all the way from the corner of the mouth to the jawline. Also, the narrow lower teeth may become exposed, especially during speech and relaxation of the mouth, while the youthful upper ones remain hidden. The “nasolabial” fold or crease may persist from the wing of the nose down to the corner of the mouth.
The jawline itself may remain irregular, especially where a persisting jowl drops across into the neck. And neck bands may persist below the chin. It is precisely to avoid these all-too-common disappointments that Dr. Little prefers to concentrate his lifting efforts up front in the face, near the nose, mouth, and chin (as in his XJ or paramedian lift), rather than in the more accessible zone further back in the face (in front of the ear). The correction of these disappointments then becomes more a matter of extending the reach of the surgical suspension, rather than its force or its tension. Finally, many within this group also present areas of deficient volume, most often around the eyes, but also in the cheeks, temples, or lips. Here the remedy most often lies in straightforward structural fat grafting.
The Unnatural Group
The second of these unhappy groups is concerned with something more serious than the persistence of their aged appearance, for they have finally come to the difficult conclusion (often after a painful period of resistance and doubt) that not only do they no longer appear as themselves (to friends)–but they no longer appear natural (to strangers); they appear, instead, altered or surgical. Even as recently as ten to fifteen years ago, such an outcome offered limited hope for reversal; but now Dr. Little can approach most such disappointments with true optimism. Structural fat grafting, especially, has brought a powerful new tool to bear against the unnatural result. Now many of these individuals can not only achieve convincing naturalness, but even beauty. Dr. Little is able to share impressive examples of such reversals during the office consultation.
The Injured Group
The remaining and smallest group is made up of patients that have experienced a complication during surgery that has altered their facial appearance or function, such as skin loss with scarring, facial nerve injury with muscle weakness, or altered eyelid position. Many of these injuries can be remedied to a significant degree, some more than others. And all but the most serious can at least be camouflaged to some extent. Each, of course, needs to be evaluated on a case-by-case basis.
Patients often wonder whether such repeat surgery is more technically difficult for the second surgeon the next time around. It certainly can be, especially when the surgery is repeated in the middle (SMAS) plane of the face; if the original surgeon was less skilled, there may be considerable difficulty in developing a proper plane or lamella at the second attempt. Fortunately, such is not the case for the XJ lift; no matter the nature of the prior procedure, a second surgery in the superficial plane presents little or no increased challenge with respect to its suspensory aspects, as no second plane or lamella is required.
Illustration: detail from Leonardo da Vinci, “Adoration of the Magi,” ca. 1481-1482, Galleria degli Uffizi, Florence.