The ideal aesthetic treatment plan now combines surgical and nonsurgical procedures

It is an exciting time in the field of aesthetic plastic surgery. As surgeons, our ability to integrate plastic surgery with nonsurgical techniques has changed the “face” of plastic surgery from a historically tight, overdone appearance to a more natural, healthy look. The surgical and nonsurgical techniques available for facial rejuvenation have helped stimulate a medical renaissance that has benefited patients and helped us as surgeons achieve superior results.

The list of nonsurgical therapies for complementing facial-rejuvenation surgery has grown exponentially in recent years. Products such as threads, lasers, and a veritable sea of injectables are available to the aesthetic surgeon.

I do not intend this article to be a treatise on nonsurgical approaches to the aging face. Instead, I will focus on three distinct categories of injectables—cosmetic botulinum toxin Type A (BTTA), hyaluronic acid (HA), and poly(l-lactic acid) (PLLA)—and their roles as adjuncts to aesthetic plastic surgery as part of a complete facial-rejuvenation program.

The Eternal Quest for Beauty

As we reach this milestone in plastic surgery, it is interesting to review how the field has evolved. The quest for beauty is as old as the human race. An exact definition of beauty has eluded artists, poets, and philosophers, in part because the image of ideal beauty changes from culture to culture and from one generation to another.

The Kirghiz people, a Mongolian tribe with a facial bone structure that resembled that of a horse, saw themselves as the ultimate in human beauty because, to them, the horse was the sublime masterpiece of all creation.1 The ancient Greek ideal of beauty, on the other hand, was based on symmetry, established proportions, and regular features. Plato wrote of “golden proportions,” in which the width of the ideal face was two thirds of its length, and the nose was no longer than the distance between the eyes.2 

Modern scientific study suggests that symmetry, defined as the similarity between the left and right sides of the face rather than its established proportions, is inherently appealing to the human eye.2 Cunningham et al showed that female faces with small, narrow chins, large eyes, and full lower lips are rated most beautiful across many different cultures.3 

The standard of beauty set by society has a vital influence on our patients’ self-image and self-esteem. Often, patients come into my office with preconceived preferences for a particular aesthetic procedure based on these ideals.

Evolutionary Trends

Today’s patients are more savvy and educated about aesthetic surgery options and outcomes than ever before. Before the typical patient comes in for an appointment, he or she has read about different procedures in magazines, on the Internet, or in newspapers, and may have talked with a family member or a friend who has had a similar enhancement.

The patient often enters my office with specific requests for certain treatment options. As a first step in the consultation process, it is therefore fundamental to set realistic expectations and decide on the most efficacious program specifically designed for the individual patient.

The significance of a thorough facial analysis cannot be overemphasized. It requires the surgeon to have a keen and practiced eye, coupled with a finely developed sense of proportion and aesthetics.

A trained aesthetic plastic surgeon understands the causality and progression of the aging process. He or she can analyze the human face and evaluate the relationship of its various components. Also, he or she can recognize that a thorough aesthetic assessment with proper injection planning will help ensure a positive outcome, minimize complications, and increase patient satisfaction.

The Facelift: Then and Now

Facelifts were initially performed in rudimentary fashion in Europe at the beginning of the 20th century. Since then, they have become one of the most common surgical procedures. From 2003 to 2004 alone, the number of people having facelifts increased by 25%, and in 2004, they were among the top five aesthetic surgical procedures, according to the Amer-ican Society for Aesthetic Plastic Surgery.4 

Until the mid-1970s, plastic surgeons focused on removing excess tissue, specifically sagging skin that caused drooping eyelids, lower-eyelid bags, jowls, and “turkey-neck” skin. The classic facelift operation is a direct and fundamental procedure:It begins with incisions—carefully placed to camouflage scarring—that undermine the facial and neck skin. The redundant skin is then excised and the wounds are surgically repaired, resulting in minimal and barely discernible scars.

The superficial musculoaponeurotic system (SMAS) procedure was introduced in the mid-1970s, with nearly universal acceptance. In this procedure, the skin is separated from the underlying fat and facial muscles. The surgeon then redrapes the skin and the SMAS separately and in different directions, according to each patient’s particular needs.

Usually, the skin is draped in a vector that is more horizontally oriented than the SMAS, which is draped in a more superior (cephalad) position. The results of this facelift are enhanced by cutting into deeper tissue planes for the purpose of restoring basic anatomical elements of the head and neck to their more youthful forms. The rotation of the skin and its redraping is critical to the aesthetic success of this surgery.

The Composite Lift

The SMAS facelift was soon followed by another advance, the “composite facelift,” which was perfected by Sam T. Hamra, MD, in the 1980s. True to its name, the lift coordinated the basic structure of the face and literally all of its components: bone, muscle, fascia, and skin. Hamra’s method includes moving tissues in a superior medial direction on the cheek rather than the singular lateral direction traditionally used in subcutaneous lifts, SMAS lifts, and malar-fat techniques.5 

The composite facelift achieves a lift that is multidirectional and oblique. Unlike the traditional facelift, it addresses the gravitational fall of the aging face. This facelifting procedure is considered more “complex” than its predecessors, and it has a higher risk of complications and a longer healing period—as a consequence, it is infrequently deployed.

Today, we know that achieving an optimal aesthetic result through surgery alone has inherent basic limitations that require the aesthetic plastic surgeon to incorporate a safe and effective combination of techniques to produce the best possible facial-rejuvenation outcomes.

Surgeons Add Injectables

The plastic surgeon’s re­pertoire has increased to routinely include the use of injectables separately and distinctly from surgical pro­cedures. However, using in-jectables in conjunction with aesthetic facial surgery has proven to be a boon to the patient.

Nearly 100% of my pa­tients are being treated with a combination of surgery and injectables such as BTTA, HA, and PLLA. I find this very beneficial for my patients because injectables can be used while the patient is anesthetized, avoiding additional discomfort that they may otherwise experience.

A myriad of short-duration and semipermanent dermal injectables is available to the surgeon. Every physician is obliged to have broad knowledge of and skills in the different products and techniques, to satisfy patients’ needs and desired outcomes, and to avoid complications.

To consistently obtain satisfactory results with minimal risks for the patient, the “gold standard” in my practice consists of aesthetic facial surgery in conjunction with BTTA or HA—or for longer-lasting results, PLLA. I use these injectables because they are all natural and not animal-based, which limit the risk of the transmission of animal-originated diseases or the development of allergic reactions to animal proteins.

Cosmetic BTTA has proven to be advantageous for reversing an aged, tired, sad, or even angry appearance. When used selectively to weaken or even paralyze targeted muscles, BTTA permits the surgeon to change an expression, soften a harsh countenance, and minimize or actually eliminate deep lines.

I have injected BTTA successfully into the glabellar area to ameliorate deeply ingrained expression lines in the upper third of the face, such as crow’s feet, bunny lines, and forehead lines. I often use BTTA as an effective adjunct during facelift and eyelid-tuck surgeries, and I have also used it to enhance age-reversing procedures on the lower two thirds of the face. The effects last approximately 3–4 months.

In my experience, the HA products have proved to be adaptable to most situations. They are biocompatible and bio-degradable materials that correct fine lines, plump lips, fill in deeper folds, and even contour the face. Deepened folds from the nose to the mouth or the mouth to the jawline, the so-called “marionette lines,” are immediately improved when HA is injected into them. A mouth with a sad appearance can be turned upward, resulting in an attractive, youthful look that lasts approximately 6 months.

Long-Lasting PLLA

It is now widely recognized that lost volume flattens the zygoma, hollows the cheek, deepens the facial folds, sinks the temples, flattens the lips, deepens the tear troughs, and makes the eye socket appear hollow. These changes are subtle but inexorable, and ultimately produce a haggard and tired look.  

Because of these facial changes, I use PLLA frequently to augment surgery. In my experience, PLLA is safe and effective for cosmetic use alone or in combination with other injectables. It is ap­proved by the US Food and Drug Administration to treat facial lipoatrophy in patients with human immunovirus.

My patients have experienced improved facial contour, dimension, and lifting because PLLA acts as a volumizer for hollowed cheekbones, jaws, and temple areas. Lines and deep folds are corrected in a subtle and gradual, but distinct, manner, and the patient’s appearance becomes healthier and younger.

What makes PLLA unique is its mechanism of action, which is believed to stimulate collagen production in the injection area, thereby reversing the effects of age. The benefits of this semipermanent treatment last 2 years or more, which is longer than many other available injectables. I reconstitute the purchased product using a standard dilution, preferably the day before the procedure, and inject it into the deep dermal, subcutaneous, or submuscular layers of the target zones for the best results.

Beyond Physical Appearance

Finally, when working with the patient to develop an appropriate facial-treatment plan, it is incumbent upon the surgeon to be responsive to the patient’s psychological needs as well as to his or her physical requirements. Although they are more difficult to discern, patients’ psychological needs are intricately connected to their appearances.

I realized long ago that if I correct a “defect” in the face, I have the unique privilege of contributing to a positive body–mind connection by enhancing a person’s appearance and self-esteem. My personal goal is to restore a healthy, natural, and youthful appearance to make the patient not only more attractive, but also more self-assured.

The field of facial rejuvenation has come a long way since the beginning of the last century, and innovations have proliferated in the few years since the dawn of the 21st century. As combined surgical and nonsurgical procedures continue to be refined, more innovative techniques that aesthetic plastic surgeons can successfully incorporate into their practices to heal the patient’s body and mind will be introduced. PSP

Paula A. Moynahan, MD, is in private practice in New York City and Waterbury, Conn. She is certified by the American Board of Surgery and the American Board of Plastic Surgery, and was one of the first plastic surgeons in the United States to perform in-office outpatient surgery. Moynahan is a graduate of the Medical College of Pennsylvania, Philadelphia. She is affiliated with Lenox Hill Hospital in New York City and St Mary’s Hospital and Waterbury Hospital in Waterbury. She can be reached at (212) 535-0800, (203) 754-4125, or [email protected].


1. Moynahan P. Cosmetic Surgery for Women. New York: Crown Publishers Inc; 1988:ix.

2. Feng C. Looking good: The psychology and biology of beauty. J Young Investigators [serial online]. 2002;6(6):doc 1. Available at: http:// feng.html. Accessed December 7, 2005.

3. Penton-Voak I, Perrett DI. Consistency and individual differences in facial attractiveness judgements: An evolutionary perspective. Soc Res [serial online]. Spring 2000; doc 5. Available at: http: // m2267/is_1_67/ai_62402556. Accessed Decem­ber 7, 2005.

4. American Society for Aesthetic Plastic Surgery. 2004 statistics. Available at: org/download/2004-stats.pdf. Accessed Decem­ber 7, 2005.

5. Jesitis J. Composite approach tackles facelift flaws: Method moves tissues in superior, medial direction on cheek; multidirectional, oblique lift prevents telltale “swept-back’ look.” Cosmetic Surg Times [serial online]. August 2004; doc 11. Available at: articles/mi_m0HMW/is_7_7/ai_n6164648# continue. Accessed December 7, 2005.