Nine plastic surgeons debunk Malcolm Paul, MD’s “Defending the Lifestyle Lift” article.

It should come as no surprise that the recent opinion article by Malcolm Paul, MD, published in the September issue of Plastic Surgery Practice, has generated a response. The presence of Lifestyle Lift (LSL) in the milieu of facial plastic surgery has represented a sea change in marketing and in the business model presented. However, many facial plastic surgeons and plastic surgeons across the country have taken issue with the veracity of the advertising, the level of patient-to-surgeon contact, the quality of patient care, patient safety, the quality of individual patient results, the litigious response of LSL to legitimate criticism, and the overblown claims made by LSL in its 10-year history.

The LSL Procedure

Although LSL has repeatedly advertised its procedure as “revolutionary,” Paul writes that “surgeons have the latitude to do as much as they feel is necessary, [including] platysmaplasty, or a corset platysmaplasty, to achieve an optimal neck contour.” This reaffirms the widely understood claim that LSL as a procedure adds nothing new to the armamentarium of facial plastic surgery techniques. This contention is backed up by the lack of any published report or data in peer-reviewed journals to substantiate these claims. The article basically states that LSL surgeons employ a wide range of previously described and well-established techniques to accomplish facial rejuvenation. This is not revolutionary, but a widely held standard of practice.

LSL Photography

Only recently has LSL added disclaimers to its ads stating in fine print that patients pictured may have had “more extensive procedures.” Its photography is replete with variability using different angles, lighting, brightness settings, position, glamour shots, and laser treatments. The captions often suggest some patients achieved the results in “about an hour procedure.” This is patently false. The results shown in Paul’s article demonstrate inconsistency in lighting that would not be publishable in peer-reviewed journals. These practices may mislead thousands of prospective patients.

Lifestyle_3aLifestyle_3b-After_revision_faceliftClick here to see a slide show of the before-and-after images mentioned in this article.

LSL Patient Safety

Paul states that, “All procedures are performed under Level I Anesthesia (oral sedation and local anesthesia) with monitoring available.” From our collective experiences, we know that performance of a comprehensive facelift (as is sometimes the case with LSL cases) requires a greater amount of local anesthesia and/or (oral) sedation to make the patient comfortable and allow for completion of the procedure. A higher level of sedation (Level II or Level III) is typically performed in accredited surgical facilities, a designation that only some LSL centers have received.

Both the American Board of Facial Plastic and Reconstructive Surgery (ABFPRS) and the AmericanBoard of Plastic Surgery (ABPS) have moved to make accreditation of office-based surgical facilities a requirement among members in good standing. In fact, Paul’s assertion that LSL is “an approach that is safer” not only lacks published statistical merit, it lacks believability. The description that “LSL performed 22,000 facelifts” in 2010 effectively means that 22,000 patients may have been treated in nonaccredited facilities during that year. Case reports of at least one overly sedated LSL patient presenting with an acute postoperative surgical wound and airway problem at a local emergency department who was treated by a LSL surgeon lacking hospital privileges add further weight to this argument. Paul states that accreditation of LSL centers “is in the process of being implemented nationally.”

LSL Consultation and Patient Care

The consultation process in plastic surgery is designed to allow for discourse between surgeon and patient, including for vocalization of concerns, evaluation, and recommendation of a treatment plan. Although certain parts of a consultation may require assistance from the office staff, the treatment plan is the sole domain of the surgeon. Numerous anecdotal reports of the LSL describe circumstances where nonmedical sales personnel described as “surgical consultants” make surgical recommendations to patients. Numerous other reports describe patients meeting their surgeon on the day of the surgery and/or having the agreed-upon surgeon switched on the day of surgery. Such practices erode the quality of patient care.

Paul describes a detailed algorithm for immediate and extended postoperative patient care that is contradicted by numerous LSL patients. Descriptions we have heard from former LSL patients range from difficulty in seeing the surgeon postoperatively to having legitimate complaints ignored, followed by referral to a national LSL complaint center. Every surgeon has both highly and less satisfied patients, and it is the responsibility of the individual surgeon to address these concerns in a reasonable yet empathetic way. Since Paul does not describe follow-up beyond 3 months, it is difficult to fully evaluate patient satisfaction. Given that one of the top complaints about LSL is the lack of longevity of the procedure, this is a serious issue.

Although Paul reports that individual surgeons have a great deal of leeway in surgical technique and the follow-up process, we have collectively heard reports from former LSL surgeons that there is corporate pressure to maximize conversion of consultations to surgeries. We maintain that surgical judgment must be individual and based purely on medical decision-making.

LSL Outcomes

Each of us have seen many dissatisfied LSL patients complaining of lack of longevity, no discernable result, and noticeable scarring. The most commonly described patient perception was that they were “oversold and underdelivered.” Yes, every facial plastic surgeon and plastic surgeon will, whether for legitimate reasons or not, occasionally have an unhappy patient. However, the frequency and severity of the complaints seen in our collective experiences and viewed on Web sites such as tell a story of misleading advertising, heavy sales pressure, quick procedures, and lack of follow-up care.

The LSL Marketing Message

There is no secret that the success of LSL is directly related to its ubiquitous advertising. The major issue we have is the veracity of the claims made in their television spots, print ads, and Web site. One particularly spurious claim is, “Most importantly, it (LSL) is safer than more traditional approaches to facial rejuvenation.” The second statement lacking veracity is the implication that LSL will minimize recovery time compared to traditional procedures. Since there is no statistical data or double-blind studies available to make such statements, they can only be viewed as opinion.

LSL continues to make statements about “dangerous procedures under anesthesia” on its website. This technique uses fear mongering of anesthesia as a selling point.

The ethical advertising guidelines of the American Medical Association contain four principles:

  • Advertisements should not contain false claims or misrepresentation of material fact.
  • Advertisements should not contain implied false claims or implied misrepresentations of material fact.
  • There should not be knowing omissions of material fact from advertisements.
  • Physicians should be able to substantiate material objective claims and representations made in an advertisement.

LSL makes two assertions in its advertising that require much more explanation to the viewing public: 1) that the procedure and the results are transferable from surgeon to surgeon, and 2) that the procedure takes “about an hour.”

Since we know, based on our training and experience, that variability exists in surgical results among surgeons, it is only fair that LSL promote the results of the individual surgeon(s) in the geographic locale in which it is advertising. For example, Paul’s LSL results could be expected to vary from another LSL surgeon in New York. If the individual surgeon is no longer with LSL, the results of that surgeon should no longer be used.

The article submitted by Paul includes four patient examples (which are not attributed to any specific surgeon), all of which have had the “LSL plus neck-firming procedure.” Most of the LSL advertising promotes a 1-hour procedure, but presents examples of “LSL plus neck-firming procedure.” If the advertised strength of LSL is that the procedure takes 1 hour, the company should only show the results of 1-hour procedures.

LSL’s Litigious Nature

Paul states that, “LSL has and will continue to aggressively defend and protect its brand name and the reputation of its doctors,” mentioning several successful lawsuits it has filed against NBC Universal and a “national competitor.” However, what he does not mention is that LSL has filed spurious copyright infringement and defamation claims against individuals, doctors (including two of the authors), news organizations (CBS Atlanta, etc), and Web sites including,, and WebMD, to suppress legitimate free speech that may be critical of the company’s claims. These lawsuits were largely withdrawn or dismissed, as was the case with CBS Atlanta, two Florida facial plastic surgeons, Infomercialscams, WebMD, and Realself.

Other surgeons have been threatened with potential legal action for opinions and commentary on in the form of letters from LSL’s in-house counsel. This letter is generally accompanied by an invitation to visit the Michigan headquarters of LSL in order to “learn more” about the process. We feel that LSL would be better served by placing more emphasis on improving patient care than squelching free speech.

The Florida Attorney General has an active investigation into LSL’s marketing practices. In 2009, the New York Attorney General fined the company $300,000 for posting false positive reviews on the Internet, a charge known as “astroturfing.” However, in addition to being fined for fake positive reviews, the company actively suppresses negative Internet posts by buying every known variation of the term “LSL complaint” and any search term using the word “lifestyle.” A user then clicks on what appears to be a negative post by an individual only to find a company message. This way, the company can relegate legitimate criticism to “Google obscurity” on page 5 and below.

Realself has gathered data from thousands of LSL patients, and the dissatisfaction rate is generally around 42%—a number far higher than private-practice plastic surgeons encounter. Furthermore, with the last patient encounter occurring at 3 months after the LSL procedure, it seems difficult to see how LSL is keeping track of quality control and patient satisfaction.

Paul’s article clearly states his confidence in the practice model of LSL, and we applaud some of the changes that have been initiated like planned accreditation of LSL centers. However, the issues enumerated in the 10-year history of LSL have clearly left a negative impression on many people.

In the words of Oscar Wilde, “Experience is simply the name we give our mistakes.” Certainly, Paul has been asked to provide his substantial gravitas to a company that has made a few.

When considering what the future holds, a second quote by Wilde comes to mind: “No man is rich enough to buy back his past.” Our opinion is that LSL’s history has been replete with mistakes and deserving of criticism. Opinions of LSL will only change with positive experiences that counter the vast number and variety of previous negative experiences with LSL. It is not hopeless.

Many other American companies have had negative consumer impressions that have taken years to change, but they have successfully done so. We feel strongly that the patient is best served when the surgeon is freely able to guide the patient through the decision-making process, when the correct procedure is chosen for the patient, when safety is fervently pursued with best practices, when concerns are adequately addressed, when marketing is accurate and truthful in the spirit of the AMA guidelines, and when criticism generates an appropriate response. n

By Anurag Agarwal, MD, Naples, Fla; Darryl J. Blinski, MD, Miami; Ross Clevens, MD, Melbourne, Fla; Edward Gross, MD, Lake Mary, Fla; Kent Hasen, MD, Naples, Fla; J. David Holcomb, MD, Sarasota, Fla; Brett Moelleken, MD FACS, Beverly Hills, Calif; Stephen Prendiville, MD, Fort Myers, Fla; and Adam Rubinstein, MD, Miami.

As with the original, the views and opinions expressed in the articles appearing in Plastic Surgery Practice are those of the author(s) and do not necessarily reflect the views or opinions of the publication’s editor, its editorial board, or its publisher.