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BackTable / ENT / Podcast / Transcript #127
Podcast Transcript: In-Office Facelifts
with Dr. Demetri Arnaoutakis
In this episode of BackTable ENT, Dr. Demetri Arnaoutakis, a facial plastic surgeon, and host Dr. Gopi Shah discuss planning and execution of in-office facelifts. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) How to Gain Private Practice Experience as a Resident Surgeon
(2) Counseling Patients on In-Office Facelifts
(3) The Pre-Facelift Physical Exam
(4) The Role of Pre-Operative Photos
(5) Non-Surgical Alternatives to Facelift
(6) Finer Points of In-Office Cosmetic Procedures: Anesthesia & More
(7) Operating Room or Office? Selecting the Appropriate Surgical Site
(8) Pre-Operative Care of The Facelift Patient
(9) Expert Tips on Performing Facelifts
(10) Post-Operative Care of the Facelift Patient
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[Dr. Gopi Shah]
This week on The BackTable Podcast.
[Dr. Demetri Arnaoutakis]
I think that's just where the art of this comes into play. It's your eye, your eye for aesthetics. Does it look good to you? That's where I don't know. I don't really foresee myself ever doing measurements in this area. It's really mostly like, "Okay, this was your mom or your sister or your aunt. Would you be okay with this, with how she looks?" That's just like caring and honestly having a little bit of a creative mind and making sure it looks good.
[Dr. Gopi Shah]
Hello, everyone, and welcome to The BackTable ENT Podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. My name is Gopi Shah, and I have a really awesome guest today. I have Dr. Demetri Arnaoutakis. He's an otolaryngologist and facial plastic surgeon practicing in Tampa, Florida, and Beverly Hills, California. He specializes in facial plastic surgery, hair restoration, and injectables. Demetri is here to talk to us about in-office facelifts. Welcome to the show, Demetri. How are you? I'm great.
[Dr. Demetri Arnaoutakis]
Thanks so much for having me, Gopi. I'm really excited to be here.
[Dr. Gopi Shah]
For our audience, just to give some context. Demetri was one of my residents for all years of your training.
[Dr. Demetri Arnaoutakis]
I think, yes.
[Dr. Gopi Shah]
Yes. It was wonderful. You were one of the hardest-working people. I don't think I've ever told you that. Now we've made this public. Demetri was one of my favorite residents. He was so hardworking. It was such a pleasure to work with.
[Dr. Demetri Arnaoutakis]
Thank you.
[Dr. Gopi Shah]
Before we get into in-office facelifts, I want you to tell us a little bit about yourself and your practice.
[Dr. Demetri Arnaoutakis]
Yes. I'm originally from Tampa, Florida. I was recruited to Columbia University for soccer. I played Division I soccer for four years and really loved my time up north in the city. It was definitely a unique college experience. Then I returned back to Florida for medical school. I went to the University of Florida College of Medicine. That's where my first mentor in my training I met was Dr. Bill Collins.
[Dr. Gopi Shah]
Shout out.
[Dr. Demetri Arnaoutakis]
Yes. Who was on the show not too long ago. How I heard about this. He's awesome. He's the man. He was just such a great teacher. He let me get involved as a medical student helping with, I think I even did my first tonsillectomy under Dr. Collins. I think I may have disappointed him a little bit when I didn't choose pediatric otolaryngology for my career.
[Dr. Gopi Shah]
You disappointed many of us when you did not choose pediatric otolaryngology.
[Dr. Demetri Arnaoutakis]
That's true. Anyway, so then after medical school, I also actually between my third and my fourth year, I applied and was selected for a Doris Duke Research Fellowship at Johns Hopkins. I spent a year in their otolaryngology department, specifically their head and neck cancer division. That's where my second mentor came into my life, Dr. Joseph Califano, who's now out in California. He was an excellent clinician and surgeon and researcher altogether.
I got embedded in their otolaryngology department. I attended all their lectures. That's really when I sort of started to take a liking towards facial reconstructive and aesthetic surgery. Dr. Patrick Byrne, a really well-known facial plastic surgeon, was really generous to me. I got to watch and see a lot then as well.
By the time I got to Dallas for my training with you guys at UT Southwestern, I already knew the path I wanted to take in facial plastic surgery. Honestly, from day one, I was sticking to Dr. Leach and Dr. Gilmore and Jordan Rahani, and the whole crew. Then after that, I was chosen for a fellowship out in Beverly Hills with Dr. Andrew Frankel, who's a world-renowned rhinoplasty, revision rhinoplasty and facelift surgeon. Then I came back to Tampa and the rest is history
(1) How to Gain Private Practice Experience as a Resident Surgeon
[Dr. Gopi Shah]
In your fellowship then, is that where you got the bulk of your cosmetic experience as well as your in-office procedures?
[Dr. Demetri Arnaoutakis]
Yes. It was definitely during fellowship, but also in my free time in Dallas. I think the smartest thing I ever did was I reached out to all the private practice plastic surgeons around Dallas. Many of them are really involved in the AAFPRS, which is the American Academy of Facial Plastic Reconstructive Surgery. Sam Lamb, who's out in Plano, is a world-renowned hair restoration surgeon. There's just so many. Rod Rohrich, who was with the UT Southwestern department. Then also Sam Hamra, whose name may not ring a bell to a lot of people, but he was the first person to describe the deep plane facelift. He was right there in Dallas, Texas. He was towards the end of his career. I would go visit him and watch him do deep plane facelifts in my free time. He was awesome. Yes.
[Dr. Gopi Shah]
For our trainees who might be listening, how do you find time? At what points in your residency training were you able to go and shadow, watch, observe, work with some of the physicians that are outside of your residency training? How did you do that?
[Dr. Demetri Arnaoutakis]
It was really, I took advantage of our fourth-year block of our research block. In fact, I did some research articles with a lot of these surgeons. Jim Thornton, who's a Mohs reconstructive surgeon within the plastic surgery department at UT Southwestern. He was so welcoming to me and just a really nice guy. In fact, we had a referral of a collaborative patient recently. I took advantage of that. I did not do any research. I actually got a couple of articles published.
I used all that free time, instead of sleeping in until 10:00 AM and taking advantage of the free time from your usual clinical responsibilities as a resident. I was still up at the same time going around town, watching these guys in the community who have excellent reputations. Truthfully, there's a difference between what goes on in the hospital and then in a boutique, five-star plastic surgery practice. It definitely has a different aesthetic to it. I really enjoyed that. I learned so much from all those guys.
[Dr. Gopi Shah]
Now for the program side, because you're right, training programs are all a little bit different, but you might be somewhere where maybe they don't have as much trauma, but you're interested in doing more trauma. Maybe you want to focus on gender-affirming voice care, but maybe they don't have a program for that, or in your case, a real high-end cosmetics practice. Are there any advice or pearls or tips that you would offer to the training programs? What can training programs do to help bridge some of those gaps or help you utilize the other resources around you in your community?
[Dr. Demetri Arnaoutakis]
Yes. I think it's really helpful for the residency programs to be welcoming to the community doctors, especially a lot of our alumni. I know a lot of the UT Southwestern alum are within the Dallas-Fort Worth area, and they've obviously had very good training. I think inviting them back to not only attend the Grand Rounds, but to be guest lecturers. I think Jordan Rahani, who's an excellent facial plastic surgeon and a UT Southwestern alum, he's still in the area. I know he's involved.
In fact, we did some injection workshops with him. I would apply for a grant from Allergan or Galderma, the main Botox, Dysport filler companies, and they would send us products. Then we would recruit some of our nursing friends and we'd do free Botox and filler on them under the guidance of Dr. Rahani and Dr. Gilmore and so forth. I think little workshops like that are extremely helpful. It was really a lot of fun too.
(2) Counseling Patients on In-Office Facelifts
[Dr. Gopi Shah]
I think that's great. All right. Let's get into our clinical topic today. We're talking about in-office facelifts. I want to just start with the basics. How do these patients present to you? Do they all know that they want a facelift or do they even realize that that's what they need? How does that sort of initial visit go?
[Dr. Demetri Arnaoutakis]
Yes. In my consultations, obviously, the patients come in. Obviously, we have our intake form and they write at the top, what's the reason for the visit? Sometimes they'll just write “deep plane facelift.” Sometimes they'll write “my jowls are bothering me” or “my eyelids” or “my neck.” As we get to know each other, what I usually do is just hand them a mirror. I also have a stool and a mirror in my office where we sometimes we'll just sit in front of it and the patients will point to things that they're self-conscious about.
Then once they've made everything clear, I'll do my assessment and sort of talk with them what I think is best. A facelift isn't for everyone, right? There's downtime, there's cost, there's, the stigma, perhaps the scars around your ears and whatnot. Some people are like, look, doc, there's no chance I'm ever doing that. What other options do you have? Obviously I do some minimally invasive type facial rejuvenation procedures as well. I have to basically, give them all their options.
Then they decide what's best for them and they break it down, whether it's their financial reasons or scarring or downtime. Then we just decide, what's best for that patient. Then, after that point, if I can get a feel for what they're leaning towards, and then I'll probably give them a more thorough explanation of that route and give them, a day one, a day two after a facelift. If truthfully they're interested in a facelift, then we just walk them down basically every day of their recovery from day 1 to day 10 or 14 or so. I think that gives them a more realistic idea of what to expect.
[Dr. Gopi Shah]
Are there certain questions that are always part of your history?
[Dr. Demetri Arnaoutakis]
Yes. In this day and age, there's so many different types of injections and non-surgical treatments. For example, there's something called PDO threads. They're sold as a “quick facelift” if you will. They don't last very long. They're these barbed wires, basically, that go underneath the skin into the dermis and SMAS and then try to lift up your jowls and nasolabial folds. Anyway, if someone's done that six months ago and you're going into surgery, you would like to know that you're going to run into that barbed wire when you're elevating the deep plane lift. Yes, there are certain things I'd like to know about what they've done to their face and neck in the past.
[Dr. Gopi Shah]
You'll go through prior procedures, filler or other sort of non-surgical or injectable or another—
[Dr. Demetri Arnaoutakis]
Yes, injectables. It falls into one big category there. Then of course their medical history as well. Any cardiac issues, we definitely want to have them have medical clearance if there's anything concerning in their medical history. Have them get EKGs, chest x-rays, blood work, and a clearance letter from their primary or their cardiologist, or whatever it may be.
[Dr. Gopi Shah]
If the patient's a smoker, for example, how do you counsel them with a history of smoking? Do you try to have them stop perioperative? Is that even reasonable or is it just setting the expectations with that risk?
[Dr. Demetri Arnaoutakis]
Yes. I think in the past that would have been a hard no for a lot of surgeons to just not operate on. I think now, I think there's certainly been a trend towards, okay, they can safely undergo a face procedure, especially a deep plane facelift, there's better vascular supply to the skin dermis area.
I would encourage, and I think a lot of plastic surgeons do this as well, is to have them undergo hyperbaric oxygen. Certainly several sessions after the procedure, that just obviously increases oxygen delivery to the tissues. I baseline have all my facelift patients at least do one session postoperatively. For smokers, we would have them do at least probably five or six just to be safe.
[Dr. Gopi Shah]
Then how does age play a role in your decision-making? My other question that's leading into is when I think of medical management or less invasive surgical management, how do when you're going to try fillers first or non-surgical versus going straight to a surgical? Does age play a role and what do you think about when you're teasing some of that out?
[Dr. Demetri Arnaoutakis]
Yes. Age does play a role to a degree. I've done a facelift on an extremely healthy 82-year-old before. it's really just a matter of how the patient feels. that person felt like they were going to live another 15, 20 years. In that case, why would I deny them just because of their age? They had no medical issues. They were extremely healthy. They exercised every day. They ate well. I thought the person was a great candidate. They did excellent. They were extremely happy.
Usually in the 30-year-old, 40-year-old crowd, obviously they don't have as much skin laxity. Usually, those patients are presenting for more minimally invasive or non-surgical options. I have done neck lifts though on patients younger in their 30s and 40s who are just hereditary. They have, we call it now like deep neck fat. When you do liposuction, you're targeting the subcutaneous fat, which underneath the epidermis, dermis, but on top of in the neck, on top of the platysma muscle.
Now deep to the platysma muscle in the neck and in between the submandibular glands, there's this hereditary deep fat. Now there's a procedure that I do a lot of, platysmaplasty or deep neck lift. You make an incision just underneath the chin and the submental crease there. The platysma, as we know, is usually the hiss in the midline. We basically undermine the platysma bilaterally. I usually do it for at least four to five centimeters. Here in that submental triangle there, and I'll directly excise that deep fat.
That's significantly different. It will provide a significant impact compared to just liposuction. After you carve out that deep fat, then you take the platysma edges and you do a platysmaplasty. You're suturing that up to like the hyoid fascia. In females, you really want to have that strong sort of 90-degree cervicomental angle. Really the best way to recreate that in a natural appearing way and a long-lasting appearing way is to do this deep neck lift or platysmaplasty as it's traditionally called.
[Dr. Gopi Shah]
Then just going back to some of the initial review of history, are there any other medicines on their medication list that you have them stop or that are red flags for you?
[Dr. Demetri Arnaoutakis]
Certainly, anticoagulants. Coumadin, even aspirin, trying to do facelift surgery or, any surgery for that matter when they're on a medication like that, it's exhausting and frustrating. Everything, you're bipolaring like every other tiny blood vessel. I would not operate on a patient who's taking one of those medications. It's just not worth it. this is elective surgery, right? This isn't life or death. The benefits don't outweigh the risks in that scenario.
[Dr. Gopi Shah]
Then I feel like an ENT, we love questionnaires. Are there questionnaires for the aging face or for your facelift candidates that's part of your history?
[Dr. Demetri Arnaoutakis]
I don't have a questionnaire that's a part of my history, but we do from just a business and marketing standpoint, we do contact the consultations ahead of time to get a feel for why they're coming in, what's bothering them. Are they aware of the downtime associated with the facelift? It's almost like a screening because sometimes people don't really have realistic expectations and we just want to set the tone from the start. It is a questionnaire in a way, but a little different than I think what you guys traditionally do.
[Dr. Gopi Shah]
Yes, no, I think that's pretty cool because like you said, it sets expectations on both sides for you and the patient. When they're coming in, it saves everybody a little bit more time and probably makes communication better.
[Dr. Demetri Arnaoutakis]
It makes it much more efficient, which as you remember, for me, I'm like the king of efficiency or trying to be efficient. Yes, we're on the same page from the get-go. It's not like, oh my God, I thought, you were going to do this and you're recommending this like we're walking hand in hand with the patient from the first step they take into the office.
(3) The Pre-Facelift Physical Exam
[Dr. Gopi Shah]
Yes, that's pretty cool. In terms of thinking about facial analysis and your physical exam, you mentioned you are looking with the patient sitting down, they have a mirror. How do you analyze the face and what is part of your exam?
[Dr. Demetri Arnaoutakis]
Yes, so for a traditional facelift consultation, I just feel like to be consistent and organized, we really just go top down. I start with their forehead and their brow position. The most common adjunct procedure I do at the same time as a facelift is an upper eyelid blepharoplasty. I'm looking to see if the patient has dermatochalasis both in their upper or lower lids. Typically in the lower lids, there can be skin laxity or perhaps infrared orbital fat pad herniation.
Then I'm looking at their nasolabial folds, their jowls, obviously the quality and the texture of their skin. Then really I migrate inferiorly to the neck. I'm looking to see if they have, a lot of subcutaneous fat, is the deep neck fat that I was referring to earlier. Do they have platysmal banding? How lax is their skin? Then another area really is the upper lip. As a patient ages, the upper lip distance elongates. The space from the columella to the top of the upper lip.
There's a procedure that I also do a lot of called the lip lift. We design a bullhorn shape and that's right at the base of the nose. The scar heals right into that crease there. A sign of youth or a sort of quote-unquote “sexy feature” is to have a little bit of an upturn to the wet part of the lip and a shorter distance there. That's also something that I'm taking into consideration when I'm evaluating the patients.
(4) The Role of Pre-Operative Photos
[Dr. Gopi Shah]
From my exposure, it’s been so long, to the cosmetic patient. This was years ago during residency. I remember photography and pictures, especially for the rhinoplasty patients. Is that part of your evaluation for, a facelift patient? Is photography or any of that important?
[Dr. Demetri Arnaoutakis]
Yes. Yes. We take preoperative photos. We do frontal, oblique views, profile views, and then also what we call the chin-down view. We have the patients look towards their feet. It shows that they have a lot of bunching of skin and subcutaneous fat in their neck. Of course, we do preoperative and then usually postoperative photos about six to eight weeks later once all the swelling and everything's gone down. That actually is very helpful to then, patients come in and they're like, what am I going to look like? With the consent of prior patients, we will show other patients' photos to the new patient. That really helps put them at ease when they see how, naturally it can be done and the scarring with time fades nicely. Sometimes you really have to get up close and personal to even notice the scars.
[Dr. Gopi Shah]
In terms of the photography, so is it similar to the rhinoplasty positions? You'd mentioned frontal, oblique, chin down is I think different, right? It's not part of your rhinoplasty.
[Dr. Demetri Arnaoutakis]
Correct. Yes.
[Dr. Gopi Shah]
There's a certain different ones that you take.
[Dr. Demetri Arnaoutakis]
Yes. Just a couple of different. With the rhinoplasty, we do like a base view. Instead of chin down, the chin tilts upward so you can see the nose in that perspective as well. Fairly similar.
[Dr. Gopi Shah]
I just remember the blue background. Does everybody use a blue background?
[Dr. Demetri Arnaoutakis]
I have a black background. I think it shows up a little bit better, but I don't think there's any quote-unquote “gold standard” when it comes to that. You look at other plastic surgeons' websites or their photos online and everyone seems to have something slightly different.
[Dr. Gopi Shah]
Two questions. One is, what camera do you use? Then is it just your iPhone camera? I just remember my attending having a big Nikon with a lens on it. Then two, how do you learn to take these photos? Where did you learn?
[Dr. Gopi Shah]
I feel like I remember you would be like, okay, take these photos and I take them and he would have to delete all of them or retake them.
[Dr. Demetri Arnaoutakis]
Yes. You're taking me back to my fellowship too. Yes. now honestly, with the quality of the iPhone, we use an iPhone and it's nice too, because it integrates. We have two electronic medical records. I use a platform called DrChrono and another iCloud-based photo storage. It's called RX photo and they integrate. You can take the photos on RX and then it automatically associates the photos with the patients in our electronic medical record.
It's great. The photo qualities with the new iPhones is excellent. To invest in a really expensive camera, that's, it just seems a little unnecessary. I like the ease and the safety of it, just going straight from the iPhone camera to the iCloud secure system. That's what we do. I think a lot of doctors have transitioned to that as well.
[Dr. Gopi Shah]
That's really cool. Do you take measurements? Are you measuring angles or have a caliper out? Do you do any of that on the photo or is there anything like that going on?
[Dr. Demetri Arnaoutakis]
I don't do that in the photo, but I of course have calipers. For example, when I'm doing an upper eyelid blepharoplasty, I'm measuring where the eyelid crease is and how much skin I can safely remove and make sure it's consistent from left to right. If I'm doing a lip lift, I'm saying I'm doing a five-millimeter lip lift, I'll use the caliper for that and make sure all my measurements are consistent. I'm doing my measurements more on the patient precisely than perhaps on a photo or anything like that.
[Dr. Gopi Shah]
What are the measurements that you usually document?
[Dr. Demetri Arnaoutakis]
For example, on an eyelid blepharoplasty, I'm measuring, from the lashes to the crease, and then I'm also measuring precisely how much skin I can safely remove without provoking lagophthalmos. Then a lip lift measuring five points in the very midline from the columella to the Cupid's bow to the middle of the Cupid's bow, and then from the sides of the columella, and then sort of a more lateral measurement as well. Usually again, depending on the patient, I'd say they're all roughly about five millimeters, but those are-- in a facelift, you don't really do measurements or anything like that.
[Dr. Gopi Shah]
Okay. Okay. I didn't know if there was, I'm thinking you measure for how much skin you can take for—
[Dr. Demetri Arnaoutakis]
It's more just after a couple hundred, you get a feel for how much you can take out.
(5) Non-Surgical Alternatives to Facelift
[Dr. Gopi Shah]
Okay. We keep throwing around facelifts and non-surgical and surgical. Can you just organize it for me? Tell me first about sort of the non-surgical facelift options and then plastics is such a language, right? If you don't know the vocabulary and the language, it's hard to know. When we talk about traditional versus NAS versus deep, can you just go through first non-surgical and then organize the surgical for me?
[Dr. Demetri Arnaoutakis]
Yes, for sure. I think within the non-surgical there's, you can say sort of non-invasive and minimally invasive. Something non-invasive would be like microneedling or radio frequency microneedling. Radiofrequency microneedling is basically where I have this platform where 24 needles come out, they penetrate the skin and they're delivering radio frequency energy into the papillary and the reticular dermis. Basically, that is promoting new collagen formation, which of course, as you know is going to help sort of improve the texture of the skin. You get some skin tightening as well.
We usually do three sessions, you space them out a month apart because that's the time period it takes for the collagen to rebuild and you'll see some nice improvements, mostly in the quality and the texture of the skin. I tell patients, your pores will improve. Again, the texture and the quality of the skin, you will see a little bit of improvement in the laxity. Botox and fillers, I would say fall within a non-invasive category as well. Botox are neuromodulators, which we use for frown lines and forehead lines and crow's feet that have other causes as well, especially reconstructive patients need facial reanimation, some types of kinesis issues, and you can do Botox to help alleviate that.
Then fillers or hyaluronic acid. We already have hyaluronic acid on the skin surface. Basically, you're providing volume to a patient in areas where they're a little depleted. I know there's been tons of marketing as far as a liquid facelift if you will. I'm not a huge proponent of that. I just think sometimes that people can look overdone and fake and you're injecting five, six syringes, that adds up financially and, it's only going to last six, nine months.
[Dr. Gopi Shah]
Just to clarify the liquid facelift. Is that part of your HA fillers or is that different?
[Dr. Demetri Arnaoutakis]
Yes, that's HA fillers.
[Dr. Gopi Shah]
That's it. Got it.
[Dr. Demetri Arnaoutakis]
Or it could be something called Sculptra. It could be Sculptra or Radiesse. There's different types of fillers. Now that I do so many deep plane facelifts that I'm more a proponent of something that I know is going to last, probably 10-plus years, it'll really give them the result they're looking for. Then they really won't have to be injecting their faces with all of these fillers and such. To each their own. Some people just, that's the route they want to go.
Then I think a step up in our totem pole is minimally invasive procedures. We have something it's called radiofrequency-assisted lipolysis. What I do is I make tiny access or port sites underneath each lobule and then right underneath the chin and the cemental crease. I basically use a 15-blade to make a tiny nick in the skin. Then it's enough space to allow the probe, but in this case, the device is called FaceTite, T-I-T-E is how they market it. Anyway, the probe goes underneath the skin and is delivering again, energy that is supposed to cause coagulation to the adipocytes and the subcutaneous tissue and the subcutaneous fat and also promote skin type.
Now that can work very well for some patients, usually for patients in their 20s, 30s, early 40s, what we refer to as these gap patients. They're in between the injections and they're not perhaps quite ready for a neck lift or a for facelift. This is a procedure that I do in my office under local anesthesia. We provide perhaps, four milligrams of Valium. We have, Tramadol, if they need, or extra-strength Tylenol. We have Pro-Nox, which is laughing gas, and that really provides for a very comfortable setting.
I inject a couple of hundred cc's of tumescence, so basically lidocaine, and they tolerate the procedure very well. It takes less than an hour and they can get a really nice result as far as jawline contouring and improving the tightness in their neck. Then of course, the step up from there would be something more invasive like a face or neck lift. As you mentioned, yes, there are definitely different techniques in performing a rhytidectomy. Now we really just refer to it as a facelift.
That was the more traditional term for it. My preferred technique is what's referred to as a deep plane lift. That's what I learned from Sam Hamra, who was the initial author and back in the early '90s, he wrote about it and now it's caught on like wildfire. What that is doing, you're elevating the SMAS in the face. As we know, the SMAS, it's continuous with the platysma on the neck. That I think provides patients with the profound difference and it's something that's long-lasting.
[Dr. Gopi Shah]
Just going back to the minimally invasive technique, you said that that's sort of for the gap ages from 20 to 40. Is there anything preventative about that? We think of people getting Botox earlier on to try to prevent wrinkles and things like that. Is there any prevention with that?
[Dr. Demetri Arnaoutakis]
I do think starting Botox, it lasts usually about three or four months, but even if you do it once or twice a year, it will likely prevent the lines from deepening as you age. Staying on top of it, I think will be helpful. the next thing if you've never done it in your 60s, then you can have really deep furrows. It can be preventative in that regard.
Of course, good skincare when you go out, wear a sunscreen. I think that's a huge and really overlooked to avoiding all the sun damages, not only just obviously the risk of skin cancer, but also just taking good care of your skin. Those are the main things I think to help us to prevent anything as you age.
(6) Finer Points of In-Office Cosmetic Procedures: Anesthesia & More
[Dr. Gopi Shah]
Then in terms of your tumescence, what's your dilution measurement?
[Dr. Demetri Arnaoutakis]
One thing that I'm not sure if you guys are using a lot of at the hospital, but I am a huge fan of TXA, tranexamic acid. My usual facelift tumescence is actually easy to remember. It's 50 cc's of normal saline. It's 50 cc's of plain 100% lidocaine, 50 cc's of plain quarter percent boricaine, 10 cc's of TXA, and then one cc of fresh one to 1000 epinephrine. I think TXA honestly has been a game changer, at least for me, and sort of in aesthetic surgery.
When I was a fellow, my fellowship director wasn't using TXA at the time. Some of the patients would have really tremendous bruising and swelling, and he's an excellent surgeon and he wasn't using TXA at that time. When I got into practice, I had heard of this other plastic surgeon in New York City using it. I started doing it and some of these patients honestly can get by without a bruise. It's honestly really incredible. I definitely include it. I use it in pretty much anything I'm trying to do. You can also prescribe it as an oral tablet too if you're doing in-office procedures and then you just have the patients take it postoperatively.
[Dr. Gopi Shah]
That's interesting. Okay. You mentioned some local anesthetics and you mentioned Pro-Nox and tramadol. Do you have to have like a special sedation license or do you have a sedation nurse?
[Dr. Demetri Arnaoutakis]
Pro-Nox, it's just like a 30-second onset and then it goes away in like in a minute so it's very short, very short acting, and with Tramadol, that's just a tablet. So that's just like prescribing someone narco or whatever. Technically anybody-- not anyone but as a physician you can do that in your office. I am in the process of building actually from ground up a new office with a surgery center attached to it and I'm working with a company to help me get it credentialed.
It would be a Quad-A SF credentialing and in that facility we are able to do obviously local anesthesia. You can do IV so I truly do the majority of my facelifts under IV anesthesia, so Propofol drip, and I have a board-certified anesthesiologist there who's a little strength medication So I would never do that just in the office I have obviously an anesthesiologist they're doing but that's I rarely maybe once a year do a facelift under general anesthesia 99.9% of the time it's under Propofol.
[Dr. Gopi Shah]
Okay, and then going back towards the surgical sort of the facelifts I think of skin is just like the traditional and then on the other end. Yes, we talked about the deep plane Where's the SMAS facelift? I understand the SMAS is part of your deep plane. Can you tell me the differences in that or the nuances?
[Dr. Demetri Arnaoutakis]
In the beginning in the I think was the early 1900s is when the first facelift was done honestly and that was just skin only and If you do that and some plastic surgeons today will still do that, They may look okay for a couple of months, but you're not really addressing the issue, which is the acutaneous ligaments underneath and that's what's leading to the jowling. You're not releasing any of that, especially in the jowling area and in the neck you need to address the platysma. Otherwise, they're just still going to look lax down the road. With the SMAS their result after the next step was then looking into the SMAS so there's plication and imbrication
Basically what you're doing is putting in like a deep suture into the SMAS and you get control, You have a 2 OPS or 20 micro whatever it may be and if you get a good bite of it a good purchase of the SMAS and then tack it back in a posterior fashion, you'll see, somewhat. Now you're not actually releasing though the most important part which is the zygomatic cutaneous ligaments, the masseteric cutaneous ligaments, the mandibular cutaneous ligaments, and the cervical retaining ligaments That is really important and that's where the significance of the deep plane facelift because it's addressing release of all those ligaments.
[Dr. Gopi Shah]
When you started saying that, I'm like, I think I studied that for my boards and I'm like, oh, yes there's we're going to be more mobility now. Also, I've seen the term mini, what's a mini facelift?
[Dr. Demetri Arnaoutakis]
People will throw these terms around just for marketing purposes. I think a lot of patients are scared when they hear, oh my God, a full-on facelift. Sometimes the mini is where maybe they're not making the full extent of their incision. When I do a facelift, the incision or the scarring extends into the sideburn. It comes around you go retro tragal and females pretty much all the time underneath the lobule into the postauricular crease and then horizontally across to the occipital hairline and then I go inferiorly along the occipital hairline. Perhaps it's a maybe a patient in their early 40s and they don't need a lot of skin removed then you'll just make half an incision if you will.
(7) Operating Room or Office? Selecting the Appropriate Surgical Site
[Dr. Gopi Shah]
Okay. Then in terms of when we talk about in-office facelifts, I would think that pretty much all your non-surgical so the non-invasive and minimally evasive RFA fillers all that can be done in the office. In terms of the surgical, are all of these on the table for in the office too? What procedures can you do and how do you decide?
[Dr. Demetri Arnaoutakis]
Obviously that's where it takes into their medical history, it's really important. If someone's had a cardiac history, then I'm certainly not, I'm going to be doing anything in the office. If it's someone maybe in their mid-40s who they're very fit, they don't take any medications, in that case, I would say they could be a candidate for doing this under Valium and local anesthesia. We obviously have monitors and we're monitoring their vitals throughout the procedure but in that case could be very safe. Again, the patient avoids going through anesthesia. It's not like there's no risk with obviously going under general anesthesia or even Propofol. This sometimes could be even safer for them.
[Dr. Gopi Shah]
Pretty much theoretically you can do everything in the office, but it's just really the medical history is obviously going to be important. Are there any patient characteristics where you're like now we got to go to the OR? What do you look for where you're like, you're just you're not going to be a candidate, other than the cardiac patient.
[Dr. Demetri Arnaoutakis]
Yes, personality, if someone comes in and they're very anxious because when they're in the office, they're awake. Some people will snooze if they're sensitive to the Valium but other people the last thing I want is to have a conversation with them while I'm trying to do surgery. I want them to be comfortable but at the same time, I don't want them yapping away at me the whole time or if they're really anxious I don't want them to be fidgety or moving around, of course. If I get a sense that the patient's going to be like that then I just say, "Hey, let's just do it in the surgery center and you'll be more comfortable. You'll be asleep and all that.”
[Dr. Gopi Shah]
I imagine you really have to explain to them and talk to them about what's going to be going on. You could probably tell just based on how they're taking that information in of what's going to actually work and not work.
[Dr. Demetri Arnaoutakis]
Exactly. 100%.
(8) Pre-Operative Care of The Facelift Patient
[Dr. Gopi Shah]
Okay. Before we get to the day of surgery, what's actually going on? What are your pre-op instructions? Do you have them do things like arnica or do you have anything that they do to prep them for surgery?
[Dr. Demetri Arnaoutakis]
Oh, yes. We actually have them come in about three weeks before their surgery or their procedure and they meet with my main nurse, Kat, and she sits with each of them for probably an hour and goes over our entire pre-operative sheet. She'll review their medications when to take the antibiotics, the pain pills. We provide them all with arnica and bromelain pills if it's a facelift. We have a custom skincare line that we give to them and she explains that to them as well. Then she'll go through just everything, what to expect if they have drains.
A lot of times, I'll actually leave JP drains for 24 or 48 hours in these patients. She'll teach them how to care for them, how to record the output, and how to take care of their sutures how to clean them all that stuff. Then we just review with them their appointments. I probably see these people three to four times in the first 10 days. We really have them come back to the office often to make sure everything's healing as well as possible.
[Dr. Gopi Shah]
We'll talk about post-op in a second but you said the TXA oral is that part of your post-op or do you ever do that pre-op too?
[Dr. Demetri Arnaoutakis]
If I'm including it in my tumescence, I pretty much I usually won't give it as a post-op as well. I think just in the tumescence is enough. Obviously especially if someone has a history of clots or anything like that then you probably won't even want to give it in the first place. I make sure before I do that, but I think in the tumescence that's plenty. If it's something maybe I'm doing like an upper eyelid blepharoplasty alone in the office where in that case I'll just use traditional local at one percent lidocaine with one to one hundred thousand epinephrine, Maybe in that case that patient could warrant some post-operative TXA, for the most part it's in my tumescence.
(9) Expert Tips on Performing Facelifts
[Dr. Gopi Shah]
Okay. Now, we're there day of, we're going to do the procedure. We talked a little bit about hemostasis and sedation is it basically the tumescence with the TXA in it that's also going to have your local in it, and then you also do a little Pro-Nox and some Valium and Tramadol if they need it?
[Dr. Demetri Arnaoutakis]
Correct. For the in-office procedures, correct.
[Dr. Gopi Shah]
What instruments do you like to have on your back table?
[Dr. Demetri Arnaoutakis]
That's taking some trial and error. We've got that down now to a T. I think the most important instruments are my lighted facelift retractors. I have three now. I have a I guess similar to a lighted off-rectal retractor that I use. It's very narrow and I use that when I'm doing the Platysmaplasty because it can fit through a small submental crease. For the neck, I have a maybe five-inch lighted facelift retractor and then one that's maybe like eight inches. I use the eight-inch when I'm trying to elevate the skin flap in the neck so I get all the way in.
I'm connecting my flaps from I basically have very wide undermining from the right ear to the left ear and across the chin, of course. When I elevate the deep plane, I will switch then to the five-inch lighter retractor, and with my left hand I am holding up the skin and the SMAS with the lighter retractor and then I have a facelift scissor in my right hand that I'm elevating in a vertical fashion to create the flap. Basically my two or three facelift scissors and my lighter retractors I would say are my most important instruments.
[Dr. Gopi Shah]
Then in terms of hemostasis, do you have any bipolar tricks? Pledgets and Afrin? What do you do for that?
[Dr. Demetri Arnaoutakis]
Honestly, it's just Bovie and bipolar. It's funny when you transition from the big hospitals where you have every gadget out of the sun it's I've forgotten about half of them all the surgical and the Fibrillar and the whatever else, you don't understand it, you don't really appreciate this stuff when you're a resident, but they're really expensive. I think the best form of hemostasis is just being a safe surgeon and being in the right plane. If you're on the right plane, a lot of times you really shouldn't have any bleeding. I think for me, bipolar is just the number one thing I use for coagulation.
[Dr. Gopi Shah]
In terms of tricks to raising your flaps, anything that you do differently now or any advice you would give to somebody that's coming out?
[Dr. Demetri Arnaoutakis]
Yes. I'll start my incisions with a 15-blade, a 15-blade, and then a 10-blade in the occipital hairline area. Then it's really getting the right instruments. In the beginning, I was operating at this one surgery center, and I was just using what they had, and it was frustrating. Then I reached back out to my mentor and a couple other surgeons I respect, and I was like, what instruments are you using? They told me, and then I bought those, and it was like a night and day difference. I have, like I said, three different facelift scissors, and one I use for elevating the skin flap, one I use for contouring the flap, and the other one for vertical spreads. The three of them really helped me be efficient in getting that safe plane.
[Dr. Gopi Shah]
Then any tricks or pearls to make sure you don't injure any of the facial nerve? I think it's probably staying in the right planes.
[Dr. Demetri Arnaoutakis]
Yes, staying in the right plane, and that's 15 years of training to help you escape, right? That's why we have, that's why residency is so long, that's why you do a fellowship, that's why you watch videos in your free time. honestly, when I was a resident, that was another thing. There was QMP, where a couple of very well-known facial plastic surgeons will post their videos of this is how I do it.
I've watched Dr. Andrew Jacono from New York City, who's world-renowned now, and Dr. Mike Nayak, who's also a facial plastic surgeon in St. Louis. They each have their own video series, and they're professionally done, like this here, a back table with all the fancy microphones and all the stuff that I got to go get caught up on.
I've watched those videos from the back when I was starting out, or in fellowship and residency, and that really helps you learn how to do these surgeries safely. Unfortunately, you just eventually got to go do it yourself, and you learn from experience. It's just, the same goes for you, or Dr. Terrelson doing head and neck cancer who's done a gazillion parotidectomies, I'm sure he's a lot better now than when he started out day one, so there's really no substitute for experience.
[Dr. Gopi Shah]
Yes. In terms of securing the flaps, what sutures do you use? What do you find are your pearls there?
[Dr. Demetri Arnaoutakis]
Yes, I basically incise the SMAS from the lateral canthus, if I can imagine an imaginary line from the lateral canthus to the angle of the mandible, and then I actually extend it. I'm technically doing an extended D-plane because I'm releasing the cervical retaining ligaments, which are the ligaments between the SEM and the platysma.
I have a long flap that's going all the way, again, basically from the lateral canthus past the angle of the mandible, and then into the neck, I'm elevating the platysma about five or six centimeters down into the neck. Then I create a little backcut into the SMAS along the mandible. I'm using two OPDs, I use about four of them in the face, and I'm getting a nice purchase of the SMAS, and I'm tacking it back to the sticks. Where I cut into the SMAS, we refer to as the mobile SMAS, and the fixed SMAS is right in front of the tragus.
That's where I'm putting in my deep sutures, and so I know that's going to be a good sturdy bite, the sutures aren't going to let go or break or anything like that. That's when you can really see a tremendous lift in the jowls and the nasolabial folds. Then I'm taking the platysma, I'm slinging that back into the mastoid fascia behind the ear, and that helps create a really sharp, defined jawline.
In the neck, when I'm underneath the chin in the platysma, I use a 2-0 Vicryl. I first actually get a deep bite, I start at the hyoid, at the level of the hyoid, and I work superiorly. I get a bite of the hyoid fascia, and then I do inverting bites from the left and the right edges of the platysma, and then I stitch it down. I do at least four or five there all the way up to my incision line. That is what really helps create that sharp cervicomental angle.
[Dr. Gopi Shah]
How do you've tacked it up enough? Is that just, again, through experience and doing enough of these?
[Dr. Demetri Arnaoutakis]
Yes, I think that's just where the art of this comes into play. It's your eye, your eye for aesthetics, and so, does it look good to you? I don't really foresee myself ever doing measurements in this area. It's really mostly like, okay, if this was your mom or your sister or your aunt, would you be okay with this or how she looks? That's just like caring and honestly having a little bit of a creative mind and making sure it looks good.
[Dr. Gopi Shah]
Then how do you normally like to close the skin?
[Dr. Demetri Arnaoutakis]
Closing the skin, that's actually the, I always love suturing. When I was a resident, some of my favorite parts of the times were when we were at the end and you get to stitch up the skin. I've always liked that. I've always—
[Dr. Gopi Shah]
They step away. You're in the zone. The music's setting in. You're like, okay, I have to go eat soon too. Yay. Yes.
[Dr. Demetri Arnaoutakis]
Yes. You get to change the music finally to something you like. I will use, a lot of it is running, locking, 5-0 proline. I'll do two-layer, always two layers sutures to obviously take off tension on the skin edges. 5-0 Vicryl or whatever it may be for deep dermals. Then I really 5-0 running, locking. I will, in front of the tragus, that's a tough area sometimes to remove stitches or I should say retro-tragal.
In that area, I've now actually switched to 5-0 chromic around the lobule, again, 5-0 nylon. In the post-auricular crease, I use 4-0 plain at the moment. Then in the occipital hairline, it's a 4-0 running, locking. Then the chin, again, 5-0 Vicryl, and then a 5-0 running, locking. I think I'm sure like most surgeons, you go through a hundred different types of techniques and sutures. Then I guess eventually you settle on something you like. That's where I am currently and I would say in the last six to nine months, I've been really pleased with the results, at least aesthetically from the scarring with that.
[Dr. Gopi Shah]
Any thoughts on skin glue?
[Dr. Demetri Arnaoutakis]
I don't use it. I've visited a lot of facial plastic surgeons over the years. I haven't seen one that I can remember. It's different if it's like a two-year-old who comes as a friend's kid who's got a little nick and, the last thing you want to do is, create more trauma. They'll heal obviously tremendously well. That could be fine. In your adult patient population, I don't think that's satisfactory.
(10) Post-Operative Care of the Facelift Patient
[Dr. Gopi Shah]
In terms of your post-op instructions, what is part of their post-op routine? Anything special? Anything that you have them do?
[Dr. Demetri Arnaoutakis]
Yes. As I mentioned earlier, they all get arnica and bromelain for bruising and swelling. We give them a scar cream to start applying once the stitches come out. We have them undergo hyperbaric oxygen. We have them undergo lymphatic massages. That's actually a big component as well, which I think really helps, their circulation and gets some of the drainage out. We have them keep, the ones who listen, really keep the suture line clean.
That's really important and just easy on us, honestly, too, when they come back to have them removed. Then just avoiding any heavy straining or exertion. Some of these patients just like they're affluent or successful business people, businessmen, and women, and they want to get back to their lives. Some of them are workout junkies. It's like, hey, just take it, like let your body heal, take it easy. Obviously, you'll get back to that before it, but I don't want you to stress yourself too soon.
[Dr. Gopi Shah]
Yes. In terms of the HBO or the lymphatic massage, when do you start that post-op?
[Dr. Demetri Arnaoutakis]
Usually post-op day one, they go for hyperbaric oxygen. You really want to find a facility that can at least, get up to two APMs. I think, if you're at 1.4, 1.5, it's almost like, not really doing anything. Ideally, you can get up to two. Then the lymphatic massage is usually like post-op day three or four. They'll love that. We have an esthetician here in my office. She's excellent, Ari. She actually also co-exists as my social media manager. She's now a trained esthetician and she's great. They'll usually get a package with her after the first one that we include for them. They'll usually end up doing like three more or so.
[Dr. Gopi Shah]
Okay. Then in terms of complications, how do you counsel patients and what have you seen in practice?
[Dr. Demetri Arnaoutakis]
Of course, we have, it's in our consent forms and the usual, the traditional with most of our skin soft tissue surgeries. Hematoma, it's fortunately very rare, maybe one in a hundred. We talk about sensory issues. It's more likely if anything nerve-related, it's going to be perhaps you cauterized or bovied close to the great auric. And now, they're a little bit numb behind their ear.
Facial paralysis is actually very rare. In fact, the rate of complication from that is the same if you're doing a deep plane versus a SMAS surgery. Any surgeon who's going to tell you that it's safer to do that, that's not actually technically true based on research. Now scarring, bruising, swelling of course is expected. I think those are the main complications.
[Dr. Gopi Shah]
As we start to wrap it up, any final pearls? I've learned so much, Demetri, and I'm so in awe. I think you have an amazing practice and I would love to have you back on to talk more about practice building and also about this custom skincare line. Very cool. Before we get it, any final pearls?
[Dr. Demetri Arnaoutakis]
For any of the residents, listening out there, anyone still in training for that matter, really take advantage of your time in residency because you're not going to get that back when you're going to have 20, 30, 40, faculty members around you who, all do things a little different and that's honestly one of the, I know it's crazy to say, but I love my residency. You guys were awesome at UT Southwestern, I'll be forever grateful for the training I received there and honestly, just the camaraderie that you develop amongst your co-residents and the faculty.
I felt like I was laughing half the time and you're busting your ass and working hard, but I loved it.
I would say, take advantage and try to learn. You pick up, one or two pearls from each of your attendings and try to, what you think works best for you and incorporate that into your practice moving forward. If what you want to do with your career, early on, then, obviously you want to get a broad training, but at the same time, I don't think it's a bad thing to hone in on, the laryngologist if that's what you want to do or facial plastic surgery.
For me, like I said, the best thing I ever did was to, latch on to the guys that we had at Southwestern, but also go out into the community and see different perspectives. Anyway, I just think take advantage of that time. I think by and large, everyone is welcoming. No one's going to turn you down and be like, no, I don't want you to be there. You got to go shoot your shot. Can't hurt to at least ask and be like, I would like to come and serve and I'm sure people will definitely embrace you with open arms.
[Dr. Gopi Shah]
That's awesome. Thank you so much, Demetri, for taking the time. If any of our listeners want to reach out to you have a beautiful website. Is it drdemetrimd.com? Is that correct?
[Dr. Demetri Arnaoutakis]
Yes, that's right. They could shoot me a message. I think everyone's so plugged into social media these days. My Instagram, you can send me a message. It's @DrDemetri, D-E-M-E-T-R-I. I'd be happy to connect and share more thoughts or have you in to hang out with us for a day or a week or whatever it may be.
[Dr. Gopi Shah]
That's awesome. Thank you again. I think it's a wrap. All right.
[Dr. Demetri Arnaoutakis]
Thanks so much for having me. It was a privilege to be here.
Podcast Contributors
Dr. Demetri Arnaoutakis
Dr. Demetri Arnaoutakis is a facial plastic surgeon in Tampa Bay, Florida and Beverly Hills, California.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, September 5). Ep. 127 – In-Office Facelifts [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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