“ . . . In science the verdict goes to the man who convinces the world, not to the man to whom the idea just occurs. Not to the man who finds a piece of grain of new, and precious quality, but to he who sows it, reaps it, grinds it, and feeds the world on it.” -Charles Darwin
The first published facelift operation was by Hollander in 1901. It is doubtful that this surgeon who practiced in Germany was the first to address a patient’s concern regarding facial aging. In fact, it was a few years later in 1906 in the United States that a general surgery trained physician wrote an entire text book describing the surgical treatment of “featural imperfections.” Dr. Charles Conrad Miller of Chicago not only described and documented his early attempts at facelifting, but insisted that cosmetic surgery was not only a legitimate and needed treatment for facial aging caused by sagging and wrinkles, but was the natural evolution of surgery as society evolved to include the “beauty business” and the beginning of the “beauty parlor” mentality in American life. Miller insisted that cosmetic surgery was unique and complicated to the point where practitioners should be specifically trained in this new field of surgery. Dr. Miller described operations to correct Crow’s feet, eyelids, forehead, nasolabial folds, thick and thin lips, protruding ears as well as excessively large or small mouths. He anticipated the role of facial muscle animation in the formation of wrinkles and devised operations to weaken the offending muscles. This simple idea led to today’s billion dollar industry based on paralyzing the offending muscles temporarily with use of Botox (Botulinum Toxin). Dr. Miller was ahead of his time in many ways and clearly was the first self-proclaimed cosmetic surgeon and deserves the credit for being the first true facelift surgeon.
We, as a country, survived two World Wars in the 20th Century both punctuated by quantum leaps of surgical expertise due to the thousands of injured warriors requiring plastic surgery. After WWI, Sir Harold Gillies of England emerged as the leading Plastic Surgeon due to his experience with the facially injured of the war. The seminal event for cosmetic surgery occurred in 1923 when the famous Ziegfeld Follies star Fannie Brice had a nose job performed in her hotel room by the notorious Dr. Henry Schireson. While Fanny Brice’s nose job, according to her biographers, generated more press attention than any other medical event and made the erstwhile Dr. Schireson into the rock star Plastic Surgeon of the day. Plastic Surgery, specifically cosmetic surgery, was a huge enticement to practitioners of the day who realized that cosmetic surgery was a lucrative endeavor without oversight by any of the medical boards of the day. Popular surgeries of that era were facelifts and rhinoplasties which caught the attention of Hollywood where a number of movies were released with facial plastic surgery as the theme. Repeated scandals and lawsuits were immortalized in the 1932 film False Faces in which a patient shoots her surgeon when it seems she will lose her lawsuit against him. The number of “beauty surgeons” now practicing as well as the number of surgical mishaps, led the leading surgeons of the time to form the American Board of Plastic Surgery in 1937. The leading surgeons of the years between WWI and WWII were early members of the American Board of Plastic Surgery and tried as they could to ride heard on the “beauty quacks” who were adulterating the cosmetic surgery of the time, specifically the facelift operation and rhinoplasty.
After WWII, Plastic Surgery experienced another resurgence as the Plastic Surgical heroes of WWII returned having sharpened their skills during wartime. Many of these surgeons spread out over the Country and started Plastic Surgery training programs in places like Atlanta, New York, and Kansas City. Problems with publicity, profit and advertising continued to arise causing friction between those who received their imprimatur from the American Board of Plastic Surgery versus enterprising practitioners with varying degrees of medical and surgical training who were busy staking their claim for patients in this growth industry. Rogue practitioners existed then as they do today, extolling an expertise without training and coercing patients by questionable advertising, the publication of self-promoting manuscripts and books, and even public displays of their facelift and rhinoplasty operations. Shades of 2011 America!
The facelift operation continued to evolve, albeit slowly, with no break throughs until the 1960’s when T. Skoog from Sweden as well as a number of Americans changed the facelift to include deeper tissues and a new description of the deeper tissues (the SMAS) instigated originally by Paul Tessier, MD of Paris, France.
The later years of the 20th Century visited slow, small improvements in the facelift operation usually based on a better understanding of the pertinent anatomy, better techniques of anesthesia and better technology such as liposuction and later endoscopy. One seminal discovery was quietly published in the late 1960’s by D. Ralph Millard, MD who was the first to describe the removal of fat from the neck of obtain an aesthetic improvement in this part of the facelift operation. Anatomically based operations for the face and eyelids evolved into major surgical interventions causing long periods under general anesthesia, long recovery periods, sometimes massive bruising and swelling, and a price commensurate with the degree of difficulty of the facelift. At the dawn of the 20th Century it seems that surgeons may have “over thought” the operation and the cost was too high for most people to pay. In the last decade, Plastic Surgeons again began to listen to their patients who for the most part are not wealthy and who usually are middle class with careers and jobs to return to. This necessarily limits the cost and the downtime required, but did not diminish the desire for a long-lasting, affordable, minimal downtime facelift.
The 21st Century has witnessed the dramatic inclusion of corporate dollars and technology into the cosmetic industry. The “beauty business” as it was once called has evolved into a multi-billion dollar industry which has expanded well beyond hair and nail care to include a plethora of devices and chemicals created to reverse the signs of aging skin. The weight loss business has also flourished in parallel to the constantly evolving societal pressure to maintain a healthy state of youthfulness and fitness. With so much money at stake, it is no wonder that big business has flooded the consumer market with thousands of competing products backed by Wall Street advertising campaigns. Many of the new and exciting products required the imprimatur of physicians and even some required a prescription for purchase. The medical and surgical practitioners were slowly becoming the employees of major consumer product and pharmaceutical companies. The money and power which once resided with the doctors was now invested in the insurance companies rather than the practitioner. The battles are not fought between doctors rather the doctor versus the insurance carriers.
The facelift operation has been the epicenter of the beauty industry miasma. Every cosmetic practitioner knows that lotions, potions, dermabrasion, and IPL will eventually lead to a facelift, where time and aging can truly be reversed. The only problem is that the facelift, even in its 21st Century version, is a real operation requiring real surgical skill and associated with real surgical complications.
The history of the facelift serves as a metaphor for the evolution of the medical-industrial complex that is medicine today.
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