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"  At 38, Juliet*, a New Yorker whose fashion sensibility falls somewhere distinctly south of the uptown/downtown divide, is simply far too cool\u2014not to mention too young\u2014to be a candidate for the F-word. Or so she thought. But last year, just before Christmas, the self-described &amp;quot;last person on earth anyone would suspect of having cosmetic surgery&amp;quot; checked into an exclusive Upper East Side clinic for top-secret eyelid-boosting blepharoplasty, laser skin resurfacing, and the very lift (albeit, she hastens to point out, a &amp;quot;minilift&amp;quot;) she had previously feared. &amp;quot;For years, you see yourself in pictures and stare at the loose jawline and the tired-looking eyes, and you know that inside, your personality is so much younger and fresher and more joyful than that,&amp;quot; Juliet says. &amp;quot;After a while, it&amp;#039;s just like, `Screw it! I&amp;#039;m taking care of this.&amp;#039;&amp;quot;  Not so long ago, with a tidal wave of miracle shots and high-tech lasers flooding doctors&amp;#039; offices, face-lifts seemed destined to land somewhere between perms and corsets in the dusty annals of beauty history. But now, the same snip that was once seen as a last resort is back in vogue, thanks to two recent realizations: (a) No matter how wash-and-wear they sound, most minor, quick-fix solutions tend to have relatively minor, short-lived results, and (b) the dreaded &amp;quot;wind tunnel&amp;quot; look is all but a thing of the past. &amp;quot;Everyone&amp;#039;s face-lift nightmare is the Joker, with those fish lips pulled back into a permanent smile. It&amp;#039;s awful!&amp;quot; Juliet says, letting out a small, smug chuckle. &amp;quot;Honestly, I look like I&amp;#039;ve had a three-month vacation.&amp;quot; Wendy Lewis, a New York City cosmetic personal shopper of sorts who charges $350 per hour to help clients navigate the bewildering world of scalpels and injections, says at least 50 percent of her clients are still adamant surgery-phobes who either fear the downtime, price tag, or anesthesia associated with going under the knife, or who simply haven&amp;#039;t made that particular mental leap (&amp;quot;having a face-lift involves a moment of reckoning, like acknowledging that you&amp;#039;re going through menopause,&amp;quot; Lewis says). However, the other half are increasingly warming up to the idea of &amp;quot;having lesser surgeries relatively early on so that they won&amp;#039;t require a major lift later,&amp;quot; Lewis says. Besides, in an era of $1,200-a-pop injections that require regular refills, surgery makes a new kind of sense. &amp;quot;I know women who spend more per year on maintenance than they&amp;#039;d spend on a face-lift,&amp;quot; Lewis says. &amp;quot;Sometimes, surgery can get you more bang for your buck.&amp;quot;  *Name has been changed THE NAME GAME  Given the number of catchy-sounding lifts\u2014some of which aren&amp;#039;t in fact lifts at all\u2014on the market, it&amp;#039;s no wonder Lewis is more overbooked than ever. There&amp;#039;s nothing wrong with the &amp;quot;plasma face-lift&amp;quot; offered by Beverly Hills cosmetic surgeons Daniel Yamini, MD, and Steven Svehlak, MD, which uses nitrogen plasma energy to resurface the skin\u2014but it&amp;#039;s not surgery. Similarly, the trademarked RestyLift, aka the Volumalift, touted on websites as a &amp;quot;30-minute injectable face-lift,&amp;quot; is really just generous shots of the hyaluronic-based filler Restylane. On the other hand, the &amp;quot;one hour, no downtime&amp;quot; Lifestyle Lift, which local TV news crews have heralded as a breakthrough in fast-recovery mini-nips, &amp;quot;strikes me as a misleading marketing scheme,&amp;quot; Lewis says. &amp;quot;As far as I can tell, it&amp;#039;s a real face-lift, real surgery, but the terminology makes it sound like nothing.&amp;quot; That said, perusing the surgical menu at A-list doctors&amp;#039; offices isn&amp;#039;t necessarily any easier. It practically takes a medical degree to choose between mini-lifts, S-lifts, and the L.I.F.T. (limited incision face-lift technique). &amp;quot;These are nebulous terms that don&amp;#039;t tell you a lot,&amp;quot; says Park Avenue plastic surgeon David Hidalgo, MD, a renowned plastic surgery &amp;quot;naturalist&amp;quot; who was once chief of plastic surgery at New York City&amp;#039;s Memorial Sloan Kettering Cancer Center. Hidalgo simplifies things considerably, explaining that all face-lifts can be classified two ways: by length of incision and by how they manipulate the tissues underneath the skin.  &amp;quot;Traditional face-lifts have a full-pattern scar that goes in front of the ear and then extends into the crease behind the ear and into the hairline,&amp;quot; he says. The procedures mentioned above, on the other hand, are variations on the short-scar technique, in which the incision stops before going into the hairline; its popularity grew in the 1990s, after minimizing downtime became a priority and surgeons began to realize they were over operating, removing too much valuable facial fat and pulling too tight. Hidalgo says a short-scar procedure may sound less invasive, but it can be 90 percent as major as the traditional method. But plastic surgeon Malcolm Paul, MD, of Newport Beach, California, says that while a short-scar procedure is perfectly adequate for a small amount of looseness in the jowls and cheeks, &amp;quot;if a neck needs to be corrected from the jawline down to the clavicle, you need a longer incision to get to it.&amp;quot;  Both doctors agree that whether a face-lift is &amp;quot;mini&amp;quot; or not is primarily determined by the treatment of the SMAS, a fibrous layer that lies between the skin and the muscle and can be tightened in three basic ways. Least invasive is the SMAS-ectomy, which Hidalgo performs on 90 percent of his patients. &amp;quot;Here, we take a bite out of the SMAS through the incision, tightening the cheeks and pulling up the jowls,&amp;quot; he says. The much more involved Extended-SMAS procedure &amp;quot;is like peeling an onion, layer by layer,&amp;quot; he says; first the skin is pulled back, and then the entire SMAS is lifted and tightened separately. The least common SMAS technique is the deep-plane face-lift, in which, he says, &amp;quot;you go down to the deepest level and lift everything sandwiched together.&amp;quot;  A Belgian surgeon named Patrick Tonnard, MD, came up with the latest way to handle this tricky middle layer: the relatively quick, less-invasive MACS (minimal access cranial suspension lift). In this version, skin is elevated just a bit, allowing the doctor to weave a stitch through the SMAS and the fat of the cheek, hoisting them up like a purse string. Manhattan plastic surgeon Lawrence Reed, MD, says the MACS has become his most popular procedure because of its limited undermining (the separation of skin from underlying tissues) and the fact that it leaves just a small scar in front of the ear. &amp;quot;People heal and look good in four to five days,&amp;quot; Reed says.  Still, the greatest advance in plastic surgery wasn&amp;#039;t technological, &amp;quot;it was people realizing they wanted to look natural,&amp;quot; Reed says. &amp;quot;We&amp;#039;ve had the ability to do a natural-looking face-lift for years. Believe it or not, a lot of people used to like that tight look\u2014I&amp;#039;ve been performing the short-scar lift since I opened my practice in 1976, but it took a long time for anyone to want it.&amp;quot; Lewis agrees. &amp;quot;The technique doesn&amp;#039;t matter as much as the amount and direction of the pull, which is a matter of taste that varies from doctor to doctor,&amp;quot; she says. &amp;quot;These are the questions you need to ask: How much tissue is being removed? What areas will be affected\u2014are you going to get my neck? And where will the scar be?&amp;quot;  WATERSHED MOMENT  Water\u2014or, more precisely, saline solution\u2014is playing a major role in a new breed of lifts that employ tumescence, a technique borrowed from liposuction, in which large amounts of saline-diluted topical painkillers are injected just under the skin to manage pain with less anesthesia and blood loss during surgery, making it easier to operate. A six-year study of 678 face-lifts published in 2004 found that tumescence significantly reduced post-op swelling and bruising, improved scar quality, and minimized other complications such as skin necrosis and hair loss.  Plastic surgeon Zachary Gerut, MD, of Hewlett, New York, is at the deep end of the tumescence pool. His Rapid Recovery Face-lift begins with the injection of nearly a liter of a diluted Novocaine/adrenaline/saline cocktail into the fatty tissues right under the skin. &amp;quot;Just before I start the surgery, the face becomes taut. If you tap on it, it sounds like you&amp;#039;re tapping a flexed muscle,&amp;quot; Gerut says. &amp;quot;Patients look like Jabba the Hut.&amp;quot; It may sound unattractive, not to mention painful, but Gerut says the trick reduces the bruising and swelling associated with anesthesia and eliminates the need for drains and heavy-duty bandages. (Other surgeons point out that post-op dressings are a matter of personal preference, no matter which technique is practiced.)  Santa Monica&amp;#039;s Patrick Abergel, MD\u2014a maverick whose new procedures are often viewed as risky by the competition\u2014has devised a &amp;quot;water lift,&amp;quot; in which a syringe injector inserts a mixture of saline, lidocaine, and epinephrine that helps liberate the skin from its underlying structures. He inserts the Abergel Skin Elevator, a custom-made tool not unlike a slim, blunt-ended knitting needle, through a small puncture wound and uses it to elevate the skin further, and then pulls back one to two inches of the loosened skin through a small one-inch incision tucked against the ear.  For those who don&amp;#039;t like the idea of all those painkillers being injected, Hidalgo says tumescence doesn&amp;#039;t necessarily mean a face-lift will be more hazardous (the drugs are too diluted to risk overdose); its main benefit is making the procedure easier on the surgeon, not producing a better-looking lift. &amp;quot;What I really don&amp;#039;t like about it is that all the swelling doesn&amp;#039;t go away when you&amp;#039;re ready to put things back together,&amp;quot; Hidalgo says. &amp;quot;You can&amp;#039;t see the elasticity or tone in the skin.&amp;quot; But Paul, who uses what&amp;#039;s known as a &amp;quot;superwet technique&amp;quot;\u2014halfway between the standard amount of local anesthesia and tumescence\u2014in all of his face-lifts, says &amp;quot;it makes the SMAS lift off like an orange peel. If separating the tissues is easier, surgery is less traumatic, there&amp;#039;s less risk of nerve damage, and recovery is faster.&amp;quot;  HANGING BY A THREAD  &amp;quot;Cautious optimism&amp;quot; is still the prevailing attitude toward what is arguably the biggest development in facial surgery in the past decade: implanted suspension devices, particularly barbed threads\u2014long, thin polypropylene strips that are inserted through small puncture openings near the hairline and swoop down under the skin, grabbing errant fat pads and yanking them back up to their youthful positions. The most popular, Contour Threads, arrived on the scene two years ago, billed as scar-free, speedy (they take less than an hour to implant), and less pricey than a real lift, with very little anesthesia required.  The technique has proven to be trickier than promised. While most doctors agree that Contour Threads weren&amp;#039;t faulty in the way they originally suspected (they&amp;#039;re don&amp;#039;t slice through tissue with normal facial movements, and they&amp;#039;re not usually difficult to remove), the end result varies widely. Hidalgo has seen puckering and irregularities and, almost worse\u2014no result at all. &amp;quot;Most of the time, when surgeons who use them show their results at national meetings, everyone looks at each other and says, `Is it me, or do you not see much difference between the before and after, either?&amp;#039;&amp;quot; he says. &amp;quot;You cannot get anywhere near the results of a traditional, albeit more invasive, face-lift procedure.&amp;quot;  Even those who do use the threads say their tensile strength is disappointing; the lift that was originally said to require a total of four threads can actually take up to 12, which means extra swelling and bruising, a downtime of up to 10 days, and, perhaps most disturbing, an increased amount of foreign material lodged permanently under the skin\u2014all for something that might not last long. Reed&amp;#039;s have persisted as little as four months; Lewis tells her clients not to hope for more than two years. &amp;quot;A regular face-lift with cutting, sewing, and suturing is more invasive but has less bruising and swelling and looks normal much sooner than the Contour Threadlift,&amp;quot; Reed says, though he finds the sutures useful for patients who are on blood thinners or are undergoing chemotherapy, for whom more invasive procedures are out of the question.  However, nearly every doctor interviewed for this story says future generations of the threads will hold more promise. First up, an absorbable version of Contour Threads that consist of polydioxanone (the longest lasting absorbable suture to date), which has received FDA approval and is tentatively scheduled to hit the market in the next few months. Absorbable sutures are said to have substantial tensile strength at six weeks, to have less at three months, and to be completely gone within six months.  What&amp;#039;s the point of an absorbable thread if the current ones don&amp;#039;t last long enough? They make sense for a new generation of hybrid techniques, in which threads are getting their best results yet by working in tandem with other procedures. &amp;quot;Facial aging is a combination of gravitational changes and loss of volume, so in many patients, it&amp;#039;s not enough to just reposition things. You have to add volume, too, whether through a cheek implant, fat injections, or other fillers such as Juv\u00E9derm,&amp;quot; Paul says. &amp;quot;When you take threads and add filler, plus Botox to quiet down the muscles around the brow, one plus one plus one doesn&amp;#039;t equal three\u2014it equals 10.&amp;quot; To wit: Paul devised a lift that combines ultrasonic liposuction on the neck and jawline, which emulsifies fat, making it easier to extract, and causes skin to tighten, with just two threads on each side to hold up the remaining lax skin.  Ironically, threads are also proving useful as an adjunct to full-blown surgery. &amp;quot;Tighter skin shouldn&amp;#039;t be the only thing holding up a face-lift\u2014you need internal support,&amp;quot; says Stephen Bosniak, MD, a plastic surgeon who works in New York City and Rio de Janeiro. His short-scar face-lift now has the addition of a few deep-reaching Contour Threads, which, he says, tack the SMAS up higher and give extra support to the lower jowls without the aesthetic problems of more superficially placed threads (plus, since the tissues are being undermined, they only need the thread to be in place until they re-adhere post surgery).  Last November, Paul published a paper on using barbed sutures in open mid-facelifts in Aesthetic Surgery Journal. &amp;quot;Part of the problem with a traditional face-lift is that skin, muscle\u2014everything\u2014gets pulled in the same direction. Barbed sutures give you more control, in that you can pull deeper tissues vertically, and pull the skin in a different direction,&amp;quot; he says. &amp;quot;When you put the barbed suture at a deep layer, it works like a shish kebab, catching multiple tissues and stacking them on top of each other to get volume over the cheekbone. If you did that with a single, normal suture, you&amp;#039;d just catch the tissue in one place, and wherever the needle goes in, that&amp;#039;s where you anchor it.&amp;quot; According to Paul, barbed sutures, which he leaves poking out of the surface of the skin for two days after surgery, also provide a revolutionary opportunity for post-op fine-tuning. &amp;quot;When the patient comes in two days later, she looks in the mirror, and I can say, `Okay, I think if your left cheek was up another millimeter, the result would be even more spectacular,&amp;#039;&amp;quot; Paul says. &amp;quot;Nothing else has offered that level of precision.&amp;quot; "^^<http://www.w3.org/2001/XMLSchema#string>
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