Archives for May 2021

By: EMILY LISTFIELD

Author Emily Listfield writes about the physical impact of experiencing loss — and her journey to alleviate those effects.

It is often said grief comes in waves. For me, it was a tsunami. It began with a phone call last year when my brother was diagnosed with lung cancer during a routine check-up. He was a committed runner and health nut and had also worked near the World Trade Center after the towers fell on 9/11, breathing in the toxic dust that continues to kill so many. 

Though doctors initially thought they had caught the cancer early, it had already begun its inexorable spread. Despite 30 rounds of radiation, two rounds of chemotherapy, and immunotherapy, the cancer worked its way from his esophagus to his ribs, spine, brain, and finally, his stomach. I watched as he toughed it out when he was no longer able to tell left from right, grimacing when he bent over, though he tried to hide the pain. 

Before getting sick, he had taken on the role of the primary caregiver for my mother, who, though active and alert, was elderly. On the first day of my brother’s chemotherapy, my mother fell and fractured her spine.

Luckily, I lived a few blocks away and was able to step in to help. What followed were countless middle-of-the-night trips to emergency rooms for them both, and assisting with showers, food, and bathroom duties. I slept with my phone by my pillow, ready to race over at a moment’s notice. Ironically, on this past anniversary of 9/11, I had to take my mother to the emergency room while my brother was with his oncologist, being told that his cancer was no longer responding to treatment. My mother never left the hospital and for the next few months, I ran back and forth between the two, sitting by their beds, managing their care, and working in nurses’ lounges while I witnessed my brother and mother’s steady and painful declines.

My usual coping mechanisms deserted me. I stopped sleeping, working out fell by the wayside, and I had trouble eating. My brother died in hospice 10 months to the day from his diagnosis. My mother died six weeks later.

I was left physically and emotionally depleted — and it showed. My face had become gaunt and haggard, my sallow skin formed shadows etched beneath my eyes that no amount of makeup could disguise. Looking in the mirror only reminded me of what had happened.

“Your life experience is worn on your face, good and bad,” observes Steven M. Levine, a board-certified plastic surgeon in New York City. “The reflection someone gets in the mirror is not just age, but what they’ve been through.”

The Visible Impact of Grief

Loss these days is everywhere. “People are grieving, not just as a result of personal losses but because of the general sense of loss during the pandemic. People have lost their jobs, connections, and everyday life routines, all of which have been extremely stressful,” says Vivian Diller, a psychologist in New York City, who studies the connection between emotion and appearance, and the author of Face It: What Women Really Feel as Their Looks Change. “When we face stress, our bodies go on alert. Anxiety increases, blood pressure rises, and our neurotransmitters can go awry.”

The result can wreak havoc on our skin as well as our health. “Grief drives neurologic and endocrine responses,” says Robert Anolik, a board-certified dermatologist in New York City, who says that prolonged activation of these responses can result in abnormalities of the immune system, increased free radicals, and subsequent DNA damage, all of which contribute to the deterioration of skin quality. “The sympathetic nervous system,” Anolik adds, “triggers the so-called ‘fight-or-flight’ response, which can lead to dull, dry skin without the same resilience or elasticity, more visible lines, pink blotches, possibly even sagging if the time period of grief is extended.” Lack of sleep may also reduce your skin’s ability to battle ultraviolet damage and free radicals.

Healing Inside and Out

Before I could address the toll the past months had taken on my appearance, I first had to deal with the emotional upheaval, including recurring nightmares, that continued to haunt me. “It’s most important to seek help in times of severe grief, from a social network and psychologists or psychiatrists as needed,” Anolik says. “Once the support is strong enough, moving on to cosmetic treatments can be helpful to the skin, but also even catalyze your return to acceptance and stability.”

I know that he’s right because I’d been there before. Years earlier, my husband had died suddenly, leaving me alone with a young child to raise. (Yes, I’m aware that I sound like the Typhoid Mary of family relationships.) For the first six months, I had no energy to do anything more than take care of my daughter and go to work, crying every moment I was alone. I soon developed bags under my eyes that should have taken years to appear. Finally, after getting therapy that helped me regain my footing, I saw a plastic surgeon to have the bags under my eyes removed. I didn’t want the loss I had been through to be written on my face. I wanted it to be my story to tell — or not. 

The outpatient procedure, known as a lower lid blepharoplasty, reduces, removes, or repositions bulging fat of the lower eyelids. “The fat compartments of the lower eyelid can be approached and treated through an inconspicuous incision inside the eyelid, known as a transconjunctival blepharoplasty, that leaves no visible external scar,” explains Adam Kolker, a board-certified plastic surgeon in New York City. (Kolker did not perform my procedure.) 

After 10 days of bruising that left me looking as if I had gone a few too many rounds in a boxing ring, the bags under my eyes were gone. For me, the procedure was an integral part of healing. It was an act of optimism.

Easing Into Treatment Options

Not everyone, of course, wants or needs plastic surgery after facing a loss. In fact, Kolker recommends an incremental approach. “The duration and sequence of the grieving process are different for everyone. When you feel ready to reengage, start slowly,” he says. “At first, only at-home treatments should be considered. Fitness, nutrition, hydration, and a proper skin-care regimen (cleanser, antioxidant serum, moisturizer) should be resumed. Specifically, antioxidants and peptide products could be most helpful.”

Anolik agrees with these ingredient recommendations. “Antioxidants reduce the impact of free-radical damage to the skin DNA, allowing for healthier development and consequently more beautiful skin,” he explains. “Peptides, on the other hand, are fragments of proteins that can sink into the skin surface and are capable of triggering specific skin functions to promote new collagen production.”

Following that, in-office procedures can be an effective and less-invasive option than surgery. Injectable neuromodulators such as Botox can treat furrowed brows, while fillers including Restylane and Juvederm can add volume and plump the skin.  

Carrieanne Reichardt recently lost her brother to cancer, and the constant worry left its mark on her face. “I’m in my 20s, but I had wrinkles in my forehead, which probably got worse from not eating and sleeping,” she says. She went to Kolker for Botox. “It was something I knew I would do at some point, but this expedited it.”

While no injectable can heal the pain of losing someone, it gave her back a sense of confidence. “I went from looking tired all the time to looking more alert and calmer,” she says.

Facing the Future With Confidence

After my mother and brother died, I sought treatment for post-traumatic stress disorder (PTSD) and slowly I began to sleep again. I started exercising and eating healthier, but my face didn’t get the memo. No matter what I did, I looked exhausted, with loose, dull skin and jowls around my mouth. I was finally ready to seek help for the outside just as I had for the inside. I had no desire to look like someone else, but rather who I had been before the last two years had done such damage. (Okay, yes, maybe just a wee bit better.) 

I turned to Levine because he is known not just for his talent and his natural results, but for his empathy. As I sat in his office, he explained what I could expect from the procedure he recommended, a lower face and neck lift. “The purpose of the surgery is to lift tissue that has fallen into the lower face and neck and return it to the midface and cheeks,” Levine explains. “The neck is addressed by tightening the muscles as well as sculpting the overlying fat and skin. The primary plane of operation is on the deeper tissue of the face and yields a natural and long-lasting result.”

Levine made sure I understood the procedure itself, the risks that all surgery entails, as well as the healing time. “What I do is elective, but it’s still surgery,” he says. “It shouldn’t be a decision made quickly but be thought through by the patient and surgeon performing it. In situations of grief or a breakup, if you are still crying every day, it may not be the best time.” I had done the work in therapy and now as I began to look to the future, albeit a different one than I had once imagined, I wanted to move forward from a place of strength.  

“Grief usually follows a period of selflessness from taking care of someone to mourning. Plastic surgery is something you do for yourself,” Levine says. “There’s nothing sad about it. It’s empowering.”

I made an appointment for surgery and as I waited for the day I felt a mix of anxiety (anesthesia!) and excitement (no more jowls staring back at me on Zoom!). On the morning of my surgery, as I lay on the operating table being prepped for the three-hour procedure, while the anesthesiologist was putting the IV in, she asked about the tiny swallow tattoo on my arm. I told her that I had wanted something to mark getting through the loss of my mother and brother, to honor the past and look ahead with a sense of hope, and that was why I was having the surgery as well. She smiled. “This is for you,” she said. It is the last thing I remember before waking up.

I spent the next 48 hours being cared for by amazing nurses who changed my bandages, fed me, and soothed me. After so many months of caring for others, it was odd to be the one sitting in a chair in the shower and having a nurse wash my hair when I had done the same for my mother. I know, though, that my mother would approve. When she was down to 92 pounds and riddled with bedsores, she still put on red lipstick every morning because it made her feel better.

I was back at work in a week, a bit tender but overwhelmingly grateful to Levine and all who had helped me get there. Now, two months later, my skin is smoother and tighter, my jowls are gone, my neck is taught. My decision to have plastic surgery is not necessarily right for everyone, but it was definitely the best choice for me. My sense of loss isn’t gone, but the scars are hidden, and I can face the future with newfound confidence.

By: JOLENE EDGAR

One doctor partially credits the “Zoom phenomenon” of the pandemic era.

Interest in plastic surgery is at an all-time high, but stigma and misinformation still surround the industry and the patients. Welcome to Life in Plastic, a new series by Allure that aims to break down cosmetic procedures and provide all the information you’ll need to make whatever decision is right for your body — no judgment, just the facts. Here, we’re covering everything you need to know about the surge in neck lifts among a younger demographic.

“What can we say about the neck that hasn’t already been said hundreds of times over the past year?” New York City board-certified plastic surgeon Steven Levine and I considered this question recently when attempting to deconstruct the surge in pandemic-era neck procedures. Because the uptick is real, folks, and we now have statistical proof to support the anecdotal spike in procedures that doctors have been reporting since last summer. According to the annual trend report just released by the American Society of Plastic Surgeons, 160,235 people managed to sneak in a neck lift in 2020, and this is despite doctors’ offices being closed for roughly eight weeks due to COVID-19.

But back to the why: “There is the perception of increased downtime and there’s the Zoom phenomenon,” Levine recaps, clearly aware that he’s stating the obvious. But he also offers a more novel observation: Beyond the fact that staring at ourselves — and our necks — on Zoom all day has made many of us all too aware of existing insecurities, the pandemic has also largely contributed to them. “This year has been incredibly traumatizing and that stress definitely took its toll,” he says, noting that many of us seemed to “age more than the chronological amount of time that passed in 2020.” And while some choose to embrace those physical marks as hard-earned souvenirs, others are eager to shed them.

Whether or not Zoom offers an accurate reflection of our necks is debatable — I mean, those angles — according to our experts, it’s not unusual for signs of angst and age to settle there earlier than elsewhere. “From a purely mechanical standpoint, necks endure a lot of wear and tear,” explains Lara Devgan, a board-certified plastic surgeon based in New York City. “Their vertebral bodies are not typical joints, because they move in many different directions, so the tissues of the neck [suffer] a lot more strain, resulting in vertical bands, horizontal lines, and laxity.” These are issues we’re perhaps hardly cognizant of, until suddenly, one day, there they are, distracting us in our virtual staff meeting.

And despite popular Ephron-inspired notions, it’s not just older folks feeling bad about their necks. Gary Linkov, a board-certified facial plastic surgeon based in New York City, occasionally sees patients in their 20s coming in to address their “congenitally ‘webbed’ necks,” he says. Their DNA simply dealt them an obtuse neck angle — resulting from superfluous fatty deposits deep below the skin — that blurs the line between face and neck.

So what can we do? While retinoids and sunscreen can help keep skin protected, we’ve yet to find a neck lift in a jar. Even the workhorse injectables and energy devices that keep our faces fresh tend to underwhelm when applied to the area in question. Injected into the platysma muscle of the neck, neurotoxins can help prevent banding and “create a slimmer and more elongated neck silhouette by causing decreased movement,” explains Devgan, referring to what’s known as the Nefertiti lift. But once those bands begin to bulge and the skin’s springiness wanes, toxins can only help so much and for so long. For etched-in neck lines, the finest of hyaluronic acid fillers can soften them some. And fullness under the chin can sometimes be modestly improved with a few rounds of CoolSculpting or a series of Kybella shots (but, as we’ve previously reported, Kybella comes with its own set of side effects and limitations).

The fact is, once skin and muscles weaken and sagging sets in, our options dwindle dramatically. “I think nonsurgical skin and neck tightening is kind of the black box of plastic surgery,” says Devgan. “We have all these promising modalities, but truly, we don’t have a gold-standard way to tighten the skin of the neck [without surgery].”

And patients, it seems, are getting wise to this fact. In board-certified plastic surgeon Melissa Doft‘s New York City practice, “there’s a paradigm shift away from noninvasive treatments, like Ultherapy and Thermage, as many patients do not see a significant difference after these expensive treatments and are looking for a more permanent and impressive improvement,” she says. Devgan notes a similar trend: About one-third of patients coming in for neck work have tried various nonsurgicals before graduating to surgery. But the other two-thirds? “They want to skip all of that [nonsurgical] stuff, because they’re realizing they’re basically paying [the equivalent of] a surgery in minimally invasive things that don’t work in the long-term.”

While, in the past, surgical interventions were commonly reserved for people with a certain number of birthdays under their belts, patients today don’t let their age determine their treatment course. “The neck lift patient is definitely getting younger,” Linkov tells us. “Women in their 40s are starting to notice early signs of jowling and loosening of skin along the jawline, and they’re willing to go through more downtime and pay more upfront for a predictable fix.” Levine is seeing an influx of 30somethings wanting to streamline their necks with a sort of lipo alternative he calls deep-neck contouring (more on that ahead).

When it comes to neck concerns, the solution will ultimately depend on your unique combination of symptoms — the specific aspects you’re hoping to correct. Here, let’s break it down.

For submental (under-the-chin) fullness and a lack of definition

What’s happening:

“Each layer of the neck can have various degrees of change, leading to a heavy appearance,” says Linkov. As we mentioned earlier, genetics also play a role, which means some folks will naturally end up with a little more padding under the chin while others may inherit a long-hanging hyoid, which is the U-shaped bone that anchors the tongue and helps determine how sharp of a cervicomental, or chin-to-neck, angle will have. (Its position is fixed and cannot be surgically manipulated.) Typically, in younger patients, excess fat is mainly to blame for below-chin bulkiness.

The fix:

Submental liposuction “is a very awesome and underrated procedure,” says Devgan, and is often recommended if the unwanted neck fat resides atop the platysma muscle, on the underside of the skin. After sufficient numbing, surgeons insert a cannula into a three-millimeter slit under the chin to vacuum out excess superficial fat. With lipo, “you can also get a pretty good amount of skin tightening by doing some scuffing of the tissues above and below [the fat], [creating] a Velcro-type of effect to give someone a really nice angle,” says Devgan. But fair warning: “There is a limit to what we can achieve with lipo,” notes Linkov, adding that enhancing the chin with an implant (or fat or filler) can help impart an even deeper angle in the right patient.

Total price tags for submental lipo can range between $2,000 to $14,000 based on the complexity of the operation and your doctor’s location and experience. Expect about three days of downtime.

If fat dwells under the platysma muscle — surgeons can determine this during a consultation — noninvasive and minimally invasive removal methods, like Kybella, CoolSculpting, and liposuction, will not be able to reach it. In these cases, Levine might suggest deep-neck contouring ($8,500 and up) — a procedure that targets, via an incision under the chin, the deep or subplatysmal fat pad while also reducing the digastric muscles and the submandibular glands, both of which also live beneath the platysma and can be “an obstruction to getting a clean neck line,” Levine says. Since this procedure is more invasive than traditional lipo, it carries more downtime — typically one to two weeks — and greater risk. “The amount of technical expertise and the knowledge of anatomy needed to adequately navigate the deep-neck space is far greater than what’s needed to perform lipo,” Levine notes, so pick your surgeon carefully.

For submental fullness, muscle laxity, and banding

What’s happening:

In this scenario, weakness of the platysma comes into play. The two halves of this large sheetlike muscle rise up from the collarbone, overlap to varying degrees under the chin, and extend out to the corners of the jaw. Over time, as this muscle deteriorates, the once-adjoined sides pull apart and their free edges can read as distinct bands or cords beneath the skin in the midline of the neck. Bands that crop up along the sides of the neck are more so due to “weakness in the [muscle] sheet itself,” notes Devgan, comparing them to creases in a bedsheet.The fix:

A limited-incision neck lift, aka an anterior or corset platysmaplasty, which can run between $8,000 and $25,000. Surgeons make a four-centimeter incision in the natural crease under the chin through which they’re able to repair the platysma with sutures, “putting it back where nature intended,” says Levine, while also removing both superficial and deep fat to exaggerate the cervicomental angle, taking it from obtuse to acute. For appropriate patients, Levine may combine the limited-incision neck lift with deep-neck contouring, if the aforementioned digastric muscles and submandibular glands are preventing a sleek silhouette.

Because surgeons can’t tailor out excess skin through the under-chin incision — skin removal traditionally requires around-the-ear incisions — decent skin elasticity is a prerequisite for the limited lift. That said, oftentimes redraping the skin over newly streamlined contours can give a modest tightening effect. As Levine explains, when we remove fat and tighten muscle, we increase the distance between the chin and the trachea, creating more real estate for the skin, and effectively taking up a small amount of slack. (If the skin has zero spring, however, this move won’t suffice.) Surgeons often pair this operation with a chin augmentation — using fat or an implant — to lend more support to the lower face and improve that aforementioned drape.

This surgery is routinely done under local anesthesia with IV sedation, and comes with a week or two of recovery time. (Some surgeons place temporary drains in the neck to prevent fluid from collecting, especially in deeper zones that have been cleared of fat.) While some patients opt to skip the sedation, be aware, it does more than merely enhance comfort: According to Levine, it allows doctors to keep your blood pressure low, which minimizes post-op bruising and swelling.

For submental fullness, muscle laxity, banding, loose skin

What’s happening: 

Loose neck skin can sometimes magnify other issues, like muscle laxity and stubborn fat under the chin. While it’s true that older patients are typically those who are looking to fix sagging skin, Doft notes that weight fluctuations — at any age — can also cause this particular issue.The fix:

A complete or traditional neck lift, which can cost upwards of $35,000-plus, sometimes creates larger scars than the previously described procedures. To fix neck bands, surgeons will still use that direct gateway under the chin. But to address jowls, remove extra skin, and resuspend a drooping platysma, they need to make incisions around the ears. The precise length and position of these incisions — in front of the ear, behind it, or both — depends on the amount of work required. Generally speaking, says Levine, an incision behind the ear alone will not be enough to address jowls, however by adding a limited incision in front of the ear, surgeons can correct early or significant jowling while also raising the platysma and trimming away excess skin.

According to Devgan, the looseness of the skin largely determines a patient’s candidacy for this procedure: “I begin to think about a surgical neck lift when I see more than one centimeter of pinchable laxity at the jowl or in the tissue of the neck — at that point, there’s really not nonsurgical or minimally invasive way to get rid of it,” she says.

(On semantics: Some doctors refer to this procedure as a classic face lift or a lower face lift, since opening around the ears gives them access to muscles of the face, too. But in most cases, the auricular scars for this type of neck lift are less extensive than what’s needed to fully address the mid and lower face plus neck.)

Performed under general anesthesia or local with sedation, a comprehensive neck lift with both ear and chin incisions may demand a longer healing period (everyone recovers on their own timetable, but figure up to three weeks). Sutures — for all neck surgeries — typically come out around the one-week mark. At that point, patients should look and feel well enough for regular daily activities (though there may still be some residual bruising). Levine has many patients who get back to life within a week of surgery, he says, and if they’re asked about their bruises or swelling, “they’ll just say, ‘Yeah, I hated my neck, so I did something about it.’ And, to me, that’s super-empowering.”