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.”

By: Jennifer Hussein

Once upon a time (in 2015), none other than queen of alt-beauty Gwyneth Paltrow took to the internet to tout an “underthe-radar” cosmetic procedure known as threading, which she also dubbed “the future of face-lifts.” Fast forward five years, and she’s not the only one to praise the procedure: Beauty guru Huda Kattan did a full self-expose and video on her love for threading, Cosmopolitan labeled it a “chiller” version of a classic face-lift, and the popular Instagram account @CelebFace even dedicated an entire post trying to “expose” celebrity faces (CC: Bella Hadid, Ariana Grande, Dove Cameron) that may have secretly gotten hooked (pun intended) on the thread trend for a subtle brow lift.

But first and foremost: What exactly is threading?

“Thread lift is kind of a colloquial term for suture-suspension lifting, [which] works by introducing a surgical suture that has barbs or perpendicularly oriented rasps on it,” says Dr. Lara Devgan, New York City-based board-certified plastic surgeon and founder of Dr. Lara Devgan Scientific Beauty. “That is introduced deep into the tissue, and when it’s placed on tension, the perpendicularly oriented rasps gain purchase in the tissue, and they allow you to pull it in different directions. To put it another way, suture-suspension thread lifting allows you to, in a minimally invasive manner, create lift and directional vector changes for the tissue.” That means you get some of the lift that you’d find from a face-lift, but in a much less invasive procedure done under local anesthetic rather than general anesthesia.

While it may seem like a newer, easier spin on the classic face-lift (a surgical procedure that improves visible signs of aging in the face and neck, like sagging, fat loss, and jowls), Dr. Steven M. Levine, board-certified plastic surgeon, notes that thread lifting isn’t necessarily a new concept—actually, it dates back to the mid-’90s. “Very little is new in my field,” he explains. “Only new marketing. This is clearly one of those examples of something that has been tried and has not been successful in the past, and then companies bring it back.”

So why haven’t these suture-based lifts been successful in the past? According to both surgeons, a variety of issues arose as a result of the procedure, like asymmetry, pleating, breakage, and even extrusion or poking out through the skin (yikes). However, Dr. Devgan does note that since their inception, the varying thread options available have gotten exponentially better over time.

“So much has changed in the aesthetic in the past 20 to 30 years,” she says. “The threads themselves have been made in a different way. Instead of taking a regular surgical suture and carving little notches out of it in order to give it barbs, now the sutures are formed with custom molds. The polymer that’s poured into them is actually stronger, and this means that each thread is able to support about two and a half pounds of pressure. This allows them to be placed in deeper tissue planes of the face—that avoids many of the problems that you’ve seen in the past.”

These technological advancements, plus the desire for less invasive procedures with quicker recovery times, have driven more patients towards thread lifting—for the face, derrieres, and bosoms. Dr. Devgan cites the treatment (which results in no scars, has zero incisions, and no general anesthesia) as the leading alternative to traditional procedures like a surgical face-lift, neck lift, or brow lift. “[In that way, it’s] extremely appealing to people.”

Dr. Devgan also notes that the trending (and appropriative “fox-eye” look isn’t the only effect you can achieve with face threading. “Just like everything else in aesthetic plastic surgery, there is a whole range of possible outcomes,” she says. “So you can have an extremely subtle and natural-looking result that focuses just on symmetry, and a little bit of added optimization, right at the margin. You don’t need to look fake.”

But just because your recovery time is lessened and the procedure is minimally invasive does not mean that all surgeons will recommend it for their patients, especially if you’re looking for permanent and similar results to a traditional facelift. Dr. Levine isn’t keen on thread lifts, nor does he offer the procedure at his practice.

“The tissue can’t be suspended from just the threads,” he explains. “If this worked, I’d be out of business—nobody would want face-lifts anymore. I have never seen a long-term result from threading that I was impressed by. There might be some truly transient lifting of the tissue—meaning days to weeks—and frankly, that lift is completely reliant on the tensile strength of the barbs on that thread. The truth is there isn’t much of a result to see that isn’t swelling related. You’re not mobilizing any tissue, and you’re not separating any of the facial ligaments. It would be the equivalent of taking a piece of tape from underneath the skin and sort of taping your skin up and hoping that [it] holds for weeks to months to years.”

Even Dr. Devgan, who has performed this procedure hundreds, if not thousands, of times, admits that thread lifts aren’t a shortcut to the same results you’d see from a face-lift.

“Suture-suspension lifting has a role, but it’s very important to understand what that role is,” she says. “Thread lifting is not a replacement for a surgical face-lift and it never will be. It’s an intermediate technique that’s part way between injectables and full open surgery. In my opinion, a surgical procedure remains the gold standard for lifting the face.

As for thread lifting for your body, both experts agree that you should probably opt out of that, too. “At the present time, thread lifts for breasts and body are not robust enough to lift the tissue well because the tissues in those areas are quite heavy,” says Dr. Devgan. “I do not think thread lifts are well suited for these areas.”

However, that doesn’t mean that you need to rule out threading entirely if you’re in the market for options to lift the face. Dr. Devgan notes that there is a time and place for this procedure—you just have to figure out when with your surgeon, while also being realistic about their limitations. “Not every nail needs the same kind of hammer,” she says. “I think that it’s true, but in a way irrelevant, to say that [thread lifts] are not as good as the gold-standard technique [of a face-lift] because if you [don’t want] an invasive procedure, then maybe this is something that can still make you happy.”

So what’s the takeaway here? Although thread lifts do come with their limitations, they can be used in a variety of ways to create the result you desire—just don’t expect them to be the end-all of traditional face-lifts. Some surgeons, like Dr. Levine, will steer you towards tried-and-true procedures that are more guaranteed to adequately address your concerns.

“If you would like to reduce fine lines and wrinkles, get a neuromodulator like Botox or Xeomin or Jubo,” says Dr. Levine. “If you want to add volume to your face, have your injector put filler in your face. But if you want to reposition tissue in your face, the only procedure that has stood the test of time and will reliably give you what you want is a facelift.” But what if you’re not quite ready to explore that option? “The answer is, I say with a great deal of sincerity, if you’re not ready, then just don’t do it.” Considering that the average age of people seeking face-lifts is 50 years old, you might still have a few years to think about it, although Dr. Levine does reveal that that number is dropping. “Some seek it in their late 30s. The average age is getting younger and younger.”

However you feel about thread lifts, face-lifts, or any cosmetic procedure, make sure to consult with a trusted board-certified surgeon or dermatologist before getting any procedure done—you’ll thank yourself in the long run for it.

Photo: Shot on site at 6 Columbus. On Solveig: Pajamas, Morgan Lane; Ring, Baker & Black; Sunglasses, Dior; Hand Mirror, Tom Dixon; Carafe, Tom Dixon; Hair, Angela Soto; Makeup, Andriani.

By: Jennifer George

The past 20 years have seen the rise and fall of eye-popping breast enlargements. But does the new trend for smaller cup sizes and more subtle surgery mean we’re less bust-obsessed, or are we just expressing an age-old fixation in a different way?

‘I remember the first time I really got the concept of ‘fashion tits’.

I was at an annual industry ball my then-magazine was hosting (as a clipboard warrior, not a guest, sadly) and the CEO of the world’s biggest online fashion retailer arrived full skirt and a silk shirt unbuttoned to just about the navel. Her breasts – neat, perky but with a natural-looking, gentle slope away from the breastbone – were braless. On the show, but not showing off, giving her look the perfect balance of sexy and nonchalant; the ultimate goal when dressing for a fashion crowd. In a sea of celebrities in microscopic and outlandish designer outfits, hers (and her braless bravery) were the talk of the office the following day.

At the time – this was in 2012 – you could have been forgiven for thinking that, after a decade or two of in-yer-face fame, boobs were over. But as with most trends, our obsession with breasts never really goes away; it’s just the obsession’s form that changes.

Back when I was a teenager, they were massive: literally and figuratively (although not personally but, oh, how I longed for them). It was the early 2000s, and huge, fake breasts -and the surgeries creating them – were big news. Actresses had them, the Spice Girls had them, the most-lusted-after girl at college had them. If the Sixties were about legs, and the Eighties hair, the Noughties were all about boobs.

‘Lad mags’ – such as Zoo, FHM and Nuts – took over shelves with female cover stars who were, shall we say, ‘heavily endowed’. WornderBra and its ‘Hello boys’ campaign (featuring a bouncy Eva Herzigova with breasts hoisted up to her clavicle) caused cars to stall at traffic ligths. This was a time, remember, when it was acceptable to stuff plastic ‘chicken fillets’ into your bra to ‘enhance’ what you had. (Although I can personally attest that they did not withstand as drunken night out on the dance floor.)

---

‘In 2013, more than 11,000 women went under the knife to boost their breast size in the UK’

So it’s not surprising that, even though breast augmentation has been around since the 1960s, demand for the surgeries, well, surged. Even the 2010 PIP scandal (with its stories of ‘erupting’) Poly Implant Prothese implants, made from non-medical-grade silicone) couldn’t dissuade us. At their breast size in the UK (a huge 30% jump from 2009).

The goal, for most, was simple: size. ‘The obsession was about sticking volume into the breast,’ says Patrick Mallucci, one of the UK’s most well-regarded plastic surgeons. ‘Pamela Anderson, Posh Spice — they were the pin-ups of that “volumetric” era.’ Surgeons of Mallucci’s calibre (his procedures start from E9,300) have always erred on the side of caution, but it wouldn’t have been difficult to find someone willing to squeeze the largest slab of silicone into a very small space, if that’s what you desired.

‘I wanted the pushed-up look, one that would just sit completely still in a string bikini,’ Laura,* who had her first boob job at age 24, tells me. ‘I didn’t care about them looking natural. If anything, I wanted people to notice them.’ Saving up for her surgery, she forked out close to E5,OOO to ditch her AA-cup bras for DD ones. For Laura, at the time at least, they were like two globular badges of honour pinned to her petite frame. She joined an army of women— WAGs, soap stars and, in her case, financial advisors — proud to display their implanted assets. Conforming to the idea that ‘bigger means sexier’, for her it wasn’t about empowerment or owning her femininity, it was about being noticed.

But then, almost overnight, ‘boob job’ became a dirty phrase. In 2014, a year after their glory days, UK surgeries dropped by 20%. Posh Spice, who had by then successfully rebranded as a fashion mogul and mother of four Victoria Beckham, had her implants — which for years she denied, but did little to hide — removed. The interest in the fake aesthetic that had reigned for so long suddenly deflated.

The British Association of Aesthetic Plastic Surgeons (BAAPS is its apt acronym), which audits all surgery figures, put the steep decline down to two things. First, a simple blip after a ‘post-austerity boom’ in 2013. But, secondly, and more interestingly, a change in ‘aesthetic preferences’. As BAAPS President and consultant plastic surgeon Rajiv Grover explained in a report at the time: ‘2014 saw men sporting bushy beards and women bushy eyebrows; the natural look [was] definitely on the rise.’ But why did our preference suddenly shift away from ‘bigger is better’?

It is perhaps no coincidence that this trend closely followed another big shift in society: the emergence of fourth-wave feminism. With previous phases focusing on women’s rights and liberation, this one — which coincided with and took advantage of a surge in the use of social media — zeroed in on body shaming, sexual harassment and sexist imagery in the media. It included campaigns that challenged misogyny and the objectification of the female form, such as the Everyday Sexism Project, the No More Page 3 campaign and, later, the 2018 Women’s Marches.

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‘Although breast surgeries declined, Illey certainly did not disappear; they just got subtler’

But even if you weren’t picking up a banner and taking to the barricades, you couldn’t help but notice that big boobs were out of style. This cartoony version of femininity had seemed refreshing and counter-cultural when it emerged from the ashes of the angsty, gender-neutral Nineties. But, gone mainstream and stripped of the knowing irony, it became tacky and obvious to some, associated with a lack of imagination and individuality. Like it always does, the wheel of fashion turned and ‘real’ boobs, of all sizes, were in style. But when I say ‘real’, what I should really say is ‘real-looking’. Because although breast surgeries declined, they certainly did not disappear; they just got subtler, softer and smaller.

‘We learnt a lot from the era of more is more,’ says Mallucci. ‘It’s associated with many negatives — PIR ill-sitting implants —and the fact that, actually, it’s ugly.’ In 2014, alongside a fellow surgeon, Mallucci came up with the ‘perfect’ 45:55 ratio, with 45% of volume above the nipple, 55% below. ‘Naturally a breast, even in a fit 19-year-old, will have more volume below,’ he says of the subtle difference. Where surgery had once turned breasts into firm, round oranges, it was actually more of a natural pear shape that surgeons, women, men, everyone preferred. (A study of more than 1,400 people was conducted as part of this research.) What’s a good example of that ratio? ‘The Kate Moss shape is often referred to,’ says Mallucci. That modestly sized, natural-looking breast — and the one that I became familiar with working in the fashion industry in the 2010s — became the gold standard.

One surgeon famous for perfecting this aesthetic is New York’s Steven M Levine. ‘Other surgeons joke that I have the smallest business in the US,’ he tells me. ‘Because I’ve carved a particular niche for this type of breast.’ Doing three to four surgeries a week, at the eye-watering cost of E 14-23,000, depending on what is being done, he’s the go-to for the citys fashion crowd and many celebrities. He simply ‘doesn’t do large augmentations’. Of course, he can’t name names, but — when I ask about certain perky-breasted models — tells me that he’s ‘operated on a significant portion of Victoria’s Secret models’. He adds: ‘I’ve done a few of the most well-known “fashion” breasts. They just want to fill a bra. They want to look as natural as possible, but with the ability to look breasty in a push-up bra. They want to be natural, but versatile.’

This was the case for Olivia, a London-based PR, who turned to surgery two years ago — not for ‘big boobs’, but a better shape. Unhappy with her tuberous breasts (a harmless but often aesthetically displeasing condition where the shape may be elongated, droopy or with enlarged areolae), her brief was clear: ‘the smallest option possible’. Not only were there practicalities to consider— her 5ft 2in frame, clothes fitting like they did before — but she also didn’t want to be painted with the ‘fake boob’ brush. ‘People automatically knowing I’d had a boob job is something I wanted to avoid,’ she tells me. ‘Because, unfortunately, there’s a stereotype that comes with it. People can be quick to judge.’

For Olivia, aged 21 at the time, the surgery involved 265CC implants (one of the smallest options) taking her from a 32B to a 30D, ‘which sounds like a big jump, but it’s not.’ It might seem easier to create neat breasts rather than turning molehills into mountains but, in fact, the delicacies of the surgery make it harder to perfect. ‘It’s easiest to fill it up to get the lift people want,’ says Levine. ‘With smaller implants, surgeons have to be more skilled with placement.’ For Laura, the passing years made her rethink her implants; she wanted to look ‘more modern, cooler in clothes without stick-on-boobs taking over’. ‘I wanted them smaller, not as high up,’ she tells me, adding in the word ‘natural’ to her list of wants. She underwent a revision surgery, taking them a cup size smaller but ‘much more normal-looking’.

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‘With the fake look ot of fashion, patients are wanting a redo’

Every surgeon I spoke to now does more ‘revision’ work than enlargements through first-time surgeries. With the fake look out of fashion, patients are wanting a redo. Chrissy Teigen, who recently admitted to having implants fitted in her early 20s, recently documented the process of ‘getting her boobs out’. They’ve been great for many years, but I’m just over it,’ she announced on Instagram. But it’s not usually a case of just plucking out an implant. ‘When coming for downsizing or reverting to a natural shape, the redundant or excess skin requires a lift or tightening,’says Mallucci, whose ‘fixes’ have now overtaken primary jobs. ‘I think of it like dressmaking: tailoring away excess skin, tweaking and lifting where needed.’

With all of these options out thereto create the optimum natural-but-fake breast, it’s near-impossible to spot who has had ‘work’ done any more. As with all aesthetic procedures these days, we’re left puzzling over images of celebrities, wondering: Have they or haven’t they? Dr Jacqueline Lewis, a surgeon who specialises in post-cancer reconstruction, says this is a problem in itself. ‘We think we’re over the fake era, but we still aren’t being shown “normal” women’s breasts,’ she says. ‘I get so many patients, often younger than 26, who come to me with perfectly lovely breasts, but they are only used to seeing what’s in magazines.’

Hopefully, though, that tide is also turning. Online movements such as #SaggyBoobsMatter, started by writer Chidera Eggerue, celebrate normal, larger breasts — bra or no bra. Victoria Beckham says we shouldn’t ‘mess with[our] boobs; celebrate what you’ve got’. And, in typical Chrissy Teigen fashion, the model and author added to her post: ‘I’ll still have boobs, they II just be pure fat. Which is all a tit is in the first place. A dumb, miraculous bag of fat.’ And she’s got a point…

THE BEST NEW THINGS IN BREASTS

Mesh

A fairly recent innovation, the use of a biodegradable mesh is helpful in lifts and reductions. it ‘trains’ the breast to stay in place while healing, then dissolves into your own collagen.

‘Virtual reality’ consultation

State-of-the-art software allows you to take three photos of your breasts before showing you what various implants will look like using A1. ‘What you see is really what you get,’ says Levine.

Lighter implants

The latest generation of lightweight implants— called B-Lite — are 30% lighter than standard silicone, meaning the drop, over time, will be slowed down.

Skin tightening

Although there’s not a like-for-like non-invasive option to replace surgery, radio- frequency skin tightening can perk things up, helping to counteract drooping by making the chest more taut. New high-intensity ultrasound system ULTRAcel Q + has been seen to tighten skin on the décolletage enough to cause a lifting effect on smaller breasts.

By: Emily Strohm

Plastic surgeon Dr. Steven M. Levine tells PEOPLE why his phone has been ringing off the hook

Since the world entered a lockdown, nearly every aspect of life has been put on hold, but one industry that’s seen a surprising uptick in demand? Plastic surgery.

PEOPLE spoke with Dr. Steven M. Levine, a New York City-based plastic surgeon whose subtle improvements grace some of the most famous faces and figures in the world — his patient list includes A-list actors, supermodels and more.

While the highly sought-after doc is naturally tight-lipped about his client list, he spoke to us about the reason behind a surge in plastic surgery requests in the age of coronavirus (COVID-19), why he’s turning away his high-profile clients right now, and when he thinks he can get back to business.

“Since our office closed in early March, we expected a decrease in phone volume,” says Levine whose price for a breast augmentation is $15,000, while face procedures can run $45,000 and up. But instead, Levine only saw a boost in his already booming business.”We had to hire new staff just to keep up with the number of calls.”

How quickly into lockdown did the requests for Botox and plastic surgery begin?

Dr. Levine: Requests actually began about five days before the formal barring of elective surgery. I stopped operating prior to the governor’s order in step alongside many of my colleagues in N.Y.C. who felt that something was coming and until we had a better handle on the situation, we shouldn’t be doing cosmetic surgery. Once we started telling people “No” and canceling already scheduled procedures, people were understandably bothered. People who choose to have plastic surgery usually plan for it several weeks or months in advance, so [having their appointments] canceled or rescheduled was anxiety-provoking for them. As the quarantine continued, requests continued for procedures. Patients started to realize that most of their social commitments would be postponed and the upside was an unprecedented amount of recovery time. At the very beginning of this, no one knew how bad this would get, so a number of patients felt like we were over-reacting. That said, in general, most were very understanding.

What was the wildest reaction you received?

Dr. Levine: Initially, I think people threw out bribes in a playful, almost joking idea. And then depending on our reaction would follow it with a statement demonstrating their seriousness. Like, “I know you said Dr. Levine isn’t able to perform surgery now, but what if I paid him double?” My patient coordinator would laugh it off, and then she would hear, “Seriously, though would he?” Someone offered me a month in their home in the Hamptons recently (in addition to payment), if I performed a procedure for them during lockdown. The answer is just no. I may be focused on beauty, but I’m still a doctor.

What was your typical day at your practice like pre-pandemic?

Dr. Levine: I have a very boutique practice which means if someone makes a request, we try to honor it. I have flown overseas for a 20-minute consultation. But the for most part, I am lucky to be in my office in the Upper East Side that is home to my private operating room and recovery facilities. Most days, I start surgery by 7 a.m. and do one to three surgeries depending on the procedure. After surgery, I start seeing patients. This is a mix of post-op visits and new patient consults.

What’s your working from home situation look like?

Dr. Levine: Video consultations have always been a part of my practice, but maybe I would have one or two a month. Now, everything is virtual. To use the phrase of the day, it’s the “new normal.” At first, I found it very confining, but I’ve learned to embrace it. ftn fascinated that since my practice has been closed, I’m putting in long hours, despite not operating. I have no idea where the time goes. For someone who is used to having a real product to show for their work, this has been extremely frustrating. I’m a results-driven kind of person. And now I just talk all day. I can’t wait to be back in the operating room. Until that day comes, I spend my time in front of a computer connecting with old and new patients over video chat. It’s not the same, but we make it work.

How busy do you expect to be when you’re back up and running?

Dr. Levine: We have been eagerly awaiting the governor’s 0K to resume our practices. We expected he would allow us to operate again in mid-May so we booked surgeries every day, including weekends. When that didn’t happen we moved everyone’s surgery. We were sure he would allow us to operate by June 1, then that didn’t happen either. Elective surgery isn’t a switch you can just turn on. We need time to plan. The patients need time to plan, the staff needs time to plan. so we canceled Cases again and have everyone rescheduled for later in June. Usually, we operate three to four days per week, but we have surgery scheduled six days per week for when we reopen. We hope that’s on June 8, but we’re awaiting final guidance from the governor and the Department of Health. It’s not just the new patients who are eager to get in the office — there are dozens of people who expected surgery in March, April, and May and they are still waiting. We have a morning and evening shift Of nurses set up for when we return so that we can work expanded days and meet the demand.

What ways will COVID-19 forever impact the practice of plastic surgery?

Dr. Levine: COVID-19 will change the way Our practices run. We are forced to be more efficient with our patient schedules to minimize or completely eliminate use Of the waiting room. But as far as demand goes, the pandemic won’t change things. All of us care about how we look. And now that more of us are faced to stare at ourselves on Our computer screens while on video conference, I expect people who otherwise may not have been interested in surgery to consider a consultation. I tell everyone — if you’re thinking about it, make a consultation. You owe it to yourself. It doesn’t mean you have to have surgery, it’s called a consultation for a reason.

By: Steven Levine as told to Alyssa Shelasky

Dr. Steven Levine is one of New York’s top plastic surgeons. He’s best known for his “natural” face-lifts and breast augmentations. His clients include some of the mostfamous actresses, supermodels, and socialites in the world. Below, he talks to the Cut about the kinds of requests he’s been getting in lockdown.

Though I’m isolated with my wife and kids outside of the city, I’m shockingly busy. I’m only doing virtual consults all day. The demand from wealthy and celebrity clients to get work done — face- lifts, tummy tuck, breast augmentation — while no one is looking, while they have nowhere to be, is extremely high. Sadly, my answer is either no or not just yet.

I was raised by two New York City schoolteachers so I can tell you, even in my own eyes, my profession can be absurd. On some days, it’s caring for wonderful, “regular” people who have entrusted me with something important to them. On other days, it’s this intersection of unlimited money and crazy wish lists. Most days, it’s a little of both.

So I’m used to unimaginable requests even before all of this. Pre-pandemic, I’d get things like someone asking to be the only patient that day — so that they have my complete focus — and they’ll offer to pay double for this, to compensate for the other surgeries that I can’t take. There’s a lot of people saying, “I want your staff to sign nondisclosure agreements.” Some people want me to personally spend the night at their house after surgery to make sure they’re okay. For the most famous celebrities, they want me to come to their homes for all their “post-op” appointments so they never have to be seen in the office. It’s a huge amount of extra time and attention on my end, but I try to accommodate requests when I can. I recently spent 20 extra hours visiting a celebrity at home for her post-op visits. I have an hourly rate, which she knew I would bill her for, and she was happy to pay.

With that said, the volume of calls, and level of intensity, is probably higher during COVID than not COVID. Almost every virtual consult ends with “How quickly can you do this?” They want to take advantage of this perceived downtime. It seems like the perfect time to recover from a procedure like a face-lift, where you need at least two weeks to lay low (whereas for breast augmentation, you only need a few days to rest at home).

I think the requests for face, neck, eyes, and nose are constant at the moment because people are looking at themselves on Zoom all day, analyzing their angles. We all have bad angles. We will all take bad photos. They don’t want to hear that. I don’t judge any of them. When you look good, you feel good.

Extremely successful people are used to getting what they want, when they want it. That is the reality of their life. One very well-known entrepreneur wanted to come to my office on the Upper East Side and get her face done, like, yesterday. She offered me more than four times my usual fee, all cash, and told me she’d have her lawyer draft a nondisclosure that she wouldn’t tell anyone we did it. I told her, “I love you to death, but no.”

Will she go to someone else? Maybe. But people who can afford to make those kinds of demands only work with the best surgeons. No good surgeon would do that right now.

I’ve gotten a lot of this: “I live alone, pose no risk, and need Botox now. I don’t care what you charge me for it.” I say no.

I had a patient last month who offered to send me a plane to her country in the Middle East (I do operate there a few times a year normally) for a face- lift. She guaranteed it would be a completely private plane, all the precautions, etc. That one, I admit, I considered because I wasn’t sure what law I was breaking. I have a medical license in that country and that country didn’t have a ban. It was a tough one. While elective surgeries are now allowed at most hospitals — including New York and certainly where she is from — it ultimately felt wrong to leave my family and go.

A lot of my clients have cornered themselves off in their mansions around the world, and they want to get things done while they’re there. I’ve had people be flirty or playful to convince me to come over with injectables or open up the office for surgery. There’s a lot of, “Hypothetically speaking would you come over and treat me in my house if I let you leave with my car?

I was taught in medical school that you get in the most trouble when you try to do a favor for a patient. You should always be acting above reproach. Like, doctors who call someone’s rhinoplasty a “necessary functional operation” — as a favor, because why not? — and then the patient wants more from you for free, and soon there’s a blackmail letter from their lawyer that you committed insurance fraud. Bottom line: You don’t lie, and you don’t do things that are unethical.

The pent up demand for plastic surgery is off-the-charts crazy-high right
now, and everyone wants to be first in line when I do open. All we can do is
stay in touch with them. Over-the-top exceptions aside, most patients
handle that response with grace. This virus doesn’t care how wealthy you
are. So for the most part, when it comes to staying home until the
government says it’s okay, all our interests are aligned.

By: Jolene Edgar

Seeing an aesthetic procedure all over social media can breed a strange sort of FOMO. (Hey, we’re not immune.) Yet it may be difficult to distinguish for-the-’Gram fads from truly “Worth It” tweaks. Which is why we’re launching a new series on RealSelf: Everybody’s Doing It. Each month, we’ll explore all sides of an of-the-moment cosmetic procedure, to bring you the uncensored truth about its efficacy and safety, so you can decide if it’s right for you. Here, in our first installment, we’re dissecting the buccal fat removal debate.

While I’ve never quite understood society’s gross fascination with pimple-popping content—stomach of steel, that Dr. Sandra Lee—I have found myself recently spellbound by extraction videos of a different variety: buccal fat removal. Anyone who’s witnessed the face-slimming surgery—that moment when glistening yellow fat erupts from the inner cheek—can no doubt relate. And I’m guessing that’s more than a few of you, given the sudden prevalence of these videos on social media. “There’s definitely been an uptick in requests for buccal fat removal,” says Beverly Hills, California, facial plastic surgeon Dr. Sarmela Sunder, who fields upwards of 10 inquires a week about the surgery, primarily from women in their 20s and 30s. The procedure’s popularity has soared in response to a collective quest for a specific face shape, she adds—one with cheekbones strong and wide, a tapered chin and a chiseled jaw.

“The whole purpose of the operation is to highlight the bony architecture, giving more definition and angularity to the face,” says New York City plastic surgeon Dr. Alan Matarasso, who was among the first to describe the intraoral buccal fat excision technique in scientific literature. As with contouring makeup, the goal of surgery is to cast a shadow across the mid-cheek hollow, thereby highlighting the cheekbone above and jawline below—only, in this case, to permanent effect. “It simulates the look one has when sucking gently on a straw,” he explains. “When done right, it’s always a subtle change.” 

Dr. Matarasso performs the surgery across demographics, he says—“in teenagers who are also having their noses done [slenderizing the cheek can help bring balance], twentysomethings after the model look, and older patients with very full, round faces.” Even men are getting wise to the perks of the procedure. “Fifty percent of my buccal fat consults are guys,” says Dr. Sagar Patel, a facial plastic surgeon in Beverly Hills, California. “The majority are wanting to look more mature and masculine so [that] people at work will take them seriously.” Imagine that—getting plastic surgery because you want to look older.

The buccal fat removal movement is not without dissenters, however—plastic surgeons who deride the rise of such “fad procedures” and fear the long-term consequences of plucking fat from cherubic twentysomethings. But before we weigh the treatment’s reputed benefits against its potential pitfalls, let’s take a closer look at this particular fat pad.

What is buccal fat, and what happens to it with age? 

When old ladies pinch babies’ cheeks, they’re usually grabbing hold of buccal fat—that pudgy part by the corners of the mouth. But the buccal fat pad isn’t limited to the lower cheek—it extends back toward the jaw and up into the temples, with some segments embedded deeper than others. It’s sandwiched between two masticatory muscles, where it serves as a sort of gliding pad. In infancy, it facilitates suckling; later in life, it assists in chewing. It also shares space with the parotid duct, which funnels saliva into the mouth, and the facial nerve.

“The buccal branches of the facial nerve, in particular, are intimately associated with the buccal fat pad, so it is in a bit of a danger zone in terms of operating,” notes Dr. Steven Levine, a plastic surgeon in New York City. (Tweaking those nerves could affect your smile and the ability to puff out or suck in your cheeks. “But such injuries are rare, and when they do occur, they usually resolve on their own within three to four months, if not sooner,” he adds.)

While all facial fat shrinks to some extent over time, “the buccal fat, in my experience, tends to maintain relatively well throughout life,” says Dr. Levine, who commonly finds a fair amount even in his 70-year-old facelift patients.

And here’s where things get controversial. The persistence of buccal fat—how much it degrades, how swiftly and how its absence may influence your future face—is a point of debate among experts. According to Dr. Matarasso, “the volume of the buccal fat pad is fairly consistent among all adults, regardless of gender, age and body type, and it doesn’t change much over time.” Several published reports support his position (here and here). One study involving the dissections of six cadavers—all older than 60—found buccal fat pads of “normal weight and volume” even in emaciated specimens.

Dallas plastic surgeon Dr. Rod Rohrich, who has written extensively about the fat compartments of the face, insists that buccal fat does, indeed, diminish with age and that “in most cases, you should not remove it—except in the person with a really full face—because doing so can cause premature aging and midface distortion in the long term.” In his estimation, buccal fat ages faster in men and in folks with genetically thin faces. 

While there are many deep and superficial fat compartments contributing to youthful plumpness, “it’s the malar fat pads, or apples of the cheeks, that are the most pleasing and important,” contends Dr. Lara Devgan, a plastic surgeon in New York City and RealSelf’s chief medical editor. As they flatten and fall, many choose to restore them with filler injections or fat grafting. On the contrary, she notes, “it would be rare and exceptional to want added fullness in the buccal sulcus [cheek hollow].”

A 2018 retrospective analysis of buccal fat removal data entitled Buccal Fat Pad Excision: Proceed with Caution makes the point that “buccal fat pad growth is dynamic and drastically increases between the ages of 10–20 … to then decrease over the following 30 years.” The authors also repeatedly acknowledge the lack of “published data regarding the long-term patient follow-up and complications of this procedure”—which makes it impossible to predict how such fat-subtracted faces will fare in the future. 

This fact has some surgeons concerned: “If you’re talking about doing this surgery on a 25-year-old looking for that whistle look—I’d advise against that in almost all cases,” says Dr. Levine, who worries about the predictability of the outcome, both now and later. “When you’re taking out buccal fat, it can be hard to judge exactly how much to remove to create enough of a difference without making someone too gaunt.” Regarding the few young patients he’s made exceptions for over the years, he says: “If you were to ask me if I’m worried about [how] those patients [will look] in 20 years… yeah, I guess I am.”

So where does that leave us? Dr. Sunder offers this indisputable takeaway: “There’s definite clinical evidence that the face, on the whole, does become more gaunt over time. To what degree depends on the individual and their ethnicity. But regardless, if you’re removing any fat from the face—whether it’s fat that’s thought to atrophy with age or not—then you’re adding to that phenomenon of facial thinning.” 

Related: The Surprising Reason I Tried Cheek Fillers for the First Time

Is buccal fat removal right for you?

If your lower-cheek fullness (aka chipmunk cheeks) bugs you enough to land you in a surgeon’s office, then buccal extraction is certainly worth discussing. Be aware though, it is feasible for a face to be too plump for this procedure: “In about 10% of cases, I have to tell someone their face is too full—usually they’re significantly overweight—and that buccal fat removal is unlikely to show results,” says Dr. Patel. “That’s a pro and a con of this surgery—it gives only a subtle change in almost everyone.”

Doctors will also turn you away if they determine your fullness to be caused by something other than buccal fat. “One of the most common things people mistake for buccal fat is masseter hypertrophy,” says Philadelphia facial plastic surgeon Dr. Jason Bloom, referring to bulky jaw muscles that can result from teeth clenching and grinding. “Those big masseter muscles are further back on the face and can be slimmed down with neuromodulator injections,” he explains. “If someone has both problems, I can Botox the back and take out the buccal fat up front, to sculpt the lower face more completely.” But rashly removing the fat alone could accentuate the heft of the jaw, so make sure your surgeon accurately pinpoints the true source of your discontent.

Age is perhaps the biggest—and most contentious—of disqualifying factors. Certain doctors will hesitate to remove buccal fat on patients in their 20s, or even early 30s, who haven’t naturally leaned out yet. Referring to the aforementioned study showing that buccal fat continues to grow throughout the teens and 20s, Dr. Sunder says, “If we remove it during this period, when it’s expanding, you could look doubly hollowed-out in your 30s or 40s.”

When consulting with young people, she’ll ask to see photos of family members they resemble. If said relatives are gaunt at 40, 50 or 60, she’ll caution patients about removing fat at such an early stage. If they decide to move ahead, she explains, “I’ll take a more conservative approach than I would with someone who’s already reached the potential of her leaning out.” But if they’re obviously chasing a more dramatic effect than the procedure can procure, she’ll refuse to operate, knowing “they’ll likely be displeased with the subtlety of the immediate result—and then they may be unhappy with the long-term outcome, because even a conservative approach can lead to significant hollowing down the line.” 

Still, plenty of doctors will acquiesce when it’s clear that someone understands and accepts their uncertain fate. “Patients will say, ‘I don’t care—this is for my career. I need to look my best right now, and if I’m gaunt in the future, I’ll worry about it then,’” says Beverly Hills, California, plastic surgeon Dr. Sheila Nazarian.

And should they later regret that decision? “A little bit of [collagen-building] Sculptra can usually take care of the problem,” says Dr. Nazarian, who also finds that “fat transfer back into the buccal fat pad works really well.” Other surgeons argue that correcting buccal hollowing can actually be quite challenging. “I have patients come in, saying, ‘I had my cheek fat removed years ago, and now I look hollow,’ so we’ll do filler or fat grafting to replace it,” says Dr. Sunder. But because this is a highly dynamic zone and “pretty much the only area of the face where there’s no firm foundation or bone, one can look really done and obvious, if treated poorly.” 

Of course, in 15 or 20 years, when buccal-depleted millennials and Gen-Zers are mourning their lost fat, volume-replacement techniques will surely have evolved exponentially. “It’s going to be a totally different game,” says Dr. Patel, “so I really don’t think [long-term hollowing] is an issue.”

What to expect during buccal fat removal surgery and after

Buccal fat extraction is, by all accounts, relatively quick and low-risk in the hands of an experienced board-certified plastic surgeon or facial plastic surgeon. That being said, “if you don’t know what you’re doing, you could be mucking around in a rough area,” notes Dr. Levine. Bleeding and infection are possible complications; nerve injury, as mentioned, is rare and usually temporary. 

The procedure can be done in your surgeon’s office or operating room (OR), under all manner of anesthesia, depending on doctor and patient preferences. Some find numbing shots to be sufficient; others combine local with oral or IV sedation; and in the OR, many use general anesthesia.

Once you’re anesthetized, your surgeon will mark a one- to two-centimeter incision line on the inside of your cheek and use a scalpel to slice through the superficial tissue. “The muscle underlying it, I don’t cut, because that can cause too much bleeding,” says Dr. Bloom. Instead, he uses a blunt instrument to vertically dissect through the muscle fibers until he’s met by buccal fat. At this point, your surgeon may have an assistant press on the outside of your cheek while he slowly teases free the fat from inside. “I only take what your body gives me,” says Dr. Patel. “If I tug gently and nothing more comes out, that’s it—I don’t go digging for more.” (Doing so can cause scarring and nerve damage.) Doctors commonly compare the size of the extracted fat wad to that of a walnut or large grape. One or two dissolvable stitches is generally all that’s needed to close the wounds.

The procedure takes 15 to 30 minutes, causing soreness and swelling akin to that of wisdom-tooth extraction. Occasional icing and sleeping with your head elevated should help minimize side effects. Your doctor may limit you to soft foods for the first few days and advise against exercising for up to a week. You’ll have to swish with a prescription mouthwash after meals, to keep your incisions clean. 

“It usually takes about two weeks for the majority of the swelling to go down,” says Dr. Nazarian, at which point, your results should gradually start to show. But doctors say it’s highly variable, with some people not noticing complete payoff until three or six months post-op. “There’s a little bit of a shrink-wrap effect at work—you have this empty space after surgery, and it takes a while for the tissues to come back together,” Dr. Sunder explains. “I’ve had patients who are thrilled at three months and then come back at six months, looking even better.”

Buccal-plus: other procedures commonly done with buccal fat removal

While buccal fat removal can certainly be a solo act, in some instances, accompanying procedures can make for a more harmonious outcome. “I don’t think I’ve ever taken out buccal fat as an isolated surgery in young patients—it’s usually done with neck liposuction and/or a chin implant for an overall slimming effect,” Dr. Levine says. In Dr. Matarasso’s office, nose jobs and neck lipo are popular complements to buccal removal, since they work together to “enhance the contour of the face,” he says.

In about half of Dr. Patel’s female buccal patients, he’ll recycle the culled fat once it’s been properly sterilized and filtered. “I usually remove about 4 cc from each side, and I’ll reinject it to give people higher cheekbones, for a more impressive result that lasts,” he says. Likewise, doctors routinely add temporary hyaluronic acid fillers to the tops of the cheeks following buccal extraction, to give the whole of the cheekbones more pop.

In older patients whose skin lacks spring, removing fat in isolation can lead to lower-face sagging. Facelifts and minimally invasive tightening procedures, like FaceTite, can help pick up the slack. Liposuction of the neck and jawline is another sometimes necessary supporting procedure. Without it, an aging jowl may suddenly steal the show: “It’s a compare/contrast issue,” says Dr. Sunder. “The jowl may appear to protrude more, once the area above it thins out.”

Related: Off-Label Is the New Black: The Weird New Ways Doctors Are Using Filler

One final note

For those of you wondering, as I was, if fat-dissolving Kybella might be a worthy competitor to buccal surgery: Nope. Doctors don’t recommend using the injectable in this nerve-rich region. As Dr. Nazarian explains, “Our nerves are all surrounded by a [protective sheath of] fat called myelin. And Kybella doesn’t differentiate between fat we don’t like and the myelin around our nerves. So if we hit a nerve, your smile might be off for six weeks or so, until the myelin regenerates.” Plus Kybella has become synonymous with major swelling and repeat treatments. With buccal surgery, patients swell just the once, she adds, “and then they’re happy and move on with their lives.”