‘Doc, how much younger will I look after a facelift?’

Artificial intelligence may now be able to give a definitive answer to this age-old question and quantify how young a person looks after facelift surgery.

For many patients, the reasons for having a facelift are simple: to turn back the clock for a younger, more refreshed and more attractive appearance. Even during 2020, a year severely impacted by COVID-19, more than 234,000 patients underwent facelift surgery in the US, according to American Society of Plastic Surgeons (ASPS) statistics. This makes it the third most common cosmetic plastic surgery procedure, with similar trends here.

One of the most common questions prospective facelift surgery patients ask is: ‘How much younger will I look?’ For aesthetic surgeons, this has been a difficult question to answer. Typically, the outcomes of a facelift have been judged on a case-by-case basis, or with the use of subjective ratings.

Now research, published in Plastic and Reconstructive Surgery¹, suggests a new, objective approach to assessing the reduction in apparent age after facelift surgery: artificial intelligence (AI) networks trained to estimate age based on facial photos.

‘Our study shows that currently available AI algorithms can recognise the success of facelifting, and even put a number on the reduction in years of perceived age,’ comments senior author James P Bradley, MD, Vice Chairman of Surgery, Zucker School of Medicine at Hofstra/Northwell in New York.

Because there are few objective studies assessing the success of facelift surgery, the authors used artificial intelligence, in the form of convolutional neural network algorithms alongside FACE-Q patient reported outcomes, to evaluate perceived age reduction and patient satisfaction following facelift surgery.

‘By training on datasets containing millions of public images, these neural networks can learn to discern facial features with much higher ‘experience’ than a typical person,’ said Dr Bradley.

Four different, publicly available neural networks were used to make objective age estimates of facial age for 50 patients who underwent facelifting. The AI estimates were made using standardised photos taken before and at least one year after facelift surgery.

The results were compared with patients’ subjective ratings of their appearance, along with responses to a standard patient-rated evaluation (FACE-Q questionnaire).

The patients were all women, average age 58.7 years. The AI algorithms used in the study were 100 percent accurate in identifying the patients’ age, based on “before” photos. In the “after” photos, the neural networks recognised a 4.3-year reduction in age after facelift surgery. That was substantially less than the 6.7-year reduction, as rated by patients themselves.

‘Patients may tend to overestimate how much younger they look after facelift surgery – perhaps reflecting their emotional and financial investment in the procedure,’ Dr Bradley comments.

On the FACE-Q questionnaire, patients were highly satisfied with the results of their facelift surgery: average scores (on a 0-to-100 scale) were 75 for facial appearance and over 80 for quality of life.

Neural network estimates of age reduction were directly correlated with patient satisfaction.

‘The younger the AI program perceives a patient’s age, the greater their satisfaction with the results of their facelift,’ says Dr Bradley.

Artificial intelligence algorithms can provide an objective and reliable estimate of the apparent reduction in age after facelift surgery, the new findings suggest. These age estimates also seem to provide an indicator of patient satisfaction scores – even if the reduction in years doesn’t quite match the patient’s own subjective rating.

‘Together with powerful image analysis tools used in modern plastic surgery, neural networks may play a useful role in counselling patients and demonstrating successful results of facial rejuvenation procedures,’ Dr Bradley adds.

‘We think that AI algorithms could also play a useful role for plastic surgeons in assessing their own results and comparing the outcomes of different techniques.’

Women under 50 achieve better results, higher satisfaction

A 2011³ study published in Plastic Reconstructive Surgery found younger patients with ‘early or minimal signs of facial ageing’ achieve better results and higher satisfaction rates at least a decade after facelift surgery.

Because of their superior long-term results, patients younger than 50 years old undergoing ‘maintenance facelifts’ should be considered preferable candidates for facial rejuvenation surgery, suggests the report by Drs Tom S Liu and ASPS Member Surgeon John Q Owsley of California Pacific Medical Center, San Francisco.

The surgical facelift remains the aesthetic standard for correction of the anatomical changes of the ageing face and for long-lasting results, the authors note. However, younger patients (younger than 50 years) with early facial ageing are often fearful of or discouraged from facelift surgery in favour of simpler yet short-lived nonsurgical and surgical options.

For the study, Drs Liu and Owsley compared the short-term and longterm patient satisfaction ratings with expert analysis of followup photographs. They analysed differences in long-term outcomes for patients in three age groups: patients younger than 50, 50 to 60 years, and over 60 years old at the time of facelift surgery.

Consistent with previous research, younger patients had higher and more consistent satisfaction scores at both short- and long-term follow-up. Those subjective ratings were supported by expert analysis of follow-up photos, which showed that patients who underwent facelift surgery before age 50 had ‘remarkable maintenance of their youthful appearance’.

The patient satisfaction ratings were generally consistent with the expert ratings of before-and-after photographs. On long-term follow-up using a 5-point scale (5 being most satisfied), patients in the under-50 age group continued to rate all facial areas with 4’s and 5’s, compared to 2’s to 5’s for the 50-to-60 group and 2’s and 3’s for the over-60 group.

In contrast, at the time of surgery, patients in the over-60 group already had ‘significant facial ageing changes’. At long-term follow-up, they still looked more youthful than other people of the same age – however, they had signs of ‘regression’ in the five facial areas graded by plastic surgeons. Patients in the 50-to-60 age group had intermediate results.

Although the study was small, it seems to support the impression of experienced plastic surgeons that ‘younger patients who have facelifts (<50 years old) have longest lasting results with less noticeable postoperative changes,’ according to Drs Liu and Owsley. Although the visible signs of ageing seem mild in patients under 50, they represent the ‘tip of the iceberg’ of the effects of ageing underneath the skin.

‘Although equal in the number of years elapsed, the facial ageing of a patient from age 40 to 50 is much less dramatic than the same patient from age 50 to 60,’ the researchers add.

Younger patients interested in facial rejuvenation may be steered away from a facelift, or undergo limited or nonsurgical procedures to ‘buy time’. ‘However, these…are also the same patients who would benefit most from surgical facial rejuvenation or so-called ‘maintenance facelift,’ the researchers write. Not only will the results last longer, but the initial change is generally less dramatic and noticeable than in older patients.

Dr Foad Nahai and the ‘Maintenance’ Facelift

In 2017, plastic surgeon luminary Dr Foad Nahai wrote an editorial4 in Aesthetic Surgery Journal, commenting that a surgical facelift performed at the right time is a superior, longer-lasting and more cost-effective treatment than any nonsurgical alternative. The following is an excerpt from his comment: ‘…Many surgeons today embrace the concept of the so-called maintenance facelift, designed for the patient with minimal – even barely perceptible – facial ageing. I admit to having a degree of discomfort with the term, if not the entire concept. Perhaps it is only a matter of semantics, but I believe the word ‘maintenance’, used in this context, seems to imply that facelift surgery is a preventive, rather than a corrective, treatment. In my mind, however, the old adage ‘if it ain’t broke, don’t fix it’ still applies.

‘In their excellent article, “Nonsurgical Facial Rejuvenation Procedures in Patients Under 50 Prior to Undergoing Facelift: Habits, Costs, and Results,”⁵ Jacono et al discuss the results of their survey of 157 patients whose facelift surgery was performed before the age of 50 (average age 44) and who had undergone nonsurgical treatments for facial rejuvenation prior to rhytidectomy, beginning at an average age of 37. Ninety-four percent (94%) of respondents to this survey cited prevention of an aged appearance as their original reason for desiring rhytidectomy. Interestingly, the average perceived age respondents believed that they appeared prior to undergoing surgery was 44, the same as the average chronological age at the time of surgery.

‘From this finding, I infer that many of these early-facelift patients were not seeking merely to look ‘good’ for their age but, rather, to look younger than their age or to ‘maintain’ their current appearance (or a slightly better version of it) by halting the visible ageing process.

‘It has been my experience, and it is my firm belief, that a surgical facelift performed at the right time is by far a superior, longer-lasting and more cost-effective treatment any nonsurgical alternative.

Determining that ‘right time’ is a multifactorial problem. I am well aware of the rationale for early facelifts and by no means wish to imply that such interventions are always inappropriate.

‘Jacono et al provide compelling data that a graduated approach to addressing facial ageing (utilising nonsurgical treatments for a number of years prior to ‘stepping up’ to surgery) may not be preferred, in retrospect, by a signifi cant proportion of younger patients.

‘While most respondents to their survey (91%) were satisfied or very satisfied with their surgical results, more than half (52%) wished they had selected to undergo surgical intervention earlier. In cases where a less invasive alternative might be suffi cient, however, I still choose to encourage patients to delay facelift surgery.

‘My motivation is not the desire for additional revenue from administering multiple injections of neuromodulators and fi llers or from providing other costly but temporary ‘fixes’. I simply believe that, frequently, there may be downsides associated with early surgical intervention when an invasive procedure is not absolutely necessary.

‘It has been argued that the ageing changes addressed by the maintenance facelift are subtle but nonetheless real, and age is irrelevant.

I agree that chronological age is not nearly as relevant as physiological ageing. However, in the vast majority of patients, I believe ‘less is more’ still applies, up to the point at which surgery becomes the only eff ective option to address visible facial ageing – at whatever age that may occur.

‘I further propose that encouraging patients to take a somewhat more forgiving view of themselves is not a terrible philosophy. The idea that every trace of every wrinkle must be eradicated the moment it appears is one that inevitably leads to patient frustration and loss of self-esteem.

Helping patients to look their best may sometimes be quite a different matter than indulging unrealistic goals of perfection and agelessness.

‘The subliminal message in the term ‘maintenance facelift’ is perhaps as subtle as the early ageing changes it proposes to address. At the very least, plastic surgeons who use this nomenclature with patients should be sure to explain that ‘maintenance’ does not mean stopping the clock.

The constant pursuit of perfection can become an impossible burden unless tempered with a sufficient dose of realism. Perhaps we owe it to some of our more highly vigilant patients to remind them that better can sometimes be the enemy of good. This being said, Jacono et al persuasively establish that a combination of nonsurgical and surgical approaches to facial ageing produces a high level of patient satisfaction. In the end, it is up to the individual patient and her doctor – based on a thorough discussion of goals, risks and benefi ts – to determine the most appropriate timing for each modality.’ AMP

1 Zhang BH, Chen K, Lu SM, Nakfoor B, Cheng R, Gibstein A, Tanna N, Thorne CH, Bradley JP. Turning Back the Clock: Artificial Intelligence Recognition of Age Reduction after Face-Lift Surgery Correlates with Patient Satisfaction. Plast Reconstr Surg. 2021 Jul 1;148(1):45-54.
2 Sinno, Schwitzer, Anzai and Thorne. Facelift satisfaction using the FACE-Q. Plast Reconstr Surg. 2015 Aug; 136(2):239-242.
3 Liu TS, Owsley JQ. Long-term results of face lift surgery: patient photographs compared with patient satisfaction ratings. Plast Reconstr Surg. 2012 Jan;129(1):253-262.
4 Nahai, Foad. The ‘Maintenance’ Facelift: A misnomer? Aesthet Surg J. 2017 Apr; 4(1); 492–494.
5 Jacono AA, Malone MH, Lavin TJ. Nonsurgical Facial Rejuvenation Procedures in Patients Under 50 Prior to Undergoing Facelift: Habits, Costs, and Results. Aesthet Surg J. 2017 Apr 1;37(4):448-453.