Andrew Frankel is not just the country’s most in-demand plastic surgeon, he’s also one of the most reluctant subjects to interview. He tends to shy away from media attention, has a naturally reticent nature—and those aren’t the only things complicating the beginning of our chat. We’re sitting in my backyard in Los Angeles, attempting to talk over the masks we wear to protect us not only from the coronavirus, but also due to smoke fumes from the fires up north. To add to the mounting distraction, there are two police helicopters circling overhead, trying to find an alleged intruder on the run in the canyon. But this circumstantial lunacy doesn’t seem to ruffle the feathers of one of the world’s most esteemed facial plastic surgeons. He chuckles and quips, “Just another day in L.A., right?”
Frankel knows L.A.—it’s where he’s practiced for 25 years, tending not just to Hollywood royalty, but to global political and foreign dignitaries as well. His artistry (and discretion) in the realm of facial plastic surgery has earned him a prominent client list.
And his vocation is booming. In the last decade, social media has been the most dominant factor impacting beauty ideals. Filters and apps have given way to duck lips and unrealistic body proportions that are simply unattainable, unrealistic, and dangerous—especially because some women attempt to achieve this aesthetic by going under the knife with outdated procedures or doctors who are not scrupulous with their surgical methods. Proper—and improper—plastic surgery procedures show no signs of slowing down. In fact, elective surgery has been on the rise since the pandemic took hold; women are choosing to have plastic surgery now because downtime is not an issue.
In this interview, Dr. Frankel gives some valuable guidance on the world of plastic surgery—through the lens of a medical professional.
What is the “youth over beauty” dilemma?
In terms of what defines beauty today, geography does play a role in affecting aesthetic ideals. Here in Los Angeles, home of Hollywood, there is this societal emphasis on looking beautiful. However, the desire to be young has bizarrely eclipsed other beauty priorities. There is a trend where youth is prioritized in an unbalanced way. This phenomenon is becoming more and more common here in Los Angeles, versus another region such as New York or Paris. I believe it may derive from our youth-centric culture, where the need to prioritize youth is necessary to remain current and relevant for employment.
It’s a clear example of the ‘youth over beauty culture.’ Many times, we’ve seen the woman who used to have incredibly striking features like high cheek bones and a defined jaw who now no longer even resembles herself. She now has fuller, circle-like cheeks and a round face, creating puffiness around the eyes and making them appear much smaller. This woman may not look her age, but she also no longer looks like a younger version of herself and no longer embodies that unique beauty she once did. In my experience, patients from European countries seem to be less willing to change their overall look because age is not as culturally taboo. It feels to me as if European beauty preferences derive more from a sense of embracing individuality and self-confidence with less emphasis on age. Surgery must also be done thoughtfully, taking the edge off the aging process without obliterating a person’s essence.
No product will ever be as effective as plastic surgery. So, if someone is going to consider facial rejuvenation, what’s the best type of “face lift?”
Despite the development of numerous technologies and products designed to stave off aging, there is still nothing that compares to a well-performed facelift. I learned the deep plane face lift technique from my iconic mentor Frank Kamer in 1994, when this procedure was first conceived. I’ve continued to use and improve this technique over decades as it has become my mainstay for facial rejuvenation. It can sound technical, but the deep plane face lift allows for greater tension to be applied to the tissues—hence, a greater lift. The deeper level of dissection also means the skin maintains a better blood supply and looks less pulled, the incisions heal optimally, and the results last longer. Of course, the technique is only as good as the surgeon and it must be modified depending on the specific needs of the patient, but I feel strongly that this is the optimal choice of procedures at this time.
What is the downtime? And what helps diminish swelling and bruising?
Normal downtime for facial surgery depends on the specific procedure. A face lift patient will typically take between 12-14 days before they feel comfortable returning to the public. When other procedures are combined with a face lift, such as eyelid surgery, midface or brow lift, the amount of bruising and swelling is more significant, but the length of the downtime is only increased by a few days. Patients usually look better within a few weeks, but it takes four to six months for everything to settle completely. Noses are different, and although the acute bruising and swelling are manageable by day eight, it takes roughly 18 months for the nose to take its final shape.
The most profound tool for minimizing bruising and swelling associated with surgery is unquestionably hyperbaric oxygen. Having these treatments done before and after the procedure not only helps the patient look better sooner, but it also minimizes the risk for complications such as skin slough and infection. Nutrition is a key element for optimal healing because surgery places increased stress on the body requiring extra protein and energy. Years ago, it became apparent that many of my patients didn’t want to eat during their recovery because they weren’t able to exercise, and they feared weight gain. In fact, it’s quite the contrary: The number of calories required to heal from a face lift is significant and adds dramatically to normal baseline needs. If a patient doesn’t replenish stores of calories and protein after surgery, they may become depleted, leading to exhaustion and sometimes even slight depression after about a week of healing.
What procedures are most easily botched and outdated?
The most unforgiving area on the face is the lower eyelid and operations that involve removing skin from there can be very problematic. Additionally, I would avoid surgeries that involve reductive techniques because removing lots of fat and muscle from the upper eyelids leads to a hollowed, cadaveric-like look—and in my opinion, this should be avoided. The old standard Coronal brow lift utilizes an invasive incision across the scalp and this procedure should rarely, if ever, be performed as there are much better ways to address this area without enduring the many downsides. I am also not a fan of cheek implants in people over the age of 50 unless it is used to reconstruct following a trauma. I also recommend that implants not be placed into the lips for augmentation as they can be problematic and there are much safer and more effective options available. Finally, I feel strongly that liposuction should never be performed in the cheeks above the jaw line.
How can I find the correct surgeon for me? What should I look for?
My checklist for choosing a qualified surgeon starts with word of mouth from trusted sources, then the frequency that the surgeons performs the surgery. But the most important factor to consider when choosing a surgeon is how often he or she is performing the procedure in question. A prospective patient should inquire as to the number of that procedure the surgeon does per year or in the past six months. Many surgeons have fine reputations that are geared toward one particular procedure. And while they might have a mastery over that particular thing, these surgeons might not have the same level of experience or skill at addressing requests that are outside of their wheelhouse.
The American Academy of Facial Plastic and Reconstructive Surgery has a website that allows prospective patients to search for someone local. This is a good starting point, because having board certification is important, but this alone does not necessarily guarantee a good experience. The most prominent qualifications for plastic surgery are The American Board of Facial Plastic and Reconstructive Surgery, The American Society of Ophthalmic Plastic and Reconstructive Surgery, American Board of Plastic Surgery. Also, make sure you’re doing your own analysis of that surgeon’s before/after photos and ask to speak with any recent patients. Most importantly, check in with your overall sense of the person during your consultation. Do you feel they were on the same page as you, aesthetically? Do they seem confident and have they provided explanations for their recommendations? Do you feel they will be there for you and are they easy to communicate with? This is extremely important because if there is a complication, you will want and need a trusting relationship with your surgeon.
What options do those who aren’t ready to go under the knife have?
Today, there are many options besides surgery that can help you achieve beautiful results. Neurotoxins such as Dysport and Botox can be artfully employed in numerous ways to provide improvements ranging from skin tone, wrinkles and facial shape. Skillful use of fillers can impart gentle improvements in contour and address specific bothersome areas related to loss of volume. Non-surgical technologies such as fractionated CO2 lasers and micro RF devices can revitalize the skin surface while other machines are designed to modestly tighten from below. Beginning with a limited scope feels better to some patients and then they can ease into the idea of having a larger operation down the line. In fact, surgery is not always the best treatment modality for a particular issue and non-surgical treatments can deliver worthwhile improvements. Patients should be more excited for their outcome than apprehensive about the surgery.
If they are not yet at that point, then it’s too soon to operate and instead a new game plan can be executed where more subtle improvements can be achieved. The key is adhering to the overall aesthetic goals and working toward those in a way that feels comfortable for that patient.
Which non-surgical devices do you recommend for those still not considering surgery?
There are non-surgical devices which can be employed to tighten and rejuvenate the skin. Surgery tightens the deeper tissues and skin by moving it while the tension applied to the skin causes it to look smoother, however there is no actual improvement in the quality; it’s still the same piece of skin. Part of a complete rejuvenation should address things like photo damage, fine lines, wrinkles, pores, etc. and I think the current use of micro needling, with or without radio frequency, combined with products that contain growth factors are also a great option.”
What’s the deal with rhinoplasty vs. fillers?
When it comes to the nose, I favor surgery over fillers, but these do not have to be mutually exclusive. Fillers are a great option that can offer some advantages because they are quick to perform, inexpensive, and reversible. Additionally, fillers are injected so they don’t have a set shape with edges that might one day become visible—which can happen with cartilage grafts that are placed surgically. Despite their popularity, nasal fillers do have some drawbacks. Fillers are safest when used in the upper 2/3 of the nose but should not be used near the alar rims or tip of the nose because they can cause a blockage of small blood vessels that supply the tissue in these areas and subsequently cause necrosis and tissue loss.
Because fillers create their effect by adding volume to the nose, there is often a trade-off for size; even if someone likes the new shape of their nose after it’s been filled, they must also accept a larger nose overall. Surgery can create a smaller nose, but fillers cannot. Fillers can be helpful for someone who is considering rhinoplasty to improve their profile. It should be noted that the only fillers I think should ever be injected into the nose are hyaluronic acid gels due to their reversibility and their safety profiles.