The Two-Finger Rule

Almost every day a patient comes to me holding up the sides of her face and asking, “Can you do this for me?”  The answer almost invariably is no, and I would like to take this blog to have you understand why that is.  I like to call this the “Two-Finger Rule” meaning when you lift up part of your face with two fingers in most cases what you are wanting cannot be accomplished or at least not exactly the way you are showing it to me.  I know that there is this inner feeling that “Hey, if I can just lift my fingers up so easily, why can’t an experienced surgeon do the same with his blade or laser?”  The answer is complicated but we will delve into it in this blog.

The first thing that the two-finger lift does is simulate a lifting motion.  This outcome is perhaps something that a surgeon can approximate but not reproduce in a 1:1 ratio for a few reasons.  First, if a facelift is performed the lifting of the face is done in the deep tissues called the superficial musculoaponeurotic system, or SMAS for short.  The skin is never lifted.  If the skin is pulled back the individual can look pulled but more likely than not the skin will stretch back to its original position and the scar will widen.  The deeper structure must be lifted not the skin.  Secondly, any lifting procedure tends to relax a little over time so when two fingers are used to lift the tissue one thinks that a tissue can be that precisely lifted, which is impossible.  So as far as lifting is concerned, a facelift can approximate but not reproduce the two-finger lift.

The second reason someone does the two-finger lift is to smooth out skin imperfections like wrinkles, pores, or other skin ailments.  This is something that is near impossible to correct in such a fashion.  This is partly due to the reason explained in the paragraph above, i.e., anything stretched surgically will relapse quickly and lead to a wider skin scar.  In addition, laser resurfacing or a filler to correct the skin problem more directly than a surgical lift would still have limited potential in rectifying matters to one’s satisfaction if held up against the standard of the two-finger lift.  Things can look just too perfect when two fingers are used to smear out any skin blemishes.

Do I use the two-finger rule myself?  Actually, yes.  I gently lift tissues to show a prospective patient what a facelift can do but I always stress the limitations of any procedure to match the power of what two fingers pulling back can do on the skin surface.  I rather speak of how fat transfer or fillers can manage hollowness of the face by pointing out areas of hollowness, how Botox can manage wrinkles by pointing out the wrinkles, and how lifting procedures can target areas of looseness by pointing out the areas of concern.  As in any procedure, setting up appropriate expectations for an individual is crucial, and the two-finger rule sometimes gets in the way of this realistic dialogue.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. Call 972.312.8188 to schedule a consultation or to ask Dr Lam a question about facial rejuvenation please visit his plastic surgery forums.