making the cut; Amid the filler frenzy, does anyone get facelifts anymore.

Byline: Julia Reed

Not long ago, a 60-something patient came into plastic surgeon Haideh Hirmand, M.D.'s, office on the Upper East Side of Manhattan. Hirmand's first thought was, This woman looks good, but the patient disagreed: "She said she just didn't look much like who she was." She'd had a facelift in her 40s, and when she produced photos of herself from before and even a few years after the procedure, the doctor finally got it. The images were of an attractive woman with high cheekbones and a sculpted face; her facelift, Hirmand said, had been natural-looking, "not overly aggressive." The problem had started ten years earlier, when she began using fillers, and though she had gone to what Hirmand describes as "very good people," her face had gotten much fuller and increasingly rounded. She was afraid, she said, that she was near the point "where I'll look like someone completely different." Her solution: Go cold turkey on the fillers for a year and have another facelift.

The knife is back. Maybe it's all those photos of the formerly adorable Meg Ryan's strange new face and inflated lips; maybe it's as simple as a woman wanting to see her actual cheekbones again. Whatever it is, says Hirmand, "the pendulum has swung. We live in a culture of excess, and before, it was surgery, surgery, surgery. Then it was all the noninvasives, and now there's a backlash." There's also the realization that there are a great many things, like gravity, that only surgery can address. "A lot of the new technology is great," Anthony Griffin, M.D., director of the Beverly Hills Cosmetic Surgery Institute, tells me, referring to Botox and the assortment of lasers and fillers now available. And like most of his colleagues, he uses fillers-with discretion-to restore volume post-surgery. "But people need to realize that it's not going to solve everything. A lot of bizarre-looking people are being created with these limited tools."

The inclination toward youth in a bottle-or, in this case, a syringe-is natural. Why go under the knife (not to mention general anesthesia) for a forehead lift if you can freeze those wrinkles with Botox? Why have a facelift if you can inject sagging lines with filler and hoist your cheeks a little higher by adding some there, too? The answer is that after a while you can start to look like a paralyzed puff adder or, when addressing the naso-labial folds (those increasingly droopy smile lines from nose to mouth), like a squirrel storing nuts for the winter. "When the fold is overfilled, it pushes on the cheek and the dynamics get distorted," says Hirmand. Then there are the eyes. You can lessen the crow's-feet around them with Botox, but you cannot fill the hanging skin of the upper lid. "We still have to excise and tighten the skin," Hirmand says. Same thing with a sagging neck. "You cannot fix your neck with fillers," says John Owsley, M.D., a prominent San Francisco surgeon.

The good news is that the knife has not only gotten kinder (shorter incisions, less bruising and bleeding), it has gotten smarter and more individualized. Endoscopic brow lifts, for example, "went out of vogue for a while," says Griffin, "because people were pulling too high." Now most surgeons are mindful that with the bone and hairline changes in older people, brows look ridiculous yanked up to where they are on the face of a 20-year-old. (He is right-I once saw the 70-something wife of a very famous and very old Holly_wood actor at a party, and her arches literally met her hairline.) Similarly, while an eye lift remains a tried-and-true procedure, surgeons are not removing as much fat from beneath the eye as before. "We've just learned to dial it better," says Hirmand. "You have to take a little fat if you're going to get the best contouring, but nobody takes as much as ...