Outside of Hollywood, Dollywood, and Neverland, a conspicuous face-lift has all the cachet of an Arkansas land deal. Many women who want to get rid of their sagging jowls and spreading crow's-feet fear that their choices are limited to tight, tighter, and too tight. "You look around at a dinner party," says one New York socialite, "and you start to feel untidy. You go home upset, thinking, maybe I should take better care of myself, have a face-lift." What's holding her back, she confides, is her fear of the wind-tunnel look. "I want my children to recognize me," she says, but she doesn't want to look older and older. She wants to look natural.

Doctors feel her pain. The aging face is a major battleground. There are many new techniques, each with equally vocal advocates and detractors. There is "an ongoing debate between those who tighten deeper levels of the face and those of us who do simple skin lifts," says John Q. Owsley, professor of plastic surgery at the University of California Medical School at San Francisco. In a perhaps overly ambitious attempt to get some answers, several theories and reputations were put to the test last year in what is surely the most elaborate competitive face-lifting match, staged at Owsley's annual teaching symposium in San Francisco. (The initial results were presented in late April of this year.) If the Consumer Reports approach could work for air conditioners, minivans, and cappuccino makers, maybe it could work for cosmetic surgery.

Some 90 years after the first face-lift was performed, four anonymous middle-aged women—two sets of identical twins—were enlisted to test four techniques. Performing the operations were four prominent plastic surgeons (each assigned to a different patient): Daniel C. Baker of Manhattan, Samuel T. Hamra of Dallas, Oscar M. Ramirez of Baltimore, and Owsley himself who called the event the twins study. Insiders, however, dubbed it the "face-lift shoot-out."

At last count, there were about 70,000 face-lifts performed annually in the United States, and the figure will probably rise as baby boomers age. Although most women don't have a clue that there are several ways to do a face-lift, they do know what they don't like. The taut face that was once a status symbol (and still is, in some enclaves) is becoming as passe as the pinched ski-jump nose. "I'd rather see someone age naturally than look too tight," says Miami plastic surgeon James M. Sruzin. He assures his patients that "the surgical look" is not inevitable. Jacqueline Kennedy Onassis, for instance, had multiple lifts yet didn't look over-processed.

Unfortunately, bad work calls attention to itself, while good work is "virtually undetectable" except by doctors, says San Francisco plastic surgeon Timothy J. Marten. The goal of most patients—and most surgeons—is a long-lasting natural look, with a reasonable recovery period and minimal complications. "Paradoxically," says Lawrence N. Seifert, assistant clinical professor of plastic surgery at UCLA, "you have to do a more extensive and riskier operation to give the appearance that less has been done."

Plastic surgeons like to say there are at least 25 variations of face-lift. Most have cryptic names such as the Skoog, the SMAS, the SACS, the S, the soft, the round, the bivector, the composite, the mask, the mannequin, the SMILE, and the FAME.

But how do the face-lifts compare? "There is no objective grading scale to measure the results," says Fritz E. Barton Jr., a professor of plastic surgery in Dallas. Complications and recovery time can be gauged, but skin quality varies widely among patients and can affect results. And aesthetic judgments are subjective at best. "A patient will come for a consultation," Baker says. "She'll say, 'I saw so-and-so on television and she looks terrific, Did you do her?' You don't answer, but if you did do her, you feel good. Two hours later, another patient says, 'I hope you didn't do so-and-so, because she looks terrible.'"

The twins study is only the first attempt in 20 years to compare different face-lift techniques—the first to use a different procedure on each subject in the study. In previous comparisons, a different face-lift technique was used on either side of one face (the "asymmetrical lift"]. Obviously, the specialists needed a better way to compare. Bernard S. Alpert, a plastic surgeon in San Francisco, suggested using twins. And so began the face-lift comparison to end all face-lift comparisons. In return for free surgery, the four women are supposed to cooperate so that complications, recovery, effectiveness, and long-term results can be compared.

The four surgeries, simulcast from San Francisco's Davies Medical Center to an audience of 200 surgeons who paid $750 a piece to watch in a hotel ballroom, were the highlight of the two-day meeting in March 1995. Egos and reputations were on the line.

Nothing was left to chance. Baker brought his own scrub nurse, sterilizer-ready tray of scissors, retractors, liposuction cannulas, and even his own suture material. Hamra arrived with two scrub nurses, special retractors, his favorite headlamp, his own disposable caps and masks, and a special headboard for the operating table. Ramirez brought a physician assistant and a case of instruments—including his Ramirez Periosteal Elevators (high-tech spatulas designed to free tissue from the facial skeleton) and special scissors and graspers. Even though it was Owsley's hometown, it was not his regular operating room, so he brought a scrub nurse, a table, instruments, and his own hydraulic surgical chair.

"All four patients will get a quality operation—a blue plate special," said Hamra, the day before he operated. "And [we doctors] will all eat a little crow if we can't see a difference."

Up until the 1970s, there was only one way to do a facelift: tighten the skin. The earliest cosmetic surgeons cut out ellipses of skin in the forehead and in front of the ears and stitched the remaining skin back together. By the 19405, the face-lift incision was one continuous hairpin curve that would loop down in front of the ear and then around the earlobe. Going more than skin-deep was considered unthinkable because of possible risk to the facial nerve.

"The skin lift is still the most common [face-lift] done around the world," explains Fritz Barton. "Just pull the skin up and back, trim the excess, close it off with tension, like pulling on the covers to make a bed. The problem is—skin is like taffy. When it's over-pulled, it will stretch back out to release the tension, and that's where the sagging comes from." And then another lift is required. And another. "The wind-tunnel look is three [skin] lifts done badly," explains Peter Mckinney, a Northwestern University plastic-surgery professor.

Some surgeons began questioning all the repeat business they were getting. In the early '70s, Owsley recalls. he was "apologetic" about lifts not lasting. "Patients came back every year. It was embarrassing. I didn't want to charge again."

Three subsequent developments set the stage for the twins study. In 1974, Tord Skoog, an innovative Swedish plastic surgeon, found the key to a longer-lasting procedure. He said the sheet of tough tissue—or fascia (now believed to be a remnant of a muscle)—that runs under the skin from the cheekbone to the neck could be a veritable girdle for the face if the skin and muscle were pulled up together. The same year, a team of French plastic surgeons rechristened the sheet of tissue "the SMAS"—short for superficial musculo-aponeurotic system. When a landmark paper on the SMAS was published in 1976, the race was on.

All over the world, surgeons began doing a variety of SMAS lifts, which tighten sagging jowls and loose necks the primary stigmata of aging. Like tailors experimenting with a new piece of cloth, surgeons pulled the SMAS this way and that—together with the skin, like Skoog, and in different directions. With the 1980s came the mask lift, an operation that can actually change the physiognomy of a face. In this procedure, the surgeon lifts the tissue of the upper face off the bone and raises it up a few centimeters.

As lifts got deeper and more high-tech, there was more chance of nerve injury, and doctors began debating whether the results justified the risks. Daniel Baker and others made a plea for restraint. The twins study became the fulcrum of the debate, "No one can say if his technique is better or lasts longer," said Owsley. "This is the beginning of trying to answer the question that has eluded all of us." Namely, are deeper lifts better?

"Involving twins was an effort to control some variables using tissues that are similar:' said Bernard Alpert. "This is not some earth-shattering scientific endeavor." Instead, it's an effort "We determine if there are nuances of technique that can help us advise patients...which operations last longer."

It became clear that comparisons—even between twins would be difficult. "They were identical twins, but they were not identical people," says Hamra. Baker points out that "lifestyle differences such as tanning, smoking. drinking. and weight affect the way (even twins) faces age and heal." Each woman wanted, needed, and got work in different areas of the face. Previous surgery further corrupted the study.

One pair of twins (whom we'll call Audrey and Andrea) was 56 at the time of surgery. Audrey was assigned to Baker. "She just wanted a freshening up," he says. The technique he's been doing for the last four years—a lateral smasectomy—is the least invasive of the four lifts demonstrated in the study. It is a classic skin lift combined with a limited tightening of the SMAS. "If it's not tight enough, I'll redo it," Baker tells patients. "I get a consistent good result...and there is a high degree of safety." (He says his redo rate is 2 percent.)

Audrey had tattooed eyebrows, says Baker, "and wasn't particularly bothered" by the vertical crease in her forehead. He decided not to do a brow lift. which he says "would just give her a surprised look." Instead. Baker used dermabrasion on Audrey's forehead (as well as on her upper lip). He also did a standard upper and lower blepharoplasty—an eye lift and filled in the corners of Audrey's mouth with fat injections.

Audrey's sister, Andrea, was assigned to Hamra. who often comes across as the underappreciated prophet of the face-lift. When Hamra lectures, he never misses a chance to zing his colleagues—and himself—with slides of over-pulled faces, pointing out "these hollow-looking eyes the up-ward sweep of the cheeks...I see them everywhere. Those faces aren't harmonious."

Andrea had a fuller, more weathered face than her sister. Time and the sun had made her look older. Bantering with Baker, Hamra complained, half-jokingly, that he had gotten the older twin. "Older by one minute," retorted Baker.

According to Hamra, as we age, the pieces of the face—the skin, the cheek pads, the fascia, the undereye muscle and fat—all sag in unison and must be repositioned in unison. Every Hamra face-lift patient gets a brow lift. "In my camp, the more you do, the better you look," he says. "I don't do bits and pieces. I say, do it all at once, like a house—and do it between the ages of 44 and 48. You'll never have to do it again. Well, maybe in 15 to 20 years. If the patient has obvious cheek implants. I remove them. They're terrible for the aging face. In L.A., they're a substitute for a face-lift. They're supposed to look like Linda Evans's checks, but they look like subcutaneous cysts."

Hamra's composite lift is an alarming operation to watch. At one point, the patient is lying on the table with her skin cut loose and spread out like a mask with holes cut out for eyes. The procedure causes more swelling and bruising than others and usually requires a longer recuperation. "I tell patients, 'You can go to the supermarket, but not a cocktail party for eight weeks." Andrea, though, was able to go back to work in one month—just as her twin was.

Betty (not her real name), who had had no previous surgery, was paired with Owsley. who considered her age, 49, ideal. "It's better to do [a face-lift] in the mid-to late 40s." says Owsley. "you'll change in a very subtle way. The average person is not going to know you had a face-lift. Then you can go 10 to 12 years, maybe even longer, until you reach a point where you look 47 and you're actually 60. You'll look a hell of a lot better than your contemporaries will, and you can say it's all in the genes."

Owsley is a proponent of the multivector SMAS lift, which is more aggressive than Baker's SMAS lift. "By putting the tension on the deeper structures, you get a less pulled look," says Owsley, "I can't think of more than a handful of patients who needed reoperating in under ten years." In inexperienced hands, it has more risk, he admits, but adds, "My facial-nerve injuries have been zero." Owsley does brow lifts only when necessary. In Betty's case, he fixed her brow furrow, did upper—and lower—eyelid lifts, and removed neck fat with liposuction.

Betty's twin, Beverly (also not her real name) was operated on by Oscar Ramirez. A golfer and a heavy smoker (she quit a month before her operation). She had sun damage and vertical upper-lip lines and had undergone an eye lift a few years earlier. Ramirez performed an endoscope-assisted sub-periosteal lift (under the tissue that covers the bone). a procedure that requires more than a little expertise. It's an offspring of the mask lift, the deepest of the deep lifts. The surgery is done with the endoscope, a camera in a tube that enables the surgeon to use tiny incisions and watch what he's doing on a monitor. This so-called scarless surgery requires five incisions in the scalp, others in the eyelid and mouth. To take care of the lower face and neck, he made traditional incisions in front of the ear and under the chin. Predictably, Beverly was more swollen than her sister. Still, she was back at work in one month.

Once the surgery was behind them and the patients had healed, there was nothing to do but speculate about the outcome. Rumors were flying: Some doctors were impatient to see the results. Hamra had Andrea and Audrey fly down to Dallas so he could take his own six-months-after photos. "He sent me pictures in October," Baker says, amused at how seriously Hamra was taking it all.

Before and one-year-after pictures were scheduled to kick off the annual American Society for Aesthetic Plastic Surgery meeting at Walt Disney World. On April 29, 1996, a thousand surgeons filled the Fantasia Ballroom. Each of the four doctors made his presentation. And, to the surprise and even disappointment of many, the shoot-out ended with all four doctors still standing. Those surgeons who had predicted that no one would be able to tell who did which operation were right, After 20 years of debating whether less is less, or more is too much, the four results looked just about...equal. Each woman looked 10 or 15 years younger.

If there was any hitch, it was the documentation of the procedures. Because of logistical problems, follow-up pictures couldn't be taken at the same time or place or in the same light. In the doctors' one-year photos, bangs obscured foreheads, earrings hid incisions, and eye makeup distorted contours.

Hamra, who had predicted a year before that "we'll all eat a little crow if we can't see a difference." was now, well, eating crow. "This has been interesting," he says, "but it's not science." For Hamra, the message is that "it's the technique, not the surgeon," that matters.

Baker disagrees. No one technique guarantees good results, he insists. "I say a lift should last eight to ten years. How can we know [Hamra's] lasts? He hasn't been doing it that long," Responds Hamra. "Five-year follow-ups have been great."

Owsley admits that the results are not conclusive. "No one can say. 'Mine looks better.'" More time is needed, he says. "It may be too soon to see major differences. We must judge them at five years and ten years."

"There's an implicit agreement," says Owsley, that the twins will allow the doctors to follow them, but there's no written contract. And right now, no date has been set for the next round of photos, What's more there's nothing to stop any of the women from going back for subsequent work if they want it.

There was some shock the day of the presentation when Ramirez told the three other surgeons that, at Beverly's request, he had seen her in Baltimore eight months after the lift for a light laser resurfacing. Consequently, in her one-year photos, Beverly still had some beneficial swelling. "Doing a laser in midstream makes it harder to compare results," says Baker. "There's sort of an unwritten rule: If you're doing a comparison, you don't do an extra procedure." Says Alpert, "The twins have a right to do what they want. A skilled observer can take that into account."

Still, with all its imperfections, the twins study wasn't a total loss. Despite Hamra's opinion, many in the audience said the message was that a good surgeon can get a good result with many techniques. "I'm not sure the public can discern what is the latest or the best—because even surgeons can't decide if A is better than B." says Sherrell J. Aston, the chief of plastic surgery at the Manhattan Eye, Ear & Throat Hospital. "[These] are all interrelated techniques. My own would be a combination of Owsley's and Hamra's—but it would be different from either one. For anyone to say that one technique is for all comers doesn't make sense."

Most of the surgeons who saw the presentation in Orlando "will go home and do the same operation they did before," says Aston. "One thing we know, a skin lift won't be as good as a SMAS lift. The goal is to correct the individual problem. If I do four face-lifts tomorrow, each one will be different. A large percentage of surgeons are doing only skin lifts. But the largest volume of face-lifts are done by a smaller group of well-trained doctors"—in New York, Los Angeles, San Francisco, Texas, and Florida. 'They are doing something besides a skin lift and delivering results without the stigmata of the over-operated look," Indeed, if the trend continues, we may not have the nipped, tucked, and wind-tunneled to kick around anymore.