Rejuvenation of the Aging Face
Aging is an inevitable fact of life that can cause undesired changes to the face. Although aging is a natural process that should not be feared, some people develop facial changes that make them appear older than they truly are, or certainly older then they feel. The aging process has many different effects on various tissues of the face and these can be grouped into three main categories:
- Skin changes
- Volume loss and redistribution
- Descent or drooping of tissue.
Often the best approach to restoring the aging face is to specifically address each of these categories to achieve the optimal refreshed, youthful, and natural appearance.
The goal of facial rejuvenation is not to "reverse the aging process" or to make individuals appear as they did in their youth: this would produce a very unnatural result. Instead, the goals are to work with an individual’s specific facial structure to optimize his or her appearance in a natural manner that restores facial harmony with a refreshed look. Certain facial changes may prompt others to suggest that an individual looks "tired" or "stressed" or "angry" despite that individual feeling awake and relaxed. Patients seeking facial rejuvenation often report a desire to "look as good as they feel" and our goal as facial plastic surgeons is to help them achieve this goal and put their best face forward.
Several changes are seen in the skin with aging and these are often compounded by a previous history of significant sun exposure. With aging the skin loses some of its natural elasticity and tone. Color changes are seen with less uniform skin tone overall and development of small brown marks or dilated blood vessels under the skin’s surface. Fine lines can develop as the skin thins and these are often accompanied by deeper furrows caused by repetitive motion of underlying facial muscles in the forehead, brow, around the eyes and mouth.
The importance of skin care in facial rejuvenation cannot be overstated, and often a skin rejuvenation program alone provides a dramatic improvement in and individual’s appearance of aging. While the best treatment for aging related skin changes is prevention by limiting sun exposure and conscientiously using sunscreen throughout life, many of the changes can be improved with a variety of therapies.
The specific recommendations for a skin rejuvenation regimen differ based on skin color, skin type, and the extent of changes seen. Several topical therapies are available to help improve skin color by reversing darkening, skin texture by improving roughness and fine lines, and overall skin tone. These come in the form of prescriptions and commercially available product lines. Topical treatments require regular, diligent use and the overall effects are rarely dramatic, but topical treatments are a well-tolerated, non-invasive option to improve skin appearance as a stand-alone treatment or in combination with other procedures or surgical interventions.
For those seeking more improvement than is achievable with a topical skin care regimen alone, more aggressive options exist including chemical peels and laser resurfacing. Chemical peels consist of an array of treatments temporarily applied to the facial skin. A chemical peel works by causing a controlled injury to the outer most layers of skin that allows for spontaneous healing with new skin growth that returns with a more even texture, color and improved tone than before the peel. In general, deeper chemical peels demonstrate more dramatic results, but are associated with more discomfort and healing time than superficial peels. Superficial peels are easily applied in the office and patients may feel a warming or mild burning sensation. The face is cooled and the peeling agents washed away. This results in some temporary redness and skin peeling much like a light sunburn. Often a series of superficial peels are recommended to achieve the desired results, and these peels work best for fine skin irregularities and color discrepancies.
For deeper facial lines, sun damage or more advanced aging changes, a deeper chemical peel may be recommended. Depending on the agent used these may require some oral or even IV sedation to minimize discomfort. These peels have a longer period of skin peeling but ultimately heal as new, more youthful skin that is tighter and more regular than before the peel. The depth of the peel needs to be carefully controlled to avoid the potential for scars to form during the healing process.
Recently, laser resurfacing has surpassed chemical peels in popularity for all but the most superficial peels. Various laser types can be used, each with slightly different properties and advantages, but a resurfacing laser works similarly to chemical peels by creating a precisely controlled injury to the skin and taking advantage of the natural improvements in skin that occur with healing. Fractionated lasers deliver the laser energy over a pre-determined fraction of the skin surface and spare some skin in between these zones. These lasers have gained wide-spread popularity with patients due to the decreased down-time associated with treatment and lower risk of treatment. Laser treatments can be directed at specific facial regions or the entire face, depending on the specific needs of the individual. The depth and amount of energy delivered is very precisely controlled to gain the maximum effect while limiting the risks.
Treatment is typically performed with a combination of local anesthesia and oral medication or IV sedation if done as a stand-alone procedure, but laser treatment can often be combined with and serves as an excellent addition to other surgical procedures if desired.
Children’s faces are characterized as round and full. Youthful faces are those with good tissue volume in the temples, around the eyes, over the cheekbones, and in the lips that taper to a more slender appearance around the jawline and neck. With aging, volume is lost in some of these crucial areas or becomes redistributed to neighboring areas by the effects of gravity. The face loses its full appearance and some bony prominences around the eyes and cheek bones become more visible. Prominent lines can develop under the eye or around the mouth. There is even some loss of bone that occurs with aging so the facial skeleton that supports the soft tissue is weaker allowing the face to take on a more sunken or deflated look.
Judicious restoration of facial volume in strategic locations can restore a youthful appearance with improved facial proportions and balance. The goal is not to “inflate” the face artificially, but simply to restore volume in locations that are naturally present in youthful faces.
There are numerous commercially available filler agents that can be used in the office setting to restore or enhance facial volume. Each filler has slightly different formulations and uses with some directed at more focal, superficial filling, and others deeper volume restoration and lift or more widespread volume replacement. A combination of filler agents may be necessary to address an individual’s specific needs. Individual fillers are discussed in more detail in the injectable treatment page. Injectable fillers are widely used and have many advantages including convenience, relatively immediate results with very limited down time, lower cost than surgical procedures, potentially reversible, and well-known reliability. Most fillers, however, are temporary and require repeated treatments for long lasting effects.
Another effective method of volume restoration is fat transfer. This procedure typically requires sedation and is performed in an operating room either alone or in combination with other procedures. Fat transfer involves removing a portion of fat from the abdomen, flanks, or thighs with a minimally invasive liposuction cannula. The fat is then processed to isolate the fat cells along with natural, restorative stem cells that make up a part of fatty tissue. Once isolated, the fat is then deposited into the desired locations in the face with small injection cannulas the size of a needle. There are no surgical incisions needed. Fat provides an excellent, natural tissue that nicely augments facial features. In some people, a portion of the fat transferred does not survive and some of the initial volume seen will diminish. In this case an additional procedure may be needed to achieve the desired results. The fat that does survive, however, produces a long-lasting essentially permanent result and the stem cells transferred in the process can help improve the quality and appearance of the overlying skin.
The eyebrows play an important role in expression of emotion, non-verbal communication, and help frame the eyes. As we age repetitive elevation or furrowing of the brow causes creases to develop in the overlying skin and the eyebrows themselves can droop, impinging on the upper eyelids and contributing to an “angry” or “tired” look.
Improvement in forehead lines or creases between the eyebrows is very effectively seen with injectable treatment to weaken the forehead muscles with medications such as Botox® (Botulinum toxin). This medication temporarily weakens muscle contraction and limits or helps reverse the formation of wrinkles in the skin. This treatment works best when these creases are mild and requires regular treatments roughly three to four times per year for the best effect. More advanced wrinkles may not completely improve with Botox® treatment alone, and in these cases a combination of treatments may be recommended. Certain individuals who notice some drooping of the tail of their brows may be candidates for targeted Botox® therapy to achieve a “chemical brow lift.” These results are not as dramatic as a surgical brow lift, and may not work for every individual, but this approach can provide a nice result in select individuals.
Addressing droopy or descended eyebrows involves one of a variety of procedures termed a brow lift. Every pattern of eyebrow descent is different and every individual’s preferred brow position and shape is unique so deciding on the best procedure to address the brow involves a thorough discussion between the surgeon and patient. Additionally, the position of the eyebrows is often not symmetric to start, and this must be carefully considered when determining the best treatment to elevate the brows and improve symmetry. The goal of brow lift surgery is to restore the brow to a more youthful location and shape and avoid an unnatural or “surprised” look.
Open brow lift approaches involve a surgical incision placed either at the hairline or within the hair of the scalp. Through this approach the entire forehead and brows can be elevated and suspended into an improved position. The muscles responsible for creation of furrows between the eyebrows can be surgically weakened to provide a more permanent reduction of these furrows. A small strip of skin is typically removed once the forehead is elevated and this helps support the new brow position and can also be used to either shorten a forehead that appears too long, or lengthen a short forehead if needed.
Endoscopic brow lift provides a minimally invasive approach that is best for some individuals. Through a series of three to five small incisions hidden within the hair, endoscopes are used to help elevate the brow and forehead. The new brow position is fixed with sutures beneath the skin and no strip of skin is removed in this approach.
A lateral brow lift may be recommended as part of a complete brow lift or as an isolated procedure that affects only the tail of the brow. This procedure involves an incision in the hair of the temple and is able to elevate the tail of the brow to create a more arched look that is desired by some individuals.
Risks associated with brow lift include asymmetry of brow position or recurrent brow drooping and sometimes revision surgery is needed. Additionally, there may be numbness of the forehead that could last weeks to months or in some cases is permanent, and brow elevation may be decrease if there is injury to the nerve that causes the brows to lift. A scar may be visible in the hair line or within the hair-bearing portion of the scalp.
Improvement in the appearance of the eyelids is one of the most commonly requested improvements of the face. The eyes are a natural focal point during daily interaction and play a huge role in interpersonal communication and personal identity. Changes related to aging often present first around the eyes and many people are told they look “tired” due to these changes despite feeling fully rested and vital. Changes to the upper eyelid can include excess skin folds, muscle thickening, or bulging fat beneath the skin. These changes can become severe enough to partially obstruct vision and are often compounded by drooping of the eyebrows as well. The lower eyelid can also develop excess finely wrinkled skin, muscle thickening or fat bulging with development of a groove or shadow under the eyelid called the tear trough.
Eyelid rejuvenation involves first a careful assessment of the specific factors affecting each individual, followed by an individualized treatment that may involve one or a combination of therapies directed at skin improvement, volume distribution, and surgical excision of excess or malpositioned tissue termed a blepharoplasty.
Upper eyelid blepharoplasty most commonly involves removing the excess skin present in the upper lid. This is achieved through an incision placed in the natural skin crease in the upper eyelid and this heals into a very fine scar that is very difficult to see once it is fully healed. Depending on the individual, this skin removal may be combined with conservative removal of bulging fat from various fat pockets of the upper eyelid. The goal is to create a smooth upper eyelid without excess skin that gives the eye a more open and alert look.
The lower eyelid blepharoplasty can be even more complex. There are two main surgical approaches that may be used based on the circumstances. The first involves an incision on the inside of the lower eyelid called a “transconjunctival” approach that does not leave an external scar. This approach is best for targeted removal of some of the bulging fat in the lower eyelid but does not address skin excess. The external skin of the lower eyelid can be tightened with chemical peel or laser resurfacing of the skin in combination with the blepharoplasty to produce an excellent result if there is a small amount of skin excess and no laxity of the lower eyelid. For larger amounts of excess skin or eyelids that are more lax, an incision is often placed just under the lashes of the lower eyelid skin to allow for removal of bulging fat along with removal of excess skin and tightening of the lower eyelid. Additionally, volume may be added to the tear trough grove between the lower eyelid and the nose with injectable filler or fat transfer at the same time.
Many people are troubled by excess fullness under the chin and along the jawline. For some this represents an isolated collection of fat below the chin, others develop prominent bands of muscle that run along the front of their neck, and others have descent of soft tissue along their jaw line forming “jowls” or a combination of the three. Regardless of the cause, most are seeking the same outcome: a smooth neck and jaw line with a sharp angle between the jaw and neck.
Identifying the best treatment option to achieve this goal requires a careful assessment of individual anatomical factors. There is no one-size-fits-all solution that works for every individual. The evaluation will starts with a careful examination of the skin of the jaw and neck including the quality and elasticity of the skin. Beneath this rests a fatty layer that may have excess deposits in various locations that need to be addressed. Deeper yet are the muscles of the neck that can become more lose with age and separate in the middle producing the prominent bands known as platysmal bands. Finally, the underlying bone structure of the chin, jaw and hyoid bone in the neck are evaluated to determine position and relative size. The goal of any intervention on the face and neck is to create a natural appearance of a smooth neck and straight jaw line without an overdone or “windblown” look.
Interventions to address the jaw and neck line are primarily surgical, but some individuals not interested in surgical facelift may see nice improvement in the jaw line with careful use of injectable fillers in specific locations. Fillers can be used to help camouflage the shadow created just in front of the jowl and to support and elevate the cheek somewhat and give the illusion of a straighter jawline without surgery. While the results are not as dramatic as a surgical facelift, this approach may be the best for certain individuals with early changes along the jawline or used in combination with other surgical procedures.
For individuals with a persistent collection of fat beneath the chin but otherwise smooth neck and jawline, a targeted removal of this fat may greatly improve their profile. This procedure termed a “submental liposuction” is performed through a small incision under the chin with removal of the excess fat using a liposuction cannula. If muscle banding is also present this can be tightened through the same approach.
If there is a larger collection of excess fat or significant excess skin or muscle banding, a submental approach may not be adequate for some individuals. For these, a neck lift may be considered that combines with incision under the chin with short incisions in the hair line. With this approach, the entire neck can be addressed with removal of excess fat if needed and better suspension and distribution of laxity in the skin and muscle.
Some individuals have a smooth neck line and neck angle, but have troubling excess and drooping along the jawline. For these concerns, an isolated facelift or “mini lift” may be considered. This procedure uses formal face lifting techniques but only addresses the jawline and jowls without making changes to the neck. This procedure involves incisions placed within the natural creases around the ear and often extends to the back side of the ear. The lose skin and connective tissue of the lower face and jaw line can then be supported.
The gold standard technique for rejuvenating the lower face and neck is a formal facelift. This typically combines the mini-lift approach with the neck lift to dramatically improve the straightness of the jawline, remove jowl formation, provide a sharp angle between the jaw and neck, and relieve the excess and droopy skin and soft tissue of the neck. This procedure combines the submental incision under the chin with hidden incisions around the front and back of the ears extending to the hairline. This procedure provides the most opportunity for improvement since multiple areas can be addressed at once, but has the longest recovery time and is best suited to those individuals who desire improvements in all the areas mentioned previously.
Combining treatment of the lower face and neck with skin resurfacing, injectable filler, eyelid or brow surgery can be a powerful approach to full face rejuvenation for select individuals. These treatment options are thoroughly discussed to determine the individual option best suited for each person.
Along with some of the soft tissue volume loss or descent seen with aging, facial bones actually lose volume as well. This is seen along the bony rims under the eyebrows, cheek bones, and chin most prominently. Others are born with a somewhat small chin or cheek bones that disrupts their overall facial harmony. Supporting or augmenting the facial skeleton is often overlooked when developing a treatment plan for facial rejuvenation, but is an important consideration for some patients. Options for augmentation include short and long-lasting injectable fillers as well as facial implants.
Injectable fillers are addressed more fully in a separate section, but there are several agents than can easily be injected along the surface of the facial bones in the office to provide lift and support to overlying tissue. Facial implants involve surgically implanting a permanent but non-reactive material along the surface of the bone that restores volume to the desired location and supports the overlying tissue. The most commonly used implants are used along the chin and cheek bones. Chin implants are place through a small incision in the natural crease beneath the chin and secured to the face of the chin and/or jawline depending on the particular treatment need. Midface or cheek bone implants can be placed through incisions inside the mouth and secured along the face of the cheek bone to improve facial projection and support in this area.