Facial Aging and Rejuvenation

A very large portion of my time is dedicated to my facial aging practice. Unlike many other areas of the body, maintenance of the aging face is a continuum that links me and my patients over time. With age, the face changes in three ways:

 

1. The soft tissues of the face (skin, fat and connective tissue) fall with gravity over time
2. The facial fat atrophies over time leaving a hollowed appearance in very distinct areas
3. The skin ages with exposure to sun, tobacco use and the oxidation reactions that go on throughout our lifetime

My goal as a physician dedicated to facial aging is to help my patients through the process from A to Z. I have spent a great deal of time and effort to study and to understand these three processes at a basic science level while also spending time with masters in each of these fields. Each face has a completely unique set of needs and challenges. I want to understand your wishes, to discuss what we can achieve, and to design procedures that will meet your needs and wants. One of my great mentors used to explain that aging is not always a problem that requires a surgical solution. Not all patients benefit from surgery. For this reason, I have dedicated time not only to understanding plastic surgery of the face, but also fat transfer and non-surgical solutions as well. In the right patients, neurotoxins (Botox) and fillers (Juvederm, Restylane, etc) offer a great deal of benefit. Likewise, skin care is paramount and the cornerstone to maintenance of facial vitality. My goal is to guide you through the process of maintaining the aesthetics of your face in perpetuity. In many people, the appropriate solution involves a combination of skin conditioning, surgery, fat transfer, and/or fillers and Botox over time. By being conservative and utilizing multiple tools to affect change, long lasting and natural results can be achieved.

Lower Face and Necklift

A lower face and neck lift can be a very powerful tool to rejuvenate the lower third of the face. Areas that can be greatly affected include the neck, jawline, jowls, and corners of the mouth. Most women concentrate on the loss of definition in their neckline as well as the muscle bands that occur in the midline. A lower face and neck lift can correct these issues by lifting the tissues below the skin and tightening the muscles of the neck. The skin is simply redraped over the tissues below and closed under no tension.

Skin stretches, and thus is used as a blanket over the tissues below. I believe that relying on the skin to hold up the face is a recipe for an operated look, wide scars and deformities of the ear and hairline that are tell-tale signs of a facelift. All my incisions are placed in natural creases and hidden in the hairline.

This procedure is done typically under general anesthesia and I am adamant that patients are observed overnight by a registered nurse in an accredited facility. This is for your safety and helps to make your post-operative experience more comfortable.

Mid Facelift/Cheek Lift

A mid facelift, also known as a cheek lift, can be a very powerful tool to rejuvenate the middle third of the face. Areas that can be greatly affected include the nasolabial folds (junction between the cheek and lip), tear trough (the junction between the lower eyelid and cheek), bags around the eyes, and wrinkles around the eyes. Most women concentrate on the heaviness and descent of their cheeks as they age. A mid facelift can correct these issues by lifting the tissues below the skin to rejuventae the cheek bones, lower eyelids and nasolabial folds.

When having a mid facelift it is very important that your surgeon be familiar with not only this procedure, but also its impact on the lower eyelids and width of the face. The procedure is done in a very different manner depending on whether your face is long and narrow, or short and wide. In addition, great care must be taken to resuspend and protect the lower eyelid to prevent retraction and eyelid malposition. 

This procedure is performed under general anesthesia and is often used in combination with other procedure to rejuvenate the middle third of the face.

Brow Lift

A brow lift can be a very powerful tool to rejuvenate the upper third of the face. Areas that can be greatly affected include the eyebrows, upper eyelids, glabellar (area between the eyes) wrinkles, forehead wrinkles, and crow’s feet (wrinkles next to the eyes). Like most procedures the brow lift can be performed in several ways depending on the patient’s length of forehead, hairline, and brow shape. Some patients are candidates for an endoscopic brow lift, which is a minimally invasive alternative where small incisions are made behind the hairline and all surgery is done with a camera and small instruments. Other approaches are used when the goal is to not only lift and contour the eyebrows, but also to shorten the forehead. A long forehead is a sign of aging (think of balding).

The attractive brow is very different in men and women. For men, the brow usually sits at the bony ridge above the eye itself and has a rather flat shape. Contrastingly, women have an arched brow that sits in a higher position. While the brow lift can be a very satisfying procedure, it must not be overdone because patients can look “surprised.” This is usually one of the first procedures women have with regards to facial rejuvenation because aging occurs in the brow/glabellar/forehead region starting in our early 30s.

This procedure is performed under general anesthesia or IV sedation and also is used in combination with other procedures to rejuvenate the upper third of the face.

Upper Blepharoplasty and Ptosis Surgery (upper eyelid surgery)

Upper blepharoplasty can be a powerful tool to rejuvenate the orbit. As we age, excessive upper eyelid skin begins to weigh on the eyelid itself causing the lid to droop and the eyelashes to turn down. Often patients begin to complain of difficulty seeing because the eyelid skin and eyelid margin begin to obscure the visual axis. 

I must explain that you cannot look at the upper eyelid without also looking at the eyebrow as well as the muscles that hold up the eyelid. Many patients that come in requesting upper eyelid surgey, also have issues with their eyebrows, and at times, issues with the muscles that lift the eyelids. In order to correct these issues, you surgeon must be very familiar and comfortable with eyelid anatomy, aesthetics, and the interaction between each of the structures.

At times, this procedure is performed by just removing excess eyelid skin. More often than not, to truly rejuvenate the orbit, I must deal with a drooping eyelid (ptosis surgery) as well as the fat compartments within the eyelid itself. Believe it or not, there are 7 layers between the skin and the conjunctiva that overlies the orbit. Each has a very important function, and surgery in each of these layers has a different effect. 

Lower Blepharoplasty (lower eyelid surgery)

Lower blepharoplasty can be a powerful tool to rejuvenate the orbit. As we age, excessive lower eyelid skin begins to weigh on the eyelid itself causing the lid to droop as well as the muscle below that closes the eye. Behind the lax skin and muscle, orbital fat often protrudes. Patients complain of a baggy lower eyelid and/or wrinkled skin. 

The lower eyelid has an intimate relationship to the cheek below. Depending on each patient’s individual lower lid characteristics, a unique operation is tailored. Some only need a minor pinch of skin removed, whereas others need either fat removal or repositioning. With these techniques and other, the junction between the lid and the cheek can be smoothed and returned to the convexity of youth. Several approaches may be used and the incision is either hidden below the lash line or behind the eyelid itself.

Lower blepharoplasty is a special interest of mine given that the most common complication of this procedure is eyelid malposition. Stigma of lower blepharoplasty can include a skeletonized eyelid, eyelid retraction, scleral show (the white below the colored part of the eye), and a rounded lateral eyelid margin. Special procedures must be used to reposition the lower eyelid, redistribute tissue at the lid-cheek junction, and resuspend the lateral eyelid margin.

This procedure is performed under general anesthesia, IV sedation or with local anesthesia, and also is used in combination with other procedures to rejuvenate the middle third of the face.

Otoplasty (surgery for prominent ears)

Otoplasty is the term used for changing the shape and contour of the ears. Children and adults often complain of prominent ears or earlobes. Prominence can be in either the upper, middle or lower third of the ear and has many different causes.

Correction of these issues is usually performed by making a small incision behind the ear and repositioning and/or removing portions of the cartilaginous framework below the skin. This procedure is performed under general anesthesia or IV sedation. 

Fat grafting (“liquid facelift”)

Fat grafting is not a new concept, but may of its applications are and its role in aesthetic and reconstructive surgery continues to be expanded. A suction cannula is used to remove fat from one part of the body (hips, flanks, abdomen, etc.). Once it is removed, it is processed to preserve fat stem cells, also knows as adipose stem cells. These stem cells are separated and injected back into the patient. Thus, the main benefit of this procedure is using a patient’s own tissue to rebuild and sculpt. 

As we age, everybody can see that our tissues become loose. However, two other very important things happen: 1) our tissues atrophy and we lose fat in our face, and 2) our skin suffers ongoing damage from UV radiation (sun) and toxins. 

I use fat grafting as a technique for many of my aesthetic procedures. It is a phenomenal tool to augment the cheeks, eyebrows, eyelids, and jawline. Likewise, it can be placed in folds and valleys to correct wrinkles and blend unnatural junctions. Small aliquots of fat are carefully deposited in targeted areas and allowed to regain their own blood supply. At times, several treatments are desired and required for full correction. Because of the stem cell component of fat grafts, it is believed that fat also rejuvenates the skin. In fact, I have used fat grafts to heal wounds caused by radiation damage! 

Good candidates for this procedure are people who are fairly stable in weight. While fat is a fantastic tool, it can have issues if used haphazardly or in a patient who has the potential to gain twenty pounds or more. The fat can grow with weight gain to give the patient a very bizarre look. Also, fat can be overused. Because it is such an exciting tool for rejuvenation, some patients’ faces have been filled with fat giving them a round appearance. Like most things in life, moderation is a good rule of thumb and I have unfortunately had experience taking out fat in patients who have been overinjected.

For me, fat transfer/grafting is a great way to augment an aesthetic result. What I mean is that it can be used with other procedures with a synergistic effect. Many of my patients who get facial procedures also have fat grafting because oftentimes it supplements conventional surgery. For example, a lower face and necklift can give a patient a nice, angular jaw and neck line. For patients who have small chins or a large jowl, it is often best to add a little fat and pull less hard on the face and underlying tissues. By being conservative but using each procedure in synergy, I can achieve a great result that does not appear surgical or “tight.” Likewise, I can use fat for patients who have been hollowed by previous surgical procedures that were overaggressive. A great example is the hollow upper eyelid or neck that has been over-skeletonized.

Fat grafting is done in an outpatient setting either under general anesthesia or IV sedation. 

Chin augmentation/reduction

The chin is often an underappreciated area of the face. Many patients who do not like their lower face or nose often underestimate the impact their chin has on physical appearance. A weak chin results in a mandible that in underprojected. On the contrary, a large chin can be a very masculine feature.

Unlike many issues in Aesthetic Surgery, a small or retruded chin is most often a problem of bony structure. Once I realized this, I learned how to place chin implants, which would augment the bony structure of the chin. After doing these, I also realized the limitations of the implants. Most people have asymmetric chins, and the implants may make them bigger but this also augments the asymmetries. Also, implants really only change the projection of the chin in one plane. Many patients have issues in multiple dimensions. Because of this, I worked with Oral and Maxillofacial Surgeons to learn how to augment and reduce the chin my moving the mandible itself. Since I fix fractures of the mandible, I am used to working in this area but working with the Maxillofacial Surgeons gave me a true appreciation of how the bony structure of the mandible affects the way the face appears. Depending on the issue, I now use both techniques.

I do this procedure by itself but at times suggest it for patients undergoing rhinoplasty and lower face and neck lifts. It is done under general anesthesia or IV sedation in an outpatient setting.

Fillers and Botox

Fillers (Restylane, Juvederm, Sculptra, Radiesse, etc) and Botox are one of the largest growing parts of my current practice. It is important to understand what they do and do not do. For the right patient, I can correct wrinkles, plump lips, accentuate brows and eyelids, and blend facial units right before my patients’ eyes. Since the results are immediate with fillers, patients love that they can help to direct their own aesthetic while I slowly enhance subunits of the face. 

I work very hard to make sure that this is a good experience for my patients. I too often hear that these are painful procedures, and they really don’t have to be. By taking the extra time, being gentle, using ice and even local anesthetic when necessary, most patients have a relatively painless experience with very little downtime. 

Botox is great for the prevention and treatment of wrinkles. Botox Cosmetic is approved for use in the glabella (the area between the eyebrows). However, I often use this “off label” for wrinkles of the forehead, eyes, chin, and neck. I also use it to raise the lateral eyebrows and corners of the mouth. In addition, I use Botox for the treatment of Migraine headaches and excessive sweating in the armpits. 

Likewise, fillers are a great way to correct mild to moderate contour issues and wrinkles. I use them literally all over the face and often in conjunction with surgery to augment the final result. Conventional injections include the nasolabial folds (junction of the cheek and upper lip), but I also use them to augment the eyebrows, eyelids, area in front of the jowls, junction of the lower eyelid and cheek, chin, lips, and columns in between the lips and nose. These minor enhancements lead to a more refreshed look with the advantage that no surgery or incisions are needed. 

While many doctors have their nurses and aestheticians do these procedures, I do all of the treatments myself. The reason is that I do surgery in these areas on a weekly basis and know exactly where the muscles are, how they contract, and what is under the skin I am injecting. I truly think this improves the cosmetic results. First and foremost, I need to understand exactly what the patients expects to get from the treatments and what he or she desires. For example, I use different concentrations and different products depending on how “animated” patients are, what part of the face they wish to work on, and what they do for a living. If a patient is on television or in sales, it is often not advantageous to completely weaken facial muscles. If the whole face is moving while you speak or you smile but the upper third is completely lifeless, people will notice and wonder why your face looks abnormal. My goal is a very natural result, and doing your own fillers and Botox is paramount in any facial aging practice. Always ask yourself, is the person doing my procedures able to fix or adjust things if I don’t like the result? Can they deal with potential complications? If the answer is no, I would never let them work on my face. 

These procedures are done in the office. Patients may drive themselves home and I often advise no exercise or bending at the waist that day and night. Aspirin and Ibuprofen should be avoided until the next day. Other than that, there are no restrictions.

Lip augmentation

Lip augmentation has become a very popular procedure. However, I would use the term lip sculpting. We have all seen people walking down the street who look like Daffy Duck walked up and kissed them. 

The lip has a very specific shape. Surgically correcting cleft lips was a big part of my surgical training. In attempting to reconstruct the “normal” shape of the lip from cleft lip deformities, I learned a great deal about the shape and definition of the lips. I too often see very large lips with absolutely no definition. Not all lips are created equal, and I approach every lip with a different set of tools and techniques. Since I have operated on so many of these, I really do understand the importance of the very thin skin, the underlying muscle, the junction of wet and dry skin, and the junction of lip and facial skin. Without an appreciation for these characteristics, it is easy to see why people injected with filler have large, amorphous lips.

The first thing to understand is that a little goes a long way. When I do lip augmentation with fillers, I often use less than one third of a syringe in each lip. By the time you have injected four or five times, the lip is so swollen that it is hard to see any definition. I then ask patients to return in 5-7 days for the creation of definition and final symmetry if needed. I would say about 25% of patients need this done for an optimal result. 

The fantastic thing for patients is they can show me examples of what kind of lips they do and do not like. The final result is created in a graded fashion and I often do this with my patients able to face a mirror so they can tailor their final aesthetic. Injections are done in several areas depending on if someone needs volume, definition, pout, or a combination of the above.

I always suggest that patients start with a filler that lasts for 6-8 months to make sure myself and the patient are comfortable with their new look. Once we nail your vision of beauty, we can use fillers that last longer or even permanent implants. In any facial aging practice, it is important to be able to undo your results when it comes to fillers or lip implants because people change their opinions of what they like and don’t like. For this reason, even my permanent implants can be easily removed and I carry an antidote for the fillers. I see many patients for revisions and second opinions so this has become a part of my facial aging practice.

These procedures are done in the office and if needed, with local anesthesia. My goal is for your procedures to be pain free. It is obvious to me that if you are in pain, you are not going to have a great memory of the experience no matter how good you look.