By Michael Sundine, MD
There has been a general acceptance of cosmetic surgical procedures in the United States. No longer is cosmetic surgery only for the wealthy and famous. Cosmetic surgery is now featured on television, the internet, and openly discussed in tabloid magazines. This increased exposure is related to a significant increase in the amount of plastic surgical procedures being performed. As patients continue to enjoy increasing longevity, they desire to keep their appearance consistent with how good they feel.
A myriad of possibilities seems to exist for the treatment of facial aging. These treatments range from skin creams and fruit acid peels promoted by lay persons extending to more aggressive treatments performed by medical people. The treatments include neuromuscular agents (Botox, Dysport, Xeomin), injectable fillers (fat, Restylane, Juvederm, Perlane, Radiesse, Sculptra), chemical peels, nonablative surface treatments (Thermage, plasma treatments), nonablative lasers (Fraxel), ablative lasers (fractionated CO2, erbium, conventional CO2), and then a variety of surgical treatments. With the numerous possibilities available to patients it is no wonder that there is a great deal of confusion regarding the best alternative for a patient. It also begs the question is when is a patient a candidate for a face lift procedure?
The choice of the appropriate treatment centers first on a careful facial analysis. The vectors of the aging face are mainly an inferior (downward) and anterior (foreward) displacement of the soft tissues. These soft tissue changes are responsible for the characteristic appearance of the aging face with deepening of the nasolabial creases and the development of jowls and marionette lines. The soft tissues seem to fall off of the cheek bones and this results in the boxiness and angularity of the aging face rather than the heart-shaped face of youth. There is also a skeletonization of the area of the cheek bones.
The use of neuromuscular agents (i.e.-Botox) can be of value to improve forehead wrinkles, the creases between the eyebrows, and crow’s feet. Patients may actually see a small amount of brow elevation with injections of the crow’s feet and the creases between the eyebrows. Unfortunately the effects of these agents are temporary and the injections will need to be repeated. In patients with deep rhytids (wrinkles) of the forehead who are using the forehead muscles to hold up their eyebrows may actually have the sagging of their eyebrows aggravated by Botox injections.
Soft tissue fillers are a useful adjunct in the treatment of facial aging and my help to delay more significant procedures.. They can be placed into the nasolabial creases, tear troughs, over the cheekbones, and in the area in front of the jowls in order to soften some of the creases, augment the cheekbones, or to hide the jowls. There has been a recent push by some practitioners and by the manufacturers for “full correction” of the face. In some cases this may improve the appearance but there are many patients who have been overfilled and appear to look like the Pillsbury doughboy. In order to achieve “full correction” patients require a fairly large volume of filler, which provides a temporary correction. A few episodes of “full correction” will be more costly to a patient than a face and neck lift, which will provide excellent results for an average of twelve years.
Nonablative technologies such as Thermage and Fraxel unfortunately do not seem to provide any sort of long lasting or significant change.
Ablative technologies such as chemical peels and lasers are very useful in tightening skin and can help to even out irregularities in skin pigmentation. We have found these treatments to have value in patients with early facial aging. Ultimately none of these modalities can actually lift and reposition tissues.
Ultimately in order to achieve an optimal correction of the changes associated with facial aging a face and neck lift along with possible brow lift will be necessary. The brow lift will allow for elevation of the eyebrows to a more aesthetic position along with treatment of the muscles responsible for the creases between the eyebrows and the rabbit creases over the upper nose. The face and neck lift will reposition the soft tissues back over the cheek bones, soften the crow’s feet, flatten the nasolabial fold, elevate the corners of the mouth, soften the marionette lines, reposition the jowl fat back up into the cheeks, and refine the neck line along with treating any banding of the muscles in the neck. The procedure is typically performed on patients in their early 50’s but may be postponed by some of the adjunctive treatments listed above. Using the technique that we employ the procedure is effective for an average of 12 years. The downtime for the procedure is about 14 days, which is comparable to many of the procedures listed above. Pricing for a face lift is also very competitive to the other procedures especially when one considers the fact that the less invasive procedures will need to be repeated at frequent intervals with the associated costs.