Facial Rejuvenation

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As with other cosmetic procedures, a person wishing to improve their appearance through surgery must have realistic expectations and be willing to have a recovery period during which time they may not wish to be seen in public. Most importantly, the decision to undergo these procedures should be based only on ones own desire and be free of pressure to do so by others.

Improving the Forehead and Eyebrows

Over time, lines and creases form in the forehead and the eyebrows become droopy, moving to a lower position on the face. At the same time, creases may form between the eyebrows resulting in an angry appearance. Such changes can be improved with either surgical or nonsurgical procedures depending on the severity of aging and the specific enhancements desired.

Nonsurgical treatments are temporary and involve the use of injectable products to give the desired effect. Botox may be used to prevent muscles from forming lines and creases in the forehead and between the eyebrows. Occasionally, a Botox injection may also be used to raise the eyebrows a small amount. Deep lines and creases that are present even when the muscles below them are not contracting may be filled in with injectable filler materials. In some cases, both Botox and filler materials may be used to achieve an optimal result. These products typically require only a few minutes to inject and if any minor bruising or swelling occurs, it resolves by the next day. The results last from 4 to 12 months but newer products may give longer lasting effects.

If the forehead and eyebrows have more significant aging, or if a longer lasting result is desired, surgical procedures may offer significant improvement.

What are the different surgical options to improve the forehead and eyebrows?

Depending on the specific problem that needs to be addressed, the position of a person's hairline and hair distribution, other procedures being performed and one's willingness to accept scars, the following options are available. As each of these procedures has its advantages and disadvantages, your surgeon may recommend an approached after examining you and evaluating the amount of improvement needed to achieve a desired result.

• Coronal incision forehead and brow lift - An incision is made from just above one ear all the way to just above the other ear running across the top of the head. The surgeon then lifts the front of the scalp, forehead and brows to a new position higher on the head to achieve a more youthful appearance.
• Hairline incision forehead and brow lift - An incision is made where the hair stops on the forehead and the surgeon lifts the forehead and brows to a new position higher on the head.
• Lateral brow lift - Through an incision in the side of the scalp, the surgeon elevates the outer part of the eyebrow to a new position.
• Endoscopic brow lift - Using 2 to 4 small incisions in the scalp, the surgeon uses a small viewing device to help with surgery and reposition the eyebrows.
• Eyelid incision brow lift - The brow can also be lifted at the same time that an upper eyelid procedure is being done.

Since the eyebrows are adjacent to the upper eyelids, at times it may be necessary to combine a brow lift with an upper eyelid surgery to achieve an optimal result. The recovery from a forehead and brow lift may last 1 to 2 weeks depending on the extent of surgery and amount of improvement desired.

Improving the Area Around the Eyes

Some of the early changes that give the face an aged appearance occur around the eyes. The skin of the upper eyelid becomes more prominent and the fatty tissue behind the skin bulges forward to give the upper eyelid a more full or "tired" look. The lower edge of the upper eyelid may droop down to cover more of the eye itself causing a "sleepy" appearance. In some cases, the upper eyelid may cover so much of the eye that it can interfere with vision. Sagging of the eyebrows may contribute to this problem and should be treated also.

In the region of the lower eyelid, the skin can become wrinkled and as in the upper eyelid, fatty tissue behind the skin may bulge forward causing "bags". Occasionally, the normal support of the lower lid may become loose causing the lower lid to sag and pull away from the eye. In some cases, dark circles may appear under the eyes which contribute to a "tired" look.

The area to the side of the eyes also may show signs of aging as wrinkles and skin crease (sometimes called laugh lines or crows feet) form with smiling and other facial movements.

Before Upper Eyelid Surgery

After Upper Eyelid Surgery Excess upper eyelid skin has been removed, creating a more youthful appearance.

Which conditions around the eyes can be treated with eyelid procedures?

Loose skin hanging in the upper eyelids, occasionally blocking vision.

• Excess skin and fatty tissue causing a puffy appearance and loss of the natural crease of the upper eyelids
• Excess skin in the lower eyelids
• Bulges or "bags" under the eyes
• Dark circles under the eyes
• Drooping of the lower eyelid

Keep in mind that each of these specific conditions may have more than one possible treatment option. For example, some wrinkles around the eyes may be treated with a Botox injection while others may be better treated with a chemical peel or a laser treatment. There are also variations of surgical procedures that can be selected for each individual depending on their own needs.

Upper Eyelid Surgical Procedures

In most cases, an incision is made in a natural crease on the eyelid which may extend past the outer area of the eyelids. A second incision is made above the first incision to allow for removal of extra upper eyelid skin. If needed, excess fatty tissue is removed through these incisions to allow for an improved upper eyelid crease. In some cases, internal eyelid structures may be tightened to correct droopy upper eyelids (eyelid ptosis). Occasionally, your surgeon may also be able to elevate drooping eyebrows through the same incision or interrupt the muscles that cause wrinkling between the eyebrows. The incision is closed with sutures that in some cases may need to be removed in 4 to 7 days. Since the incision is typically hidden in a natural skin crease, it is barely visible after a few weeks. Bruising and swelling typically resolve in 1 to 2 weeks.

Lower Eyelid Surgical Procedures

Depending on the specific problem that needs to be addressed, the incision for lower eyelid surgery may be made just below the eye lashes or inside of the eye lid. Just like in the upper eye lid, extra skin may be removed. The bulging fatty tissue which is responsible for puffy lower eyelids can be removed or repositioned. If needed, the lower eyelid may be "tightened" at the same time. This may result in a temporary "cat eye" appearance which resolves in a few weeks. Through the same incision, the cheek area may be raised to a more youthful position on the face resulting in a midface lift. At times, a laser or chemical peel may be used to tighten the lower eyelid skin. The incision becomes barely visible within 2 to 3 months while bruising and swelling typically resolve in 1 to 2 weeks.

Improving the Lower Face and Neck

Various techniques are available to improve the area from just below the lower eyelids all the way down to the neck. Depending on a surgeon's perspective, a facelift may include treatment of any of these areas. One common way of defining specific facelift procedures is:

Midface lift - A procedure usually done through a lower eye lid incision (or less commonly through a scalp incision or incision in front of the ear) that repositions the tissue in the upper check to a more youthful position.

Facelift - A procedure usually done through an incision in front, or behind the ear, or more commonly in front and behind the ear, that allows for repositioning of deeper facial structures and removal of extra skin.

Neck lift - A procedure typically done through an incision under the chin that removes excess fatty tissue and tightens the loose muscles in the neck.

Each of these procedures may be done alone or in combination depending on the specific problems that need to be treated.

In younger patients with good skin tone and fatty tissue deposits in the neck, a neck liposuction procedure may offer a significant improvement.

What are the specific areas of the face that can be improved with a facelift?

• Deep wrinkles in the cheeks and sagging of the cheeks
• Deep lines, or creases, from the corner of the nose to the corner of the mouth
• Jowls which result in the absence of a well-defined jawline
• Loose skin, vertical bands and excess fatty tissue in the neck

What areas will a facelift NOT improve?

• Fine skin wrinkles
• Wrinkles and lines around the eyes
• Lines around the lips

Variations in Facelift Procedures

One common cause of confusion about facelifts are the differently named facelift procedures (SMAS lift, MACS lift, short scar facelift, S-lift, lifestyle lift, weekend facelift, thread lift, etc). While some are legitimate terms used to describe variations in surgical technique, others are simply marketing ploys used to promote a specific surgeon's practice. The choice of a facelift technique depends on an individual patient's specific areas of desired improvement, degree of facial aging and desired recovery period. Techniques that promise fast recovery with minimal incisions tend not to have long lasting results but may be good options for younger patients or those who need to be able to present themselves to the public in a short period of time.

Combining a Facelift with Other Facial Procedures

Since aging of the face occurs at different degrees in some people, it is possible that only specific areas of the face may need to be treated in order to improve overall facial appearance. More commonly, and especially in older people, the entire face may show characteristics of aging. In such cases, improving the appearance of one area without addressing other aging areas may result in a lack of harmony in overall facial appearance. For example, correcting sagging checks, jowls, and loose neck skin but not treating tired looking eyes and a droopy brow may result in an "unbalanced" face. It is therefore important to discuss the overall plan for rejuvenating your face with your surgeon. Although less commonly done as procedures to improve facial aging, nose reshaping (rhinoplasty) and use of chin implants (chin augmentation) may also be combined with a facelift to achieve a more youthful appearance.

Recovery After a Facelift Procedure

In most cases, at least 2 to 3 weeks are needed to recover from a facelift but this depends on the extent of the procedure and each persons individual healing. It is not uncommon for bruising and swelling to last for 3 to 4 weeks but most people can be presentable in public during this time with the help of cover makeup. If removal sutures are used, they are removed 4 to 7 days after surgery.

Procedures to Improve the Appearance of the Skin

Although surgical procedures such as facelifts improve appearance by repositioning facial structures and removing loose skin, these procedures do not improve the quality of the skin itself. Skin color irregularities, age spots, fine wrinkles and other changes seen in older or sun damaged skin can be improved by skin rejuvenation techniques which can complement the results seen with facelift procedures.

Current technology offers procedures that either work on the surface of the skin or deeper within the skin to result in a younger appearance.

Procedures that "resurface" the skin:

• Dermabrasion - The surgeon uses a mechanical device that "rubs off" the top layer of skin to improve fine lines and wrinkles. It is best used in the area around the mouth and lips.
• Chemical peels - Depending on the amount of treatment needed and the recovery period desired, a chemical may be applied to the skin that removes the top layer of skin. This results in smoother skin and occasionally improvements in pigment irregularities. Glycolic acid is a mild product found in some over the counter cosmetic products that if used regularly gives modest improvements in skin appearance. A more significant improvement can be seen using TCA (trichloroacetic acid). The amount of improvement and recovery time needed when using these products depends on the concentration of the product and technique used for application. The most dramatic results are seen with phenol peels but the recovery period is much longer.
• Laser treatments - Most commonly, a CO2 or Erbium laser may be used to remove the top layer of skin to give the skin a smoother appearance.

Each of these resurfacing procedures has specific advantages and disadvantages and their use should be based on an assessment of each person's skin type, skin quality and desired outcome. Generally, the better the desired outcome, the longer the recovery period is after these procedures.

In addition to resurfacing procedures, there are new technologies that treat the deeper skin without removing the outer skin layer. These procedures use special light or other energy applications to tighten and thicken the deeper skin structures and improve wrinkles and loose skin. While the initial results with these newer technologies appear promising in selected patients, the long lasting results are not yet fully known.

Frequently asked Questions in Facial Rejuvenation Procedures

What should I expect during a consultation for improving the appearance of my face?

You should be prepared to show what is bothering you. This is best done by pointing out your specific areas of concerns in a mirror to help your surgeon understand the problem and your expectations.

Since it is important to have your health history available to your surgeon, you should bring information regarding any medical problems you may have (especially problems like high blood pressure, thyroid problems, heart conditions, diabetes, bleeding or blood clotting problems), prior procedures, treatments or surgeries you may have had, medications you are taking, and allergies to medications or other medical products.

For procedures involving the area around your eyes, you should notify your surgeon about any specific eye problems such as "dry eyes", difficulty wearing contact lenses and vision problems. It is possible that you may need to be evaluated by an eye doctor (ophthalmologist) before eyelid surgery.

Where can the surgery be performed and what kind of anesthetic is used?

In most cases, facial rejuvenation procedures are done in a way that an overnight hospital stay is not need. Some procedures such as a simple upper eyelid surgery may be done in a procedure room using a local anesthetic injection (similar to having dental work done). Other procedures are typically done in an operating room either using a local anesthetic injection and medications to give sedation, or with general anesthesia resulting a person being totally "asleep". This can be done in a surgeon's office operating room, a free standing outpatient surgery center, or in a hospital. If a person has significant medical conditions or if the surgery is expected to last a longer period of time, then the surgeon may recommend that it be done in a hospital and may suggest an overnight stay.

Are there risks associated with these procedures?

While most people undergoing cosmetic procedures on their face don't have any significant problems afterwards, it is possible for unexpected results to happen. While not truly a risk, prolonged swelling or bruising may result in a longer time before a person is able to present themselves in public. Some degree of numbness is common after many procedures and tends to improve with time. Minor problems such as slow healing or a skin infection typically do not result in any long-term problems. More serious complications such as significant bleeding, major scaring, or injury to important structures (nerves, muscles, eyes) are rare but may result in long lasting or permanent problems. As some complications are more common in certain people, such as smokers or those with high blood pressure, it is important to tell your surgeon about all aspects of your medical condition.

Are procedures ever revised?

While the goal of these procedures is to give the best possible result, it is not unusual for a minor revision or "touch-up" to be done at some time if needed. It is important to discuss the revision policy with your surgeon to be sure that any reasonable concerns you may have after your procedure can be dealt with in a satisfactory way.

What about less invasive procedures which promise the same results as a surgical facelift?

While much progress has been made in procedures that give good results with less of the discomforts and recovery of more invasive surgical procedures, many "quick fixes" have not stood up to the test of time. Recently, the use of special sutures during an office procedure, or "thread lifts", was promoted in the media and claimed to give results similar to a traditional facelift. Unfortunately, the results were modest at best and lasted less that a year most cases. Similarly, use of skin treatments with energy or laser techniques has been promoted to replace facelifts with frequently disappointing results. When considering new (and not rigorously studied) procedures and technologies, it is important to have a sense of health skepticism and obtain a second opinion.