Historically, procedures for rejuvenating the face have entailed surgical treatments designed to remove excess fat or skin, and elevate or suspend descending tissues. In the last two decades, great strides have been made in non-surgical facial rejuvenation techniques. These advances were guided by our increasing understanding that facial aging involves not only gravitational descent, but also volume loss, muscular over activity, and skin changes. Non-surgical facial rejuvenation entails the use of injectable fillers, injectable muscle relaxing products, and medical lasers. In younger patients without significant skin sagging, non-surgical facial rejuvenation is an attractive alternative to facelift surgery. In older patients, non-surgical facial rejuvenation may not replace surgery, but it can still have a remarkable effect.

The three main components of non-surgical facial rejuvenation are: injectable muscle relaxers (Botox Cosmetic or Dysport), injectable fillers (Juvederm, Restylane, Radiesse, or Sculptra), and skin resurfacing lasers (Fraxel). Botox Cosmetic and Dysport help erase wrinkles in the forehead and the Crow’s feet. Injectable fillers restore volume to highlight the cheeks, plump the lips, rejuvenate the lower eyelids, and erase the naso-labial folds, the marionette lines, and the jowl folds. Resurfacing lasers restore tone, color, and elasticity to the skin.

Facial aging

A new study by Dr. Howard Lanstein at the University of Rochester confirms long standing plastic surgeons’ assumption that changes in the shape of facial bones, specially the mandible, has a significant impact on facial aging.

In this study, CT scans of the facial bones were obtained in nearly 120 patients. The patients were then divided into three groups: young (ages 20-36), middle (ages 41-64), and old (65 and older). There were equal numbers of male and female patients in each group. Comparison of these groups showed that with aging, there is a significant reduction in length and height of the jaw. This leads to reduced chin projection, and loss of jaw-line definition.

The study findings confirm our updated understanding of facial aging, where multiple factors including loss of skin elasticity, soft tissue volume loss, and bony loss are responsible for changes that occur in the face. In regards to bony loss in the jaw, new treatments for tooth loss such as dental implants could help maintain more bony volume. Otherwise, chin implants have a long standing history as an adjunct to facelift surgery, and neck liposuction to enhance lower face and neck appearance.

I’ve heard the term “preventative cosmetic surgery” once too often lately and I wanted to address this subject.  Rejuvenative cosmetic operations are being touted to younger and younger patients. Smaller  operations, “mini facelift”, with shorter incisions are being proposed for patients as young as thirty five or forty. Midface lifting is espoused in even younger patients. Is that appropriate? I believe the answer is no.

Here is an example of a relatively young patient , I found on the web, who has undergone a facelift operation:

Besides having makeup, and perhaps a slightly improved upper neck contour, it is hard to see any effect from a facelift operation in this patient. The neck contour could have been improved with a simple liposuction procedure.

The concept of preventative cosmetic treatments took hold with popularization of Botox. Cosmetic doctors began to talk about Botox treatment in younger patients, as a way of preventing the development of frown lines or crow’s feet. Smaller procedures such as Botox or filler injections (Restylane, Juvederm), have relatively low risk, and they are temporary. As such, the risks are very low and the treatments may be justified. Surgical procedures carry real risk, they should be recommended in a more considered manner. There is no real place for a “preventative facelift”.

Rhinoplasty has been traditionally a cosmetic operation for younger patients, as young as fifteen. Rhinoplasty is a reshaping operation and not a rejuvenation procedure. Fat liposuction in the neck is appropriate for patients as young as their twenties when there is a clear over abundance of neck fat. Patients in their late thirties to forties are candidates for blepharoplasty or eyelid rejuvenation. However, facelift, midfacelift, and neck lift operations should be performed in patients who need rejuvenation, not in those who want to “prevent aging”. Facelift procedures are best suited for patients in their late fifties to sixties who show sings of aging such as jowl formation, nasolabial folds, marionette lines, and neck skin redundancy.

Although cosmetic surgery is safe and patient satisfaction surveys show high level of satisfaction in those who have had cosmetic surgery, as surgeons, it is up to us to maintain high standards in choosing the appropriate patient and recommending the proper procedures.

A new animal study published in the prestigious Journal of Plastic and Reconstructive Surgery (March 2010) reports the benefits of Calcium Channel Blockers (a category of anti hypertension) medication in reducing the risk of skin necrosis and skin loss in animals who were exposed to cigarette smoke. Smoking has been shown to triple the risk of skin injury or skin loss during face lift surgery.  Most plastic surgeons refuse to perform elective face lift surgery on patients who actively smoke.

The adverse effects of cigarette smoking on tissue healing have been widely studied and published. Smoking-related skin necrosis is multi factorial and complex. In addition to reducing blood flow due to nicotine effect on blood vessels, smoking can cause increased blood clot formation and delayed tissue repair. Calcium channel blockers relax the muscles in the lining of blood vessels and partially counteract the spasm inducing effects of nicotine.

Although this finding won’t change my mind in refusing cosmetic surgery in smokers, these results will alter my treatment of smokers who require reconstructive surgery which can not be delayed.

2010 plastic surgery trends

Happy new year! 2010 promises to be an exciting new year, and hopefully an end to the global recession that affected every one so significantly in the past decade. In light of the continuing advances in the medical field, I have the following predictions in regards to trends in facial plastic and cosmetic surgery.

1. New products that rival Botox Cosmetic in treatment of facial wrinkles will become available. Botox Cosmetic has revolutionized office based facial rejuvenation, by allowing treatment of dynamic wrinkles of the brow and crow’s feet area. In 2009 Dysport was introduced as a competitor to Botox Cosmetic. In 2010 new products such as Pur Tox are likely to become available for use.  Research is also progressing in developing products that can be applied as a cream, and avoid injections. We may have to wait till 2012 before those products are available.

2. Increase in the number of plastic surgery procedures. As the economy recovers, we will see an uptick in the number of cosmetic procedures overall. The greatest increase will be in the minimally invasive treatments such as Botox Cosmetic and dermal filler injections, and skin laser treatments. But we will also see increases in surgical treatments such as face lifts, and rhinoplasties.

3. Fat injection will become more in vogue. Fat transfer from one part of the body into another area will gain more attraction. Facial fat injections for treatment of wrinkles and achieving a fuller and rounder face is well established. In 2010, we will see more fat transfer in other parts of the body such as the breast or the buttocks.

4. Face transplants will become more common. Thus far, there have been eight cases of face transplants in the world. The early success with this procedure will fuel further growth in this highly specialized surgery which is a last resort for patients with massive and catastrophic facial deformities. The biggest advances in face transplant will involve immunosuppressive therapy that will prevent transplant rejection.

As the summer comes to an end and fall season starts, I thought it would be an opportunity to discuss and review options of facial rejuvenation, and in particular face lift surgery updates.

Historically, face lift is known as an operation to rejuvenate the lower face and upper neck. Forehead or brow lifting, and blepharoplasty are procedures that allow rejuvenation of the upper face and the eyelids. There are several variations to the face lift, each with its own advantages and disadvantages.

1. SMAS face lift: This is the commonest form of the operation. In this type of surgery the skin and the underlying facsia (fibrous layer on top of facial muscles) is tightened.  This form of face lift surgery gives excellent results in the jowl and neck region.

2. Short scar face lift/ mini face lift: In this variation of the surgery, the incisions do not extend behind the ear or into the hair line. The surgery is more limited in its effects. It does not allow tightening of the neck skin, and is more suited to patients with isolated jowl formation.

3. Deep plane face lift: This is a variation of SMAS surgery, where the dissection of the fascia layer (fibrous tissue on top of facial muscles) is more extensive.  Extending the scope of dissection leads to better rejuvenation results near the mouth. However, the recovery and bruising can be more extensive.

4. Liquid face lift or non-surgical face lift: This is not an operation, but rather a way of rejuvenating the face with a combination of injectible fillers and Botox. Such techniques are limited in their rejuvenating effects and therefore most appropriate for younger patients without significant aging.  Volume augmentation of the face via fat grafting is often performed as an adjunct to various forms of face lifting.

I am often asked this question from patients who seek facial rejuvenation.  I can make some broad generalizations based on the “average patient”, to say that facelift surgery can be considered in the mid 50’s, but once a patient reaches his or her 70’s the operation is not very effective. However, I need to emphasize that facial aging is not a strict chronological phenomenon. There are many factors that affect facial aging and can hasten or slow the process. These factors include:

1. Genetics: The quality of skin, fat, muscle, and bone in each of us is dependent on our genetic heritage. For example, Asian patients tend to show facial aging less, showing jowl formation in their 60’s vs Western Europeans who exhibit jowl formation in their 50’s. Also, patients with well developed/prominent cheek bones and jaw bones appear to age less quickly. Evaluating the parents and their pattern of facial aging is the most effective method of predicting facial aging in any patient.

2. Sun Exposure: Adverse effects of sun exposure on facial skin are well documented, and include wrinkle formation, thinning of skin, and uneven pigmentation.

3. Smoking: Chronic smoking results in formation of facial wrinkles. In one recent study of patients 40 to 60 years old, smoking was estimated to equate 1.4 years of aging.

4. Weight: A recent scientific article, comparing identical twins, concluded that in women over 40, being slightly over weight, imparted a younger appearance to the face.

6. Hormone Replacement in Women: Estrogen replacement therapy delays facial aging in post menopausal women.

So, in answering the title question individually, I like to have a consultation with a patient in order to garner the information listed above. The consultation also allows clinical examination of the face to look for sagging, wrinkle formation, loss of volume (fat or bone), and skin quality. In many instances, it becomes evident that simple office procedures such as Botox or filler injections are sufficient in rejuvenating the face. In other patients though, facelift surgery is clearly the most efficient and even the most cost effective method of facial rejuvenation.

In the last two decades, there has been significant progress in facial cosmoceuticals and cosmetic lasers. We can now recommend specific treatments for maintaining and improving facial features and complexion for various age categories:

In your40’s:

Use Vitamin A creams (retinoids) such as Retin A Micro or Renova to boost collagen production and skin turn over. This will help give your skin uniform in color and radiant. Begin treatments as every other night application and increase to every night, to avoid irritation and excess dryness.

Exfoliate regularly. You can use Alfa Hydroxy Acid (AHA) creams two or three times a week to boost the effects of retinoids. Alternatively, you can consider micro dermabrasion once a month.

Consider Hydroquinone. Hydroquinone is a bleaching agent which when used over time can help minimize dark skin patches and uneven skin tone. The prescription strength has a 4% concentration, but OTC preparations are available with %2 concentration. It’s important to avoid sun exposure as much as possible.

In your 50’s:

Hydrate. With onset of menopause, female hormones diminish and skin can become increasingly dry. Avoid harsh cleansers or soap, and use effective skin moisturisers. You may consider Try L’Oréal Paris Age-Perfect Pro-Calcium Restorative Hydrating Cream ($20; drugstores) and the Body Shop Wise Woman Regenerating Night Cream ($34; thebodyshop.com).

Continue using retinoids, and consider switch to Renova or Atralin; both are moisturizing. Also, use a nightly eye cream to plump lines.

In your 60’s and beyond:

In this age group the skin begins to sag, and deep folds or jowls can form, dryness of skin becomes a more significant issue. Use only creamy cleansers such as Albolene ($12; drugstores) and Avène Gentle Cleanser ($20; drugstores). Use seriously intense moisturizers. Look for formulas with a high concentration of oils, such as petrolatum.  You should also adjust your retinoids and mix it with a moisturiser as you apply it to your face.

Turning to the pros:

In each age category, there are treatment options that are only available as physician administered procedures. These include laser treatments, IPL treatments, or LED treatments to: even skin tone, increase skin thickness, and remove fine wrinkles. Botox or Dysport injections to: eliminate frown lines, and crows feet from the face. Filler injections such as Restylane, Juvaderm, or Radiesse to: smooth folds or depressions such as nasolabial fold or the jowls. Some fillers can be injected into the lips to make them fuller and plumper. Surgical treatments such as blepharoplasty to eliminate sagging eyelids, and face lift surgery to rejuvenate the face by removing exc            z               fess skin in the face and neck.

On the home page of our website, I state: “Although we are ardent supporters of innovation in medical devices and technology, we prefer to offer treatments that have proven clinically helpful rather than those that attract headlines without proven benefit”. A recent article in the Archives of Facial Plastic Surgery speaks to that philosophy. The authors evaluated the long-term results of a technique known as thread lifting. Thread lifting was espoused as a minimally invasive alternative to face lifting. The procedure could be performed under local anesthesia. A long needle with an attached barbed suture is passed under the skin in the cheek and pulled up towards the temple. As the suture is pulled, the cheek skin is pulled back to get rid of skin redundancy. Typically multiple such sutures are placed on either side of the face. This procedure garnered significant media attention when it was first introduced about 5 years ago. Many surgeons embraced the technique in an attempt to be perceived as trend setters in plastic surgery.

The Archives article concludes that: “thread-lift provides only limited short-term improvement that may be largely attributed to post-procedural edema and inflammation. Our results objectively demonstrate the poor long-term sustainability of the thread-lift procedure. Given these findings, as well as the measurable risk of adverse events and patient discomforts, we cannot justify use of this procedure for facial rejuvenation“. The Food and Drug Administration has rescinded approval for use of this device, although similar products are still available, and the procedure is widely advertised.

I believe the thread-lift phenomenon is symptomatic of a media driven environment in which cosmetic surgery has been evolving for the last decade. Patients and physicians are increasingly in search of the newest device or technique. Unfortunately, science has been playing catch-up with the hype and occasionally, long-term clinical evidence conflicts original claims of device manufacturers. It’s precisely in this envirornment that physicians and surgeons must act as patient advocates and resist the temptation of embracing sexy new techniques without credible clinical evidence.

In a recent medical conference entitled “About Face 2009″, one of the panel members, Dr. Burgess,  gave a presentation regarding aging in the ethnic population. I found her observations astute and would like to share them with you.

Signs of aging in the ethnic population are similar to Caucasian patients and include: loss of volume, skin laxity, wrinkles. Additionally, ethnic patients frequently experience uneven complexion and skin tags. Dr Burgess had the following recommendations for best results in the ethnic patients:

Sun screen and vitamin D3 supplements: Ethnic patients are at risk for sun damage to their skin, just as Caucasian patients. Therefore, a sunscreen with UVA and UVB protection is important. In addition, many patients have low vitamin D levels in their bodies. This is specially true for people living in the northeast with cold and long winters. Vitamin D3 supplements will restore vitamin D levels in the body.

Anti aging topical medications: Retinol (Retin A) and its equivalents, as well as glycolic acids or salicylic acid topical agents help rejuvenate skin.

Treatment of pigment irregularities: Several options are available such as microdermabrasion, chemical exfoliation, or Q-switched Nd:Yag laser treatments.

Volume loss in the face and wrinkles around the eyes and in the forehead can be effectively treated with a combination of dermal filler injections and Botox injections. More involved procedures such as blepharoplasty, face lift surgery, brow lift, and neck lift are options for patients with more notable aging of the face. In the ethnic population there is an increased incidence of keloid (unsightly) scar formation. It is important that the surgeon attain a detailed clinical history in regards to past scarring and family history of keloids, in order to minimize the risk of poor scarring after surgery.