This chapter is designed to help facial surgeons address common questions and concerns posed by patients contemplating rejuvenation procedures. Specific procedures designed to accomplish rejuvenation are discussed in subsequent chapters 18–25.
To provide an algorithmic approach to facial rejuvenation surgery, I developed the following classification. It addresses the stages of aging and the surgical procedures that are available to stabilize or reverse them and should assist facial surgeons in providing “informed consent” to potential patients.
Facelift is the term commonly used to describe a surgical procedure better known in medical circles as “rhytidectomy” (the surgical removal/repositioning of loose, wrinkled skin of the face and neck). The procedure is designed to re-create the firmer, smoother face of youth. However, not all facelifts are the same—nor should they be! The reason is that not all faces are the same. And at different ages, the same face is a different face.
The McCollough Facial Rejuvenation System was introduced in 2012 in the peer-reviewed journal Facial Plastic Surgery.1 The system comprises five general treatment plans:
• Stage I (The Less Than 30 Facial Rejuvenation Plan): for the younger individual who has little or no loose skin and may require only liposuction to remove unwanted fat and bulges in the neck and lower cheeks.
• Stage II (The 30-Plus Facial Rejuvenation Plan): for the patient who is beginning to notice sagging of the brows and cheeks, but not the neck. Whenever sagging tissues are present, facial muscles and fat must be repositioned into their more youthful relationships. In such cases a small amount of loose skin is removed.
• Stage III (The 40-Something Facial Rejuvenation Plan): for the patient who exhibits sagging brows, cheeks, and neck. These patients may or may not need liposuction for contouring jowls and fullness under the chin. All, however, require suspension techniques to muscles and fat.
• Stage IV (The 50-Something Facial Rejuvenation Plan): for the patient with generalized facial and neck sagging, with—or without—jowls and wrinkles around the mouth. With more obvious muscle, fat, and skin laxity, more suspension of these structures is required.
• Stage V (The 60-Plus Facial Rejuvenation Plan): for the patient with advanced aging, coupled with sagging of all facial areas, including the forehead, brows, cheeks, and neck. At this stage in the aging process, deep folds develop in the groove between the nose and face, jowls droop below the jawline, and the muscles of the neck often produce stringlike bands that run vertically from the chin to the upper chest. Many of these patients are also beginning to exhibit wrinkles and blemishes over most of the face. Transcutaneous removal of skin and fat in the upper and lower eyelids is almost always indicated.1
■ Does Age Really Matter?
I rarely pay attention to a patient’s chronological age. The reason is that individuals who share the same chronological age will exhibit more—or less—aging than their peers. Several factors contribute to this fact, including genetics, lifestyle, stress, nutrition, nicotine, and (excessive) alcohol use.
Surgery that addresses facial aging must focus on more than sagging skin of the cheeks and neck. For naturally enhanced faces, volume replacement and redistribution must be considered. While a facelift may play a significant role in a master plan, if the best results are to be obtained, more than traditional facelift surgery should be considered. Many patients benefit from work on the eyebrows and/or upper and lower eyelids to remove bags and sags in those regions. Those with wrinkles, acne scars, and sun-damaged skin should be advised that one of the level II or III skin resurfacing procedures mentioned in Chapters 21–24 could provide the “icing on the cake.”
Some patients will require liposuction in the lower cheeks and neck. In fact, patients under the age of 40 might require nothing more than facial and neck liposuction, following which their youthful skin will “contract” to conform to the newly sculpted shape of the face and neck. And temporary injectable fillers can help bridge the gap until surgery can provide more permanent correction, or as “bridge alternatives” between “continuing maintenance” surgical procedures.
Depending on the length of time it takes a surgeon to perform individual elements of rejuvenating facial surgery, multiple procedures can be performed at the same time as the facelift, and without extending recovery times.
A good rule of thumb is to limit the total operating time to less than 5 hours, especially if surgery is being performed outside a hospital.
In the formative years of a facial surgeon’s career, it is wise to exercise Ockham’s logic: the simplest treatment plan is usually the correct one.
Not all faces should have the same treatment. Instead, a long-term rejuvenation plan should be considered prior to the initiation of treatment, even for treatments that promise only short-term benefits (i.e., injectables). Facial rejuvenation plans should be personalized and tailored to meet the needs and desires of each patient, at every stage of life. Each treatment plan must also coincide with the experience and skill of the surgeon.
Unfortunately, we live in a world with an appetite for instant gratification, even if it means short-lived results. That mind-set has found its way into the appearance-enhancement industry. The result is that commercialization (and not condition-specific, verifiable science) too often drives public demand. And in a rapidly changing society, demand tends to generate the opportunity for predatory exploitation.
In response to market-driven consumer demand, too many facial surgeons appear to be playing the role of trend follower rather than leader. For fear of losing patients to competing doctors, the tendency is to give patients what they ask for, rather than take the time to explain alternative methods of treatment and recommend the best alternative for each patient. The challenge is greater today because patients present with preconceived ideas and ask for therapeutic options television and print commercials prompt them to ask for.
Changes within the medical profession itself are also contributing to the dilemma. With the oncoming avalanche of regulated health care and declining imbursements from government and private health insurance companies, many doctors are turning to cosmetic procedures as a way to shore up consistently dwindling incomes.
Technology companies recognize the changes taking place throughout the health care industry. That industry appeals to doctors to include the products and machines they manufacture—laser treatments, injectable therapies, and “cookie cutter” types of surgical procedures, some of which can be “franchised.” The imprudence in such a trend is rather obvious. Promoters prosper; physicians—and the patients they are entrusted to care for—pay the price.
Unfortunately, commercialized facelift procedures fall into the “one-sizefits-all” (or perhaps fits none) category. And some surgeons have been trained in only “one way” to perform the procedure, regardless of the conditions exhibited by the patients who entrust theirface to that practitioner. So facial rejuvenation is subject to the age-old truism that if all one has is a hammer, everything takes on the shape of a nail.
The fact is that aesthetic plastic surgery is very much an art form and can be tailored by an experienced surgeon/artist to meet the specific needs of each individual who presents for treatment.
The same face changes with advancing age. In one’s late 30s the tissues of the brows, cheeks, and neck begin to descend from their youthful position, creating a “tired look.” Alternating ridges and valleys create shadows in the face, and tissues begin to hang below the jawline and under the chin. With each passing year, these conditions progress, until the individual exhibits the undesirable characteristics of “old age.” It is possible, however, to prevent these typical changes and to correct them as they occur. The “youth maintenance approach” addresses the signs of aging as they occur so that the individual never seems to age. The “rejuvenation approach” addresses the conditions of aging after they become obvious to the patient, and to others. Both approaches are effective. The bottom line is that surgery is available to either retain or regain a youthful and vibrant face.
■ When Is Facial Plastic Surgery Indicated?
The following questions are frequently asked—by patients and developing surgeons alike.
When is an often asked question. The best answer a facial surgeon can give is when sagging tissues of the face and neck or “bags” around the eyes are not temporary conditions relieved by rest, or when they become increasingly difficult to camouflage with cosmetics. When it comes to a specific age, the right answer is that one’s chronological age does not matter!
As the life span lengthens in modern America, most people feel vigorous and energetic long after their appearance begins to deteriorate as a result of advancing years.
The onset of aging plays an important part in the personal and financial welfare of men and women from all walks of life. Almost everyone knows of people whose employment opportunities have been limited or curtailed because they “appear old,” even though they might be more capable and competent than younger individuals.
For hundreds of years experts have confirmed that favors are granted to beautiful or handsome people. In Chapter 10 you were reminded that good looks affect school grades, enhance the probability of prosperity, determine who will be our friends, and shorten stays in mental hospitals.
The appearance of aging also imposes certain limitations in the area of social interests. Finally, the emotional impact of looking older than one feels can be disconcerting.
Fig. 17.1 (a) This woman had upper and lower blepharoplasty and temporal, cheek, and neck facelift (b) Several months later she had full face resurfacing with a combination chemical peel and dermabrasion to remove deep facial wrinkles.
There are two schools of thought: (1) to preserve one’s youth and/or beauty by having problems corrected as they occur, or (2) to wait until the aging process has erased the appearance of both youth and beauty then take measures to recapture that appearance with several surgical procedures. In short, choose between preventive maintenance and restorative rejuvenation (Fig. 17.1).
If a patient wishes to remain looking younger, the elite facial surgeon will explain that it is possible to perform a continuing series of relatively minor cosmetic surgery procedures as each of the irreversible changes of aging makes its appearance. With such a maintenance program, the patient can maintain a youthful appearance. Family, friends, and acquaintances are apt to remark that the patient doesn’t seem to grow older. Today, most people choose this route. But in patients who didn’t start such a preventive maintenance program when they were younger, a facial surgeon should outline a rejuvenation program to help the patients look as young and well as they feel.
■ Why All Faces Droop and Sag
In any given face, changes associated with aging do not occur all at once. Rather, they happen in a slowly progressive manner and involve all components of the face and body. There is no debate that human beings age differently. Patients frequently become aware of the changes over a 2- to 4-year period in their early 40s, occasionally sooner. They often tell me that it seemed as though things were aging well and then things seemed to change almost overnight, especially following a period of intensive and prolonged stress.
With aging, the skull becomes smaller, some fat is absorbed, and the skin loses much of its elasticity. As a result, the enveloping tissues, particularly in the face and neck, droop and sag. The envelope becomes larger than its contents. This phenomenon results in a series of events, including deepening of the lines of facial expression in the forehead and at the sides of the mouth; sagging of the eyebrows, which causes the eyes to appear smaller and crow’s-feet to form at their corners; pouches or jowls forming along the jawline; and of course, development of the well-known “double chin.”
At the same time, certain degenerative changes occur within the skin itself so that it seems to look “tired.” In addition to the sagging, some faces become etched with wrinkles, especially those repetitively exposed to the sun and wind.
As occurs in other parts of the body, the muscles and tissues around the eyes eventually lose some of their tone so that a portion of the fat normally located inside the orbit around the eye bulges forward, or herniates, to produce the commonly seen “bags” or pouches. This condition can also be seen in younger people. “Circles” under the eyes may be a result of a shadow falling in the crease between mounds of pouches in the lower lid and cheek.
Finally, because of absorption of tissues in the upper lip and gums, the lips become thinner and the tip of the nose drops, causing it to appear larger and longer. Repositioning and supporting the tip of the nose can have dramatic and lasting effects on reversing this telltale sign of the aging process.
One needs only to study a child’s face to see the physical characteristics that exemplify youth (fuller lips, larger eyes, arched eyebrows, smoother skin, and a shorter nose).
Each individual who wants to look “better” presents a different set of problems. This fact is why I created the “condition-specific” approach to facial rejuvenation. The corrective procedures indicated vary with each face, at every age. For example, one person may require only elevation of sagging eyebrows or improvement in the eyelids; a very young individual may need only correction of an early double chin with liposuction. On the other hand, a partial or complete face and neck lift followed in 3 to 6 months by a skin resurfacing procedure may be called for in more advanced cases.
When the skin is weather-beaten in appearance or has deep wrinkles, a chemical face peel, dermabrasion, and/or a laser resurfacing procedure may provide the icing on the cake (see Skin Rejuvenation, Chapter 20).
As a rule, a facelift, blepharoplasty, or submental lipectomy improves sags and bulges; resurfacing (laser, dermabrasion, and peeling) improves wrinkles and replaces sun-damaged skin (that is more prone to develop skin cancers) with more youthful and healthier skin.
■ Prevention or Rejuvenation?
There are two acceptable schools of thought. Some experts believe that as soon as aging signs appear, they should be corrected; thus patients will never appear as old as they are on the chronological scale. Most entertainment personalities or public figures have followed this principle. They have never allowed themselves to look old.
The motivation to look good is often rewarded in terms far beyond dollars. People who take pride in their health and pay attention to clothing, grooming, and overall personal appearance soon realize that exercise and proper nutrition can keep every part of the body other than the face toned up and looking more youthful than its chronological age. Regardless of what one might read or hear, nothing short of surgery can help the face maintain that same youthful appearance. Temporary “fixes” (neuromodulators and injectable fillers, facial exercises, electrical stimulation, acupuncture, creams, etc.) provide short-term improvement but will not correct the inevitable signs of aging.
■ Injectable Therapies
In Chapter 25, I provide a more detailed discussion on injectable therapies.
Temporary fillers dissolve within weeks to months, requiring multiple treatments, and may lead to problems. It took years for the medical profession to report on cases of skin necrosis following injectable fillers to the glabellar and nasal tip areas. The age-old adage “If it sounds too good to be true, it is usually is” applies to injectable treatments to treat the aging process. I feel that more predictable and time-tested procedures should be recommended to patients. Quick fixes generally lead to quick returns of the condition treated. Thus, the condition requires ongoing temporary treatments.
Many new tissue fillers are more promising than their predecessors. Neuromodulators (Botulinum Toxin type a) only treat conditions that occur with facial expression. They paralyze muscles and (for a while) prevent the wrinkles of expression from appearing. Concerns about atrophy of facial musculature following long-term, uninterrupted use of muscle-paralyzing agents linger.
Science-focused facial plastic surgeons are constantly investigating procedures, products, and techniques designed to provide the best result, with the least risks, with long-term benefits. My experience-based advice is to be slow to incorporate “new” products and technology into one’s practice. In the long run, patients and colleagues alike appreciate—and reward—prudence in their appearance-enhancement providers.
Fig. 17.2 This drawing demonstrates the changes that occur in the same face at 10-year intervals. Surgery can generally move one back one step, sometimes more, depending upon which procedures are performed.
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