Facelift

Overview of the Aesthetic Face Lift

The concept of face lifting has undergone dramatic improvement over the last last decade, it has become less focused on skin-tightening and more focused on the resuspension and addition of fat with gentle redraping of the skin. This eliminates the over-done “surgical look” and creates a more natural, youthful appearance.

Aesthetic Lift

Facial aging is a very complex process. It primarily involves the descent and loss of facial fat and muscles and secondarily the sagging of the skin. This is why it is essential to address each patient’s specific problem areas instead of performing a one-size-fits-all lift. The Aesthetic Lift is a methodical way of identifying the individual causes of each patients facial aging and applying the most appropriate correction method possible. This creates predictable results with minimal down time. It addresses the underlying problem instead of creating a “pulled” look.

The real value of the Aesthetic Lift is in the experience and methodical thought process of the board certified plastic surgeon. Rather than a “one size fits all” procedure created by a cosmetic surgery marketing team, the Aesthetic Lift is unique for each individual and performed by highly experienced Board Certified Plastic Surgeons. These Plastic Surgeons have their own practices based on great results and patient referrals as opposed to being managed by a marketing group.

What exactly is Aesthetic Lift?

There are three fundamental processes that make the Aesthetic Lift exceptionally predictable and successful:

  • Clearly Define the Primary Concerns
  • Identify the Contributing Factors
  • Prioritize

The fundamental concept of the Aesthetic Lift is to educate each patient in an easy to understand fashion outlining the causes of their facial aging. Then, to prioritize their treatment plan so that the patients can achieve their desired result in the least invasive manner possible.

1. Clearly Define the Primary Concerns. 
A consultation with a board certified plastic surgeon will accomplish this task.
The most common concerns include:

  • a tired appearance of the eyes
  • a gaunt, hollow look of the cheeks
  • sagging jowls
  • hanging neck

It is essential to understand the patient’s primary concern to make sure that, at a minimum, this concern is corrected.

2. Identify the Contributing Factors. 
Aesthetic Lift categorizes this via a “Regional Approach” to facial rejuvenation. Facial aging is not an isolated process; it usually involves an entire region, if not the entire face. This can be a difficult concept to understand but it makes sense. A great example is the tired, sagging upper eyelid. Patients routinely believe that simple removal of the upper eyelid skin will take care of their problem. Usually, this is not the case; especially in people over 40 years of age. Often, there is a sad look to the outer corner of the eye caused by descent of the temple region. In order to treat the problem completely a regional approach is necessary; otherwise you will get an unnatural appearance as one part is rejuvenated and the other stays lax. Typically this is best addressed by an upper blepharoplasty and temple lift. Together they correct all the contributing problems to this region. Conveniently, adding the temple lift does not significantly increase the recovery or cost of the procedure.

A more complex example is what occurs with aging with the face and neck. There are always multiple contributing factors. It is the plastic surgeon’s responsibility to determine what they are based on his/her extensive experience and training. Later in this section we will break down each area into components. This is the methodology that is used by plastic surgeons who perform the Aesthetic Lift. Breaking down each area will allow you to easily understand what is causing your area of concern.

3. Prioritize. Simply telling the patient what needs to be corrected is not enough. It is critical for the surgeon to accurately assess what is the relative importance of each contributing factor and to prioritize them. This enables you to make an educated decision as to what is necessary to achieve the results you are looking for. You can make an educated decision regarding how much or how little you wish to have done. A “one-size-fits-all” face lift is never appropriate.

Obtaining the Best Result Possible

Other heavily marketed face lifts concentrate on a “one-size-fits-all” factory-type face lift. Aesthetic Lift, on the other hand, represents the best that plastic surgery has to offer. To enhance the results certain ancillary procedures such as a chemical peel,laser, fat transfer or BOTOX® can be added. This allows for a more complete facial rejuvenation.

Components

The Aesthetic Lift evaluates facial aging by separating the face into three anatomically linked regions; the upper face, the mid/lower face and the neck. This regional approach allows the patient to understand all the components of aging within that area.

Typically, it is critical to address multiple components within the problem area in order to obtain an optimal natural rejuvenation. It is essential for you to understand the relative importance of each component. This allows you to obtain the optimal result with the least invasive approach.

Upper Face Rejuvenation

Approach to the problem areas of the Upper Face.

The six most common concerns regarding the upper face are listed below. Remember, the entire concept of Aesthetic Lift is to identify which of these problems are of concern to you AND the relative importance of each concern. With this information you can intelligently outline which procedures are best suited for you. Unfortunately, with time everyone will experience aging to ALL six areas but this does not mean that each area must be addressed at the same time.

1. Upper Eyelid. 
The most common concern with the upper eyelid is excess skin. Fat excess is rarely a problem except in the Asian population. In fact, the upper eyelid region LOSSES fat with age and becomes hollow and gaunt. Sometimes, there is a little bulging fat pad right next to the nose. Aside from this all fat in the eyelids is precious and should be preserved. If this fat pad is present, it is located just above the corner of the eye near the bridge of the nose. This should be removed at the time of upper blepharoplasty surgery.

What does the Upper Blepharoplasty do? 
The approach to upper blepharoplasty is to remove the redundant skin to define the upper eyelid and give it a youthful appearance. In women, this creates an elegant, defined upper eyelid, which allows makeup to go on easily without smudging. The size of the upper eyelid is decided by the patient. Men, on the other hand, are usually looking for a less dramatic result. They do not tolerate an “operated-on” appearance.

How do I know if an Upper Blepharoplasty is right for me? 
If your upper eyelid skin is loose and sagging you would most likely benefit from an upper blepharoplasty. Typically, this redundant skin can be easily pinched and feels “paper” thin.

2. Temple Region, Outside Corner of the Eye and Crow’s Feet
This is the area of the upper face that typically ages the quickest. Yet, it is often not addressed by the majority of plastic surgeons. The temple region is the outer part of the eyebrow and the outer corner of the eye. Elevating this area with a Temple Lift creates dramatic improvement in appearance. The nice thing about this procedure is that it can easily be done under local anesthesia with or without a blepharoplasty.

What does the Temple Lift do? 
The temple lift does several key things in terms of rejuvenating the upper face. It lifts the outer corner of the eye. This dramatically improves the lateral hooding of the eye that often makes you look sad even when you are not. It raises the outside part of the eye brow creating a very elegant look. In fact, it usually replaces a brow lift completely. It’s effect is not to raise the central eyebrow, which can oftern can make you look older and surprised, but rather improve the shape.

How do I know if a Temple Lift is right for me? 
The best way to see if a temple lift would benefit you is to elevate your own temple and see if you like the look. Simply, place the tips of your index, middle, and ring finger right at the hairline of your temple and elevate it gently; not too much because this will over correct. Most likely this will create a more youthful, elegant appearance. Notice, this creates a completely natural look that does not look surprised. Dr. Montroyal routinely performs both an upper blepharoplasty and a temple lift at the same time. This rejuvenates the entire upper facial region. Best of all, both can be easily done under local anesthesia without discomfort.

3) Brow 
With aging and loss of facial volume, the brow routinely deflates and drops down. Sagging of the eyebrows is never uniform. The outer part of the brow almost always drops more than the inner part. Look in the mirror and see if this applies to you. If only the outer part of the eye brow has fallen then a temple lift is the best choice for correction. If the entire brow has dropped, then a brow lift may be necessary. Often the brow falls because the upper eyelid/brow area has lost significant fat.

The loss of fat volume causes the brow to descend not because there is an excess of skin. It also causes the upper eye to look hollow. The best way to correct these problems is to perform a temple lift to raise the outer brow. Then, to replenish the lost volume with either fat or a soft tissue filler.
By correcting the cause of the problem, facial rejuvenation looks much more natural.

What does a Brow Lift do? 
A traditional brow lift elevates both the inner and outer part of the brow. The temple lift, however, elevates only the outer part of the brow.

How do I know if a Brow Lift is right for me? 
It is far more likely that you will need a temple lift before you need a brow lift. Remember, the goal is to make the brow look more youthful not just higher. The real question in the approach is whether or not you need a brow lift in addition to the temple lift. If the central part of the brow still seems low than a brow lift may be necessary.

Caution: A traditonal brow lift without a temple lift will create an older, hollow, surprised look.

4) Hollow, Sunken Appearance of the Upper Eyelid
This topic is a perfect continuation of the brow area. The brow often falls because the brow region and upper eyelid losses fat with age. Not only does this cause the brow to drop but it causes the upper eyelid to appear sunken and hollow. Traditional cosmetic surgery principles would treat this problem with a tight upper blepharoplasty and a brow lift. This often leads to a hollow, surprised appearance that actually looks older. The excess skin is removed as necessary.

What are soft tissue fillers? 
Soft tissue fillers are a myriad of injectable products that add volume. There are two distinctly different types to choose from. One type comes packaged and ready to inject. You most likely have heard of them by name, i.e. Restylane®, Juvéderm™ , Radiesse, etc. These last anywhere from 6 to 24 months. The other type is your own fat. Obviously, this fat needs to be removed from other parts of your body, purified, and then re-injected. The clear advantage of the packaged soft tissue filler is that it does not require a donor site and, therefore, is much simpler with less down time. The advantage of fat is that it lasts forever.

How do I know if I need a soft tissue filler for the upper eyelid? 
This can be done by first simulating a temple lift with your index, middle and ring fingers. Now, look at your upper eye lid. Is it hollow? Does it look sunken? If so, a soft tissue filler will help tremendously. The good news is that it is relatively quick with minimal to no down time. A huge advantage of the packaged soft tissue fillers for the upper eye lid is that they last much longer here than they do in the lips or naso-labial folds. They can often last up to two years.

5) Crow’s Feet and Forehead Wrinkles
Wrinkles that are caused by facial animation are best corrected with Botox®. As mentioned earlier, crow’s feet that are caused by excess skin can be removed by performing a temple lift. Crow’s feet that only occur during smiling require Botox®.

6) Poor Skin Quality and Sun Damage
With age and sun exposure many unfavorable things happen to facial skin. The surgical procedures above address how to manage skin excess, skin sag and volume loss. The most difficult problem to correct, however, is poor skin quality.
Aging causes the dermis to become thin. This, along with sun damage, causes the skin to loose its elasticity. Therefore, neck and facial skin that is tight and smooth in a 30 year old becomes loose and saggy in a 50 year old.

How can skin quality be improved?

A chemical peel or laser treatment. This penetrates the dermis causing it to heal with thicker, more elastic dermis. It has anywhere between a 3 day to a 2 week recovery period depending on how strong of a effect is desired. The most impressive result of a chemical peel or a laser is its ability to get rid of the aged spots and caused by sun damage.

The other is daily exfoliation and dermal thickening. This is typically done with a glycolic acid moisturizer in the morning and retinoic acid at night. Both of these agents are excellent exfoliators. They effectively get rid of the top layer of dead skin and leave a healthier, radiant appearance to the skin. They are effective and inexpensive, unlike many highly marketed products which really do not work. Other products can also be incorporated but these two are essential.

Mid and Lower Face Rejuvenation

1. Lower Eyelid
The lower eye lid is the most complex region of the face when it comes to the aging process. Only recently has plastic surgery begun to comprehend what really is causing the aging appearance here and even more recently have we figured out how to treat it.
The biggest culprits of lower eye lid aging process include:

  • excess skin
  • sagging of the outer corner of the eye lid (crow’s feet)
  • bulging eye lid fat (bags)
  • circles under the eyes

Each one of these problems is caused by different aspects of the aging process. The key is to identify which ones are your primary concerns, prioritize them, and address them in methodical fashion.
Before we go into the individual aspects of the lower lid, one needs to consider the profound effect fat loss has on the cheeks and lower eyelid. It is most likely the single biggest contributor to the aged look of the lower lid and mid face, yet, only recently have we begun to understand this. Replenishing volume is treating the problem at its root cause.

Excess Skin of the Lower Lid
Excess skin of the upper eyelid occurs relatively early in the aging process. The lower lid, however, is somewhat different. Skin laxity becomes a problem typically later in the aging process. Fat loss routinely precedes skin laxity. Excess skin shows itself as redundant, wrinkly skin over the lower lid. This skin can often be pinched and pulled away from the lid once it becomes significant.

Excess skin of the upper cheek and crow’s feet; tired appearance
Traditional plastic surgery techniques typically treat this problem with skin and muscle removal. The Aesthetic Lift addresses this by performing a temple lift with, or without, skin removal of the lower eyelid. This tightens the saggy skin all the way down to the upper cheeks and crow’s feet area. This accomplishes many positive things. It gets rid of the crow’s feet as well as the excess skin of the lateral part of the lower lid. In addition, it creates a youthful, bright, elegant appearance. The temple lift is a very effective treatment for both the upper and lower eye lid. This is because the temple lift has a powerful rejuvenating effect on entire lateral eye region. Aging of the temple region is responsible for a significant portion of what we recognize as upper facial aging.

Bags under the eyes
Bags of the lower eye lid are caused by two completely different processes involving fat. The first process is the most obvious. It is caused by bulging fat of the lower lid. This fat swells more in the morning and when you are tired.

The other process is less obvious. It is caused by LOSS of fat within the upper cheeks. You can confirm this by pushing down on the circles under your eyes with your index finger. Most likely you will immediately feel skull bone. This is because the fat that once covered this bone has melted away.
It is not uncommon to remove the fat that is causing the bags and then to transfer fat into the circles under the eyes. This directly treats both issues and, thus, is the most effective treatment for lower lid rejuvenation.

. 2. Hollow Cheeks and Circles Under the Eyes.
All humans begin losing fat in their cheeks starting from the day they are born. Losing fat before the age of 16 is considered “losing baby fat.” Losing this same facial fat after the age of 30 is considered “aging.” At 20, this aging is attractive as it sculpts and defines the face; especially the lower cheeks and jaw line. Once we get over the age of 30 our fat reserves are gone and aging sets in.

This fat loss becomes a problem in women around the age of 30 and with men around the age of 40. This is because a more defined look is desirable in men whereas, in women, it is considered an early sign of aging. This is why most female models are in their teens and early 20′s, whereas, men tend to look more attractive somewhat later in life.The significance of loss of cheek fat has only recently come to our attention. This is perhaps the most significant cause of what we perceive as facial aging.

By the age of 50 most of the cheek fat has gone away leaving behind a hollow, gaunt appearance. Loss of fat over the upper cheek bone leaves the characteristic circles under the eyes. The only way to treat this problem is to replace the fat with fat transfer.

What does Fat Transfer do? 
There are several aspects of fat transfer that make it exceptionally appealing.
1. First and foremost, it replaces the precious fat of the cheeks creating a youthful appearance that can not be obtained by any other method.
2. It takes fat from an area that usually has an excess, i.e. the abdomen creating a win-win situation. Unfortunately, with age we accumulate fat in the areas we don’t want it and lose it in the areas where we need it most.
3. It can easily be done under local anesthesia, thus, making it cost effective and convenient.
4. Finally, the amount of fat transferred is controllable as the procedure can be repeated until the desired result and shape is obtained. Adding fat not only replaces the fat you have already lost, it gives you a buffer so that when you lose fat in the future it is not noticeable.

3. Naso-labial Folds
The approach to the naso-labial folds, aka “parenthesis deformity,” is dramatically different than the current standard treatment. The mainstay of the current treatment is injecting a soft tissue filler to plump up the crease. This does not treat the root cause of the problem; it is a short term cammouflage. These folds are not actually caused by the crease getting deeper. It is caused by the fold above the crease hanging down making it appear deeper. Therefore, just filling in the crease does not make sense. In addition, soft tissue fillers rarely improve the look for more than two months.The fold above the crease begins to hang because of loss of cheek fat. Once the volume of the cheek has diminished the skin begins to hang exagerating the crease. Therefore, long term treatment to the problem is to replenish the lost fat. This will significantly improve the hanging folds by inflating the cheeks.

4. Jowls, Jaw line, and Marionette lines
Marionette lines, jowls and poor jaw line definition are routinely treated by a face lift. It is important to go over the causes of these problems so we can better understand the treatment. Marionette lines are the lines that form at the corner of the mouth and go downward (they are named after the moving mouth portion of a marionette).

They may look like an extension of the naso-labial folds but they are different and must be treated differently. The root cause of jowling, marionette lines, and poor jaw line definition is the similar. It is a combination of saggy facial skin, droopy facial fat, and loss of facial fat volume. Correction of jowls, marionette lines and poor jaw line definition with face lift. Optimal correction of these issues requires correcting each of the underlying problems. Having said that, you may choose to obtain partial correction by choosing a more conservative procedure.

The MiniLift performs a basic face lift under local anesthesia correcting primarily skin excess. Aesthetic Lift offers this one dimensional procedure as well to specific patients who do not need much fat elevation and fat replacement. This is rare. In addition, MiniLift does not routinely directly address the neck problems which is often a primary concern of the patient interested in face lifting. Still, in the right patient, the MiniLift can obtain good results but it is limited.If all that is necessary is skin tightening than a mini face lift under local anesthesia may be a good option.

Fat elevation and fat transfer is an integral part of the Aesthetic Lift when jowling and hollow cheeks are present. Fat suspension elevates the jowl fat so that it is repositioned back into the cheek where it belongs. Then additional fat is added to fill in for the fat that has melted away with aging. This provides the optimal rejuvenation as it defines the jaw line, eliminates the marionette lines and recreates fuller, youthful cheeks.

Facial Aging in Men
Anatomically, there is very little difference in facial aging between men and women. There is, however, a significant difference in treatment and expectations. Men are much less tolerant of an “operated-on,” surgical appearance. Therefore, it is critical to make sure that their result is completely natural.

5. Weak Chin
The primary goal of facial rejuvenation is to create a more attractive, rejuvenated facial shape. If it is needed, adding a chin implant greatly enhances the result. In fact, it is common for the chin to sag and recess with age. A chin implant will plump the chin out and fill in the area in front of the jowls, creating a more triangular, defined look.

What does a chin implant do? 
In women, a chin implant will create a more defined jaw line as well as a more triangular face. With men, it will not only define the jaw line but will create a more powerful, masculine appearance to the entire face.
6. Upper Lip Wrinkles
Wrinkles around the lips are caused by a combination of factors. The most significant are

  • loss of collagen,
  • loss of fat, and
  • the constant motion of the underlying muscles.

The most effective way to improve these wrinkles is with a laser along with a tiny bit of Botox®. The laser will smooth out and thicken the underlying dermis. Then, a very small amount of Botox® can be injected just under the skin to flatten the muscle. This will not affect lip motion but will do a great job of decreasing or even eliminating the wrinkles. The overall result may be enhanced with the addition of a conservative amounth of soft tissue filler to plump the lips.

7. Thin Lips
The standard for obtaining fuller lips with very little down time is Hyaluronic Acid. Soft tissue fillers made of hyaluronic acid are marketed as Juvéderm™ , Restylane®, Perlane, etc. These are a dramatic improvement over the previous standard – collagen. The enlargement lasts 6-12 months in the lips.

8. Down Turned Corners of the Mouth
Often, patients complain that they appear sad or upset because they have a permanent frown. This is because the corners of their mouth have become down turned with age. The most effective treatment for this is a face lift. There is, however, a much simpler answer – Botox®.

By selectively relaxing the muscles that cause frowning with Botox®, the corners of the mouth will elevate about 3-4 mm. This simple maneuver, when performed properly, can eliminate the frown and give a happier, more pleasant facial expression. The lips will continue to move normally and no one will ever know.

Neck Rejuvenation

1. Jowls, Jaw line, and Marionette lines

This is mentioned here in the Neck Rejuvenation section but, in reality, it is part of the Mid/Lower face region. These cause of these problems are the descent of fat and skin from the face into the neck region. They are usually best corrected by performing a face lift.

When is a neck lift necessary in addition to the face lift?
There are three primary indications for making a chin incision and operating directly on the neck as part of the Aesthetic Lift.

1. Prominent Neck Bands
These are the cords often referred to as a “Turkey Gobbler.” They represent the inner border of the Platysma muscle. The best way to predictably correct these bands is to remove and suture the neck muscles together in the midline. This removes the cords and creates a more youthful, smooth contour with a defined neck angle

2. Poor Definition of the Neck Angle. 
People with poor definition of their neck angle have a neck that essentially goes from their chin to their upper chest. Many jokingly say that they have “no neck.”

The key to the Aesthetic Lift is to define and treat what is causing the heavy, undefined neck. Routinely, it is a combination of excess fat and hanging platysma muscle. The best way to address this problem is to begin with liposuction of the midline neck and jaw line. Then the remaining excess fat and hanging muscle in the midline must be directly removed via small incision under the chin. The muscle is then tightened in the midline and suspended in an lifted position. This will create the desired, defined neck angle that did not exist preoperatively.

3. Heavy Neck
The heavy neck will always have poor definition as well. This is because the increased mass completely covers the neck angle and gives an undesirable heavy appearance.

A word of caution: Face and neck lifting is best done on people within 30 lbs of their ideal body weight. Heavier people will have considerable improvement with facial rejuvenation but the result will not be as good no matter what technique is used.

The advantage of the Aesthetic Lift is that it directly addresses even the heavy necks and will provide the best result possible. This is especially true when compared to face lifts claiming to be quick with a “one-size-fits-all” technique. The procedure is similar to that performed for the undefined neck angle but there is considerably more fat removed.