Harmony in Facial Rejuvenation Surgery

Studies across cultures show that people are remarkably consistent in judging what is a beautiful face, but the relationship between different facial features does not lend itself well to a mathematical formula. The best effort relies on the Golden Ratio, but seeing how celebrity faces are disfigured by imposing the Golden Ratio is a good illustration of how mathematics and facial beauty clash. 

If appreciating beauty does require an artist’s eye more than a tape measure and calipers, creating beauty, particularly for the aging face, is similarly an artistic endeavor. But where to start?

When evaluating a prospective patient, we like to start at the top and work our way down.  

Are there problems with volume in the temples? Particularly thin patients will benefit from fat grafting to overcome the skeletal appearance that can come with advanced age.

Are there problems with forehead wrinkles? Often these are secondary to heavy brows or lax eyelids that force you to raise your brow (and create wrinkles) to correct for the skin excess. The best brow lift is often a temporal brow lift with a scar hidden at the edge of the hairline, as it prevents the high hairline look you get from coronal or endoscopic brow lift. Men often do best with a direct excision over the brow as the scar is inconspicuous and the effectiveness of the procedure in shaping the brow is so high. We will assess if correction of brow position will still leave excess eyelid skin or fat, and recommend upper lid surgery to correct for this if necessary.  

Lower eyelids are the most challenging area of the face to get right- remove too much fat and you appear gaunt, remove too much skin or create muscle scarring and your lid can become tethered. We favour the ‘pinch’ blepharoplasty to remove excess skin without distorting eyelid shape, and transconjunctival fat excision if fat is too conspicuous. Facial fat and skeletal volume are lost in the upper cheek as we age, so fat grafting is often the best tool for restoring this lost volume.

Nasal changes with aging are not always appreciated. Loosening of ligaments in the nose allows the tip to hang progressively with aging, exaggerating a hooked nose. Simple suture techniques can be an alternative to formal rhinoplasty for the aging nose.

The cheeks, from jowls up to lateral malar area, and folds running from edge of nose to corners of mouth (nasolabial folds) are addressed by the ‘facelift’ part of the surgery. In a SMAS lift, the skin and underlying fibrofatty layer (SMAS) are treated as two separate sheets allowing for tension to be optimized by distributing it in different directions. It also allows the SMAS layer to be folded or repositioned to create more volume in areas it is needed. In a Deep plane lift, the skin and SMAS are moved as one over top of the muscle. This increases the risk of motor nerve injury, and in ‘Twin’ studies that compare the SMAS and Deep plane lift in identical twins, the SMAS comes out best.

Aging ears-definitely! Earlobe lift is a subtle but powerful tool for creating a more youthful appearance

Neck rejuvenation requires real surgical insight for great results. Is the problem just lax skin, is it excess fat, is the excess fat deep or just under the skin, are the muscle bands a problem, are salivary glands hanging too low- analysis of these features is necessary to plan the best solution for each patient.

Deep lines in the mask area around the mouth are difficult to solve without heavy artillery like dermabrasion or medium depth chemical peels. Many patients choose to accept the modest improvements that can be had with botox or fillers, as recovery period is much shorter than with the surgical options.

Finally, skin quality needs consideration. Particularly if there is history of heavy sun exposure, a chemical peel can be recommended to even out pigmentation problems and shrink fine lines in the skin. We try to time the recovery from the peel to coincide with the facelift (looking good by two weeks) to allow a quick return to social activities.