Address the aging face with Plastic Surgery: Facelift, Brow lift, Eyelid lift, Lip Lift and more
Facial Analysis
When a patient comes in and expresses a desire for a facelift or brow lift, it becomes clear that they are looking to refresh their appearance. Most individuals simply want to look like themselves, albeit 10 to 15 years younger. As a cosmetic surgeon, I begin by performing a facial analysis to assess the patient's needs. Although no one's face is perfectly symmetrical, I usually use my own features as a reference point to illustrate the approach.
The face can be divided into three sections:
The upper third - spans from the hairline to the brow
The middle third - ranges from the area between the eyebrows (called the glabella) to the bottom part of the nose
The lower third, which extends from the bottom border of the nose to the chin.
These areas may have more specific names like "sub nasality,” but they are essentially defined by the horizontal lines drawn across the face. When a patient's face is in repose, or at rest, and aligned proportionally, it is considered a well-proportioned face.
What happens during facial analysis?
During a facial analysis, I aim to ensure that the one-third, one-third, one-third ratio of the face is maintained. I evaluate the length of the lower third, middle third, and upper third, and also consider the effects of aging, which can cause the forehead to appear longer due to hairline loss. I also examine the vertical lines on the face, dividing it into five sections that should be roughly equal distance.
Ear to corner of your eye
Eye
Between the eyes
Eyes
Ear to corner of eye again
I apply this analysis to myself, I have a wide middle face. If someone with a similar facial structure to mine asks for more cheekbone filler, I would advise against it because that is already prominent on my face would make it look more unbalanced.
I also consider the distance from the bottom of the nose to the closed lip in the lower third of the face, which should be 50% of the distance from the nose to the chin. In my case, I have an imbalance with my upper lip being too long. If someone would want a chin augmentation, I would not recommend it in my case, but I could correct this unbalanced part with a lip lift and it would look good. These are some of the things I look at during a facial analysis.
Forehead and Upper Third of the Face
Back to the upper third of the face, during aging, we develop dynamic lines on our forehead due to the frontalis muscle that stretches from the forehead to the scalp. As we age, the skin on our upper eyelids becomes more redundant with age and it begins to shade or close. Shading, also called hooding can dropping the lash line, and it reduces the amount of light getting into your pupils. Our brain compensates by trying to raise our eyebrows to help us see better, causing wrinkles in the forehead known as the accordion effect. Botox can help freeze those muscles, forcing them not to contract as much, and erase those wrinkles.
Open method vs Endoscopic Method Brow Lift
A brow lift is a surgical option that can do something similar to Botox that can lift the skin and the deeper layer called the galea, which is the muscle layer, to position it higher but we don’t want to be to extreme and make you “permanently surprised,” subtlety is key. We’ll also address and brow asymmetry - meaning if one brow is slightly higher than the other, we’d correct that by lifting one a little more than the other. We also down want to lift too much laterally either as you can make someone look angry. It’s a balance of slightly upward and slightly outward for most people.
A brow lift can be done through a traditional open method, where an incision is made within the hairline so it’s largely invisible. The browlift does move the hair back a little so it looks good on someone who has a short forehead. Conversely, if someone has a longer forehead, we can make the incision before the hairline, cut some excess skin away, and “move” the hairline forward, shortening the forehead. If we use this version, we’ll actually make the incisions along the hairline curvy rather than straight because straight scars are more obvious and if we use the curvy pattern, when the hair regrows it will hide them better and make them less noticeable. It’s more labor intensive but it’s the best visually appealing method.
Whichever the patient has, we can use the “side effect” to our benefit and balance the one-third ratio of the upper forehead.
Another type is an endoscopic brow lift, where an incision is made in the middle and two on each side, and we use a camera is used to lift the skin up and suture it to a higher position. The endoscopic method does not require much sewing or external incision, but it has it’s own limitations.
Eyelids and the Middle Third of the Face
Now, moving on to the middle third. The muscle between and just above the eyes are called the corrugators (visible when you frown). This can be treated with Botox to relax the muscle and prevent the vertical frown lines on your forehead. During a brow lift, the corrugator muscle can be surgically removed but it’s very critical in our facials expressions and non-verbal communication. Instead, I prefer to weaken it with neurotoxins over time to avoid a frozen appearance.
Blepharoplasty
Besides a browlift, in the middle third of the face we have the eyes and blepharoplasty is surgery that I would perform here on the eyelids, of which there are two types of blepharoplasty: upper and lower.
Upper Blepharoplasty and Who Should Undergo Blepharoplasty
Upper blepharoplasty can address a couple things:
excess skin
hooding on the upper eyelid
fix asymmetries
Symmetry is very important and we also take into account the patient's ethnicity to what will look normal for them.
When analyzing a patient, we make a strategic decision where we decide to make the incision placement when the upper eyelid is closed. There is a hard plate right underneath your eyelid called the tarsus or tarsal plate. At the top of the eye, there's a muscle called the “levator” that acts like window shades to help you open and close your eyes.
If the levator muscle is working properly on both sides, then there shouldn't be any problems and we can proceed with a cosmetic blepharoplasty. However, if there is an issue with the levator due to aging or other factors, I actually usually refer my patients to an ophthalmologist who can repair that.
When it comes to cosmetic blepharoplasty, the issue is primarily with the skin around the eyelid. It's important to be cautious to only remove as much skin as we need. I also need to take into account how much the patient relies on their eyebrows to open their eyes and avoid over-removing skin.
Before Blepharoplasty
Before a blepharoplasty, the surgeon will ask a lot of questions about the patient's eye health history including:
any history of dry eyes
contact lens use
past ocular injuries
I will test their vision and they will also assess the “excursion of the eyelid” or the ability of the eye to lift up, which can indicate whether there is an issue with the levator muscle or not.
During Blepharoplasty
The surgery itself can be done under light sedation, local anesthesia, or general anesthesia, in an operating room. During the procedure, I usually like to ask the patient to open and close their eyes to help guide me in achieving the desired result, so light sedation is preferred.
To begin with, we determine how much excess skin needs to be removed from the patient on both sides of the eye(s). We use very fine calipers for this purpose because as it has to be exact as possible. We take measurements to ensure accuracy, as the adage goes, "measure twice, cut once." This step is critical for upper eyelid surgery.
After measuring, we remove any excess skin and any redundant muscle if present around the eyes. Moreover, if the patient has any fullness in the upper eyelid due to an excess fat pad, we address it as well.
The surgery itself can be done under light sedation, local anesthesia, or general anesthesia. During the procedure, the patient may be asked to open and close their eyes to help guide the surgeon in achieving the desired result, so light sedation is preferred.
During upper eyelid surgery, we deal with two fat pads: the medial and middle fat pads. On the outer part, we have the lacrimal gland or tear ducts, which we do not touch. We can only suspend it, not resect it. 10-15 years ago, it was common to remove more of the fat pad, but now we are more careful in removing just the right amount. It's the same with lower eyelid surgery. Instead of removing the fat, we can reposition and redrape it because taking out too much can make the patient look older and more hollow. We have to be careful with that and we are very conservative with how much we remove.
There are various ways to perform lower blepharoplasty.
During a lower blepharoplasty, we can address the bulging fat pads under the eyes, which form a tear trough deformity. There are three fat pads in the lower eyelids, namely, the medial (near the nose), middle, and lateral pads. We can either remove, debulked, or re-drape them lower over your cheek bone, depending on the patient's anatomy, to make sure that they don't bulge out under the eye. There are different ways to do this, and we can tailor the approach based on the patient's needs.
Facelift
In terms of a facelift, it specifically targets the sagging of the midface, lower face, and neck, and does not address issues with the temples or forehead.
A facelift procedure involves making an incision from the temple area down towards the sideburns, in front of the ear, and behind a small notch in the front of the ear called the tragus, right in front of the earlobe, behind the ear, and down to your hairline. This curved incision allows us to lift the skin from the lower face to the midface region.
By doing so, we gain access to the deeper “SMAS” layer (superficial musculoaponeurotic system), which is the structural layer holding the fat and facial muscles. This layer needs to be addressed and lifted during the procedure, otherwise a facelift is not effective.
A facelift is not just skin-only procedure. Skin is pretty elastic so if we just removed the skin, the effect of the facelift would not be long-lasting. The skin will stretch out and you’ll be back to square one again.
Importance of Facial Analysis in a Facelift
As we stated earlier, the facial analysis is an essential part as how we perform the facelift is determined by that analysis. We want the SMAS to be lifted in a way that suits the patient's face.
If the patient is losing volume in the front, the SMAS should be lifted upwards.
If the patient has a wide face, they wouldn't want more width to their face. Instead, the surgeon should lift the tissue more vertically than laterally to create a flattering result.
A patient with a narrow face, moving the SMAS laterally would look good on them.
In addition, on the lower face, we have to choose the right direction as well. Typically when lifting the tissue closer to the jaw bone, it would be more upwards and back toward the ears to lift the jowls out of the way, rather than making the cheekbones look abnormally wide. Always diagonal but where and by how much is important.
Performing a full facial analysis before getting a facelift is crucial because everyone's face is unique.
Facelift, Jowling, and Necklift
A facelift is particularly effective in enhancing the jawline because lifting the SMAS can eliminate jowling. When a patient lifts their face with their fingers in the mirror and sees a significant improvement in their jawline, they are likely a good candidate for a facelift.
Furthermore, we often combine a facelift with a bit of a neck lift, do some dissection of the skin around the neck, pulling that tissue up and tightening the tissue around the neck as well. This procedure can make a big difference in appearance and when done right, patients love the look when it’s complete.
Facelifts are labor-intensive surgery, requires a lot of effort and is one of the longest surgeries I perform. It is done in an operating room under anesthesia. The surgeon has to be meticulous during sewing because once the SMAS is pulled up, we have excess skin, we trim it to fit in with the hairline and ear without putting any tension on the skin. This way the skin lays nice and flat, there is no stretching of the skin and, we can prevent scars from becoming too wide.
How Facelifts are performed
When we use sutures and pull the SMAS up, that is called a SMAS plication creating an accordion effect on the SMAS layer. This is a standard way of performing a facelift, just moving the SMAS itself.
There are other ways to lift the SMAS layer, such as the deep plane facelift, which involves going deep underneath it and pulling it up. This facelift is becoming more popular nowadays, but it does come with risks.
One of the major risks is damaging the facial nerve, which is responsible for our facial movements and allows us to animate. If the facial nerve is damaged, it can cause paralysis on one side of the face, which is a scary outcome and indeed devastating. That’s why we always respect our anatomy and stay within safe layers during a facelift.
I usually prefer to do SMAS plication or SMAs-ectomy (remove parts of SMAS if needed) while staying lateral and being aware of the underlying anatomy. It is crucial to remove only what is needed and always ensure patient safety.
Facelift recovery
When it comes to recovery, we use a supportive garment that the patient needs to wear for about a week or so. This helps to provide support and reduce any swelling or discomfort after the procedure. We can also place drains to help remove any excess fluids that may have built up and reduce swelling.
As we age, we not only experience sagging of the skin and changes in the underlying structure of the face, but we also lose volume. While hyaluronic acid fillers can help with this, using our own fat is a more permanent solution of addressing the volume loss. So sometimes together with a facelift, we can fat-graft an area and use fat from other parts of the body to add volume to the face.
During the fat grafting procedure, the fat is taken from a small incision near the belly button, specifically from the lower abdomen. The abdominal fat is then cleaned and purified using a centrifuge, which separates intact fat cells from any damaged or free-floating fat cells, which are discarded. The purified fat cells are then injected into the cheeks to create a pillowy-lifted and fuller appearance. That can be done concurrently and added to a facelift for added rejuvenation.
Revision Facelift
It's possible to have a revision facelift, but it's important to know what was done in the first place and what the patient doesn’t like now. It's not uncommon to have more than one facelift in a lifetime and generally, patients can expect to look 10 to 15 years younger after a facelift, but it's important to understand that if you're 70, it's not going to make you look 30.
If you had a facelift done when you were very young and you feel like you need a touch-up later on, that's okay. There's nothing wrong with the first one you had, but if you want to refresh it again. Now a revision facelift does NOT mean the first facelift was botched or done incorrectly, you just want another one done. That's one way to look at it. There are situations where perhaps the first facelift wasn't aggressive enough. But as mentioned, we need to analyze the situation.
For example, if someone had a facelift and feels that they look too chubby, maybe a lift isn't what they need, they may need more volume instead. How can we address this issue of volume? Can we use fillers only, or do they want a more permanent solution like fat grafting? Or do we need to lift the fat layer or SMAS layer up, and do a full second facelift?
This is a very nuanced decision because it depends on each individual case. Whether it's a primary surgery or a revision surgery, the most important thing is to listen to the patient. I let them talk and figure out what they really want. Are they concerned about the symmetry or flatness of their face? We need to address their concerns specifically rather than simply agreeing to a revision facelift. That's not the right approach.
Other “Types” of FaceLifts
In terms of facelift options, you may see a lot of “marketing” terms out there:
Mid facelift
Cheek lift
S lift
Vampire facelift
Pony tail facelift
Thread facelift
Cutaneous facelift
Lots of different names but most of them are very similar to each other. Their effectiveness is a different story.
In particular, just pointing one out, a cutaneous facelift, which is a skin-only facelift. Here’s the thing with skin: skin is elastic and has mechanical properties so it can stretch or sag.
For example, if we gain weight, our skin stretches to accommodate our body. If we lose the weight, that skin is still there and we’re saggy. Same thing with a breast augmentation, at first it looks really tight but a month later, the skin looks relaxed.
For a cutaneous facelift which is a skin-only facelift tightening the skin, it doesn't address the underlying structures that caused the issue in the first place. That goes against everything I’ve been taught in my plastic surgery training. Eventually, the skin will stretch out again and you’re back to where you were in the first place after spending thousands of dollars and not getting the result you wanted.
Buyer beware to be cautious and avoid falling for marketing terms. They may make a procedure seem minimally invasive but just because a procedure is labeled as such does not necessarily mean it is effective. Spending money on an ineffective procedure is like throwing your money down the drain.
Lower Third of the Face and Upper Lip Lift
In addition to fat grafting, some patients may request an upper lip lift. This procedure can be performed separately from a facelift and is particularly suitable for people with longer upper lips, where the white lip appears too long for the face and the upper red lip appears deficient.
That lip lift can “shorten” the white lip while rolling out and exposing the red lip, giving a very nice appearance. However, it's important to ensure that this procedure is suitable for the individual patient before performing it.
To perform an upper lip lift, a careful incision is made underneath the nose along the rim. Using calipers to measure accurately, we remove just enough skin to create a symmetrical lift and eliminate excess skin. The resulting scar is really well camouflaged under the shadow of the nose, which helps it blend in and works really well.
New Fillers for Chin Enhancement
Moving on to the chin, there's a new FDA-approved filler called Juvederm Volux that can enhance the jawline. Juvederm Volux has a high G prime, which is a measurement used in rheology to determine the firmness of the gel. Compared to other fillers on the market, Juvederm Volux has the highest G prime product that is out there right now, making it an excellent option for patients looking for a more cohesive and firmer result. Additionally, this filler is made with hyaluronic acid, so it can be dissolved with hyaluronidase if the patient is unhappy with the results. While the filler is temporary and lasts for about a year, studies have shown that it can last longer.
For patients who don't want to undergo surgery or bony work to address a deficient chin, Juvederm Volux can be a great option. One of the major benefits of using hyaluronic acid fillers for jawline enhancement is that the patient can remain awake during the procedure. I work together with the patient during the procedure and we communicate throughout the process
“Do you like this? Should we do more?
That cross talk and the opportunity to give feedback by looking in a mirror and telling me when they are satisfied with the results is very valuable. With a filler, we can make adjustments as we go along to achieve the desired look, giving the patient more control over the outcome.
This is something that can't be done with an implant because it is a more permanent solution and the patient is under anesthesia during surgery.
Chin Augmentation or Enhancement
Speaking of which, for chin augmentation. In either case, there are two options:
A bony chin advancement where the jawbone is cut - of course in a safe range below the teeth roots and mental nerve and we can advance the chin that way completely autologous, meaning only your own body is used.
The other option is to use a silicone implant to enhance the projection of the jaw.
Chin Reduction
We can perform a chin reduction in a couple of ways, usually if there's too much projection caused by bony issues. The chin may appear too prominent when viewed from the side.
One way to address this is through a bony reduction technique called bur genioplasty, which involves shaving down the bone.
Another option is a setback genioplasty, which involves cutting the bone and pushing it back to its correct position, allowing it to heal in the new position. This is a major surgery and is usually performed through an intraoral incision inside the mouth, which means there are no external scars. However, in each case, we need to plan carefully and decide how many millimeters of bone we need to remove.
The good thing about both burr genioplasty and setback genioplasty is that they typically produce an almost one-to-one translation of the soft tissue. For example, if we set the bone back five millimeters, the soft tissue will also move back about five millimeters. Therefore, it's important to take great photographs, measurements, and plan carefully to achieve the best results. Also, patients must have good oral hygiene and be good candidates for the surgery, with no underlying bone loss or other issues.
Neck Lift
Let me explain something about the neck lift, as there are many issues involved. The platysma muscle, which is continuous with the SMAS layer, and can form bands as we age. There are a few ways to address this platysmal banding.
We have platysma muscles on each side of our neck and in conjunction with a facelift and a necklift, sometimes I do what’s called a platysma-plasty, a procedure where the muscles are pulled and sutured in the middle to avoid a split or “turkey neck” appearance. This can one way we can address neck aging issues.
In many cases, excess skin can be the issue with a neck lift as well. This means that the incision during the neck lift procedure may need to be extended towards the hairline in the back so that the excess skin and muscle layer can be pulled up. It's similar to a facelift where the underlying structural layer, which is called the platysma and is similar to the SMAS in the face, needs to be addressed for long-lasting results in the neck.
Conclusion
Everything we talked about today - brow lift, facelift, or jaw - it all comes back to the facial analysis, did your plastic surgeon analyze your face very well? Are their recommendations going to be balanced for your face? What is going to change if we complete a brow lift? Is it going to change the size of your forehead? Do we need to do something to balance the rest of the face?
That’s really the key to ending with the result where a patient looks really refreshed and looks good, instead of looking “done” where it’s very obvious they had some work. That balance is so important and it’s something I owe my training to and am very grateful for.