Facial Fillers or Facelift:

To Fill or Lift the face

I recently saw a patient who came in because I did a facelift on one of her childhood friends and she liked what she saw: a more youthful look without looking "pulled." For privacy sake, let's call her by an alias, Debbie. Debbie is slender with attractive, high cheekbones and very little body fat. She had a facelift about 7 years ago and feels that it helped a little but the skin of her lower face is "wrinkley" and hangs. She was also concerned about nasolabial folds (folds from the corner of the nose to the mouth). She sought out a few opinions.

Suggestions from other physicians ranged from revision facelift to facial fillers to a chin implant. Debbie has already tried Juvederm and Radiesse with little lasting improvement. My first inclination was to suggest another facelift. This would help the jowls and extra skin under her neck. What concerned me is that when listening to her explain what she doesn't like about her face, Debbie was more concerned about the way the skin hung around her mouth and narrowing of her cheeks. As a surgeon, facelifts are more interesting to perform and the patient was basically asking if a revision facelift would be the best solution without specifically stating it. However, I was concerned that a facelift wouldn't be the best initial solution for her concerns.

The first procedure I dismissed was a chin implant. This is a superb procedure for the right patient. However, Debbie is thin with a small frame and small face. She had very minimal difference in the projection of her chin on profile from a standard line drawn from the top to the bottom of her nose. The chin implant was suggested to essentially expand the skin to fill out the wrinkles. I felt that a chin implant would make the lower third of her delicate face appear too heavy. In anti-aging treatments we desire to reverse the aging process. In the teens through 30's the face is "egg shaped" with the wider portion on top. As we age, the egg turns upside down. A lot of what we seek to do in anti-aging treatments is to flip that egg back up again. Since she really didn't lack chin projection, expanding the chin might make her bottom heavy.

A facelift would pull the skin and drooping muscles back and upward. However, I think she first needs expansion of the tissue; muscle, fat, basically everything between the bones and the skin. To expand the face the options are fillers or fat. The patient is so thin that I wasn't sure I would find sufficient fat, plus it requires a procedure almost as invasive as a facelift to harvest and re-inject. As for the nasolabial folds, these commonly are more of a problem when there is mid-face hollowing that creates mounds next to the folds. Just filling out the folds or pulling the skin back doesn't solve the problem. This is best treated by restoring more youthful cheeks. I discussed this more extensively in a prior blog called Facial Fillers in New York City. So I suggested Sculptra. This should give at least two years of facial volume enhancement and demonstrate if volume is more an issue than gravity. We can always go back and do a facelift with minor fat grafting, but here we are offering a much less invasive alternative that may solve more of her primary concerns.

This is really about deciding priorities. I categorize facial aging into 5 categories: skin changes, dynamic muscle action, loss of volume, gravity and loss of elasticity. Everyone experiences all 5 as they age. It's more a matter of what should be addressed and in what order. For Debbie, I feel it is volume first (high volume fillers with longevity - Sculptra) then combat gravity and loss of elasticity next (facelift).

Dr Steven Pearlman, MD, FACS