Facial Aging

Re.ju.ve.nate
1a: to make young or youthful again: give new vigor to b: to restore to an original or new state (Merriam-Webster Dictionary).

It is important to recognize the cause of aging in order to select the proper treatment. Most patients demonstrate more than one of these signs, however, they should be evaluated and prioritized according the patient's needs and desires. When truly looking at treatment of the aging face, there is no such thing as a "non-surgical facelift," what is really being referred to is using non-invasive techniques to camouflage aging. For example, over-active facial muscles can be softened with BOTOX®, wrinkles reduced by using lasers, peels and filled with injectable materials such as Collagen and Restylane. Especially when used in combination, these treatments can make one's face appear younger. But to truly "lift" sagging skin, reduce jowls improve a drooping neck, a facelift is necessary.

Facial aging occurs as the result of several factors:

	Inherent changes within the skin		Effects of gravity
	Facial muscles acting on the skin		Soft tissue loss or shift and bone loss
	Loss of tissue elasticity		See below for treatments for each.

Facial Aging can be categorized into 5 causes. Each is linked to the best treatment in the flow chart below. As a specialist in Facial Plastic Surgery, Dr. Pearlman understands the need to offer each patient the appropriate therapy for all of these conditions. Every patient is evaluated and a treatment plan is created based on the patient's needs, desires and goals.

*alternative treatments

The above changes are influenced by intrinsic or genetic factors. These aging factors correlate highly with inherit and/or ethnic influences. Other major factors are environmental such as sun exposure, which causes photoaging as well as habits such as smoking and alcohol, which can alter the skin--causing acceleration in aging of the skin.

The Skin

The skin ages when the epidermis (outer layer of the skin) begins to thin, causing the junction with the dermis (outer layer) to flatten. Photoaged skin has a thicker epidermis (keratin), which is "dead" and irregular. There is increased water loss from the skin and a decrease of the sebaceous glands, which provides natural moisture to the skin. More abnormal cells accumulate in aged skin, especially if there is chronic sun damage, which can lead to pre-cancerous and cancerous lesions. Photoaging also causes chronic inflammation of the skin. Sun damage to the skin causes an increase of elastin that clusters into thick bundles. Collagen decreases as we age and the bundles of collagen, which gives the skin turgor, become looser and loses strength.

The skin's capillaries and small blood vessels pull away from the skin, reducing blood flow. The more superficial vessels can thicken from sun exposure, reducing their capacity to nourish the skin. Telangiectasias (spider veins) appear on the surface of the skin, which are too superficial to provide nourishment. Loss of blood supply can also contribute to thinning of the hair and paler skin. This can be treated by a minimally invasive technique called IPL to reduce redness of the skin.

When the skin loses elasticity (ability to bounce back), it is less able to resist stretching. Coupled with gravity, muscle pull and tissue changes, the skin begin to wrinkle. The skin is less able to resist mechanical damage and heals slower from insult. Water loss and breakdown of bonds between cells also reduces the barrier function of the skin, which can cause the skin's pore size to increases. Wrinkles are best treated by peels and lasers and can be filled with injections of filler substances.

Facial Muscles

Facial muscles acting on the skin create dynamic lines. The most obvious dynamic lines are in the upper face. Glabellar lines lay between the eyebrows, which are caused from voluntary and involuntary frowning and are often accompanied by horizontal lines that appear across the bridge of the nose.

Horizontal dynamic lines come from holding up drooping eyelids or eyebrows. Crows feet--dynamic lines at the corner of the eyes--appear after years of squinting, laughing, smiling--all in the course of living! For more on treatment of dynamic lines in these and other areas of the face see BOTOX®.

Loss of Elasticity and Soft Tissue Volume

Facial aging also is associated with a loss of tissue elasticity where the skin and underlying muscle can no longer rebound from the effects of gravity. Newer lasers and Radiofrequency devices such as Themage and ELOS can tighten the collagen under the skin to improve texture. Despite recent media popularity, these devices can tighten collagen and may give a minor lift in younger patients. However, they cannot substitute for surgical facial rejuvenation when a face or browlift is indicated. During your consultation, Dr. Pearlman will help determine the most appropriate procedures to reverse facial aging for you.

As we age, one would think that the face gets fatter, with the appearance of jowls. Actually, the face loses volume, soft tissue and fat. The appearance of jowls and folds are from drooping of facial tissues and folding of areas like the jowls over areas where the muscles below are attached to the skin. As part of this reduction in soft tissue the face gets more hollow. There may also be loss of bone volume that may require replenishment. Fillers such as Restylane and Hylaform, Fat transfer by lipostructure and promising substances such as Sculptra help restore youthful facial fullness.

Forehead

The forehead or brow--droops--which lowers the eyebrows and causes the upper eyelid skin to bunch. Forehead lines appear when one tries to hold the brows and eyelids up to counteract these changes. Changes in the brow may actually appear as excess skin of the upper eyelid. It is important to distinguish the actual cause before any course of treatment. This is treated by endoscopic browlift.

The Eyes

The eyes are often the first facial feature to show signs of aging. As we age, fat surrounding the eyes begin to bulge. This is caused when the orbital septum, designed to "dam" or hold the fat back, begins to weaken. Skin changes around the eyes occur earlier than the rest of the face since the skin is thinner around the eyes. The skin contains fewer glands and is subjected to constant blinking, squinting, rubbing and pulling. The treatment is blepharoplasty.

The Midface

The midface ages when the cheeks begin to droop, causing nasolabial folds. Nasolabial folds are the lines that run from the sides of the nose to the corners of the mouth. These folds are treated with facial fillers. The midface or cheek area also descends creating more visible eye sockets. Where there was once a straight youthful contour from the lower eyelid to the cheek, now have two "bulges." The first bulge is the lower eyelid fat, then a valley over the now visible bone of the eye socket. This valley comes from drooping of the cheek mound. A valley may appear near the nose that is called the tear "trough." This "double bulge" deformity comes from aging of the midface. Suspension of the midface via midface lift is the treatment of choice.

The Aging Nose

As we age, the nose elongates. Common causes are thinning of the soft tissue and loss of elasticity, which causes "drooping of the tip," and unmasking of the bone above, creating a new hump. Loss of bone near the upper teeth and jaw coupled with the drooping tip decreases the angle between the nose and the upper lip. Flattening of the forehead can make the nose appear longer. Rhinoplasty may be performed in conjunction with aging face surgery.

The Lower Face

The face ages by the descent of facial tissues. The muscles of the face are attached to the skin along the nasolabial line. This results in what is called "laugh lines" and a sign of a happy individual in youth to a sign of aging when people get older. Folds and lines in this area are best treated with facial fillers. Further down on the face, the corners of the mouth may droop and descent of the jowls can create folds often referred to as "marionette" lines. Short of surgical rejuvenation by a facelift, these areas, too, can be smoothed with facial fillers. BOTOX® is sometimes used to weaken the muscles pulling the corners of the mouth down as well.

Jowls form when the cheeks sag around a fixed point along the jaw where fthe facial muscles attach to the jawbone. The facial muscles continue down into the neck as a sheet called the Platysma muscle. This muscle often has a gap in the center of the neck creating two bands. Simple platysma bands can be softened with BOTOX®, otherwise a facelift is the treatment of choice.

The chin may appear narrower, which is caused by the loss of support in the chin pad. The loss of elasticity thins the jawbone, narrowing the chin and causes the chin fat pad to droop. This also exaggerates the appearance of jowls. The chin muscle can be re-suspended or supported by a chin implant with wing like extensions to fill in the gap in front of the jowls called a pre-jowl implant.

Dr. Glogau, a famous dermatologist characterized the best classifications of aging in 1994. The 4 Facial types were described as:

	Type I: Mild (age 20’s to 30’s)
		Little to no wrinkling (even with animation) and no skin spots
		Minimal or no makeup needed by these people for a clear complexion
	Type II: Moderate (30s to 40s)
		Early wrinkling (especially with motion)
		Loss of smoothness
		Early appearance of brown lesions, slight yellowish discoloration or brownish cast with increases freckling
		Makeup needed for uniform appearance of the facial skin
	Type III: Advanced (age 50s)
		More visible wrinkles
		Sallow, yellowish skin discoloration with telangiectasias (spider veins, reddened areas)
		Obvious visible brown skin lesions
		Heavier makeup always worn to even skin color but can accentuate deeper wrinkles by flaking
	Type IV: Severe (age, 60’s to 70’s)
		Wrinkling heavy
		Almost no pink color at all
		Increased brown spots, becoming more elevated
		Heavy makeup worn that cakes and does not cover well

As we age:

	30’s (Glogau type I)		Treatments
		Skin starts to develop color changes		Home skin care: Alpha hydroxy acid treatments or mild Retinoids with topical vitamin C and other anti-oxidants, copper peptide. Office micro-peels, minimally invasive laser resurfacing (IPL)
		Fine skin texture changes		Exfoliation, microdermabrasion
		Few spider veins		Spot Laser or IPL treatments
		Early upper facial dynamic lines, frown lines		BOTOX®, possible endoscopic browlift
		Early nasolabial folds, lip lines		Fillers injected, possible lip enhancement
		Lower eyelid bags (may appear early if hereditary)		Transconjunctival Blepharoplasty (from inside lid, no visible incision) with or without mild skin peel
		Upper eyelid excess		Upper Blepharoplasty: skin only or endoscopic browlift if low eyebrows
	40’s (Glogau type II)		Treatments
		Skin with some yellowing or brown pigment		Same as above with added bleaching creams. Medium depth peels. IPL or minimally invasive laser peels
		Redness, spider veins		Full cheek, facial vascular Laser or IPL treatment
		Skin texture less smooth		Microdermabrasion with above regimen
		Dynamic lines more prevalent (frown lines, horizontal forehead lines, crows feet)		BOTOX® 1,2 or 3 areas of the forehead
		Drooping brow		Endoscopic Browlift (usually needed once in a lifetime) or BOTOX® “browlift”
		Upper and lower eyelid “bags” and skin excess		Upper and lower eyelid Blepharoplasty.
		Deepening nasolabial lines, mid face droop		Nasolabial fillers, possible insertion of gortex or alloderm, possible mid face lift
		Thinning of lips, lines		Lip enhancement, fillers possible minimal BOTOX®
		Early jowl formation		BOTOX® for “marionette” lines Fillers, liposuction (conservative) “Mini” short-flap facelift
		Excess neck fat with good skin tone		Neck liposuction
		Neck Platysma bands		BOTOX® or surgical sub-mentoplasty
	50’s (Glogau type III)		Treatments
		Skin with discoloration, brown spots		Good skin care maintenance Medium depth face peels Medium depth laser resurfacing Multiple passes IPL treatment
		Wrinkles, irregular skin texture		Medium to deep laser or chemical peel or Minimally invasive laser or IPL with multiple passes (less invasive moderate results)
		Dynamic lines		BOTOX® may help but browlift, Blepharoplasty can reduce compensation for drooping eyelids or eyebrows
		Eyelid bags and skin wrinkles		Blepharoplasty
		Drooping brow		Endoscopic browlift (unless performed earlier)
		Deepening of nasolabial folds “double lower eyelid” deformity		Midface lift
		Jowl formation, excess neck skin, "double chin"		Facelift If indicated: midface lift or deep-plane lift
		Drooping nose		Tip rhinoplasty for rotation upward
	60’s (Glogau IV)		Treatments
		Skin discoloration, raised brown spots, skin cancers		Skin care maintenance Medium to deep chemical or laser peels Shave, freeze, laser, peel raised lesions Biopsy suspect skin lesions
		Wrinkles: deep		Raise drooping areas with surgery, fillers for depressions, full face laser, peel Minor improvement from minimally invasive lasers
		Dynamic lines		BOTOX® plus fillers for very deep folds, Browlift, * BOTOX® may be ineffective or even cause more problems if the tissue has little support
		Eyes		Blepharoplasty
		Face, jowl and neck drooping		Deep plane facelift with possible mid facelift
		Drooping nose		Tip rotation rhinoplasty

In a recent survey by the American Academy of Facial Plastic and Reconstructive Surgery, 70% of American adults considered their eyes to be their favorite feature.