Faces, Eyes, Cheeks, Jowls, Foreheads, Wrinkles, Bags, and Scowls

New tools for a new lift: what to use, what to lose.

Each year our capabilities change as tools and techniques change. The body is a constant: the physiology of healing has stayed much the same. However, the people we see are potentially healthier. Smoking and tanning are less common, and exercise is a lot more popular. People presenting for facelift tend to be fit and very conscious of their health.

Thirty years ago the facelift lifted the skin and ignored the deeper tissues. Newer techniques lift the deeper tissues as well, and specialized approaches address problem areas such as submental fat collections contributing to turkey necks and festoons of puffy tissue below and lateral to the lower lids.

Lasers and peels change the surface texture of the face; this can help reverse progression seen as skin ages and subcutaneous tissues atrophy. Less dramatic microdermabrasion and retinoic acid approaches make possible skin care and medical spa advances enjoyed in the last fifteen or twenty years.

Volume changes and control of muscular activity have been increasingly precise as fat grafts and a variety of fillers have become more available, and neurotoxins such as Botox and Dysport allow fine-tuning of facial muscles of expression. These techniques expand the available possibilities and allow a more nuanced treatment of the aging face. One technique does not really replace another.

All techniques are temporary in the sense that these annoying aging changes start at infancy and proceed through adulthood until our demise. The surgical approaches and materials produce the illusion that time has moved and the clock has reversed only to start grinding forward again. Too much change and the result is alarming and incongruent. The full lips of an infant can be startling when they appear suddenly on Grandma.

Cost is often a factor. Not only dollars but downtime influences decisions for treatment. Perhaps the most important is the patient's own priorities. "Jowls like Aunt Betty's," or "a frown just like my father's": these are the problems that lead to treatment, and other signs of aging are often secondary. Treatment does well to consider the whole. If one area is corrected in isolation, the patient may develop a startling appearance.

What to consider first and in what order? We start with what is bothering you and try to come up with a plan that does the most for the least. A change in brow position may erase a frown and conceal baggy upper eyelids. Botox or Dysport can work in a day or two after an office injection, lasts 3-4 months, and costs about $600. Add a blepharoplasty for removal of the extra skin and fat in the lids, and recovery is a week or two. Costs increase to $2000-$4000, and the effects last for years rather than months. Blepharoplasty, or eyelid surgery, does not replace Botox but may be just the thing in combination with skin care, fillers and a neurotoxin to balance a frown. For some patients, this may be the the perfect solution. But it isn't for everyone. The fifth grade teacher with an unruly kid in the back row may want to look younger and still keep the "look" she shoots in his direction. We listen to our patients' individual concerns, and find the right combination of treatments for each person.