Facial Rejuvenation

by Dr. Dennis Nigro MD, FACS, FICS

The arena of facial rejuvenation has expanded exponentially in the last decade with the advent of new technical procedures, new adjuvant therapy and the use of topical drug therapy. While, in theory, all of these are positive developments, as with anything in the human endeavor, this allows more chances for misuse, misapplication, and abuse.

I will attempt to put some structure around these modalities to help the patient increase their knowledge so that informed understanding will help both the physician and the patient.

There is a seminal understanding of the aging process and it is important to understand the origin of the concerns that the patient develops as they are based on two undeniable concepts: the genetics of the patient and the anatomic structure of the patient's face and how that genetic influence begins to influence the anatomy.

The facial aging process affects every layer, namely the bone, the muscle, its attaching tendons, the soft tissue which will be the fascial planes, the soft tissue which is normally the subcutaneous fat and in the face it is the temporal fat pad as well as the skin.

Starting with the bones Any anatomic imbalance in the bony structure including a relative lack of cheek bone, balance, chin position, either a lack of chin projection, jaw projection or an over abundance of jaw projection will manifest what appears to be increasing imbalance with the aging processes. I refer the patients to the basic anatomic relationship of boney structures, which is a Da Vinci-like balance. These have to be a primary consideration in even the first steps of aging reconstruction because they are the platform upon which the facial structure rests.

Augmentation and reduction can be carried out by open surgery techniques including cheekbone implantation and/or addition by injection of some of the fillers, which will be done in the subperiosteal space and can give the cheek a greater projection.

Similarly, in the jaw, chin implants and sliding genioplasty, my personal choice, are used to make correct boney relationship. I favor genioplasty because it brings with it the attachments of the muscle and corrects for any origin and insertion of imbalance that might be manifest in the jaw line. This is especially true in a male.

One frequently unrecognized aspect of this is the nose. Although, it is not boney, there are some boney implications in that the cartilage and nasal tip seem to sometimes lengthen and dive down somewhat and a small, corrective, almost what appears to be minimally visible correction, of these nasal aging changes can nicely influence the result.

Muscle Process The muscle process is the cornerstone of aging reconstruction because it is here where the most significant changes can be counter balanced, repaired, or restored. Recent types of technical innovation have allowed this to be done with less visible incisions. Endoscopic surgery, utilizing a television camera and instruments that allow surgery to be done with small incisions have helped a great deal. We are in the position to utilize these techniques and they have been more effective.

Coming with this has been the realization (for at least the past 10-15 years or longer in my practice) that the understanding of these vectors of descent; i.e. the way the muscles fall off the bones are critical in establishing a "natural" reconstruction. That is the simple adage of "putting things back where they started." Pulling skin back towards the ear or back towards the neck may have been some help in certain patients. However, as a universal rule, it probably is going to be fraught with a number of odd-looking results including making some of the patients have that "operative look" that is so repugnant.

Understanding that the doctor is going to address the muscle is absolutely critical whether they are part of the therapy or not. By that I mean, in the simple case of a tightening procedure with an external device such as a non-ablative laser or fillers that are contemplated in lieu of surgery, part of the consultation discussion should be what the limitations are and how the muscle issues will not be affected by procedures that do not directly deal with the muscles.

Soft Tissues Soft tissues of the face, exclusive of the muscle, are the buccal fat pad, the temporal fat pad and the subcutaneous fat in the neck and face. These are all again critical in the understanding of the process of facial rejuvenation. Frequently, there are misconceptions or lack of appreciation of the temporal fat pad loss, buccal fat pad loss and an over exuberance of removal of fat from the neck and face.

In my office, I have a picture of my daughter. It demonstrates a very soft face of a child and indeed soft tissue is equated with youth. Tight pulled looks are unbecoming and certainly not optimal.

As I pointed out above, putting things back where they used to be also means restoring things where they used to be and this is also a critical portion in the understanding of the multilayer reconstruction of the face. Soft tissue augmentation can be accomplished with fascial grafts, usually taken from the mastoid fascia behind the ear, as well as fat injections, which can be taken from a number of places. There is also the bevy of permanent and non-permanent fillers of which Restylane and Juvederm are used in our practice. Artefill, a permanent filler, is used in our practice also. These all have nice applications; however, they can have problems, if they are used incorrectly. A couple of notes about some of those soft tissues fillers: The concept that fat injections do not last forever, in my opinion is incorrect. Having done thousands of these, my experience is if the fat injections are done in small amounts, in small areas and the fat is carefully prepared and injected, without much trauma, you will obtain a significant result from these fat injections but it requires patience. It is not like buying an entire new part for a car; expecting all of it to be restored in one sitting is probably not realistic.

Skin Rejuvenation In my opinion, skin rejuvenation probably has received the most press as it involves virtually anybody - from a radiologist (who owns a spa) to a gynecologist (who has no business working on someone's face) trying in a breakneck race for the patient's dollar.

There are types of skin rejuvenation, which involve topical application of chemicals and ablative and non-ablative lasers.

The cream and chemical applications are relatively tried and true. Again, they have to be done very carefully. The overall idea that is important to understand is the skin is a growing organ. It would be much like restoring your lawn in that it is far better to slowly nurture it along, so as to not infuse any injury, which will change the content, color and texture of the skin in an irretrievable way.

Ablative and non-ablative lasers have a great deal of applications because of their overall effectiveness. The class of ablative laser is the CO2 laser. Types of other ablative lasers include Fraxel type lasers or anything that peels the skin off and has an ablative portion to it.

It is very important that dark skin and patients taking estrogen realize that there are some risks. Some patients, more than others, are having hypo and hyperpigmentation after using these types of lasers. I prefer to avoid them in these types of patients unless it is a very unusual circumstance. A great deal of understanding also needs to be brought to bear on the patient's history and current medical conditions.

In general, the caveat that one should have is that the skin is a covering that has some structural importance. This applies especially in certain patients with aging, collagen, sun damage or both, as well as with people who have genetic tendencies to have breakdown of their collagen at an early age. It is not, however, the lynch pin of aging facial reconstruction. Moreover, someone that only has one tool to deal with that is woefully ill equipped to deal with all the levels of facial surgery.

The final caveat I would leave the prospective patient with is:

Check the quantities of all the procedures performed at the office where you are getting a consultation.

Check if these wide varieties of modalities are available.

Check if they were taken into consideration in your case.

If they are not, I would suggest that you are getting incomplete information.