Consisting of the region between the hairline above the forehead above and a horizontal line drawn through the middle of the eyes, Dr. Fechner believes that the upper face is virtually never spared of aging and therefore, deserves thorough analysis and appropriate management. Small alterations of this important area can lead to significant enhancements; it is also commonly under-appreciated and therefore under-treated. In general, unless aging-related deformities in this region are recognized and addressed, the best results cannot be achieved.
The Hairline
Most men and women observe changes to the hairline as part of aging: the density of hair decreases, especially where the hair meets the forehead. In addition, the hairline moves higher over the years, commonly more on the sides than in the center – a condition that Dr. Fechner calls fronto-temporal recession. Many women who are bothered by high hairlines use bangs as their trade mark. In addition, some woman always had a hairline that starts high. Although men with significant balding may only find hair restoration procedures useful (usually with follicular grafting), many women benefit from hairline lowering forehead procedures leading to harmonization of the upper face. The browlift is the surgical approach that can effectively improve the apparent hairline height through removal of excess forehead skin as part of the surgical procedure.
The Forehead
Deepening of furrows and grooves are frequent occurrences, most notably horizontal forehead wrinkles and frown lines between the eyebrows. These creases are the result of voluntarily and involuntarily raising the brows and scowling, repetitive animations that are impossible to control for most of us. Therefore, injections of botulinum toxin A (for instance Dysport® or Botox®) are helpful by temporarily weakening muscles responsible for these movements. Although very effective, these treatments require continued maintenance and Botox® or Dysport® injections are usually repeated every 3 to 4 months for best results. As part of facial rejuvenation surgery, the same muscles can be permanently relaxed leading to a more lasting effect. In addition, deeper grooves may benefit from structural filling, an effect achieved with tiny amounts of fat. Boney and fat volume changes can also lead to depressions and volume loss between the brows (glabella) and of the area where nose and forehead meet (a.k.a. radix or naso-frontal angle). In these instances, facial fat transfer has proven beneficial in many patients.
The Eyebrows
Similar to other facial structures and aesthetic units, the brows cannot be seen as stand-alone elements. Rather, Dr. Fechner observes the eyebrows’ configuration in conjunction with their surroundings. The brows frame the eyes and as such they should effectively support this key focal point of our faces. In addition to a facelift procedure, forehead and brow rejuvenation are extremely beneficial as long as crucial guidelines are respected. First, it is not useful to elevate the eyebrows really high; rather, it is the shape of the eyebrows that counts. In women, the brows should ideally arch up with the outer brow tail located higher than its center. In addition, the brow bone (a.k.a. superior orbital rim) should create a light reflex underneath the eyebrow. Unfavorably shaped eyebrows create the tell tale “operated-on” look of high brows in the middle which gives the person the surprised appearance – a look that must be avoided. The eyebrows loose fat padding leading to more prominent brow bones. This harsh transition is incompatible with youthfulness. Therefore, Dr. Fechner will commonly include fat grafting as part of the upper face rejuvenation in order to replace some of the patient’s own fat that has been lost over the years.
Temples
Starting routinely in one’s thirties, the temples loose important fat padding leading to hollowing, unattractive concavities and prominent display of bone structures. This is due to fat loss from distinct compartments, a condition that is effectively improved through fat restoration. Rarely, diminished fat volume is compensated by a bulky temporalis muscle, part of the chewing musculature. Possibly associated with habitual use of gum chewing or teeth grinding (a.k.a. bruxism), Dr. Fechner observes this scenario mostly in men. Associated with temporal volume loss is commonly the presence of larger veins which cross the region as prominent worm-like structures. Frequently used by Dr. Fechner, facial fat grafting to the temples allows for rejuvenation and softening of the temples.
Upper Eyelids
An area that has been routinely changed using upper eyelid lifts for decades, Dr. Fechner feels that critical assessment of what is youthful and attractive requires rethinking of blepharoplasty surgery. Conventional eyelid lifts are mostly performed by removal of skin, muscle and fat. Study of patient outcomes from these “regular” eyelid lifts reveals that the procedure was frequently overdone creating hollow eyelid sockets associated with the appearance of poor health. According to Dr. Fechner, the eyelids should support the eyes through softness, definition and “charm” – a look not attainable with “nursing home eyes”. The error does not lie within the surgical technique employed by the plastic surgeon but rather in the aesthetic planning done beforehand. Overly deep-set eyelids can develop or worsen through fat loss of a specific fat compartment in the center of the lid (a.k.a. pre-aponeurotic fat). In the quest for dramatic eyelid definition, this fat is commonly reduced or removed during conventional blepharoplasty surgery leading to an abnormality called “A-frame deformity”. In contrast, Dr. Fechner restores youthful eyes through various degrees of conservative fat reduction from the compartment closest to the nose, volume enhancement within the depth of the “A” and removal of skin redundancy. Employing these techniques according to the specific needs and desires of the patient, upper blepharoplasty can achieve eyelids that appear soft and natural with a lid crease that parallels the eyelid margin.
Solution: Complete Forehead Rejuvenation Surgery
Once the above changes of hairline, forehead and eyebrows are noted, improvements require comprehensive technique and artistic vision. Because it is not enough in most patients to simply lift the brows, recommendations commonly strive for harmonization of the upper face allowing for improved balance – a distinctly different goal rarely achieved with one single procedure. Dr. Fechner’s philosophy appreciates that aging represents a complex phenomenon not limited to sagging of tissues. Rather, these three-dimensional changes require a specific comprehensive plan of treatment.
