Lower Eyelids and Cheeks
The region from the lower lids to the level of the mouth we commonly call the midface. In the past, this area was artificially divided: a lower eyelid lift was performed by removing fat and skin. Dr. Fechner believes that this approach is conceptually limited and therefore leads to suboptimal cosmetic outcomes. Rather, the goal should be to re-unite the cheek and lower lids into one aesthetic unit – similar to the contour flow of a youthful face. In order to achieve this look, Dr. Fechner combines various approaches including volume enhancement with fat injections to areas of deflation. By filling in hollows and depression, the need for removal of fat from the puffy compartments of the lower eyelids are minimized or sometimes unnecessary – a great bonus. At the end, we embrace soft lines with youthful fullness over sunken eyes and hollowness of the cheek. In some patients, fat tissues from the lower lids are surgically redistributed but not removed in order to achieve reduction from where it is abundant and a fill effect in areas of loss. This “lower blepharoplasty with fat repositioning” has benefited hundreds of patients in achieving a more youthful and less tired look. At the same time, it allows for some tightening of the skin and removal of excess for under-eye wrinkle reduction.
The cheeks are affected in everybody during the aging process. It is rather rare, that lifting is sufficient for youthful enhancement; rather, the specifics of fat volume loss have to be assessed and treated methodically. Fascinated by the variations in extent and location of midface volume loss, Dr. Fechner sometimes fills over the cheekbone only. Most commonly though, a little filling over the cheekbones (a.k.a. malar eminences) is combined with fat grafting into the region just below (submalar enhancement). In addition, some patients loose a particular fat space called the buccal fat pad. Replenishing of this buccal fat is very beneficial for a softer and healthier appearance.
Upper and Lower Lips
Aging has sometimes quite dramatic impacts on the anatomy and appearance of the lips. Most people notice that the lips get smaller and thinner in addition to deepening of lip wrinkles. Dr. Fechner’s philosophy of shape over volume helped him to appreciate how the lips are affected by decreased definition over the years. For instance, the attractive poutiness of the lips is replaced by a stern and worn appearance with flattened anatomy and vertical worry-lines. Anatomical examinations reveal that, again, fat loss plays a significant role during lip aging. And because of the lip’s complex anatomy of transition from skin over red lips (vermillion) to wet mucosa (inner lip lining), less wet of the red lips are visible in older individuals than in youths. Deflation of the lips and skin aging in addition to the constant ring-like muscle action of the lip muscle (a.k.a. orbicularis oris muscle) lead to deepening of lip wrinkles over the years and constricted lip appearance.
When we rejuvenate the lips it is important to understand normal lip aesthetics: the lower lip should be slightly fuller than the upper lip. If this volume relationship is reversed, an unattractive “duck lip” will result. In addition, the red lips are not simply sausage like structures; rather, distinct areas of fullness exist. The youthful lower lip has two gentle mounds, one on each side of the midline with the sides tapering to the mouth angles. This volume distribution is distinctly different in the upper lip where there are separate areas of volume, one in the center and one on each side separated by a region of relative lesser prominence.
A further change of the upper lip seems to occur in meaningful magnitude in only some people: the vertical length increases hereby changing the balance between chin, upper and lower lips. Affected patients notice partial disappearance of the teeth when talking or smiling resulting in an aged and sometimes even toothless look.
Around the Mouth
In addition to the lips themselves, the area around the lips and mouth should flow smoothly into the neighboring structures.
Nasolabial Grooves
Many patients are concerned with their naso-labial creases, the grooves that extend from the sides of the nose towards the corners of the mouth. These creases get more pronounced in many people over the decades due to various reasons. Droopy cheeks can accentuate the nasolabial creases in addition to volume loss in the areas of the creases. Normal animation including smiling will – over the years – lead to varying degrees of creasing and may contribute to a weathered appearance. Facelifts will usually not correct nasolabial creases in a satisfactory way, a point that Dr. Fechner frequently stresses with his patients. Instead, filling (usually with fat) will allow for lasting softening. Some fat is placed deep for structural volume enhancement. In addition, small amounts of fat can be injected more superficially for additional improvement.
The Nose
The nose is rarely considered as part of the aging process of the face but observant patients report significant changes to the nose over the decades. There are many reasons for aging-related nasal changes. For one, the skin on the nose tends to get thicker over the years, which leads to decreased nasal tip definition. In addition, the support structures of the nose weaken. Volume loss, which is so significant in other parts of the face, affects the nasal appearance to only a mild degree. Dr. Fechner frequently observes deflation of the very top of the nose where it creates an angled depression before sloping into the forehead, an anatomical area also referred to as nasofrontal angle. All these aspects lead to a nose which tends to appear bigger, droopier and less defined. Sometimes, a bump on the nasal bridge which may have been mild in younger years can become more apparent and prominent. Therefore, rhinoplasty for the aging nose has to be approached differently than when the same operation is performed in teenagers. Most patients in their 40s or 50s do not seek dramatic changes to the nose. Rather, the goal is a more youthful nose with the balance on the face maintained. Sometimes, Dr. Fechner’s patients simply wish to enhance the nose to a point where it used to be in younger years. Some patients even describe worsening of the nasal breathing as part of the aging process.
Dr. Fechner’s approaches aging rhinoplasty in a systematic manner. Nuances of the procedure commonly include strengthening of tip support, reduction of a nasal bump and conservative tip refinement. Dr. Fechner stresses the importance of maintaining or enhancing nasal support for a lasting result and a structurally sound nose.
Loss of volume in the nasal-frontal angle region can be reestablished with either fat grafting or cartilage crafting. Cartilage is also used to support the nasal tip. For these purposes, Dr. Fechner uses routinely the patient’s own cartilage material which is safely harvested from the nasal septum. He is careful not to make the nose too small – a look that leads invariably to unnatural or pinched appearances. Twenty-first century aesthetics as embraced by Dr. Fechner stresses the fact that a nose should have appropriate shape rather than being tiny.
