Shedding Light on the Mystery of Facial Aging
Although it will happen to all of us, the aging face continues to represent an enigma. Most people start to be aware of some changes in their thirties or early forties. Interestingly, many women and men in this age group take note of one or two issues that apparently cause them to look older. After correction of “just this one issue”, they assume, the clock would be turned back by 5 or 10 years. For instance, Dr. Fechner’s 30-something patients commonly point out droopy and puffy eyelids and grooves extending from the nose to the mouth corners (a.k.a. nasolabial creases) as their main concerns. Experience proves that correction of these problem areas may lead to a more alert appearance or softer skin lines, but a truly younger appearance is rarely achieved.
Once we accept that aging does not only lead to deeper skin creases, heavier eyelids or jaw and neck line issues, a thorough evaluation of the patient’s face and neck aging reveals many other, sometimes subtle changes. Dr. Fechner observes that a youthful and vibrant appearance usually is closely associated with attractiveness. This means that a younger face makes the person routinely prettier as long as a normal look is maintained.
Careful analysis reveals that aging of the face takes place on many anatomic levels: the bone, facial muscles, fat and the skin. Only if these complex facts are recognized, a patient’s aging pattern can truly be understood. One of the first things medical students learn is “diagnosis comes before treatment”. Surprisingly, this truism is commonly forgotten in cosmetic facial surgery. Plastic surgeons and patients rather wonder “what can a facelift do?” instead of “Which anatomical changes have occurred over the years and how can it be corrected?” Based on his thorough facial analysis, Dr. Fechner will develop a treatment plan aimed at achieving the final aesthetic vision.
Deep Face Structures Change during Aging Process
When structures located relatively deep under the skin surface change, the overlying face contour will be affected. It was only recently that anatomical maturation of deep facial tissues has been systematically analyzed.
Bone
Understanding aging-related changes of the facial skeleton is important as the boney support will considerably impact the overlying soft tissues. For instance, the eye socket (a.k.a. orbit) increases noticeably in height and overall dimension over the years, contributing to sunken under-eyes and dark circles. The bone of the mid-face and cheek area (maxilla) decreases its angularity contributing to a hollow and drawn mid-facial contour rather than the convex contour present in youth. In addition, the jaw bone (mandible) undergoes aging-related alterations with reduction of its length and height and loss of angularity. These changes of the underlying boney support will contribute to jowling, an apparent reduction of chin projection (smaller chin) and decreased jawline definition.
Neck
The skin often becomes lose and wrinkly with excess underlying fat. Interestingly, if neck rejuvenation is limited to these two anatomical layers, the neck improvement will often be of poor quality, short lived and therefore disappointing. Fat removal, performed through neck liposuction for instance, can uncover neck “banding” or “chords”, an issue often not present in heavy necks before such intervention. Dr. Fechner believes that a “healthy” layer of fat just underneath the neck skin is important for a natural and soft look. In some people the neck skin is devoid of fat leading to thin loose skin with prominent vertical neck bands. Beneath this superficial fat lies the platysma muscle and under that a second partition of fat (“deep neck fat”). Anatomically, this “subplatysmal deep” fat can be divided into five compartments.
We observed that in many people, this deep fat becomes more prominent with age causing the neck to appear fuller. The deep neck fat is not readily available for removal with liposuction. Within the same layer and located adjacent to the deeper fat compartment are the submandibular glands – one on each side. In youth, these salivary glands are tucked away behind the jawbone and usually not visible. With time though, these glands start to descend hereby obscuring the jawline; sometimes, the submandibular glands become visible as large walnut-like structures.
The extent to which these various anatomical entities contribute to neck aging differs from person to person. Unless deeper neck structures are examined, well understood and their treatment is individualized, the desired improvements of the neck and jawline will be limited and longevity of rejuvenation disappointing.
Fat Compartments of the Face
Dr. Fechner feels that a person’s facial surface contour determines overall appearance and attractiveness. Attentive examination of the face and neck leads to the understanding of how the aging process has influenced specific facial regions. As a result, various areas of the face become sunken (i.e. temples, under-eyes and cheeks) while others became more prominent (jowl fat and neck). Therefore, it is rare that tightening of face and neck tissues alone, even with the best of all face lifts, will provide superior results. Rather, specific volume changes of the face demand appropriate restoration. Both, fat loss and addition of fat will lead to changes of surface features associated with the aging face.
Facial fat grafting allows for approximately 90% of necessary enhancement, an ancillary procedure routinely combined with the face and neck lift. But it would be a fallacy to perform the same procedure combination on everybody. First, all of us have unique facial features including unique distribution of fat before appreciable aging began. This starting point of adipose anatomy will have important impact on fat changes over the decades. In addition, genetics and generalized body characteristics including weight tend to determine how much facial fat is lost and where. Lifestyle habits (e.g., exercise, sun exposure and smoking) will contribute to the overall facial fat distribution.
Skin of Face & Neck
The skin can be considered the largest organ of the human body. It serves multiple purposes; first and foremost it protects the body from the potential harmful surroundings. Defending us of environmental factors such as sun, weather, infections, particles etc., no other organ of the human body mirrors so readily a person’s past lifestyle behaviors. Because of its vast surface, the skin does tell our age. Therefore, Dr. Fechner feels that dermal rejuvenation represents an important aspect in overall treatment of aging related facial changes. Because a gentle but definite skin enhancement complements nicely the contour improvements achieved with facelift surgery, Dr. Fechner commonly advocates for skin enhancement in conjunction with the procedure. On the other hand, we do not desire tight skin covering an aged contour – an unnatural combination that would compromise the normal facial balance. Therefore, aggressive resurfacing (for instance with a laser) is rarely required. Rather, the treatment should provide significant skin texture improvements and color harmonization while reducing fine lines and wrinkles for an overall healthier and younger looking skin.
