Facial aging is due to a combination of factors. In the last Panorama of Plastic Surgery we discussed photoaging or aging due to sun exposure, which is fortunately a largely preventable cause of aging. In this article we will explore some other factors that contribute to aging. Some of these factors are less preventable, but fortunately are able to often be corrected once established.

Gravity

One prominent cause of aging is due to the effect of gravity. As you study the difference in facial features between the extremes of age, you see a drooping of certain areas of the face and neck frequently.  Such areas include the jowls or lower cheeks, the neck or "turkey wad", the chin, the nose, the eyebrows and forehead, and the upper and lower eyelids.

Plastic surgery has various techniques designed to rejuvenate the face once gravity has caused these areas to droop and thus form the folds and deeper wrinkles associated with aging. No other form of facial rejuvenation such as chemical peel or laser surgery is effective in treating these drooped areas once formed.

Plastic surgery techniques include facelift, which typically elevates the cheeks, jowls and neck. Facelifts remove excess skin from the lower face and neck through incisions around the hairline and ear area and underneath the chin. Typically deeper layers including the muscles are tightened to help prevent recurrent drooping of facial tissue. Facelifts are rarely necessary before age 40 and are usually performed in men and women when they have sufficient laxity of tissue to justify the small but real risk of surgery.

Sometimes a series of chemical peels and laser surgery or increasing lax facial areas with fillers can achieve some tightening of tissue and thus delay the time when facial laxity would only be corrected with a facelift.   The neck, however, cannot be treated with a deep chemical peel due to potential complications, so this area is best treated with a facelift. On occasion, usually in men who do not object to a visible neck scar, excess neck skin can be removed directly. This scar is much more prominent and visible than the usual facelift scars. Facelifts usually last from 5-10 years although some patients with poor skin elasticity notice a recurrence of facial drooping sooner. Usually the second facelift is longer lasting.

Other areas, which are susceptible to gravity, include the chin and nose.  Elevation of the chin directly or elevation using a prosthetic implant produces a more youthful appearance. Many different techniques are available and the particular technique best suited to your bone structure and appearance is best discussed with a plastic surgeon. Incisions are placed inside the mouth or under the chin. Elevation of the nose including the nasal tip can usually be accomplished through incisions hidden inside the nose.

One early sign of facial aging is around the eyes and brow area.  Perhaps this is due to the thinner tissues of the eyelids and their constant motion compared to other areas of the face. Most people show their first signs of facial aging around the mid 30's when the eyebrows begin to droop. You can see for yourself if your eyebrows are drooped by elevating the outer half of the eyebrows while looking in the mirror. Do you see the small fold of excess skin of your upper eyelid become less prominent?

Drooping of the brow has several effects including a shift in position of the eyebrow, especially the outer half, drooping of the tissue of the eyelids due to pressure of the brows on the thinner skin of the upper eyelids, and horizontal forehead wrinkles due to constant elevation of the forehead muscles in order to relieve this pressure from the drooped brows. Vertical forehead wrinkles are usually due to over activity of certain muscles and will be discussed later under expression lines.

The surgical treatment for drooped brows is a forehead lift. This is usually performed by making an incision across the top of the scalp and lifting the tissues of the brow and forehead. The overactive muscles can be removed and the elevation of the forehead and brow helps eliminate the horizontal forehead wrinkles after a browlift. Often crows feet are softened or eliminated.  There is less upper eyelid skin to remove after elevation of the brow and in some patients a browlift is all that is required to correct aging around the eyes.  Mild brown laxity can be corrected with fillers as well.

For drooping of the upper eyelids not corrected with a browlift, or in patients who prefer less surgery, an eyelid lift or blepharoplasty is possible.  Excess skin and fat is removed from the upper eyelid and the incision is mostly hidden in a natural crease. Some insurance policies will cover the costs of an upper eyelid blepharoplasty or a browlift if visual field tests by an ophthalmologist or optometrist are abnormal. If you have a moderate to severe amount of hooding of the brow and upper eyelid skin that may be obstructing your vision off to the side, you may consider having this test performed.

For drooping of the skin and treatment of the fatty bulges that develop in the lower eyelid area, a lower eyelid lift or blepharoplasty may be helpful.  This procedure removes excess skin, muscle and fat from the lower eyelid.  The incision is usually made just under the lash line and usually heals with minimal scarring. Sometimes the incision can be made through the conjunctiva, or pink tissue on the inside of the eyelid, if there is only fat to remove.

Depending on your particular facial structure, gravity is more likely to take its toll in one area before another. Although one cannot neutralize gravity, various methods exist to counteract its effects.

Expression Lines

The next category of facial aging involves expression lines. These lines form due to facial muscle activity such as squinting and smiling and are mostly prominent around the eyes and mouth. Preventive measures include wearing sunglasses to avoid squinting and never smiling or laughing. Only so much prevention is possible, however, and I would not recommend limiting your facial expression, unless that expression is that of frowning. Treatment for facial expression lines depends on the position and depth of the line. Lines that are less deep may be treated with a chemical peel.  Medium deep lines are treated with placement of fat, dermis, or filler materials such as collagen, hyaluronic acid and other fillers under the crease.  Some of these filler materials last longer than others.  Deeper lines are usually treated with surgery such as facelifts and eyelid and brow lifts and also may be treated with replacing lost volume of the facial area with filler materials..

Inherited Facial Features

Inherited facial features can contribute to premature aging. Lack of adequate bony support in the area of the upper cheeks can cause premature drooping of the lower eyelids. This can be corrected with malar or cheek implants at the time of the lower eyelid lift so the condition will be less likely to recur. Upper eyelids are more likely to droop with inadequate bony support of the brow.

Fatty deposits in the cheeks and under the chin can contribute to a plumper, older appearing face. These can be corrected using facial liposuction and/or the removal of the cheek fat pad through an incision made inside the mouth. A thinner more youthful appearance results from sculpturing the unwanted fat from the face. If the skin is still elastic, it will redrape without needing more extensive plastic surgery procedures, which remove excess skin.  

Balance of facial features such as the chin and nose creates a youthful appearance. In some people, plastic surgery procedures are done to create fuller lips or reduce lips that are too full in order to restore balance to the face.

Stress

The last cause of facial aging I would like to discuss is stress. Researchers studying aging have discovered that aging often occurs in spurts. You may have noted this in yourself or your friends when you see signs of accelerated aging after particularly stressful times. If you don't believe me, look at pictures of our former presidents before and after their 4 to 8 year terms.

One field of research that I feel is largely unexplored is that of the effect of stress reduction techniques on aging. The ability to reduce stress through daily practices such as exercise, yoga and meditation can produce remarkable delays in facial aging and may even reverse some already established signs of facial aging. Of course a healthy diet including use of distilled or filtered water is also advisable, for the skin acts as a secondary organ for the elimination of unwanted material from the body. Dermatologists have long been able to study the effect of various diseases and malnutrition by the appearance and quality of the skin.

So what can you do to maintain your youthful skin and face?  Avoid sun exposure, use a broad-spectrum sunblock of S.P.F. 15 or higher, wear sunglasses to avoid squinting, eat a healthy diet consisting of fresh vital foods with elimination of excess fat and sugar, drink filtered or distilled water and exercise regularly.  I would also advise you to investigate some form of meditation where you quiet the mind perhaps while listening to soft music or perhaps while walking in nature, to allow the daily stresses to dissolve. Take time also to listen to your inner guidance for solutions to your stressful situations. And above all, celebrate and enjoy life, for in the enjoyment of the simple pleasures, we are renewed and rejuvenated in our body and soul.

S:\Transcription\Articles\Facial Rejuvenation-Due to Gravity, Expression Lines, Stress November 2008