A woman in her early 70’s who is bothered by an aged appearance and laxity of her neck skin. She has significant sun damage and was a smoker in the past, but has not smoked for more than 6 years. Examination shows significant volume loss around the eyes and cheeks from the aging process, and her left cheek is much deeper than her right. She also has a weak chin.
She is shown before and again, 6 months after a facelift, including a chin implant and fat grafing to her midface and upper eyelid sulcus to treat the aging related hollowing of her eyes. She also has had some Restylane Lyft to her cheeks after surgery.
Discussion: The poor quality of her skin from years of smoking and the sun damage will limit the result that we can obtain from a facelift. Her skin elasticity is quite poor. It is not just the tailor but also the fabric that we are working with that influences the result. But the fat grafting can improve the volume loss and may bring in stem cells that improve the quality of the skin. When a chin is weak, a chin implant can also dramatically improve the results. Fat grafting is unpredictable- even though significantly more fat was placed to her hollower left cheek at the time of surgery, it still remains hollower. It is common to “build the foundation” with the fat grafting and then return at 6-12 months and add a some of the non animal stabilized hyaluronic acid (NASHA) fillers such as those in the Restylane/Juvederm families to further improve the results. A patient with prominent creases of the skin from poor elasticity is prone to “jokers lines”-and upward sweep of the skin lines at the corners of the mouth. This has been limited in her case by the fat grafting at the time of her surgery to replace volume loss in these areas.
A woman in her early 60’s who is bothered by an aged appearance of her face. She is shown before and again, 9 weeks after bilateral upper eyelid blepharoplasty with facelift utilizing a platysma window and lateral SMAS plication, combined with fat grating to the cheeks and upper and lower eyelids. The fat grafting improves the quality of the skin, but also helps to correct the “a frame” hollowing of her upper eyelids that adds to her aged appearance. She has significant volume loss of the cheeks with aging that is not corrected with skin tightening- it is corrected by the careful replacement of volume with fat grafting.
A woman in her mid 70’s who is bothered by an aged appearance. She has also lost 100 lbs following a gastric bypass. Analysis of her face shows some brow asymmetry as she holds her left brow higher to compensate for some left eyelid ptosis. She has prominent fat pads of the lower eyelid and significant volume loss of the midface. A weak chin contributes to the laxity of her neck, and the vertical lines around her lip bother her as well. She is shown before and again, 3 months after bilateral upper eyelid blepharoplasty, bilateral lower eyelid blepharoplasty, lateral smasectomy face lift with placement of a chin implant, fat grafting to the midface and perioral dermabrasion. She is thrilled with her natural but markedly improved appearance. Dermabrasion is an “old fashioned” technique that works well to improve the vertical lines of the lip without as much a risk of bleaching of the skin that can be seen with laser or deep chemical peels. She has a natural look because our procedure was tailored to fit her aging deformity. We have “lifted and filled” not just pulled her tighter. The key to a natural appearance with facial aging is a careful diagnosis and then correction of the different components of the aging deformity- there is not one key that fits all locks.
A woman is shown before and again 7 months after facelift combined with a chin implant. When a patient with a “weak chin” is requesting a facelift or a rhinoplasty, a chin implant is typically recommended at the same time to improve the subsequent facial balance and results.
A woman in her early 60’s who is bothered by the appearance of her neck. Evaluation shows that she has hypogenia, a “weak chin”. An easy way to tell is to look at an imaginary line that connects the upper and lower lips. If the chin falls behind this it is “weak”. A weak chin especially influences the result of a facelift or a rhinoplasty, and is frequently corrected at the same time. In her case, she elected for a chin implant combined with a face lift using a “lateral smasectomy” tightening of the deep tissues of the face, and an incision hidden in the front of the sideburn, to avoid over elevation of the side burn that would look unnatural. She is shown just 3 months after her procedure. A natural improvement of the neck line and jowls are seen. She did not choose to have fat grafting to the area of volume loss in her cheeks, wishing instead to focus only on her neckline. The scars that go in front and in back of the ear are already hidden. The sideburn scar is still red at 3 months and is seen on close inspection, but will continue to fade over the next year, and is designed to allow the new hairs at the edge to grow up through the scar and camouflage it further.
Our patient is shown again at 6 months. She has maintained her elegant neck and jawline achieved at surgery. Her scars have faded nicely. She has volume loss of her face that we typically see with aging, but did not wish to have fat grafting at the time of surgery. Facial fillers could be added later in the office is she wished, but she is thrilled with her improvement after surgery, and does not feel the need to replace her volume loss.
She is seen again at 12 months. Scars have faded and she has maintained a beautiful neckline after her surgery. She has a natural appearance after her surgery. Her acquaintances do not suspect that she has had surgery- but she likes feeling more confident about her appearance.
A woman in her early to mid 60’s who is bothered by the appearance of her neck. On examination she also has a “weak” chin. She is shown before and again, 2 months after a lateral smasectomy face lift combined with fat grafting and a chin implant, and perioral dermabrasion (sanding of the lines around the mouth) The quality of our results is often determined by the “fabric” that we are working with. When the skin elasticity is decreased, we can expect more recurrent laxity. At 2 months, she still has some swelling from the fat grafting which improves the appearance of the cheek volume lost with aging and the lines around the mouth.
She is now shown exactly one year after her surgery. The lines abound her mouth and cheek volume loss are improved from before her surgery, but a little more noticeable now as the swelling has completely resolved. She has maintained her improved neck and jaw line. She could now improve her lines and volume loss further with injections in the office of Restylane or Juvederm type products, but is pleased with her appearance. Her small skin vascular telangiectasias could be improved with Intense Pulse Light treatment as well, but do not bother her. Skin texture and color problems are not usually improved with a face lift alone, which only addresses the problems of looseness of the skin. The fat grafting does often give some improvement in the skin texture.
She is now shown more than 18 months after her surgery. She has maintained her improved neck line. The quality of the skin seems improved. Cheek volume and lines around the mouth appear better. This is felt to be a result of the micro fat grafting done at the time of surgery, that may show continued improvement in the skin quality with time. The theory is that a large source of stem cells reside in our fat stores, and are transferred along with the fat cells when they are grafted. She has had Juvederm 9 months ago to the lips. Her scar in front of the ear and sideburns is undetectable from even close inspection.
Our patient is a nurse in her middle 60’s who has lost 60 lbs following a gastric sleeve. She has some difficulty with excess upper eyelid skin which is starting to block her vision. She has had an upper lid blepharoplasty when she was in her 30’s. She also has “festoons” of her lower eyelid skin. Her chin is slightly weak. When the chin is weak and we are considering a facelift, we will frequently add a chin implant at the same time. She is shown before and again, 5 months after an endoscopic brow lift. Upper and lower eyelid blepharoplasty, facelift and chin implant. She is thrilled with her natural appearance after surgery.