Rejuvenation of the Aging Face Christopher A. Perro, MD, FACS UT Health‐Facial Plastic Surgery February 2, 2020 1 Rejuvenation of the Aging Face • The process of facial aging: what happens to our face and neck as we age and why • Full range of options for facial rejuvenation including skin care, skin resurfacing, dermal fillers, Botox, and surgery • Detailed discussion about surgical options including facelift, brow/forehead lift, eyelid surgery (blepharoplasty), neck lift, and chin implants • Hair restoration and its role • Functional problems related to aging of the face like visual field deficits related to excess upper eyelid skin 2 1 Increase in cosmetic procedures • Advances in medicine allowing people to live longer and with improved quality of life • Sparks desire to “look as good as you feel” • Improved safety of procedures • Anesthesia is safer than ever before • Well developed products: implants, dermal fillers, Botox, etc. • Emphasis on natural looking results 3 How do we age? 3 Dimensions of Facial Aging • 1. Skin Surface Aging Changes • 2. Volume Loss • 3. Drooping/Descent of Soft Tissues 4 2 What makes a face look youthful or beautiful? • Vibrant fat pads in the cheeks • Upside down egg shape • Few shadows on the face • Smooth, homogeneous skin texture and color • Seeing natural almond shape of eyes, unobscured • Facial harmony, balance, proportion, and symmetry 5 Shapes 6 3 Skin Changes • Coarse lines/wrinkles • What happens? • Static • Loss of collagen support of skin • Dynamic‐related to chronic • Thinning of skin tension in muscles of facial • Loss of “bounce back” resiliency of expression skin • Fine lines/wrinkles • Other textural changes • Contributing causes: smoking, sun exposure, genetics • Pigment changes‐ • spots, streaks, broken blood vessels 7 Treating the Skin • An ounce of prevention is worth a • Wrinkles: fine lines and textural pound of cure: SUNSCREEN! changes may respond to topical therapy • Botox or other neuromodulators help by • Good skin care regimen: cleanser, temporarily weakening the muscles toner, moisturizer responsible for making the deeper skin lines • Dermal fillers may also be used to help improve appearance of lines by effacing • Topical Retinoids: Retin A, etc shadows • Skin resurfacing • Chemical peel: i.e. TCA • Laser resurfacing: i.e. CO2 laser • Dermabrasion: not used for full face resurfacing anymore 8 4 Botox‐what is it, how does it work, and what can it do for me? 9 Botox works… 10 5 Volume Loss • 1. Bony remodeling • Mechanical forces enacted by muscles on bone lead to changes in facial skeletal bone structure • 2. Soft tissue volume loss • Fat pad and subcutaneous fat atrophy • Fat pad descent giving illusion of loss of volume • Volume loss in one area may cause • Movement of fat from behind the eye sagging in another area forward to where it causes bags above and below the eye • Both may lead to deepening of lines/furrows like nasolabial folds‐ promoting aged appearance 11 • Bony changes in the supraorbital rim contribute to apparent volume loss and hollowing of the brow and upper eyelid • Loss of facial width in the upper 1/3 of the face leads to more egg shape of face in age • Maxilla shortens and soft tissue excess forms 12 6 Lip Augmentation Pitfalls… ‐Overfilling the body of the lip—Sausage Lips ‐Overfilling upper lip—Duck Lip ‐Not staging lip injections‐too much too fast ‐Not respecting the harmony of the face‐not everyone looks good with Jolie lips 13 Addressing Volume Loss • Dermal Filler Injectables • Fat Transfer • Facial Implants 14 7 Dermal Fillers • Replacement vs Stimulatory Fillers • Juvederm: • Ultra XC • Ultra Plus XC • Temporary vs Permanent vs Semi • Voluma XC Permanent • Volbella XC • Restylane • Viscosity • Lyft • Silk • Reversible vs Non‐reversible • Radiesse • Sculptra • Intended Depth of Injection 15 Fat Transfer/Grafting • Pros • Cons • Your own tissue • Less predictable growth • Living graft • Potential for asymmetries • Ample supply • Possibly difficult touch‐ups • Permanent • Permanent 16 8 Facial Implants • Previously used much more widely for midface • Advent of injectable fillers and desire for more control of volume deficient area has led to decline in use for midface • Chin implants still an excellent choice for microgenia (small chin) 17 Soft Tissue Drooping • Loss of elasticity in skin • First sign is often seen in upper eyelid skin • Loss of strength of attachments of skin and deeper soft tissue structures to bone • ‐special skin‐to‐bone ligaments that give support to the soft tissues • Effects of gravity 18 9 Fighting Gravity: Addressing Drooping Soft Tissues • Limited role for fillers to help suspend soft tissue (liquid facelift) • Surgery is gold standard • Eyelid skin drooping: Blepharoplasty • Jowls, neck sagging, deep nasolabial folds, marionette lines: Facelift/Necklift • Eyebrow/forehead descent: Brow Lift • Ear lobule reduction 19 Surgery • Facelift • Brow/Forehead Lift • Blepharoplasty (eyelid surgery) • Neck Lift • Chin Implant 20 10 Facelift • Most definitive way to address the descent of facial and neck soft tissues due to aging • Many different “styles” of facelift (mommy lift, weekend lift, minilift, etc), mostly distinguished by placement of incisions and extent of dissection • Best results for facelift occur when done with neck lift as face and neck are one unit • Gold Standard: Deep Plane Facelift 21 Neck Lift • Addresses: • Sagging of Skin • Banding of Muscle • Excess Fat Under the Chin • Performed by working through facelift incision and adding small incision below the chin • Tightens the loose neck muscle and skin • Allows removal of excess fat 22 11 Brow/Forehead Lift: aka “Upper 1/3 Facelift” • Why address it? • Improve tired, angry, or “RBF” expressions • Improve visual field • Improve forehead or eye fatigue • Goals of Brow Lift: • 1. Elevate brow to youthful level and “open up” the eyes • 2. Surgically weaken muscles that push the brow downward • 3. Smooth out the forehead 23 Blepharoplasty (Upper and Lower Eyelid Surgery) • Another procedure to rejuvenate the tired, heavy appearing eyes • May involve removing: • Excess skin • Protruding fat pads • Thickened muscle • Results in: • More youthful and open appearing eye 24 12 Chin Implant • Improve facial harmony • Ease transition to jowls • Support soft tissues • Sharpen neck angle • Make a large/prominent nose look less so 25 Other adjunct or stand‐alone procedures available • Kybella • Microneedling • Platelet Rich Plasma (PRP) • Growth factors and cytokines isolated from blood • Reinjected in area of interest to promote healing/rejuvenation 26 13 Functional Problems Related to Aging of the Face • Visual field obstruction • Eye fatigue • While driving, reading, watching tv • Due to: • Drooping brow, and/or • Excessive, droopy eyelid skin • Workup includes visual field testing in office • Treatment: • Brow Lift • Upper Blepharoplasty • Often covered by insurance as a medically necessary procedure 27 Hair Restoration • “Framing the Face” • By age 35, 2/3 men and women • Medical Therapy have some degree of appreciable • Rogaine (minoxidil) hair loss • Propecia (finasteride) • Low Level Laser Light Therapy • By age 50, 85% will have hair loss • Platelet Rich Plasma (PRP) • Hair loss and thinning may be • Surgical Therapy: Hair Transplant associated with aged look beyond • Strip Harvest (Follicular Unit Transfer) one’s years • Follicular Unit Extraction (FUE) • i.e. NeoGraft, Artas robot, etc. 28 14 29 In Summary… • There are many options available for rejuvenation of the face • The best approach is to create a custom plan for the individual patient that provides the most natural and sustainable look • Questions? • Call me at 903‐747‐4098 • Christopher A. Perro, MD, FACS • 2210 Three Lakes Pkwy, Ste. 100 • Tyler, TX 75703 30 15.