What is Face and Neck Rejuvenation?
Our body image is the dynamic perception we have of our body. Alterations to our body image, either congenital or acquired over a lifetime, can cause significant distress. Like the disproportionate development of the nose or ears during puberty, the changes in tissues during aging can cause much suffering for some people, even though aging is a good thing.
Face and Neck Rejuvenation is dedicated to all those who suffer from deformity and disfigurement and seek an opportunity to improve their appearance and restore function. The skills of the Aesthetic Surgeon in helping Cosmetic Surgery patients, as illustrated in our services, can be translated to helping those such people.
Face and Neck Aging, What Happens?
Facial aging is the result of the complex interplay between the body skeleton, facial retaining ligaments, soft tissues envelope, facial fat compartments, and the overlying skin elasticity. As a result of the many anatomic components involved in facial aging both genetic and extrinsic factor.
The genetic factors are fixed. Gravity is responsible for a lifetime of downward pull upon facial tissues, and, coupled with a loss of ligamentous support and localized fat collection, results in skin redundancy and loss of smooth facial contours.
Perceptions of facial attractiveness are largely founded on the work together of the eyes, nose, lips, and cheeks. The midface conveys a heart-shaped appearance, with the malar eminence serving to frame the features within the inverted facial triangle. Youthful cheeks are high and round. Overhead light reflects off the skin and accentuates the zygomatic arch, and the transition zones—under the eyes and between the cheeks and nose—are smooth and uninterrupted, without the hollows or shadows that will later characterize the older face.
Around the fourth decade of life, things begin to change; nearly every aesthetic unit in the midface begins to lose homogeneity. Skeletal changes in the face occur predictably in the orbital rim and maxilla; the next increase in orbital aperture, in combination with a shortened vertical maxilla, results in a so-called collapse of bony support for the overlying tissues, much like a cloth draped across an ever-shrinking table.
Retaining ligaments attenuate, while deep and subcutaneous fat pads atrophy and shift down. In the epidermis, cellular function deteriorates, with a decrease in dermal collagen and elastin, leading to skin that is dry, lax, and finely wrinkled.
Extrinsic factors can be altered and include excess sun damage, smoking, a healthy diet, and exercise. Rejuvenation of the face should be tailored to the individual by improving the patient’s overall health, addressing the health of the skin, and possibly using adjunctive surgical procedures to enhance beauty. For smokers, the single most effective method of improving one’s health (including the skin) is to stop smoking. For “sun lovers,” it is old news: excessive sun exposure damages (burns and dries out) the skin. The goal of facial cosmetic surgery is to improve and refresh the appearance of the face without any signs of obvious surgical intervention after healing is complete. Visually, damage to collagen and elastin fibers produces rhytides, pigmentation, and irregular skin texture.
The key is to do a thorough facial analysis and show the degree of ptotic descent and volume loss, so that a comprehensive treatment plan may be developed. The most natural results may occur by using a balanced approach that appropriately addresses the person contributing components of facial aging
My Approach to Face and Neck Rejuvenation
Facial aging reflects the cumulative results of multiple intrinsic and extrinsic factors over time on deep structural components, soft tissues, and the skin, and its effects in the face and neck are undeniable. Because these changes are multifactorial in etiology and occur across different tissue layers—bone, fat, dermis, and epidermis—treatment requires a 3-dimensional approach. Clinical experience shows that combining multiple aesthetic therapies targeting multiple aspects of the aging process provides optimal results, with greater overall efficacy and a higher level of patient satisfaction.
A 3-dimensional treatment approach with combination therapy in face and neck rejuvenation reflects a greater understanding of the complicated, multilayered process that occurs over time, with bony remodeling, atrophy of soft tissues, and deterioration in the condition and appearance of the skin.
Combined treatments for facial rejuvenation are in high demand and are often performed together on the same day. Although there are no guidance in facial aesthetics, clinical data show a high level of efficacy and patient satisfaction when combining therapies and this makes sense: treating the whole area of the face and neck, from the bony structure and loss of volume to skin laxity and surface irregularities, targets multiple aspects of aging for understandably better outcomes.
Prof. Moawad is a true believer in combination approach to face and neck rejuvenation. His experience in clinical practice is that many rejuvenation techniques can be joined safely. A combination approach often produces the best outcome for the patient seeking skin neck rejuvenation. Prof Moawad used a combination of these procedures for nonsurgical rejuvenation. With no guidelines in place and evidence for the safety of most procedures in any order, a stepwise approach to combination therapy is subject to individual preference and clinical experience.
In our beauty-centered culture, where life is fast paced and people are rapidly judged as regards their appearance, the face is frequently the focus of anxiety, especially in people who have attained a certain stage in their lives. Job competition, interpersonal relationships and physical well-being are reasons that many times motivate the patient to come to the plastic surgeon, seeking for a more youthful look.
The surgeon should understand that the purpose of any procedure for the aging face is to help the person cross with enhanced self-confidence the sometimes-difficult path to a mature age, and not to return the patient to an earlier stage of life.
Experience is necessary to investigate and appreciate these subjective motivations. This evaluation requires both empathy and openness towards the patient.
In the last few decades, facial aesthetic surgery has undergone enormous progress, with a greater understanding of anatomy and the development of newer technology and products that complement the operation.
The surgeon must be knowledgeable in details of different surgical approaches and variations thereof to attain the best result for each individual case. Ancillary procedures present the surgeon with a vast array of surgical and nonsurgical techniques that should be used in an individualized way, as each patient presents differences not only in anatomy but also about regional complaints.
A satisfactory outcome of an aesthetic facial procedure is obtained when signs of an operation are un-detectable, and anatomy has been preserved. Visible scars and dislocation of the hairline are among the most common complaints and everything should be done to avoid these stigmas.
Volumetric sculpturing of the lower two thirds of the face and neck is the contemporary attempt to beautify the facial appearance which has been called for many decades classic face lift
Using the SMAS to reposition sagging deep facial tissue allows the skin to be re-draped under normal tension, which preserves normal skin function and results in a natural appearance. Healing of skin incisions is without tension. Preauricular natural contours are preserved. In addition, using the SMAS extends the longevity of a facelift.
The main point for choosing the technique is a careful preoperative examination of the anatomical structures of the face and neck, to evaluate the flaccidity of the platysma muscle and the adiposity in submental and submandibular regions. Achieving a fresh and natural look, safely, with minimal risks and without visible scars, is the key goal of all facial rejuvenation surgery. Some of the unfavorable stigmata of rhytidectomy are visible scars, earlobe malposition, distortion or flattening of the tragus, superiorly or posteriorly displaced hairlines, and unnaturally directed wrinkles (lateral sweep) caused by lateral vector tightening of the lower face with downward and inward sagging of the midface.
I would like to refer to a face lift as surgical facial rejuvenation, as I feel the word “face lift” is confusing to both the patient and surgeon. It is also a misnomer. It is very difficult to divide the face into zones as all the anatomy is interlinked and interdependent. In modern surgery today, one tends to combine more than one procedure, both surgical and nonsurgical, so it is more appropriate to name it Surgical Facial Rejuvenation.
Surgical treatment of eyebrow position can harmonize the facial expression. Very often we can see the asymmetric position of eyebrows owing to unilateral hyper-action of the corresponding m. frontalis. This can be corrected through grasping more frontalis fibers on the more elevated side.
If one eyebrow is positioned too deep, it can be elevated by a unilateral endoscopic procedure. In bushy male eyebrows, the asymmetry can be reached by asymmetric direct skin excision more over the lower eyebrow.
Today’s trend is “less is not more but very often more than enough”. Or to use a German saying: “Enough is better than too much.” We should operate on eyelids as conservatively as possible. For lower blepharoplasty the special “no-touch technique” has been developed. “No touch” is related to the orbicularis oculi muscle and its innervation. Access to the infraorbital herniated fat should be done trans-conjuctivally – through a 1-cm-long incision parallel to the lower eyelid rim and 3 mm below it.
The fat pads could be repositioned or carefully reduced. The excess skin should be removed superficially without touching the fibers of the orbicularis oculi muscle from both sides
The nose is also a central organ in formative art: when sculptors create a bust, the nose is often “set” first. In the human energy field, the nose has a central position from where vibrancy emanates and decreases in concentric circles. The sensors for intuition are assumed to be in the nose.
Apparently, they lie on the mucous membrane above the juncture between the triangular and quadrilateral cartilages. It would seem plausible not to injure these sites with the scalpel during surgical corrections to the nose.
The nose has a special significance within our civilization. Noses misshapen as a result of accidents, fights, or congenitally draw remarks from the environment of the affected person which are often very offending. It is quite understandable that only very resistant personalities can withstand this emotional stress. Especially with adolescents up to the age of 25 years, whose social and emotional standing has not yet established itself, the mirror and the critical look returned from it play an important role. Work and family are admittedly a distraction from this problem in later life; the psychological pressure can sometimes be so great, however, that the person in question decides to consult a plastic surgeon.
Given the universal meaning of the nose, it is understandable that mentally ill people also project their neurotic problems onto the nose. However, the surgical correction of the nose of a person with an untreated psychosis can have disastrous consequences for both sides.
Nose corrections are arguably the most delicate of all aesthetic operations. The surgical technique is difficult, and the intraoperative view is restricted. What is required is absolute anatomic accuracy, spatial sense, dexterity, and the gift of shaping the nose, as well as a sound psychological understanding. It is no rare occurrence that a latent psychopathologic problem is projected onto the nose.
The development of the ear is virtually completed by the age of five, when operative measures can be undertaken. If the parents want the operation, then – according to some authors – it may be assumed that the child also wants. This will avoid possible emotional damage to the child from teasing. Some surgeons, however, prefer to wait until the children themselves are aware of their deformity and develop a positive motivation for the operation. One should surgically correct this deformity by the time of puberty if the children are bothered by it.
Only humans have exposed lip redness to imitate visible mucous membrane. This phenomenon does not exist in primates as they use direct sexual signals opposite from humans, who communicate and mostly copulate frontally owing to an erect gait.
Only carps (fresh water fish) and humans have such a small mouth compared with their face size. I have done many lip enlargements but only in female patients – none in male patients. I have done some lip reductions but only in male patients – none in female patients
For lip enlargements there are numerous fillers, which provide a simple and inexpensive method. Nowadays we have the very reliable method of fat injection which gives stable results for years without allergic or foreign-body reactions.
Genioplasty is a type of surgery done on the chin. Both plastic surgeons and maxillofacial surgeons (surgeons who work on the mouth and jaw) can do this type of surgery. Genioplasty is most often a cosmetic surgery, meaning people choose to have it for looks and not because of a medical problem.
A “witch’s chin” is often a problem in elderly women. It is prominent in a frontal and caudal direction. To reduce it we make a spindle-like skin excision including skin in front and behind the submental skin crease. Then we remove a slice of mental subcutaneous connecting and fat tissue if liposuction alone is not enough to reduce the chin volume sufficiently.
Over the last decade there has been an exponential increase in the number of new nonsurgical procedures that are designed to rejuvenate the aging neck. Most of them are marketed as being minimally invasive with no down time, yet at the same time providing maximal safety and effectiveness. A popular example includes the use of radiofrequency energy for skin tightening. Applying thermal energy to the dermis is thought to stimulate new collagen formation, which will ultimately result in skin contraction.
Vibro-lipolysis represents another recent innovation that is believed to help with skin tightening through mechanical vibration, while at the same time enhance the sculpting effect of liposuction.
Even Botulinum Toxin Type A has been used to diminish the appearance of unsightly platysmal bands. Another procedure that has received much attention in the realm of neck rejuvenation is mesotherapy. This involves the injection of strategically placed small doses of phosphatidylcholine and deoxycholate (with or without additional homeopathic ingredients) to dissolve fat.
While all these procedures may have some role in neck rejuvenation it is clear that the literature supporting their efficacy and durability is not mature. Just as important is the fact that these procedures do not address the problems of bulging subplatysmal fat or provide effective long-term solutions for age-related changes of the platysma and submandibular glands.
Prof. Moawad provide his approach to treating age-related changes of the neck. Even though these patients present with a wide variation of abnormalities, he prefer a simplified approach to stratify the patients to undergo either micro-cannular liposuction, or some form of submentoplasty, with or without rhytidectomy Prof. Moawad have found that an excellent aesthetic outcome that is durable can consistently be provided.
The sudden explosion in recent years of non-surgical rejuvenate techniques is patient-driven. The modern patient, man or woman, desires quick, safe and predictable nonsurgical techniques that will confer some form of facial rejuvenation and at the same time allow them to get back to work or their social lives with a minimum of downtime. By that is meant a modicum of bruising and swelling for 2–3 days (i.e., over a weekend) and not the 2–4 weeks of downtime and scars that often accompany open surgical techniques.
Whilst nonsurgical techniques are not a substitute for traditional rejuvenate surgery, the combination of several nonsurgical tools and procedures has become a powerful adjunct to or a temporizing substitute for open surgery. Aesthetic medicine comprises all medical procedures that are aimed at improving the physical appearance and satisfaction of the patient, using noninvasive to minimally invasive cosmetic procedures. These aesthetic procedures consist of:
- BOTOX injection
- Fillers injection
- Fat injection
- Chemical peels
- Non-surgical skin tightening
- Energy-based technology for photoaging
- Mesolift and platelet-rich plasma (PRP)
Certain wrinkles are primarily caused by facial movement. Others are caused by other factors as well as a component of animation. Therefore, if a wrinkle or unattractive shape is as least partly caused by muscular action, it can be treated with BOTOX; however, how well a specific unaesthetic area responds to treatment with BPTOX injection depends on how much of the unattractive area is caused by factors other than animation.
Aging of the skin, particularly that of photoaging, is readily apparent to both patient and practitioner and a common reason to visit a cosmetic physician. Because the pathologic process of photoaging is primarily limited to the epidermis and upper dermis, it is readily amenable to treatment with a wide variety of lasers and light sources. In 2014, over a half a million-laser skin resurfacing procedures were performed in the United States.
Minimally invasive procedures to tighten and lift skin give natural results with minimal risk and recovery time. Monopolar radiofrequency devices deliver a high frequency electric current (volumetric heating) to the deep dermis and underlying tissue at, with concomitant surface skin cooling. The resulting heat leads to immediate collagen contraction and a delayed wound healing response, with new collagen formation up to 4 to 6-month post-treatment. Similarly, micro-focused ultrasound selectively heats the superficial musculoaponeurotic system SMAS) and, stimulating long-term collagen remodeling and producing subsequent tissue tightening and lifting without any damage to the epidermal surface.
There is a variety of vascular, pigmented, ablative, and non-ablative resurfacing lasers, which all may help with skin rejuvenation of the face, neck, and hand. Ablative technology, long considered the gold standard in skin resurfacing, has largely been replaced by nonablative modalities that direct thermal energy to the reticular dermis and subcutis, where immediate tissue contraction and delayed remodeling are believed to cause collective tightening and lifting of the skin.
Intense pulsed light (IPL) is a non-ablative, broadband light source that emits a continuous spectrum ranging from 500 to 1200 nm in the dermis, selectively destroying targeted chromophores by wavelengths and pulse duration. Intense pulsed light is used for the treatment of photodamaged skin, reducing both lentigines and vascular lesions, such as telangiectasias, port-wine stains, and poikiloderma, and improving skin texture.
Volume Restoration (Fillers & Fat Injections)
Rejuvenation of the aging face has undergone significant transformation over the past 20 years. Collective understanding of the physiologic forces of aging on skin, soft tissue, and facial bony structures has permitted the development of various surgical and nonsurgical treatments to correct or limit these effects. Further, increased understanding of the importance of volume restoration in facial rejuvenation has improved the results of interventions and addressed a critical part of aging that was before ignored. Although almost all aspects of facial plastic surgery have much evolved during this time, restoration of the face and neck has been particularly rewarding for most surgeons and patients.
In the facial region, our improved understanding of the volumetric changes in fat and bone tissue that occur with the passage of time has revolutionized our conception of facial rejuvenation. The aim today is not just to correct sagging facial tissue but also to restore the volume lost areas to reconstruct a rejuvenated facial contour and to improve tissue quality. In many cases, fat and its stromal vascular fraction are key components of treatment
In the midface, these manifestations of aging are treated with a combination of soft-tissue fillers to bolster structural support and replace lost volume; skin tightening devices to improve laxity; and lasers and light-based therapies, along with topical cosmeceutical products, to reduce fine rhytides, improve surface texture and hyperpigmentation, and brighten the skin.
Two elements are critical in the morphologic appearance of the aging face: volume loss and homogeneity of the skin’s texture and tone. Replacing volume through soft-tissue fillers provides instant gratification and often corrects deficits in adjacent anatomical regions without need for further injections.
Soft-Tissue Fillers Injectable hyaluronic acid (HA) is one of the most popular fillers on the market due to its ease of use, ability to produce natural-looking results with a low incidence of adverse reactions and the additional benefit of reversibility, in the event of product misplacement or overfilling. Other agents that provide substantial support and are appropriate for deep implantation include 2 stimulatory fillers that induce neocollagenesis, calcium hydroxylapatite and poly-L-lactic acid, and autologous fat.
The clinical applications of adipose tissue have undergone a remarkable expansion in recent years. For their part, face lift techniques have evolved significantly and are now able to avoid the signs associated with the classical approaches. They now involve moderate dissection of tissues to allow fat transfer in the central areas of the face. There is also a growing tendency toward a combination of techniques, making it possible to meet results that are both more natural and more complete.
The loss of subcutaneous fullness results in pan-facial deflation, the results of which were previously attributed solely to skin redundancy and descent. Recognition of this volume loss and its effects has resulted in a paradigm shift in our understanding and treatment of facial aging. Surgeons can no longer simply excise or reposition tissue in a superior vector and claim to have achieved a true restoration. Aging is a three-dimensional process and must be treated as such.
There are many possible techniques and approaches to make effective facial rejuvenation. To ignore either the gravitational descent of the soft tissue and fat pads or the loss of facial volume will lead to consistent sub-optimal results.
Exposure to ultraviolet light—particularly inevitable in the mid-face—hastens and exacerbates these changes for skin that is deeply lined and rough, with mottled hyper-pigmentation.
One of the most important components of any anti-aging treatment plan is topical skin care. A basic skin care regimen includes a cleanser, moisturizer, and sunscreen. Moisturizers that contain beneficial ingredients are called cosmeceuticals and can be used to improve skin tone, texture, radiance, hyper-pigmentation, pore size, fine lines, and wrinkles.
Skin radiance can be enhanced with the appropriate cosmeceutical regimen. Topical retinoic acid (tretinoin) is the gold standard topical treatment for the clinical signs of photo-damaged skin. The daily use of a broad-spectrum sunscreen protects against the damaging effects of UV exposure, which hastens the signs of aging and gives rise to fine wrinkles, changes in texture and tone, and hyper-pigmentation.
Antioxidants—vitamins, certain botanicals—work against free radicals and oxidative stress and have anti-inflammatory properties, reducing redness and producing visible improvements in fine lines and brightening the skin. Other additives include peptides and growth factors, which stimulate neocollagenesis for improvements in skin texture and laxity.
Treatment outcomes from lasers, chemical peels and even surgical procedures are significantly affected using skin care products. For this reason, it is essential to give patients explicit pre-procedure and post-procedure instructions about what they should and should not use on their skin.
Deterioration in the appearance of the skin may be treated with IPL, vascular or ablative lasers, and the addition of certain cosmeceutical preparations. Radiofrequency and MFU devices tighten and lift the skin.
Facial rejuvenation surgery is a young specialty. It has been around for barely 100 years, and it has known some periods of exponential development followed by prolonged times of things as they are. Every generation is tempted to believe they have reached the pinnacle of scientific development, but realistically we know that to do the ultimate goal of making patients really look more youthful, not just different, we still have a long road ahead of us. Also, our present day “state of the art” techniques will probably be outdated in another 30 years or less.
We believe that now again we are at the threshold of an era of an enormous burgeoning of innovative approaches. We are in the age of volumetric restoration and at the start of the new era of regenerative surgery and medicine. Both these concepts are disruptive, because they have generated a completely different way of contemplating and treating facial aging.
At MSI one of our principles is to give an up-to-date account of the latest in cosmetic facial surgery, as the trends and techniques seems to change with the times. We surgeons spend our lives learning and improving our techniques, honing and refining them, said Prof. Moawad. A new trend of nonsurgical solutions has been added, as now facial rejuvenation encompasses both surgical and nonsurgical.
There are many traps for the unguarded clinician that can be largely cheated with an understanding of the needs and realistic expectations of the patient. The dysmorphic and psychologically vulnerable patient must be identified and protected from their harm always. Similarly, if a surgeon can provide for an appropriately selected patient’s desire, then modern aesthetic medicine and surgical practice can be immensely satisfying and rewarding.
Facial cosmetic surgery has gained tremendous popularity in the past decade. One reason for this rise in interest is the consumer’s increased accessibility to information through television, the Internet, and other media sources. Also, the development of safe and effective surgical techniques, with reduced “downtime” and long-lasting, natural-appearing results has popularized this field.
Facial cosmetic surgeons must intimately understand facial anatomy, in addition to the anatomy and physiology of the aging process. Although some patients seek to rejuvenate their appearance to “turn back” the hands of time, others are interested in altering their appearance to a more desirable social norm.
In each area of the face, several different surgical techniques have been developed to improve the appearance; each of these techniques has its own merits.
The rationale for surgical techniques to improve the outcome and do lasting results based on facial anatomy and the process of facial aging. Ultimately, the techniques used by facial cosmetic surgeons are based on the surgeon’s preference and training and the clinical situation.