The Aging Face: Analysis, Surgical Approach, and Result Assessment

I recently heard a retired professor of plastic surgery offer a critique on a presentation showing preoperative and postoperative photographs of attractive young women who had undergone “rejuvenative” surgery. He remarked that in his opinion many of these women would have been better served by going on a fabulous vacation rather than going to the operating room. The point was well taken, but a dilemma still exists—what are the indications for surgery of the aging face? Indications to change acquired or congenital anatomy are more straightforward. Surgery such as rhinoplasty or otoplasty change rather fixed anatomic structures particular to each individual. Rejuvenation of the aging face is an entirely different matter. In contrast to rhinoplasty or otoplasty, no one needs surgery for “aging” changes when young. In its early stages, the onset of aging is insidious, making a discussion of indications for its improvement difficult. However, every human undergoes similar aging changes and every part of the human face reflects these changes. I approach each face lift candidate with the following philosophy: Everyone ages in a similar way. Although individual variations exist, such as the amount of neck fat or eyelid skin, we all undergo congruent progressive changes from youth to old age. Every part of the aging human face undergoes topographical changes that reflect changes in the deep anatomic structures—primarily a downward descent that is observed when one is in the upright position. These deep structures, or “pieces” of the aging face are inherent anatomic structures common to all. To effectively and harmoniously rejuvenate the aging face, the plastic surgeon must reposition these multiple structures to their original youthful position. Excess tissue such as neck fat and muscle or upper eyelid skin must also be removed. In short, all movable components of the aging face must be surgically repositioned to achieve a harmonious appearance. Limited surgical techniques that alter some, but not all, of the components will produce a disharmonious appearance, such as when a face lift is performed without a neck lift. This imbalance can become more obvious with further aging. The question then arises, what are these changes, and what should be the goal of rejuvenative surgery? If a photograph of the patient when young is available, the youthful contours one strives to create will be demonstrated. Better still, if a female patient has a daughter with similar facial characteristics, her multiple photographic views can be compared to those of her mother. In Figure 1, the photograph of a 51-year-old patient demonstrates every sign of the aging face. A, This 50-year-old patient has all the signs of an aging face. B, Topographical areas of the aging face showing changes common to everyone. C, Positional changes of underlying deep anatomical components are responsible for changes in each area of the aging face. The aging forehead and frown lines are caused by soft tissue ptosis and corrugator muscle activity. The youthful upper eyelid contour is obliterated by excess upper eyelid skin, muscle, and fat. A wider and deeper orbital appearance is caused by orbicularis oculi ptosis, whereas infraorbital fat under a distended septum orbitale creates an irregular contour and a more obvious bony orbital anatomy. This skeletonization of the periorbital appearance is progressive and absolutely constant in everyone. Congenital excess of orbital fat creates a more distinct infraorbital rim. The ptotic inferior border of the orbicularis oculi may create a “malar crescent” or malar bag deformity on the malar eminence. A deeper nasolabial fold is created by ptosis of the cheek fat. The jowl or broken jawline is created by ptosis of the facial portion of the platysma muscle. The youthful cervical angle is lost with aging cervical platysma changes. Excess cervical subcutaneous fat further obliterates a youthful contour. If one accepts that the signs of aging are created by progressive changes of deep anatomic components, the surgeon's goal must be to effectively change the position or character of each of those deep pieces of anatomy to create youthful contours of each part of the face. The technique used to accomplish these goals in this patient (Figure 2) is a composite rhytidectomy, 1,2 in which the orbicularis oculi, cheek fat, and platysma remain in a composite flap and are repositioned while maintaining their original intimate relationship to each other. The orbital fat was preserved and repositioned over the infraorbital rim. A, Multiple areas on the surface of the face must be changed to reflect a youthful appearance. B, Each improved area of the aging face was rejuvenated by repositioning underlying deep structures. C, Orbicularis oculi, cheek fat, and platysma are repositioned in a composite face lift flap. The orbital fat is repositioned after arcus marginalis release. The result (Figure 3) of this complete rejuvenation can be compared with the facial anatomy of this patient's young daughter, whose youthful facial contours serve as the “end point” or standard of the surgical goal. Brow, jawline, and neck contours of the mother compare favorably to those of the daughter. Note in particular the youthful contour of the mother's orbit and midface. A, The postoperative results of the 50-year-old mother can be compared with her 21-year-old daughter. Of particular significance is the more narrow and more shallow orbit and the improved nasolabial fold, which are comparable to that of the daughter. Brow level and neck contour of the daughter are guidelines for the mother's rejuvenated face. Forehead lift procedures are well known and usually include corrugator muscle removal. I use an open technique, but an endoscopic approach is gaining in popularity, although I believe results are too early to judge. Conventional upper lid blepharoplasty is more accurately done in conjunction with a forehead lift because the ptotic brow contributes to upper eyelid skin excess. Orbicularis oculi repositioning (Figure 4) elevates the inferior border of the muscle from its ptotic position on the malar eminence. 3–10 The inferior border of this muscle is not altered with conventional lower lid blepharoplasty. Therefore if a “malar crescent” or malar bag deformity was present on the upper cheek area before conventional face lift surgery, it will be there after surgery and appear even more obvious because the surrounding tissues may appear smoother as a result of the skin redrape. Orbital fat (Figure 5) should be preserved 11–15 because removal will create a deeper orbit and more obvious skeletonization. Repositioning orbital fat after release of the arcus marginalis is a permanent way to obscure the infraorbital rim and avoid the sunken appearance that usually occurs when orbital fat is removed (Figure 6). Congenital excess of orbital fat may be removed transconjunctivally, but this should be done in the young patient only with no signs of facial aging. The cheek fat (Figure 7) must be repositioned to improve the nasolabial fold. Techniques that elevate and reposition the fat, 16–18 or release the SMAS, 19–21 will improve the fold. Removal of fat will cause an irreversible contour distortion of the aging face. Techniques that fill out the nasolabial crease with various injections or implants may help soften the crease but have no effect on the ptotic cheek fat. The nasolabial fold improvement should be compatible with the total rejuvenation (Figure 8). Skoog 22,23 was the first to describe deep tissue repositioning to improve the jowl or broken jawline (Figure 9). SMAS techniques,24 which are all modifications of platysma repositioning, will also create a smooth jawline, but in time these techniques leave a more obviously unimproved nasolabial fold (Figure 10) because the cheek fat is not repositioned. A straight jawline from platysma repositioning (Figure 11) must be accompanied by improvement of every area of the aging face, or disharmony will occur. The cervical contour (Figure 12) is improved by modifying the fat and cervical platysma muscle. 25–29 Many techniques have been described with similar goals—leaving an even layer of subcutaneous fat and suturing the midline muscle borders. Excess muscle in the midline can be removed. If an aging chin is present, it must be corrected 30–35 (Figure 13) to prevent the ptotic chin from becoming obvious in an otherwise total rejuvenation (Figure 14). The orbicularis oculi must be elevated so that the inferior border can be repositioned. This “tightens the sphincter” and gives a more narrow youthful orbital appearance. Removal of orbital fat will create a deeper orbit. Preservation and repositioning of the orbital fat over the orbital rim will create a more shallow orbit under a repositioned orbicularis muscle and prevent skeletonization of the orbit. A and B, Preoperative and postoperative views of a patient who has undergone brow lift, composite rhytidectomy, and orbital fat repositioning. C, Front view of the preoperative face shows the wilder orbit of the aging face. D, Postoperative anatomy after orbicularis repositioning is a narrower orbital soft tissue appearance. E, Lateral preoperative view is necessary to evaluate debth of the aging orbit. F, The postoperative view with fat preservation and midface rejuvenation creates a more shallow orbit. The cheek fat must be repositioned to improve the nasolabial fold. A, Preoperative patient with significant nasolabial folds. B, Postoperative composite face lift and brow lift. The nasolabial fold is compatible with the appearance of the straight jawline and narrow shallower orbit. The postoperative position of the cheek nevus demonstrates the superomedial advancement of the inferior border of the orbicularis oculi muscle. The facial portion of the platysma muscle or the SMAS must be repositioned to correct the jowling or broken jawline. A, This patient had a conventional face lift 3 years previous. The ptotic midface appears incompatible with the improved jawline. B, Postoperative view after composite rhytidectomy. Note improvement in the nasolabial folds and the periorbital rejuvenation, bringing the face back into balance. Preoperative and postoperative views of a 50-year-old after composite rhytidectomy, brow lift, and rhinoplasty. Repositioning of all deep structures is necessary to create youthful contours of the face. A straight jawline is compatible with other areas of the rejuvenated face. The excess platysma in the midline has been excised and the anterior borders sutured together. If excess fat is present, it is removed from the cervical flap. The aging chin is corrected without tissue removal. A vest-over-pants mentalis-to-platysma closure will obliterate the submental crease without skin removal. Preoperative and postoperative view of a patient with total facial rejuvenation. The chin and neck contour must be compatible with the rejuvenated face. The results of facial rejuvenation have always been subjective at best. Both surgeon and patient are usually happy with almost any improvement. Preoperative and postoperative photographs may be examined for result assessment, but improvement has usually been judged by looking at the face as a whole rather than at each individual component. Makeup, lighting, and momentary positional changes of the forehead and neck tend to prevent standardization. The surgeon's eye is trained to judge what is traditionally obtainable. Newer techniques produce contours not heretofore seen. For example, for decades surgeons accepted “substandard” results from conventional reduction rhinoplasty; more recent innovative techniques created contours now considered both desirable and obligatory because they are obtainable. Side-by-side photographs may be impressive, but areas such as the midface, which is not improved by conventional SMAS techniques, are frequently overlooked in the assessment of the total face. For a plastic surgeon to judge the results of any facial rejuvenation, the preoperative hemiface and the postoperative, same-side hemiface should be matched. In this way, each specific area of the face can be more accurately assessed. The preoperative and postoperative results of the patient shown in Figure 6, C and D, can better be judged with a same side, hemifacial comparison (Figure 15). Here, the results of surgery on the forehead, periorbital areas, and midface can be matched and accurately assessed. The neck and chin are evaluated in lateral view, but these results are easy to obtain with conventional techniques. It is possible to compare the mother in Figure 3 to her daughter, but in the final analysis, only the matched hemifaces of the mother (Figure 16) will help the surgeon best determine if his or her goals were met. Only by repositioning these multiple components can the surgeon maintain harmony of the face. Surgeons can use whatever techniques they prefer, but the position or character of all the pieces must be altered to achieve optimal results. Preoperative left and postoperative left hemiface 1 year after composite rhytidectomy. Result assessment of forehead and periorbital midface and jawline changes are easily seen and evaluated. Preoperative and postoperative views of the mother allow accurate result assessment if one side is compared to itself placed side by side. The composite rhytidectomy meets the criteria as a technique that can reposition the three important anatomic components of the midface. Many surgeons have stated that a subcutaneous rhytidectomy, SMAS, or extended SMAS will achieve the same result. 36–39 Others believe that lifting the skin first, then the underlying structures (bidirectional lift) 38,39 provides results superior to the one-flap composite rhytidectomy. These views are anecdotal because no evidence is offered that a procedure that does not alter the midface components produces results comparable to a technique that repositions the three significant structures. The problem is that we have never been able to objectively assess face lift results. Without universal and objective criteria, we can only claim advantages for the personal techniques we prefer. Surgeons should be encouraged to demonstrate their results, using same-side hemiface comparisons because each patient is his or her own standard for result assessment. Published photographs of face lift patients confirm that conventional SMAS face lifts do not influence the midface structures. Conventional face lifts consistently leave the midface, the area between the corner of the eye and the corner of the mouth, with minimal if any improvement. This imbalance can easily be corrected during secondary rhytidectomy if the midface anatomy is repositioned (Figure 17). The midface of patients undergoing conventional face lifts will always be disharmonious with the improved lower face area. In many instances, this appearance is what the public subconsciously recognizes as an unnatural anatomical arrangement. This unattractive appearance—iatrogenic in origin—may, in fact, influence potential patients not to have rejuvenative surgery. A, Preoperative photograph in 1985. B, Patient in 1986 after conventional blepharoplasty and rhytidectomy. The lower eyelid skin is smoother but the periorbital appearance is just as wide and deep as before surgery. C, Patient in 1995, 10 years after conventional face lift. The periorbital area appears even wider with progressive aging of the midface and forehead. D, Patient in 1996 after composite rhytidectomy, brow lift, and arcus marginalis release. The harmony of the face has been regained. Compare the youthful orbital appearance to the 1985 photograph. The combination of conventional lower lid blepharoplasty and conventional face lift creates an appearance inconsistent with features of a normal human face—the empty lower eyelid and unimproved midface combined with a youthful jawline and neck contour. This appearance is pathognomonic of an “operated” face. In my opinion, it is more normal and appealing to see a totally unoperated aging face, or an operated face, in which every area has been significantly improved and balance maintained. Conventional blepharoplasty removes orbital fat and smoothes the skin cover, leaving a deeper and still wide orbital appearance (Figure 18). The inferior border of the orbicularis muscle is not changed. Transconjunctival fat removal with laser or chemical abrasion also leaves a deeper and perhaps wrinkle-free lower eyelid, which is not a youthful contour and is particularly obvious in an otherwise unoperated aging face. “Laser blepharoplasty,” fat removal and wrinkle ablation results in exactly the same appearance that surgeons have obtained for many decades using a phenol peel after blepharoplasty. The results are initially exciting, but in time the patient's sunken appearance may make both surgeon and patient wish that the fat was never removed. A, The youthful orbit is shallow and narrow. B, The aging eye orbit becomes wide and deep. C, Orbital fat removal leaves the wide appearance only deeper. (From Hamra ST. Orbital fat preservation in aesthetic facial surgery. Clin Plast Surg 1996;23:17, used with permission.) As newer techniques evolve, results must be judged over the long term. Early edema is the great imitator of exciting results, but only with the passage of time do the true results become manifest. Good results obtained by repositioning anatomic structures during a primary procedure should be present many years later (Figure 19). A, 1983; preoperative view. B, 1984; after conventional blepharoplasty and rhytidectomy. C, 1990; 7-year postoperative view. D, 1991; 1 year postoperative composite rhytidectomy and lower blepharoplasty. Note periorbital narrowing and improved midface. E, 1995. There is little change in the repositioned orbicularis and cheek fat after 5 years. The characteristics of the aging face are common to all humans, and everyone has the same anatomic components that undergo these changes. Every “piece” of the aging anatomy should be identified and surgically altered to achieve a harmonious rejuvenation. Every trained surgeon is capable of changing every component in the aging face using varied techniques, and his or her results can best be assessed by comparisons to contours of youth, long-term results, and, most importantly, the use of same-side hemiface photographic comparisons.