Achieving A Youthful Natural Appearance
WRITTEN BY BORIS ACKERMAN, M . D .
PUBLISHED BY SKIN DEEP WORLD

Contrary to popular belief, a tight face is not synonymous with a young face. Indeed, outdated procedures that simply tighten or lift the skin often result in patient disappointment and frustration.Today, facial rejuvenation surgery entails much more than simply cutting excess or loose skin. With the help of a qualified plastic surgeon, successful facial rejuvenation surgery can result in a youthful natural appearance.

Choosing A Plastic Surgeon

Successful plastic surgery depends on a surgeon with proper experience, technical skill, aesthetic vision and innate talent. For this reason, choosing a proficient plastic surgeon is the top priority when considering any cosmetic procedure. Initially, patients should obtain referrals from their family physician, relatives, friends and/or other acquaintances in appropriate social settings.

Patients should consult with multiple--at least two or three--board-certified plastic surgeons certified by The American Board of Plastic Surgery. Ensuring satisfactory certification is just the start, however. Ultimately, you will want to choose a surgeon with an excellent reputation for producing successful results each and every time.

Patients should also ask to see multiple photographs of a surgeon's previous work. Likewise, patients should feel free to bring old photographs of themselves that reflect an idea of their expectations. While nothing is guaranteed, the surgical expectations of a particular patient are often clarified through old photographs. Combined with the surgeon's aesthetic talent and trained eye, old photographs serve as the foundation for a youthful outcome.

Figure I A Typical patient in her mid-fifties who shows signs of uniformly distributed aging present throughout the entire face. She is shown after undergoing a full face lift, which addressed all of the individual facial subunits. Note the naturally balanced youthful appearance.

Successful Facial Rejuvenation Surgery

Figure 2
A male patient in his late forties who underwent a full face lift which rebalanced the facial proportions. This resulted in a not only more youthful, but a more aesthetically appealing appearance.

Figure 3
This patient in her early seventies demonstrates a great degree of skin elasticity breakdown and other aging components typical of a patient in this age group. She underwent a full face lift with laser resurfacing performed simultaneously.This allowed for a remarkable rejuvenating effect of the facial structures and correction of intrinsic loss of skin elasticity.

SUCCESSFUL FACIAL REJUVENATION SURGERY

Modern facial rejuvenation surgery spans a large gamut of procedures. Many patients fail to realize that a facelift is not a single procedure. In fact, the term "facelift" implies many different things depending on both the patient's needs and the surgeon's skill and talent level.

Appropriate candidates for facial rejuvenation surgery include both men and women who want to look naturally younger. Historically the typical face lift patient would be a woman in her fifties. (Fig. 1). In the present day this can include patients in their 30s, well into the 70s.

Because each face is unique, successful facial rejuvenation can require one or several approaches. Initially, a skilled surgeon will conduct a thorough analysis of the patient's current anatomy. In addition to focusing on the actual look of the face, a comprehensive analysis considers proportions of fatty layers, muscle layers, boney tissues and other aspects of facial aesthetics. Keep in mind that a talented surgeon addresses all components of aging--not just the skin. The surgeon will listen to the patient and envision what a patient's face might have looked like 10, 15 or 20 years ago.

After analyzing the face, the surgeon will determine the best procedures to reach the end goal. Some facial components may need to be repositioned or re-contoured, while others may need to be resurfaced, tightened or lifted. Although making a patient look younger is often the top priority, a talented surgeon will also make a patient's face more balanced and aesthetically pleasing overall. (Fig. 2)

A natural, youthful appearance is achieved only by knowing how to apply specific surgical maneuvers and instruments to the detailed anatomy of the face. Facial rejuvenation surgery entails procedures that address specific facial areas, including:

• Contouring of the upper and/or lower eyelids
  
• Repositioning of fatty layers
  
• Suturing and tightening of muscle layers, including not only the so called SMAS layer of the cheeks, but the muscles of the eyelids, as well as the various muscle layers of the neck
  
• Resurfacing of the skin with sophisticated laser technology (Fig. 3)
  
• Recreating youthful contour and fullness

But, once again, the result is not entirely dependent on the surgical removal of excess skin. A talented surgeon must always keep in mind the vision of a youthful facial contour. On occasion, achieving such a vision includes adding volume or fullness to replicate a younger face.

Endoscopic Facial Surgery

Endoscopy entails the use of small incisions through which specialized surgical instruments, including a miniature camera, are inserted. Magnified images of internal facial structures are then transmitted from the camera to a viewing screen, where the surgeon can clearly view the surgical site almost as if a larger incision had been made. Endoscopic facial surgery generally results in decreased bleeding, bruising and swelling, and may allow for a quicker recovery than does open surgery.

Endoscopy has long been used in orthopedic and gastrointestinal procedures. Improved technology now allows endoscopy to be used successfully by trained plastic surgeons. Although the use of endoscopic surgical techniques in plastic surgery has significantly evolved over the last 10 years, endoscopy is still a relatively new technique. For this reason, it is extremely important to select a board-certified plastic surgeon with ample training and experience in endoscopic surgery. (Fig. 4)

Despite the advancement of endoscopic surgical techniques, certain patients may nevertheless require more involved skin incisions. A talented surgeon will make incisions nearly invisible by hiding them in natural skin folds and by ensuring that they follow the naturally occurring ear contours. If done correctly, the hairline will not be distorted. The distortion of the hairline and sideburns is one of the telltale signs of a facelift. (Fig. 5)

Figure 4
This rather young patient wished to regain some of her youthful appearance. She underwent endoscopic face lift with some adjunct procedures. Note that the patient has a more youthful, rested appearance.

Figure 5
Before and after photograph of a patient in her mid-forties with some premature signs of aging.She underwent a full face lift which addressed all of the structural elements of her aging. Note, that there are not tell-tale signs of surgery and no unnatural tightness of any of the facial structures.

Outcome/Recovery

The outcome of surgery is almost entirely dependent on the surgeon and his or her surgical maneuvers. Directly related to any successful surgical outcome, however, is the manner in which the patient is prepared prior to surgery. A thorough assessment of a patient's general physical health is crucial. While high-risk patients--including those who smoke or those with diabetes or compromised cardiovascular health--are capable of being operated on, the surgeon must be ready to deal with all potential problems. The Board Certified plastic surgeon should also honestly evaluate and counsel such high-risk patients regarding the risk/benefit tradeoffs for facial rejuvenation.

For all patients, the surgeon must be aware of how individual tissues respond to surgery and healing. To ensure optimal healing, patients are placed on a specific regimen of high quality vitamins, including Vitamin C, Vitamin B complex, and on occasion Vitamin A. They are also instructed on the use of some homeopathic remedies, such as Arnica and Bromelain. Often the patients are also started on proper skincare preoperatively. This can include anything from moisturizer with sunscreen to retinoic preparations and fruity acids. Careful and thorough post-operative care should ideally include frequent visits to assess healing, specialized bandages, further homeopathic remedies and/or occasional oxygen treatments.

While recovery times vary, patients can generally go back to work within one or two weeks after surgery. Patients will most likely require some form of coverup makeup to hide residual bruising or discoloration. Before planning any important social engagements, patients should keep in mind that recovery can take up to a month or longer.

Serious complications are quite rare. Nevertheless not uncommonly I see patients that were operated on elsewhere, that are dissatisfied with the results. This is not due to some specific complication, but as a result of either unmet or unvoiced expectations, minimal improvement in their appearance, or due to significant disharmony of their facial appearance after the procedure. With proper analysis, planning and care, even these patients can be helped with corrective surgery to rejuvenate their face and recreate the youthful harmony.