Who hasn’t dreamed of ‘getting a little work done’? It is so tempting to get rid of those undereye bags, crow’s feet, or flabby neck. Heck, maybe an entire facial overhaul is in order! But hold on: Dreaming is one thing, doing is another. There is much to consider—recovery time, costs, doctor choice, goals—before you can turn the idea of facial fixes into a reality.
[fabulous & natural]
So, can you really have too much of a good thing when it comes to cosmetic facial fixes? The consensus, among both docs and the public, is: heck, yeah! If the mouth struggles to convey human expression and the eyes can’t close comfortably, something is wrong.
common pitfalls
The key to a natural look following cosmetic surgery is an adequate combination of skin removal, skin tightening and volume positioning, says Dr. William G. Hart Jr. of Hart Cosmetic & Reconstructive Surgery Institute. “You want to avoid the windblown look, like your face is in a wind tunnel,” he says. “Patients who have too much tension in the tissues have an unnatural smile, and in some cases are unable to close their eyes adequately. This look may result from the patient’s insistence on a taut face or from over-aggressive work by the surgeons.”
the right balance
“A natural look involves repositioning of fat or adding volume through fat injections or the use of injectable hyaluronic acid derivatives,” Hart says. “Also, there should be tightening of underlying structures, including the platysmal bands (neck muscles), some auxiliary glands, if necessary, and the SMAS , the sub-muscular aponeurotic system.”
The SMAS is the layer of tissue that covers and attaches to the deeper structures of the face and neck. “In most situations where patients following a face-lift or blepharoplasty have an ‘operated on’ look, it results from having too much skin or fatty tissue removed from around the eyes and/or face,” Hart says. “Another contributing factor is the amount of tension placed on the skin.”
back to basics
A natural-appearing face results when the surgeon starts with the foundations, says Dr. Mike Nayak of Nayak Plastic Surgery in Frontenac. “We have to rebuild from the inside out to create a young structure. We shape the foundational portions the way they are supposed to be, and then the skin follows that new shape,” he explains.
Hart agrees. “A face-lift should result in a relaxed look with good support in the underlying soft tissues,” he says. “The region below the chin should be smooth without excess skin or banding.” The placement of incisions can make the surgery appear more or less obvious, he notes. “A straight-line scar in the pre-auricular area (in front of the ear) is a dead giveaway to a face-lift.” The incision line should be tucked under the ear, where it touches the side of the face, and then hidden behind the ear, Hart says. “The scar should follow the natural curvature of the ear.”
Banding of the neck muscles is another tell-tale sign that a face-lift has happened, he says. The platysma is a sheet of muscle that extends vertically from the upper chest to the chin and cheek. Over time portions of this muscle can become prominent and protrude, leading to the ‘turkey neck’ appearance.
skin deep
Skin care before and after surgery can optimize results, says Dr. Michele Koo. “The eyelid skin is one of the first structures to show signs of stretch and damage, and therefore aging,” she says. “Most people neglect the eyelid skin. Continued skin care after surgery can optimize the surgical results.”
Also, she advises, check the references of plastic surgeons. “Always make sure you see your surgeon’s ‘before and after’ results and talk to his or her former patients. Read the reviews. Surgery should replace tissues to their former state, creating a soft, natural, rested appearance rather than over-resecting the skin to cause an unnatural, shortage-of-skin appearance,” she says.
[eye-catching]
A glance at the eyes tells others so much about us: how we are and what we are thinking. The eyes also reveal precisely how long we have lived. Fortunately, we have a few tricks up our sleeves that can fool Mother Nature.
windows to the soul
“Our brains are hardwired to look at the eyes and the mouth, and studies of preverbal infants have found that they follow eye movements,” says Dr. John Holds of Ophthalmic Plastic and Cosmetic Surgery. We continue to focus on the eyes for nonverbal clues throughout life. “As our faces age, there are very distinct chronologic changes in anatomy,” Holds says. “They vary from person to person, but many of these changes are predictable and we can use them to predict age.”
the inexorable march
As the face ages, muscles and skin sag, and fat deposits, which once kept the eyelids smooth and youthful, move or diminish. “Eyelid aging typically begins around 40 to 45 years of age. There is usually excess fat protrusion in the upper and lower eyelids. Lower eyelid bags and upper eyelid fullness and heaviness create the appearance of fatigue,” says Dr. Michele Koo. “There also can be dark circles around the lower eyelids from the pressure of the fat on the skin.”
“Everyone has some amount of eyebrow sagging,” Holds says. “In the upper lid you lose some fat volume below the eyebrow, and the contour starts to hang over.” The lower eyelid may sag far enough to expose some of the eye itself. The shape of the eyelid changes, the fat pads drop and the ’tear trough’ at the inner corner becomes more pronounced.
slowing the hands of time
The aged look can be delayed, Koo reassures. “The eyelid skin is very thin and more subject to sun damage, allergies and the aging process. One of the best safeguards is to use sunglasses and sun protection. Also use good facial sunscreens and eyelid-specific lotions. “And Botox for the crow’s feet around the eyes is another method to ward off aging,” she says.
Additionally, surgery techniques have evolved. “In lower eyelid surgery the concept was that you cut skin, muscle and fat out to create a concave lower lid, which sometimes is a reasonable approach,” Holds says. “But that can give you a hollow, skeletonized look that actually makes you look older.”
Now surgeons replace lost volume with repositioned fat or dermal fillers. “It is an individualized thing,” Holds says. “You have to look at the patient’s age and the amount of volume loss.”
bad genes/good genes
Eyelid surgery is not always prompted by aging. “Some people have lower eyelid bags due to redundant muscle and excess fat from a very young age, which can be a hereditary trait,” Koo says. Younger people can be the best patients, says Dr. Holds. “They otherwise have very good skin elasticity, so we are able to correct the underlying defect, such as an excess of fat or tissue, whereas with aging you have a whole constellation of issues.”
botox or surgery?
Botox injections around the eyes may reverse deep creases that make the eyelids appear heavy and aged, Koo says. “I suggest surgery, however, when there is too much skin in the upper eyelids and too much fat protrusion of the lower lids,” she explains. “There are people who have eyes that look old compared to the rest of their face, but when we look at facial rejuvenation we have to look at a bigger assessment and decide if this person also needs a face-lift or some other treatment,” adds Holds. Costs vary with complexity, but upper or lower eyelid surgery may be $3,500 to $7,000; together they can range from $7,500 to $10,000.”
[firm & focused necks]
don’t take your lumps!
“A heavy or full neck is like an overstuffed pillow,” says Dr. Mike Nayak of Nayak Plastic Surgery. “You can do everything you want to the cloth cover layer, but unless you get underneath and move the lumpy stuffing around, it is not going to look good. The skin is just the wrapper that takes the shape of what’s underneath.”
But plastic surgeons early in the 20th century didn’t know this. They used a simple approach to loose necks: pull the skin up around the ears, snip off the excess and apply some sutures. The modern neck lift deals with layers of tissue and correcting muscle, fat and sometimes the salivary glands and lymph nodes.
A neck lift derives its name, platysmaplasty, from the platysma muscle that covers the lower face and neck. “To get a really nice neck, you need to begin at the foundation, reshape those layers so they are in the shape of a young neck, then drape the skin over it at the end,” Nayak says.
southbound
As the neck ages, every tissue joins the journey south. “The muscles that come across the neck can stretch with age and separate,” says Dr. Bruce Kraemer of SLUCare and Saint Louis University School of Medicine. “We sometimes have a little fat collection under our chins after the middle years, and the sub-mandibular glands can hang down. And the jowl descension starts: That’s when the cheek fat pads that used to give us nice apple cheeks move down.”
Neck tissue aging begins “when you’re born!” Nayak says. “But some people have a great neck until they are in their 60s or 70s, some from the time they are teenagers have an ill-defined neck.” And it’s an equal-opportunity problem. “Some guys accept it a little more gracefully than women, perhaps, but when you look at those pictures from your 20s and 30s, you see that nice, sharp angle. Then in your 40s and 50s, it isn’t there anymore,” says Kraemer.
the solution: surgery
“There are almost no non-surgical options to improve the shape of the neck,” says Nayak. But if you’re not quite ready for the complete fix, a new procedure, ‘cool sculpting,’ might help with fat removal, according to Kraemer. “There are special pads that freeze the fat under the skin and have it resolve slowly,” he says.
Once you commit to having a neck lift, other issues might need to be addressed the surgeons point out. “It is usually not just one area that has aged,” says Kraemer. “If we are taking fat out of the neck area, we may want to graft it into the cheeks because they are sagging. It can make for a nice, qualitative change.”
let’s talk numbers
A neck lift may take up to two hours in the operating room for a young person, Nayak says. An older patient may require more structural reshaping and a surgery lasting up to four hours. As for costs, liposuction of the neck may begin around $1,000 or $1,200, the doctors say. A simple neck lift may be $6,000, while more complex or combined cases may cost $10,000 to $15,000.
Recovery can last up to three weeks, Kraemer notes. “There will be a little bruising,” he says. “The patient will wear a neck support—a strap that goes under the chin—to hold the skin in place. We may want them to be on a lighter-chew diet and not talk a lot.”
