Jowls

One of the signs of the aging face that people object to is jowling. The jowls are areas of fullness along the jawline that tend to increase with age. The straight, strong jawline of youth is gradually replaced by the soft, irregular jawline of the aging face. It is thought that jowls result from the combination of muscle, skin and fat that all begin to sag with age. An area known as the pre-jowl region is located directly in front of the jowl. It is thought that a ligament (the mandibular ligament) attaches the skin to the bone in this region, creating a depression in front of the jowl. Because the ligament doesn't stretch with age, as the howl increases in size with age, the pre-jowl depression becomes deeper and deeper, making the jowl look even bigger.

There are several ways to treat the jowls, both surgical and non-surgical. Surgical options include mainly facelifting and liposuction. During a facelift, the facial soft tissues are pulled upward and backward, thereby raising the jowls upward above the jawline so that they don't hang over the jawline. Adding a mid-face lift may improve things even further, since the mid-face lift pulls the facial soft tissues vertically, raising the jowls even higher above the jawline to hide them even more than with just a facelift alone. These procedures don't remove any jowl tissue, they simply reposition the jowls.

Another surgical option is a facial implant. These pre-jowl implants are similar to chin implants, but the part of the implant over the chin itself is paper thin. The implant then flares out to thicken in the pre-jowl area. The implant minimizes the jowl by filling out the depression that forms in front of the jowl, in the area of the mandibular ligament. With this implant, the jowl is not repositioned or removed, it is simply camouflaged.

Recently, another surgical option has been developed, although the jury is still out on this one. Various suture suspension techniques have been developed over the last few years in an attempt to minimize downtime. Names such as Featherlift and Threadlift have been bandied about in the media for the past few years. There is very little long-term data on these procedures at this time. At a recent plastic surgery conference in Palm Springs CA, the consensus among the surgeons in attendance was that it was too early to tell what role these suture suspension techniques would play. However, it was apparent that the techniques may be appropriate for younger individuals who want a minimal procedure that may last less that a year.

Liposuction, which actually removes some of the jowls, can be performed in conjunction with a facelift or it can be performed as a stand-alone procedure. Many surgeons feel that repositioning alone will not completely eliminate the jowls. These surgeons feel that the jowls need to be reduced in size somewhat in addition to being repositioned. However, liposuction needs to be performed carefully in this region with a very small cannula (1.5 to 1.8 mm diameter) because it is easy to cause irregularities and ridges if this area is liposuctioned too aggressively. Some surgeons use scissors to directly remove the jowls during a facelift, in an attempt to avoid irregularities from liposuction.

Non-surgical options include fillers, Thermage and mesotherapy. Of these, fillers have the longest track record. Any number of fillers can be used, including collagen, Cosmoplast, Restylane, Radiesse and fat. While none of these fillers is permanent, Radiesse and fat potentially last the longest. With the recent FDA approval of Radiesse, this is becoming more and more popular to treat jowling. With any of these fillers, the principle is the same: the filler is placed in the pre-jowl area in order to camouflage the jowl, similar to the pre-jowl implant.

Like the suture suspension techniques, the jury is still out on techniques such as Thermage and mesotherapy. Thermage uses a radiofrequency device to melt the fat and mesotherapy uses a "cocktail" of various ingredients injected into the jowl to melt the fat. The body then absorbs the fat and the skin then shrinks and tightens, theoretically.

Many surgeons, including myself, use a combination of techniques. During surgery, I will often perform a combination of a facelift, midface lift and jowl liposuction. After that, I will inject Radiesee into the pre-jowl area to fill the depression. In the months and years after surgery, I will inject Radiesse every year or so to maintain volume in the pre-jowl area. There may be a role for such things as mesotherapy or Thermage for maintenance, but I am waiting for more solid data before I proceed with these modalities.

Marionette Lines

The lines that extend down from the corners of the mouth toward the chin are known as marionette lines. The marionette lines tend to deepen with age and they give the appearance that one is frowning. Some people have a strong tendency to have marionette lines, even at a young age, whereas some people never develop them. Surgical procedures like facelifts are notoriously ineffective in treating marionette lines.

The most commonly used method to treat marionette lines is to simply fill the lines with a substance known as a "filler". In the past, fillers such as fat, collagen and Cosmoplast were used. Today, fillers such as Restylane and Radiesse are more commonly used, since these fillers last much longer than most of the other fillers previously available. A five minute injection of Restylane can minimize -- or eliminate -- marionette lines. Repeat injections are performed at six to nine months. With Radiesse, repeat injections are necessary at twelve months. Microinjections of silicone, considered controversial by many physicians, is also sometimes done. Finally, permanent implants are sometimes used in this area as well. Implants made of Gor-Tex are sometimes done, but these implants can sometimes be visible or palpable.

I have found that Botox injections can be quite helpful in the treatment of marionette lines. Certain muscles, called the depressor muscles, can pull the corners of the mouth down and contribute to the downward slant to the corners of the mouth, which then leads right into the marionette lines. By injecting Botox into the depressor anguli oris muscle, the corners of the mouth go up slightly, and the n marionette lines are diminished. Typically, with this regimen, the patient will come into the office every three to four months for Botox injections and every six to twelve months for a filler, depending on the type of filler (Restylane v. Radiesse).

There are a few rarely-done surgical options that are designed to address the corners of the mouth directly. A corner lip lift involves cutting a small triangular piece of skin away from the corners of the mouth in an attempt to give an upturn to the corners. However, the scar can be objectionable and the corners can look unnatural. An ever rarer procedure involves cutting the depressor anguli oris muscle in order to deactivate it (like the Botox injections do). But most surgeons feel that the risks out weigh the benefits for this procedure.

Anastasia Oscar Spa

Anastasia hosted her second annual Oscar Spa on Wednesday, March 1 and Thursday, March 2 at her home in Beverly Hills. Anastasia spa is arguably the most private and exclusive of the increasingly popular pre-Oscar spas, because it is held at her secluded home in the hills, unlike most of the spas which are held in public places like hotels. Because of this privacy and exclusivity, Anastasia attracted the likes of Oprah, Nicolette Sheridan, Eva Longoria, Kelly Preston, Debra Messing, Teri Hatcher the very first year she hosted the Oscar Spa. Of course, most of these people are Anastasia's regular clients as well and they were happy to support her new endeavor.

This year, Anastasia expanded the Spa, so that virtually every room in her house her house was devoted to a different service -- hair and makeup, pedicures and manicures and, of course, eyebrow sculpting by Anastasia. A new addition to the Spa this year was Twin Magic. Jimmy and Daniel performed eyelash extensions after Anastasia finished with the guests' eyebrows. Between treatments, guests lounged by the pool and were served lunch. Attendees this year included Lauren Sanchez, Catherine Bell, Amber Valetta, Garcelle Beauvais, Debra Messing, Molly Sims, Angela Bassett and Jessica Alba.

2005 Cosmetic Surgery Statistics

The 2005 American Society for Aesthetic Plastic Surgery (ASAPS) Statistics on Cosmetic Surgery were released on March 2, 2006. The ASAPS consists only of surgeons certified by the American Board of Plastic surgery and these surgeons must have extensive cosmetic surgery experience and must meet certain ethical standards.

Here are some facts:

1. There were 11.5 million surgical and non-surgical procedures performed in the US last year.

2. Since 1997, there has been an increase of 444% in the total number of cosmetic procedures.

3. The top five surgical procedures were:
(a) Liposuction -- 455,489.
(b) Breast augmentation -- 364,610
(c) Blepharoplasty (cosmetic eyelid surgery) -- 231,467
(d) Rhinoplasty -- 200,924
(e) Abdominoplasty (tummy tuck) -- 169,314.

4. The top five non-surgical procedures were:
(a) Botox injections -- 3,294,782
(b) Laser hair removal -- 1,566,909
(c) Hyaluronic acid injections (Restylane) -- 1,194,222
(d) Microdermabrasion -- 1,023,931
(e) Chemical peels -- 556,172

5. Women accounted for 91.4% of the total

6. Eighty percent of patients were Caucasian, 9% Hispanic, 6% black and 4% Asian.

7. For breast augmentation, 83.4% of implants used were saline and 16.6% were silicone.

Endoscopic Browlift

Forehead lifts (or browlifts) are an important part of overall facial rejuvenation. There are several types of browlifts, including coronal, anterior hairline, direct, suprabrow and endoscopic. With the exception of the Endoscopic Browlift, all of the other methods require fairly extensive incisions (coronal browlift and anterior hairline browlift) or incisions that are located in fairly visible locations direct browlift and suprabrow browlift). The coronal incision is located several inches back from the hairline, but the scar goes from ear-to-ear. The anterior hairline incision runs along the length of the anterior hairline, where the forehead meets the scalp. The direct browlift incision runs from one side of the forehead to the other. This technique is usually reserved for older patients with extremely deep forehead creases. In these cases, the scar will usually blend in with the other deep creases on the forehead. The suprabrow browlift involves incisions located directly over the eyebrows and is also often reserved for older patients with deep forehead creases. Because of the extent and visibility of the incisions with these more traditional browlifting methods, patient acceptance was quite low. This limited patient acceptance

In the mid-1990's, the Endoscopic Browlift was developed. The endoscopic browlift is a form of minimally-invasive surgery, where the incisions are quite small and, therefore, are relatively imperceptible when they healed. The endoscopic browlift became the preferred methods for many plastic surgeons, because patients were much more willing to accept five small incisions hidden in the hair, as opposed to the much larger and more visible incisions of the other methods.

The technique involves four or five small (less than an inch) incisions placed an inch or two behind the hairline. The forehead tissues are freed up from the bone, allowing the tissues to be moved upward. Various methods are used to keep the forehead tissues in place once they are lifted. Methods of "fixation" include titanium screws, absorbable screws and other methods. I have been using, for the past few years, a method of fixation known as the Endotine Method. The Endotine device is an absorbable, triangular device that has five tiny spikes (or "tines") on the top and a post on the bottom. The post is secured to the bone and the scalp is pulled up and placed firmly on the tines, thereby keeping the brow lifted. The Endotine devices dissolve in about six months, but by that time the tissues have healed into place and they stay where they are at that point, even thought the device has dissolved.

Minimally-invasive browlifting methods like the Endoscopic Browlift have led to much greater patient acceptance, and refinements like the Endotine Device has further improved the success rate with the Endoscopic Browlift. In the past, it was not uncommon to see a patient with a tight face, but with a brow that was droopy. This was because many patients simply did not want the large scar of the coronal browlift. Today, it is rare to see that "disconnect" between a youthful face and an aged brow.

Endotine Browpexy

Although the endoscopic browlift was a tremendous advance in browlifting, there were still a group of patients who preferred not to have any scars on the scalp, since they had thinning hair or had no hair at all. In general, male patients with male pattern baldness are quite hesitant to have any scars at all on the scalp. Even the tiny endoscopic scars were too much for many men. For these patients, the Endotine Browpexy is the perfect procedure. The browpexy differs from the browlift in that in the browpexy, the eyebrows are raised only slightly and then fixed into place at this modestly higher location. With the browlift, the eyebrows are usually raised more than with the browpexy and fixed into place at this significantly higher location.

In 2005, the Endotine Browpexy was introduced and I have been very happy with the surgical results, especially in male patients, since no scars are needed in the scalp. The procedure is performed in conjunction with upper eyelid surgery (upper blepharoplasty), since nearly everyone that needs a brow procedure also needs an upper eyelid procedure). The browpexy is performed through the upper blepharoplasty incision. After the upper blepharoplasty is completed, the Endotine Device is fixed to the forehead bone just under the outer part of the eyebrow. The brow skin is lifted up and placed firmly on the small spikes ("tines") on the Endotine Device. The brow remains elevated at this position, even after the Endotine Device dissolves in a few months.

Although the Endotine Browpexy is commonly-used in both men and women, I have found it particularly useful in men. Most men do not want a dramatic browlift, and the browpexy, by definition, only provides a subtle lift. This, combined with the fact that men are hesitant to have scalp scars, makes the Endotine Browpexy an excellent procedure for male browlifting.

Eyelid Fat Transposition

Puffy lower eyelids can be due to any number of anatomic factors. The eyelid is made up of several anatomic layers, including skin, muscle and fat. Any one of these structures can contribute to puffy lower lids and any or all of these structures may need to be addressed surgically in order to eliminate puffy lower eyelids. Of course, other factors such as allergies, lack of sleep, salt intake and alcohol intake can all contribute to puffy eyelids. These things cannot be addressed surgically.

For decades, the standard method of performing lower eyelid surgery (or lower blepharoplasty) involved making an incision in the skin just below the eyelashes. Excess fat, muscle and skin was removed and the incision was closed with stitches. The scar is almost invisible. With this method, however, it was not uncommon to see too much skin removed, resulting in the lower eyelids hanging like a hound dog's.

About twenty years ago, a method of lower eyelid surgery known as transconjunctival lower blepharoplasty became popular. The "transconj bleph" involved making an incision on the inside of the lower eyelid, eliminating the need for a skin incision. The transconj approach gave access to the fat only, however. The skin and muscle could not be addressed from this approach. To get around this limitaion, plastic surgeons began doing a "skin pinch" to get rid of any extra skin of the lower eyelid. Small forceps (resembling small tweezers) are used to "pinch" the skin, so that is stands up in the air. This extra skin is then cut off using scissors. The incision is then closed with stitches and, as with the standard blepharoplasty described above, the scar virtually disappears. Another advantage of the transconj approach: there was less scar tissue that formed during the healing process, since the muscle was not touched at all (only the skin and fat).

A potential disadvantage of the two procedures described above is the accidental removal of too much fat (or skin). If too much fat is removed, the lower eyelids begin to look hollow, which is not a youthful look. A youthful eye has just the right amount of fullness, somewhere between puffy and hollow.

In the last several years, a procedure known as lower Eyelid Fat Transposition has become very popular. As the name suggests, the lower lid eyelid fat is not removed, but it is transposed, meaning that it is shifted from one location to another. Many people that complain of dark circles actually have a problem known as a deep nasojugal groove. This groove extends from the corner of the eye near the nose and extends toward the cheek. Because a shadow tends to fall in this groove, it appears as a "dark circle." Instead of removing any fat, the fat is simply slid down (transposed) into the nosojugal groove and secured into place with stitches. This technique preserves the fullness of the youthful lid, but takes some of the fullness and simply puts it where it is needed.

I have been performing this procedure for the last several years and the results are excellent. There are still many situations where removing fat or muscle or skin are appropriate, of course. But in general, the trend is toward removing less and less fat from the lower eyelid.