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Introduction to Facial Aging

Several factors affect aging of the face including heredity, one’s health, environmental exposure (sun and wind, smoking, et al.) As we age, some predictable changes occur in the face and neck and these changes can be classified into three general types, each best improved by a particular treatment approach.

The three manifestations of facial aging include;

  1. Sagging of skin and soft tissues (fat and muscle)
  2. Volume loss in the mid and upper face with concomitant increased fullness in the lower face (jowls)
  3. Superficial changes of skin pigmentation and texture.


Progressive sagging of skin and soft tissues (fat and muscle) due primarily to loss of elasticity and gravitational pull can create jowls, deepened skin folds and wrinkles, muscle bands on the neck, and puffiness on the eyelids. The various surgical lifts (face, neck, eyelid and brow/forehead) are designed to correct these problems by repositioning and firming up the saggy tissues and, thus, creating a more youthful, refreshed look.

Volume Loss

Age-related volume loss in the mid and upper face is due to fat atrophy and leads to a sunken-in appearance in the cheeks and temples. The typical youthful face is somewhat triangular with fuller features in the mid and upper face. As volume decreases, these areas deflate, sagging increases, and soft tissue fullness shifts to the lower face and jaw line creating a more squarish shape to the lower face. The appreciation of age-related volume loss in the mid and upper face and recent attempts to recreate the fullness of a youthful face represent the newest trend in facial rejuvenation.

Superficial Skin Changes

Environmental-induced superficial skin changes include darker skin pigmentation (blotchy sun and age spots) and roughened skin texture (leathery and fine lines scattered primarily around the lips and chin). Although heredity certainly plays a role in how the skin ages, the environmental effects of chronic sun and wind exposure and smoking are significant causes of these changes. Various types of chemical peeling, laser resurfacing, and dermabrasion can help improve skin appearance and create a more youthful complexion. In some cases, home skin care programs are also helpful in improving skin pigmentation and texture.

Every person ages differently and each person’s face will manifest varying degrees of these three general types of facial aging. At your consultation, Dr. Schwartz will listen to your concerns about what bothers you. He will then examine and analyze your face and neck, and discuss his recommendations for a customized treatment plan to help you look your best.

Face Lift

A face lift (rhytidectomy) is an operation that corrects the signs of facial aging related to loose, saggy skin and soft tissues, such as jowls, wrinkles, deepened folds, neck bands, double chin, etcetera. By lifting and firming up what has drifted downward, the surgeon can recreate the characteristics of a more youthful, vibrant face including a straighter jaw line, sharper and firmer contour to the neck and smoother cheeks. Today’s face lift often includes fat removal from the neck and various techniques to tighten the deeper muscles layers of the face and neck. The newest trend in facial rejuvenation surgery stems from an appreciation that the youthful face has a more triangular shape with more fullness in the upper cheeks. As we age, due to sagging and fat atrophy, the mid and upper cheeks often become flattened and depressed, while the lower face becomes fuller and wider, essentially reversing the triangular youthful shape. The latest technique in facial rejuvenation involves adding fat or other fillers to the upper cheeks to recreate that youthful fullness. This can be done at the time of the face lift or by itself.

Eyelid Surgery

Poets have called the eyes the windows to the soul. They are certainly one of the most expressive parts of the face. If your eyes have lost that refreshing sparkle of youth and are looking tired and old, then consider eyelid surgery to give you back that rested, vibrant look. Two common aging signs around the eyes include loose stretchy skin that forms folds and wrinkles and the bags or puffs of fat that bulge outward. A blepharoplasty is a relatively painless operation performed under local anesthesia with IV sedation, which removes the protruding fat and extra skin folds, thereby creating a smoother, more youthful appearance for your eyes. The scars are hidden in natural skin lines. It’s important to realize that the so-called crow’s feet or smile lines are caused by the movement of your facial muscles and respond much better to Botox® Cosmetic injections than surgery. Also, the fine crisscrossing aged texture lines of the eyelid skin may require chemical peeling or laser resurfacing to improve. These treatments can often be combined to create a total rejuvenation of your eyelids.

Brow Lift

As with other features of the face, the eyebrows may sag with age. Eyebrow sagging can contribute to a tired look by causing the skin and fat just below the brow to fold over the eyelid. Indeed, some patients think they need upper eyelid surgery when the real culprit is their loose, saggy eyebrows. A brow lift elevates the eyebrows into a more youthful position, thereby opening up the area above the eyes and creating a more vibrant appearance. Dr. Schwartz’ goal is always to create a natural look. We can also remove portions of two small muscles between your eyebrows to soften any frown lines. The horizontal creases across the forehead cannot be completely eradicated, as they are caused by the contraction of the muscle that raises your eyebrows and are part of normal expression. However, these lines can be significantly diminished with Botox® Cosmetic injections. A forehead lift is performed through one or more incisions in the scalp, where the scars are hidden, or at the hairline (in patients with an already high hairline). In a male patient with deep forehead creases, we may occasionally place the incisions there, so the final scars appear just like natural expression lines.

Nasal Surgery

The nose is one of the most prominent features of the face, a feature that makes an impression by itself, as well as by the way it balances the rest of the face. The structure and characteristics of a nose must be considered in relation to one’s other facial features. People sometimes complain about their nose being too big, too long, too wide, the tip too boxy, bulbous or dropping, etcetera. The nose may have developed that way or become misshapen after a nasal fracture. Surgery of the nose (rhinoplasty) involves making changes to the underlying nasal skeleton, the bones and cartilage that support and shape the nose. The newer open (external) rhinoplasty technique allows the surgeon to directly visualize these skeletal structures and to be much more precise in reshaping them. Rhinoplasty is always performed as same-day outpatient surgery, usually under general anesthesia, with the patient wearing a splint over their nose for one week.

Regarding facial balance, keep in mind that a small chin can accentuate the nose, making it seem larger, so that placement of a chin implant to add more prominence to the lower face will create better facial harmony and a more attractive profile.

Ear Reshaping

Protruding or prominent ears is a congenital condition that can cause emotional distress for children as well as adults. Patients often relate that their child has complained of teasing from classmates and has asked them if their ears can be fixed. Adults sometimes express annoyance at having to wear their hair long to camouflage large ears. An otoplasty is performed to set prominent ears back closer to the head or to reduce the size of overly large ears. The surgery involves sculpting or folding ear cartilage into a new shape, and all work is done from behind the ear so the final scar is hidden. The goal of an otoplasty is to create a more normal-appearing ear that looks natural.

Laser Skin Resurfacing

Many changes of facial skin create an aged, weathered look. These include multiple lines, a rough texture, dark pigmented spots and a sallow complexion. If these problems are too severe for the milder skin peels, micro dermabrasion and home skin care programs to correct, then laser resurfacing can help. The various lasers use intense light to vaporize and remove the older, more superficial skin cells, allowing the deeper cells to form a new, healthier skin covering. This procedure has significantly replaced the older techniques of dermabrasion and deep chemical peels. Laser resurfacing can create a smoother, more youthful complexion.

Lipstick bleed lines around the mouth are best treated by this technique. Depending upon the severity of your problem and the type of treatment, healing may take 1-2 weeks. After healing, a pink color gradually fades away over several weeks to a few months. Depending on the depth of treatment, the skin may appear lighter due to some pigment loss. The newer Fraxel laser uses a different technology that allows quicker healing, often in only five days, with negligible color change. Although the recovery is quicker, the degree of improvement in skin texture and pigmentation is more modest than with a stronger laser treatment, so Fraxel treatment is often more appropriate for younger patients with earlier, minimal aging changes.