In fact, J. William Little, M.D., suggests that what is far more important than smoothing the nasolabial fold, for example, is restoring the underlying volume and architecture of the face.
He presented his views on the topic of facial rejuvenation — or what he calls sculptural rejuvenation — at Plastic Surgery 2005, the recent annual meeting of the American Society of Plastic Surgeons."Shape trumps surface," says Dr. Little, clinical professor of surgery at Georgetown University, who is also in private practice in Washington, D.C. "The important aging changes are not surface-based. I still want to treat the nasolabial lines and wrinkles, but they are nowhere near as important as the architecture of the face."
Contours of youth
Dr. Little likens desirable facial architecture to what an artist thinks of as an "inverted cone of youth." The wider end of the cone represents a younger person's fuller cheek and submalar volume, while the cone's narrow end represents a sleek lower face and jawline. As we age, the cone shape turns right side up, and facial volume settles into the jowl (wider end of the upright cone) and diminishes to visibly bony architecture at the eye sockets and cheekbones (narrow end of the upright cone).
Taken from an oblique view, that desirable inverted cone of youth has a curvilinear shape, whereby the upper part is wide and full, or convex, and the lower end is empty, or concave.
"I strongly believe that to accomplish anything worthwhile in this complex project we call facial rejuvenation, we must restore the concave quality of that lower zone. We must totally eliminate the jowl," Dr. Little says.
Eliminating the jowls
Dr. Little's preferred technique for doing this "is completely contrary to the whole development of facelifting over the past 20 years. That has focused on deeper planes of surgery in which a glut of tension could be developed and held for a long time, often with permanent sutures," he says.
Rather, he performs an external jowl lift by freeing the skin from the underlying fat to the extent of the commissure. He lifts and secures the subcutaneous plane with multiple, fine sutures that are absorbed within six to eight weeks. He says the tissue elevation is retained in place by wound healing.
He says that, unlike a traditional facelift, his facelift moves the jowl in a purely vertical direction and the lifting does not create tension in the jowl.
"There is nothing pulling fat down — except gravity — because it has been freed from its overlying cover of skin. (The fat being pulled only by) gravity will take 10 to 15 years to show signs of re-aging."
With the external jowl lift or vertical subcutaneous plication, Dr. Little may then choose to further refine the jaw and remove 1 mm to 3 mm or more of additional dense fat that cannot be liposuctioned.
This fat removal "is very powerful in reshaping that part of the face."
To address the upper areas of the aging face, Dr. Little often finds that performing an external jowl lift achieves the desired facial curve, and no further surgery is necessary.
For patients who have flat cheek areas but are hesitant about deeper surgery, he performs structural fat grafting to the region. If still more fullness is desired, the fat grafting can be repeated six months after surgery.
For a well-motivated patient who has advanced signs of aging, Dr. Little says a mid-facelift is an appropriate addition. Tissue lifted subperiosteally from low in the face is held in place by a single absorbable suture, which results in a fuller curve to the upper cheek and an overall significant improvement in architecture.