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Key Points
- Shape reversal is most important aspect of facial aging, expert says
- In preop consultation for facial sculptural rejuvenation, surgeons should request early, non-smiling photographs taken during the patient's 20s or 30s
Sensitivity to the architectural changes that define the aging face underscores the importance of jowl development and establishes correction of this feature as a primary target in surgical rejuvenation, according to J. William Little, M.D., who spoke at the American Society of Plastic Surgeons' Plastic Surgery 2010 conference.
In a two-part course on sculptural rejuvenation of the aging face, neck, eyes and mouth, Dr. Little emphasized that the focus of surgery to restore a more youthful appearance should be on facial shape or architecture more than on changes in the facial surface (folds, texture or pigmentation). He emphasized that shape reversal is the most important aspect of facial aging, typically manifested as a change from what artists might call an "inverted cone of youth" to an upright cone, or gourd-like, shape.
Since jowl formation and descent are the main culprits in causing this shift in facial architecture, a surgical technique that concentrates directly on eliminating the jowls while restoring fullness to the cheek area is a logical approach to rejuvenation, says Dr. Little, clinical professor of surgery, department of plastic surgery, Georgetown University School of Medicine, Washington.
Plastic surgeons have generally embraced this concept since the mid-1990s, as evidenced by the introduction of a variety of mid-face lifting techniques at that time. While Dr. Little was among those who developed such a subperiosteal mid-facelift (combining it with a simple subcutaneous plication in the superficial plane) and published on this technique, he has since abandoned the deep or mid-facial component, concentrating instead on the "old-fashioned" subcutaneous plication — but now with added structural fat grafting. ![]()
A 63-year-old patient before (left) and 10 months after subcutaneous placation (XJ lift) to the face, liposuction (only) to the neck, and structural fat grafting to the lids and lips, but not the face. (Photos credit: J. William Little, M.D.)
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"The correct mid-facelift presents sculptural benefits, of course. However, subcutaneous plication addresses the fatty excess of the lower face (jowls) by re-suspending the tissues directly to fill the accompanying submalar deficiency or hollow," Dr. Little says. "This becomes a simple manipulation that produces superior results, especially in correcting the jowl and its bitterness and the labiomandibular folds that so often prove recalcitrant to facelifting."
Dr. Little calls the simplified procedure an XJ lift — or external jowl lift — emphasizing that the jowl is manipulated from its outer or subcutaneous aspect, as opposed to the inner or SMAS aspect.
HOW IT'S DONE In performing the surgery, Dr. Little employs a limited facelift incision that follows the subsideburn hairline into a standard, hidden tragal crest preauricular component, culminating in a retroauricular section that remains and ends within the sulcus, without posterior or inferior extension (ever). He continues by undermining the skin beyond the jowl to the oral commissure, thereby freeing the jowl for easy re-suspension.
