Littleton Facelift doctors

Dark circles under the eyes can be contributed by multiple factors:

• post-inflammatory hyperpigmentation
• uneven surface contour such as 'tear-trough' deformities or bulging orbital fat casting a shadow in this location.
• inherent dark color of the eyelid skin versus the cheek skin due to the lack of any substantial fatty layer between the skin and eyelid muscle.

At this point 4 months following your face lift, the majority of healing will have occurred and a reasonable diagnosis regarding the cause of the dark circles should be possible.  Once the cause has been determined, then attempts at correction can be suitably chosen.  For example, if the cause is a tear trough deformity then injectable fillers or fat transfer can be tried.  If the cause is hyperpigmentation, then topical whitening agents or intense pulsed light my be of benefit.  If the cause is bulging orbital fat then perhaps a lower blepharoplasty will improve the dark circles. 

Sincerely, Mario J. Imola

Dear Hanna19:  This is an excellent question.  In order to achieve the best possible outcome in rejuvenating the midface, it is best to first carefully analyze the face and determine the main cause of aging.  From your photo, it is somewhat hard to tell but it would appear that the main issue is descent of the midface tissues and therefore the ideal result will be with a surgical repositioning procedure such as a midface lift.  Although fillers will give some some degree of lifting as a byproduct of their revolumization effect, the degree of lift will be minor at best.

For simplicity sake, I prefer to categorize the causes of facial aging into 3 basic groups known as the 

3 D's of Facial Aging:

1.  Deterioration of the skin surface.  As we age, the skin gradually transitions from a smooth, evenly colored, translucent surface to a coarse, unevenly colored (brown and red spots), wrinkled surface.
2. Deflation or loss of volume.  The face can be thought of as consisting of 4 layers:  a) skin, b) fat (subcutaneous layer), c) muscle and d) bone.  Over time, the tissues atrophy (shrink or deflate) and we loose volume.  Shrinkage occurs in all layers but is especially evident in the fat layer.  The effects of deflation are particularly visible in the cheeks where people go from the full cheeks of youth to the haggard, deflated cheeks of the elderly.  Deflation also contributes to surface wrinkling.  This can be thought of in terms of the process whereby a grape turns into a raising. 
3. Descent of downward movement of facial tissues under the effects of gravity.  As we age, the facial tissues weaken, become less elastic and unable to resist the constant pull of gravity.  This is especially true for the so-called retaining ligaments of the face.  the retaining ligaments are deep fibrous bands that attach the SMAS layer and skin to the fixed structures of the face such as the zygoma (cheekbone), parotid fascia and mandible (lower jaw).  What does this translate to in the face?  Droopy brows and eyelids, lower eyelid bags, malar grooves and nasolabial folds, jowls and turkey necks!

In order to achieve the best possible outcome and in order to determine how to best spend one's money it behooves the patient and the doctor to determine the exact role that each of the 3 D's of Aging are contributing to the facial aging appearance.  Only then, can one decide what the ideal treatment to obtain the most rejuvenation for your dollar is.  All of the facial rejuvenation procedures can be grouped into one of the

The 3 R's of Facial Rejuvenation:

1. Resurfacing.  These treatments are targeted at reversing the changes that have occurred on the skin surface and include:  microdermabrasion, hydrafacial, chemical peels, intense pulsed light (IPL), fractional laser treatments, etc.
2. Revolumization.  These treatments refer to those that aim to restore lost facial volume and include:  injectable fillers (hyaluronic acid, hydroxyapatite, poly-lactic acid, polymethylmethacrylate), fat transfer, and implants (porous polyethylene, silastic). 
3. Repositioning.  These treatments are surgical in nature.  They include things such as Forehead-brow lifting, blepharoplasty (eyelid rejuvenation surgery), isolated midface lifts, face-neck lift and isolated submentoplasty. 

Getting back to your situation and your main concern, the midface and the nasolabial folds in particular.  The nasolabial folds deepen over time as the result of several factors.  The main factor is descent of the cheeks which allows the cheek fat to overhang the tight skin of the lip.  Also contributing to the nasolabial folds is the constant pull of the lip into the cheeks by the smiling muscles.  Over many years, as tissues deflate and weaken, the nasolabial folds become a permanent crease.  Rejuvenation in your case would be best served by a combination of both a midface lift to reposition the sagging cheeks and injectable fillers to revolumize both the cheeks and the nasolabial grooves.  In my opinion, the ideal filler would be using sculptural micro fat transfer, especially if you go ahead and have a surgical midface lift.  

Injectable fillers such as Juvederm, Radiesse, etc. will provide temporary relief.  Bear in mind, however, that typically these agents last about 1 year and their cost tends to add up quickly.  If the situation is begging for surgical repositioning, then injectable fillers provide only a short-lived camouflage and come nowhere near the results that surgical lifting can attain.  It is probably best to save up for the proper treatment in these situations. 

Good Luck, Mario J. Imola, MD, DDS.

Your situation illustrates a common dilemna faced by people interested in facial rejuvenation procedures.  The key to achieving youthful and natural results is to first perform a careful assessment and identify the cause of the aged appearance in each individual.  Facial aging can be categorized into three basic groups known as the 3 D's:  1) Deterioration of the skin surface, 2) Deflation or loss of volume and 3) Descent of the facial tissues.  Once the role that each of these aging processes is playing is assessed in each individual then the proper corrective procedures can be selected, depending on the patients desires.  One of the hallmarks of facial aging is that the basic shape changes from a triangle in which the base is located across the cheeks and the apex towards the chin during youth to an inverted triangle in which the base is now located across the jowls and the chin and the apex is across the midface.  This finding can be viewed as a "boxy' look through the lower face.

In this 44 year old male it is likely that the full cheeks characterisitc of youth have given way to a flattened appearance due to a combination of deflation and descent.  Revolumization procedures such as injectable fillers, fat transfer or placement of cheek implants will all restore the fullness of the cheeks.  Injectable fillers are quick and simple but the results will only last 1 to 2 years at most.  Fat transfers and even better, cheek implants are a more permanent method or restoring lost volume.  Surgical lifting of the cheek region can be accomplished through either an extended facelift approach or through a midface lift technique.  I view these procedures as a means to reposition tissues that have descended "southward" due to th effects of gravity and weakening of the zygomatic retaining ligaments over time. If you are not ready for a full surgical lifting procedure then an isolated midface lift plus cheek implants would be a good alternative to reposition the descended  tissues and restore volume.

As far as the chin and neck is concerned, it is likely that some early signs of jowls and perhaps a heavy appearance due to some fat accumulation are combining to give a "weak chin" appearance.  These are all the result of descent of tissue under the influence of gravity.  The ideal correction would indeed be a lower face and neck lift combined with submentoplasty.  However, if you are not ready for this then a chin implant combined perhaps with liposuction will provide enough improvement.