Sometimes surgery isn't the answer

As we age, we need to address both the quality of the skin (thinning, looseness) and the loss of volume in the face that causes the skin and face (especially the cheeks and jowls) to droop.  Is isn't that there is one best treatment, it's really a multi-pronged approach.  It's usually a good idea that before considering surgical approaches you try some of the non-surgical treaetments.

As we age, we lose volume in our faces and we can look hollow and saggy.  Dermal fillers, like Restylane, Perlane, Juvederm, and Radiesse, replace the volume that has been lost over the years.  By injecting these fillers into the cheeks and the lower face, sometimes including the mouth, the skin appears lifted and does not look as "saggy."  You would need this treatment every 6-12  months.  Fillers can give a "liquid facelift," which means that by replacing the lost volume the skin and face appears more lifted and youthful.

Another option is skin tightening with radiofrequency, like Thermage.  Thermage helps tighten the skin by directly tigening the collagen, and can give you a bit of a lift.  One Thermage treatment should last 1-3 years, but as time continues to march on you will probably want to get treated more often than that.

The skin gets thinner and wrinkled as we get older, but if you have had much sun exposure and/or you smoke, the texture of the skin really suffers.  So you want to avoid excess sun exposure by wearing sunscreen every day.   And do not smoke- it's the worst thing you can do for your skin.  Using creams containing the vitamin A derivative Retinol or Retinoid acid will help promote collagen building in your skin and will help improve your skin tone and texture. 

Of course none of these treatments replaces surgery.  It is important to discuss with your doctor exactly what concerns you and what each treatment will do for you.  You may not be a candidate for surgery, or it may be better for you to use a combination of all these treatments and surgery in order to get your desired result.

The most effective and best way to get rid of jowls is with surgery.

• My favored procedure is a mini face-lift called an S lift. This procedure involves incision lines that are hidden behind the ear and thus create no visible scarring. The downtime is shorter than a traditional face-lift (usually only 4 to 5 days), and the procedure can be performed under local anesthesia.

• For those with less advanced jowl drooping (usually people in the forties), I perform an endoscopic face-lift procedure called a ScarFree Facelift which I helped pioneer. This procedure utilizes two small incisions the width of a drinking straw in the hair bearing scalp. Through these incisions, micro instruments and a surgical endoscope are used to lift the drooping face. 

• Short of surgery there are facial tightening devices that use radio frequency energy that helps the skin shrink wrap. The two most commonly used are Titan and Thermage. The results from these treatments are subtle (usually a 5-10% improvement), and often require multiple treatments so they can be costly. 

• Some doctors perform procedures called Thread Lifts that lift the skin with threads placed under the skin. These treatments provide a subtle result as well, but the problem is that the effect is short lived, lasting only 9 months. The company that made these threads has stopped producing them due to these problems.

There are several essential truths that must be stated in order to fully answer this question completely.

• There is an old saying that states: "Small surgery, small results." With rare exception, this continues to ring true. This also applies to treatments in general.
• A patient and a procedure must match each other in two key ways:
  • A patient's anatomy must be appropriate for the proposed surgery, because surgeries are based on anatomy.
  • A patient's expectations must be appropriate for the expected results.
• A patient's goals must be clearly understood by the physician so that the appropriate treatment plan can be made.
• If something sounds too good to be true, then it probably is.
• Try not to be the first person on the block having a new procedure.

If you remember these facts when considering treatment options, then you will likely make the right decision about cosmetic treatments for facial aging.

There are so many options available to patients that it can be quite difficult to reach an informed decision. Trends are constantly changing and new treatments emerge, while others disappear.

Therefore, if you have a small problem with photoaging of the skin, then topical therapies (Retin-A, acid peels), non-ablative lasers, Botox, and volume fillers will all likely help you achieve your goals. These treatments, in general, have shown benefits in the vast majority of patients and are reliably safe.

If you facial aging problem is severe, then it is likely you will need some of these treatments as well as surgery. Facelifts of all varieties help to elevate the skin, but do not create changes to the skin itself. That is why a comprehensive program involving skin care, sun avoidance, laser therapy or chemical peels are usually suggested to patients undergoing this procedure.

Those patients that fall into the middle category are the most challenging to treat. Although some patients will opt to wait a few more years for formal treatment, many want improvements now. Thermage, stronger laser treatments, Portrait plasma resurfacing, and modified facelifts (with small incisions and quicker healing) are perfect solutions, as long as the patient understands the limitations of each therapy and the likely need for further treatments in the future.

So think of your problem, your goals, and your lifestyle needs.

If your problems are small or your goals are modest, then quick, minimal downtime solutions are probably right for you. If your problems are big or your goals are big, then you will likely be disappointed with simple solutions and probably need comprehensive treatment, likely including surgery.

Most facial surgery will required 1-2 weeks of downtime before you feel comfortable socializing with others.

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Although the skin is sagging and the jowls look unsightly, the best way to correct these problems is to tighten the underlying structures. These structures include fat, muscle and fascia (strong connective tissue that holds it all together) in a structure called the SMAS (submusculoaponeurotic system). There are many different techniques to accomplish this but they all have several key points;
1- Lifting the SMAS to its original position makes for a more natural result.
2- Lifting the SMAS will restore facial volume where it is needed most and in a smooth natural way.
3- Lifting the SMAs will take the tension off of the skin so it can be pulled and stretched without undue tension creating an nicer overall appearance with less scarring.
Thus, any surgical skin tightening procedure should include treatment of the SMAS.
Non-surgical treatments are all about prevention.
1- Retin-A
2- Anti-oxidants
3-Zinc Oxide Sunblock
4-Alpha Hydroxy Acids
5- Hydroquinone
6- Frequent Chemical skin peels in your physicians office.
7- Lots of sleep.
8-Lots of water

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The answer, simply put, is a facelift. There's lots of hullabaloo about lasers and Thermage tightening the layers of the face, but in the absence of real controlled and peer-reviewed data (not provided by the manufacturers of the devices) and before and after photographs documenting any longterm results of these methods (and thousands of dollars/ multiple treatments later), the facelift is still the gold standard for lifting and tightening sagging facial skin and soft tissue.

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With every patient that comes into my practice, it is important to evaluate three key components of aging:

1. Skin
2. Gravitational changes
3. Volume loss

If your problem is sun-spotted, wrinkled skin with mild laxity, then skin resurfacing with either laser or chemical peel should be considered.

If the issue is gravity, then the answer is surgery to restore the skin & underlying structures to their former position. The aggressiveness of the facelift (from "mini" to traditional) will be determined by your expectations and your own physical characteristics.

An open & honest conversation with your facial plastic surgeon is incredibly important. Sometimes the sagging cheeks & early loose jowls can be corrected with volume replacement, better known as injectible fillers. As we age, we lose fat & volume from where we would like it & seem to collect where we don't! Fuller, higher cheeks are youthful and early jowls can be "hidden" with a small amount of filler.

Before jumping ahead with any of these approaches though it is essential that you have a consultation with an honest, versatile facial plastic surgeon who will really discuss with you your options.

Most people come in the office and say they want their jowls to "go away" and to be able to see their neck again. They then look in the mirror and push the skin from their cheeks up and out. Their next question is how do I accomplish this without surgery. It is best to think about the face like a grape and a raisin. When a grape is dehydrated, it looses volume and turns into a raisin. With the aging process, the face looses fat and volume, which leads to loose skin and wrinkles. If the problem is addressed soon enough, it can be corrected with fillers such as Radiesse, Evolence, Restylane and Juvederm to bulk up the midface. Additionally, fat grafting can be used to replace the missing fat in your face from other parts of your body. Fillers and fat, however, do not address your neck. Over time, gravity pulls the volume from your face into your neck. The only way to tighten up your neck and define the jawline is a lower facelift. This is accomplished through a small incision under your chin and an incision around your earlobe and behind your ear. In this procedure, the muscles are tightened, preventing the volume from your face falling into your neck. Additionally, excess skin is removed as the skin is gently re-draped over the tightened muscles. This allows a significant improvement of a wrinkled and loose neck without giving you a tightened or windswept look.

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Saggin facial skin is often the result of deflation of the face as well as weakening of the elastic properties of the skin.  Really, the only way to treat this is by performing a facelift and perhaps augmenting this with fillers or autologous fat injections to compensate for the deflation of the soft tissues.  A facelift should not tighten the skin. A facelift should reposition the deeper tissues of the face to provide rejuvenation.  The skin should only be redraped to remove any excess that has developed from the laxity of the tissues.

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Hello Ms Anne,

Lots of great answers to your question here.  I wanted to specifically also recommend the option of autologous fat grafting for sagging cheeks.  As you have learned by now aging changes related to volume loss are best addressed by volume correction.

The BEST way to tighten jowels?  Vertical elevation with cranial suspension.  Sorry but that is surgery!

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The first thing to consider when evaluating the face is whether the skin has sagged or volume has been lost.  Think of a grape becoming a raisin.  The raisin's "skin" did not become saggy - it lost volume associated with water.

As a person ages, it is common to lose facial fat, resulting in a loss of facial volume.  This loss results in "sagging skin."  One option is to restore this volume with an injectable filler material.  There are many options for this, including Juvedern, Restylane, Radiesse, and Sculptra.  One may also consider fat transfer where one's own fat is harvested from the lower body and transferred to the face.

In addition to loss of volume, gravity takes its toll and results in jowls and descent of the facial tissues.  A facelift helps move these tissues back to their original position.  It is important to maintain the proper direction so as not to have a windswept look.  There are a variety of techniques to perform facelifts, some of which require IV sedation or general anesthesia.  Scars will vary depending on the technique of the surgeon.

Other procedures exist such as Thermage and ThreadLifts.  These procedures generally provide subtle improvement and realistic expectations are critical to avoid disappointment. 

It is important to check the credentials and experience of your surgeon.  See if you like the way other patients look on whom that surgeon operated.  Be sure to clearly communicate your goals to your surgeon so he/she can meet and hopefully exceed your expectations.