The Facial Rejuvenation Revolution - Sam P. Most, M.D.


In the past few years we have seen a significant evolution in thinking about facial rejuvenation. In this space I hope to shed some light on this, and what this means when you visit the doctor’s office. In the past, facial aging has been thought of as primarily a battle lost to the effects of gravity. We understand now, however, that the process of aging is a complex one, and involves more than simply sagging of the skin on the face. Recent research has shown that the changes that occur are, to use an oft-used phrase, ‘more than skin deep’.

For example, we know that what we see in an aging face is partly due to changes in the skin at the microscopic level—changes in pigment cell and collagen fiber organization, as well as loss of elasticity (the ability of the skin to stretch and “bounce back”). While in the past it was thought that fat should be removed from the face (especially in areas such as the upper and lower eyelids), we realize that one of the stigmata of facial aging is loss of facial fullness, partially due to fat loss or redistribution . Finally, we are just starting to understand the interaction of the facial fat and muscle with the cartilage and bony skeleton, and what makes a young face look the way it does. All of these have changed the way we (as facial plastic surgeons) approach our patients.

What can I do?

What can YOU do to reduce the effects of father time? First, take care of yourself. Eat a healthy, balanced diet. Don’t smoke. Cleanse, moisturize and protect your skin. Avoid the sun . Even if you do all of the above, there are some things you will not be able to control. You can’t go back in time and tell your twenty-something self to be more careful with your skin. You cannot stop the biology of aging (despite what you may read on the internet). No anti-aging cosmeceutical yet exists that can penetrate your skin and change the process of aging . Even if you do all of the above, the time may come when you search for ways to rejuvenate your face.

“It’s not your mother’s facelift anymore”

As I alluded to above, the old way of thinking about facial rejuvenation was ‘tighter is better’. Given what I discussed above, I’m sure you can appreciate that our approach to facial rejuvenation has likewise changed. While in the past the primary approach for facial rejuvenation was surgery (a ‘facelift’); we now have many non-invasive techniques that can be used to restore a youthful appearance to the face.

Non-invasive facial tightening
Chemical peel, dermabrasion, and laser peels are tried-and-true methods for removing skin wrinkles. You have probably heard of these procedures, or you may know someone who has undergone one of these. While these techniques have been around for a while, most all of the new research has centered on improvement of the laser. Specifically, the goal has been to reduce the ‘downtime’ associated with it maintaining its benefits. The latest technology involves treating only a fraction of the skin with the laser, thereby stimulating rejuvenation with less downtime (this is called a ‘fractionated laser’; some brands include Pixel and Fraxel).

You may have also heard of techniques that promise ‘nonsurgical facelifts’. One of the first such techniques was Thermage®, but many similar techniques have come along. The premise of these technologies is to transfer energy (often in the form of heat) to the deep tissues of the face, thereby ‘tightening’ the tissues that have ‘loosened’ over time. The results on this have been mixed. Some studies have shown that about 1 in 3 patients will have a noticeable effect. Unfortunately, we cannot tell who those patients will be.

There are 2 main types of injectables. Muscle ‘freezers’ and facial fillers. Botulinum toxin type A (most commonly Botox®) is the most commonly used ‘muscle freezer’ and is one of the most common facial rejuvenation procedures in my practice in the San Francisco Bay Area (as it is nationwide). It works by temporarily blocking the muscle from getting a nerve signal. Since muscle movement causes some types of wrinkles, it is only effective in treating so-called ‘dynamic’ wrinkles. Note that Botox® is FDA approved for use in the glabella (the area between the eyebrows), but is commonly used ‘off-label’ in other areas of the face. It takes about a week to show its effects, and lasts typically 3-4 months.
The other main category of injectables are the fillers. Classically, collagen was used to ‘plump’ the face, especially the lips. Given what we now know about loss of volume throughout the face, our use of fillers has expanded to include virtually all areas of the face. Our repertoire of materials has also expanded far beyond collagen. The hyaluronic acid (a naturally occurring substance) derivatives include Restylane®, Perlane®, and Juvederm®, to name a few. Radiesse® is derived from a calcium base. Other, more permanent fillers, include Artecoll®. The ultimate injectable is your own tissue, namely, your own fat. In this procedure, called fat transfer, we move small droplets of fat from an undesirable place to areas of the face that need more volume.

What about surgery?
The non-invasive procedures can only do so much. When you and your surgeon feel the time is right, surgery may the best choice to give a natural, more long-lasting result. As you can see, there are a number of options available prior to taking the plunge into a surgical procedure. Surgery of the face to reverse aging includes brow rejuvenation (endoscopic browlift), eyelid lifts (blepharoplasty), and lower face/neck lifts (rhytidectomy). These procedures can be done alone or in combination. Each of these has undergone its own evolution, the discussion of which is beyond the scope of this summary. Suffice to say that the trend is towards more conservative and natural-looking results.

OK, I want to take that first step…

Do your research. Find someone who has experience and limits their practice to the face. Importantly, this person should be familiar with the full range of facial treatments (surgical and nonsurgical). Finally, it is important to find someone you trust will give you an honest assessment. The goal of facial rejuvenation in 2010 is just that—rejuvenation. This implies a natural restoration of facial youthfulness.The goal of your doctor should be to achieve this as safely and effectively as possible, with as minimally invasive a procedure as possible.

Article by
Bay Area Facial Plastic Surgeon