Facial skin rejuvenation can be skin deep. Chronic sun exposure is a major cause of surface defects in the skin. Gravitational aging can affect deeper layers of tissue, with resulting sags in eyelids, forehead, cheeks, chin, and areas around the nose and mouth (Click on What is Aging Skin). Improvement of the effects of gravitational aging in addition to improvement of surface defects are options to consider in consultation with a dermatologic surgeon (Click on Cosmetic Procedures for a description of procedures to rejuvenate aging skin).

Gravitational Aging and the Eyelids

The esthetic appearance of the region around the eyes projects much of the perceived quality called "personality." The eyelids carry a large part of the "personality." When eyelids are changed in appearance by loss of tissue elasticity, loss of muscle tone, and fatty deposits—all changes that may be associated with advancing age—a person may be perceived as having a "grumpy," or "sleepy," or "nervous" look. Blepharoplasty (eyelid surgery) may be able to correct these age-associated changes in eyelid tissue.

However, eyelids are only a part of the entire area called the orbital region of the face—upper and lower eyelids, forehead and brow, and upper regions of the nose. After medical and esthetic assessment and discussion with the surgeon, the patient and surgeon may agree on the need for additional procedures in order to meet the patient’s esthetic goals—for example, a forehead/brow lift if severe "frown lines" accentuate the appearance of aging .

The dermatologic surgeon’s assessment of the eyelids will include medical history and examination to assure that changes in eyelid tissue are age-related and not due to an underlying medical condition. The dermatologic surgeon may recommend an examination of the eyes by an ophthalmologist to detect any eye conditions such as glaucoma or retinal detachment that could rule out or postpone blepharoplasty.

Alterations in the eyelid associated with aging vary from person to person, depending on such factors as heredity, smoking history, habits of facial expression, and general health. Age-associated changes in the eyelids occur as early as age 30 to 40 years in some persons:

• The skin and underlying tissue thins and loses elasticity
• The muscle responsible for voluntary and involuntary "blink" relaxes, loses tone, and descends to cause a "sleepy" look
• Supporting structures of the aging eyelid relax and become less supportive;
• Fat tissue in the eyelids which is normally a "shock absorber" for the eye prolapses (falls down) from normal position into pockets in upper and lower eyelids, giving eyelids a "baggy" appearance
• In some instances a displaced lacrimal (tear) gland may add to puffiness of the upper eyelid

Gravitational aging changes can occur in the upper eyelid, lower eyelid, or both. It is very important for the patient to explain what changes in the eyelid(s) he/she feels should be corrected, and to discuss these with the dermatologic surgeon in both medical and esthetic aspects. In some instances a patient may initially want a correction that should probably not be carried out—for example, crinkles that appear in lower eyelids when the patient smiles may be a personality-enhancing trait that should be retained rather than removed.

After the patient and dermatologic surgeon agree on the details of blepharoplasty, the surgeon will plan the procedure. Blepharoplasty is performed in an outpatient setting using local anesthesia. Depending upon the agreed-upon outcome the blepharoplasty may include any combination of:

• Removal or revised placement of fat in the eyelid(s);
• Removal of redundant or sagging skin;
• Surgery at the angle of the eyelids (canthopexy) to restore shape and tone; and.
• Surgical removal or reshaping of muscles to restore muscle tone.

The rejuvenating effects of blepharoplasty tend to be long-lasting. The procedure can have the effect of literally restoring a patient’s personality.

(Link to American Society for Dermatologic Surgery for a description of the blepharoplasty procedure and postoperative recovery.).

Gravitational Aging and the Forehead/Brow

A forehead/brow lift may be considered for forehead/brow ptosis (relaxed or falling tissue). While the procedure may be carried out alone, it is frequently done in combination with blepharoplasty when blepharoplasty alone cannot improve age-associated changes in the eyelid-forehead/brow region. Upper brow positioning can be a major factor in accomplishing the full positive effects of blepharoplasty. A forehead-brow lift also helps correct forehead creases in the triangular area between eyebrows and root of the nose, folds at the root of the nose, and even may correct drooping of the tip of the nose. The dermatologic surgeon will recommend the procedure(s) best suited to the individual; the dermatologic surgeon and the patient must agree upon the procedures to be performed and goals to be achieved.

The extent of forehead/brow lift depends upon goals agreed upon by the patient and dermatologic surgeon. Surgery needed to achieve agreed-upon goals may include:

• Removal of redundant skin
• Selective removal or restructuring of underlying muscles; and,
• Creation of skin/muscle flaps to reposition the forehead and brow, and reposition the hairline if needed

Forehead/brow lift is performed in an outpatient setting using local anesthesia. It may be performed at the same time as blepharoplasty if the combined procedures are necessary to achieve esthetic goals. The forehead/brow lift benefits both men and women in restoring youthful and pleasant appearance to the upper portion of the face.

(Link to American Society for Dermatologic Surgery for a description of the forehead/brow lift procedure and postoperative recovery).

Gravitational Aging and the Lower Face and Neck

Blepharoplasty and forehead/brow lift are procedures to improve the appearance of the upper third of the face. But gravitational aging can affect the lower portion of the face as well. Face lift (rhytidectomy) is a procedure to lift and reposition the skin of the lower two-thirds of the face and upper portion of the neck. In some persons, age-associated changes are most apparent in wrinkles and lines in the face and neck—changes that can be temporarily improved by rhytidectomy. Patients should understand that rhytidectomy does not influence the continued gravitational pull on tissues over the years, and cannot be expected to permanently rejuvenate appearance.

There is no "best age" at which rhytidectomy should be considered. People of similar calendar years can experience very different levels of skin damage and gravitational aging due to such factors as chronic sun exposure, genetic predisposition and physical stress.

With these qualifications, a rhytidectomy may be a procedure to consider when:

• Lines and wrinkles of face and neck would not be adequately improved by chemical peel, dermabrasion or other skin resurfacing procedure;
• Facial anatomy is consistent with a good result from rhytidectomy;
• The patient is not overweight—e.g., no excess deposits of fat in facial areas;
• Skin wrinkles and lines are due more to time and the effects of gravity than to photoaging—rhytidectomy tends to be less effective in heavily sun-damaged skin; and,
• The patient is not a long-term heavy smoker – "smoker’s skin" -- is damaged similarly to sun-damaged skin.

The patient who considers rhytidectomy has expectations and goals for face-lifting that must be discussed with the dermatologic surgeon in the context of the patient’s medical condition and skin condition, and the surgeon’s assessment of procedures required to achieve the patient’s goals. Once goals for rhytidectomy are agreed upon the surgeon plans the procedure in detail. (Link to American Society for Dermatologic Surgery for a detailed description of the various rhytidectomy procedures and postoperative recovery).

When rhytidectomy can restore a youthful appearance to a patient who looks inappropriately old because of gravitational aging, it may achieve every goal the patient hoped to achieve. In occupations and professions where personal appearance is important to success, rhytidectomy may be a procedure worth repeating to keep minimizing the effects of gravitational aging.

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