Facial Skin: Surgical Rejuvenation
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.
Improvement of the effects of gravitational aging in addition to
improvement of surface defects are options to consider in
consultation with a dermatologic surgeon.
Gravitational Aging and the Eyelids
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 .
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
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
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
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.
rejuvenating effects of blepharoplasty tend to be long-lasting. The
procedure can have the effect of literally restoring a patient’s
Gravitational Aging and the Forehead/Brow
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
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.
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
Lines and wrinkles of face and neck would not be adequately
improved by chemical peel,
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
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.
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.
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.
Roenigk RK, Roenigk HH, Jr. (Eds). Dermatologic Surgery. Principles
and Practice, 2nd ed. New
York: Marcel Dekker, Inc.;
All content solely
developed by the American Academy of Dermatology