The Eyes Have It:

The Mid-Face, Facelift

By Brian J. Reagan, M.D.

I am a firm believer that the eyes are the window to the soul. Instinctively, we look to the eyes to decipher one's mood. A certain sparkle denotes love and happiness. Clear eyes reflect attentiveness. Dark circles, redness, heavy eyelids, or bags under the eyes suggests sadness or fatigue. It is also true that the eyes act as a barometer of our youthfulness. As a plastic surgeon, I analyze a patient's appearance relative to their stated age. In this way, I can comment on whether someone is aging well. "Wow, you look great for your age," is a welcomed response in my office. I am sensitive enough from uttering the opposite. Many of the visual cues I use to determine apparent age come from analysis of the eyes. Drooping eyebrows, redundant upper and lower eyelid skin, bags under the eyes, wrinkles to the sides of the eyes and hollowness-these are all traits that mark aging. While many patients want to turn back the hands of time, other simple want to look their age. These days are competitive in and out of the work place, and youthfulness implies the desirable traits of energy and beauty. Whether one is seeking a promotion, a new job, or a new companion-people want to feel and look their best. Plastic surgery can help. Below are age-specific guidelines on many of the procedures available to maintain or improve the aesthetics of the eyes.

Teens and Twenties - It's All About the Sun

I know what you're thinking. What has the world come to when plastic surgeons are pushing their wares on teenagers? But hear me out. This is the time when simple steps can go a long way to maintaining beauty. Much of the solar damage to the skin happens during childhood and the teen years. This is a time for summers at the beach, in the pool, or on the court. Wear a hat and use sunscreen. Drink plenty of water, avoid burning, and practice good skin care. Many products are available that combine a moisturized with sunscreen. Daily use is imperative. And parents-teach your children early. The teens are a good time to think about skin care. Acne can cause disfiguring scars that can remain throughout one's entire life. Seek out the services of an aesthetician for simple skin care maintenance. Routine facials will keep pores clean and reduce acne. For more serious conditions, seek the care of a dermatologist before significant damage occurs.

Having studied throughout the United States, I can tell you that people in San Diego look great in their twenties. With an emphasis on outdoor activities and healthy lifestyles, it feels like San Diego is a picture postcard for the pretty people of the world. All I can say is…enjoy, but maintain a good skin care regimen and don't smoke cigarettes (don't even get me started on the aging effects of smoking).

Thirty-Something - Do the Little Things

Many of my patients are women in their thirties who are noticing some signs of aging and they don't like it! Gone are the days of carefree weekend volleyball tournaments, hello to parenthood and/or corporate ladder climbing. No doubt there is more stress and less sleep. For the first time in their lives, they realize they aren't indestructible. Chinks in the amour begin to show, but thirty-something is no time to panic. My advice is: do the little things.

The most common complain is the appearance of wrinkles lateral (crow's feet) or medial (frown lines) to the eyes, or in the forehead. These wrinkles are caused by the activity of certain muscles of facial expression. With time and aging, these wrinkles can persist even when not activating the muscles. The solution-BOTOX. Botox is neurotoxin that blocks muscle activity and therefore wrinkle formation. It is injected into the desired site with a small needle. It generally takes three days to take effect and lasts approximately three months. The idea with Botox is to prevent these wrinkles from becoming deeper and more permanent. The artistry in injecting botox is knowing where to inject so that some facial expression around the eyes still persists, creating a natural, youthful look. Nobody in the industry thinks the "stepford wife" look is desirable. Injecting too close to the brow can lead to brow ptosis (drooping), leaving the patient looking tired. Bruising is not uncommon, and anti-inflammatories like aspirin or ibuprofen should be avoided prior to injection since they can make bruising worse.

If the wrinkles are too deep to go away after the use of Botox, they can be treated with "filler." Fillers are substances that can be injected into the skin to "fill in" a wrinkle or other deformity. Bovine collagen has been used for years but is being replaced by newer products that don't require skin testing. One such filler is Restylane, a gel consisting of hyaluronic acid (a normal component of dermis). Restylane should last about six months, and my experience supports this claim. The artistry of injecting Restylane is placing it precisely in the right depth of the dermis. Placed too superficially, it can leave unsightly ridges. Placed too deeply, it may not adequately fill the wrinkle or be reabsorbed too quickly. I routinely inject frown and forehead likes in conjunction with botox with great results.

Thirty-something is no time to forget about skin care. Keep up the regimen you learned in your twenties. Your aesthetician may want to begin periodic dermabrasion or light chemical peels to exfoliate the outer, less vibrant, layer of skin.

Lasers can play an important role in skin rejuvenation. People hear the word "laser" and falsely assume it must be better. Like any technique, lasers have certain advantages and disadvantages. There are two types if lasers when it comes to skin care-ablative and non-ablative. Ablative lasers remove the outer skin causing a controlled burn which tightens the skin as it heals. This type of treatment of treatment requires about a two week recovery and is appropriate for older, more wrinkled skin. The non-ablative lasers are more appropriate for someone in their thirties. These lasers are gentler, creating their effect without damaging the outer layer of skin. There is essentially no down time, but multiple treatments are necessary to achieve desired results. These lasers best treat brown spots (pigmentation) and prominent blood vessels (telangiectasis). Some skin tightening can be achieved, and ultimate results may depend on the technician. Make sure the person doing the procedure shows you before/after photos of their work.

A word to the wise-declining health insurance reimbursement, coupled with an increase in demand for skin treatments by the general public, has led to an explosion of skin care medical spas. Make sure you do your homework before committing to any services. Questions to ask include: Who is doing the procedure? Who is the medical director? What is the director's specialty? Can I see your results? Remember, these procedures are not inexpensive, and it's your face we're talking about!

The Fearless Forties - Take Control One

Step at a Time

Ah, the fortieth birthday! We've lived approximately half our lives. With age comes many good things-more wisdom, experience and hopefully more money. Unfortunately, we also show signs of aging. But fret not! The forties are about empowerment. You are in control of your life, and you can take control of how you look. Twenty years ago, women were waiting until their 50's and 60's to seek facial rejuvenation. Getting a "major overhaul" was the standard. Now, I see more and more women (and men) addressing concerns as thy present themselves. In this way, facial rejuvenation is accomplished in a gradual, step-by-step manner.

The face generally ages in a predicable fashion. The following are typical signs of aging around the eyes seen in the forties, and the recommended procedure for correction.

Wrinkles Around the Eyes- Botox ™

Fillers as mentioned before, are a simple approach to staying young.

Excessive Upper Eyelid Skin- Upper Blepharoplasty

For many women in their forties, the first sign of aging is manifested by excessive upper eyelid skin. They complain of difficulty applying make-up, and fell that hey look "tired" in photos. This can be easily corrected by a procedure called "upper blepharoplasty" whereby the skin and fat are surgically excised. The incision is hidden in the natural crease, and the procedure can be performed under local anesthetic. Recovery is approximately one to two weeks, and the results are amazing.

Droopy Brows- Brow Lift

The excessive skin seen in the upper eyelid is partly due to the dropping of the eyebrows (called brow ptosis). This can begin during the late thirties and become very noticeable in the forties. A woman's lateral brow should be a few millimeters above the bony prominence of the eye socket (orbital rim). With mild degrees of brow ptosis, an upper blepharoplasty may be sufficient to restore aesthetic form. With more significant brow ptosis, a brow lift is indicated.
While various techniques exist to the elevate the brow, the two most common approaches today include the endoscopy brow lift and the anterior hairline brow lift. The endoscopy approach utilizes a camera and tiny incisions behind the hairline to release and elevate the brows. The brows are "fixed" in the new position with either a temporary or permanent screw. This is my preferred approach since the incisions are hidden. This technique can slightly raise the hairline, so patients with a high hairline already may be best served with the anterior hairline approach. With this technique, the incision is placed high on the forehead at the junction of skin and hair. The skin is directly excised, thus raising the brow. This is a very reliable approach, and the scar fades with time. Recovery from a brow lift is two to three weeks.

Excessive Lower Eyelid Skin/Lower Eyelid Bags- Lower blepharoplasty

Lower eyelid aging in the forties generally is manifested by "bags" under the eyes. Patients commonly complain that other people comment on how tired they look. These bags are caused by fat bulging outward. The fat can be removed either from inside the lower eyelid (transconjunctival) or on the outside below the eyelashes (subciliary). A subciliary approach adds the benefit of being able to remove extra skin at the same time. Care must be taken not to over resect fat since this can lead to a hollowing effect later in life. A known complication of a lower blepharoplasty is a pulling-down of the lower lid (ectropion). This often corrects itself, or can be treated with a minor additional procedure. Recovery from a lower blepharoplasty is two to three weeks.

The 50's and Beyond - Look As Good As You

Feel

"Dr Reagan, I feel great, but I don't recognize the person in the mirror." I hear this all the time. People are taking better care of themselves, and they want to look as good as they feel. Again, plastic surgery can help. Often, by the time we enter our fifties, the soft tissue of the face and neck has dropped enough to warrant a face/neck lift. If not already previously performed, rejuvenation of the eyelids/brows should be included to create a more natural, balanced result. In addition to the procedures list previously (see 40's), there are two scenarios when I do additional procedures to achieve facial rejuvenation.

Excessive Wrinkling/Poor Skin Texture- Ablative Laser Resurfacing

The skin around the eyes can become excessively wrinkled such that botox or a blepharoplasty may not be sufficient. In these cases, an ablative laser can be used to tighten the skin. As mentioned before, these lasers remove the outer layer of skin in a controlled fashion. As the skin heals, new collagen is formed which results in a tighter, smoother appearance. Not all skin types are appropriate for this procedure, so check with your surgeon. The two commonly used ablative lasers are CO2 and Erbium. My preference is the Erbium laser since it seems to cause less pigment loss after treatment. Patients are in make-up after two weeks.

Droopy cheek tissue with deep Nasolabial Folds- Malar Lift

Jowling and a "turkey neck" are signs of aging recognized even by a novice. A classic facelift procedure will treat these areas quite well. Relatively new to the discussion on facial rejuvenation, however, is the idea of a "cheek or malar lift." The malar region compromises the soft tissue over the cheekbone area (malar prominence). Like other areas of the face, this tissue can fall over the years due to gravity. Patients will complain of flattening cheeks, a hollowing or lengthening of the lower eyelid vertical height, or deepening of the nasolabial folds. While nasolabial folds can be softened via injection with a filler (i.e. Restylane), a more lasting approach involves directly lifting the malar tissue and restoring it to the proper anatomic location. This technique will restore fullness to the cheek area, shorten the vertical length of the lower lid, smooth the transition from lower lid to cheek, and soften the nasolabial folds. Various approaches to elevating the malar tissue exist, so ask your surgeon to describe his preferred technique. Some surgeons directly lift the tissue either through a lower eyelid incision or through the mouth. Others use suspension sutures that attach to the temporal area. Look at pre and post-surgery photos and ask yourself if you like results - you should. A malar lift can be an invaluable tool to achieving natural rejuvenation of the eye and cheek region.

In summary, rejuvenation to the eyes can keep you, and those looking at you, smiling. The techniques used depend on the extent of aging. Make sure your surgeon explains his reasons for recommending a particular procedure. Seek multiple consults with board certified physicians. And remember, plastic surgery is a simple tool to help you look and feel your best. True happiness lies within!