Real wrinkles actually can’t be corrected by surgery. But the good news is that what we sometimes call wrinkles (and plastic surgeons call pleats or folds from sagging skin), can. “Real wrinkles are caused by sun and repeated creasing of the skin,” explains Dr. Brock Ridenour. “Some of it is due to inelastic redundant skin. We can remove some of that skin, but we need other modalities like lasers, fillers, peels or Botox to deal with those fine lines and true wrinkles.”
Ridenour says that aging has three main components. One is loss of volume around the mouth, eyes, the deep portion of the cheek and the temples. Volume loss causes sagging of the skin because of the lack of underlying support. The second component is loss of elasticity, which leads to folds and sagging, especially when combined with lost volume. The third is pure physics: the pull of gravity on our faces over time. “Surgical correction addresses mostly the gravitational and some of the elastic effects, but we also have to deal with volume replacement with fillers or fat grafting, and the surface of the skin with lasers or peels,” Ridenour says. “Surgeons can’t ignore the non-surgical aspects of aging.”
For the eyes, Ridenour repositions fat into hollow areas, corrects sagging skin and takes care of the lid support system. When there is sagging tissue in the neck and jaw line, a face or neck lift is the best option, he notes, but these have gotten a bad reputation in the past. “Some surgeons ignored the volume replacement need and pulled the facial skin too tight. A face lift should look natural, never stretched,” Ridenour explains. “We do that by replacing lost volume with fillers, fat grafts, or cheek or chin implants.” He says loss of volume may include bone, as well, and certainly the collagen support that makes skin look healthy. When any of those go away, the skin wrinkles, so an adjunct to surgery is restoration of some of the elastic scaffolding under the skin by collagen-stimulating laser treatments or peels.
Dr. Greg Branham, Washington University division chief of facial plastic surgery in the department of otolaryngology, says he still sees people who want a face lift as tight as possible so it will last. “Some people think overtightening will fix all their problems, and they will be done forever,” he says. “But skin continues to sag as we age. A good face lift tightens and redrapes skin as part of the rejuvenation process. Rather than just pulling skin taut, we move underlying tissue that has sagged. But the aging issue is larger than that. I would like people to think more comprehensively about balance. That involves restoring volume, resuspending sagging tissue, and dealing with the quality of their skin.”
No one approach, whether Botox, fillers, or surgery, can fix everything, he insists. “A brow lift can also make you look more youthful, but it doesn’t deal with wasting in the temples and heaviness in the jowl area, the combination of which can give the face a square look,” he points out. “Youth and beauty equate to symmetry, volume and smooth skin.”
Dr. Samer Cabbabe of Cabbabe Plastic Surgery notes that “most true wrinkles are caused by sun damage and smoking.” He says there are different approaches for different parts of the face. “The gold standard for forehead wrinkles is Botox,” Cabbabe says, “while fine lines respond well to chemical peels. Newer is not necessarily better. There is still a place for these older treatments.” For sagging folds, Cabbabe does some minimally invasive mini-lifts in his office. For patients with early changes, a cheek lift with small incisions in the hairline can work well. If the issue is too much extra skin, however, he recommends a full face lift. An endoscopic brow lift with its small incisions can be very rejuvenating, he says, particularly when combined with Botox to immobilize the muscles that want to pull down the brow.
Cabbabe says of Lifestyle Lifts, “They involve incisions in front of the ear like a face lift, but they just take the skin and pull it.” He says they address the neck only, leaving the jowls and upper face problems unaddressed. “The skin tends to stretch right back out, making the results short-lived, “ he says. “With a face lift, the reason it lasts is that the tightening is done with the deeper structures. The skin is then redraped without pulling and extra skin removed.” He recommends for facial rejuvenation that clients go to a plastic surgeon, who can offer a full scope of modalities.