Dr. Lindsey's Newsletter #32: Plastic Surgery By Decade - 60s: The Middle Third

60s Continued: Meet Me in The Middle - The Middle Third

Last newsletter we discussed the upper third of the face as it relates to facial aging and plastic surgery. This week we will discuss the middle third with a focus on the eyelids and nose. This is a very complex region of the face with some of the highest stakes in plastic surgery. After all, the eyes and their lids are the focus of the face and a poor cosmetic outcome can be disfiguring. Rhinoplasty surgery is complex problem solving and each case is as unique as the person. As a plastic surgeon I evaluate facial aging by dividing the face into horizontal thirds. There are aesthetic, genetic, and anatomic reasons why this makes sense. If you did not read the newsletter last week I invite you to backtrack and learn about the upper third of the face as we move into today’s discussion of the middle third. 

Your eyes, nose, and cheekbones live in the middle third of your face. Features of aging in this region from top down include:

• Upper eyelids: drooping, excess/crepey skin, irregular contour with hollowing and fat bulges
• Lower eyelids: drooping, excess/crepey skin, prominent fat bulges, and deep hollows
• Cheeks: loss of volume, flattening, drooping, changes in skin quality, discoloration, wrinkles from squinting and smiling 
• Nose: enlarges and the tip droops 

Upper Eyelid Surgery

There are two main types of upper eyelid surgery including functional and cosmetic. As the eyelid ages there are changes that can be undesirable from an aesthetic standpoint, but there can also be change in the integrity of the anatomical structures which make up your complex upper eyelid. If the integrity of the muscle and other soft tissue is compromised to a significant degree then you can end up with an eyelid that not only droops, but falls down into your visual fields. It is important to have an evaluation with a properly trained (real) plastic surgeon so that you can have a proper diagnosis and an appropriate surgical plan. 

My patients have two main complaints regarding the aging of their upper eyelids:

1. Excess skin creating folds and creases of the upper lid 
2. Bulges of fat just above the inner corner of the eye. 

The third problem I see in an aging upper lid is not frequently identified by the patient, but is a change that contributes to an aged appearance:

 3.  Hollowing of the space between the upper lid and the eyebrow. 

The surgical answer to these three aesthetic problems with upper eyelid aging is a blepharoplasty/eyelid lift with or without fat grafting. The term "blepharoplasty" originates from the Greek words "blepharon," meaning "eyelid," and "plastikos," meaning "fit for molding." A blepharoplasty is a single term to refer to a procedure that is carefully planned and crafted to answer the needs of your failing anatomy. In general a blepharoplasty will improve the appearance of the eyelids by removing excess skin, muscle, or fat. If my patient has hollowing I perform fat grafting at the level of the brow bone to support the area and restore youthful volume. It is important to be in the hands of a well trained surgeon when electing to have fat grafting performed in this region. There are nuances to fat grafting that your surgeon must understand in order to keep you safe and also to prevent over filling.

Lower Eyelid Surgery

I could devote an entire newsletter, or even series of newsletters, to the topic of lower eyelid surgery. Lower lid anatomy is complex, there are a number of contributing factors that affect the appearance of the lower lid, and there are significant complications that must be considered when tailoring a surgical plan to each patient. 

My patients have two main complaints regarding the aging of their lower eyelids:

1. Excess skin creating folds and creases of the lower lid
2. Bulges of fat with adjacent hollowing creating a striking contrast with shadows

The lower lid is much more complex than these aesthetic features of aging. Once again, it is important to have a well trained plastic surgeon evaluate your lower lid integrity in order to create a proper surgical plan. Lower blepharoplasty surgery is not a one-size-fits-all approach. If your soft tissue quality is poor, or if you have significant dry eye, then you may need a referral for a functional surgery or you may not be a candidate for surgery at all. 

From an aesthetic standpoint, and not including functional surgery to address failing attenuated structures of the lower lid, the surgical answer to excess skin and irregular contour is a lower blepharoplasty. This operation improves the appearance of the lower lid by removing excess skin, muscle, and fat. The incisions will depend on your anatomical needs but can either be hidden inside the eyelid, or just under the lashes. Either way this area of the face scars nicely and are rarely obvious to the untrained eye after they have healed. 

A word of caution: if you have dry eye please be sure to discuss this with your plastic surgeon prior to signing up for a blepharoplasty. Your surgical plan will change, and you may need additional procedures prior to undergoing cosmetic surgery. 

Let’s Get Cheeky

As you age the face loses volume of both the soft tissues and the bone. You may be blessed with full cheeks that have not diminished with age, and if so, count your blessings. More commonly you may notice flattening of your cheeks in the area under your eyelids, and even along your cheekbone as it travels towards your ear. This area can also suffer from wrinkles caused by smiling. Pleats will form in your skin and the extra skin will move up towards your eyelids when your mouth stretches open to smile. Both a brow lift and a facelift will help minimize pleated wrinkles pooling around your cheeks and lower lids. A facelift will also help pull volume that has descended back into the region of your cheeks. These procedures can be augmented with fat grafting and/or conservative filler.  

Rhinoplasty

You may have previously thought that the aging doesn’t have a predictable path, that we are all victims of entropy. While to some degree this is true, you may have noticed through reading my newsletters that the process of aging is predictable, and there is science behind it. The nose is no different from the rest of our body, it follows the rules of gravity and has its own predictable pattern of aging. The most common features of aging in the nose include:

• Drooping tip
• Enlarging size
• Thinning of skin 

Your anatomy may express these changes in a very visible manner, or it may be so subtle that you do not recognize the changes with time. Take a look at your parents’ photos when they were younger and compare their noses now. You can also do the same with your own photos. There are disorders including phymatous rosacea and rhinophyma that will cause an enlarging nose disproportionate to natural aging. These are medical conditions that can be treated with the help of a good dermatologist and plastic surgeon working together.  

For the natural aging nose the surgical answer is a rhinoplasty. An expert evaluation will determine if you need a total rhinoplasty or a tip rhinoplasty. Either way the goals will include reduction in the size of your nose and also rotate of your tip back to an aesthetically pleasing position relative to your gender and goals. 

Surgery is heavily nuanced and is never to be cherry picked off a menu. If you are interested in any of the procedures discussed, please make a consultation with me in order to have a proper evaluation of your anatomy. I would love to work with you to achieve your aesthetic goals.

As always, here's to choosing how we age, on our own terms!