Dr. Lindsey's Newsletter #34: Plastic Surgery By Decade - 60s: The Lower Third

60s Continued: Free Fallin’ - The Lower Third

If you read the prior newsletter in this series we discussed the middle third of the face with a focus on the eyelids and nose. This week we are moving down to the lower third of the face and including the neck because often these are treated together in the same surgery. 

The lower third of the face contains the lips, jaw, chin, and for surgical purposes we will include the neck. Features of aging in this region include:

Lips: the skin above your upper lip droops with gravity and lengthens overtime, the corners of the mouth turn downward, the upper and lower lips lose volume and become thin, deep vertical wrinkles frequently form throughout the entire area 

Jaw: the bone of the jaw becomes smaller with time, loose skin begins to droop as it tends to sag down and forward creating a jowl with hollowing on either side

Chin: the bone of the chin becomes smaller with time, deep wrinkles and puckers can form from a highly active mentalis muscle, and if your chin is larger it may begin to droop

Neck: the neck loses definition as the aged, inelastic skin hangs and platysma bands form 

Lips

There are three main problems to address when it comes to lip aging and I like to categorize them as such:

• Deep wrinkles
• Long upper lip
• Volume loss 

If you address these three features of aging then you can take years off the appearance of this very central feature of your face. My approach to each of these problems will depend on the patient, their goals, and my findings when I perform a facial analysis. Really important things that I take into consideration when formulating a plan include, skin quality, Fitzpatrick score (melanin content), and donor sites available for grafting. In general, the solutions that I offer include:

• Laser or/chemical peel for deep wrinkles
• Lip lift surgery for a long upper lip
• Dermal fat grafting for lip augmentation (a personal favorite)

Jaw, Chin, & Neck

I combined these three anatomical structures into one category because often the changes that occur in this region have one main solution, a facelift. This surgery is powerful, precise, and can appear oh-so-natural. 

Facelift surgery has evolved significantly over the years. Gone are the days of the tell-tale signs of a "pulled" appearance. Modern techniques emphasize natural-looking results that enhance without leaving obvious footprints of surgery behind. The features of aging that are addressed by a facelift include:

• Sagging skin + deep creases
• Poorly defined jawline
• The dreaded jowl 
• Loose hanging skin in the neck 

A well planned and executed facelift should restore volume to your cheeks (from whence it came), stretch your skin across your jaw + neck leaving you with a well-defined jaw, and your jowl should be (nearly) eliminated. Outcomes across patients will be variable depending on inherent skin quality, cumulative sun damage, size of your mandible (jaw/chin bone), and the size of your salivary glands. 

The same surgeon with the same toolbox will have a spectrum of results because a facelift is only as good as the materials you are starting with. I think this is important to understand when setting your expectations, and should be a significant part of your conversation during facelift consultation. Always ask your surgeon, “what do you think a reasonable expectation is for my outcome based upon your evaluation of my anatomy?”

Know Your Surgeon

I want to clarify a very common misunderstanding that comes up frequently. “Facial Plastic Surgeons” do not have longer training in facelifts or cosmetic face/neck surgery than plastic surgeons that completed a Plastic & Reconstructive Surgery residency. The reason why I bring this up is because often patients think that Facial Plastic Surgeons have lengthier and more specialized training in cosmetic surgery of the face, and this is not the case. This is not to speak poorly of Facial Plastic Surgeons - this term is generally used for surgeons that completed an ENT surgery program followed by a one year fellowship learning facial cosmetic surgery. They are absolutely legitimately trained surgeons, but their training in plastic surgery procedures begins after residency in a year long fellowship. Comparatively, Plastic & Reconstructive Surgeons (who attended an ACGME approved residency) are trained in plastic surgery for a minimum of six years. So what is the meaningful takeaway for patients? Facial Plastic Surgeons go through a much shorter training program in facial plastic surgery than plastic surgeons. When you are searching for a facelift surgeon that is the right fit for you, it is helpful to understand these terms. 

If you are wondering what the surgical options are to address your areas of concern, the best first step is a consultation with a plastic surgeon. Before offering any surgery I evaluate my patient’s medical history and then perform a facial analysis which will determine what surgeries are the right fit for you. 

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