The Severity of Time: A Case of Total Facial Rejuvenation
Let me tell you a story about a face—a face that had lived seventy years, a face shaped by sun and genetics. Imagine a 69-year-old woman who looked in the mirror and saw the deep etchings of time. She wanted a transformation, a total facial rejuvenation. The question was not whether it was possible, but how much could be achieved when the aging was severe. To understand the answer, we must first understand what we were working with.
We began with a clinical assessment, breaking down the major components of her facial aging. Two stood out immediately: the loss of skin quality and the severe laxity of the tissues beneath. Both were profound.
The Alchemy of the Skin: Dermatoheliosis and Actinic Damage
On first look, the severe aging was unmistakable. Her skin told a story of decades, marked by what we call dermatoheliosis and photoaging—the cumulative effects of chronic sun exposure. This wasn't just about wrinkles; it was about a fundamental change in the skin's structure. The underlying process, known as actinic dermal elastosis, is a degenerative shift. It involves an erratic jumble of elastic fibers and glycosaminoglycans deposited within the dermis, creating skin that is inelastic, thickened, and discolored.
This elastotic skin had specific features. We saw severe facial wrinkles, medically termed facial rhytidoses. The skin had a thickened, yellowish hue, a condition that goes by the name of poikiloderma. The static rhytid formation was extensive: deeply etched lines across the forehead, around the crow's feet area, along the lateral cheek and jowl, and all across the neck. There was also hyperpigmentation—multiple age spots, known as solar lentigines, that darkened her complexion.
To manage these aging-related skin issues, a powerful tool was required. We chose an ablative fractional laser. Specifically, the Lumenis Ultrapulse Fractional CO2 laser was selected for its strength and its capacity for thermal ablation. This laser simultaneously peels the damaged epidermis and induces remodeling of the papillary and superficial reticular layers of the dermis. This process aids in tightening and smoothing the skin, restoring a sense of youthfulness and uniformity.
But laser skin resurfacing, while powerful, has limits. It can restore skin quality, but it cannot fix a sagging foundation. And sagging, in this patient, was the second great challenge.
The Sinking Foundation: Tissue Laxity and the Facelift
This patient had significant ptosis—a droopiness of facial tissues—across every segment of her face and neck. It was severe, but not unusual for a 69-year-old. Addressing this sagging required a facelift. But choosing the correct facelift procedure was crucial for a natural result. We essentially broke the face down into four regions when considering the technique: the upper face, midface, lower face, and neck.
The lower face displayed moderate-to-severe aging. There was severe laxity, wrinkle formation, and a loss of definition along the jawline, driven by the formation of jowls. For the lower face, a facelift is the primary solution, and essentially all facelift types are effective here.
However, the midface told a more complex story. Here, we saw flattening of the cheek, hollowing below the lower eyelids, worsening of the nasolabial fold, and an additional compounding of the jowl. This meant we needed an extended facelift technique to properly lift the cheek. The two main types that achieve this are the deep plane facelift, introduced by Dr. Hamra, and the Hester midface lift, developed by Dr. Barton.
In this patient, the Hester technique was chosen. Why? Because it allows not only for adequate mobilization of the cheek but also permits the further separation of the skin from the muscle layer. This lets the muscle layer be lifted vertically upward while the skin is redraped posteriorly. This is known as the bilamellar Hester facelift, popularized by Marten. It maximizes cheek lifting without distortion of the natural grain of the facial skin, leading to a more natural result.
The neck presented another layer of challenge. There was severe aging of the anterior neck, evidenced by the blunting of the cervicomental angle and extreme laxity of the anterior neck tissues. All facelift techniques improve the neck, but patients with severe neck aging carry too much "baggage" in the anterior neck—excess fat and loose muscle and connective tissue. To address this, we expanded the facelift technique to include an anterior platysmaplasty. This step removes the excess loose tissue and retightens the platysma muscle, creating a sharper, more contoured neck angle.
And then there was the upper face. This patient had moderate-to-severe aging here as well: significant ptosis of the brow, severe laxity, and wrinkle formation in the lateral orbit and cheek. Because of the sagging, the forehead muscle that lifts the brow—the frontalis muscle—had become chronically contracted in an attempt to keep the brows in place. This is known as frontalis dependency. Over decades, this constant tension results in deeply etched forehead creases.
Many surgical techniques exist for lifting the brows. Given this patient’s features, we chose the endoscopic-assisted biplanar trichophytic brow lift technique. This approach provides a powerful and complete rejuvenation of the upper face.
The Third Element: Volume Loss
A third component of facial aging—volume loss—was also significant in this patient. A recommendation was given for future volume restoration with filler to the cheeks, tear troughs, lips, jawline, and to soften the nasolabial folds. However, she chose to defer this for later, prioritizing the surgical and laser components first.
The Orchestrated Plan: A Summary of Recommendations
The total facial rejuvenation plan for this patient consisted of four key elements:
- A bilamellar Hester facelift
- An anterior platysmal plication
- A bilamellar endoscopic-assisted trichophytic brow lift
- Fractional CO2 laser skin resurfacing of the face
- Facial volume correction with filler (deferred to a later date)
She made the decision to proceed with the surgical and laser recommendations as outlined. The procedure typically requires five to six hours of surgical time, and it necessitates at least one month before she began to look her best.
Severe facial aging requires more work. And the end goal is always a great, natural result. A great result takes time.
The Result: Six Months Later
Here are her results, six months post-procedure. They show the power of a carefully planned, multi-modality approach—proof that with the right strategy, even the deepest marks of time can be lifted away.