Most of the patients at the appointment with a plastic surgeon first of all are interested in facial rejuvenation – What are the operational methods and cosmetic techniques. It is very important for a qualified specialist to be able to convince the patient that interventions in appearance should be moderate, and corrective techniques are designed to preserve the harmony of the face, and not fundamentally change its features in pursuit of a rejuvenating effect.
Doctor of Medicine, plastic surgeon, head physician of the beauty clinic "Academy" Irina Khrustaleva spoke about these problems in her report "Surgical facial rejuvenation today. What? Why? When?"
Analysis of trends in anti-aging surgery
First, a little history. If we now comprehend everything that happened with facial rejuvenation surgery, and I remind you that its history began at the beginning of the 20th century, then I would divide all the past time into several large general groups. First there was the accumulation of experience – this is the stage from the beginning of the 20th century to the 1940s. Then, after this experience had been accumulated, a period of so-called subcutaneous rejuvenation set in – the famous circular face support (the term is obsolete, but still used), which took the period from the 1950s to the 1970s. It was definitely a planar, two-dimensional rejuvenation, because we peeled, stretched, cut.
Further in the 1970-90s – accumulation of experience in anatomical studies of deeper layers, which led to a significant increase in surgical aggression. Various SMAS dissections, DMAS dissections became fashionable, but still it was the so-called two-dimensional surgery, although very aggressive. 1990s – early 2000s – this is already a three-dimensional rejuvenation, the pioneer of which can be considered Oscar Ramirez, who was the first to seriously talk about the need to take into account all projections of the face, and not just the medial and lateral ones. Then there is the introduction of endoscopy, the analysis of the stage of significant aggression and the gradual abandonment of it.
What do we have today? According to all the statistics in America and Europe, the number of non-invasive, non-surgical procedures is growing, and vice versa, there is a decrease in the number of operations performed in aesthetic surgery, and, in particular, in facial rejuvenation surgery too.
On the one hand, today we have accumulated colossal, literally detailed knowledge of the applied anatomy of the face. We know everything about how bone tissue ages, we know about the aging of adipose tissue – that it is heterogeneous, that there are superficial and deep fat compartments, and some of them are able to increase (depending on gender) or dissolve with age. We know the structure of the spaces and the structure of the deep subcutaneous ligaments, the structure of the skin – we know everything. On the other hand, modern cosmetology has stepped forward very widely: it is the introduction of various injection methods, various physical methods of rejuvenation, the involvement of high technologies that allow us to reduce the amount of surgical aggression (in the form of an endoscope and other instruments) –
Today there are several possible ways to solve any problem: - surgical techniques (from minimally invasive to aggressive, from primitive to complex), the use of surgical lasers, RF, ultrasound, endoscope, etc. ;
- injection techniques, auto-fat, synthetic fillers, BTA;
- surgical sutures.
The question arises: who are we with you in general? Are we specialists who are equipped with knowledge, who have some kind of concept within themselves, who research, who know how to refuse a patient, or are we just "cutters"? The answer to this question will be a competent, qualified, safe facial rejuvenation of the patient.
Facial rejuvenationSo, what is facial rejuvenation. A number of questions arise in this regard:
- following a single concept or fulfilling the specific desires of the patient? - an integrated approach or using the monomethodology that you have learned and which you apply to everyone, regardless of who comes to you?
- restoration of harmony or "any whims for your money"?
- use of postoperative rehabilitation or "I do without it all my life"?
Each of us can make a list of similar questions to which he answers.
If we talk about the harmony of the face, its very first and main dominant is the axis of symmetry.
I draw your attention to some information that may not be directly related to plastic surgery, which you need to know. Back in the Middle Ages in the city of Pisa, a man named Fibonacci developed a numerical sequence that formed the basis of the principle of the "golden" or "divine" section.
The "golden section" is such a division of the whole into two unequal parts, in which the larger part relates to the whole in the same way as the smaller one to the larger one.
Both the person's face and his body completely fit into the "golden" section model. Should we keep proportions? Certainly yes. Including when we plan something on the face.
California oral and maxillofacial surgeon Dr. Stephen R. Marquardt created such a three-dimensional model (Marquardt mask) from pentagons: a photograph of the patient is taken under standard conditions, combined with the scheme, and we see how much his facial features correspond to the "golden" pattern. proportions. What is it for? To explain to the patient what is wrong with him.
If we talk about a computer model of an average Eastern European face, then we will pay attention to some flattening of the mid-medial zone of the face, inherited from the Mongols, to rather soft rounded contours of the face, to rather low-set eyebrows. What does it say? When we plan some kind of surgical intervention, we must also take into account ethnic features.
Mechanisms of soft tissue agingTwo main mechanisms of soft tissue aging are known – these are volume loss and gravitational ptosis. Our task with you – find out in which zones what prevails in order to develop the correct algorithm of actions in each specific case.
Loss of volume (may be most important in severity) – usually covers the following areas: periorbital zone, eyelids, malar eminences, lips, perioral region, temporal region, middle cheek. That is, it's all – central oval of the face. The loss of volume is practically not expressed if we are talking about the lower part of the cheek, about the neck.
Neck and lower face – This is the zone of gravitational ptosis. Gravitational ptosis can be expressed in the following areas: lower cheek, neck, middle cheek, periorbital zone, eyelids, temporal region. The lips and perioral region are practically not affected by gravitational ptosis at all, because the lowered corners of the lips are the result of an imbalance in the antagonist muscles and the predominance of depressors over levators.
Morphotypes of aging face
Should we take into account, when planning this or that intervention protocol, facial aging morphotypes? Of course yes. There are many attempts to classify individuals. In 1973, Dr. I. Kolgunenko developed a classification that has not lost its relevance to this day. What did she suggest?
Morphotype "tired face"This is a rather favorable morphotype. Changes in the lower third of the face occur late. With this type of face – you need to think very carefully before grabbing a scalpel, because first of all you need to use injection techniques here.
This morphotype is the aging process in thin women with an oval or diamond-shaped face, with normal skin in youth and moderately dry – in middle age. People look tired and sleepy: the corners of the mouth are lowered, the nasolabial fold is strongly pronounced, there are “bags” under the eyes, the skin is dry and dull, of an earthy hue. Withering of tissues is observed, but there are few permanent wrinkles. The shape of the face is preserved for a long time without significant deformations.
Small wrinkled morphotypeAlso very favorable in terms of changes in the oval of the face. Subcutaneous fat is poorly expressed. These are the best candidates for various methods of influencing the skin, as well as for changing the volumes of certain anatomical regions.
This type is defined by the early appearance of wrinkles. Usually such skin is reddened, irritated, thinned and dry. Subcutaneous fat is poorly developed. Favorable factor – muscle tone weakens slightly, therefore, the deformation of the lower third of the face is weakly expressed.
Deformation morphotypeThis morphotype differs in that the lower parts of the face are aging first and most clearly, and no methods of injection plastic surgery here will be effective compared to lifting manipulations.
Swelling of tissues, pronounced flabbiness, especially in the lower part of the face – all this characterizes the deformation morphotype of aging. Auspicious moment – there is no wrinkling and pigmentation disorders, the skin is dense, shiny, rarely porous. Perhaps pronounced redness of the cheeks due to rosacea. This morphotype of aging, as a rule, occurs in women who are prone to fullness. Excessive subcutaneous fat layer on the face leads to a pronounced deformation of its contours.
Muscular (muscular) morphotypeIt is more characteristic of eastern, Asian people. But, nevertheless, Europeans can also age in this way. Here, too, the lower third of the face and the oval of the face are kept in order for a long time, mainly fatty inclusions suffer.
In Caucasians, the muscular type of aging is less common than the previous three. Genetically, it is more characteristic of representatives of the Mongoloid race. The oval and shape of the face almost do not suffer. Visually, the face becomes more prominent with age. This is due to the fact that facial muscles are very well developed in persons of this type, but the subcutaneous fat, on the contrary, is poorly developed, due to which the skin of the cheeks and lower face remains smooth for a long time. In addition to strong protruding muscles, the muscular type of aging is often accompanied by pigmentation disorders, and one of the main problems – wrinkles around the eyes. Over time, when the amount of subcutaneous fat decreases to a critical limit, deep folds may form in the mouth and cheeks.
Combined (late) morphotypeIt is typical for people over the age of 55, when initially there was one type of skin aging, but in the process of increasing age, other changes join, so that elements of each of the listed morphotypes can be determined.
Ageing Slavic faceIf we talk about the aging of the Slavic face, then it is characterized by deformation-type aging. In the lower third of the face, it is most pronounced. This does not mean that everything is fine from above, just that we should pay more attention to this area.
The main common problems of the aging face
When it comes to the general problems of facial aging, it is not just one problem. These are the following changes:
1. Gravitational ptosis of soft tissues.2. Change in volumes of individual anatomical regions (loss/gain).
3. Increasing changes in the skin (loss of elasticity, melasma, etc.).
4. Resorption of the bones of the facial skull, enhancing volumetric and gravitational changes in the soft tissues lying in their projection.
Accordingly, there can be no single solution. Each problem is solved in its own way, for example – like this:
Loss of volume – tissue imbrication, fillers.
Leather quality problems – physical (lasers, IPL, RF, etc.), chemical, mechanical methods of influence, injection techniques, combined treatment.
Problems of bone resorption and loss of teeth – rational prosthetics of teeth, orthodontic treatment, etc.
Plastic surgery can also be a solution to the problem, if there are certain indications for this.
Important aspects of surgical facial rejuvenation
What is very important? Preoperative diagnosis is important. This is just a question about whether the doctor is acting according to some specific plan and whether he professes a certain global approach or whether he solves some specific problem of the patient with which he came.
Preoperative diagnostics includes a complex. It is carried out sequentially in key areas. It determines the condition of the skin, and soft tissues, and bones. And, in fact, it is very important to take into account the relationship between ptosis and volumetric disorders, so as not to give the face a satirical look.
Periorbital area – the most important, because with our interlocutor we look at this zone in the first place.
The tactics of correction (injections / surgery / combination) is determined by the severity of gravitational and volumetric changes in tissues inside and outside of the Besins line. This French surgeon, in one of his publications, suggested using an oblique line that divides the face into a central oval and into lateral parts – these areas age differently. From anatomical studies, we know that these are two completely different zones. They have a different structure and completely different mechanisms of aging. Therefore, it is necessary to separately evaluate one and the other zone.
If we talk about gravitational ptosis, then in patients with a deformation type of aging, this is the main problem with which they come to us – lower third of the face and neck. However, we must remember that gravitational ptosis – the phenomenon, though unpleasant, but harmonious. Its harmony lies in the fact that it does not start from the lower part of the face, but from the periorbital zone and slowly spreads to the underlying areas: first the periorbita, then the middle third of the face, and then the lower and lateral parts of the face and neck.
Why, when a patient comes to us with a problem of the lower part of the face and neck, do we make her an isolated lift in this area, not paying attention to the overlying areas? After all, the face ages, while maintaining certain quantitative relationships between the various parts of the face (we remember the laws of harmony). And, pulling up something from below and doing nothing from above, we break this harmony, we bring a satirical expression to the face. Why, when a patient comes to us with ptosis of the mammary gland, we do not perform a half operation on her and do not lift only the lower slope, but want to fill the upper one in one way or another. Why do we, when performing harmonious operations in the area of the mammary gland, decide on disharmony in the area of the face? Just because the patient came in and complained about some particular problem?
This kind of conflict arises between doctors who work with facelifts and those who work with fillers. Depending on the morphotype of aging, we can draw up a plan for surgical treatment and decide which principle will be most effective for a particular patient.
There are a fairly large number of studies and classifications. In my opinion, the classification by F. Nahai (2005) on the aging of the periorbital region is very good. Unfortunately, it only deals with gravitational ptosis, not volumetric aging, and focuses only on the periorbital region, not on the lower face and neck.
Another well-known classification – aging of the lower and lateral parts of the face and neck according to D. Baker.
These two classifications are not connected in any way. Should they be combined for practical use?
I decided to compile these classifications to make it easier to use in everyday life. I have identified 3 groups of patients.First Group
– this is a combination of the first type according to Nahai (minimal changes in the periorbital region, actually concentrating inside the orbit) and virtually zero changes according to the Baker classification (gravitational changes have not yet occurred in the lower face and neck). When these patients come to you for any reason, you should not immediately grab the scalpel, because they – the best candidates for some injectable and minimally invasive techniques. If you still take up the scalpel and do something serious – for example, the installation of some kind of facial implants, then this is beautification, but not rejuvenation.
Second group of patients– with the onset of age-related changes: according to Nahai, these are types 2 and 3 (changes that go to a minimum or to a greater extent beyond the limits of the orbit), and minimal changes according to Baker – type 1 and 2 (the condition of the skin slightly worsened in the area of the lower third of the face). Here we can use a combination of methods: endoscopy, blepharoplasty (if necessary), and minimal lateral interventions on the platysma. Finally,
type three– patients in whom everything has already happened: these are detailed changes both in the periorbital region and in the lower parts of the face and neck. Here, of course, surgery as such is needed, but I would like to draw your attention to a few points. First – no partial interventions, because, pulling up from below and doing nothing from above, we get monstrous people whose muscles work as they want and the face is extremely unharmonious. Secondly – these are patients of the older age group, therefore, when venturing into some huge operations, we must also think that these interventions must be safe. Patient Safety – this is one of the principles that we must abide by in the first place. It’s better to do a little bit everywhere and get a harmonious face than to aim at some kind of medial platysmaplasty, bring the patient to intensive care (if the patient has health problems) and end up with a disharmonious result.
More detailed videos about the classifications of facial correction methods depending on the type of patients can be viewed here:
Video fragment of I.E. Khrustaleva about facial aging morphotypes can be found here: