Let’s Face It

A Blog About the Process of Aging by Dr. Loftus

We are committed to educating you about facial plastic surgery. Before we get into specific plastic surgery procedures like face lift, neck lift, blepharoplasty, brow lift, etc., we should make sense out of what happens to our faces as we age. Perhaps you are thinking, "I know what happens because I’ve been watching in horror every morning as my mirror shows me the whole process." We can empathize. However, when we break it down for you, the various procedures will make much more sense. Also, you may be concerned about a specific area, like your eyes, and we may recommend different procedures than you would expect to get the best, natural looking result. After you understand how we age, you will be surprised how it helps put your entire face into perspective when you read about specific procedures or visit with us in the office. We are going to break things down into three main parts: bone, soft tissue and skin.

Let’s start with bone

You do not generally consider bone when you are thinking about a face lift. As you age, bone becomes less dense. We typically see it in all areas of the body. Mild loss is called osteopenia, and severe loss, osteoporosis. The facial bones are the foundation on which the rest of your face is built. As the bone thins, the bone does not lend as much support to the tissue over it. As a result, older faces do not have features that project as strongly as young faces. This can be accelerated in people who have dentures. Without teeth, the jaw bones are not stressed as much, resulting in further weakening and erosion. You can see a dramatic demonstration of losing skeletal support when someone removes their dentures. The lower facial features look retracted; the lips look less full.

Soft Tissues

The soft tissues of the face are layered on top of the skeletal foundation. These tissues consist mostly of muscle, fat and connective tissue. Connective tissue is the glue that holds it all together; it is the mortar between the bricks. It is critical to understand this as you learn about face lifts. The muscles generally connect from the bone to the skin and give us the ability to smile, open our eyes in the morning and chew on a juicy steak. Most people hate fat. We love it! Fat fills the skin and spaces between the muscles to create the unique shape of your face. The fat adds volume. Volume is youth. Fat seems like a problem as you age because it is not supported properly by weakening tissues. This causes it to go places you would prefer it did not. Further, fat atrophies (withers away) as we age. So you actually may have less fat than you need to fill out a more youthful version of your face. People frequently ask us to remove fat to make them look younger. Usually, what we need to do is put the fat back to its’ original location. Removing fat may actually make you look older. Remember, volume is youth!

SMAS

To help you understand face lifts, we need to talk about SMAS. SMAS is a sheet of very important connective tissue in the face that envelops many of the muscles together in a layer. There is usually some fat honeycombed throughout this layer. This fibrous sheet of fat and muscle is right under your skin. This creates unity between the many tissues of your face. Bands of connective tissue, called "ligaments," pass from the bone to connect to the SMAS to hold it in place so that your face does not fall off. Skin attaches to the SMAS. SMAS, not skin, is what holds everything together on your face. SMAS is the support layer that holds the rest of the soft tissues to the bone in the right place to construct your facial shape. SMAS stands for Superficial Muscular Aponeurotic System. Let’s just call it SMAS.

Skin

Last, but not least, is the skin. Now that you understand the importance of everything underneath the skin, you can see that extra skin is only a part of the problem addressed by face lift, neck lift, blepharoplasty and brow lift. The quality of the skin deteriorates. It becomes thinner, wrinkled, and pigment changes occur (age spots). Your skin stretches to some degree as you age. This is caused by the loss of elasticity over time. Your skin, thus, loses its’ ability to snap back into place and becomes more loose. Much of the perceived extra skin is actually caused by deflation from loss of fat volume. The skin is held in place through its’ connection to the SMAS. As the connective tissues weaken and stretch, the skin descends along with the fat and SMAS.

Facial Aging

When we put all of this together we can understand facial aging globally. Predictable changes happen. Specific ligaments attach the soft tissues to the bone in specific areas. As these ligaments stretch, they let the fat and skin sag in a similar way in everyone. That is why we all get jowls hanging over our jaw lines, progressive deepening of nasolabial folds (smile lines), puffy eyelids, lower brows, and saggy necks. These predictable changes turn a youthful, oval-shaped face into a more square-shaped face.

There IS Hope!

Our point is not to depress you. Rather, to give you hope. We can improve many of these changes with safe techniques and artistic insight. Although we cannot make you look 18 again, we can make you look refreshed, rested and younger. In subsequent face blogs we will cover many more details about facial plastic surgery procedures.