Facial Rejuvenation: Signs of Aging Face and Its Solutions


Facial aging rarely occurs in one region of the face alone. It occurs throughout the whole face and affects all layers; including bones, muscles, and skin. Atrophy of the deep layer accelerates the sagging of unsupported fat above the muscles and the loss of skin elasticity, creating jowls, marionette lines, nasolabial folds, and neck changes, including the platysmal band. This article will explore these aging changes and introduce facial rejuvenation surgery such as facelifts, neck lifts, and brow lifts.

1. In What Facial Part Does Aging Occur?

aging process
Age 20 vs 70
Neligan Vol2. Ch.6.2 Face lift: Principles of and surgical approaches to face lift 

This wonderful lady above is of her age 20 and 70. Analysis of the aging change is as on the right.
In the past, doctors used to think that aging was just due to skin sagging or fat herniation. However, several anatomical studies have shown that aging affects all layers of the face.

facial aging change
Schema of aging change
Neligan Vol2. Ch.6.1 Face lift: Facial anatomy and aging 
  1. Bone is absorbed.
  2. The retaining ligaments and muscles become lax.
  3. Fat underneath the muscles is atrophied.
  4. As a result, the fat above the muscles is not supported and begins to sag downwards.
  5. The skin lost elasticity and became lax.
plastic surgery analysis
Aesthetic Rejuvenation of the Face and Neck

A plastic surgeon evaluates the face into three parts: upper, middle, and lower thirds, and establishes a plan accordingly. This article will discuss the aging face similarly and introduce surgical solutions.

2. Upper Third of the Face

1) Forehead wrinkles: Solution ▸▸▸ Botox or Brow lift

As one age, the skin on the upper eyelid sags and often disturbs vision. This drooping leads to raising eyebrows unconsciously to improve eyesight, result forehead wrinkles. As botox blocks muscle movement, it helps to fade creases a little. Forehead or brow lift is a surgery that can improve moderate wrinkles. However, these may have some limitations in improving deep wrinkles.

forehead rejuvenation
Three month after endoscopic forehead lift

Three months after the endoscopic forehead lift. Though wrinkles may dramatically improve, deep wrinkles may remain to some degree.

2) Glabellar wrinkles: Solution ▸▸▸ Botox or Endoscopic forehead lift

When expressing anger, the medial eyebrows descend downwards, the same direction as contracting glabellar muscles. Usually, the wrinkles between the eyebrows begin at the 40s and make 11 lines.

11 lines
Two months after the endoscopic forehead lift: Before and after photos of without expression(upper row) and frowning(lower row).

3) Temporal hollowing: Solution ▸▸▸ Fat grafting

As we age, the soft tissue on the temple shrinks and bony appearance becomes more prominent. In this case, it is helpful to fill in the depressed area. If the contours of the facial bones are jutting, the fat graft will soften the border.

facial fat graft
Frontal and three-quarter view of full face fat injection: temporal depression is well restored.

4) Hooded eyelids surgery ▸▸▸ Upper blepharoplasty or Sub-brow lift or Endoscopic forehead lift

hooded eyelids surgery
Cases of improving skin lax by various methods; (upper)Upper lid lift with ptosis correction, (middle)Sub-brow lift with simultaneous Upper blepharoplasty and ptosis correction, and (lower)Endoscopic forehead lift, respectively.

The #1 reason that middle-aged visit plastic surgery clinic is to improve the sagging upper lid. There are usually three operative options depending on the characteristics of the eyes, and each has its pros and cons. The upper lid lift is the single most performed plastic surgery in Korea and it is beneficial when the patients want a double eyelid crease. However, it may result in an operated look if inappropriately performed. Subbrow lifts are an excellent choice for skin excess with natural results. Still, they can aggravate wrinkles in the glabellar area. Although endoscopic forehead lift benefits the forehead and glabellar lines, the outcome may limit the effect on sagging skin compared to sub-brow lift. Middle-aged eyelid rejuvenation: upper blepharoplasty vs. sub-brow lift vs. endoscopic forehead lift article will give you more information.

5) hollowed eyes: Solution ▸▸▸ Fat grafting or Upper eyelid surgery with Ptosis correction

hollowed eyes
9 months after ptosis correction.
Typical triad of aging eyes; upper lid hollow, high lid fold, and a droopy eyelid. These signs usually indicate a levator dehiscence, which is often related to orbital aging.

Caucasians lose upper lid volume more than East Asians when they age. Fat infection can be helpful if you have a nursing home appearance. Occasionally, ptosis surgery together with blepharoplasty can improve moderate depression. In addition, there are cases of sunken upper lids due to compensatory forehead muscle action, and it is essential to diagnose the cause for each feature.

3. Middle Third of the Face

1) Lower lid and mid-cheek depression: Solution ▸▸▸ Lower blepharoplasty W/wo Fat injection

under eyes anatomy
The Face: Pictorial Atlas of Clinical Anatomy

Lower lid fat bag bulges as we age. These bags under the eyes are often misunderstood as fat that has been enlarged with aging. Actually, the loosening of the muscles and other soft tissues surrounding the fat bag is the cause. Though someone with large fat should be trimmed cautiously, fat repositioning during lower blepharoplasty can fill most of the depressed tear trough. But people with extensive mid-cheek hollows should consider the fat graft together as fat repositioning alone may not be sufficient. Fat infection is advantageous when the mid-face beyond the lower lids is aged.

2) Wrinkles on lower lids: Solution ▸▸▸ Lower blepharoplasty 

bags under eyes
A 52-year-old man with three months after lower lid surgery
facial rejuvenation
under eye bags surgery results

This 64-year-old female is three months after lower blepharoplasty and subbrow lift. Wrinkles caused by sagging and excess skin almost always require an excision. If the wrinkles are not deep, dermabrasion with CO2 or Er:YAG laser might benefit Caucasians. However, it seems less effective in Asians.

3) Tear trough: Solution ▸▸▸ Lower lid surgery, either transconjunctival or skin approach

under eye bags surgery
Infrabrow lift and lower eyelid rejuvenation: 5-month post-op

Above is five months post-op of subbrow lift and lower lid surgery in a 56-year-old female. The tear trough is a depression that sits near the sides of the nose in an oblique shape. This location is where the retaining ligament is attached. As the adjacent soft tissue change with aging, the retaining ligament pull becomes more noticeable. If it is not severe, it will improve through fat repositioning, which moves the fat to other areas.

4) Nasolabial fold: Solution ▸▸▸ Midface lift or Facelift W/wo Fat injection

The nasolabial fold is the most addressed reason for those seeking face rejuvenation. And it is also the most challenging area to improve. People with severe smile lines usually have redundant tissue over the fold and insufficient skeletal support beneath it. So the doctor should fill the volume of the deep layer with a fat graft and lift the sagging tissue with a facelift. 

male facelift
59-year-old male eight months after the face lift

4. Lower Third of the Face

1) Elongated philtrum: Solution ▸▸▸ Upper lip lift

The area between the nose’s base and the upper lip’s border is called the philtrum. Because the philtrum gets elongated as one age, an upper lip lift can make one look younger. Please refer to the before and after photos of the upper lip lift.

2) Marionette line and Jowls: Solution ▸▸▸ Thread lifting or Face lift W/wo Fat grafting

A) Marionette line

The wrinkles that run vertically between the corners of the mouth and chin are called the marionette line. Retaining ligaments are located near this wrinkle and add to the aged appearance. The various kinds of facelift procedures can improve this crease by severing the retaining ligament to move lax soft tissue freely. And for long-lasting results, the doctor should fill the depression with a fat injection.

B) Jowls

The jowls are bulging skin and fat just lateral to the marionette line. As there is no retaining ligament in this structure, soft tissue laxity appears more prominent than the marionette line. It can be improved by face lifting, thread lifting, or micro-liposuction. It is an important area to make a smooth jawline.

facelift neck lift before and after
A 76-year-old female, four months after the face lift and neck lift. Frontal, three-quarters, and profile view

5. Neck lift

1) aging neck Solution ▸▸▸ Neck lift with fat removal

As in the photo above, the neck may look droopy on the lateral view. Patients call this “turkey neck.” For ideal shape and rejuvenation for the neck, we will discuss more in other articles. 

6. Conclusion

Facial aging affects multiple areas of the face; therefore, a comprehensive treatment plan is necessary to achieve optimal results. For this reason, a multi-disciplinary approach is crucial to restore balance and harmony to the entire face.

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