Aesthetics of the Face

Early artists and geniuses found that most pleasing faces have equal thirds in the horizontal and equal fifths in the vertical direction and this holds true even today. A symmetry of >97% between the two halves of the face or other parts of the body is aesthetically most pleasing.

Understanding facial aging

A young face is free of wrinkles because it has appropriate amount of soft tissue (collagen and elastic fiber) support, which keeps the skin stretched and wrinkle free, together with adequate amount of subcutaneous fat. As a person ages he/she looses the soft tissue support and the essential subcutaneous fat. Fine wrinkles develop, gradually the wrinkles deepen with the combined action of muscles and loss of soft tissue support. The skin hangs downwards, with the assistance of gravity, as small bags at the eyebrows, lower eyelids, cheeks and lower jaw. These bags enlarge with time and it seems as if the whole face slides downwards.

The key areas from top to bottom that reflect aging may be divided arbitrarily into upper, middle and lower face.

upper face
Upper face

Forehead

The smooth forehead of a young person gradually turns into a wrinkled forehead. When the wrinkles are present and the skin is not very loose the best treatment is Botulinum toxin injections (BOTOX). If the skin is very loose and the wrinkles are very deep then a forehead lift surgery is required.

Eyebrows

With aging the eyebrows descend and ride over the upper eyelid. This makes the youthful big eyes appear small and tired. Eyebrow lift is the best surgical modality to put the eyebrows back to their youthful position. Either it is performed alone or in conjunction with a forehead lift.

Eyelids

As the eyebrows descend so does the skin over the upper and lower eyelids because the skin looses its elasticity. The upper eyelid skin hangs like curtain and may even obscure vision. Similarly the lower eyelid skin hangs downwards like bags as the soft tissue descends with the loose skin. Eyelid surgery (Blepheroplasty) is performed to remove excess skin and restore youthful lids. Most of the times, this procedure is combined with eyebrow lift to give complete upper face rejuvenation.

Eyeball

The hollow sunken look of an old age eye is because of various factors, around as well as behind the eyeball. Loss of soft tissue volume happens behind the eyeball as well. The bony encasing of the eyeball gradually thins out and the eye ball cavity is enlarged. But these changes are not easily amenable to surgical correction.

Tear Trough

The change of contour from the lower eyelids to the cheek is very gentle in the young age. As a person ages there is loss of soft tissue and subcutaneous fat. This causes sudden cut offs in the contour as well as hollowing commonly called as the Tear Trough. A temporary solution is to inject fillers but a more permanent solution is via fat grafting. Although fat grafting may have to be repeated a couple of times. Tear trough hollowing may also be addressed along with eyelid surgery or as a part of a complete face lift procedure.

Crows feet

These are the diverging lines of wrinkles starting from the meeting point of the upper and lower eyelids. Facial muscle activity deepens these wrinkles especially while squinting or smiling. Early wrinkles are best treated with Botulinum toxin injections (BOTOX). When they present along with a much larger facial aging process including the eyelids and cheeks a formal face-lift is a much better option

midle face

Middle face

Cheeks

Soft, supple cheeks with rounding contours is the hallmark of youth. As a person ages there is soft tissue volume loss along with skin loosening. The cheeks begin to droop downwards and the upper region becomes hollow. The parts of face appear as separate sections instead of a smooth single contour. There is a natural divide between the nose and the cheek where the nose starts to project from the face. The downwards shift of skin causes deepening of this natural crease called as the Naso-labial crease which extends from the outer edge of nose to the lips on both sides. Aging in the cheek region is best managed by face lift surgery. Some times liposuction may be required to remove unwanted fat from the deeper fat pockets. In some other circumstances fat fill may be required to achieve the desired contour. Naso-labial crease may be managed by fillers or fat fill if they are superficial. Very deep Naso-labial creases are best managed by a face lift surgery.

Lips

Skin loosening and muscle activity cause fine wrinkles around the lips and these are much more prominent on the upper lip. Treatment is by fillers, fat fill and Botulinum toxin injections. The corners of the lips may turn downwards giving a false sad expression. This is best treated with face lift surgery. Any volume loss may be corrected temporarily by filler injections or by fat fill surgery.

Nose

Although not very evident the nose also undergoes change as a part of aging process. The tip of the nose turns slightly downwards. Volume loss may accentuate previous deformities like a minor hump nose may appear more humped or a crocked nose may appear even more crooked. Some times sebaceous gland over-activity causes the tip of the nose to enlarge and become bulbous. Such problems are addressed on individual basis and an appropriate Rhinoplasty surgery is the best solution.

lower face

Lower face

Lower jaw

In the young there is a well defined lower margin of the jaw arising from the chin and disappearing towards the ears. The continuous sharp line is broken by hanging bags of skin called jowls along the lower jaw in older individuals. It is treated by limited liposuction in minimal cases. Markedly hanging skin is treated by face-lift surgery. Just like the Naso-labial folds, Marionette lines are creases that run down around the chin arising from the corner of the mouth. These creases are amenable to correction with injectable fillers or fat fill only in the initial stages. Deeper lines are corrected with face lift surgery.

Chin

Like all parts of face the chin also looses volume and becomes flat. The underlying chin bone resorbs and the chin recedes. This is treated by fat fill and chin augmentation with implants in severe cases.

Neck

Below the face lies the neck region. As aging progresses one finds two distinct changes. First is deposition of extra fat. The slender evenly contoured neck becomes thicker. Secondly there is loosening of skin which causes wrinkles and creases. If there is only fat deposition in a relatively young patient then liposuction alone is sufficient. If there is much loose skin then a neck lift surgery is advised. Usually a neck lift surgery is combined with face lift procedure to gain the most advantage.