The Mechanics and Treatment of the Aging Face

The poor prune. Delicious and rich looking as it may be it is saddled with epithets like “prune-face”, a “wrinkled grape”, and a prune every morning keeps you “regular”. For a fruit whose taste is enjoyed by so many the euphemisms seem dishearteningly displaced and not the least metaphoric. I mean, isn’t the image of the aging face wrinkled and collapsed? Don’t we think of the elderly as sweet and interesting but not to be overindulged? Of course neither you (the reader) nor I know what it is like to be “old” but like a red face in an embarrassing moment we know it when we see it. And none of us want to be there.
That said, what is going on here? How is it that the firm and beautiful grape that makes such lovely wine becomes the wrinkled prune with time? How do our faces age and can we arrest time? Yes we pretty much know and yes we can arrest some of the aging process of the face. The obvious attempts by some actors and actresses with fat lips, pulled faces, and altered mouths hardly qualify as arrested aging. More like promoted grotesque. The reality is the subtle modifications best exemplified by Meryl Streep and Kate Winslet are difficult to discern and so pleasing to the eye.
Cosmetic surgeons agree that the aging process is one of deflation. The most noticeable changes are the loss of facial fat and with its disappearance the face collapses. More subtle changes include loss of muscle and bones. Bones atrophy and whither and this is especially noticeable in the orbital bones around the eyes and in the maxilla and mandible which frame the mouth. Eyes sink in, bags appear beneath the eyes (often accompanied by dark circles) and the mouth recedes into oblivion as lips vanish and withdraw into the recesses of the mouth. (The visuals are almost too much to bear). To this the skin envelope, hanging from attachments to formerly firm muscles and subcutaneous tissue, degenerates with elastotic changes due to damage from the sun and wrinkles in a prune-like fashion into an amorphous cover.
Yet there is some good news. Joel Pessa, MD. a surgeon in the Department of Plastic Surgery at University of Texas Southwestern Medical Center, has done extensive work on the fat compartments of the face. Because of his work we now know that fat is distributed into fat compartments and is not a confluent layer under the skin. This adds mightily to the work done by Roger Amar, MD, of French fame who observed that the form of the face follows the tension and thickness of the muscles of facial expression. Now, knowing where the muscles of facial expression exist and knowing where the compartments of fat exist, we can erase many of the signs of facial aging by enhancing these two structures.
In my opinion fat grafting is the best material with which to reconstruct these tissues. The reality is many of our patients, in fact those most in need, may not have enough fat to harvest and others do not want to share their fat with their face. (Shame, shame! Why look older and more gaunt by not keeping up your weight.) Facial fillers have created remarkable results in the past 10 years toward improving facial outcomes. What is important here is that injecting fillers into facial lines is not only passé, it looks unnatural. The medi-spas and the untrained practitioners of cosmetic enhancement and surgery who not recognize that a youthful face is properly structured are out of touch. They are penny wise and pound foolish. Restructuring the face requires not only proper placement of augmentation, but the time to do it correctly (Picasso did not sculpt in one day, why should facial rejuvenation be done with a single filler intervention?). Aging is a process and so is its remedy.
Next week, popularization of a collagen promoter to naturally recreate lost tissue in the aging face.