Natural-appearing facial rejuvenation requires a comprehensive approach addressing the different anatomical aspects of aging. One way to think of this is the 4 R’s: resurfacing for smoother and even-toned skin, relaxing hyperactive muscles either surgically or with Botox, refilling with injectables or fat grafting to replace volume loss, and redraping loose skin with a facelift when necessary. Together these components produce a 3-dimensional effect that avoids the flattened, pulled look associated with facelifts.
For example, skin that has been damaged from sun exposure and weakened from normal aging may unable to support the smoothed and more youthful appearance provided by skin lifting, because it will stretch and relapse. Resurfacing the skin with a laser or chemical peel not only enhances the surface appearance of the skin, but can stimulate rebuilding of collagen. Think of it as strengthening the fabric of the skin. Reducing muscle hyperactivity with Botox, Dysport, or Xeomin takes away the constant folding and unconscious furrowing that eventually makes permanent creases in the skin. (Sometimes the surgery can reduce muscle hyperactivity, such as with a browlift.)
Volume restoration is also critical. In younger patients, volume replacement with fillers such as Voluma, Restylane, or Juvederm is sufficient. Longer-lasting results may require fat grafting. When a facelift is done, the deeper layers under the skin (SMAS) are elevated and reshaped which provides a 3-dimnensional effect. Often fat grafting is done in addition.
The famous phrase “less is more”* might be turned around for thinking about facial rejuvenation, where more can look like less. In other words, trying to do it all with injectables (“liquid facelift”) can look overdone, compared to a well-done facelift and skin resurfacing. Contrarily, a pulled facelift without volume restoration is a hallmark of the overly obvious surgical result.
*The phrase is said to come from a Robert Browning poem, and made popular by architect Mies van der Rohe as a precept for minimalist design in the mid-20th century.
