Top techniques to rejuvenate your visage can help reveal the youthful spirit within.
At a certain point in one’s life, the likeness in the mirror may no longer resemble the countenance one wishes to see. If only Oscar Wilde’s Dorian Gray could have enlisted the expertise of modern physicians, his tale might have been one of courage and beauty instead of debauchery and cowardice. Then, as now, many of us desire that the face we show others reflects not our true age but how youthful we feel on the inside.
Cosmetic dermatologists and plastic surgeons offer a range of tools to help reverse the effects of time’s ever-ticking passage, but many patients are wary after seeing celebrities whose surgery outcomes are rather severe. “I always tell my patients that we are aiming for natural-looking results,” says Lisa Ishii, MHS, MD, facial plastic surgeon at Johns Hopkins Medicine. “If anyone [can tell that] you had a procedure, then I did a poor job.” H. Ray Jalian, MD, assistant clinical professor in the division of dermatology at the David Geffen School of Medicine at UCLA concurs: “I want patients to look like they had a good night’s sleep or went on a relaxing vacation.” Here Dr. Ishii, Dr. Jalian, and their colleagues at other top institutions reveal which cosmetic procedures they find themselves performing most and the new ones that are coming into vogue.
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1) Whole Face
A face-lift, or rhytidectomy, addresses sagging in the middle of the face, under the eyes, in the nasolabial folds that connect the corners of the nose to the mouth, and around the jawline.
Treatment: In most cases, the surgeon makes incisions on the sides of the face in front of and behind the ears, then gently repositions the superficial musculoaponeurotic system (SMAS), a deep layer of muscle attached with ligaments to the skin. The skin and SMAS are then sutured into position. After the incisions heal, scars are rarely visible, says Steven Jacobson, MD, plastic surgeon and assistant professor of plastic surgery at Mayo Clinic. He adds that surgeons have changed the way they approach face-lifts, with greater focus on shoring up the structures under the skin, compensating for the loss of subcutaneous fat and muscle and any bone wasting. They often add fullness with dermal fillers or fat transplants during surgery. “You do not want patients to look ‘pulled,’ like they have had a face-lift,” he says. “You simply want to make them look like a refreshed, younger version of themselves.” Face-lifts are often performed in combination with neck lifts or eyelid surgeries.
Recovery: For a face-lift, about one to two weeks. Up to four weeks for lower eyelid surgery.
Frequency: Usually only once every 10 years.
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2) Jowls/Double Chin
Nonsurgical options may address the earliest signs of loose skin around the chin and neck.
Treatments: Thermage is a radiofrequency procedure that uses electrical current to deliver heat deep into the skin. The current heats and shortens collagen fibers, which is designed to tighten the skin, Dr. Jalian says. The procedure is “relatively uncomfortable” and provides a small amount of tightening in some patients, he adds. Ultrasound procedures like Ultherapy target muscle under the skin on the chin to stimulate collagen growth. Again, the results are “pretty subtle,” Dr. Ishii says, but may help patients for whom surgery is not an option.
Jay Austen, MD, chief of plastic and reconstructive surgery at Massachusetts General Hospital, says he is watching development of a new product known as ATX-101, a patented formulation of deoxycholic acid in late-stage clinical trials. Produced by Kythera, ATX-101 or Kybella is injected under the skin, where it is said to dissolve the fat that contributes to a double chin. The product has just been approved by the FDA for use under the chin, and “the jury is still out on how and where it will be most effective, but the studies for the FDA are promising,” he says.
If patients want particularly dramatic results in the neck and chin area, neck lift surgery, also known as a lower rhytidectomy, may be best. The surgeon typically makes incisions under the chin and around the ears, and may use liposuction to remove excess fat from the area. The deeper, drooping tissues of the neck are then elevated to their natural position with sutures and excess skin is removed. “These operations are not about pulling the skin tight,” Dr. Austen says. “The best results are very natural and rejuvenating.”
Recovery: Between two and five days for both Thermage and ultrasound therapy for the reduction of redness and swelling post-procedure. Usually a few weeks for neck lift surgery.
Frequency: Nonsurgical options are typically performed every few years to maintain results. A neck lift usually is not repeated for 10 years or more.
3) Eyelids and Brows
Eyelid lifts, or blepharoplasty, can address sagging skin on the upper eyelids that creates a tired, stern look, or bulging “bags” under the lower lids.
Treatment: On the top lid the surgeon removes excess skin and fat, hiding the incisions in the lid crease. Lower lid “bag” problems emerge when the fat surrounding the eyeball begins pushing through weak tissues, a condition that “frequently is genetic,” Dr. Ishii says. Surgery may involve a transconjunctival incision, made inside the lower lid, to remove extra fat. Excess skin may be a problem here, in which case it is also removed. Patients often undergo upper and lower lid lifts at the same time.
A brow lift can address forehead wrinkles and sagging brows. The surgeon makes several small incisions in the hairline, or one incision across the top of the head, and “lifts” the forehead to smooth wrinkles before suturing the tissues back in place.
Recovery: An eyelid lift can be done in the office with a local anesthetic and requires a week of recovery time. A brow lift is typically performed in the OR and recovery takes 10 to 14 days.
Frequency: Patients usually need blepharoplasty performed only once. A brow lift typically is not repeated for 10 years or more.
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4) Fine Lines Around the lips
Women with fine vertical lines and skin discoloration from sun damage may see improvement with fractional laser treatments like Fraxel.
Treatment: This device uses microscopic lasers to create “tiny columns of injury surrounded by normal skin,” Dr. Jalian says. The combination of healthy and injured cells causes skin to heal rapidly, and the body responds by “pushing out pigment,” he says, fading discoloration. In the months after the procedure, skin reacts by producing new collagen, giving it additional elasticity.
Recovery: Three to seven days.
Frequency: “Certain procedures—say, Botox—are like oil changes that you perform three times a year,” Dr. Jalian says. “Fractional laser treatments are like 25,000-mile tune-ups.”
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Physicians use lasers to remove the brown spots or liver spots officially known as lentigines, usually caused by a combination of sun exposure and genetics.
Treatment: These concentrated beams of light target melanin pigment in the skin, and can provide results with as little as 30 seconds of treatment.
Recovery: The treated area becomes “a little red and crusty, and will darken and peel off in about a week’s time,” says Dr. Jalian.
Frequency: Can be performed annually.
Forehead wrinkles and crow’s feet are among the most common problems male patients ask to address, Dr. Jalian says. Caused by muscle movements below the skin—say, the brow furrowing triggered by deep thought—wrinkles on the forehead and between the brows respond well to injectables such as Botox.
Treatment: A toxin produced by the bacterium Clostridium botulinum is injected into the skin, paralyzing the muscle below. The muscle can no longer contract, causing those wrinkles to relax. The procedure usually consists of five to 10 injections depending on the site and takes about five minutes. The forehead typically requires more injections than crows’ feet.
Recovery: “We inject a small amount of fluid with a very, very tiny needle, and patients can go back home or back to work immediately,” Dr. Jalian says. The injection may rarely cause mild bruising.
Frequency: When the toxin takes effect after about a week, wrinkles soften and the results last for roughly three to four months. Some physicians ask patients not to fly the day of the procedure, but “I see no clear evidence for this,” Dr. Jalian says, and Dr. Ishii agrees.
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7) Ears and Neck
Laser hair removal can help men with dark, coarse hair on their ears (a tough-to-shave spot) or unattractive, painful neck bumps caused by shaving ingrown hairs.
Treatment: The procedure sends highly concentrated light into the hair follicle, damaging it and preventing future hair growth.
Recovery: The process involves four to eight treatments depending on the patient’s hair and skin type, and the treatments are usually four to six weeks apart, Dr. Jalian says.
Frequency: “Those who complete this series can expect a roughly 60- to 90-percent reduction in hair that can last five or more years,” he adds. In some cases the hair removal is permanent, but other patients may need maintenance treatments.
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8) “Parentheses” from the Nose to the Mouth
Many patients are troubled by their nasolabial folds or the lines that run from the corners of the nose down to the mouth.
Treatment: Fillers made with hyaluronic acid (with brand names such as Restylane and Juvéderm) can be injected into the area to add fullness and soften wrinkles, a process that takes minutes and provides immediate results. Hyaluronic acid is naturally present in the body—“it is like the Jell-O of our skin, giving it buoyancy,” Dr. Jalian says—but the substance is lost with age.
Recently introduced products incorporate lidocaine, a local anesthetic, to reduce potential discomfort during the injections. If patients like how they look with hyaluronic acid fillers, they might try newer, longer-lasting products such as calcium hydroxylapatite (known as Radiesse) or poly-L-lactic acid (brand name Sculptra), which produces results gradually and can involve three or more treatments.
Recovery: With hyaluronic acid injections, downtime is usually no more than a couple of days. If a patient dislikes the result, his physician can inject an enzyme to dissolve the filler. “It is completely reversible in 48 hours,” Dr. Jalian says. These injections may cause bruising, which may take up to two weeks to fade, adds Dr. Jacobson.
Frequency: Hyaluronic products are popular because they provide predictable effects. Those such as Juvéderm and Restylane can last six to 18 months, Radiesse can last 12 to 16 months, and “a product like Sculptra will stick around for a few years if patients go through the full treatment course,” says Dr. Ishii.
Alternative Treatment: Instead of fillers, some plastic surgeons use the patient’s own fat cells as autologous fat grafts. The fat is harvested with liposuction or syringes from areas such as the flanks or love handles, immediately prepared, then injected into the patient’s face to create fullness or to smooth wrinkling. Hyaluronic acid fillers are reabsorbed by the body and completely disappear over time. In contrast, successfully transferred fat cells stay in place and in most cases eventually regenerate, says Dr. Jacobson. Some fat cells are reabsorbed in the weeks after injection, reducing fullness, but the procedure has been refined to increase predictability and the percentage of fat cells that take, he adds.
While surgeons have used fat grafting techniques for many years, “it is one of the most rapidly growing areas in plastic and reconstructive surgery,” says Dr. Austen, with physicians discussing new ways to use fat for a wide range of cosmetic and reconstructive procedures.
Recovery: Up to two weeks for larger-volume fat grafts.
Frequency: Once every few years.
9) Hair loss
For men and women coping with hair loss, Dr. Ishii performs micrograft hair transplants, which she terms “hair redistribution.”
Treatment: She numbs the scalp with lidocaine and takes individual hair roots from a donor area on the patient’s body, most commonly the back of the scalp or sometimes the chest or back, and transplants them in bald areas. The process is “very tedious” and takes several hours, Dr. Ishii says. (The average man with male pattern hair loss requires 2,000 individual hair grafts, while women usually need about 1,000.) “It is a long procedure, but it is worth it because the results are really fantastic,” she says. “The hair grows just like it grew in its original location.” In typical cases, just 5 to 10 percent of grafts fail to take.
Recovery: Dr. Ishii recommends that patients take a week off work after the procedure. “It is not uncommon to get a fair amount of swelling, because you can imagine that it is quite traumatic to poke 1,000 to 2,000 holes in your scalp,” she says. Yet few patients need pain medication after the procedure.
Frequency: One time typically, although patients may need to repeat the procedure if their first took place in their 20s to 40s.
Jay Austen, MD, chief, plastic and reconstructive surgery, Massachusetts General Hospital
lisa Ishii, MHS, MD, Johns Hopkins Medicine facial plastic surgeon, and associate professor of otolaryngology—head and neck surgery, Johns Hopkins School of Medicine
Steven Jacobson, MD, plastic surgeon, assistant professor of plastic surgery, Mayo Clinic
H. Ray Jalian, MD, assistant clinical professor, division of dermatology, David Geffen School of Medicine at UCLA