In my Midwestern practice, our cosmetic patients generally do not want anyone to know that they’ve had a cosmetic procedure. This attitude varies geographically across the US. In some places, especially in major metropolitan areas on the west and east coasts, patients want others to know that they’ve had a procedure. But here, most patients come in and say, “I really don’t want anybody to know that I’ve had something done. I just want to look a little fresher or a little younger.” When I approach these patients, I look at a few things. First, I give them a mirror and find out what really bothers them; I watch what they point out, but also where their eyes go—usually it’s to one or two areas. Second, I have them bring pictures of themselves from 5 or 10 or 20 years ago, and then we take a look at where they’ve aged the most and what can be restored. It is usually an eye opening experience for them when I point out the areas that have changed the most over the years. Once they have seen this, they are ready to make some decisions on where to start their rejuvenation.
In general, I break the face down into two general components, the canvas and the frame. First I examine the canvas—the skin—and what the skin looks like. Sometimes the things that bother patients are the brown spots or the roughness or texture of the skin. That type of thing can either be removed or treated with a laser or chemical peels and easily improved. And sometimes all it takes is just some topical therapy, like a little tretinoin (Retin-A) for some fine lines. As a part of nearly everyone’s maintenance regimen, I often recommend creams that have growth factors in them. These can help thicken the skin a little if it has thinned through aging, which can help the texture and hide some fine lines and wrinkles. Deep lines and wrinkles can be addressed with fractional ablative lasers. At superficial settings, this laser can help clear up the photo damage to the skin, and can be used with deeper settings to help with deep lines, creases and scars.
The second thing I look at is the structure and volume of the face. Patients often notice volume loss in the prejowl area, which is below the corners of the mouth on either side of the chin. Everybody tends to lose volume there over time, which may make that skin look crepey and wrinkly; that’s an easy area to fill. With a little support and volume restoration using a hyaluronic acid or calcium hydroxyl apatite filler, and the area won’t wrinkle or indent as much when they speak and smile. This also helps correct the “jowels” which some patients see. With careful placement of the filler, we can restore the straight and youthful jawline from the chin to the angle of the jaw. Another more gradual filling option in this area is poly L lactic acid injections, which gradually fill the area by stimulating the patients own collagen production.
Many patients come in asking about neurotoxins, like Botox, Dysport, or Xeomin. I tell patients to initially be very conservative in their use of neurotoxins, even though they are quite safe when used properly. We use them strategically to help relax the muscles that cause creasing of the skin. This helps to soften some of the deep lines and wrinkles. It can be done without removing all expressiveness from the area by conservatively injecting a conservative amount and then adding more later, if necessary.
In sculpting the face, I pay careful attention to the actual shape of patients’ faces (it helps if they have old pictures) and not try to alter that shape. Putting too much filler in the nasolabial folds can give a simian-like appearance, and putting too much into the cheeks can often result in a feline appearance. So, I try to avoid putting in too much. I actually just restore a little volume only where it’s needed and try not to exaggerate the volume in any one place.
Ashish C Bhatia