Recently I was asked about the treatment of nasolabial folds. As we age, the region of the nasolabial creases is often a region that patients complain about. This situation is consistent with the unfortunate aging process. As we grow older, the soft tissue of the cheek sags downward with the force of gravity. Because of tethering of the skin to the deep structures of the face at the nasolabial area, the drooping tissue forms a fold and shadow at the nasolabial crease.
Increasing volume in the cheek area with an implant can help this a bit, and alternatively fillers placed to the crease can bulk it up and reduce shadowing. Unfortunately, while both of these procedures improve the symptom of the shadows at the nasolabial fold, neither looks natural or mimics the look of youth.
Literally yesterday I saw two sisters who both came in for Restylane in their nasolabial creases. Both had previously had this procedure performed by another surgeon, and complained of a firm ridge at their nasolabial area. I explained that further injection of filler to this area is certainly possible and popular these days, but it does not tend to look youthful or natural. I can spot a woman who has had soft tissue fillers from across the room- it rarely makes a woman look more like she did at a younger age.
For these women, I instead showed them the effects of a cheek lift on the mid-face and nasolabial folds. When a lifting of the soft tissue of the cheek back to its proper position over the natural cheekbone is performed, the entire mid-face is rejuvenated, and the shadows of the nasolabial fold are improved in a natural appearing manner. Instead of placing bulk into the crease (where it does not belong in the first place), the shadow is eliminated by rejuvenating the entire cheek structure. This can be mimicked by gentle traction on the cheek area in the direction of the temple- the fold is greatly improved, and the volume of the full and youthful cheek is restored. Both women decided against further injectables and are planning on getting this more natural appearing, more permanent solution.
My reputation for natural appearing plastic surgery in Santa Barbara depends on my honest assessment and recommendation for my patients. While many women come to the office for fillers and it remains a large part of my practice, I recommend injection of the nasolabial folds in only a limited fashion. When limited to the upper fold and a subtle injection of the lower aspects of the nasolabial crease, soft tissue fillers such as Restylane and Juvederm can be great. For women who have significant shadows in this region, however, I routinely discuss the more permanent option of the cheek lift- I have never had a patient undergo this procedure who was disappointed with the outcome.
A friend showed me an article in a recent edition of Forbes Magazine about a New York plastic surgeon that is performing something he calls a Y-lift. This is apparently an outpatient procedure with minimal recovery and patients “look amazing immediately afterward, and in a day or two they look even better.”
After I read the article, I was very excited to learn more about this technique, and in order to see the results, I checked out his website.
While this procedure does have very nice results in some patients, it has significant limitations and is a poor substitute for a true facelift to which the article seems to claim comparison.
While I have not actually seen Dr. Yan Trokel’s procedure personally, the description sounds like a particular application of soft tissue injectables to sculpt the face and re-create the fullness of a youthful appearance. This concept is not new – dramatic effects have been accomplished in patients with “wasting” syndromes such as AIDS in which excessive hollowing in the face have been treated with soft tissue fillers. Dr. Trokel seems to be utilizing similar concepts in different planes of the face – closer to the bones – in order to provide plumping. His argument for this is a very valid one: “As people age, they don’t grow extra skin…”
In fact, the concept that I believe he is getting at is that as patients age, there is a loss of apparent volume in the face – some of this is perceived, and some of this is real. As the natural fat in the face atrophies with age, some volume is actually lost. Additionally, the ligaments that hold the youthful volume in place over the cheekbones and jaw line atrophy with age as well. Sagging below the cheekbone causes these areas of youthful definition to diminish. Sagging below the jaw line causes jowls. Re-filling these areas with soft tissue filler should then provide volume in the areas where there is loss, and the skin, which appears wrinkled and deflated over the lost volume, should again appear rejuvenated as it re-drapes over the new volume. Liken this to a balloon where the rubber that appears dull and wrinkled when deflated appears smooth and shiny once volume (air) is used to inflate it.
And all of this is true. Unfortunately, fillers alone have limitations to a very specific group of patients. The Y-lift (and many other uses of soft tissue fillers) addresses volume loss without necessarily addressing volume droop. If you examine the before and after photos closely, you will see that the best results are seen in women who are actually rather young. These women are beginning to experience some volume loss, and have not yet had significant atrophy of their facial ligaments. All of the women who have after photos of their full face (not profile) are marginal candidates for facelifts in the first place, and have great results from this application of filler. In several of the older women you can see the persistent aging in the neck, and the uneven contour of the remaining facial skin outside of the injected areas. The droop has not been addressed.
Please do not take this as a criticism of Dr. Trokel – I think his technique is a good one and I would like to hear more about it. In properly selected patients, I think the Y-lift concepts are sound, and I think Dr. Trokel deserves praise for his work there. I think that the Forbes article paints his procedure as a substitute for a face lift, which I do not believe it is.
In Dr. Trokel’s own words, “You can’t just throw on the duvet. You have to do all the layers to make it look really nice.” He also says, “So we really don’t need to be cutting the excess skin, because there is no such thing.” Both statements are (almost) completely true, and to a point, I agree. The misunderstanding is that a facelift is not about cutting off excess skin. That would be a face-tightening, not a face “lift”.
When I do a face lift, the majority of the work is addressing the layers of the face- particularly the youthful volume and connective tissue that has dropped because of the aging ligaments. This is addressed in the LIFTING of the SMAS layer underneath the skin, and you can read about that here. Often, minimal amounts of skin are actually cut off. The SMAS layer is elevated and replaced into a more youthful position, and often it can be sculpted in the area of the cheekbone to produce enhanced volume here as well. The skin is re-draped over the newly lifted underlying soft tissue, and if any excess is apparent (usually because of laxity and stretching as aging skin looses youthful elasticity as it ages), this is removed to allow a natural closure to the skin incision.
In addition, the platysma layer of the neck is addressed in most facelift procedures. Here again, the skin is not the focus – the banding and blunting of the angle between the jawline and neck are addressed by sculpting the aging layers lying underneath the skin. The aging muscle here is tightened and shaped in order to re-create the youthful shape of a more defined angle here. Again Dr. Trokel is right: “You can’t just throw on the duvet.”
An alternative to a full face lift in some patients who have only early volume sagging is a cheek lift. In this procedure, the layers under the skin are lifted back over the cheek bone, called the malar eminence, through a lower eyelid incision. This smaller procedure, like the Y-lift, gives great results in properly selected, usually younger patients. In combination with a lower facelift, many patients can get outstanding outcomes. Unlike the Y-lift, however, the results are much longer lasting and use only your own tissues and dissolvable sutures.
So again, kudos to Dr. Trokel for his fine work with soft tissue fillers. I will look forward to continuing my use of these tools in patients who benefit from them. In the right patient, I think this is a commendable short-term solution for early volume loss. A face-lift, as I’m sure Dr. Trokel will agree, it is not.
One last comment- as always, it is important to be comfortable with your surgeon’s training and credentials before undergoing any plastic surgery procedure. In accordance with the American Society of Plastic Surgery, we suggest that patients find a plastic surgeon that is certified by the American Board of Plastic Surgery. Remember that any physician can call himself or herself a cosmetic surgeon. It is up to the patient to ensure that their plastic surgeon is well trained and certified in his or her field of practice.
Last Friday I got to attend a course on the new soft tissue filler- Evolence. This is a Johnson and Johnson product that consists of cross linked collagen, which is a natural protein that makes up much of the connective tissue of the body. The advantages of this product seem to be many, but the primary thing that strikes me is that Evolence seems to last at least 6 months as opposed to the hyaluronic acid products like Restylane and Juviderm. (more…)
