The nasolabial folds, sometimes called the nasolabial crease, is a highly misunderstood region of the face that gets a lot of attention in facial cosmetic surgery. Since the increased popularity of soft tissue fillers exploded with the aesthetic enhancement of the lips, many practitioners have taken to injecting the areas of the nasolabial folds in an attempt to make them disappear.
While injection of soft tissue filler into the nasolabial folds can helps soften their depth, it demonstrates a misunderstanding of how the fold develops and what its causes are. When we “fill” an area with an injectable such as Juviderm or Restylane, we usually do so in an attempt to add volume to an area that is deficient or has shrunk. In the nasolabial area, however, there is never a loss of volume causing the crease. In fact, you can see that even babies and children have nasolabial folds…
The nasolabial crease itself is not a sign of aging. For the same reason, a puffed out, over-filled nasolabial fold that has been treated with excessive injectable does not produce a youthful, or even natural appearance.  Why is this?
In fact, the nasolabial folds appear worse as we age because the cheek above and lateral to the fold falls downward as we get older. Like the skin and tissue in the area of the jowl and neck sags progressively over time, the cheek tissue falls over the nasolabial region, causing a worsening shadow in the crease. The fix for this problem is not to fill the area below the fallen tissue, but instead to lift the cheek back to its youthful position. Just as a Santa Barbara face lift repositions the facial tissue to eliminate excess in the jowl and neck, the cheek lift recreates the natural youthful appearance by returning the cheek tissue to its rightful place. The cheek lift enhances the soft tissue over the cheek bone, where this tissue was found in youth, and removes the fullness from the lower cheek. The result is a youthful appearing mid-face with less wrinkling and less shadows in the upper and lower cheek region. This is why this procedure is often referred to as a mid-face lift.  I will be very pleased to discuss the Santa Barbara cheek lift with any prospective patient- the minimal incisions that are required and the excellent results that are seen make this operation one of my most popular enhancements in facial plastic surgery.
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…)
