Harmonious Facial Rejuvenation

An aging face is more than just separate parts of the face. As humans age, every part of the face undergoes changes almost simultaneously. Whereas eyelid changes may start in the third decade, by the mid-40s the average person usually has a uniform and harmonious appearance of normal aging. When we analyze the patient in the standing position, the vectors of aging are well known because the forehead, cheek, and jowl areas descend downward in a predictable manner (Fig. 42.5a). Loss of contour of the youthful neck has long been understood as have recognizable changes in the naso-labial fold and jowl area. While lower facial aging has been reversed with conventional facelifts for many decades, the peri-orbital area was an area that was poorly understood and frequently ignored except for removal of lower-eyelid fat with traditional blepharoplasty techniques. The removal of this lower-eyelid fat did little to give true peri-orbital rejuvenation. As the peri-orbital area ages, the changes are inevitable because of normal skeletonization that occurs as the patient enters the fourth decade. (Fig. 42.6a).

From the front view, the peri-orbital diameter becomes wider because the youthful eye usually shows no signs of bony anatomy and becomes wider with aging. The youthful eyelid shows no signs of the underlying bony anatomy. The peri-orbital diameter is very narrow with a very convex appearing lower youthful eyelid. As one ages the appearance is of a deeper and concave lower eyelid compared with the convexity seen in the lower eye. Just for that reason, the arcus marginalis release with preservation of the lower-eyelid fat is obligatory in composite rhytidec-tomy in order to create a more youthful appearing lower eyelid (Fig. 42.6b).

Arcus Marginalis Release
Fig. 42.5. a The aging face. Arrows demonstrate the normal results. The arrows demonstrate the two-direction lift of the gravitational direction of aging. b The rejuvenated face. The composite facelift (Courtesy of S. Hamra, Dallas) normal direction of aging must be reversed to achieve optimal
Hamra Composite Face Lift
Fig. 42.6. a Normal aging eyes. Contours have become wider and deeper. b Youthful eyes. Narrow, shallow, youthful contours are restored with a composite blepharoplasty. (Courtesy of S. Hamra, Dallas)
Meso Temporalis
  1. 42.7. a The three mesenteries are created during the composite facelift dissection. The meso-temporalis contains the branches of the frontal nerve. The meso-zygomaticus contains the nerve branches to the zygomaticus musculature and the meso-mandiublaris contains the rami-mandibularis. b The mesenteries permit superiomedial movement of the face and forehead without restriction. The tension on point 1 must be stronger than the tension on points 2 and 3 to prevent a lateral sweep. (Courtsey of S. Hamra, Dallas)
  2. 42.7. a The three mesenteries are created during the composite facelift dissection. The meso-temporalis contains the branches of the frontal nerve. The meso-zygomaticus contains the nerve branches to the zygomaticus musculature and the meso-mandiublaris contains the rami-mandibularis. b The mesenteries permit superiomedial movement of the face and forehead without restriction. The tension on point 1 must be stronger than the tension on points 2 and 3 to prevent a lateral sweep. (Courtsey of S. Hamra, Dallas)

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