Understanding Facial Changes: Insights from Plastic Surgeon Monica Fawzy

Monica Fawzy is a Consultant Plastic surgeon with a facial reconstructive and aesthetic surgery practice. In this article, Monica has summarised part of her patient consultations for readers and has serialised the answers to common questions, such as ‘Why one’s face is changing’ with an introduction to face lifts and neck lifts.

Why is my face changing?

As we age, changes occur within skin cells as well as our facial structure.

Skin changes include thickening of the outer layer, and thinning of the inner layer- with uneven pigmentation.

The most notable structural change is a reversal of the ‘triangle of youth’- with facial tissue centred along the jawline rather than the midface. This is due to volume change and sagging of the SMAS muscle layer (and with it, the overlying skin).

Volume loss is from fat pads in the face, and even bone loss further along the ageing timeline. Volume increase may occur in the buccal fat pads in the lower cheeks, fat deep to a neck muscle layer, as well as growth of glands and thickening of deep muscles under the jawbone.

Sagging of the SMAS muscle layer creates grooves and folds in areas where tissue is held in place by underlying ligaments, adjacent to areas more susceptible to gravitational effects. Hence, the development of folds between the nose and mouth, and between the mouth and chin. Lesser-known changes include upper lip lengthening and earlobe enlargement.

Surgical facial rejuvenating techniques aim to negate these effects by replacing any lost volume, reducing unwanted additional volume and lifting the overlying structures (SMAS muscle layer and overlying skin).

What is a facelift?

A facelift is an umbrella term for several techniques that address the consequences of aging in the lower face. These address different anatomical layers, such as the fibromuscular layer under the skin- called the SMAS, and the plane between the facial bones and the thin layer overlying it- called the periosteum.

The basic principle involves an incision in front of the ears (which may be adapted in men), that is of variable length depending on the chosen technique to a certain extent, but more importantly on the amount of soft tissue laxity in your face- and may extend from the lower temple hairline to the posterior hairline.

Facelift techniques are divided into less invasive techniques that approach the SMAS muscle layer from the superficial aspect (such as a SMAS plication- amongst others, where the fibrous layer above the muscle is pleated in front of the ears) and relatively more invasive techniques, where the layer is approached from the deep surface (such as a ‘deep plane facelift’, amongst others). The former relies on the good tone of the layer -so tightening the area in front of the ears lifts the rest of the layer (this is more suitable for early- moderate ageing of the face). The latter involves dissection under the fibrous layer with the division of ligaments that hold it in place centrally (near the nose and mouth) to achieve a much greater lift with a more long-lasting result, but one downside is a longer recovery period.

What is a neck lift?

This is a procedure to address the sagging of the skin and the underlying muscle layer that may cause vertical folds in the neck or sagging tissue under the jawbone. Numerous techniques exist to address this by lifting the underlying superficial muscle layer laterally and fixing it to the area behind the ears-such as a ‘lateral platysmaplasty’, as well as bringing the anterior edges of the muscle together to tighten the entire muscle envelope- such as an ‘anterior corset platysmaplasty’. The incision to access the lateral aspect of the neck starts from the front of the earlobe to the posterior hairline, the extent of which depends on the amount of tissue that needs to be trimmed. Accessing the front of the neck is through a short scar under the chin.

If there is too much volume under the chin (most noticed when bending the chin point downwards, such as when checking mobile phones), then several steps may need to be taken to address this. This includes removing the fat under the muscle, reducing small glands that help to make saliva (called the submandibular glands) and thinning thickened muscles (called the digastric muscles)- if required. As with facelifts, once the muscle layer has been tightened, any extra skin that has been lifted along with the muscle is then trimmed behind the ears.

Most patients who want a neck lift combine this with a facelift as the sagging SMAS layer in the face is continuous with the muscle that is lifted in the neck. Some patients with very short hair, including some men, opt for an anterior neck lift only to avoid hairline scars, which are more difficult to hide in the early post-operative period until the scars fade.

About Monica Fawzy

In the NHS, she performs microsurgical reconstructions for head and neck cancer and facial palsy. Her private practice is exclusively devoted to surgical facial rejuvenation with face and neck lift techniques and adjunctive procedures, such as eyelid and lip lifts. She has held national leadership roles and is heavily involved in plastic surgery education- both for trainee surgeons and the public.

To find out more about and to book an appointment, please click here.