Chapter 73. The Aging Face: Rhytidectomy, Browlift, Midface Lift

Facelift surgery or rhytidectomy, browlifts, and midface lifts are performed in an effort to redrape and suspend facial soft tissues to gain a more youthful appearance to the face. Facial aging has traditionally been attributed to the force of gravity causing soft tissue ptosis of the face as patient ages. The actual causes of facial aging are incompletely understood at this time, but the pathogenesis of the aging face continues to be a fascinating, hotly debated topic among physicians. In general, facial aging tends to occur in three dimensions and involves all tissue components of the face: skin, muscle and soft tissue, facial fat pads, and the bony facial skeleton.

Facial aging can be thought of occurring from superficial to deep, and tends to begin in the late twenties and thirties in the skin. Photodamage is defined as the functional and structural damage that occurs to skin after chronic exposure to ultraviolet radiation from the sun. The structural changes involve gradual thinning of the epidermis, flattening of the epidermal-dermal border, loss of collagen and thickness in the dermis, decrease in collagen Type I to Type III ratio, and reduction in the skin cellular and protein components. Lax skin with decreased collagen manifests through sagging and increased propensity to be wrinkled and furrowed.

Deeper into the facial soft tissues, muscle laxity and atrophy, as well as bony remodeling and resorption can potentiate the loss of facial, mandibular, and neck definition. These anatomic changes manifest clinically as brow ptosis, deepening of the nasolabial fold, jowling, blunting of the cervicomental angle, and platysmal banding (Figure 73–1). These features of the aging face are particularly amenable to correction with a rhytidectomy, platysmaplasty, midface lift, and/or browlift.

However, there are limitations to these surgical procedures. The surgeon must know that there are options to deal with aspects of the aging face for which a facelift or a browlift is not as effective. Although photodamage from the sun or tanning beds can increase the process of skin thinning, it causes fine skin wrinkling which may be more amenable to a skin treatment such as laser resurfacing or a chemical peel. Also, there is a gradual volume loss in the face which occurs over the time from change in facial fat pads and bony remodeling of the facial skeleton. Fat pads in the temporal and malar area lose volume, and the malar fat pad descends. Although a facelift may elevate the malar fat pad, additional augmentation of facial volume may be necessary with injections of autologous fat, fillers, or even implants.

SMAS

The key to understanding facelift surgery is understanding the anatomy of the superficial muscular aponeurotic system (SMAS) (Figure 73–2). The SMAS is a fibromuscular fascial layer that invests and interlinks the muscles of facial expression. It maintains consistent relationships with the vessels and nerves. The SMAS is contiguous with the platysma inferiorly and the temporoparietal fascia superiorly. In the temporal region, the frontal branch and the superficial temporal artery pierce this layer and become superficial. Inferior to this, the nerves and vessels are all deep to the SMAS, with motor innervations coming from the undersurface. Around the eye, the SMAS interdigitates with the orbicularis oculi. Medially, it has attachments to the zygomaticus major and minor as well as the dermis of the upper lip. The SMAS also has fascial condensations which are adherent to the overlying dermis and underlying muscle and bone. While not true ligaments, they are termed as such and act as support for the soft tissues of the cheek. The major osseocutaneous ligaments include the zygomatic ligament (McGregor's patch) and mandibular ligament and the fascia–fascia retaining ligaments include the parotid and masseteric ligaments.

Platysma

The platysma is innervated by the cervical branch of the facial nerve, a branch deep to platysma, and assists the depressor anguli oris in depressing the lower lip. As mentioned previously, the SMAS and platysma are contiguous; however, the location of the superior extent of the platysma is controversial and can be found up to 4 cm above the mandibular line and 3 cm below the malar eminence.

Medially, at the level of the thyroid cartilage, the platysma fibers interdigitate forming an inverted “V.” The apex can be at the level of the chin, or slightly below at the level of the thyroid cartilage. Because of this, the submental area may or may not be covered by the muscle fibers. If there is laxity or dehiscence of the anterior borders of the muscle, it creates banding in the midline, which occurs with age. Patients may then also have a chin droop, as the submental area lacks tissue. Laxity of the platysma can lead to “turkey gobbler” deformity and a more obtuse cervicomental angle. Flaccidity of superolateral fibers of the platysma muscle may be a contributing factor to chin droop and submental laxity.

Facial Nerve

The facial nerve exits the stylomastoid foramen and courses through the parotid gland. It branches into five branches: temporal (or frontal), zygomatic, buccal, (marginal) mandibular, and cervical rami. (Figure 73–3) within the parotid gland, the main trunk usually divides a superior (temporofacial) and inferior (cervicofacial) branches. From there, the branching pattern becomes variable. There is frequent anastamosis between the zygomatic and buccal branches. After exiting the parotid gland in the face, the nerve branches are just deep to the parotideomasseteric fascia, which is a barely appreciable thin facial layer just deep to the SMAS.

Knowledge of the anatomy of the facial nerve is essential to avoiding nerve injury. The frontal and marginal branches are the most commonly injured branches in facelift. The frontal branch runs within the temporoparietal fascia and is superficial to the superficial layer of the deep temporal fascia. It crosses the zygoma midway between the tragus and lateral canthus of the eye. The marginal mandibular branch runs just deep to the platysma and can be found as low as the level of the hyoid bone, usually two fingerbreaths below the mandibular line.

Greater Auricular Nerve

Derived from second and third cervical nerves (C2 and C3), the greater auricular nerve provides sensation to the upper lateral neck and ear lobule. It emerges at the posterior border of the sternocleidomastoid muscle 6 cm inferior to the external auditory canal, wraps around this border, and ascends in the neck on the surface of the SCM. Eventually it gives off a small postauricular branch then pierces the parotid gland to provide its sensory innervation.

Prior to the 1970s, much of facelift surgery involved a superficial skin dissection with the excision of excess skin. While this technique was popular at that time, skin excision did not provide a long-term benefit nor does it have any effect on the midface. Additionally, the technique tended to make patients look “over-pulled” and unnatural look. In the 1970s, facelift techniques changed dramatically with the description of the SMAS layer by Mitz and Peyronie. Skoog is credited with the development of SMAS manipulation. This began an era of different strategies to attain optimal vector pull for lax soft tissue and fat pad repositioning. The field is constantly evolving as evidenced by the push for minimally invasive techniques using smaller incisions and endoscopic instrumentation. The surgeon's armamentarium is vast and the choice of which technique to use depends on a variety of factors.

Patient Evaluation

Each patient is entirely different and requires a unique, individualized approach. The surgeon must thoroughly discuss the patients concerns and expectations. In addition, a full medical history and physical exam must be performed. A careful bleeding history should be taken to rule out need for hematologic consultation. A full list of medications, including over the counter and herbal supplements, must be obtained as many drugs can increase the risk of bleeding with surgery.

All patients should be photographed preoperatively. Standard photographic views include: frontal, right and left oblique, and right and left lateral. The reliability and consistency of the photographer is essential to the preoperative consultation. During the initial aesthetic consultation, each patient is evaluated for signs of facial aging, as well as intrinsic anatomic imbalances. A thorough facial analysis should be performed, and the surgeon should be prepared to diagnose photoaging of the skin, volume loss, bony abnormalities, and soft tissue deformities. Specifically, the signs of facial aging identified in patients who proceed to facelift surgery are jowling, neck laxity (with or without platysmal diastases), and midface descent. Patients are given options for treatment and counseled on expected outcomes. The surgeon must be certain that the patient has realistic expectations. The full surgical plan is discussed, including proposed areas of incisions and the reasoning behind placement of these incisions. Patients should also be counseled on all the risks of the surgery, which are discussed later.

Preoperative Preparation

Markings are made on the patients face in the holding area while sitting upright. This allows the surgeon to mark anatomical sites, which he or she needs to identify locations of the face during surgery. In Figure 73–4 it also allows the surgeon one last time to communicate with the patient about the surgical plan.

Once the patient is in the operating room, the patient's hair is combed away from incision lines and rubber bands or petroleum jelly are used to keep hair away from the incisions. Preoperative hair rinse with betadine or chlorhexidine has been shown to decrease the rate of surgical site infections, as one dose of intravenous antibiotics has been given before surgery and within 1 hour of incision.

Rhytidectomy can be performed with local anesthesia and sedation; however, many surgeons prefer to use general anesthesia because of the length of the procedure and meticulous dissection needed to prevent facial nerve injury. The airway can be secured with either a laryngeal mask airway or an endotracheal tube. Muscle paralytics should be avoided during any procedure that may necessitate intraoperative facial nerve identification.

With either sedation or general anesthesia, local infiltration of tissues is necessary for hemostasis, anesthesia, and enhanced tissue dissection planes. Knowledge of the maximum weight-based dose of the local anesthetic, either with or without epinephrine, is essential and the amount used should be communicated with the anesthesiologist.

Skin Excision

Subcutaneous rhytidectomy has the lowest complication rate of facial nerve injury. The flap is elevated superficially to the SMAS and platysma in the subcutaneous plane. There is no risk of injury to the facial nerve in the subcutaneous plane; however, inferiorly, one must be preserve the great auricular nerve. The extent of dissection depends on the surgeon's comfort. A shorter flap may be used in patients with comorbidities that have propensity toward flap ischemia. As with other types of lifts, meticulous hemostasis with bipolar electrocautery are performed, excess skin is excised, and skin is closed under minimal tension.

Sub-SMAS Rhytidectomy

Techniques which address the SMAS-Platysma complex tend to have long-lasting and more favorable results than a simple skin excision. The SMAS can be addressed by plication or imbrication. SMAS plication allows the surgeon to mobilize the SMAS without exposing the facial nerve to potential injury. In this technique, the SMAS is sutured to itself without performing any sub-SMAS dissection. The imbrication technique involves incising the SMAS and dissecting in the sub-SMAS plane. A portion of the SMAS is then excised and the edges are sutured together in a superior and posterior direction. Since the SMAS layer is penetrated, there is theoretically a greater risk of facial nerve injury with the imbrication technique as compared to a SMAS plication. However, plication does not free up the SMAS or platysma to allow it to mobilize as freely as elevating a sub-SMAS flap. In the imbrication flap, incision is made into the SMAS just anterior to the ear and carried anteriorly in the plane just immediately deep to the SMAS (Figure 73–5). This dissection must be stopped just inferior to the zygomatic arch, and while it can be carried anterior to the parotid gland and inferior to the mandibular angle, facial nerve branches lie here. Excess tissue is excised and flaps are sutures posteriosuperiorly. The inferior part of the flap is sutured to the mastoid periosteum. The superior portion of the flap is sutured to the temporalis fascia. In the temporalis fascia, a horizontally placed suture is a stronger fixation point than a vertically placed suture, due to fibers of the fascia being vertical.

Deep Plane Rhytidectomy

In the deep plane rhytidectomy, the surgeon dissects under the temporoparietal fascia in the temporal area, subcutaneously and sub-SMAS in the midface region, and subcutaneously in the neck. In the midface, the flap is initially raised in the subcutaneous layer but at the level of the malar eminence, the SMAS is incised and dissection proceeds beneath the SMAS and above the masseter, zygomaticus major, and zygomaticus minor muscles. Bridges of tissue are left intact between the temporal and midface regions to prevent injury to the frontal branch and between the midface and neck to prevent injury to the marginal branch. In the neck and midface, the platysma/SMAS layer is sutured posterosuperiorally to the mastoid soft tissue and periosteum. In the temporal area, the temporoparietal fascia is sutured posterosuperiorally to the deep temporalis fascia. The excess skin is then excised making sure that the remaining skin can be closed under no tension. The composite rhytidectomy is a variation of a deep plane technique. The dissection is the same as in the deep plane rhytidectomy, but there is an additional supraperiosteal dissection beneath the orbicularis oculi muscle (Figure 73–6). Since these dissections are carried anteriorly into the midface, this technique is thought to elevate the malar fat pad and soften the nasolabial fold. This technique has the highest risk of injury to the branches of the facial nerve, but has been shown in some studies to have superior, long-lasting results.

The minifacelift or minilift has evolved to describe a variety of facelifts which utilize smaller incisions than the aforementioned standard techniques. Typically, candidates who are excellent candidates for a minilift are younger patients with limited skin laxity and patients requiring “tuckups.” The advantages of the minilift are: limited incisions, shorter surgical time, avoidance of general anesthesia, lesser risk of facial nerve injury, and quicker recovery. The disadvantages are: limited access to the neck, limited access and improvement in the midface, and difficulty for visualization which is required for suture placement and hemostasis. Currently, two techniques commonly used and described are the short scar lift, and the Minimal Access Cranial Suspension lift (MACS-lift).

Short Scar Lift

The short scar facelift uses a short incision that does not extent postauricularly beyond 2–3 cm from the lobule. There are no incisions in the temporal area or postauricular hair-bearing region. The SMAS is addressed either with resection, plication, or anterior imbrication. As with other minilifts, the use of the short scar has the potential complications of skin bunching at the temporal and postauricular regions. This technique also provides minimal access superiorly into the temporal region and inferiorly into the neck.

Minimal Access Cranial Suspension Lift (Macs-Lift)

The MACS lift described by Tonnard is geared toward patients in a younger age range (40s–50s) who require a more vertical lift compared to the posterosuperior lift of most facelifts. This lift uses a short incision and skin flap to place a pretragal purse-string suture that is anchored to the deep temporalis fascia. The suture continues inferiorly in a narrow U-shaped, incorporating the SMAS overlying the parotid gland and ending in the platysma at the angle of the mandible before returning to the starting point 1 cm anterior to the first leg of the suture. The second, more O-shaped, purse-string suture is then placed from the same starting point is used to elevate the jowls and nasolabial grooves. The skin is then elevated superiorly, and excess skin is excised.

In conjunction with facelift, a necklift or platysmaplasty can restore the youthful appearance of the neck and jawline. The youthful neck is comprised of a strong chin, smooth and defined mandibular border, minimal submandibular gland ptosis, and a cervicomental angle of 90° with a gentle indentation of the thyroid notch.

To achieve the attributes of a young neck, there are a variety of approaches. Submental lipectomy can remove excess fat that allows for a thin flap to be redraped over the underlying bony framework. Suction lipectomy can also help dissect preplatysmal tissue planes before a necklift to allow quicker dissection. Submentoplasty or platysmaplasty is the central suturing of the medial platysma edges to eliminate the platysma banding. Lateral dissection of the platysma with posterosuperior suturing drapes the skin and platysma over the neck structures to improve the cervicomental angle. There are also those that perform submandibular gland and digastric muscle excision to further improve the submental area and jawline.

Facial Nerve Injury

The most commonly injured nerve during facelift surgery is the great auricular nerve, occurring in up to 7% of the patients. This can cause anesthesia of the earlobe. For some patients, this is permanent and bothersome, as they have a hard time with earrings and using the telephone. The nerve must be protected when elevating the postauricular flap over the sternocleidomastoid muscle as the surgical plane in that region is not well defined.

An injury to a branch of the facial nerve is less common. Sub-SMAS dissections have a higher chance of injury as compared with skin only or SMAS plication techniques. The most common injuries are to the frontal and marginal branches. The buccal branch may also be a commonly injured branch, but because of the large number of anastomotic branches, it may not be clinically evident. The likelihood of a branch being injured depends on surgical technique and areas of dissection. The frontal branch has a superficial course at the level of the zygomatic arch and in order to avoid injury, dissection must be either subcutaneous or subperiosteal. Both the cervical and marginal branches often consist of multiple branches that anastamose before reaching target muscles. In order to avoid injury to both branches, dissection should be performed in a plane superficial to the platysma toward the anterior neck. The most crucial location to avoid injury is the area 2 cm posterior to mandubular angle and the area immediately adjacent to the lateral commissure of the mouth. This area must be dissected carefully, and often a branch of the facial nerve can be seen superficial to the plane of dissection.

When evaluating patients in the recovery room, it is important to note that a temporary paralysis may be caused by use of anesthetic injection. Furthermore, most cases of paralysis beyond the immediate postoperative period are temporary and usually due to local trauma from retraction and not necessarily from a transected nerve.

Hematoma

Hematoma formation is the most common and major complication after facelift, occurring in 0.2% to 8.1% of patients. Factors associated with an increased risk of hematoma formation include male gender, hypertension, smoking, and aspirin or NSAID use. Hematomas can lead to tissue ischemia, prolonged facial edema, hyperpigmentation, and if untreated, skin necrosis. If dissection occurs into the neck, life-threatening airway obstruction can occur. Large expanding hematomas require immediate evacuation. The incidence of hematoma ranges from 0.2% to 8.1%, and it is much more common in males. Smaller hematomas or seromas are more common and are easily treated with needle aspiration in the office setting. The best way to prevent hematoma formation is meticulous hemostasis. Pressure dressings, drains, and fibrin glue may be used to minimize the risk of hematoma formation. In the early postoperative period, it is imperative to prevent hypertension and nausea and vomiting.

Infection

Surgical site infection occurs in facelifts in less than 1% of cases and typically involves the incisions. Early culture and treatment is important, as there is an increasing incidence of methicillin-resistant staphylococcus aureus. If there is a purulent collection under the flap, the incision should be partially or completely opened, irrigated, and left open to drain. Large infections may require hospitalization with administration of intravenous antibiotics.

Scars

As with any surgery, scarring is to be expected along the incision lines. Scars may become more visible if they become hyper- or hypo-pigmented or hypertrophic. It is imperative that the incisions are closed in a meticulous, tension-free manner. If hypertrophic scarring does result, intralesional steroid injections may be used. If there is persistent scarring, patients may benefit from excision and primary closure.

Allopecia

Hair loss is a complication of rhytidectomy that may be temporary or permanent. Alopecia can be secondary to compromised hair follicles or from elevation of the temporal hairline from poorly planned incisions. In addition, if there is a widened scar in the hair-bearing scalp, hair cannot grow from the area. Allopecia can be avoided by the following: carefully planning surgical incisions taking into account the patient's temporal hair tuft, raising a thick flap in hair-bearing areas, avoiding the cauterization of hair follicles in the skin flap, and minimizing tension when closing incisions.

Parotid Injury

Aggressive undermining of the SMAS and suction lipectomy can cause injury to the parotid gland and lead to a sialocele. Fluid may drain externally through incisions, through a fistula, or internally through the mouth via buccal mucosa.

Flap Necrosis

Lack of optimal blood supply and tissue tension can lead to flap necrosis. In a facelift, the area which is most susceptible to flap necrosis is the superior aspect of the postauricular skin flap. Factors which increase the likelihood of such a complication are systemic diseases such as diabetes, peripheral vascular disease, and connective tissue disorders. Other factors that increase the chance of flap necrosis are infection, excessive skin tension, and poor flap design. Nicotine use increases the risk of flap necrosis by over tenfold. Smoking is a relative contraindication to rhytidectomy and it is recommended that patients abstain from smoking for at least 4 weeks before and after surgery.

Earlobe Deformity

A pixie or Satyr's ear (devil's ear) deformity can occur due to excessive skin tension at the inferior aspect of the lobule. If too much skin is excised from the flap and the closure at the inferior part of the lobule is under tension, over time, the earlobe will get pulled inferiorly. This is a tell-tale sign of facelift surgery and repair can be difficult. A V–Y plasty can improve the appearance, but repair should be delayed 6 to 8 months after surgery.

While many think of rejuvenation of the aging face as rhytidectomy, the face ages in other areas that are not addressed by a facelift alone. Over time, descent of the brows and midface occurs in a fashion that requires a combination browlift or midface lift. These operations can also be performed alone, if the patient only requires rejuvenation in a specific location. Browlifts and midface lifts are now often performed endoscopically.

Browlift

A browlift in conjunction with blepharoplasty can improve both cosmesis as well as any functional visual field deficits a patient may have. The “classic” brow has a medial origin along a vertical line drawn through the alar-facial grove and lateral canthus. The lateral aspect should be at a line drawn from the nasofacial groove to the lateral canthus. In a female, the high point of the arch should be at the lateral canthus or lateral limbus (Figure 73–7). In a male, the high point should be at the lateral limbus but the overall shape is more horizontal as compared to females

Anatomy

The frontalis muscle originates from the galea and inserts in the forehead skin. Its motor innervation is the frontal branch of the facial nerve, and it is the primary elevator of the brow. The depressor muscles of the brow are the paired corrugators supercilii, the obicularis oculi, and the procerus muscle. The corrugators create the vertical rhytides of the glabella. The procerus, which originates from the nasal bones, produces the transverse rhytides in the glabella.

Sensory innervation of the brow is provided by the trigeminal nerve. The supratrochlear and supraorbital branches emerge from the skull deep to the eyebrow. They exit from the supraobrital notch or foramen. In 10% of cases, one or both of the nerves may arise from a true foramen which is found 1–2 cm superior to the orbital rim.

Approaches

There are variety of procedures, both surgical and nonsurgical, that may be used to elevate the eyebrow (Table 73–1). The coronal approach is the classic approach for browlift procedures. It involves making a large incision approximately 4–6 cm posterior to the hairline and elevating subgaleally down to the brow. Once all the tissues are released, the brow is then suspended in a more superior direction. The pretricheal browlift is performed in a similar fashion, but instead, the incision is placed at the anterior hairline. This offers the advantage that when the brow is elevated, the position of the hairline will remain unchanged. The midforeahead lift is performed by placing the superior incision in a deep, horizontal furrow. Incisions should be placed at different levels on each side so that there is not one long horizontal scar. The direct browlift is a skin excision technique that acts to pull the brow vertically upward. The incision cannot be carried deeper into the orbicularis muscle due to the risk of damage to sensory nerves. The inferior incision is placed just above the superior aspect of the eyebrow and the superior incision is placed more superiorly depending upon the extent of elevation needed. The transblepharoplasty browlift or brow pexy, also called the supratarsal browlift, is a great technique that can be used in combination with an upper lid blepharoplasty. It allows superior elevation of the brow complex as well as access to the eyebrow depressor muscles.

With the advent of endoscopic equipment and the push toward minimally invasive procedures, the endoscopic browlift has become the most popular technique today. During the procedure, small incisions are placed in hear-bearing scalp which allow access for a wide release of the brow complex as well as good visualization of the eyebrow depressor muscles. In the central forehead, the dissection plane is subperiosteal while lateral to the temporal line, the dissection occurs deep to the temporoparietal fascia or superficial temporal fascia. This avoids injury to the frontal branch of the facial nerve as the dissection is deep to the nerve. During the lateral dissection, a series of bridging vessels including the sentinel vein is identified which represents the close proximity of the facial nerve. The brow is released widely and the periosteum and galea is secured to the skull using a variety of drill-assisted securing techniques and devices. As compared to the coronal browlift the endoscopic approach does not require excision of hair-bearing skin while still allowing the surgeon to widely release the tissues necessary to achieve long-term brow elevation.

Botulinum toxin may be used to achieve eyebrow elevation as well, eliminating the need for an extensive surgical procedure. Botulinum toxin may be injected into the eyebrow depressors (procerus, corrugators, and orbicularis oculi) to temporarily paralyze them and allow the frontalis to elevate the eyebrow unopposed. This is a good technique for individuals who do not wish to undergo surgery; however, the duration is temporary.

Midface Anatomy

The malar prominence is the upper lateral mound of the cheek. It is composed of a subcutaneous malar fat pad with overlying orbicularis oculi. Deep to the orbicularis oculi is the suborbicularis orbital fat (SOOF). Motor supply is from the zygomatic and buccal branches of the facial nerve and sensation is from the infraorbital nerve and zyomaticotemporal branch of the trigeminal nerve. During the aging process, the cheek descends inferomedially, which consequently deepens the nasolabial crease. A midface lift intends to resuspend the cheek prominence and thus decrease the depth of the nasolabial crease.

There are two basic planes via which the midface lift may be accomplished. The approach can be either superficial to the investing fascia of the zygomaticus major muscle or deep to the periosteum. The choice of dissection plane depends on the patient's anatomy. Incisions to access the midface include the standard rhytidectomy incision, blepharoplasty incision, transoral incision, and endoscopic temporal incisions.

In an endoscopic midface lift, the midface is approached via the temporal or forehead area. Endoscopic forehead approach with midface suspension can be performed either with or without a browlift. A lower eyelid procedure is usually performed in conjunction with a midface lift because elevation of the malar tissue causes bunching of skin under the eye. Dissection is carried in a subperiosteal plane from the temporal line to the superior orbital rim. Dissection in the temporal region is over the deep temporal fascia to the bone of the zygomatic arch. Tissue over the arch is released and the dissection is continued inferomedially in a subperiosteal plane. The medial extent of the dissection is to the nasal bones and piriform aperture. As with the browlift, the midface/SOOF is suspended via sutures or absorbable suspension systems.

Patients typically experience edema of the midface region that may last for up to 6 weeks. In addition, they may experience masticatory tenderness postoperatively due to the dissection around the masseter and temporalis muscles.

There are many tools in the facial plastic surgeons armamentarium to combat the natural aging process. Each procedure and approach must be tailored to the individual patient. A thorough evaluation with appropriate diagnosis of the areas of concern, coupled with a well thought out plan of treatment should be discussed. Most importantly, communication with the patient to understand their goals and desires is an essential element in achieving an optimal result in aging face surgery.

We would like to acknowledge Anil R. Shah, Eugene J. Kim, MD and Corey S. Maas, MD for their contribution to this chapter in the previous editions of CDT.