Dr. Little’s Philosophies
The architecture or shape of a person’s face tells more about their apparent health and vitality (and age) than any other aspect; while folds and wrinkles are important to correct, they are almost never as important as overall facial architecture.
Thus, while it is the folds and wrinkles that we see when we look for aging in ourselves and others, it is the architecture that we recognize instantly and unconsciously that sends the more powerful message. While it is true that a few patients limit their personal aging to the development of loose skin alone (without the shape-based changes that affect most of us), this group represents a small minority in facial aging that responds well to almost any simple lifting technique (these are often the patients seen in a single before-and-after view within cosmetic surgery advertisements). Thus traditional surgeries that have targeted surface redundancies through tension at various facial planes have proven less effective in Dr. Little’s experience than surgery that has restored the face to an earlier architecture or shape, without tension.
The Inverted Cone of Youth
Portrait artists understand that the youthful face presents an “inverted cone of youth,” with a graceful fullness high in the cheek region, while the jawline remains sleek and sculpted. With aging, this architecture reverses itself, as the cheeks flatten…then hollow, while the lower face accumulates fat and skin that distorts the jawline, producing what we think of as the jowl. A good metaphor for such shaped-based facial aging (as first suggested to me by Maryland plastic surgeon John Eng, M.D.) is the common hen’s egg: when the egg is positioned upright with its narrow end down, it presents the volumetric distribution of a young face with an “inverted cone of youth;” when the egg is turned over, with its broader end down, the shape now resembles that of the aging face with jowls. [view: Egg Metaphor for Volumetric Facial Aging in diagrammatic form] Associated with this jowl and its volume excess may be a “marionette line” (deep crease in front of the jowl), a “bitterness fold” (a sagging of the corner of the mouth), and a “ptosis” (or sagging) of the jawline itself, as well as of the chin and the neck.
Reversal of this lower facial excess and sagging remains Dr. Little’s foremost surgical priority, as he focuses on elimination of the jowl, with its associated aging distortions. The multiple components that make up this “jowl complex” can be reviewed schematically. [view: Components of the “Jowl Complex” in diagrammatic form] Dr. Little has found that if the jowl is redistributed in a precise vertical direction, there will follow a concomitant filling of the lower cheek (submalar) hollow, along with firming and sculpturing of not only the jawline, but–to a significant degree–the neck, as well. Such vertical resuspension of the jowl complex is, in fact, the only maneuver required to restore both the face and the neck to a natural, earlier appearance in many patients. For those patients who have lost shape from their upper cheek region (or who have always envied fuller cheeks), a simple further enhancement of the cheeks by fat grafting may be added during the basic procedure. Among patients consulting Dr. Little because of disappointment with a prior facelift, the most common complaint remains inadequate correction of the jowl region, with persistence of marionette lines and jawline irregularity. [But while reversal of the jowl remains an almost universal goal in facial rejuvenation, every such principle invariably presents exceptions in this complex field: thus do some of the patients in the photographic Results section actually show evidence of volume and fat added back to the lower face or jowl region.]
Illustration: detail from Leonardo da Vinci, “The Lady with the Ermine (Cecilia Gallerani),” ca. 1483-1490, Czartoryski Museum, Cracow