Dr. Little’s Techniques
What’s New? in Facial Rejuvenation
Our Fascination with “New”
Household cleaning products are regularly marketed as “new and improved.” But over the last decade or so, how much have they actually improved in their day-to-day performance, despite their successive “new and improved” claims? Not that much, of course; breakthrough changes just don’t come along that often in cleaning products. Much the same can be said of cosmetic facial applications, such as lotions, moisteners, and emollients, for example. Yet most are regularly reintroduced as “newly improved” (or with new product names altogether). The reason for this, of course, is marketing: people like to think they are using the “latest” and “newest” products technology can offer.
So, what is new in surgical rejuvenation of the face, that part of overall facial rejuvenation that brings to the face meaningful improvements that are truly fundamental and long-lasting? Well…not much, actually… at least not in the way of substantive recent breakthroughs.
Some form of resuspension or lifting of fallen facial soft tissues is necessary for an effective rejuvenation result, and such lifting options are limited to the three basic facial planes (lifting of the skin alone has long been discredited as ineffective).
Suspension of the superficial or subcutaneous plane was first introduced in 1960, but fell out of favor by the mid 1970s (an inadequate number of sutures placed in the wrong location failed to create a lasting effect in those early efforts). A number of plastic surgeons have subsequently improved on those initial designs. Dr. Little returned to this plane of surgery in 1993 (the XJ lift) and, by fundamentally changing both the pattern and the extent of the suspensory sutures, found a highly effective method to restore the aging facial shape to a younger architecture, especially in the difficult jowl region (published in 2000 as the superficial component of his two-plane rejuvenation (see: about Dr. Little / abbr. C.V. Part II: publication #101).
Middle and Deep Planes
Suspension of facial tissue in the middle or SMAS (submusculoaponeurotic) plane was introduced in 1974. Here, too, there followed a series of refinements to the basic SMAS lift, most recently to extend its reach higher in the face, to include the midface region, as a “high SMAS.” Finally, suspension of tissue in the deep or subperiosteal plane (against the bone) was introduced in 1989. Again, refinements followed (Dr. Little introduced his own version of the subperiosteal facelift as the “malar imbrication” midface lift in 1994…the deep component of that same published paper). The point is that lifting in each of the three basic planes has been around a long time, albeit modified and refined over time. It is interesting that among the three, the “newest” (the subperiosteal lift) has suffered the greatest disaffection of late: despite initial enthusiasm for the procedure in the 1990s, many surgeons have returned to the two earlier facelift planes (Dr. Little continues to use the deep plane in selected cases, but far less commonly than before).
Endoscope and other Advances
An accompanying technological breakthrough in the 1990’s, endoscopic facelift surgery (performed through small incisions by way of narrow optical telescopes and long instruments), also enjoyed an initial wave of popularity as a major “new” advance in facial rejuvenation surgery. But use of the endoscope has also subsided dramatically (Dr. Little now employs it only in rare circumstances). More recently, facelifting techniques have arisen that depend on long, heavy sutures suspending fallen tissues that have not been exposed with the traditional degree of undermining and tissue release. While nearly all of these less-invasive techniques have proven disappointing, even over the short term, one has not…providing a “new” option in lifting that gives good (but not excellent) results with less surgery (Dr. Little now utilizes a similar suture in most of his neck corrections, providing better neck contour while limiting the extent of neck surgery in both his XJ and cable mini lifts). Still more recently, specialized “new” sutures with projecting irregularities have been tried to create a lifting effect to the face with minimal direct surgery. While initial designs have proven disappointing and ineffective (especially in their short-lived effect), other designs are ever under development. Should these eventually prove more successful, however, their application will likely remain limited to cases of early aging, as opposed to established structural aging with jowl and marionette-line formation, coupled with neck deterioration. For the foreseeable future, such established markers of middle and late aging will continue to require a conventional facelift performed in one of the three facial planes, with undermining and soft-tissue release, followed by resuspension, to provide meaningful, natural, and lasting benefit.
Finally, there are any number of highly marketed facelift techniques with Madison-Avenue-inspired names that appear regularly, all claiming the designation “new” or “revolutionary.” But each continues to lift in one of the three basic planes, sometimes with a cable-type suture, sometimes not. The “new” part usually represents some modified technical detail or other that brings little or no impact to the facelift final result. Typically, they are recommended to patients as a “one-size-fits-all” treatment (as contrasted with the multiple surgical options from which Dr. Little makes his recommendation for a specific patient). Some of these “new” facelifts may prove worthwhile, to a degree, in improving some strightforward aspects of facial aging (such as redundant, creased skin); their effectiveness in eliminating the challenging age markers around the mouth (nasolabial line, slumped corner of the mouth, bitterness fold, jowl, and marionettte line), however, remains predictably limited. As with any proposed facelift, the prospective patient should assess the supporting data critically by reviewing photographic results of sufficient number, consistency, longevity, and size (as discussed by Dr. Little in photographic About Results). Here, one should remain especially distrustful of dour, frowning “before” results displayed next to cheerful, smiling “after” ones (these latter often in motion).
The initial breakthroughs in correction of the aging neck began in 1968 and continued over the next decade, as alterations were brought to the fat, muscle, and later submusclar layers, accessed in part through an incision under the chin. After the further refinements that invariably follow such an introduction, open submental (under-the-chin) cervicoplasty (neck correction) continues to offer a time-honored solution for the challenging, heavy aging neck. But a “newer” re-examination of this traditional practice (that began in Europe) is questioning the movement of the relaxed neck muscle (platysma) toward the midline of the neck in favor of a vertical movement, in concert with movement of the rejuvenated jowl and corner of the mouth. The current trend suggests that fewer necks are now being “opened” with a scar under the chin; but an accompanying concern is that more necks will now end up under-corrected. Dr. Little is a member of the “newer” camp here, but as a long-term “neck specialist,” he also remains willing and able to “open” any neck (including reduction of the submaxillary glands) whenever the special situation requires.
Excisional surgery of the eyelids dates back to the early 1900s. Following a myriad of refinements over the following century, the main philosophical and technical approach to aging eyelid restoration has nevertheless remained excisional in nature, until quite recently. The “new” paradigm in thinking about aging eyes accepts that there is a significant lack of tissue volume around the aging orbit, rather than an excess (as believed before). Surgical solutions are now, therefore, more likely to be volume-neutral, or even additive, rather than subtractive. Dr. Little has been particularly committed to this “new” belief for a decade-and-a-half. While he adds volume to almost everyone’s eyelid region, he removes eyelid skin from only a minority of patients (and removes fat or muscle from almost none). He finds micro structural fat grafting his primary tool for the convincing reversal of eyelid aging.
Dr. Little has long considered rejuvenation of the mouth one of the most overlooked areas in facial rejuvenation. Shortening of the elongated, aging upper lip (through an external scar between the lip and the nose) was first introduced in 1975, but little else has since been added to help improve the slumped position of the aging mouth. Dr. Little described strategies to elevate mouth position internally (without scars) in that same paper of 2000 cited above. He has since added multiple additional maneuvers (of his own and others’ design) to further boost the consistency and effectiveness of such internal elevation (which he calls stomapexy). One of these is his routine division of the DAO muscle that depresses the corner of the mouth (contributing to the bitterness fold and marionette line), as described by French plastic surgeon Claude LeLouarn. His “newest” efforts in this regard include his direct elevation of the modiolus (corner of the mouth region) that becomes possible after DAO division and his direct, further suspension of the upper lip by “sub-alar hitch” (without the conventional scar that stretches clear across the lip). Although many practitioners maintain that fat grafts do not persist in the lips, this is contrary to Dr. Little’s experience; although not strictly “new,” he continues to prefer micro structural fat grafting over all other techniques for tasteful, volumetric enhancement of the lips.
The first modern, effective fat grafting to the face was described in 1989…making it hardly “new.” But it very much presents a “newness” about it, as its controversial nature has delayed its wide acceptance, especially among plastic surgeons who experienced problems in their initial attempts at such grafting. Today, while perhaps a majority of plastic surgeons perform some fat grafting to certain areas of the face, it appears that only a strict minority have confidence in its regular use in the challenging area of the eyelids (where its effectiveness is both greatest and most difficult to match by other techniques). But now that the clinical success of facial fat grafting has been largely accepted, areas of basic and clinical research are being actively pursued to further define, enhance, and refine its growing applications, among them its ability to introduce mesenchymal stem cells into areas of aging or other tissue damage for enhanced repair. A recent enhancement receiving attention (especially in Europe) is the addition of PRP (platelet-rich plasma with concentrated growth factrors derived from the patient’s own blood) at the time of fat grafting, to enhance the take of the graft. Although considered “new,” Dr. Little has been using (and teaching about) this additive for a decade (whose effectiveness he considers likely, but unproven).
While mesenchymal stems cells (derived from fat) present an exciting new entity with promise extending far beyond the field of facial rejuvenation, their effective use today is probably limited to those transplanted as a by-product of proper structural fat grafting. Widespread claims for their commercial success in a myriad of clinical applications at this time is seen by many leaders in this emerging field as premature or out ahead of supporting scientific research and validation.
The area within facial rejuvenation in which technological advances are most regular and ongoing remains its more “dermatological” aspects, including lasers, fillers, and paralytics.
Laser and related technologies are under constant development, with “new” models appearing on a regular basis. Although Dr. Little continues to prefer laser to other forms of skin resurfacing (albeit with a particular conservatism), he recognizes a sizeable contingent of facelift specialists who have turned away from lasers altogether to re-embrace earlier, lower-tech treatments, such as chemical peels and dermabrasion. The CO² laser that Dr. Little uses on the eyelids of almost all of his patients is not “new,” but is rather among the older laser modalities still in use; what is “new,” however, is the way in which he utilizes it–with a strict conservatism that reaps a worthwhile benefit in nearly all (but without the undesired side effects of heavier use).
Man-made dermal fillers are also in a state of perpetual development (especially with regard to longer-lasting materials), with new products coming to market at regular intervals. But even as emerging “new” products appear to offer longer survival periods with correspondingly longer intervals between re-injections, it is unlikely that the duration of any of theses dermal fillers will ever approach that of living fat grafts (which Dr. Little naturally prefers).
Neuromodulators such as Botulinum toxin (Botox™) that paralyze certain actions of the face represent another product line that is spawning “new” materials and alternatives with this or that purported advantage over the original. For example, there will soon be available a toxin in a cream base that the patient will likely be able to apply to her own crow’s feet lines. While Dr. Little finds these agents useful, he prefers longer-lasting solutions to muscle imblance and over-activity when available, such as surgical division of the DAO (the muscle whose activity is associated with bitterness-fold and marionette-line formation).
Illustration: detail from Leonardo da Vinci, “Study for the Virgin and Child with St. Anne,” ca. 1501 (?), British Museum, London