Correction of involutive changes in the lower third of the face: possibilities of plastic surgery

Sergey Kadochnikov, PhD, leading surgeon at the Virtus clinic (Odessa)

The lower third of the face is, rather, not an anatomical concept, but a visual one. Dividing a face into thirds is based on the idea of the proportional relationship of parts, the so-called “golden section” rule. According to this rule, the lower third of the face is the area located between the lines drawn at the base of the nose and at the very bottom of the chin. However, in practice, as a rule, operations that improve this area also affect adjacent zones: the middle part of the face and neck, therefore, in terms of surgical anatomy, the division into medial and lateral triangles of the face seems more logical. Nevertheless, in modern aesthetic medicine this approach, divided into thirds, is more common, so we will start from it when analyzing surgical methods for correcting involutive changes in the lower third of the face.

18–35 years old: correcting natural characteristics

At this age, as a rule, problems of facial disproportion come to the fore due to impaired development of the bones of the facial part of the skull. These may be conditions associated with developmental anomalies of the bones of the upper and lower jaw - retro- and prognathia, retro- and progeny. The presence of these conditions disrupts the ratio of the thirds of the face, leading to the formation of a “bird-like” face, visual dominance of the nose, or, conversely, weighting of the lower part of the face, which causes aesthetic imbalance and, accordingly, discomfort in women.

Depending on the severity, the problem can be solved by osteoplastic surgery. For example, severe retrogenia requires surgical lengthening of the branches of the lower jaw, which is performed through intraoral approaches. However, in most cases, retrogenia is not so pronounced and, in the presence of a normal occlusion, can be corrected using silicone implants. The operation is usually performed through intraoral access. There are several models of implants, differing in width, height, and profile, which allows you to select the required shape with a sufficient degree of individuality. The implant bed is formed subperiosteally; the presence of a sufficient layer of tissue above it makes the implant practically indeterminable visually and can only be determined by palpation with a thorough examination.

Excessive development of the mental tuberosity (severe square chin) may require resection through an intraoral or anterior neck approach. Part of the bone tissue that forms the tuberosity is removed, while the projection of the chin is reduced, which, in turn, makes facial features more harmonious and “softens” the expression.

There are options for resection of the angles of the lower jaw, which allows you to change the shape of the face from round or square to oval or triangular. Such operations have become widespread mainly in the countries of the Far East, and this is due to the desire for “Europeanization,” although the round face was originally considered the standard of beauty in China, Japan, and Korea.

Also, the problem of facial fullness in the lower third at this age can be solved using liposuction along the contour of the lower jaw, the front and side surfaces of the neck. With hypertrophy of Bisha's lumps, they are removed from intraoral access. This is a relatively common operation performed on young people of Slavic appearance.

It is necessary to mention the operation to form cheek dimples . Using intraoral approaches, subdermal sutures are applied, fixing the skin to the underlying muscle structures, which leads to the formation of retractions - dimples on the cheeks when smiling and articulating. This operation is popular in the Middle East.

Methods of surgical augmentation of the upper lip by V-Y-plasty, sutures that suspend the upper lip, and lipofilling are quite in demand. Moreover, as practice shows, lipofilling is becoming increasingly popular as a means of replacing artificial fillers and allowing one to obtain a result that is stable over time.

36–42 years: correcting the initial signs of atrophy

In this age interval , signs of atrophy and caudal displacement of facial fat packets begin to appear, as well as initial signs of soft tissue ptosis:

• caudal translocation of cheek fat pads and depletion of soft tissues of the midface and periorbital zone occurs;
• there is a lowering of the level of the oral fissure relative to the upper row of teeth, and when smiling, the lower teeth become visible;
• The outer corners of the mouth may also droop...

As a rule, the contour of the lower jaw does not change directly, and there is no sagging of the platysma along the anterior surface of the neck. Accordingly, correction of changes in the area of the lower third of the face in this age category can occur “remotely”, due to the elimination of ptosis of the middle zone of the face, moving and fixing fat packets upward.

Operations such as endoscopic lifting of the midface, lifting the midface from a subciliary approach, the so-called check-lift, make it possible to redistribute and lift the buccal fat packets and strengthen the ligamentous apparatus of the periorbital region through sutures. This leads to raising the corners of the mouth, reducing the severity of nasolabial folds, and the redistribution of adipose tissue upward restores the “middle zone triangle” and reduces the fullness of the perioral area.

Of course, in this group all the same interventions described above can be performed, including correction of bone structures, lipofilling of the lips, perioral zone, formation of cheek dimples, and surgical correction of the shape of the lips.

There is some interest in techniques that allow one to lift the drooping corners of the mouth. This is achieved indirectly by lifting the midface, but there are local lifting techniques. This is an intraoral lifting of the orbicularis oris muscle according to W. Little, excision of the skin in the area of the outer corners of the mouth, resection or intersection of the depressor muscles of the corners of the mouth, followed by lipofilling in the area of diastasis.

It should be noted that the zones of the anterior and lateral surfaces of the neck are very closely connected with the lower third of the face. In fact, this is one anatomical zone, the basis of which is the platysma - the muscular component of the superficial muscular-aponeurotic system of the face. In the middle age category, as a rule, there is no ptosis and relaxation of the platysma, no true excess skin, and the amplitude of manual tissue movement is very small. However, patients at this age often come with a desire to improve the contours of the neck and the severity of the cervical-mental angle . In the absence of indications for performing open lifting of the lower part of the face and neck, operations are performed to apply tracer sutures to the platysma. In this case, the medial edges of the platysma are sutured with sutures that are passed under the skin and fixed in the retroauricular space to the periosteum of the mastoid processes. These operations are minimally invasive and are performed using mini-approaches. The use of threads (for example, Silhouette Lift) simplifies these interventions.

If there are excess fat deposits on the front and sides of the neck, liposuction of these areas is performed. The absence of superficial fascia on the face and neck, separating the superficial and deep fatty tissue, requires special care when performing liposuction in this area, so that subcutaneous irregularities and retractions do not form. The resulting fat aspirate can be successfully used for facial lipofilling: filling lips, nasolabial folds, “marionette lines.”

42–45 and older: a variety of surgical methods

Historically, the area of the lower third of the face and neck is a “key area” for surgical rejuvenation, the correction of which uses a variety of surgical methods. It is with the improvement of the oval of the face that modern plastic aesthetic surgery of the face originates. It is the improvement of the contour of the lower jaw, neck, the absence of “puppet folds”, sufficient tension of the muscular frame, according to D. Marchac, F. Nahai, that determine the success of the face lifting operation. Most aesthetic surgeries on the lower part of the face are performed to tighten this area together with the neck.

Ptosis of the superficial muscular aponeurotic system of the face determines characteristic problems - loss of the contour of the lower jaw, the appearance of sagging - “jowls”, the severity of the platysmal strands on the anterior surface of the neck, “weighting” of the lower part of the face due to ptosis of fat packets and an increase in subcutaneous fat deposits, the formation of true excess skin.

Changes in the superficial muscular aponeurotic system (SMAS) determine the tactics of surgical correction, namely the need to fix the subcutaneous structures to obtain a long-term result. The main key points are movement and fixation of the SMAS with a vertical direction vector and excision of excess skin flap. There are classical techniques where a long skin incision is made and a SMAS flap is formed, followed by cutting off the excess and fixing the flap.

There are well-known methods of deep facelifts according to Hamra, where mobilization of flaps is performed in the subfascial layers over a long distance, after which the combined skin-SMAS flap is moved in one block.

B. Mendelson introduced the concept of “prebuccal and premasseteric” spaces into aesthetic facial surgery, by working with which one can achieve a significant improvement in the contour of the jaw, eliminating “jowls” and “marionette folds.”

In the last decade, short-scar lifting with SMAS plication or thread suspension has become very popular - MACS-lifting (minimal access cranial suspension lifting) according to A. Verpaele. In this technique, there is no need to perform a behind-the-ear approach, and the SMAS is suspended with three threads according to the problem areas: the middle third, the corner of the mouth, and the neck. The threads are fixed to the deep structures of the face.

The popularity of low-traumatic techniques is determined by a shorter postoperative period, but there are factors limiting their use: significant tissue ptosis, the presence of large excess skin, severe neck ptosis. The arsenal of a facial aesthetic surgeon should include several techniques that may be applicable depending on the condition of the soft tissues of the patient’s face.

Considering the anatomical relationship of the lower third of the face and neck, in order to achieve a good oval contour of the face, it often becomes necessary to eliminate the platysmal bands and improve the condition of the anterior surface of the neck, for which purpose it is performed according to Feldman. Most aesthetic surgeries on the lower part of the face involve lifting this area together with the neck.

In patients of the older age group, improvement of the condition of the lower third of the face is impossible without a combination of surgical correction technologies and cosmetic effects on the skin. The main priority is the possibility of tissue regeneration and improvement of tissue blood flow, for which platelet-rich plasma and platelet lysate are actively used in the postoperative period, which accelerates healing and tissue revascularization. Excised excess skin flaps can be sent to a cell laboratory to obtain a culture of skin cells - fibroblasts, the introduction of which in the postoperative period has a stimulating effect on the skin. It is the combination of technologies that makes it possible to eliminate not only tissue ptosis, but also stimulate skin regeneration.

First published: Les Nouvelles Esthetiques Ukraine, No. 5 (87), 2014, pp. 80-84