UNDERSTANDING FACIAL REJUVINATION

Dr. Mentz was the first surgeon in the United States to achieve triple Board Certification in Plastic Surgery, Facial Plastic Surgery, and Head and Neck Surgery-Otolaryngology (in 1999 there were only 4 in the U.S.). Because of this he is among the best trained and sought after plastic surgeons for facial rejuvenation. He has recently published the chapter "The Multilayer Facelift" written for the textbook Operative Plastic Surgery describing the most advanced techniques for natural facial restoration and rejuvenation and has given many lectures in many countries on expert facelift techniques. His five years of residency training at Tulane Medical Center in New Orleans with two of the best in the field of Facial Plastic Surgery created a vast experience in the area of facial rejuvenation surgery and open structure rhinoplasty. During his additional two years of Plastic Surgery fellowship in Houston he gained additional depth in facial reconstruction and reconstruction with Dr. Tom Cronin and Dr. Raymond Brauer, both internationally known for innovation and expertise in facial surgery. Beginning his practice in 1991, he has worked to build the largest Houston Cosmetic Surgery practice known as The Aesthetic Center for Plastic Surgery. His interest has been to develop comprehensive plastic surgery care, incorporating as much as necessary to improve results and speed recovery for his patients. He has continues to improve his technical expertise by continuing to study and improve. Recently Dr. Mentz was one of first to receive the Certificate of Advanced Education in Cosmetic Surgery granted by the American Society of Aesthetic Plastic Surgeons, along with the Physician’s Recognition Award and Certificate of Recognition from the American Medical Association and the American Society of Plastic and Reconstructive Surgeons. Recent presentations to the International College of Surgeons have includes topics focusing on Structure Rhinoplasty, new techniques for endoscopic browlifts and facelifts, Special techniques for eyelid and brow lifts, and many liposuction techniques. In the last few years, Dr. Mentz has made an effort to incorporate nutritional healing into his practice. Dr. Mentz believes that when these advances are utilized together with the most advanced surgical techniques available, patients can achieve their best possible result with the lowest risk and effort. We hope that you are able to fully utilize this small book and hope that you will keep it for future reference or pass it to a friend for their benefit.

Dr. Mentz’s goal is to reverse the effects of time on the aging face. This requires specialized knowledge in nutrition and holistic medicine, skin biochemistry, pharmacology, and modern plastic surgical techniques and methods. The scope of knowledge is broad. Dr. Mentz’s training has been unique and comprehensive. He began with basic general surgery principals, focusing on head and neck surgery, specifically on the cosmetic portion of facial plastic surgery, developing more depth with full plastic and reconstructive surgery and getting fully boarded in these three specialties. He feels that the following information will be of benefit to you. Dr. Mentz’s goal is to provide comprehensive cosmetic medicine and surgery that minimizes risk, maximizes benefit, and provides the service at a reasonable cost.

Our patients very frequently request facial rejuvenation. The goals of facial rejuvenation are:

Perhaps in no other area of plastic surgery does the individual surgeon’s aesthetic sensibilities and choice of technique create such a difference in the final result. In the early days of plastic surgery, mini-lifts and minor procedures were performed. However, the corrections achieved by those techniques were quite limited, and they did not last long. In the past decade, surgeons have described a variety of techniques designed to give a better and longer-lasting correction, but each had its own drawback.

To create a more youthful face, we utilize different surgical procedures, often in combination: one portion deals with the upper third of the face (endoscopic brow or forehead lift), one with the middle third or the cheek (deep layer repositioning) and lastly, the bottom third (necklift). It is worth mentioning that prior to having any of these procedures performed, a good skin care program and the gentle use of topical Retin-A or alpha - hydroxy acids, as prescribed by you doctor, can prove highly beneficial in decreasing the aging process of the skin.

We may first become aware of the aging process when looking in a mirror, viewing recent photographs, or when family, co-workers or friends comment that we look tired. While much of the aging of our skin is predetermined by our genetics, smoking excessive sun exposure and poor health habits certainly can affect your skin. With time, skin tone deteriorates when collagen and elastic fibers thin, and gradually a drawn and tired look appears. Fine lines and wrinkles develop. The skin surface may loose its tone; develop irregularities in both color and texture because of decreased blood supply. The smooth glow and translucent appearance of a baby’s skin is gradually lost. While a facelift provides improvement to skin wrinkles and folds and repositions soft tissues, it does not affect skin quality (color, translucency, and texture). Skin quality is best treated with a combination of good skin care and perhaps laser resurfacing, chemical peels, and fat or collagen injection (these are discussed later).

However, the most characteristic sign of the aging face does not occur in the skin, it occurs deeper. Underneath the skin, muscle tone and volume decrease with age. As facial muscle lose tone, the cheek and brow tissues slide downward due to gravitational forces and can cause either a "sad" or "mad" appearance to the brows. In the midface, "jowling" at the jawline and deepening of the cheek creases causes a hound dog look. The nasolabial folds - those lines that run from the corner of each nostril to the corner of the mouth - become deeper with time. We often see accumulation of tissue and deep wrinkles near the corners of the mouth, and sometimes this sagging disrupts the naturally smooth line that used to run from the chin to our ears. As we age, we tend to lose the thin layer of fat that supports and "plumps" the skin of the face. We may note "bands" in the muscle in the front of our neck, creating a hooding between our lower chin and neck or a sagging of skin in the neck. Weakening of other facial muscles causes eyebrows to sag and eyelid fat to protrude. Combined with very fine, sun-related wrinkling of the skin, these are the first signs that make us feel that we are starting to show our age.

The typical facelift patient may not be concerned just with an aged appearance, but may be concerned about having a facial expression which does not actually portray how they actually feel. A tired sad look even when well rested is the most obvious, but there are many patients who seem to appear unhappy, angry, or scowling - even when they are perfectly happy! These expressions are often due to drooping facial fat and skin, creating deep folds and lines that obscure our true outward emotions.

This is where the facelift works its wonders. It corrects deep nasolabial folds, jowls, and bands in the neck. While facial peels and the laser may firm skin and improve color, the facelift lifts and restores all the deeper soft tissues of the face that have fallen over time from the effect of gravity. In other words, the treatment of facial aging is directed at two different conditions. The first category is the treatment of excessive loose skin and the second category is sagging of the underlying supportive tissues and fat. Most often people will have some portion of each of these. You will see that we treat these conditions in much the same way you would "take in" a jacket that is too large by first replacing sagging padding in the shoulders (deep layer lifting) then removing excess material and restitching the garment (tightening the skin). Ironing is then used to take out small wrinkles (chemical or laser peel). Dr. Mentz will help you evaluate your own face to discover what contribution the deeper sagging tissue and the excess skin and wrinkling makes to your appearance, so that you can better understand what to expect from the various treatment options.

The time to consider a facial rejuvenation and its associated procedures is when the aging process becomes noticeable and bothersome to you. For some unusual patients this happens in their 20’s. For others, it could be the late 70’s. The average "age" ranges in the forties and fifties. Facelift surgery does not "stop the clock," but it does turn back the hands of time. After a facelift, most patients look seven to fifteen years younger. The aging process then continues, but you will always look younger than if you never had the surgery. Patients frequently wonder whether having a facelift will make them need another surgery sooner: the answer is no. The clock is turned back for you at the time of your facelift, and in no way does it make you need another one sooner or at all. For example, if an identical twin of yours had facelift surgery, that twin would always look younger than the one who did not. The aging of an individuals face, again, is based on your own individual aging process which is affected by age, heredity, health, exposure to the sun, diet and exercise, smoking, and other habits along with technical factors like strong bone structure. The better you take care of yourself, the longer the results will last.

For years, many surgeons believed that the underlying cause for "jowling" and "sagging" of the face was looseness of the skin. Based on that thought, techniques were developed for skin tightening. The results did not last long and left sweeping redraping lines where the skin was loose or a wind tunnel look if too tight. Later, muscle tightening was utilized. Trying to correct these muscles resulted in a longer recovery with more swelling. More recently we have learned that facial aging is due to two factors: the loss of elasticity in the facial skin (skin looseness and wrinkles) and the descent of facial soft tissue including the fat and muscle of the face (jowl, sagging neck, tear trough, brow heaviness). This is not unlike breasts or buttocks where time and gravity causes descent of fat and skin. A non-invasive procedure called MRI (magnetic Resonance Imaging) has been recently used to study the aging face. These studies have shown that it is truly the descent of facial fat and muscle that cause jowling and sagging of the face.

Previous facelift techniques would just tighten the skin, leaving the fat in place. This would look like tightened skin with the jowling still in place. Tightening of the muscle layer alone (known as the "SMAS") without ensuring all fat was elevated would oftentimes give an abnormally drawn appearance. With this appraisal, over the last few years Dr. Mentz believes that the combination of several techniques can maximize your results:

Multilayer facelifting allows tailoring at every level - skin and soft tissue can be lifted at different tension and different directions. Every patient ages in a different way and multilayer facelifting can create better harmony from brow to eyes to cheeks to neck. Achieving a natural and undetectable result is Dr. Mentz’s goal.

These concepts have allowed me to lift and relocate all of the fat and skin to give a more youthful appearance. All of the drooping fat of the jowls and cheek folds are elevated back into their proper anatomical position. It allows for a more complete lift without having to pull the skin as tight, giving a much more natural result. Although this technique is more challenging for the surgeon, it appears to be easy on patients. In our hands, this has given the most noticeable improvement of any techniques that I have used. Patients experience very little post-operative discomfort, their recovery is brief and comfortable, and in our experience, they can return to their normal routine sooner than with other techniques.

The face-lift (rhytidectomy) is a frequently requested procedure. After evolving through a series of techniques, Dr. Mentz now has an approach, as authored in the book Operative Plastic Surgery, which can give a predictable, long-lasting, and natural result. The goal of face-lift surgery is to create a natural, more youthful facial contour with removal of wrinkles and folds of the cheek and neck with minimal detectability.

The face shows aging as the skin grays, thins and wrinkles, the brows, cheek and neck fat sags downward due to gravity, the muscles weaken and lengthen due to the continual weight of the soft tissues, and the bones and teeth begin to shrink. Optimal facial rejuvenation gives a natural look by altering all the aging facial elements in proportion. It is impossible to achieve a natural look when a plastic surgeon pulls with all his strength against the skin. This creates distortion. A natural rejuvenation typically requires bony augmentation, soft tissue repositioning, skin tightening and skin quality improvement. Dr. Mentz believes that for most patients the best strategy to achieve this combination of tasks is through a combination of techniques. He typically uses a multi-layer multi-vector technique and sometimes utilizing endoscopic brow and cheek suspension. Dr. Mentz can overlap soft tissues for cheek and jaw enhancement, lift and suspend soft tissues and muscle to reposition sagging or stretched tissue, and tighten the skin to take away wrinkles and looseness. Skin quality can be enhanced preoperatively with a program of Retin-A and/or alpha hydroxy acids to offset the chronic effects of the sun or smoking. Both substances increase blood flow to the skin and increase skin thickness and tone.

The most frequent face-lift done in the world today is a superficial skin lift. This is when one layer of skin is undermined and repositioned. The results from this procedure are good because the facial wrinkles and jowling are improved and the face remains balanced. However, it does not treat the underlying force creating the sagging (sagging muscle, sagging brow, cheek and neck fat, and receding bone). Therefore, many patients who have seen plastic surgeons that primarily utilize this procedure may have an unnatural pulled look with abnormal skin redraping. Furthermore, patients who receive this type of treatment may require a secondary face lift in 5 to 10 years since the underlying force creating the sagging was not treated and the skin undergoes "stress relaxation." In stress relaxation, the skin stretches due to the underlying forces.

The second generation of face-lifts involves the tightening of the skin and tightening a portion of the deep layer of neck and cheek muscle. This gives an outstanding, long-lasting appearance to the neck, but again the effects on the face can be short-lived. It can create facial disharmony by giving an extremely youthful neck but an older face, especially in the area of the mid-cheek. Early stress relaxation of the facial skin can lead to the need for secondary surgery in a few years.

The third generation of face-lifts separates and repositions all the aging elements of the face at a deeper plane. The brow and cheek soft tissues, muscle, and neck muscle are all undermined and repositioned at a deep layer. Since these structures have more strength than skin, the results last longer. The skin is also pulled up in addition to the deeper elements creating a "double tightening" which is stronger and lasts longer. Separating and repositioning these facial elements and pulling them in a natural direction avoids the abnormal skin redraping effect. This is the method most utilized by Dr. Mentz.

Sometimes augmentation of bone is used to offset the shrinking that occurs with age that cannot be addressed with the soft tissue overlap. Silastic implants are used primarily along the chin to reestablish a more youthful jaw line. This is performed with small implants, and the results can be dramatic. Dr. Mentz can make the incision in the mouth just under the lower teeth and place the implant through there. Soft food diet and mouth rinsing for three days is required in the recovery. Expect temporary fullness in the jowl area for a week or two. Usually there is no bruising. Dr. Mentz often utilizes fat grafts to fill areas that have thinned through the years. New processing equipment and microinjection techniques have drastically improved results and durability of the fat grafts.

The face-lift improves the signs of aging in the lower two-thirds of the face, and with deep layer lifting especially useful in the midface. The brow lifting improves the upper third. Eyelid procedures reduce aging around the eyes and nasal and jaw contouring techniques restore youth in these areas. These are used often in combination for full facial rejuvenation. In order to create a natural and youthful appearance it is important to restore and reposition structures. That is to replace and retighten soft tissue and muscle along with the standard skin tightening. Facial rejuvenation is not only face lifting but also a larger number of adjunctive procedures, which enhance the result. Creating natural and undetectable rejuvenation is the key. The real difference between the specialized aesthetic plastic surgeon and the plastic and reconstructive surgeon who does an occasional face lift is the ability to use these additional tools to maximize a natural balanced appearance

Tobacco in any degree affects your result. Cigarettes, cigars, chewing tobacco and even nicotine patches and gum interfere with the blood flow inside small vessels of the skin. Smoking or being exposed to a smoker’s second hand smoke decreases blood flow in your facial skin and can cause skin death. If this happens to you, the healing time will be very long and the scars will be more significant. Therefore, if you cannot stop smoking Dr. Mentz will have no choice but to reduce the extent of the surgery and create less change for you. If you do not stop smoking and do not tell the truth to Dr. Mentz you can jeopardize your result and put yourself at significant risk.

A certain degree of apprehension and anxiety is normal with any operative procedure. Fear is generally associated with the unknown. Dr. Mentz believes that by providing you with as much information as possible may alleviate much of your concern prior to surgery. If your concern is postoperative pain, severe pain is very uncommon for this type of operation. Slight to moderate discomfort (similar to a headache) is the rule. When the operation is performed by an experienced, skilled plastic surgeon, any fear you may have should be minimized. Sufficient preparation and pain medication can usually alleviate any discomfort. If you feel that you need supervision and assisted care Dr. Mentz may recommend one of several specialized overnight facilities.

The face lift procedure may be performed in a plastic surgical facility or hospital with comfortable sedation and local anesthesia (twilight sleep) or total sleep (general anesthesia). Dr. Mentz usually prefers general anesthesia in healthy patients because it reduces operative time and allows full control by the anesthesiologist. While asleep, a long-acting local anesthetic is injected so that you feel minimal discomfort following your surgery for the first several hours. The Aesthetic Center for Plastic Surgery has state certified and AAAASF credentialed operating rooms for all types of anesthesia, including general anesthesia. We only use physician anesthesiologists at our center.

The incision lines are usually carried from the mid hairline above the ear to the crease just in front of the top of the ear, then either in front or in back of the tragus (a protuberance of cartilage just at the front of the ear canal) (Dr. Mentz will use either but prefers the incision in front for most patients because it leaves the ear looking more natural). The incision is then carried around, hugging the earlobe of the ear, curving onto the back of the ear and high into the hairline. If an endoscopic browlift is done there are another three incisions in the hair above the forehead about a third of an inch long. If the necklift is performed there may be an incision under the chin crease less than an inch long. Although this sounds quite extensive, the incisions are quite inconspicuous once they heal and are made at the junction of anatomic zones. Typically all sutures are removed before the seventh day. Dr. Mentz almost never uses staples. The incisions will remain slightly pink for 6-12 weeks and may be covered with makeup. Usually a mint green base under your regular makeup will take the pink out.

Preoperatively (and even postoperatively), it is valuable for the patient to utilize a skin conditioning program (Dr. Mentz recommends Biomedic or a dermatologist monitored program) which may include Retin-A, glycolic acid, alpha and beta hydroxy acids, sunscreens and moisturizers. Systemic illnesses such as hypertension or diabetes must be controlled, and the patient should be deemed in good health by their family practitioner. Dr. Mentz recommends these steps prior to your surgery:

On the day of your surgery you may be anxious so here are some tips to keep your day organized:

On the day of your surgery you will first check in. Preop labs may be done afterward, including bloodwork, urine tests, pregnancy, chest xray and EKG, depending on your history and health. You will then meet the anesthesiologist. If you have anesthetic questions this is a good time to ask them. If you have serious anxiety about the anesthesia, Lupe, your patient coordinator, can arrange for a special meeting with the anesthesiologist several days before your surgery. You should do this if it will allow you to sleep better. Later an IV will be started in your arm. Dr. Mentz will see you next to review our plans and to discuss new questions since your consent. If you are second or third on the schedule and the case before you is running overtime, please be patient. We cannot always predict whether cases will be easy or not and no one would want Dr. Mentz to hurry through their surgery because of an impatient client. From there you will be rolled on a stretcher to the operating room. The operating room will be bright and busy. The anesthesiologist will usually give you some oxygen by mask and you will soon be put to sleep with IV medicines. The anesthesiologist throughout the case will closely monitor you and adjust your medicines, as they are needed. Everyone requires differing amounts of medication and the anesthesiologist adjust these dosages immediately as necessary. You will awake in recovery typically with a soft ice pack covering your eyes so you will not be able to see. You can ask the nurse to remove it temporarily to get you bearings then it should be reapplied to reduce bruising and pain. After an hour or so you will be moved to a step down area or may be moved to an overnight facility.

These are some helpful guidelines to speed healing and ease recovery:

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Billions of dollars per year are spent to camouflage the effects of aging. Until recently, no cosmetics had any scientific benefit. Many companies have found that moisturizing skin and adding sunscreens to makeup can slow the aging process by lessening the effects of the sun. Furthermore, the use of sophisticated skin treatment programs incorporates the use of alphahydroxy acids or glycolic acids to thicken the skin and promote exfoliation and cell rejuvenation. Since this is a huge market, cosmetic companies have put millions of dollars into research. This has finally begun to pay off by incorporating scientific information and applying it to skin products rather than merely trying to camouflage the problem. It is appropriate at this point to discuss the different types of wrinkles before explaining potential treatment programs.

There are five types of wrinkles:

Multiple treatment modalities are available - Retin-A, alphahydroxy acids, glycolic acids, chemical peels, dermabrasion, fat injections, collagen injections, or even face-lifting. Depending on the cause of the wrinkle, the treatment can range from minimal treatment of Retin-A to moderate treatment, such as chemical peels or dermabrasion. The most aggressive treatment is face lifting. Fat and collagen injections have been effective but are a temporary compromise, as they ultimately will recede in effectiveness.

Skin tone can be improved by increasing the thickness of the dermis with collagen or elastin. Methods of doing this involve Retin-A, glycolic acid, alphahydroxy acids, or repeated superficial or medium depth chemical peels. Cosmetics that contain collagen are not effective since collagen is a macromolecule and cannot penetrate the skin.

At the Aesthetic Center for Plastic Surgery we offer superficial, medium and deep peels. In general, the deeper the penetration of the chemical the better the result. However, deeper penetration of the chemical involves greater risk. Therefore each patient must be individually evaluated for depth of penetration and risk/benefit.

Jessners Solution and dilute trichloroacetic acid (20-30%) are superficial peeling agents. Superficial peels are done in the office with minimal discomfort. One or more coats can be applied to increase depth. In general, the patient can return to work with only some redness of the face that resolves with subsequent flaking of the skin over the next tow to three days. Multiple superficial peels are equal to one medium depth peel. Multiple medium depth peels are equal to one deep peel.

Retin-A is a potent form of Vitamin A that can partially reverse the sun-damaged problems of aging skin. Retin-A stimulates the blood circulation and restores a "rosy glow" to the skin. This increased circulation increases cell growth and turnover. This helps replace the skin collagen and elastic. Patients will require a moisturizer and absolute sun protection. It generally takes three to four months to see an affect with Retin-A. Fifteen percent of the people have a dramatic effect from Retin-A in reducing wrinkles of the skin. Fifteen percent are totally unable to tolerate the treatment due to severe irritation. Seventy percent see a mild to moderate improvement in the quality of the skin.

Some people do not tolerate Retin-A. Luckily, alphahydroxy acids have been shown to increase cell proliferation and deposit collagen and elastic in the skin when used on a chronic basis. Glycolic acid or alphahydroxy acids can be used as a mild chemical peeling agent to reduce facial wrinkles. Detectable changes occur in two to three months. The typical program involves twice daily application of the glycolic or alphahydroxy acid.

These aging spots represent and advanced form of facial aging and sun damage. These lesions must be peeled off to allow deeper elements of the skin to resurface and replace the sun damaged skin. This can be done with frequent superficial peels or medium depth peels depending on the degree of damage. Sending a high frequency radio wave through the skin to coagulate the blood vessel and diminish spider veins of the face. This is done in the office with minimal discomfort. These veins unfortunately do come back with time and must be retreated.

Alpha-hydroxy acids are naturally occurring acids that are found in many foods. The AHAF include glycolic, lactic, citric, and tartaric acids. These agents have been utilized for many years by facialists. Dr. Mentz performed his first Alpha-hydroxy peel in 1986 with Glycolic Acid. Glycolic acid is present in sugar cane, lactic acid in sour milk, citric acid in grapefruit, and tartaric acid in grapes. Ancient use-restoring remedies, such as sour milk baths to smooth the skin or stale wine application to the face for wrinkles, probably worked because of the alpha-hydroxy content of lactic or tartaric acid, respectively. Today, alpha-hydroxy acids and glycolic acids are used to treat wrinkles. Constant daily use of low-dose acid and a night cream gradually creates a freshening effect. When combined with a program of superficial or medium-depth peel using alpha-hydroxy acids, one can get a more dramatic response. It is almost always a part of a comprehensive face rejuvenation program. Patients with many small veins in the skin or who have rosacia may not be good candidates.

Trichloroacetic acid (TCA) 20-50% is the most popular medium depth-peeling agent today. It is applied in the office sometimes after a pretrial treatment with Retin-A or glycolic acid. This peel eliminates many skin lesions and fine wrinkles associated with aging, but does not eradicate deep wrinkles. The patient is left with a "rosy glow" of the face. It also rids the skin of superficial pre-cancerous or cancerous growths and helps blend in areas of blotchy pigmentation. TCA is predictable and safe; however, it is not a cure-all solution. One peel will not last a lifetime and typically Dr. Mentz prefers to use three peels in sequence six weeks apart. It is a part of a comprehensive face rejuvenation program. Recovery from the first peel is one to seven days, and is usually quicker on the second and third peel. The skin usually peels like sunburn. Dr. Mentz believes that this peel has the most impact after the second peel.

Phenol peels are deep-depth peels and have been around the longest. This chemical penetrates the deepest but also has a prolonged recovery period and higher risks. When appropriately applied, years will melt away as the facial skin tightens, lifts, and smoothes wrinkles. It is not a substitute for cosmetic surgery but is a great adjunct, especially in removing the deep wrinkles around the mouth. This procedure is done in the office or the operating room with an intravenous solution for comforting, pain control, and sedation. After the peel, the patient may go home or recover in the hospital for 24 to 48 hours to control pain and facilitate care. Recovery from this peel generally takes two weeks. The principal drawback is the permanent bleaching effect on the skin, which requires makeup to correct. The laser has almost replaced this method.

The principal risk to the patient is dissatisfaction due to inadequate correction of the wrinkles. Dr. Mentz’s feeling is that we would rather re-treat rather than over-treat the skin. Peels that go deep can give dramatic results. However, complications are directly proportionate to depth of the peel. Complications such as scarring, bacterial infection, viral infection, prolonged redness, permanent color mismatches, and worsened cosmetic results have been reported. Patients with a history of fever blisters or Herpetic facial blisters should alert their doctor and will likely need a preventative antiviral before the peel.

Dermabrasion is also effective in removing wrinkles and acne scars. It can be even more effective than the superficial or medium depth peeling agents. It has the advantage of being directly controlled by the surgeon and is more effective than peels in the treatment of scars from acne or trauma. Peels normally do not remove raised grooves from the skin unless the peel is quite deep. Dermabrasion of any depth is very good at destroying raised grooves from the skin. It is easiest to visualize the dermabrasion as a snowplow scraping away everything down to a certain level, whereas the peel is like a lawnmower that rises up over a bump and down the opposite side. Its principal use lies in the treatment of wrinkles around the mouth.

Laser resurfacing has been used for many years but has advanced signifigantly in the last few years. Dr. Mentz did his first laser surgery in 1985. New types of lasers and gadgets have improved the technique. Dr. Mentz prefers that all laser procedures be done with general anesthesia. The laser is passed over the skin and removes the surface layer. Lasers are tuned to very specific energy settings and will peel to a specific depth. Usually CO2 lasers require extended recovery with skin heeling completed in 7-10 days and skin pinkness resolving in 6-24 weeks. Erbium lasers heal in half the time. New lasers that combine CO2 and Erbium and stronger Erbium lasers promise faster healing and reduced risks. It is generally accepted that the longer the healing the better the result, but deeper peels carry more risks and longer recovery.

There are a variety of additional procedures that are frequently done in conjunction with a facelift, depending on individual patient’s aesthetic desires. Some of these procedures are part of completing the "rejuvenation" of the face, and other times patients may want to improve a feature that may have bothered them for years. Many patients will try to combine these with their facial rejuvenation experience. In most circumstances it can be beneficial to reduce your recovery to a single experience. In some instances it may be in your best interest to separate the surgeries. Dr. Mentz will give you his best advice for these combination services.

EndoscopicBrowlift Breast Augmentation

Chin Augmentation Breast Lift

Cheek Augmentation Breast Reduction

Cheek Fat Removal (buccal fat) Tummy Tuck

Blepharoplasty (eyelids) Body Lift

Lip Augmentation Thigh Lift

Rhinoplasty (nose) Hand Rejuvenation

Skin Resurfacing Liposuction (arms, trunk, tummy, thighs, calves)

Neck Lift (platysmaplasty) Abdominal etching

Fat grafting

Endoscopic Forehead Lift or Facelift (or browlift): The facelift addresses the lower two thirds of the face, but does little for the forehead. Many of our patients also desire improvement in this region, and the procedure we most frequently perform here is called the endoscopic forehead (or browlift.) In this procedure three of four very small incisions are made behind the hairline, and a special fiberoptic camera is inserted through one hole while instruments are inserted through one hole while instruments are inserted through the other. Watching our instruments at very high magnification on a television monitor, we can elevate tired droopy eyebrows, and decrease the wrinkles between the eyes and on the forehead. These techniques can be applied to the cheek. By tunneling underneath the cheek and suspending and lifting the cheek with anchors the midface can be lifted without the traditional facelift scars. Careful patient selection is important in achieving the best results.

Cheek and Chin Augmentation: As the skin begins to sag and the fatty tissue layers drop or are lost, contour imperfections of the face may be very noticeable. In such cases additional procedures can be performed to support or augment the bony structures of the face. At the level of the cheekbones, for instance, flattening can be improved through placement of naturally shaped, silastic cheek implants. Made from a form of soft plastic, these are introduced through the mouth or facial incision lines. Likewise, silastic chin implants can enhance the contour of the chin and help to sculpt the neckline. Depending on the degree of augmentation, extra fat can be placed atop the cheekbones for a natural augmentation. This bony augmentation is an important, modern technique for creating a youthful, yet natural appearance. Chin implants are often placed through a small incision inside the lower lip.

Cheek Fat Removal: These techniques are combined with spot facial or neck suctioning, or buccal fat excision, in which excess cheek fat is removed through a tiny incision inside the mouth, resulting in a more sculptured appearance to the cheeks. While the chin augmentation makes the cheek bones themselves wider or more foreword appearing, the buccal fat excision removes fat from "chubby cheeks" below the bones. Fatty tissue removed from the face or other parts of the body can often be processed and used to fill out thinning lips or small depressions of the face at this time.

Blepharoplasty: Many patients that are seeking facelifts also have excess skin and or fat in the upper or lower eyelids. This can be treated at the time of you facelift, if you desire. There are a variety of techniques and options available, and Dr. Mentz will discuss which of these would be best for you. Most combine some fat removal and skin tightening to improve the eyelids. Occasionally lower lid fat can be shifted onto the cheekbone for improved balance. The eyelids may also need tightening if the cheeks are flat or the lids are loose.

Lip augmentation: As we age, our lips tend to thin. On frontal view there is less red showing, giving a thin appearance to the lips. As the volume "deflates," deeper wrinkles appear in the lips. On side view the lips seem retracted. Augmenting the lips often does wonders to improve the balance and appearance of the face. This can be done through a variety of techniques, either with temporary measures such as collagen, or permanent measures such as fat injection or the placement of fascia. Fascia is a very special tissue in the body that is a film covering muscles which we expose during a facelift; this can be placed in the lips to make them fuller, restoring a "pouty" appearance and diminishing the depth of folds within the lips themselves. Dr. Mentz prefers fat grafting for lip enhancement because of better contouring control. Fat grafts do create 1-3 weeks of post-operative swelling.

Rhinoplasty: Some patients notice that with time their nose gradually began to look larger, or droop more at the tip. In these cases nasal refinement becomes an important part of achieving a natural and harmonious result. Others have a bump on their nose or a bulbous, ill-defined tip that they may have noticed for years. The nose can be operated on during a facelift, and if this is a concern, you should discuss it with the Dr. Mentz.

Hand Rejuvenation: There is an adage that says you can always tell someone’s age by looking at their hands, and to some degree that was true - until now. Today, many patients are having minor surgery to rejuvenate their hands while they are already asleep for their facelifts. As we age, the skin gets marred with sunspots, and hand fat is lost making the veins, tendons, and bones become prominent. The skin can be treated with a light peel, large veins can be removed, and the tine skin plumped up to a more youthful configuration by fat injection.

Skin Resurfacing: As the analogy made earlier stated, the facelift (and brow lift) are like when a tailor "takes in" fabric and the skin resurfacing is like when the garment gets ironed or pressed. While the facelift removes or improves the deeper lines, the very fine liens would still remain. Many years ago, surgeons attempted to correct these fine wrinkles and sags by pulling the face as tight and flat as possible. This gave a very unnatural, mask-like appearance. Perhaps the notion that may people have of the "unnatural facelift look" came as a result of this sort of surgery. Today these lines can be corrected with either a light peel , either with a special chemical or with the computerized carbon dioxide laser. These can help treat "crepe" appearing skin of the eyelids, crow’s feet, fine lines around the mouth, and fine wrinkles and texture and color irregularities throughout the face. Some of this may be done at the time of the facelift, and other areas may have the best result if treated at a later time.

Other Procedures: Depending on the total time involved and the patient’s overall medical condition, other procedures such as breast surgery, tummy tuck or liposuction on the abdomen or thighs are often done at the same time as a facelift. Ask Dr. Mentz or Lupe if you are interested.