Any treatment suggestions for deep marionettes lines and jowls?

Dr. Dean Kane Q & A.

Q. I have a heart shaped face which is slim. I'm 47 and do not want a facelift. What are my best options to smooth out deep marionette lines and jowling. Had Juverderm late last year and some Voluma added to cheeks to try and lift and plump my mid face a little. Right now my face looks miserable even when I'm not, because the corners of my lips drop downwards. I exercise a lot too. Which treatment would be most economical? Any advice would be greatly appreciated. Thank you!

A. Various options for facelifting, minimally and non-invasive facial enhancements and skin texture improvements are available according to the skin laxity and areas of lift or tightening you wish or need.

​Your question centers over the use of fillers yet your description sounds as though you have a significant amount of skin laxity. Fillers do a wonderful job up to a point but if you can "pinch more than an inch of skin along the jawline in front of the earlobe" I recommend you consider surgery to redrape the underlying soft tissue descent and skin lift with skin excess removal.
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​Please consult with a Board Certified, well experienced Plastic Surgeon or ENT Facial Surgeon for your best evaluation and recommendations.
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​A patient with significant skin laxity may note some improvement with facial fillers alone but the value is in lifting the tissues and removing the skin excess first and then filling in volume loss thereafter. Don't forget skin tightening therapies like ZO Obagi Skin Health.
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​Both surgical and minimally invasive / non-surgical options are listed below.

Surgical lifts would be likened to pulling the bedspread and or top-sheet of your bed up to the head-board and removing the excess material.

Minimally invasive procedures such as fillers provide volume such as adjusting a pillow under the bedspread. Botox and Dysport act by pulling the top-sheet which drags the bedspread upwardly. If the bedspread (or skin) continues to fall to the foot of the bed despite fillers, Botox or Dysport you will need to consider a facelift.

Non-invasive options such as laser and light therapies, skin tightening products and technologies perform their tightening and smoothening of the skin similar to sending your bedspread to the dry cleaners. A more refreshed, even colored, glowing smoother and tighter spread covers the surface of the bed.

The most popular of the fillers, Restylane and Perlane, a jelly-like clear skin filler is used to fill lines, wrinkles and folds. Juvederm and its longer lasting "cousin"Juvederm Ultra Plus are similar skin fillers, used to soften and fill the nasolabial ("parentheses") and marionette folds, the brow ("number 11") lines and fill and lift the cheeks and lateral brow or chin.Voluma is the longest lasting, up to 2 year duration HA filler. Each one is used to expand or volumize the loss of tissue associated with expression, weathering or aging. All the fillers come with numbing anesthetic!

Non-surgical facial contouring is possible with fillers such as Radiesse, a bone mineral for the nose or cheeks, jaw and chin as well.

Sculptra is the latest of the injectibles stimulation collagen at different levels of the skin adding volume but primarily firming and adding resistance to the formation of wrinkles, folds and descent.

Botox and Dysport too have been found to rebalance excessive facial expression, provide a non-surgical brow lift and lip lift and reshape the nose, as well as reducing wrinkles!

Dr. Obagi's new, second generation ZO Skin Health programs may be added to personalized chemical peels, light and laser resurfacing and tightening and will, smoothen and even the color of your skin.

IPL and fractionated lasers such as CO2 and erbium and now RF (radiofrequency) are additions to smooth the texture of the skin, tighten and reduce red and brown uneven pigmentation.

Face lift and / or neck lift or any of the other procedures and their combinations should be discussed following a proper examination by a Board Certified Plastic Surgeon who performs all of these options so you will not receive a biased approach because he or she is limited in their skills.

​I hope this has helped! All the best!

I'm considering CoolSculpting for my arms as they have become saggy. Could it make them worse?

Dr. Dean Kane Q & A.

Q.  I'm considering CoolSculpting for my arms as they have become saggy. Could it make them worse?

A.  CoolSculpting is a "tried and true" method to reduce fat content in skin bulges!

​It has worked very well on properly selected patients for the arms. In fact, even heavy patients have been pleased because the small increments of arm fat reduction allows them to wear tops with sleeves that have previously been tight.

Thinner patients are pleased with CS's results on their arms as well. Caveat emptor: do not expect skin reduction or tightening with CS! On occasion, patients, particularly of color or reddish coloration have experienced some skin shrinking. This is due to the inflammatory response which is seen more in these patients, than those of white, north european descent.

You should discuss CS as well as other options such as lipocontouring and / or arm lift with a well experienced, board certified Plastic Surgeon who has properly examined you.​

​I hope this is helpful!

All the best!

At age 45, I understand a facelift would be best, perhaps augmented with other treatments. What should be done?

Question from Virginia, VA: I am aged 46, and have gained and lost and gained again 25 pounds over the past ten years. I have tried to manage areas of my face with injectables, but ultimately where I once had a very defined bone structure, my lower face has become saggy and more jowly than I would like. In regards to my lower face, what would you recommend? Also, could this area be effectively managed with injectables for a couple of years before doing a more invasive procedure?

 Answer from Dr. Dean Kane, Board Certified Plastic Surgeon from Baltimore:​

​It would be helpful to see full face and neck photos but I will review and offer you options.  It will be best for you to review these with a in-person evaluation.

Various options for facelifting, minimally and non-invasive facial enhancements and skin texture improvements are available according to the skin laxity and areas of lift or tightening you wish or need. Both surgical and minimally invasive / non-surgical options are listed below.

Surgical lifts would be likened to pulling the bedspread and or top-sheet of your bed up to the head-board and removing the excess material.

Minimally invasive procedures such as fillers provide volume such as adjusting a pillow under the bedspread. Botox and Dysport act by pulling the top-sheet which drags the bedspread upwardly. If the bedspread (or skin) continues to fall to the foot of the bed despite fillers, Botox or Dysport you will need to consider a facelift.

Non-invasive options such as laser and light therapies, skin tightening products and technologies perform their tightening and smoothening of the skin similar to sending your bedspread to the dry cleaners. A more refreshed, even colored, glowing smoother and tighter spread covers the surface of the bed.

The most popular of thefillers,RestylaneandPerlane, a jelly-like clear skin filler is used to fill lines, wrinkles and folds. Juvederm and its longer lasting "cousin"Juvederm Ultra Plusare similar skin fillers, used to soften and fill the nasolabial ("parentheses") and marionette folds, the brow ("number 11") lines and fill and lift the cheeks and lateral brow or chin.Volumais the longest lasting, up to 2 year duration HA filler. Each one is used to expand or volumize the loss of tissue associated with expression, weathering or aging. All the fillers come with numbing anesthetic!.

Non-surgical facial contouring is possible with fillers such asRadiesse, a bone mineral for the nose or cheeks, jaw and chin as well.

Scuptrais the latest of the injectibles stimulation collagen at different levels of the skin adding volume but primarily firming and adding resistance to the formation of wrinkles, folds and descent.

BotoxandDysporttoo have been found to rebalance excessive facial expression, provide a non-surgical brow lift and lip lift and reshape the nose, as well as reducing wrinkles!

Dr. Obagi's new, second generationZO Skin Healthprograms may be added to personalized chemical peels, light and laser resurfacing and tightening and will, smoothen and even the color of your skin.

IPLand fractionatedlaserssuch asCO2 and erbium and now RF(radiofrequency) are additions to smooth the texture of the skin, tighten and reduce red and brown uneven pigmentation.

If you can pinch more than an inch of skin along the jawline in front of your earlobe, you should consider a surgical option to redrape and remove extra skin. 

You may consider: a traditional face and neck lift, short scar face and / or neck lift.

The recent resurgence of the S-Lift (created in the early 1900's), also called by other names as the Quick-Lift, Lifestyle-Lift, Swift-Lift, Soft-Lift, MACS-Lift and others; are a single modification of the S-lift targeted to elevate sagging lower cheeks jowls and lateral upper neck. The shorter scar, limited undermining and second layer lift achieve the "quicker" procedure but not necessarily the quicker recovery or the improvement you desire.
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It is my thoughts based on these limited photos that you consider a face and neck lift. Thereafter, the use of skin firming, tightening and filling options to maintain or improve your investment. 

Face lift and / or neck lift or any of the other procedures and their combinations should be discussed following a proper examination by a Board Certified Plastic Surgeon who performs all of these options so you will not receive a biased approach because he or she is limited in their skills.

​I hope this was helpful! All the best!

Dr. Dean Kane Q&A – My face is aging from weight loss and age. I have Ehlers Danlos. What are my options?

Question from Chicago, IL: I am 45. Until 3 months ago, I had a youthful face. I've lost weight over the last year, about 20 pounds. I weight 105 and am 5'2.5". Lines around my mouth are forming that weren't there before and I have mildly lax neck skin. I'm also wrinkling around my eyes. I've been told to stay away from lasers, as a treatment burned and scarred me. Retina-A made my pores worse. Honestly, with Ehlers-Danlos, what are my options for this aging -- do I have any? Or is my best course to regain a few pounds?

 Answer from Dr. Dean Kane, Board Certified Plastic Surgeon from Baltimore:​

You appear to have lost significant weight creating a more laxed skin as well as creasing around the lips. 
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​Ehlers-Danlos Syndrome is a constellation of elastic tissue problems due to improper production of the various forms of collagen in the skin, joints, intestines, blood vessels and other organs and tissues. 
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​Depending on the type of inherited problems you have will there be different options for you. 
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​It will probably take a university hospital group effort with your Dermatologist to provide the best opportunities in achieving a more youthful appearance. For greater fullness, fillers with different properties may help. Consider the use of Sculptra to stimulate greater fibroblast formation of skin molecules such as collagen. Ask about the use of laser or light therapies. As you probably know, surgery may not heal well. 
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​As this is not my super-specialty, I can only offer you these usual options to consider.
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​I hope this has been somewhat helpful. All the best!