 
My name is Jim Zins
and I can tell you I've been doing facial aesthetic surgery
for a long time.
A gentleman doesn't divulge his age
but I have been doing this for a long time.
And I'd like to speak with you about a topic
which I have a passion for.
It's my profession but it's also my avocation.
So, what I'd like to talk with you about
for the next 20 minutes is a couple of pearls
on how to look better and maybe even look younger.
So, principle number one is the face ages
in a global fashion.
So, the face ages in its entirety.
It doesn't just age in the eyelid area or the cheek area
or the neck area but the entire face
ages in a global fashion.
And therefore, the best treatment really is
treating the face globally, not just treating it
in a single area.
Now, let's just look at this resemblance,
this mother and daughter photograph.
Clearly, we can recognize the semblance
but look what's happened with age.
With age that very attractive oval face of youth
has been now changed to a more masculine or square face
in the lower face.
And look, what's happened in the eyelid area.
The eyelids have skeletonized as the cheek
has descended in the lower face and the lower face,
the jowls have masculinized the lower face.
If we look at again, we can show this pictorially,
again, look at the eyelid and the cheek,
how it really is one in youth
but as the patient ages, the cheek descends
and the eyelid becomes separate from the cheek area.
The fold from the nose to the corner of the mouth lengthens
and the jowls for making the face
look more masculine or square.
So therefore, the best approach
because it's a global phenomenon is to treat the face
in a global fashion.
Now this is the best approach
but not necessarily the only approach.
But let's look at a few patients and we can see
the very nice changes that we can bring upon,
making the patient look better
and perhaps even look younger.
So, this is a before and after picture at one year
on a patient who first we treated with skincare
to improve the appearance of the skin,
to correct the muddily browns and whites in the skin,
blend the skin.
And then after that was done,
we did a face and neck lift and eyelid blepharoplasty.
And you can see the very nice change she's had
in the front view and the very nice change she's had
in the profile view.
And also, I just bring to your attention,
the change in the pigment of the skin,
how much nicer the skin looks
because of the skincare regiment.
The quality of the skin has improved,
in addition to improving the overall face, wow!
And if we look at another patient,
again, before and after the patient looks rested,
looks more relaxed and perhaps even younger,
after having a face and brow lift surgery,
facelift, neck lift and brow lift surgery.
If we look at this patient,
you can see the very traumatic change
she's had around the mouth.
In addition to a facelift, she had a chemical peel
where we treated the wrinkles around the mouth area.
Now, this requires a deeper chemical peel
than you get from the esthetician
because these wrinkles are so deep
and this was done at the same time
that we did her facelift surgery.
So, what happens with age?
Why do we age and what can we do about it?
Well, we think about this
as intrinsic and extrinsic problems.
Intrinsic problems are those problems which arise
because of your heredity, your skin thickness,
your facial bone architecture,
much of this you inherit from your mother and father.
And I'm gonna give you some example.
So, those are things we have no control over.
The extrinsic problems with aging,
those are smoking and significant verifications in weight.
Those things are very, very detrimental to your aging.
In addition to actinic changes or changes you get
from sun, wind, weather.
So, those are extrinsic changes which you can control.
Now, when we look at the face,
we can look at it from a subjective standpoint
but actually, as plastic surgeons,
what we do is we actually have numeric facial proportions
which we can observe and correct
and make the patient look better.
Now, after this lecture, you're gonna be able
to actually do this on your own
'cause many of these facial proportion concepts
are very, very simple.
So, if we look at the distance A,
that is distance from the brow to the corner of the eye,
that distance a should roughly be the same distance
as the distance of the upper lip
and that is the distance from the nose
to the corner of the mouth.
Similarly, that distance, C,
that distance of the upper lip
should roughly in the vertical dimension
be approximately one half of the distance
of the vertical distance of the chin,
or the, from the corner of the mouth to the chin area.
And when these distances vary,
then patients look less than ideal, less attractive.
Similarly, if we look at the transverse dimension,
that is the dimensions, horizontally from side to side,
the distance from the cheekbones here
should roughly be the same as what we call
the bigonial distance or the distance along the jawline.
And that should be roughly equal to the distance
in the temple region.
And then if we look at the profile area,
here's a line which is very, very easy to decipher,
if we just draw a tangent,
that is a tangent from the upper lip to the lower lip,
the ideal chin should fall on that line.
When the chin falls behind this line,
the patient has a weak chin.
When that chin falls in front of that line,
the chin is too prominent.
Both of which can be changed
with relatively small surgical procedures.
When the facial proportions are not ideal,
surgical correction can have
a very, very significant effect.
And let me just show you a couple of examples.
So again, we've looked at those distances.
If we look at the distance from the brow,
to the corner of the eye, it's relatively short
in this preoperative view.
And look what happens when we open up that eye
and we correct that distance.
So, the distance from the brow to the corner of the eye
is roughly the same as a distance from the base of the nose,
to the corner of the mouth.
Look how much that improves the appearance of her eyes.
And if we look at another patient.
This patient, if we look at the transverse dimension,
we've talked about the distance from the temples
should be roughly equal to the transverse distance
of the jaw.
Now, look what happens when that's abnormal,
look how abnormal that patient looks.
With a relatively straightforward operation,
we contoured the jawline and you can see
how we've made that patient looks so much more feminine
and we also lengthened the chin.
If we look at the distance from the nose
to the corner of the mouth,
we said that's roughly half the distance
from the mouth to the corner of the chin.
It's about one to one here
but look, what happens when we lengthen that distance,
how much more attractive that patient looks.
Here, we did a 45 minute operations
on this patient ventriloquist,
who was planning on getting married.
She came in, she didn't like the position of her chin,
in the vertical dimension or in the horizontal dimension.
Again, upper lip, roughly equal to the distance of the chin.
Look what happens when we vertically lengthen that shin
in a 45 minute operation,
you can see the very dramatic improvement that she has.
Again, that line from the upper lip to the lower lip,
that tangent now falls on that line.
And look what a decided improvement
that 45 minute operation has done.
We can put that together in this face, that patient.
And you can see, we've done a facelift
but we've also vertically lengthened the chin
to significantly improve the overall appearance.
So, facelift and a chin advancement to decidedly
improve the result of her surgical procedure.
Now, that's a fair amount of surgery of facelift.
You know, that's an operation
that requires general anesthesia,
requires a recovery of really a couple of weeks.
And many patients don't have the time
or don't wanna undergo such an involved procedure
but there is a subset operation where we can achieve
a very significant improvement in the jawline
with a much more simple operation.
If we look at this patient here,
this patient didn't have a facelift.
This patient had an operation limited to a small incision
under her chin and we liposuction chin area
and we put in a small chin implant.
And you can see the very decided improvement she had,
again with a 45 minute operation.
Now, we can extend this procedure and this is an operation
which I've championed over the years.
Here is a patient before and after.
Some may think she had a facelift,
but no, she didn't have a face of,
she had an operation that we limited
to just an incision under the chin,
we liposuction the neck area
and then we just tighten the muscle in the neck area.
And you can see the very decided improvement that she's had,
especially in her profile view.
So again, an operation that is much simpler,
much less recovery, much less costly
but with a very significant operation.
Again, no incision in front of the year,
no incision behind the ear, just a small incision
and a 45 minute operation to correct the neck line.
Here's another patient.
This is actually a patient.
It's actually a friend of mine
whose daughter was getting married
in about a month, six weeks.
She really didn't have the time to have a face facelift
but she was hoping to look better
at the time of her daughter's wedding.
So, what we did was did this limited operation
by making a small incision under the chin
and picking out the fat in the chin area
and tightening the muscle.
Again, not much change in the front view
but a very decided improvement in her profile,
in the neck line and in the jaw line.
So, you can see the very nice improvement
that we can get with a relatively straightforward operation.
Again, facial aging affects the entire face.
It's not just affect the eyelids or the chin or the neck.
It affects the entire face.
However, many patients come in
and they are concerned about one specific anatomic area.
Then that area can be, it certainly can be addressed.
The eyelid is a very common area for patient's to come,
they come in complaining of changes,
aging around their eyelids.
They really are not concerned about aging
around the rest of the face.
So, here is a patient with a significant lower lid problem,
lower lip lax.
And you can see, you actually see the whites of his eyes
in the lower lid area and you see the lower lid bags.
So, this was an operation.
This was a lower lid blepharoplasty
which requires a small incision under the eyelid area,
the removal of fat in lower lid area
or repositioning of that fat and then tightening up.
Again, very, very minor procedure
that gives you a really very, very significant.
He looks less tired.
He looks less angry.
Maybe he even looks younger.
Another patient who presents with what we call
congenital bags, that is baggy lower eyelids
which she had her entire life.
This wasn't just because of facial aging.
This patient is treated with an operation
where we just made an incision inside the eyelid area.
So, there's no incision made on the outside at all.
And you can see the very nice improvement
that she's had in the lower lid area.
Another patient, this is different problem.
This is not a problem of extra skin in the upper lid.
This is a problem of the muscle in the upper eyelid
is not functioning properly
and she has what's called upper eyelid ptosis.
So, what we can do again with an operation
that lasts about 45 minutes under local anesthesia,
with sedation, we can open those eyelids
by tightening that muscle and make that patient
look much, much more awake and alert.
This patient doesn't require upper blepharoplasty surgery
but really upper lid muscle tightening,
in addition to the blepharoplasty
and can see the very nice improvement.
Also, I'll point out to you that how the upper lid show
is consistent across that whole lid,
making that upper eyelid so much more attractive.
Before and after.
Again, tightening that upper eye lid
and making that upper eyelid look so much more attractive
and the patient looking so much more wide awake.
This patient has a lot going on in the upper,
in the orbital area.
She's got sleepy eyes
because the upper eyelid muscle's not working properly,
she's raising her eyebrow to try to correct
that upper eyelid ptosis because she has
very significant aging in the lower lid.
So, we did upper lid blepharoplasty,
we tightened lower lid and did a lower lid blepharoplasty
to get this kind of.
Again, all these procedures require surgery,
requires some downtime.
These various procedures, some requiring
a little bit more downtime than others.
Now, there are things that we can do in the office
that don't require the downtime.
And then we're talking about things
such as fillers and Botox.
Now, fillers fill, fillers to not lift.
That's a common misconception.
So, what we do is with facial aging,
patients have at least have the perception,
if not the reality of losing volume in their face.
So, what we do is we add volume.
I mean, who has no wrinkles?
Fat people, right?
So, what we're doing is we're adding volume to the face
to take away some of the appearance of deflation
or loss of facial volume or loss of weight.
And these fillers, there are wide variety of fillers.
The very most common ones are the hyaluronic acids.
That's the Restylanes, the Juvederms, the Volumas et cetera.
And the reason that these are so popular
are because they are reversible.
Should there be any type of problem,
patient is dissatisfied with the filler,
these are reversible.
So, that is one of the reasons,
they're so very, very popular.
Again, hyaluronic acid, Restylane, Juvederm, Voluma.
Radiesse is a more long lasting filler.
So, that is desired by some patients.
The problem is with Radiesse,
things are not reversible.
And then Sculptra, yet another prototype,
developed initially to treat patients with HIV,
lipoatrophy or AIDS to again, add volume to the face
with longer lasting results.
Now, when we talk about fillers,
the paradigm is very different from surgery.
And what do I mean?
When we do a surgical procedure,
the patient is told what the cost of the procedure
is gonna be.
And then we take the time and effort to do whatever it does
to deliver the best results.
Fillers, on the other hand is a bit different.
Fillers we have to, the patient has to pay
by how many syringes, how much volume we use.
So, if we use one syringe, it's one price.
If we use a second syringe, obviously it's more costly.
So, what a patients do?
They come in, I wanna treat my eyebrows.
I wanna treat my lower lids.
I wanna shoot down corner of the mouth
and I wanna use one syringe.
Well, you know, it doesn't work that way.
We need to use enough of the product to get the best result.
So, what occasionally can happen is that in an attempt
to save money by the patient or the doctor,
the patient is undertreated.
And therefore, they say the product didn't work.
Well, it wasn't that the product didn't work,
it was that not enough product was used
to get the optimal result.
On the other hand, it is perhaps best,
obviously we want to treat and get the ideal result
but probably under-treating is better than over-treating
because we can always come back and do a little bit more.
It's much harder to remove that filler,
than it is to add a little bit more.
So ideally, we'll look for the optimal result
but probably undertreatment is better than over-treatment.
So, is longer better?
The hyaluronic acids, for example,
they're relatively shorter lived
than products such as Radiesse or Sculptra
but when it lasts longer, it can be good.
But when it lasts longer, it can be bad,
especially if there's an adverse effect.
If you get a lump, irregularity, et cetera,
then in the longer lasting products,
that lump is gonna be there for a longer period of time.
So here, a couple of slides
on how we actually do the fillers in the office.
What I like to do is I like to use this eyeliner pencil.
I mark the areas that I'm going to treat,
and then I show the patient in a mirror.
Here are the areas that you and I decided
we're gonna treat.
So, in this patient, the folds were deep
and she had what we call marionette lines
or she had jowls in the lower face.
So, we're gonna treat what we call the nasolabial folds,
aligned from the nose to the corner of the mouth
and then we're gonna treat the lower face as well.
So, we marked out with the eyeliner pencil.
And then what I like to do is I like to treat
one side of the face and then allow the patient to sit up,
take a look in the mirror
and then they can compare the side that's treated
to the side that's untreated
and that they can see the difference
and they can participate in the decision.
Well, oh, it looks better
but I'd like a little bit more volume.
I'd like a little bit more effacement of the wrinkles.
Okay, then we can do a little bit more filler.
Or, you know what?
That looks ideal
and let's stop right there.
This is especially true in the lip area
where many patients want just a subtle change in the lip
and they don't want the lips overdone.
So, we can do low lips, we can have the patient sit up,
they can take a look and say, okay, you know, that's enough.
Or you know what?
That's better but I'd like to see my lips
a little bit bigger.
The areas that I most commonly treat with fillers
are the nasolabial folds.
That's the folds from the nose to the mouth,
the lips, the marionette lines or the so called puppet lines
or the lines just in front of the jowls,
the corners of the mouth and the tear trough
is that skeletonized area under the lower lids
which I showed you at the beginning of the talk.
So, nasolabial fold from the nose of the corner
of the mouth, these are really easy areas to treat.
And the ideal candidates are those patients
who like everything else,
the younger, the easier they are to treat
because the skin is elastic.
There's not a lot of skin to fill.
So, the ideal patient is a patient
with relatively tight skin.
The more difficult patients are those patients
with very deep fold and have true skin excess
and I'm gonna show you examples of both.
So, here's a before and after.
This patient had two CCs or two syringes of hyaluronic acid
to treat the nasolabial folds,
the line from the nose to the corner of the mouth.
And this is approximately six months later.
Here's another patient treated with one CC on either side,
treating the lines from the nose to the corner of the mouth,
softening the corners of the mouth.
And finally, another patient,
nose to the corner of the mouth.
And another patient.
Again, softening those lines,
nose to the corner of the mouth with one CC
on each side of hyaluronic acid.
The next patient, this is a patient you can see
that the folds from the nose
to the corner mouth are significantly improved.
But this 70 plus year old patient,
for me to correct these with filler
would take a gallon of filler because the skin is so loose
and he really has true skin excess.
So, instead of filler, what we did was we did
a direct excision or cut out the skin
between the nose and the corner of the mouth
and you can't even see the scar
because that scar is so well hidden within the fold.
So again, a procedure that's done under local anesthesia,
with approximately five or six day recovery,
very simple and a very significant improvement.
We treated this patient with the direct excision
of the skin to achieve this result,
rather than using filler.
The tear trough area or that area skeletonized
in the lower lid, that's the difficult area to treat
and that's gotta be treated judiciously
by someone who's fairly experienced.
We treat that area, again, with local anesthesia.
I use a blunt catheter that minimizes the pain.
I use local anesthetic with epinephrin in it
to minimize the bruising.
And again, office procedure to camouflage
that skeletonization of the lower lids.
And you can see this before and after picture.
This area requires very, very little filler.
So, this was just a half of CC of filler on each side
to correct this area.
And here's another patient,
again, age has skeletonized the lower lids.
So, we've gone ahead and we put filler
in the lower lids, using a half a CC on each side
to correct the hollowness or skeletonization
of the lower lid region.
Lips are tricky.
Lips are also another more difficult area.
The easiest patients to treat, to fill their lips
are patients who have substantial amount of lip
to start with.
And I'll show you a couple of examples.
And then the patients with very, very thin lips,
they're more difficult to treat.
So, here's an example of one CC of filler in the upper lip.
If we're going to treat the upper lips,
we will treat the lower lips 'cause the upper lip
really should be smaller than the lower lip.
So, once the upper lip is treated,
we also treat the lower lip.
So, you can see the improvement that this patient
had with a very small amount of filler in the lip region.
And then finally, Sculptra.
Sculptura, as I've mentioned to you,
this was developed initially,
you treated patients with HIV
what's called lipoatrophy where they lose volume
in their face, they loose soft tissue fat.
And I got a lot of experience in treating those patients.
Then this became approved for facial aging.
And now, we can use this very akin to fat grafting.
So here is Sculptura.
It comes as a powder.
We reconstitute that with a local anesthetic
and then that's injected into the face
and it's actually stimulates fibrosis and wound healing
and it adds volume to the face.
So, you can see this patient with hollow cheeks
was corrected with two sessions of filler,
using L polylactic acid or a Sculptura.
Again, fillers augment facial volume, fillers fill.
They can correct contour irregularities.
They soften the aging lines.
They cannot lift.
They can give the appearance of lifting
but they cannot truly lift.
Complications, nothing we do is free of problems.
Fillers are relatively free of problems
but there can be problems with fillers.
Those problems can be addressed with hyaluronidase.
That is an enzyme which dissolves the hyaluronic acid.
So again, that's one of the main reasons
that we favor the use of hyaluronic acids,
as opposed to the other fillers.
If you can see here again,
wait, don't tell me, something must be different.
It's a pleasure talking with you.
I'd be glad to answer any questions.
And it's really been a lot of fun.
One question we have is,
how do I maintain dermal fillers?
Is there anything I can do to make them last longer?
Longer-lasting fillers can be good
and they can be bad.
So, one thing is the choice of filler will dictate
to some degree how long the filler lasts.
The more cross-linked the hyaluronic acid,
the longer it tends to last.
Hyaluronic acids work.
We inject them but they have absorbed water very avidly.
So, as they're absorbing water,
that's how they maintain their volume over time.
One way to maintain that filler.
I like to see the patients back in four to five months.
And if I see you back in four to five months
and you've had a little bit of loss of filler,
just a small booster at that time,
I can generally get the filler to last for a year,
to a year and a half.
So, the best way to maintain that filler appearance
is to return to see me or to see your doctor,
rather than when it's all gone.
In four to five months, when there's only been
a small amount of loss,
then a small booster can lead to longterm maintenance.
How old is too old for face lift?
That's also a wonderful, wonderful question.
And I have to refer you to the article
which I wrote on this topic about two or three years ago.
When what we did was I took my last 215 facelifts
and we divided those patients into
what we considered the older age patients.
Those were patients who were over 65 years of age.
And we took the younger age patients
who were less than 65 years of age.
And then we looked at problems
which is what you're asking me.
When do the problems become so apparent
that it's inadvisable to do the surgery?
When we looked at those two groups of patients,
the older age group and the younger age group patients,
there was no increased incidents of problems
in the patients over 65 years of age,
minor problems or major problems,
compared to the younger patients, less than 65 years of age.
But what does that mean?
That means that's presupposes good screening.
So, when you come into the office,
we do a good history to make certain that there are not
significant predisposing factors
that would make surgery inadvisable.
So, what do I mean?
Well, if there were significant heart disease,
significant lung disease, something that's gonna make it
more likely for you to have a problem.
I actually saw a patient last week, very anxious,
an older patient of mine had done surgery before
who wanted to have a facelift,
but her medical history precluded that.
So, I had to say, you know, although you're a candidate,
you know, you have the sign to facial aging.
This is not an operation for you.
It's really too risky.
We certainly don't wanna take a chance
with elective surgery, if your health is in question.
So, those patients would have to be turned down.
So therefore, although those patients, over 65,
had no higher innocence of problems,
it was because they were pre-screened.
Now, other specialties don't have the luxury of doing that.
I mean, if you need bypass surgery,
we can't turn you down
just because you're not terribly healthy
or you have a cancer, you still have to have the surgery.
We have the luxury of being able to pre-select our patients,
unlike many other surgical subspecialties.
Therefore, physiologic age is more important
than chronologic age.
So, your actual age is not as important as your health,
basically is what I'm saying.
So, we operate on patients who are 65 years of age
for face lift.
We operate on patients who are 70, 75
and I've even operated on a patient who is 90 years of age
to have a face lift
because these patients were in good health.
Wow, thank you.
That also answers the question of who isn't eligible
for a facelift.
So, thank you for that.
And then the last question that I see right now
is how long will face lift last?
Well, again, these are all wonderful questions.
These are great questions.
How long have face lift will last is individualized,
depending on many of those factors
which I talked to you about before,
the intrinsic factors and the extrinsic factors.
Intrinsic factors, we're talking about your bony structure.
Those patients who tend to have weak chins,
that if the skeleton,
it doesn't support the soft tissue well,
then those patients tend to age a little bit prematurely.
So conversely, those patients with good bone structure,
with the chin is an ideal position,
the cheek bones are strong.
Those patients are going to age better
and their facelift is going to last longer.
Conversely, that patient who has had a lot of sun damage,
has got a lot of extra skin,
that patient who has lost a huge amount of weight.
We're talking about a hundred pounds.
Those patients, their face lift is not gonna last as long
as patient who are younger, whose skin is more elastic,
who haven't had the amount of sun damage
that they have and have a good bone structure.
So again, it's very, very variable.
But if you were gonna globally ask me,
what do I see?
What do I see about my patients coming back?
You know, I've been doing this long enough
that patients come back for a second faces
very, very commonly.
Generally, patients are coming back to see me
in about 10 years.
The neck has held up very, very well
during that 10 year period
and the amount of work I need to do on the neck
and a secondary face life is relatively little.
The cheeks and the nasolabial folds,
the cheeks have descended more.
So really, what we can do is you can limit that surgery
just to the cheek area and really do little or nothing
in the neck area at that 10 year interval.
But by and large, I'm finding the patients are the,
the face that is lasting about 10 years.
Well, that seems to be all of our questions
that we have for the evening.
Again, thank you so much Dr. Zins.
My pleasure.
For innovative and interacting
with your patients in this way.
My pleasure.
We appreciate it
and we hope you enjoy the evening.
All right, have a great night.
