Why does a facelift not remove the lines, particularly around my mouth?

Aging appears to be the passive wearing and dysfunction of human tissues. Facial aging is recognized by the deflation and sagging of facial tissues and the wrinkling and folds of the skin “cloth”. Over time, epidermal (and dermal) thinning and loss of collagen allow the facial skin to lose elasticity. The response is a greater pull by the facial muscles on thinner skin producing more wrinkles. Add to this, the deflation of the facial fat even with weight gain and a “deflation wave” occurs at the brows, naso-jugal (tear trough) fold, nasolabial fold, marionette fold and the neck. Even though a facelift ( in appropriately called a rhytidectomy, ie “excision of wrinkles”) may improve some perioral (around the mouth) wrinkles, the correction is limited, as this area is surrounded by zones of adherence, is typically not undermined, lifted and redraped, It is also the farthest area from the point of pull and therefore receives the lease amout of stretch. Even in the most experienced hands, these patients lack complete rejuvenation and are simply “face lifted”. By not addressing the rhytides and deflation of the perioral region, a facelift alone fails to obtain adequate global facial rejuvenation and thus creates facial disharmony. This understanding has transitioned the art of facial rejuvenation from simply pulling and tightening to a more intricate model of a “lift-and-fill” technique. Recently, there has been an evolution of transferring autologous fat to treat facial aging. Facial aging is not merely a skin problem, as all layers of the face (i.e., skin, fat, and bone) change with age and therefore collectively contribute to aging.  Facial fat is not composed of a single confluent mass; it is maintained in deep and superficial compartments separated into compartments. These compartments are divided by fascial membranes that drfine the unique appearances of the face.[12,13] The perioral region has distinct superficial fat compartments and is an aesthetically fundamental component that aids in expressing emotion, passion, youth, and vigor. An aesthetically ideal lip, characteristically, has a vermilion/cutaneous border thickened with a pout, philtral columns prominent and full, and commissures slightly upturned. Bioengineered fillers have been used successfully to provide perioral fill and line reduction. They are readily available and tolerated by most patients, with good outcomes, but do have their limitations, Autologous fat would serve as the ideal filler particularly when removed at facial surgey because it not only provides volume replacement for the perioral region but also may offer dermal regeneration of the thinned skin. Bioengineered fillers should be first line for rejuvenating the white roll, and autologous fat can be reserved for volumizing the deeper perioral region. Our next approach in the mechanical approach of a face”lift” is the replacement and redistribution of lost fat volume and physiologic stimulation of crease correction in our skin “cloth”.
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