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Ramirez. Plast Aesthet Res 2020;7:25 I http://dx.doi.org/10.20517/2347-9264.2019.78 Page 9 of 21

Beautification
Rejuvenation is also a beautification procedure. The three-dimensional enhancement brings back the
curves and projection of a youthful and beautiful face. This is different to the stretched look of traditional
facelifts. The creation of the ogees of the face is a powerful maneuver to obtain simultaneous beautification
and rejuvenation. Other attributes of a beautiful face are angularity and facets, provided by facial implants,
in addition to replacing the bony support lost during aging.

Rejuvenation of facial expression
The subperiosteal repositioning of the point of origin of muscles of facial expression in the entire face gives
a generalized happy expression in repose and a gentle smile without effort. These changes arose due to
the elevation of the modiolus, lifting of the corner of the mouth. The orbicularis oculi muscles are rotated
upwards. The dynamics of the perioral muscles changed when mentopexy or chin implants are integrated
during surgery. The origin of the lip depressors and of the lip elevator (Mentalis muscle) are detached and
advanced upwards. These steps allow the modiolus to be elevated even further and the lower orbicularis
oris to be relaxed, diminishing hypertrophy secondary to orbicularis straining. This allows the lower lip
to pout easily. The chin dimples secondary to mentalis straining also disappear creating a youthful, happy
look. In my view rejuvenation of facial expression is the ultimate paradigm shift in facial rejuvenation [36,39] .

Repositioning of sagging tissues
Although deflation of tissues has been emphasized as the most important component of aging, sagging of
facial tissues is just as important as deflation. The Endotemporo-midface, that includes a periorbitoplasty
and a Bichat’s fat pad repositioning, elevates most of the sagging structures of the central oval of the face.
The effectiveness of midface elevation decreases as the distance from cheek to jawline increased. Therefore,
correction of jowls requires additional maneuvers. This is particularly relevant for patients over 50 years of
age, who require the addition of traditional cervicofacial lift to remove the excess skin of the lower face and
jawline.

My cervicofacial lift includes skin undermining of the neck from side to side across the midline. The
platysma with or without a digastric corset is advanced towards the midline and the skin in the opposite
direction. Treatment of the submental crease and the marionette lines, requires skin separation from
the platysma, allowing unrestricted opposing vectors of pull during repair and closure. I open the
deep subplatysmal space in approximately 30% of my patients. This is done to resect deep fat, treat the
enlarged digastric muscles and the enlarged salivary glands. Digastric corset, or shaving, is done for thick
digastric muscles. Ptotic and or enlarged submaxillary salivary glands are treated with partial resection or
suspension [40,41] .

Patients with poor chin and/or mandibular support usually age worse than those that have good support.
Moreover, aging produces atrophy of the skeletal support. This is addressed with chin and gonial angle
implants. Implants make remodeling of the lower face and neck easier and provide superior aesthetic results.
Rejuvenation with implants appear to be more durable. Enhancement of the entire mandible is done using
[42]
specially designed implants that I named the “Mandibular Matrix Implant System” [Figures 9 and 10] .

Rejuvenation of the skin envelope
A comprehensive approach also requires skin excision. After improving the foundation with volume
augmentation, with any or all of the strategies described, skin excision is more a re-draping maneuver
followed by a tensionless closure. This avoids tension bands on the face that give a typical windswept look.
The dissected tissues are robust, allowing use of laser resurfacing when required. I also use stem cell rich-
fat graft in the intermediate and subdermal plane without fear of vascular compromise of the skin.