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Facial Rejuvenation and Maintenance

Only 5-7% of aesthetic surgeons use our natural, but complex methods of facial rejuvenation. We are not perfect, just very good at what we love to do. All patients are actual patients of Dr.

Keller. Individual results may vary. Please contact us for further information and consultation.

Maintaining and Restoring Your Youthful AppearanceGregory S. Keller, MD, FACS

Facial Rejuvenation

Maintaining our appearance is important. Having an appealing persona is valuable in a work environment or in our personal lives, no matter what our age. We feel better if we like our look.

As we mature, the structures of our face fall and we lose our facial volume. The end result is a "mad", "tired", or "sad" appearance. We are not projecting the happy persona that we really feel.

Our approach is not to simply "do a facelift", but to work at restoring the natural, beautiful or handsome persona that resides within each of us.

Maintaining and Restoring Your Youthful Appearance

Maintaining and Restoring Your Youthful AppearanceGregory S. Keller, MD, FACS

Disclaimers and ExplanationsDr. Keller performed all off the procedures that are illustrated in this book. The patients

pre and postoperative pictures are picked to illustrate specific problems and procedures.

Some of these patients may have had other procedures; for instance, a patient with upper eyelids, may have undergone a facelift. This is not done to mislead; rather, the pictures are picked to illustrate specific points about a procedure.

These pictures and illustrations, in no way, guarantee results of a particular procedure. Results may vary. To achieve a better idea of the risks and benefits of surgery for facial rejuvenation, an individual consultation is necessary.

About Dr. Keller (www.gregorykeller.com)Dr. Keller completed his medical training at the University of Illinois Medical Center in

Chicago. He specializes in facial plastic surgery, and limits his practice to facial rejuvenation and maintenance, primary and revision rhinoplasty, and blepharoplasty. He is board certified in Facial Plastic and Reconstructive Surgery, Otolaryngology and by the American Board of Cosmetic Surgery.

An up to date physician, training other physicians is an important part of Dr. Keller's life. He is a full Clinical Professor of Surgery at UCLA and is co-director of the Facial Plastic Surgery fellowship at UCLA. He also serves as a section editor of a major American Medical Association journal, the Archives of Facial Plastic Surgery.

Among his many honors, Dr. Keller has been granted "awards of surgical excellence" by both the American Academy of Facial Plastic Surgery and the American Academy of Cosmetic Surgery. He is a peer elected Castle and Connolly US News and World Report "Top Doctor" and was named the "Who's Who" publication's Facial Cosmetic Professional of the Year, 2007, an international honor bestowed on only one physician.

He has hundreds of publications and presentations and two textbooks to his credit. His is the singular honor of inventing endoscopic facial plastic surgery (1991 procedure patents).

Dr. Keller has multiple media appearances, including Good Morning America, Discovery Health, Allure Magazine, Vogue Magazine, Longevity Magazine, and many others. He has been a featured guest speaker in China, Brazil, Australia, USA, and Europe.

IntroductionAesthetic facial plastic surgery requires technical expertise and an artistic eye to achieve

a "natural appearance". Our goal is to provide improvement that, in our before and after pictures is dramatic, but, in real life, may not be noticed.

The surgeon needs not one, but many techniques at his disposal to achieve consistent aesthetic results. In addition to technical expertise, an artistic eye is helpful. Many patients cannot be treated as a "formula". This book is an introduction to our "eye" and "methods".

Our approach is to utilize all of the "tools" at our disposal to improve appearance. That requires not only our own expertise, but also intimate access and knowledge of complex technology that can provide results. "if you have a hammer, everything looks like a nail" is an old saying that applies to almost any field. We truly are not limited in that manner.

In addition, care of a patient is not limited to a patient's surgery, filler,or laser treatment. Our caring staff and "concierge" level care help to make your experience a positive one. Our team has explored and analyzed the details that result in a positive confidential, experience.

Dr Keller is a specialist. A Board Certified Facial Plastic Surgeon (a board recognized by hospitals and the California Medical Board), Doctor Keller has a background that is unique in its ability to care for patients in a variety of ways. He is the inventor of endoscopic facial plastic surgery (US and world procedure patients); is a laser pioneer (textbook, and a friend and colleague of Ted Maiman, inventor of the laser); co-founded a stem cell company (International Stem Cell), founded one of the first independent multi specialty surgicenters.

AffirmationsThe following three patients have, along with many others, written testimonials for us.

Here are samples from patients that have allowed us to make their comments public. They represent different ages and aesthetic desires. Perhaps they mirror your feelings.

"Looking good" is as much about "feeling good about the way that you look", as it is about anything else. Many of us feel younger than our chronological and facial age. We want to look as good as we feel.

A personal quote from Dr. Keller: "I realized, during my month of recovery time after I was hospitalized for an automobile accident (where I had fractures of my facial bones) that it was horrible to feel ugly and "deformed". I had three operations to put my face back together. It was during that period of time that I realized that aesthetic facial plastic surgery could have a positive impact on a patient's life. It persuaded me to change my aspirations from being a cardiac surgeon to becoming a facial plastic surgeon."

"I feel very young, but I looked very tired. People would ask me if I were angry. Now I look as young as I feel".

Picking up the cheek, neck, face in a natural manner. A little bit of a lot of things to avoid a "stretched" appearance.

Lifting the "structures" of the face, rather than stretching the skin reverses the "SAD look (structures angled downward).

"I wasn't going to tell you, but I was actually "carded" when I went to buy a bottle of wine . I said "you're kidding". The clerk said "no", we card everyone under 30 years of age. I'm 49, so it was one of the highlights of my week. My fiance appreciates things now, too".

A natural restoration of the forehead, cheeks, and brow allowed this woman to be a younger version of herself.

The Neck The neck is a more complex structure than most patients realize. Merely removing fat, utilizing laser tightening, and suturing muscle are techniques that do not necessarily optimize results. Everyone is different.

Different muscle structures, different layers of fat, skin that is sun-damaged, weight loss, prior surgeries of all kinds, "bull" neck tissue", fallen salivary glands, and many other conditions are all involved in neck rejuvenation. The proper diagnosis and differing surgical procedures give the most consistent results.

We studied (and published) the first look at ultrasound diagnosis of the aging neck (with the Cottage Hospital radiology department). This gave us a unique insight into what caused the problems of the falling neck. For the most part, physical diagnosis is all that is needed to diagnose the "fallen neck". Ultrasound can be useful in questionable cases.

Often the skin of the neck requires treatment, even after the surgical procedure. Use of different laser, RF, and high intensity focused ultrasound can "paint the walls", after surgical treatment to "set the foundation".

Newer work with platelet rich plasma has provided evidence based affirmation for treatment of aging skin. Fat stem cell treatment , while an attractive concept still has not proven to be more effective than alternate treatments. Stem cell creams are useful to help rejuvenate the skin.

A balanced approach to the neck, while not perfect, usually gives "best results".

Laser liposuction for a younger woman's neck: It is easier to treat problems such as this at a younger age. Many patients have a "genetic lliposdystrophy" or genetic fat pockt that grows worse with age. Many patients notice this problem in their mothers or older relatives.

The small bulge in the neck bothered her, especially with her "head down".

A younger woman with a set back chin . Laser liposuction and a small chin implant were used to improve her appearance. People thought that she had lost some weight. So after this picture was taken, she felt so much better that she did go on a weight loss program.

This view from the front, illustrates the "illusion" of weight loss that the surgical procedure provided.

Our "web neck" procedure. We have published an article in Facial Plastic Surgery journal about this. It helps support sagging muscles and ligaments. The woman in the next patient picture had this procedure to help support a sagging "digastric muscle" .

An ultrasound picture from our study (AMA Archives of Facial Plastic Surgery Study). The red arrow shows the platysma muscle lining,the "D" is the digastric muscle. The top line is the skin. Fat layers are in between the skin and platysma and between the digastric muscles.

Minimally invasive web neck lift: The llump" under this patient's chin was not just a collection of fat. It was a bulging overly large digastric muscle (a muscle used to open the mouth). There is a characteristic lump in the middle of the neck, which moves with swallowing.

A web neck lift procedure was performed in this patient. She has a sagging platysma muscle, as welll as excess skin. An incision was performed behind her ear and into the hairline fo remove the excess skin. No facelift was performed, but would have improved the result

The platysma muscle in the neck forms "bands" that make an "11 sign".Treatment of these is effective, but is the most common cause for revision in neck surgery. This woman has also had a facelift. The muscle extends into the chet and is supported by ligaments .

Men are commonly concerned about their neck "waddles". This is a solitary "webneck" lift with posterior muscle pull; without a facelift. This patient's platysma muscle was cut and pulled backward and skin removed. In addition, liposuction was performed.

This woman had a "corset platysmaplasty", a more extensive procedure. A cheek lift was also performed without a facelift.

Face and Necklift with lateral corset and web neck techniques

Facelift Surgery: the younger woman (man)While it is "never too late" to perform facelift surgery, the younger patient (45-60) often

will experience results that take off years. The tissues are in reasonable condition, and there is often enough of a natural difference after the facelift that years are taken off without people noticing. Incisions can be hidden so that the hair can still be worn "up".

Around the time of pre-menopause, women often age over a relatively short period of time and lose the attention that they took for granted. Many woman complain that they "became invisible overnight". Men want to not appear "over the hill" or unkempt.

For a woman, appearance is important to the way that she feels about herself and relates to the caring that she bestows on herself, her mate, her fellow workers, and others. Her appearance is related to the self-confidence that she feels (the field of psychosynthesis), and is a part of her overall "being". For a husband or a significant other, what makes a lady or man happy, often makes the significant other happier.

Besides the sudden process of aging that occurs "peri-menopause", other factors can influence the aging process: weight loss, hormonal changes, genetics, sun damage, and many others.

Volume loss in the younger patient is often not one of the chief factors of aging. Gravity carries the facial structures downwards as the facial ligaments that hold them up weaken. Repositioning these structures in a sophisticated manner is a more natural and lasting solution than pumping the face full of fat or fillers (though these may be indicated at times).

In youth, the cheek fat pad sits high upon the cheek bone, attached by ligaments. Over time that fat pad falls. One of the keys to our facelift is that we lift the cheek along the lining of the bone and stabilize it. Neither filling nor implants gives this natural of a result.

While you can tell from the before and after pictures, neither this 50y/o's daughter or mother guessed that she had a facelift.

Small structural improvements make a natural difference in this 50y/o, even with the head down. She just looks "refreshed".

This patient had prior eyelid surgery, but did not have eyelid surgery in these pre-op and post-op pictures. The cheek lift did the work that eyelid surgery could not accomplish. Note that the distance from the lower eyes to the bottom of the eyelid is reduced.

None of this teacher's classroom children noticed the difference after a natural "structural face and cheek lift". Note the difference that lifting the cheek makes in relation to the length of the eyelids (from the lashes to the bottom of the lower eyelid).

The same woman as in the previous picture. During the time in between these pictures, she maintained herself with media-spa treatments. The "less is more" philosophy of less sophisticated surgeons would not have given this result. "Less is more" can be "less".

"Freshening up" with facial rejuvenation, this patient lengthened her career in entertainment. A gentle lift ing of the structures of the face with a neck lift and cheek lift provided a 10 year younger appearance. A mini facelift was also performed. The result is a less tired look.

The Cheek One of the first signs of aging is a sagging of the cheek. The cheeks and lower eyelid

muscles are held up by ligaments that suspend these structures. As the ligaments loosen (similar to knee, and shoulder ligaments), these structures drop.

The result is a falling of the cheek fat pad and lengthening of the eyelid. The most noticeable signs of this are are 1) a "tear trough" from the middle corner of the eyelid down the cheek 2) a lengthening of the eyelid distance from the eyelashes to the bottom of the eyelid, 3) and a protuberance of the eyelid fat over the fallen cheek (the "pot belly over fallen jeans".

Lifting the structure of the cheek is the best solution and the most natural one. If you smile, while looking in the mirror, and your cheek volume is restored, a cheek lift to re-suspend your fallen structures is the natural solution to a younger middle face.

A "band-aid solution" may be to inject volume into the cheek to "cover up" the sagging structures. Fillers such as juvederm, restylane, and radiesse are used in our medi-spa to fill in the cheeks and brow. While we have used fat injections since 1982 for volume injections, the procedure involved often causes more bruising than a facelift. Fat can also resorb in an unpredictable manner, and a patient can look "overfilled". For the last two years, we have used a "vampire lift" procedure, which involves using your own platelet rich plasma (drawn from a test tube of your own blood) and a small amount of restylane as a "scaffold". The change in the cheek and the eye area wrinkles is dramatic and natural.

Lifting the cheeks in this 54 y/o model gained her a job posing as the perfect cheek implant patient in a medical journal. No implant, though. Notice the fact that the distance from the eyelashes to the bottom of the eyelid is decreased by lifting the cheek without eyelid surgery.

Opening the eyes with a "blepharoplasty" helps to remove the "tired" look, while lifting the cheek rejuvenates the lower eyelid area. Note that the distance from the lower eyelashes to the bottom of the eyelid is diminished after cheek lift surgery.

The cheek lift youthens the face by restoring the Ogee curve, a convexity dissolving into a concavity that is a standard of beauty. In the preoperative view, the eyeball is in front of the cheek (negative vector). In the postoperative view, the cheek is in front of the eye .

A cheek lift and endoscopic browlift opened up the upper face.

Facelifts for the Mature PatientWhether in for the first or second facelift, most patients prefer a natural look that

appears "normal" and "natural". We achieve this by concentrating on the structures of the face. Lifting the facial structures below the skin and muscle allows the facial skin and muscles to be repositioned without stretching. The natural ligament retaining structures of the face are elevated and secured at multiple levels in the deeper planes.

"Deep plane" lifting and "sub-periosteal mid-face" lifting are our standard techniques. We are adept at these techniques and are able with them to achieve results that less sophisticated surgeons may not enjoy. Recovery periods and complications are similar to a mini-lift.

Nonetheless, there is a time and a place for doing procedures in segments and working on different areas of the face. Fillers and less invasive procedures may be indicated with the time constraints of modern day life and in a hurried world.

We feel that it is important to tailor a "customized" approach to each woman and man. Consequently, we offer the gamut of non-invasive, laser, and minimally invasive techniques. We have pioneered many of these techniques, and Dr. Keller invented and holds the procedure patents on endoscopic facial plastic survey.

Refreshing her look in a natural way with a facelift and eye lift.

Subtle changes in the cheek, neck, and face can make a difference that people do not even notice.

A natural "freshening up" with facial rejuvenation and blepharoplasty (eyelid surgery) was this patient's desire.

Facial rejuvenation to restore a natural, more youthful appearance in this 74 y/o patient.

Gently lifting the brows endoscopically with small incisions along with facial rejuvenation can give a "happier" more awake appearance.

Lifting the neck and cheek gives a "refreshed" appearance to this musician in his 70's and extends his career. Men are having facelifts as they wish to continue in the work environment and not to appear "tired" or "over the hill". Many are at their natural career "peak " .

Facial rejuvenation and eyelid surgery can "brighten up" the more mature patient. Often aging gives us a "mad ", "sad", or "tired lookl. Natural "structural" facial rejuvenation can give us a happier appearance that reflects the way that we feel and an emotional "boost".

Rhinoplasty for Facial Rejuvenation Often the nose grows older with the patient. The supporting structures of the nose

weaken, and the skin loosens. Consequently, many patients say that "my nose grew and fell" as I became older.

Depending on the complexity, the nose surgery may be performed at the same or different times as other surgeries. Often the patient has had a previous rhinoplasty that needs revision or a "touch up".

The results may magnify the results of a facelift. Or the nose may be modified as a primary procedure.

Often younger women and men are concerned with only fixing their nose. When this is the case, the proportions of the face need to be taken into consideration. Attention, particularly needs to be paid to the chin and neck for a proper aesthetic effect.

Nose surgery combined with a facelift made a nice difference for this equestrian. A small chin implant added" artistic" proportion.

After a recent mini- lift elsewhere, we lifted the cheek and neck and refined her nose. She had a previous rhinoplasty elsewhere, but refining her nose helped to give her a younger, fresher appearance. A small amount was taken off the "dorsum" and the tip refined.

1/3 of facia rejuvenation patients are men. This is a revision facelift and nose surgery shown only 1 months after his procedure . Refining the nasal angles gave a "cleaner " and more "refreshed" look. It will take time to see the final result, but the face is in better "balance".

Eyelid SurgeryThe eye is a gateway to the personality. If we look tired, mad, or sad, the world looks at

us differently. Different problems can affect the eyelids. The eyebrows can fall and push skin over the

eye. When this happens, the skin over the outside of the eye may create a "visor". This problem is called "brow ptosis". Adjusting the brow is often an important part of treating the upper eyelid.

With age, the eyelid skin can increase, and obliterate the eyelid "fold". This can also happen with skin damage from the sun. An excision of skin can be performed to open up the eyelid. For women, this is an important, as this is the area that eyelid make-up is applied.

For some, the eyelid muscle can fail to open the eyelid so that the eyelid droops over the pupil. This condition is called "eyelid ptosis". Eyelid ptosis surgery can adjust the muscle to open the eyelid.

The lower eyelid can develop "bags" and excess skin. To correct this fat can either be excised or "repositioned" over the cheek.

The cheek area can also fall downward and cause the eyelid to look more "baggy". The combination of the cheek falling ("fallen jeans") and the eyelid developing bags (pot belly) is termed a "pot belly" over "fallen jeans".

For upper blepharoplasty (eyelid lift), sometimes all that is necessary is to remove some of the excess skin and/or muscle. I also performed a facelift on this patient.

Sometimes, a droopy eyelid (ptosis) needs to be opened up by lifting the muscle to produce a more "awake" appearance.

This patient had upper eyelid surgery to remove some of her execss eyelid skin and provide a framework for her eye make-up.

Lower eye "bags" are a common problem, as illustrated in the before and after views of this patient. They are similar to a "hernia" Removing some of the fat, and repositioning the rest over the fallen cheek can improve the look of both men and women.

When both the eyelid bags appear and the cheeks fall, the results can be a "pot belly" over fallen jeans". This patient was not ready for a surgical procedure, so a "vampire lift" (using her own platelet rich plasma) was used as a "filler" to temporarily correct her problem.

This patient had a upper and lower blepharoplasty and facelift. For the lower blepharoplasty, the fat in the lower eyelid was repositioned into the cheek. Dr. Keller made no external incisions for the fat repositioning in this patient. The incision was a "transconjunctival" incision.

Ptosis of the upper eyelid is a condition where the eye muscle no longer completely opens the eye. Opening this woman's upper eyelids (in addition to performing a cheek and brow lift) helped to restore an "awake, alert" appearance. A neck lift was also performed

BrowliftAs the face ages, several things happen to the brow. Brow descent, loss of volume,

bony resorption, and muscle imbalance are all factors that require consideration for a balanced correction. It is a combination of these things, rather than any one of them, that cause aging of not only the brow and forehead, but of the eye, as well. Overcorrection of any one of these problems can result in an "un-natural" look. Bringing in old photographs is often helpful for physician/patient communication. The sophisticated surgeon strives for a balanced approach to correct all of these problems for a "natural" rejuvenation.

The brow falls downward, pushing eyelid skin over the eye. This creates a "hooding" or "visor" over the eye that can extend toward the temple. The brow is held up by weak muscles and ligaments, particularly in the temple area. It is brought downward by strong muscles. Re-establishing the muscle, ligament relationships of the face is a necessary part of facial rejuvenation. Over-correction produces a surprised look.

The brow fat also deflates and the outside corner of the underlying bone is resorbed. Re-establishing these volume relationships is essential to achieve a rested, less tired look.

The muscle relationships of the brow can produce forehead lines and wrinkles. Adjusting these relationships is an essential part of rejuvenation of the upper face. Each individual needs an evaluation, as the approach to the "unilateral brow lifter" or the "compensatory brow lifter" can affect the entire eye (or "periocular") area. Dr. Keller has a textbook and has edited journals about these topics. Contact us for a consultation.

The "visor" formation over the outside of the eye socket is characteristic of a fallen eyebrow.

Lifting the brow and cheek with an endoscope and hidden incisions (Dr. Keller's invention) changes a tired look to a more alert, happy one. Sometimes this procedure is called an "endoscopic face lift" and there are no incisions around the ear, only the hairline and mouth.

Gently lifting the brows endoscopically with small incisions along with facial rejuvenation can give a "happier" more awake appearance.