Many years ago, I had a patient come in and ask me to liposuction the area below her breasts, right on top of her lower rib cage. I remember being surprised because so much of my time was spent removing fat from the lower belly, and the area over the ribs always seemed to be naturally slim. When I examined her, I was surprised to find that there was in fact a significant fold of fat sitting right on top of her ribs, despite the rest of her belly being fairly thin. When I performed the procedure, I was even more surprised at the amount of fat that I removed from the area, and the dramatic result that she had in the end.
After that case, I have never underestimated where fat can go to hide as we age. In the face, as things migrate down with gravity, the jowls form on either side of the chin. This too is part skin, part small amounts of fat that make a huge difference in contour. In some cases, suctioning a teaspoon of fat from the jawline can remove the jowl entirely, almost becoming a pre-facelift lift for patients who are not ready for the whole thing. In the leg, while the usual focus is hips and inner thighs, the knees never cease to amaze me in otherwise fit patients who are nearing menopause. Something happens at some point where, all of a sudden, there is a horseshoe-shaped rim of fat/fold that just creeps around the kneecap, and no amount of running in the world will remove it.
The nose is a particularly frustrating case, where the problem is not fat, but rather cartilage migration. The lower lateral cartilages that make up the tip of the nose often start to fall off of their upper support with time, leading to a longer and larger looking nose with advancing age. Add that to the jowling and squaring of the jaw, and the overall look becomes much heavier and less refined.
In cosmetic surgery, things are not an issue until they are. There might be a small annoyance hanging around for a while, irritating but tolerable, until one day it just becomes a problem. Even as you watch it carefully, there is that one morning when you get up and decide that enough is enough. It just seems to have crossed the line and something must now be done. The good news is that there usually is something that can be done, and surgery has the wonderful quality of being permanent in most cases. So whether it is the fatty ribs, the saggy jaw, the heavy nose, or the knobby knees, rest assured that the days of fitted T-shirts and short skirts need not be over. After all, in the last few decades it has become clear that 60 is the new 40 these days; and you can totally keep up.
