FACIAL AGEING

With ageing many changes occur in the face. These changes include not only the development of wrinkles, but also a thinning of tissues (skin, fat, muscle, bone) and drooping of structures. The combination of these changes affects not only your appearance, but also how people respond to you. A face that was previously young and happy can come to look old, gaunt, unhappy, grumpy, surly, angry, tired, closed, or any combination of these. Many patients mention to me that people say that they look tired or angry, but that is not how they feel. They want to bring their face in line with how they feel, which is not as old as they look! Part of facial rejuvenation surgery is therefore not only to make your face look younger and refreshed, but also to make your face look happier, more open and more receptive or interested: so called expression surgery. I therefore see facial rejuvenation surgery as being more than a facelift and, in fact my facelift technique has evolved to be a lesser procedure (although still just as effective) and I much more frequently combine a facelift with other elements to give a more comprehensive rejuvenation.  

MY APPROACH TO FACIAL REJUVENATION: MORE THAN JUST A FACELIFT

My approach to every new patient who desires facial rejuvenation is to obtain a full history from the patient and to examine the patient's face carefully. Aspects that I want to know about include what it is that you see as being the main problem(s) with your face or the elements you do not like. This allows me to fit the treatment according to what you see as your main area of concern. In addition I also want to know:

• your age
• your weight and height (including weight fluctuations over time)
• the work that you do, your interests and hobbies
• your general state of health, including your medical, surgical and psychiatric history
• whether you have any chronic medical problems (heart problems, high blood pressure, peripheral vascular disease, stroke, diabetes mellitus, lung problems, emphysema, chronic obstructive airway disease, asthma, bleeding or bruising problems, epilepsy, neurological problems, psychiatric problems or previous problems, arthritis, porphyria or any other chronic medical ailments)
• previous surgery or hospitalisations you might have had: cosmetic surgery and non cosmetic surgery
• chronic medication you regularly take: oral contraceptive pill or hormone replacement therapy, aspirin, blood pressure treatment, insulin or other treatment for diabetes, etc.
• if you suffer from drug or medication allergies
• whether you smoke, ever smoked, how many per day, when you gave up, are you on nicotine replacement products such as the patch, gum or spray?
• regular exercise that you do
• state of your relationships
• your motivation for surgery

When I examine your face I first look at your overall appearance, expression and elements that seem to age your face or to be out of kilter with the rest. I watch you carefully as you talk to me as this gives me a good idea of which areas may need attention. I then examine the face area by area and tissue by tissue. Digital photographs are taken and serve as part of the pre-operative record. I usually put these photographs up on the computer screen and together with you a comprehensive treatment plan is formulated which is tailored to your specific situation and requirements.

Forehead

Forehead problems may be:

• Deep transverse forehead lines
• Horizontal and/or vertical frown lines
• Drooped brows or poor brow shape

Deep transverse forehead lines are due to the action of a muscle, which runs from the scalp to the eyebrows (the frontalis muscle). Paralysing the muscle with Botox prevents these lines from occurring and for the period during which the muscle is not working, the lines start to fade. The lines can also be filled with a number of substances. Fat grafting is effective and can fill the line with your own tissue which has the advantages of being easily available, cheap and safe (no allergic reactions), but which usually requires a visit to theatre. I often perform fat grafting as part of my facial rejuvenations. Off the shelf products can be injected in the rooms, but as with fat grafting, may also need to be repeated for optimal effect. Resurfacing techniques can also improve the quality of the skin. I often use two or three of these methods in combination. These are minor procedures and some not even surgical. An open brow lift operation is a major procedure that leaves long scars and creates scalp numbness.  

Horizontal or vertical frown lines (also called glabellar lines) are also due to muscle action and are very effectively eliminated with Botox injections. In addition, filler materials can be used and again I will often fat inject this area as part of my facial rejuvenations.

Drooped brows or poor brow shape is traditionally corrected with a brow lift operation. In women, the normal eyebrow position is just above the bony margin above the eye, while in men it is at this bony margin. Ageing and gravity cause the brows to droop that can give an angry or sad look. Brow droop also causes an apparent excess of upper eyelid skin giving a tired or worn out appearance. The tradition brow lift involves an incision from ear to ear across the top of the scalp or just at the hairline. This results in extensive scar, prolonged healing, sensory disturbances behind the scar, possible hair loss and other undesirable sequelae. Although still occasionally performed, most patients find this approach too aggressive. Endoscopic brow lift is currently popular, as it is minimally invasive surgery. It relies on cutting and removing the muscles that depress the brow, thus allowing the brow to elevate. This elevation is then held by means of screws or drill holes in the skull to which the forehead structures are sutured. This is currently the most commonly performed procedure. One can do a suture suspension browlift or a limited open brow lift through smaller incisions. The procedure is performed under local anaesthesia with sedation if done in isolation. The operation takes about 1 hour and is usually done as day case surgery. Brow lift may be combined with other procedures such as facelift. Ancillary procedures may also be done at the same time, especially some form of resurfacing and/or Botox to improve wrinkles.
Post-operative recovery is quick, usually about a week. Swelling and bruising may persist for 2-3 weeks and a feeling of tightness even longer. Complications are rare, but include nerve damage (less than 1%) which if it occurs is usually transient.

Eyes, Eyelids and Crow’s Feet

Upper lids may be too baggy, puffy or have too much skin. Once the brows have been placed in the correct position, attention can be given to the upper lids. Upper lid surgery or upper blepharoplasty is one of the winner operations in plastic surgery: it is relatively simple and quick and gives a high degree of satisfaction to both patient and surgeon (surgeon satisfaction is important too!) Removal of excess skin and fat may be combined with other facial rejuvenation procedures or performed on its own under simple local anaesthesia.

Lower lids may have similar problems to uppers although lower lids are slightly trickier to treat. The reason for this is that the effect of gravity has to be taken into account and a lower lid droop or ectropion should be avoided. For this reason I believe in a relatively conservative skin removal, fat removal either through a skin cut (conventional lower lid blepharoplasty), or through the back of the lower lid avoiding a skin cut altogether (transconjunctival blepharoplasty), and lower lid suspension. If transconjunctival fat removal is done, lower lid skin can be improved by resurfacing.

Tear troughs often appear on the aspect of the lower lid closest to the nose. These may be seen as dark rings under the eyes. The reason for their appearance with age is because the fat that was there has descended down the cheek (hence the nasolabial fold becomes heavier). Correction requires re-elevation of fat with a malar lift or replacement of fat with fat injections. A malar lift is a tricky operation that lifts the descended cheek fat. It does change the facial shape and can give "cheek bones" where before there were none.

Crow's feet or smile lines at the sides of the eyes appear because of the muscle action there. Smile hard or scrunch up your eyes and you deepen these lines. I find the best treatment for these lines is Botox, which effectively causes a temporary paralysis of the muscles for 4-6 months.

Cheek

Cheek lines may appear in front of the ear, in the mid-cheek or near the mouth. Often cheek lines will be associated with the development of jowls and a saggy neck. Correction is best attained with facelift. My style of facelift is relatively conservative with a cut extending from below the sideburn, down in front of the ear, around the ear lobe, up behind the ear and finally for a short distance backwards along the scalp. The skin is undermined, the underlying layer (the SMAS) tightened and lifted, the excess skin removed and the wounds closed with dissolving sutures. More information follows lower down.

Mouth

Patients may seek lip improvement to correct the signs of ageing or to alter the shape of their lips. Ageing, gravity and smoking lead to the development of lines around the mouth. With ageing the lips become thinner and droop. Thin lips may be plumped up with a number of filler materials. Lips that are too thick may be thinned by surgical excision of any excess. All procedures on the lips may be performed as day case surgery, under local anaesthesia and may be combined with other procedures. Wrinkles around the mouth are a common occurrence as one ages. These wrinkles can be effaced with resurfacing techniques such as chemical peels, laser, dermabrasion or needle abrasion, or the wrinkles can be filled with filler materials. For a number of reasons, I do not perform laser surgery. My preferred resurfacing technique is chemical peel. To fill out thin lips a number of filler materials may be used. These may be divided into autologous (if they are derived from your own body, e.g. fat, dermofat, scar, etc.) or non-autologous (collagen, hyaluronic acid). Fat injections are quick and simple to perform under local anaesthesia. Over correction is done initially, as there is unpredictable resorption of fat with time. On average, about 40% of the fat remains although this varies from patient to patient and procedure to procedure. Fat is usually harvested via a very small liposuction; the fat is separated and injected. The lips will remain swollen for approximately 2-3 weeks, but once the swelling settles, the new effect can be seen. Artificial filler materials such as collagen and hyaluronic acid are both natural body substances which have been bio-engineered and which are available in a pre-packed syringe for injection. This procedure can be performed in the rooms under local anaesthesia. Bruising, tenderness and discomfort can occur following injection, but this usually lasts less than three days. Following any lip procedure, there can be some degree of asymmetry. With all lip enhancement procedures some degree of loss of effect should be expected and touch ups may be required with time. A severely unhappy mouth can be corrected with a corner-plasty: an operation that removes a triangle of skin from the corners of the mouth and actually lifts the corners. It does create some degree of scarring.

Chin

Chin creases and skin texture problems can be treated with resurfacing techniques and filler substances. A weak chin may require either a chin implant or actual breaking of the jawbone and sliding the chin forwards.

Neck

An aged neck may be due to skin excess and wrinkles, fat excess and muscle problems. With ageing, the muscles of the neck spread apart and can cause vertical bands - so called vertical platysma bands. Skin excess can be treated with facelift while fat excess responds well to liposuction. More subtle neck problems can be treated with sutures that bring the muscles together and suspend the neck skin to the bone behind the ear. This can create a more youthful appearance with a better (cervico-mental) angle between the lower jaw and the neck. This operation is usually performed under local anaesthesia as day case surgery and is usually combined with other procedures of the face or neck liposuction. Complications are as for neck liposuction, but recovery time is usually slightly shorter. A fat neck can be well treated with liposuction. The neck is one of the body areas which responds particularly well to liposuction. Not only will liposuction remove excess fat, but it can also restore or create a better jaw line and angle between the lower jaw and the neck (so called cervico-mental angle). Liposuction tightens skin by causing skin retraction (shrinkage). Also, by removing fat, the skin that is there has to cover a greater surface area and must stretch to do so. These effects advantageously lead to an enhancement of appearance. Neck liposuction is usually performed as day case surgery under local anaesthesia. The operation takes approximately one hour or less and may be combined with other facial or neck procedures. Incisions are small (less than 5 mm) and hidden in the region of the ear or under the chin. The wounds heal relatively quickly and well, and should leave an almost invisible scar. Bruising and swelling can last for up to three weeks and a pressure garment is recommended during this period. This is an elasticised headband that attaches with Velcro above. Complications are rare, but include nerve or skin damage as well as poor scarring.

PREPARING FOR SURGERY

Very little preparation is necessary for surgery. If you are well informed and know what to expect, if you are fit and healthy, if your reasons for surgery are good and your expectations realistic, you should get through the procedure with the minimum of problems. Smoking is generally unhealthy, but in particular it interferes with normal blood flow and wound healing. Facelift patients who smoke have a twelve times greater incidence of complications than patients who do not smoke. You should cease smoking a week or two prior to facelift and not start again until the wounds have healed, usually 3 weeks after the operation. Although nicotine replacement products such as the spray, patch or gum are of great assistance, these products also adversely affect wound healing and should be avoided for the same period. Since I usually perform facelifts as inpatient surgery and you will be unable to drive the following day, you should arrange for someone to collect you from the hospital and take you home or back to your accommodation. In addition, there should be a responsible adult to look after you on the night after. If your hair is very short, you might want to let it grow out before surgery, so that it is long enough to cover the scars while they heal. Alternatively it is a good idea to bring a scarf to wear post-operatively on discharge from the clinic. If you need a sedative for anxiety relief prior to surgery, this can be arranged. You will, in any case, be given a sedating pre-med on the morning of surgery if required. The night before surgery you should shampoo your hair and wash your face and on the morning of surgery you should again wash your face well. Do not apply make up on the day of surgery. On the day of surgery, you should be healthy and not suffering from flu or any other illness. All cosmetic surgery is elective and it is better to delay surgery than to tempt problems.
You should arrive at the hospital on the morning of surgery having fasted and being nil by mouth for six hours. The anaesthetist will see you prior to surgery and take your medical history. I will mark you up prior to surgery and take further photographs.

SURGERY

Almost all surgery is carried out as inpatient surgery: you go home either later that day or the day after surgery. General anaesthesia is used which is administered by a specialist anaesthetist and which will keep you asleep and pain-free. Once asleep, long-acting local anaesthetic is injected and the surgery is performed. A facelift on it's own usually takes me about 2.5-3 hours, although I will often combine this with brow elevation, eyelid work, cheek fat elevation, fat injections, resurfacing or neck liposuction and so surgery can take between 4 and 6 hours. Following surgery minimal dressings are applied, usually just an absorbent bandage and an elastic chin compression bandage. You should drink lots of fluids, remain semi-recumbent and use ice packs regularly to help bring down the swelling. You will feel and look rotten, but you should not experience a lot of pain. All sutures are removed at one week (except eyelid sutures, which are removed on day 3-5). Swelling and bruising are at their worst during the first week after surgery, but by 3 weeks have mostly dissipated and you should be starting to look and feel better.

POSSIBLE COMPLICATIONS AND PROBLEMS

Like anything else, surgery carries the possible risk of complications or adverse outcome. If due care is taken and surgery is performed by a qualified Plastic Surgeon and a well trained team, then the risk of these complications should be minimal. Nevertheless, it is important to be aware of them:

Reaction to the sedation, fluids, drugs, etc - extremely uncommon, but always a possibility.

Bleeding can complicate the procedure and can manifest early or late. Early bleeding shows itself as sudden swelling of the face, either on one side or both. Treatment requires a return to theatre. Late bleeding a week or two following facelift may require treatment with aspiration in which case blood is removed with a syringe.

Infection is rare as the face has a good blood supply. Nevertheless it can occur.

Skin loss is less likely to occur with the conservative facelifts of today, but it can still happen. Usually skin losses heal with dressings, but this takes time and requires patience.

Nerve injury is always a possibility. Motor nerves carry impulses from the brain to muscles and are responsible for facial movement and expression. Temporary or permanent paralysis can result if these nerves are injured. The commonest areas affected are the forehead and the mouth. Usually recovery does occur and this usually occurs within six weeks, but it can take up to two years for recovery to happen. Sensory nerves carry touch, pain and other impulses from the skin to the brain. The nerve conducting sensation from the lower half the ear is frequently injured with facelift. As with motor nerves, some degree of recovery can be expected, but this takes time.

Scars always occur with facelift and these scars are permanent. It is important to understand that these scars need to go through a period of maturation and that this takes time. Scars often look good immediately after surgery, become red and raised from about 3 weeks to 4-6 months, and then fade to become an inconspicuous, thin, fine, white line. Movement of the sideburn occurs with facelift as the hair-bearing skin is moved back. Men may occasionally need to shave behind their ears. Asymmetries, irregularities and bumps can occur early on, but with time these usually settle.  

LONG TERM RESULTS

A facial rejuvenation procedure can turn back the clock and make you look younger and happier with an improved expression and a refreshed appearance. On average a facelift should take off 10 years or more, but it does not stop the clock. The ravages of time, gravity, air pollution and other effects will ensure that the ageing process continues. It is therefore important to combine any facial rejuvenation procedure with a healthy diet, a sensible exercise program and a proper skin care regimen.