To gain the best possible results from aesthetic surgery requires careful patient selection. Not all procedures are suitable for all patients, therefore it is impossible to offer anything other than very general advice before seeing a patient. It is certainly better to have no procedure than an inappropriate one. To undergo aesthetic surgery is a major decision requiring appropriate discussion and thought.
Cosmetic Procedures
Facelift

The term “facelift” no longer represents a single procedure but rather a variety of options which should be planned to suit an individual patient's needs. Many factors are taken in to consideration when deciding on the best option, most of which relate to the patient’s anatomy (bone and soft tissue structure), but also their personal and work circumstances, time available for recovery etc.. A detailed examination and discussion are necessary before proper recommendations can be made. There have been a number of very significant advances in facial aesthetic surgery since the late 1970’s. Most of these have arisen from a better understanding of facial anatomy through the development of craniofacial techniques for the correction of congenital facial abnormalities.  In more recent years technical changes born of studying outcomes in large groups of patients have dramatically reduced complications and speeded recovery (see “publications”). The aim is to produce a natural, un-operated appearance which enhances facial contours and is durable. The avoidance of tension or stretching of the skin is crucial.  Consequently most contemporary facelifts are of a “deep plane” type in that they provide support to the soft tissues of the face – fat and muscle and do not simply pull on skin.  Although technically more challenging than skin based procedures, in skilled hands they carry no more risk but do produce a superior longer lasting outcome.

The SMAS Lift
SMAS facelifts are a type of “deep plane facelift. They require a detailed knowledge of facial anatomy to avoid damage to important structures such as facial nerve branches, but in experienced hands the risk to these structures is no greater than with any other type of face-lifting procedure.

SMAS is an acronym for Sub-cutaneous Musculo-Aponeurotic System. This is a thin but quite strong layer of tissue beneath the skin to which muscles and fat are attached. By freeing the SMAS layer from its deeper ligamentous attachments, it is possible to reposition facial soft tissues with stitches to create a more youthful contour. The basic idea of the SMAS lift has evolved over the years (and indeed continues to do so) so that not only are deep tissues replaced in a better anatomical site but they tend to remain there making the results of surgery more durable.

There are a number of variations in the specifics of SMAS lifting techniques which can be confusing. Having studied and compared outcomes in a large number of my own patients, I have found my evolution of the SMASectomy to give the best combination of predictability, reliability and durability with a rapid recovery and low complication rate. I have titled this the REST lift –Rhomboidal Extended SMASectomy with Tumescence.  

A recently completed large study (March 2012) based on computer analysis of standardised patient photographs and objective observer analysis confirms that this procedure eliminates unwanted sequelae of facelift surgery whilst ensuring a stable long-term outcome.  This will be published in the major international scientific plastic surgery journal – “Plastic and Reconstructive Surgery”.

In some individuals (particularly when a facelift has been carried out previously) I may elect to manipulate the SMAS layer in a slightly different way, overlapping it with stitches.  This is known as a SMAS plication. Some surgeons use what are known as purse string sutures to elevate the face in a procedure known as the MACS lift. These are prone to produce irregularities beneath the skin and so I do not favour them. Neither am I fond of the acronym - it stands for Minimal Access Cranial Suspension and whilst the scars are shorter than average facelift scars they certainly could not be described as minimal access and there is no cranial suspension! Whilst catchy the acronym is inaccurate.

Facelift – Subperiosteal Techniques
The periosteum is a fine but very strong tissue layer which covers bone. Operating in this tissue plane enables all of the soft tissues of the face (fat, muscles, skin, etc.) to be released from their deeper attachments, lifted and repositioned as they were before time and gravity produced its downward drift.  Once healed the periosteum is very “sticky” and so tends to keep in position producing a very long lasting result. It takes 8-12 weeks to “stick” and during this time is supported by deep stitches which dissolve in about 6 months. Specific techniques and the resulting scars vary depending on exactly what one is trying to achieve.

Subperiosteal surgery can produce some of the most impressive and long lasting results seen in facial rejuvenation. Their disadvantage is that, on occasion, swelling can be prolonged (rarely up to 6 weeks) delaying final recovery.  They may be used alone or in combination with other procedures and can be very helpful in treating complications of lower eyelid surgery (blepharoplasty).

Subperiosteal Midface Lift
In some (usually relatively younger) patients it may be appropriate to support the midface, i.e. from the eyes to the corners of the mouth via an incision inside the mouth and a small incision in the temple. This is known as a subperiosteal midface lift. It is generally relevant for patients who have no skin excess and relatively modest facial change but does produce a very worthwhile enhancement to cheekbone contour. It is sometimes combined with other procedures – see below.

Concentric Malar Lift
The concentric malar lift is an evolution of the subperiosteal midfacelift taking elements from it and from lower lid blepharoplasty (eyelid surgery). It aims to improve the appearance of the middle third of the face (eyes to mouth) incorporating the cheekbone area and the lower eyelid. It is specifically designed to keep the scars as small and invisible as possible and to reduce the potential for complications.

There is a scar immediately beneath the lash line of the lower eyelid, which continues beyond the corner of the eye for approximately 5mm, a small scar (1cm long approximately) in the outer part of the upper eyelid skin crease and a third scar inside the mouth, where the cheek joins the upper gum. It designs to free the tissue of the central third of the face from their deep attachments and to elevate them and fix them to the bone of the eye socket.  This is done with buried dissolving sutures which take approximately 6 months to disappear and therefore; provide support for a prolonged period.  The main concern with operations of this type in the past has been of disturbing the position of the lower eyelid, i.e. pulling it downward after surgery.  The CML disturbs the lower eyelid muscle (orbicularis oculi) as little as possible so as to maintain its function and reduce this risk to a minimum. This is the main difference between it and previous subperiosteal facelift techniques which involved the lower eyelid.  Supporting the soft tissues of the central part of the face and moving them upwards, improves the contour of the cheek, rejuvenates the central third of the face and makes the junction between the eyelid and the cheek smoother, therefore; improving “eye bags” and the hollow which tends to lie beneath them. It can be particularly useful in treating complications of lower eyelid surgery when the lid has been pulled downwards (ectropion).

Mask and Endoscopic Facelift
The theory and practice of this type of face-lifting is entirely different from most other varieties of facelift and it is not suitable for all patients.  In essence, all of the soft tissues of the face (fat, muscles, skin, etc.) are released from their deeper attachments, lifted and repositioned to the site which they occupied before gravity produced its downward drift.  Generally speaking the most suitable patients are in a relatively younger age group (35 to 50), and have heaviness of the brows, sagging of the outer corners of the eyes and cheeks but without, necessarily, major changes in the neck. The mask lift uses a scar within the hair designed rather like an Alice band and a small incision inside the mouth. It provides the opportunity to re-contour or alter the facial skeleton when this is indicated as well as reposition soft tissues.

The endoscopic facelift is a very similar procedure but it uses small incisions within the hair and an incision in each lower eyelid, immediately below the lashes, similar to that used for blepharoplasty (eye bag surgery).

Like most surgical endeavour, facial endoscopic surgery continues to evolve and in some patients the lower eyelid incision may be unnecessary and a small incision within the mouth is used instead. In endoscopic surgery a surgical telescope (endoscope) is used for vision, so there is no need for large

Facelift - Volumetric Facelift
The volumetric facelift is effectively a combination of a subperiosteal and SMASectomy based facelift.  It is designed particularly to address the fullness of the cheek area characteristic of youth and to recreate the S-shaped curve seen over the cheekbone particularly in an oblique view of the face, described by some as an Ogee curve (an architectural term for a sinuous curved line). Unlike other subperiosteal techniques it will produce a significant improvement in neck contour by re-tensioning the platysma muscle. The final surgical design will depend on the patient’s anatomy and aims.

Facelift - Cutaneous Facelift
The traditional facelift, which has been done since the early part of the last century, is a technique where the skin is lifted from the underlying tissues and re-draped, backwards and upwards.  While the overall facial appearance and skin quality will be improved the basic structure of the deeper, ageing facial tissues is not changed. This technique is the easiest to accomplish surgically and has a relatively short convalescent period. For some patients it will be the most appropriate procedure, particularly when the major problem is within the skin rather than beneath it or when the time available for recovery is at a premium. For younger patients, however, the improvement is not usually as long lasting or as impressive as with deeper level techniques that do address fundamental structural changes.

Facelift - Scars
Scars for SMAS based facelifts are hidden within the hairline and around the ear. They are designed in such a way so as not to disturb the position of the hairline so that you should be able to wear your hair in any style that you choose once they are mature. It must be remembered, however, that whilst in general the site of these scars make them extremely reliable and well concealed even in the short term, the outcome of a particular scar in any given individual can never be “guaranteed”.

In some individuals a shorter scar than is used in most facelift techniques can be employed which is hidden around the ear but does not extend back into the hairline behind the ear. Good outcomes will be achieved only when there is no significant improvement needed in the neck contour.

Neck Lift and Platysmaplasty
All deep plane facelifts re-tension the muscles of the neck to improve both the jowl area and jaw line. To eliminate vertical folds in the neck, reduce excess fat beneath the chin and restore the angle between the neck and the chin (which tends to become more obtuse with age) an additional procedure known as a platysmaplasty is often indicated. Frequently this can be achieved via the incision used for the facelift by re-tensioning the platysma muscle in a backwards and upwards direction – this is known as a lateral platysmaplasty.  In some individuals with very marked platysma muscle bands visible through the skin (often associated with a long slim neck), to obtain an optimum result it may be necessary to make another small incision beneath the chin.  This allows the platysma muscle bands to be cut and joined together in the centre with stitches to make a smooth, defined neck contour. This is known as an open or corset type platysmaplasty.

All of these options will have been considered and discussed at your consultation to decide, together, on the optimum treatment plan.

How long does a facelift last?
This is one of the most frequent questions which patients ask and until very recently has been impossible to answer accurately. We have completed an extensive study of patients for whom I have follow-up of longer than five years after facelift surgery. We have used a sophisticated computer program to measure changes which have occurred in the face and neck and to compare this with “rating scales” in which observers score changes in appearance from photographs. The study confirms that SMAS-based and volumetric type facelifts are extremely stable over a period of greater than five years. There is little change in the appearance of the jowl, neck and area around the mouth and cheeks for up to 10 years.

We are all genetically programmed to age and surgery will not stop this but when carried out carefully it will arrest the signs of facial ageing for a considerable period. The study referred to also confirms that unwanted sequelae of this type of surgery do not occur. Patients often ask whether the mouth will become wider – it does not but the corners of the mouth are elevated slightly. There are no adverse changes in the position of the ears or ear lobes.  The study suggests that techniques which release and reposition the SMAS layer such as SMASectomy and extended SMAS type techniques are more durable than those which fold the SMAS upon itself known as SMAS plication procedures.

The exact rate at which a face continues to age will of course vary from one individual to another depending on genetic and external factors such as how carefully the skin and facial tissues are cared for, whether the individual smokes and how much sun they are exposed to. However, we now have sound scientific evidence that appropriate surgery is effective, durable and avoids unwanted sequelae of facial surgery that are so often referred to as the “wind tunnel look”.

How long does it take to recover from a facelift?
In general swelling and bruising after these procedures nowadays tend to be less than might be expected. After facelift surgery alone most can expect to be presentable after 10-14 days. When brow and eyelid surgery are combined with facelift it is wise to leave 2-3 weeks for recovery to return to work and normal social engagements.

Full resolution, to a point where one can judge an end result critically, will take 3-6 months and in most adults scars mature completely over a period of 9-12 months.  Fortunately, in facial aesthetic surgery, scars are well hidden in natural body contours (e.g. around the ear) and tend to be hard to detect even when they are new.
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