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
Facial Cosmetic Surgery - Overview

The twenty first century prizes youth and vitality.  The population is generally fitter and living longer.  The generation gap has narrowed following the revolution in culture and the power of youth stimulated by The Beatles, Dylan, Warhol and their contemporaries so that parents are more likely to share interests such as music and fashion with their children than was once the case.  The presently middle aged children of the sixties do not view themselves as ageing, finding it difficult sometimes, to accept the changes in appearance which inevitably accompany the passage of time.  What they see in the mirror does not necessarily reflect their inner wellbeing.  Increasingly women occupy senior positions of power and influence in the workplace where physical suggestions of wisdom, born of maturity, may be less valued than the expression of dynamic physical energy.  The burgeoning explosion of visual media constantly bombards us with images (often digitally retouched!) of “perfect” people with the implication that they represent an aspirational goal for all.  Paralleling these changes in society’s perception, medical science and technology has reached a level of sophistication that can offer the potential to mitigate the physical signs of ageing with low risk.  Survival is no longer the only principal effort (of modern medicine): improvement of the quality of life is also important.  As a consequence, aesthetic surgery in general and facial aesthetic surgery in particular has seen an unprecedented expansion in recent years.
A plethora of non surgical interventions such as dermal fillers, botulinum toxin and skin resurfacing (laser, chemical peel, phototherapy etc.) have emerged since the initial introduction of bovine collagen injections in the late 1970s and gained enormous popularity. 

They can be very helpful in improving skin quality, particularly when used in combination with a supervised skin care program, and in making superficial wrinkles and creases less noticeable but their aim is different from surgical procedures.  The two approaches should not be seen as exclusive – either surgery or  non surgical, but as complementary.  The more specific an individual can be about their aim when seeking to improve their facial appearance the more likely it is to be achieved.  When giving advice it is important for a doctor to have experience of all contemporary techniques in order to give unbiased information about what they will, or sometimes more importantly will not, achieve and so decide with the patient what is best for them specifically.
Surgical approaches should address the effect of time and gravity.  Our understanding of the true anatomical changes which occur in the face as we age has expanded greatly in recent years as a result of many scientific studies and allows us to create an entirely natural look without any of the undesirable consequences of an “operated” appearance.  It is probably easiest to consider them from the top down i.e. from the hairline to the neck.

The Brow
In many individuals frown lines at the root of the nose associated with downward movement of the outer part of the eyebrow create an appearance of being cross or angry even when relaxed and make the eyes themselves appear smaller.  Browlift surgery can alleviate these features and the introduction of endoscopy (keyhole surgery) has meant that scars should be very small (1-2cm) and hidden within the hair.  The hairline should not be disturbed.

The Eyelids
Eyelid surgery, or blepharoplasty aims to eliminate excess skin folds and puffiness making the eyes look brighter and less tired.  The scars should be well hidden in the natural skin crease of the upper lids and immediately below the lashes of the lowers or inside the lid when appropriate.  Although removing fat to improve “bags” seems logical, we now know that the volume of fat in the eye socket reduces with age making the eyes look hollow.  Surgical fat removal will make this worse so, although it is technically more difficult, a better long-term outcome will be achieved if the membrane which holds the fat in the eye socket is repaired rather like a hernia.  The amount of skin which can be removed is dictated by functional considerations – the upper lids must close comfortably and the lowers must sit against the eye globe properly.  It is never possible to remove every wrinkle and expression lines will remain.

The Face – Cheeks to Jaw
A facelift is now a sophisticated procedure which can be tailored to individual needs.  In almost all cases it is vital to support deep tissues beneath the skin (fat and muscle) so that there is no tension on the skin itself creating a natural appearance and undisturbed movement.  Scars should be very fine and concealed in contours around the ear or sometimes inside the mouth.  The hairline is not disrupted. There are many technical variations with confusing acronyms such as SMAS and MACS but the underlying principles are similar. Volumetric techniques focus on recreating the natural cheek fullness of youth, a heart shaped face, and combine an approach from around the ear with one from inside the mouth.  In some individuals an endoscopic facelift will be an option so that scars are very small, hidden within the hair.  Whichever technique is selected the result should be entirely natural with no pulling, stretching or flattening of the face, eliminating jowls, supporting the upper lip and enhancing cheek contour.

The Neck
Most facelifts will have a positive influence on neck contour but in some patients, when the angle between neck and chin is poor or where muscle bands are very visible, a platysmaplasty will be necessary.  This will restore tension in the platyma muscle beneath the neck skin.  It is sometimes done from behind the ear making no extra scars (lateral platysmaplasty) but may require an incision under the chin (anterior platysmaplasty).  The latter is more uncomfortable and has a higher incidence of minor complications but when used correctly will produce an outcome unachievable by other means.  Very gentle fat contouring using a syringe is frequently helpful should be sympathetic to avoid skeletonising the face.

The Lips
Volume and definition loss can be improved by structural fat grafting when fat is taken from the tummy, hip or knee and impurities removed before grafting back using a syringe and specially designed needle.  The objective is a natural, young appearance not a “trout pout”.  The same procedure is sometimes helpful in the cheeks and around the mouth.  Resurfacing techniques such as chemical peeling are useful for fine lip lines but should be gentle to avoid disturbing skin pigmentation.   In some individuals shortening the upper lip by a few millimetres can improve its contour and recreate the “tooth show” associated with youth.

Facial surgery is unique in that the period of recovery is determined, not by any kind of disability, but by visibility i.e. swelling and bruising.  This should not be extensive but for comfort it is wise to allow a period of two to three weeks.

In all aspects of surgery, but perhaps particularly aesthetic surgery, safety is of paramount importance. A surgeon undertaking facial aesthetic surgery requires a thorough grounding in plastic surgery principles combined with a detailed knowledge of facial anatomy from bone to skin. A thorough working knowledge of the evolution of current surgical concepts is essential as is intimate acquaintance with contemporary literature and techniques. Excellence in outcome is probably as much operator-dependent as technique-dependent, i.e. a highly skilled surgeon is likely to produce a pleasing outcome irrespective of the specific technique that he chooses but it is necessary to adapt one’s own methods to the particular needs and physical demands of an individual patient. There is no “one-size-fits-all”; the surgeon must be flexible in his thinking, planning and execution.

In an age when marketing, spin and image are becoming an integral part of plastic surgical practice, it should be remembered that there is no substitute for technical excellence borne of thorough training and experience.  Media exposure does not necessarily imply competence and the best route for referral is via another doctor - GP, gynaecologist etc, or patients who have had a satisfactory experience.

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