The Ageing Face

Bryan Mayou carries out 150 operations on the ageing face every year. These included the face or neck lift, endoscopic brow lift, mid-face lift, liposuction of the chin, neck and cheeks, upper and lower eyelid reduction, trans-conjunctival fat reduction for bags of the lower eyelids, nasolabial fold excision.

As part of the aging process which happens to all of us sooner or later, our skin progressively loses its elasticity and our muscles tend to slacken. The stresses of daily life, effects of gravity and exposure to sun can be seen on our faces. The folds and smile lines deepen, the corners of the mouth droop, the jaw line sags and the skin of the neck becomes slack. Around the eyes, the eyebrows droop and the skin of the eyelids gathers in loose folds. In the skin the first sign is fine wrinkles developing around the lips, at the outer corners of the eye and lines of expression. The rate at which this happens varies from one person to another and is probably determined by our genes. Ageing of the skin of the face does not necessarily reflect the rate that the rest of our body and mind is ageing and many people feel frustrated that the face they see in the mirror is not the one they feel should be there. Substantial weight loss can produce similar changes in facial appearance to those of the ageing process.


The Facelift

The best candidate is one whose face and neck has begun to sag, but whose skin still has some elasticity and whose bone structure is strong and well defined. Most patients are in their 40's to 60's, but facelifts can be done successfully on people in their 70's or 80's.

It should not be obvious that a patient has had a facelift, but instead they look younger, more vital and cheerful. It is a procedure that technically works well but also increases morale and is well appreciated by the patient.

What a facelift does not do?

A facelift works better for the lower half of the face and particularly the jaw line and neck. If you have sagging eyebrows and wrinkles of the forehead then you should perhaps consider an endoscopic brow lift. Loose skin with fine wrinkles, freckles and rough areas will benefit more by chemical peel or laser resurfacing.

What should you do before the operation?

If you are overweight and intend to lose it you should do so before the operation. This allows the surgeon to remove more skin and therefore achieve a more pleasing result. You should avoid taking tablets containing aspirin and non steroidal anti-inflammatory drugs, herbal remedies, vitamins and tonics for at least two weeks before surgery as they increase the risk of bleeding.

You should stop smoking at least two weeks before surgery as this is the main cause of reduced healing. It decreases circulation of the skinflaps, particularly behind the ears.

Have your hair permed and tinted, if you wish, before your operation as fresh scars are sensitive to these chemicals for a few weeks.

The surgery

A facelift is carried out in Hospital usually under general anesthesia. It is possible to carry out the procedure under local anaesthetic and intravenous sedation but the patient would still be advised to spend the night in hospital. The procedure, although long, can be combined with other operations of all sorts. The most common however would be an endoscopic brow lift and an eyelid reduction. Other extra procedures which can be used to enhance the face at the same time are malar (cheek bone) and chin augmentation and lip enhancement.



Incision lines follow the natural crease, or tagus, in front of the ear and extend into the hairline above and behind the ear.
 

Platysma muscle and its fibrous attachment (SMAS) are sutured tightly in front and behind the ear as an extra sling under the chin.
 

Incisions are made above the hair line at the temples and extend in a natural line down the front of the ear, or just inside the cartilage at the front of the ear, and continue around behind the earlobe and up in the crease behind the ear and off into the lower scalp. Occasionally it may be necessary to make a small incision under the chin. Sometimes only the skin is lifted following separation from the underlying platysma muscle.

More usually however the platysma muscle and its fibrous attachments (S.M.A.S.) is dissected free and sutured tightly to the solid structures in front and behind the ear. At other times the skin and the S.M.A.S. layer are lifted together as a single layer, but will still be sutured separately. Fat along the jaw line and under the chin may be removed by liposuction or on occasion through an incision under the chin. The skin is sutured so that it is lifted upwards and backwards, just as when one lifts the skin when looking in the mirror. The face is bandaged overnight to minimise bruising and swellling. These bandages are removed the following morning and the hair washed. The patient then goes home without a bandage and returns seven days later to have the sutures removed.

After your surgery there is usually some bruising of the cheeks and with gravity this tends to descend into the neck. Discomfort is usually mild and can be controlled with Paracetamol. It is normal for there to be some numbness of the skin of the cheeks and ears. This will usually disappear in a few weeks or months. It is better to keep the head elevated for a couple of days to reduce swelling. Avoid strenuous activity, saunas and massage for at least two weeks.

At the beginning your face will look a little puffy and may feel rather strange and stiff. Bruised areas may become hard and tethered for a month or two. The scars can be very well hidden by women with their hair and disc shaped earrings so that they should be able to resume work and social activities within a couple of weeks. Camouflage make-up can be helpful in masking bruising.

Men find it more difficult to disguise the scars and will need to shave their beard closer to the ear in front and also behind the ear where the skin has been lifted.

The scars in the hair do not usually show except that the hair is cut shorter immediately around the wound. There may be some slight reduction in hair growth in the temples, but this is not usually a problem unless the hair is very thin and repeated facelifts are being carried out.

How long does a facelift last?

A facelift does not stop the clock, but it does put the clock back. The effect of the facelift is likely to always be there, in that you will not look as old as you would have done if it had not been carried out.


Endoscopic Browlift (Endobrow)


Endoscopic or keyhole surgery has been used by gynaecologists to do laparoscopy, orthopaedic surgeons to do knee surgery and general surgeons to remove gall bladders for some years. It is relatively new to plastic surgery and although extremely promising, its place has yet to be established. In principle, a lighted telescope is inserted in a stab incision and viewed on a video monitor.

Instruments are inserted through another stab incision. The advantages of endoscopy are that scars are small and can often be well hidden and bleeding, bruising and swelling and the general upset of surgery may be reduced. The surgeon's view of the procedure is often greatly enhanced by having the eye of the telescope only a centimetre or two from the operation site.



Forehead Lift


The forehead lift is the commonest procedure carried out endoscopically. Three or more stab incisions are made just behind the hair line instead of the usual ear to ear incision. It allows the surgeon to reduce the transverse frown lines of the forehead and vertical glabella frown lines between the inner end of the eyebrows.

Sagging eyebrows can be lifted to a higher level. The procedure on its own can be carried out as a day case or with one night in hospital under general anaesthesia or local anaesthesia with intravenous sedation. There is usually swelling around the eyes after surgery which takes a few weeks to settle. Hair is sometimes lost around the scalp incisions and if this is the case it takes several months to re-grow.

Incision lines are made behind the hairline

Deep Facelift

This is an extension of the forehead lift which is designed to tighten the skin of the upper half of the face, as opposed to the standard facelift which helps the lower half of the face. The Deep Facelift carried out endoscopically avoids the same ear to ear incision. It is usually carried out at a younger age than the standard facelift. It tightens the skin of the mid-face and freshens the eyes, opening and lifting the outer angle and reducing the wrinkles of the crows feet. There will be swelling around and below the eyes which gradually resolves in about a month. There will also be scars beneath the eyelashes of the lower eyelid and sometimes in the upper gum line. There is a slight risk of damage to the nerve which supplies the muscles of the forehead. This weakness is usually partial and temporary, on rare occasions it may be permanent.