The answer to sagging skin

Today there are many non-surgical options for wrinkles and volume loss, but sometimes only surgery will suffice in lifting sagging skin – and creating truly age-defying results.

The face lift

First performed more than 100 years ago, surgical facelift techniques have continued to evolve and today can enhance virtually any part of the ageing face. Predominantly used by women to restore the contours of youth, a facelift, or rhytidectomy, can correct sagging, loose skin and reposition fat and tissues to add volume back to the face.

Over time, the effects of gravity, sun damage and the stresses of everyday life appear on the face, altering the way people appear to the outside world. Deep lines may appear around the eyes and mouth, sagging skin may fall from the cheek, jawline and neck, and fat deposits that were once full and firm deplete, leaving hollow and sunken areas of the face. As people are living increasingly lengthy lives, a facelift is designed to address these age-related changes and help both men and women look as young as they feel inside.

By repositioning both the skin and the layer of muscle and tissue beneath (known as the superficial musculoaponeurotic system, or SMAS), the modern approach to facelifting restores facial elements to a more desirable position to create a younger looking appearance while avoiding the tell-tale signs of surgery.

While the modern approach to facelifting predominantly addresses volume replacement and vectors of lift, the procedure also helps smooth lines and folds. A facelift does not, however, address overall skin texture, skin thickness, or wrinkling and creases around the nose and mouth.

Facelifts can be divided into full, lower and mid-facelifts. Typically, a full facelift will begin with incisions made and concealed within the hairline. From here, the skin is separated from the muscles and tissue beneath, and the SMAS layer is then tightened in the mid and lower face, as well as the neck. The skin is then pulled back, reducing lines and wrinkles. Excess skin and fat is removed, and the incisions are closed.

A lower facelift addresses the appearance of ageing features in the lower part of the face. It is common for a single incision to be made within the hairline extending down around the perimeter of the ear and into the hairline on the back of the head. Through these incisions, the skin is lifted from the underlying tissue of the lower face, jaw line and neck to expose the muscle and fibrous tissue beneath. The SMAS is repositioned to elevate and tighten the underlying facial structures and the skin is repositioned, with any excess being removed. A lower facelift procedure typically takes three hours, depending on the extent of surgery.

A mid-facelift is concerned with tightening the underlying tissues and elevating the fat pads to give improved shape and volume to the face. Although capable of restoring a firmer, younger-looking appearance, a mid-facelift cannot correct loose skin in the neck and jaw line.

A mid-facelift can be performed using a variety of different incisions and surgical techniques. For example, when combined with eyelid surgery (blepharoplasty), the surgeon may choose to make incisions in the lower eyelid. When performed in conjunction with a lower facelift, the surgeon may make additional incisions inside the mouth along the gum line to help release the mid-face tissues.

Another approach is the endoscopic technique, whereby small incisions are usually made just above the hairline, above the ear or by the temple. Additional incisions are made inside the mouth over the cheekbone. With the aid of an endoscope, the surgeon can gently manipulate the facial tissues and lift them to a more youthful position.

A mid-facelift procedure takes around one and a half hours, depending on the extent of treatment.

Recovery from modern facelifts is typically much less extensive and lengthy compared with facelifts of the past, with less swelling, bruising, pain and recovery time. There are also different procedures, such as mini-lifts, which use smaller and fewer incisions, offering less recovery and downtime.


As the ‘windows to the soul’, the eyes offer an indication of someone’s age, level of fatigue and even overall state of health. Studies have shown that factors such as the degree of wrinkling, skin texture and upper eyelid ‘hooding’ can indicate poor health and lifestyle to others.

As the effects of ageing take their toll, a blepharoplasty procedure, which addresses the upper and/or lower eyelids, can help not only recapture a sense of youth but also express an overall sense of health and happiness to others.

From skin laxity to thinning and fat depletion, ageing can take its toll on the eye region, resulting in delicate changes. The muscle layer beneath the skin starts to lose its tone; the fat of the eyelid can protrude forward to cause a dark shadow; the cheeks begin to shrink, leaving a groove-like valley known as a tear trough; and the brows descend. The result is a tired-looking, aged appearance.

The effects of ageing can also be exacerbated by sun-exposure and smoking.

Despite the largely uniform ageing process, however, the variety of ways in which these effects present themselves on each individual means that blepharoplasty is not suitable for everyone. Even when someone is convinced an upper or lower blepharoplasty procedure is right for them, this may not be the case, and it is the surgeon’s job to identify where the real opportunity for improvement lies. A thorough consultation, including a review of past photos, can help determine whether someone will benefit from blepharoplasty.

The approach to eyelid surgery will be individualised to each patient. Skin quality, ethnic features, as well as anatomical differences will dictate the ideal approach for each patient.

Surgeons will typically consider the aesthetics and function of both the upper and lower eyelid, and consider whether altering one or both is the appropriate surgical approach. Often, an upper eyelid blepharoplasty is sufficient in rejuvenating the appearance of younger patients, whereas a lower lid blepharoplasty may be needed to remove redundant skin and bags in older patients. In others, a brow lift or fat sculpturing may be the best option to address specific concerns.

Upper blepharoplasty

Considered a more straightforward procedure than lower eyelid surgery, upper blepharoplasty is well suited for those with excess skin that creates a ‘hooded’ effect over the eyes. Typically, the procedure involves removing excess skin to create a more ‘open’ appearance in the eye area, revealing the contour of the brow and inner eyelid crease.

Upper eyelid surgery is usually approached from the skin crease in the outer surface of the eyelid. The incision is typically made in the lid crease and is made with either a scalpel or CO2 laser that seals the blood vessels as it incises. Skin and muscle are removed to reduce hooding in the upper eyelid. In some cases, fat pockets may need to be repositioned during surgery, but this is dependent on the patient.

For suitable patients, upper blepharoplasty can produce dramatic results and is a minimally invasive surgical procedure when no fat transfer is required.

Lower blepharoplasty

Approaches to the lower lid are more likely to require a combination approach, which may involve surgery, filler and laser to give the best result.

Incisions for the lower lid blepharoplasty can be made either inside the eyelid or just below the lower lash line. Excess skin in the lower eyelids is removed through these incisions to correct undereye bags or sagging.

Eyelid heaviness caused primarily by excess fat may be corrected by a transconjunctival blepharoplasty. The incision in this case is made inside the lower eyelid, and excess fatty material is removed.
The supporting muscles and structures surrounding the lower lids play an important role in the appearance of the eyes, and therefore lower blepharoplasty requires an intimate understanding of the periocular anatomy. Damage to any of the surrounding structures can lead to complications such as scarring and droopy lids. The preservation of the blinking mechanism is also of critical importance in order to avoid problems with eye irritation post surgery.

The results of eyelid surgery become apparent gradually, with swelling and bruising usually subsiding after around two weeks to reveal a smoother, better defined eye region and a more alert and rejuvenated appearance. Results typically last around seven to 10 years. Some patients may also elect to have their eyelid surgery combined with a facelift or brow lift to maximise the rejuvenating effect and further enhance results.

Brow lift

The eyebrow area can be especially influential in the appearance of ageing eyes, as the brow can descend and cast an aged, tired and often angry expression across the face.

The brow and the forehead can be the first part of the face to show early signs of facial ageing. Deep creases across the forehead and between the eyebrows can appear, even when the face remains in a static position. The effects of gravity, sun damage and the natural ageing process all contribute to a gradual descent of the brow, giving a ‘heavy’ or ‘hooded’ look to the upper face, which can make a person appear angry, sad or older than their years.

Also known as a forehead lift, a brow lift elevates a low or sagging brow to a more youthful position, minimises the creases and wrinkles that develop across the forehead, and improves frown lines that develop high on the bridge of the nose. It can also rejuvenate the upper eye area, reducing heaviness and sagging over the eyelid and at the outer edges of the eye.

Brow lift surgery can be performed using several different techniques. Generally there are two commonly used methods of performing a brow lift: the traditional coronal open incision brow lift and the endoscopic brow lift.

The traditional brow lift procedure involves an incision made behind the hairline across the top of the head from temple to temple. The forehead skin is lifted from the underlying tissue and tightened along with the muscle using sutures under the skin. The incision is then closed with stitches. Surgery typically takes around one to two hours.

Instead of one long incision, the endoscopic approach to lifting the brow involves three to five short incisions above the hairline, each about 2cm long. An endoscope is passed through an incision and positioned near the brow. From there, surgical instruments are inserted through another incision to allow the tissue and muscle beneath the skin to be repositioned.

Gauze is placed over the closed incision and an elastic bandage may be wrapped over the area to reduce swelling for the first few days. Most patients can resume everyday activities within a week, although rigorous activity should be avoided for several weeks. Bruising and swelling typically subsides after around three to four weeks and some temporary numbness of the scalp is normal. Healing is usually complete and the final results apparent within around two months.

A brow lift is often combined with a facelift or blepharoplasty to provide a harmonious rejuvenation.

Ear correction

Affecting around one in 20 people, overly large ears often result in a significant aesthetic and psychological handicap.

Many people with protruding ears often learn to hide them from a young age, be it with a hat or hairstyles, to avoid unkind remarks.

Otoplasty (or ear correction) is a surgical procedure that reduces the appearance of prominent ears, pulling them back closer to the head and making them less noticeable. An otoplasty is a relatively simple operation to correct protruding ears, and can result in a pleasing and long-lasting outcome.

Suitable for both adults and children, the procedure usually takes around two hours. The surgeon makes a small incision, using either a scalpel or laser, at the back of the ear so that the cartilage is exposed. The cartilage is then sculpted and bent back toward the head. In cases where only one ear may protrude, the surgery is usually still performed on both ears for better balance.

After the surgery, a bandage is wrapped around the patient’s head to help with moulding and healing. This stays on for approximately one week, after which a lighter and smaller headband is usually worn during sleep for the next two to three weeks. In most cases the incision leaves a faint scar at the back of the ear, which fades over time. Swelling and bruising post-surgery is usually minimal.

Facial implants

Available in a wide range of sizes suitable for the cheek, jaw, nose and chin, facial implants are designed to restore the contours and proportion of the face, which may be left depleted by the natural ageing process. Facial implants are used to correct sunken cheeks, a receding chin or enhance the jaw and also to create structural balance in the face.

Chin augmentation, for example, can build up a weak chin and contribute to an overall balanced profile. Facial implants are often inserted in conjunction with rhinoplasty to achieve facial proportion. It is also possible to add balance to the face by building up and enhancing the cheekbones using implants. Placed through a small incision in the mouth, they give the ‘high cheekbone’ look. Incisions for cheek implants can also be made through the hairline or lower eyelids. Chin and jaw implant incisions are usually hidden in the mouth.

The implants themselves are specially formed from solid, biocompatible materials and are designed to augment the physical structures of the face and create more defined contours and angles. The incisions are normally closed with absorbable sutures that dissolve over the next seven to 10 days.

Neck & chin lifts

A neck lift is designed to reduce excess skin and fatty tissue of the neck and correct poor definition of the chin/neck angle and jaw line. The technique used will depend on several factors, such as the degree of excess skin, the level of skin laxity and the presence of fatty tissue.

The traditional neck lift incision begins in front of the ear lobe and loops under and behind the ear, ending in the scalp towards the back of the neck. An additional small incision under the chin may be made to tighten the platysma muscles.

Other techniques may involve an incision only inside the hairline at the back of the neck (known as a posterior neck lift), or behind the ear only (for some suspension techniques).

During a typical neck lift procedure, the platysma muscles of the neck, which weaken and separate with age, are tightened and sewn back together in the centre. In some cases the surgeon may choose to remove a small part of the muscle to further reduce the appearance of skin laxity and neck banding.

Neck & chin lipo

Two of the defining features of a youthful face are a well-defined jaw line and a pleasing angle where the neck and chin meet. Chin and neck fullness or a poorly defined jaw line can create the appearance of excess weight and premature ageing.

Facial liposuction is a relatively minimally invasive surgical procedure and is best suited to patients presenting with excess fatty tissue but minimal excess neck skin. Through several tiny incisions, the fatty tissue is removed by way of a specialised suction device. The procedure is most often performed with a microcannula using a tumescent technique that involves injecting fluid into the targeted area while suctioning the fat out.

Swelling and bruising should typically subside in around seven to 10 days, after which most patients can return to normal everyday activities. Final results can take several months to become evident.

Thread lifts

Today, surgeons are equipped with a repertoire of procedures aimed at rejuvenating facial features. One technique used to lift sagging features – typically in the mid-face – to create a fresher, more contoured look, is a thread lift. By inserting threads into the cheek area, not only can the cheek be suspended to a higher position but collagen production can also be stimulated, thus improving the hydration, tone and texture of the skin.

Thread lifting is a minimally invasive technique that elevates the soft tissues of the face using specially designed internal sutures and can deliver subtle yet effective results. The procedure involves the use of multiple fine biocompatible threads to lift and support sagging skin on the face and neck. Tiny ‘nicks’ are made to the skin, which are hidden in the sideburn area. Threads are then looped to the sagging soft tissues that support the face and neck, lifting and anchoring the facial tissue to an elevated, more youthful position.

This process allows the threads to have a firm hold on the underlying tissues, without causing trauma to the outer layers. Acting as a kind of scaffolding, the soft barbs gently hold to the tissue as they lift the skin, complementing the natural line of the face or neck. Once in position, the body generates new collagen that surrounds each thread to maintain the lifting effect. Excess skin is then removed through a fine incision along the ear.

New-generation threads are completely absorbable. This means the threads dissolve within around nine to 12 months, whilst maintaining the revitalising and lifting effect for several years to come.

The procedure is typically performed under local anaesthetic and usually takes around one hour to perform. Patients can usually return home within one to two hours after the procedure. However, patients should be aware the threads take a few weeks to settle and integrate properly with the skin.

This procedure does not replace a conventional facelift; rather, it offers patients a minimally invasive approach to address the early signs of facial ageing. Results tend to last around two to four years.