The complete guide to facial surgery

Facial-Surgery

The face, more than any other part of the body, defines an individual to the outside world. With age, the effects of gravity, sun damage and the stresses of everyday life become apparent and can alter the appearance of a person’s face.

As such, these age-related changes can make people feel as if their identity has changed over time. As people are living longer and more active lives, many seek facial cosmetic surgery to help them look as young as they feel.

Changes can occur in the upper, mid and lower portions of the face due to the downward descent of facial fat and skin, resulting in deep lines around the eyes and mouth, sagging skin in the cheeks, jaw line and neck, as well as banding around the neck.

Facial tissues weaken over time, losing their resiliency and ability to maintain a firm, youthful position. In addition, facial muscles weaken and stretch, and fat deposits which normally give the face a soft, rounded appearance deplete and descend to create hollow areas. A facelift, or rhytidectomy, is designed to address these age-related changes and can restore a firmer, more youthful appearance.

Modern facelifts

By repositioning both the skin and the SMAS, the modern approach to face lifting restores the facial structures to a more desirable position to create a younger looking appearance while avoiding the telltale signs of surgery.

While a modern facelift predominantly addresses volume replacement and vectors (directions) of lift, the procedure also helps smooth wrinkles and folds.

A typical full facelift today begins with incisions that are concealed within the hairline. From these incisions, the skin is separated from the muscles and tissue beneath. The SMAS layer is then tightened in the lower face, mid-face and neck, after which the skin is pulled back to reduce lines and wrinkles. Excess skin and fat is removed and the incisions are closed.

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 that use smaller and fewer incisions, offering less recovery and down time.

There are different types of face lifting surgery, with each tailored to correct different regions of the face. For example, a lower facelift is performed to rejuvenate the lower portion of the face, while a brow lift or mid-facelift can typically correct age-related changes in the upper and mid-face, respectively. In addition, sagging and puffy eyelids can be addressed with eyelid surgery, or blepharoplasty.

It is important to note that facelifts do not address overall skin texture, skin thickness, or wrinkling and creases around the nose and mouth. Instead, modern face lifting techniques are designed to correct sagging, loose skin and reposition fat and tissues to add volume back to the face.

Lower facelift

A lower facelift can be performed using different types of incisions, depending on the patient’s individual needs and wishes. A single incision is commonly made within the hairline that extends downward around the perimeter of the ear and into the hairline on the back side of the head.

Through these hairline incisions, the skin is lifted from the underlying tissue of the lower face, jaw line and neck to expose the SMAS, a layer of tissue composed of muscle and fibrous connective tissue.

The SMAS is then repositioned to elevate and tighten the underlying facial structures to a more youthful and aesthetically pleasing position. There are a variety of methods that can be used to lift the SMAS, such as excision or plication in which the tissue is augmented and suspended in a higher position with sutures.

After the necessary adjustments, the skin is then repositioned over the face and any excess skin is removed. In some cases, the surgeon may place a surgical drain beneath the skin to prevent fluid build-up during healing, although this is not usually necessary. The incision is then closed with sutures. A lower facelift procedure typically takes around three hours, depending on the extent of surgery.

Mid-facelift

During a mid-facelift, the underlying tissues are tightened, and fat pads that give the face shape and volume are lifted to restore a firmer, younger looking appearance. A mid-facelift cannot correct loose skin in the neck or along the jaw line, nor can it address fine lines or uneven skin tone and texture.

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 physician 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, a thin tube-like instrument with a tiny camera on the end, the surgeon can gently manipulate the facial tissues and lift them to a more youthful position.

The tissues are typically suspended by use of sutures or absorbable medical-grade material that dissolves over the course of a few months. Once the underlying tissues are tightened and the fat pads are lifted, the incisions are closed using sutures.

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

SMAS lift

The SMAS (Superficial Musculoaponeurotic System) technique concentrates on the thin underlying connective tissue and muscle layer called the superficial musculoaponeurotic system, as well as repositioning and removing excess skin. Tightening this foundational tissue gives a smoother and improved shape without noticeable tension in the skin. This type of facelift is generally considered to be the gold standard in facelift surgery today.

Extended SMAS lift

An extended SMAS lift separates the SMAS from the underlying facial structures more extensively towards the nose and upper lip compared with the SMAS lift. This can address age-related changes in the nasolabial area (around the nose and mouth) more than the traditional SMAS lift, however increasing the amount of SMAS lifted also increases the risks of complications, such as skin necrosis.

Deep plane lift

A deep plane facelift is designed to reshape the entire face, including the upper and lower eyelids, the brow and the neck, by lifting facial tissues, fat, muscle and skin in one continuous section. Because the dissection is deep, the flap is thicker than in the SMAS method. This procedure is more invasive than other methods and may require a longer recovery period.

Subperiosteal lift

Commonly performed with the aid of an endoscope, the subperiosteal lift is designed to reposition skin, fat and muscle simultaneously since the tissues tend to sag together, not individually. This type of facelift releases tissues off the bony layer, separating the bone from all of the tissues covering it. There is more swelling with the subperiosteal lift than with more superficial lifts due to the depth of the dissection. It also usually causes more swelling and takes longer to recover.

Composite lift

The composite facelift is similar to a deep plane lift, with the addition of an extra step to include the muscle around the lower eyelid. The orbicularis oculi muscle (around the eye) is separated from its attachment to the cheekbone through an incision in the lower eyelid and then lifted and sutured into place. The composite facelift essentially involves elevation and resection of the SMAS layer, orbicularis muscle and cheek fat pad. There is typically more swelling with the composite lift than with more superficial lifts.

S-Lift

The S-Lift is a type of facelift named after the S-shaped incision made in the hairline at the temple and in front of the ear. The SMAS and attaching skin is usually elevated as one unit and only excess skin is removed. The best candidates for an S-Lift are those who do not have significant skin laxity of the neck and jowls. It is most suited to patients beginning to show signs of facial ageing and want some tightening of the lower face without longer incisions.

Mini-lift

This type of facelift typically refers to any limited-incision facelift, usually with a quicker recovery time compared with other more invasive techniques. Also referred to as a MACS Lift (Minimal Access Cranial Suspension) and the short-scar facelift, it is typically suited for patients with early signs of ageing, usually aged in their 30s and 40s, to achieve a natural-looking facial rejuvenation. During a mini-lift, the surgeon usually makes a short incision on the front side of the ear. Via this incision, deep plicating sutures lift the deep tissues and the extra skin is then removed. Due to its less invasive approach, this type of facelift typically offers less recovery time and a lower risk of complications.

Thread lift

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 in an elevated, more youthful position. Excess skin is then removed through a fine incision along the ear.

Once in position, the body generates new collagen that surrounds each thread to maintain the lifting effect. The procedure is typically performed under local anaesthetic and usually takes around one hour to perform. In most cases there is minimal discomfort, bruising and swelling and patients can usually return to normal activities in a few days. 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.

A facelift can significantly improve the appearance of an ageing face, however it may not be able to address all age-related changes. Additional procedures may be required to achieve overall facial rejuvenation and harmony, or only one particular area of the face may need correction. Depending on the individual patient’s needs, these procedures may include a brow lift, neck lift, chin liposuction, blepharoplasty, rhinoplasty and facial implants. They can be performed alone or in combination with other procedures.

Brow lift

Often the brow and forehead area can show the first signs of facial ageing. Deep creases across the forehead and between the eyebrows can become evident, 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, depending on the patient’s individual requirements and the surgeon’s preferred method. Generally there are two commonly used methods of performing a brow lift: the traditional crononal open incision brow lift and the newer 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, a thin instrument with a tiny camera at one end, 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 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.

Neck lift

Performed in conjunction with a facelift or as a standalone procedure, a neck lift is designed to correct excess skin and fatty tissue of the neck (the so-called ‘turkey gobbler neck’), platysmal bands which run from beneath the chin to the lower neck, as well as a poorly defined chin/neck angle and jaw line.

The type of technique used for a neck lift procedure depends on several factors, such as the degree of skin excess and 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), depending on the techniques used and the degree of lifting required.

During a typical brow 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. Tissue and skin can also be elevated to a more youthful position during the procedure. A small amount of skin trimming is performed as needed and the incisions are closed, followed by a support bandage.

Liposuction of the chin and/or neck area may be required to remove excess fatty deposits and help create a more defined chin/neck angle and jaw line. In younger people with good skin tone, unwanted fat in the neck and jowls area can be removed with liposuction alone.

In most cases recovery time is around two to four weeks and healing is usually complete within a few months.

Neck and chin liposuction

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.

Blepharoplasty

Blepharoplasty is a surgical procedure to improve the appearance of the upper and/or lower eyelids to give a more refreshed appearance to the surrounding area of the eyes.

The incision lines for eyelid surgery are made within the natural structures of the eyelid region, allowing any resultant scars to be well concealed.

The incision for an upper lid blepharoplasty is in the lid crease and is made with either a scalpel or CO2 laser that seals the blood vessels as it incises. Skin, muscle and fat are removed to reduce hooding in the upper eyelid.

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 under-eye bags or sagging.

Eyelid puffiness 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 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 elect to have their eyelid surgery combined with a facelift or brow lift to maximise the rejuvenating effect and further enhance results.

Rhinoplasty

Rhinoplasty, or nasal surgery, improves the appearance and proportion of the nose to balance it with the other facial features. It can also correct impaired breathing caused by structural abnormalities.

As a person gets older, the nose tends to elongate and droop and the skin becomes thicker and less elastic. The hallmark of nasal ageing is the loss of support for the lower one-third of the nose. The major and minor tip support mechanisms weaken with age, which can lead to a dorsal hump as a result of decreased tip projection and a longer nose as a result of tip ptosis, or droopiness.

A rhinoplasty procedure can create a more youthful appearance to the entire face by reversing the signs of an ageing nose and can be an effective adjunct to other facial rejuvenation surgeries.

Surgery of the nose is typically performed either using a closed procedure, where incisions are hidden inside the nose, or an open procedure, where an incision is made across the columella, the narrow strip of tissue that separates the nostrils. The soft tissues that cover the nose are lifted, allowing access to reshape the structure of the nose.

Most people take around seven to 10 days off work to allow swelling and bruising to subside. Results are permanent and it may take up to a year for the new nasal contour to fully refine.

Facial implants

Cheek, chin and jaw implant surgery are procedures to reshape the contours of these features and achieve more defined and harmonious facial contours. The implants themselves are specially formed solid, biocompatible materials designed to augment the physical structures of the face and create more structured contours and angles.

Reshaping the chin is often combined with a facelift, blepharoplasty or rhinoplasty to achieve facial proportion. Incisions for cheek implants are made through the hairline or lower eyelids, while a chin or jaw implant incision is usually hidden in the mouth. The incisions are normally closed with absorbable sutures that dissolve over the next seven to 10 days.

Bruising and swelling may last for several days and make talking and eating difficult for a short time. While the initial results are visible almost immediately, it may take several months for swelling to fully dissipate. Results are permanent unless the implants are removed.