Cosmetic Surgery Magazine - A Surgeons Perspective

How old you look depends on many factors including your genes, weight, facial bone structure, health, exposure to UV light, smoking, etc. Some of these are clearly determined by your lifestyle and some are not. Surgical intervention, invasive and non-invasive, can effect many, but not all of them. All treatments have their limitations but, if used in combination, can produce excellent results.
For younger patients, it is possible to offer non-invasive treatments, whereas for the older patient surgery is the main option. When assessing a potential patient one has to determine the extent of their ageing as well as the degree of desired improvement.
The main components of ageing are the skin, soft tissues, bone structure, as well as facial balance.
Skin is extremely important in ageing and the presence of wrinkles and poor skin texture will indicate the patient's age. In early stages it may be possible to improve wrinkles with Botox, fillers and retinoic cream, as well as superficial fruit acid peels. However, their impact on improvement can be made with so-called skin resurfacing, such as laser or chemical peeling. Laser resurfacing has been around for some time now but it is not my first-choice treatment for several reasons. Although it removes most wrinkles it does not improve skin texture and, in some cases leads to permanent loss of skin pigment. The other issue is healing which is very distressing to patients and more likely to lead to infection and delayed healing. However, it is still the choice treatment for acne scarring and very deep wrinkles.
Chemical peeling of any significance has to be either medium or deep. Deep peeling with phemol and crotton oil has its place for severe actinic damage and wrinkling. However, the recovery is slow, and the loss of natural skin pigment is a real possibility.
Medium chemical peels appear to be a happy medium in peeling because of their rapid healing and very low complication rate. The best among medium peels is trichloroacetic acid. At a certain concentration it can achieve excellent results after a relatively short healing period, with low incidence of complications and high patient compliance.
Brows are often forgotten in facial rejuvenation. If low in position they can affect the appearance of upper eyelids, making them look saggy, and have an overall effect on the shape of the face as a whole. A smooth forehead, free of frowning, and brows in the normal position has a youthful and rested effect. Modern brow lifting is carried out through keyhole surgery, remarkably devoid of any visible scars and gives a natural appearance. In combination with a facelift this procedure has an excellent effect, but can be done in isolation, especially in the younger patient.
Surgically, the next area of attention is the eyelids. These are usually the first to age because of continuous muscle activity and because of inherited fat herniation that becomes more apparent with increasing age. These changes results in a tired and aged look.
Although blepharoplasty is an old and established procedure much of it is carried out with a simple concept of removing fat and skin. In most cases this leads to an operated and "hollow" appearance.
Current blepharoplasty is based upon the understanding of the ageing process and recognition of what makes them youthful and beautiful. Good blepharoplasty depends on inconspicuous scars, preservation of natural eye shape and restoration of youthful contour. The current trend in lower eyelid rejuvenation is conservation of fat and repair of weak tissues which lead to the tell-tale signs of ageing. This technique is significantly more technically demanding and failure to adhere to good surgical practice can lead to significant post-operative problems.
The facelift remains the mainstay of facial surgical rejuvenation because it repositions sagging tissues and reshapes the face to its former youthful shape.
The current trend in simple surgical tightening should be discouraged because the results are not optimal and are not lasting. Unfortunately, good facelifting is not and quick. A good facelift is more dependent on tightening and repositioning soft tissues of the face than tightening of the skin. Attention to detail such as well-hidden scars and an undisturbed hairline are also important, as they can indicate whether facial surgery has been carried out or not.
The neck should be considered an inseparable part of facelifting. A good neck is a youthful neck. Unfortunately, there is currently a tendency to ignore neck lifting largely because of its technical difficulties. There is no doubt that it is a technically difficult operation, and, if carried out inexpertly, can result in post-operative complications and problems which can be taxing even for the most skilful surgeon. The current trend in simplistic facelifting produces unnatural results which are obvious to everyone.
Most candidates for facelifts have some degree of neck ageing and this should be corrected. Technical problems are not an excuse for avoiding this challenging problem. Cosmetic surgeons interested in facial rejuvenation should face the fact that if they want to achieve a pleasing and natural result they should address these problems and introduce neck lifting as a routine addition to facelifting.
In thin faces it is important to replace some of the facial volume lost through ageing. Thin faces can give the appearance of a gaunt and tired look. Full and chubby faces invariably look youthful and rested. Most of the facial fat lost through ageing is lost in the cheeks and that in turn gives rise to skin sagging, creasing and formation of skin folds. Simple "refill" is all that is needed. This is achieved with the patient's own fat taken from abdomen or thighs. If carried out carefully, a portion of fat transplanted into the face will survive permanently.
It has to be remembered that facial rejuvenation is not only about setting the clock back but also, equally important, about making faces more attractive. Equally, it is important to stress that this whole process must not change the overall appearance, so that the individual looks unrecognisable.
Facial balance is important to determine attractiveness and certain procedures, such as nose, chin and cheek alteration will contribute towards achieving this result. After surgical rejuvenation a person may look younger but if she has a large nose and receding chin she may not look attractive. Equally, a long face can be made more triangular with the addition of cheek implants.
It has to be said that 10 Years Younger patients do not represent the average patient one sees in one's office. They are patients with a multiplicity of extreme problems which have resulted in these individuals looking well beyond their chronological age. The overall approach to these patients is multidisciplinary, involving not only surgical intervention but also dentistry, hair styling, make-up and clothes styling.
The results can be quite striking in the end. However, the overall message this programme should be conveying is that change of lifestyle is all important and prevention is better than intervention.