Medical terms
haemorrhage – bleeding
haematoma – blood clot
necrosis – delayed healing

Face Lifts and Other Facial Operations

Time was when a face lift meant such prolonged bruising, swelling and visible scarring that patients had to disappear for months. Today’s medical advances mean much shorter in-patient and recovery times.

Endoscopic Face Lift and Brow Lift

Endoscopic or keyhole surgery for faces is a recent arrival. For the ‘endoface’, the surgeon inserts the endoscope (a surgical telescope) through five small cuts in the hairline and two inside the mouth, which heal rapidly, leaving virtually no visible scars. A minute camera on the endoscope allows the surgeon to reposition facial tissues and muscle inside the face and brow by watching progress on a large television screen.

The ‘endoface’ has very limited application because it does not remove slack skin but relies on repositioning skin and anchoring it with a form of skin glue, so it’s only suitable for mild cases in young-ish patients.

Recovery Time: post-operative swelling should subside by 14 days, six weeks at worst. The ‘endoface’ should give a younger-looking upper face and jawline, plus tauter skin texture, but is not as effective as ‘open’ face lifts in patients with severe sagging.

Risks: there is a greater risk of damage to facial nerves with this way of operating than with other types of face lift.

The ‘endobrow’, which can be combined with any type of face lift, involves just three small cuts on the scalp, unlike the traditional brow lift which necessitates an Alice-band cut from ear to ear. It can be done in a day and corrects furrows, lines and heavy brows.

Like any brow lift, it is not advised for those with a high forehead (as it will make it even higher), but is an ideal procedure to lift a heavy brow. As the incisions are so small, it is also useful for men who have gone thin on top, where an ear-to-ear brow lift would be impossible because the scars would show.

Recovery time: swift (about a week) – although one energetic patient was ballroom dancing four days afterwards.

Risks: damage to sensory nerve with numbness in the forehead and the scalp; also damage to the motor (movement) nerve to the forehead.

Mask (or Sub-Periostal) Lift

The soft tissues of the face are detached from the bone and repositioned. Some of the facial bone structure can also be altered. Two small cuts are made inside the mouth; the other cut runs from ear to ear.

The mask lift is suitable for the same group of patients as the ‘endoface’.

Recovery time: results are usually dramatic, although there is considerable swelling and most patients need six to eight weeks’ recuperation.

Risks: disadvantages are that this Alice-band cut will feel numb for two to three months after surgery and there is a five per cent risk of temporary injury to the facial nerve, particularly with surgeons less experienced in this technique.

Skin Lift with SMAS Lift

The most commonly performed lift is the skin lift, where the surgeon cuts around the ear, pulls up the skin, tightens the musculoaponeurotic fascia (the deeper layer of fibrous tissue and the sling muscle which embraces the jawline), and removes the excess skin. Most surgeons combine the skin lift with a SMAS lift: the skin is lifted from the SMAS (subcutaneous aponeurotic system – the layer where the muscles are attached to the skin) through a cut which runs around the ears and down into the hairline. The SMAS and the muscle are repositioned and excess skin removed. This corrects heavy cheeks, jowls and sagging necks in patients of any age.

This can give quite dramatic results in older patients and, as with the skin lift, usually lasts ten years, providing patients keep a constant weight. Some patients do have more than one operation.

Recovery time: patients are leading a normal life within two weeks.

Risks: permanent damage is extremely rare; possible short-term problems include haemorrhage, haematoma, skin necrosis and temporary facial nerve damage.

Extended SMAS Lift

The extended SMAS, which needs a very experienced facial surgeon, penetrates further down to smooth out heavy lines between nose and mouth.

Recovery time: usually about two weeks.

Risks: same as for skin lift.

Brow Smoothers

As well as the endoscopic brow lift, which removes the grooves by detaching the skin from the muscle, there are other methods, notably injections of a plant toxin called Botulinum (known as Botox). These have for years been used for blepharospasm (eyelid twitching) and squints and appear to be completely safe, with no side effects. Botox is ideal for vertical frown lines where collagen injections (another option, see Lip Re-Shaping, opposite) are usually inappropriate. Not only do you then lose the habit of frowning but, with the release of pressure, the lines start fading almost immediately. The initial effect lasts about three months but should become permanent after several injections and a year or two of frown line immobilisation.

Recovery time: none needed.

Risks: safe in experienced hands but toxic if the wrong dose is given.

Arteplast (Artecol)

This combination of 40 per cent collagen and 60 per cent dental cement PPMA (polymermethylmethacrylate) is said by some surgeons to be effective on superficial facial lines.

Recovery time: none needed.

Risks: irregularity of the treated area, allergy (prolonged swelling and redness).

Eyelid Surgery (Upper and/or Lower Blepharoplasty)

This removes the fatty tissue, extra skin and wrinkles which build up around the eyes. Scars, positioned in the upper eyelid groove just above the crease or under the lower eyelashes, should be virtually invisible. The most painful part is removing the stitches.

Operating inside the eye (trans-conjunctival surgery) avoids stitches but is only suitable for younger patients with minimal excess skin to remove.

Recovery time: seven to ten days.

Risks: pulling down of the lower eyelid if too much skin is removed, excessive scar tissue formations, haematoma, dry eye syndrome.

Cheek Implants

These are traditionally made of silicone, but the cheek may also be built up with collagen or the patient’s own (autologous) fat. The most recent advance is hydroxyapitite, a synthetic with the same composition as bone, which is mixed with the patient’s blood to make a paste that can be moulded and applied directly to the bone.

This is recommended for cheeks or other bone-deficient sites, but not for chins where there is too much motion. The results should be permanent.

Recovery time: seven days.

Risks: asymmetry, infection.

Ear Correction (Otoplasty)

Surgery to pin back protruding ears, an inherited condition, can be performed as early as five years old. Incisions are made in the groove behind the ears so that the scars are hidden from view. (N.B. babies may be able to have protruding ears corrected with a soft pliable splint called an Ear Buddy, which retrains the ear.)

Recovery time: seven days.

Risks: incomplete correction, haemorrhage, infection.

Nose Re-shaping (Rhinoplasty)

Bumps can be removed, a broad nose slimmed down or the tip altered. Underlying excess bone and cartilage are usually removed from inside the nose, thus leaving no scars.

Noses can also be built up with cartilage, bone or, less commonly, with silicone.

Recovery time: mouth breathing is necessary for several days after surgery which can be uncomfortable. Ninety per cent of swelling and bruising should go down in two to three weeks, although the nose shape may take up to six months to settle down.

Risks: haemorrhage, a poor result, asymmetry.

Lip Re-shaping

Temporary re-shapers include:

• injection of collagen. A patch test is necessary four weeks beforehand to test for possible allergy to the purified bovine collagen (now also caught up in the problem of BSE, ‘Mad Cow Disease’). Results are only short term – lasting from two to six months.
• your own (autologous) fat, often taken from the stomach, being processed and injected into numbed lips. The supply is inexhaustible and your own fat won’t set off a reaction. Results should last up to a year. (Hands can also be treated this way.)

More permanent methods include:

• injection of micro-droplets of silicone into the lip, although many surgeons reject this method because the silicone can cause skin ulceration.
• removal of skin from an over-long upper lip, or of skin and underlying tissue from over-thick lips.

  Recovery time: two to seven days (for both).

Over-thin lips can be enhanced by:

• shaping and threading Gore-Tex (the biologically compatible membrane used in cold-weather clothes and equipment, including skiwear) into the lip;
• or by inserting a dermis (skin) graft.

  Recovery time: two to seven days.

  Risks: with Gore-Tex, lip induration (abnormal hardening), possible rejection.

Chin Augmentation (Mentoplasty)

Permanent re-shaping of receding chins is sometimes performed at the same time as nose re-shaping to get a better profile. This uses an implant – traditionally silicone, although new materials including HTR polymers are starting to be used. The incision is usually made inside the mouth or under the chin. People with long jaws can also have bone removed to improve the shape of the jawline.

Recovery time: one week for implants, two weeks if bone is removed.

Risks: infection, damage to the mental nerve (which controls sensation in the chin and lower lip) by anaesthetising the chin.

Skin Peeling, Dermabrasion and Laser Re-surfacing

These various techniques have revolutionised the treatment of fine lines, poor skin texture, brown spots, dark circles and even acne scars, but they must be performed by experts (dermatologists, cosmeto-dermatologists or aesthetic plastic surgeons) – never by the local beauty salon.

Skin Peels deep clean and soften skin. The mildest professional chemical peeling agents are high-concentration glycolic or lactic acid, followed by trichloroacetic acid, then phenol. Skin is often prepared with Retin-A, itself a peeling agent.

Dermabrasion uses an electrically-operated fine brush to remove scars and create a smoother surface.

Recovery time: both these treatments may be uncomfortable, although surgeons will take care to alleviate pain. Afterwards, the skin reddens, becomes itchy and dry and possibly painful for several days or even weeks before the new soft skin grows through. The new skin is also very sensitive to UV light and must be zealously protected with high factor sun preparations (SPF 25/30 or total block).

Laser Resurfacing Rapid shallow pulses of laser light burn away the top layer of skin, tightening skin and helping with acne scarring. There are several types of lasers used for different purposes. The Silk Touch laser is currently the most popular for skin rejuvenation, but some predict the new Ultra-Pulse CO2 laser will replace it. The PhotoDerm laser is showing great promise with facial thread veins.

Experts claim that laser treatment is more predictable and safer than dermabrasion and chemical peels.

Recovery time: skin will be noticeably pink for a few weeks.

Risks: the main danger of all the above lies in going too deep into the skin, so creating a lasting scar rather than removing problems. However, new laser technology, such as the Ultra-Pulse CO2 laser, is computerised, making it easier for the surgeon to control.

Fat Removal

Liposuction
The removal of fat by suction means that most regions of the body can be re-contoured, including the face and neck (particularly double chins and back neck humps), breasts, arms, waist, abdomen, buttocks, inner and outer thighs and knees. This is suitable for removing stubborn localised areas of fat – it is not an alternative to exercise and sensible eating.

Recovery time: seven days, although bruising takes up to four weeks to fade.

Risks: liposuction is more complex than it seems, and can cause nasty problems if not done by an expert (one woman ended up in intensive care after poor surgery and there have been deaths reported). If too much fat is removed, the skin will ripple or sag irreversibly. Poor liposuction can cause grooves and ruts which are difficult to put right. And if you put on weight again, the fat settles in a different area, which can lead to odd shape changes.

Liposculpture
This is another name for liposuction but sometimes also involves injecting fat into depressed areas to re-contour the body. It also includes superficial liposuction – the removal of fat just below the surface of the skin with a very fine cannula (syringe). Results can be excellent but you must go to an experienced surgeon.

Recovery time: as for liposuction.

Risks: as for liposuction.

Ultrasonic Liposuction

With the patient under local anaesthetic, incisions are made in the skin and an ultrasound probe slid into the tissue. By using a specific frequency of ultrasound, surgeons claim fat can be dissolved, then suctioned off, so more can be removed. Skin is said to shrink better.

Recovery time: as for liposuction.

Risks: as for liposuction, plus skin necrosis which can be a serious complication so, again, this should only be done by experts.

Abdominal Reduction (Abdominoplasty)

This ‘tummy tuck’ operation takes out the excess skin and fat which often affect women after pregnancy and which defy exercise. Tummy muscles can be tightened at the same time. Liposuction is often carried out simultaneously for best results.

Recovery time: three weeks.

Risks: infection, haemorrhage, asymmetry, poor quality scars, skin necrosis.

Breast Reduction and Augmentation (Mastopexy)

Breast Reduction and Uplift
Over-large, pendulous breasts can be surgically reduced and uplifted. Breasts are marked with a special pen before the operation with the patient standing. Under general anaesthetic, the nipple is detached from the skin but left attached to the breast tissue, then an incision made vertically down and under the breast, skin and breast tissue are removed, the nipple replaced and the wounds sewn up. Scarring will fade but is permanent. More recent techniques avoid a scar under the breast, but leave a wrinkled vertical scar which takes a few months to become even.

Pregnancy must be avoided for one year to avoid stretching the scars.

Recovery time: two to three weeks.

Risks: haemorrhage, infection, skin and nipple necrosis, asymmetry.

Breast Augmentation
Demand for this once common operation dropped off sharply after the eruption of the (ongoing) fear that silicone implants filled with silicone gel may lead to an increased risk of cancer or of auto-immune disease. Although subsequent medical research suggests that the risk is probably no greater for women with implants, they can form hard lump scar tissue; if so, one can either repeat the operation, or live with the lumps. Improved implants with a textured surface reduce this risk.

Patients now have a choice between saline-filled implants (which don’t look or feel very natural and may leak), silicone gel-filled implants (which give the best shape and feel), or triluscent implants filled with soya bean oil (which have the advantage of being radiotranslucent so that they allow better imaging in mammography, and fall halfway between saline-filled implants in feel and shape).

Recovery time: two weeks. We don’t recommend exposing delicate breast skin at any time, let alone after surgery.

Risks: haemorrhage, infection, capsules contract and harden, asymmetry.

Varicose Veins
This common problem is best treated with a combination of surgery and sclerotherapy (injections of an irritant solution which shrinks the vein). An expert assessment with ultrasound scanning is vital, even if the only surface sign is a slight ‘flare’ of veins. A general (rather than cosmetic) surgeon with special expertise in veins may be your best bet for treatment.

Recovery time: back at work in three to five days.

Risks: the main risk lies in not removing all the affected veins (which can lead to further problems).

Support Systems
• Take a good multivitamin/multimineral supplement at least four weeks before and eight weeks after surgery to speed healing.
• Also take arnica (available from some chemists and homoeopathic pharmacies) before, during and after surgery.
• Avoid salt after surgery – it promotes fluid retention; alcohol and aspirin – they tend to increase bleeding and oozing; smoking – it slows down the rate of tissue repair.
• Apply ice packs or cold compresses with witch hazel continuously for the first 24 hours to lessen bruising.
• Use a good moisturiser.
Vitamin E is believed to help healing so you could try applying natural vitamin E directly.

Detailed fact sheets on many of these procedures are available from the British Association of Aesthetic Plastic Surgeons, and some surgeons have also written their own information sheets for patients. The more information you can get, the better placed you are to make a decision.