Facelifting & Necklifting

Facelift and necklifts
Dominic Bray Debbie 90 Facelifting & Necklifting

Introduction to the various Facelift procedures.

As part of the normal ageing process, the skin of our face and neck gradually loses volume and elasticity. This process begins in our mid 20’s with the development of fine wrinkles but speeds up significantly from our mid 40’s onwards where descent of the mid facial tissues and volume loss causes lower facial third jowling, hollowing under the eyes and laxity of the neck skin. Even with the most careful skin care regime and avoidance of contributory factors, this process is inevitable and progressive. It is particularly cruel in women during the menopause who often see dramatic changes in the skin over this time.


Consultation

The initial consultation is an opportunity for you to talk and me to listen. I like to understand what has led to my patients seeking advice on improving their appearance. It is clear to me, contradictory to popular misconception, that the majority of patients seeking correction of signs of aging are motivated by far more than just vanity. There is no doubt that for most of us, when we look our best, we have renewed confidence and energy about every aspect of our lives. This new confidence is life enriching.

I recognise that It is a big step when somebody asks for help with any aspect of their appearance. The media is full of quickfixes, trademarked procedures and “dermatologically tested” products. I see my role as an advocate in guiding you through what may seem at first a minefield of possibilities. Listening carefully to your exact concerns, explaining in clear language what the options are and then collaborating on a treatment path is so satisfying and is the key to a perfect outcome. Occasionally, I will suggest that surgical treatment may be premature and, if appropriate , suggest less invasive alternatives. I will ask you to show me historical photos so that we can really discuss what may be achievable, take baseline photography and/or 3 dimensional imagery and only when you really understand the options available will we embark on a treatment path together.

Dominic Bray Lesley+Sue 2 Facelifting & Necklifting

"I believe all people have a natural beauty about them and it is my job to bring that out. My philosophy is to enhance natural beauty, not alter looks, what I do is make people look as good as they can for their age, refreshed, rejuvenated and happy - they still look like themselves - just better! "


Types of facelift

There are many options for facelifts, but few that I believe give a natural, balanced and long-lasting result. Early facelifting focussed on skin elevation and tightening alone. This lead to the short lived tight appearance of old. I never perform this procedure.

SMAS facelifts

The 1970’s saw the description of SMAS facelifts by Skoog, Mitz and Peyronie. The Superficial Musculo Aponeurotic System (SMAS) is a deeper layer of tissue to which the underlying fat and facial muscles are attached. By lifting this tissue the face can be rejuvenated without leaving any tension on the skin which leads to neater scarring and a more natural lift. There are many different ways to lift the SMAS and this is the basis of my preferred facelift technique often in conjunction with a volumetric lift and plastysmaplasty (see below)

Subperiosteal facelifts

The subperiosteal (or Deep place / Composite / Endoscopic“endoface”) lifts more recently gained prominence after being described by French Surgeon Dr Paul Tessier. The facial soft tissues are detached from their deeper attachments and repositioned like a mask. Whilst I believe these lifts to be more anatomically appropriate, they have their downsides. They have limited ability to remove excess skin after lifting and due to their deeper nature are more likely to traumatise deeper structures such as nerves and blood vessels. I therefore do not perform these lifts.

Short scar / mini face lifts

There are many variations of these procedures described in the medical literature and even more described on the internet (eg. S-lift, minilift, one-stitch lift etc.) These are all quick fix lifts that take less than 90 minutes. They have a place in those patients that seek a very subtle result for a well defined indication - The classic 2 finger sideburn lift that we all do in the mirror! If I were to perform these they would be in a younger patient who understood they would not have the longevity of full facelifting. For similar reasons to the MACS lift, I rarely perform these lifts.


There has been a rash of needle based facelifts popping up in the industry press and online. These are generally based on barbed (threadlift) or coned (silhouette lift) sutures that are passed with a needle under the skin. Whilst these may temporarily elevate the tissues, they cannot address skin laxity, volume loss, the neck or more profound soft tissue descent. In my practice I have met more patients who have been disappointed with these than happy. That does not make me want to start using them!

MACS Facelift

MACS is an acronym for Minimal Access Cranial Suspension and it does exactly what it describes, it uses a loop of suture to suspend the facial tissues through a shorter scar. It was developed by Belgian surgeons, Verpaele and Tonnard in 2004 and whilst a good procedure for early jowling and mid facial descent, it does very little for the neck. I rarely perform this lift as I believe the face and neck age together and just treating the face does not correct the actual process that has led to the features of ageing.

Volumetric facelifts

Recent years have seen huge advancements in our understanding of the aging process. Whilst descent of the mid face certainly plays a huge role, there is also a decrease in total facial soft tissue volume. Some advocate solely replacing this volume to rejuvenate the face. My approach is to do both, elevate native volume back to where it should be and then add additional volume (with dermal filler or fat) only if necessary.

Submental tuck / Platysmaplasty

Usually with my facelifts I can address secondary laxity of the midline neck skin via the normal facelift incision. Occasionally in patients who have significant excess skin or midline neck fat, I perform an additional procedure called a Platysmaplasty. This involves a 2cm incision under the chin to tighten midline neck muscles directly, remove fat and redrape the skin. This procedure beautifully defines the neck chin angle.


Cosmetic doctors often advertise non-surgical injectable facelifts. These are combination treatments with Botulinum Toxin to reduce surface wrinkles, reduce the jawline muscle bulk and fillers to volumes folds, depressions and sculpt the mid face. There are few, and by few I mean one or two cosmetic doctors nationally who I would recommend to my patients to perform these treatments. They are true injectable artists and neither would refer to this work as a facelift!


Preparation

This is a vital part of my surgical philosophy. When setting out my practice I wanted my patients to ENJOY their surgical experience. This is after all surgery they have chosen to have! I could have followed convention and operated out of leased theatres in large private hospitals but this didn’t fit with this philosophy. Overflowing car parks, receptionists I didn’t know, bank staff, theatre overruns and management dictat over patient experience. I travelled throughout Europe and the US to refine the model and my surgery is the result of this research. Custom built and registered facilities for facial cosmetic surgery, an environment that is a clinical home from home, staff hand picked not only for their expertise but their approach and interpersonal skills, and surgery that is natural, contemporary, safe and individually planned and performed by me for each and every patient from initial consultation through surgery to final follow up visit. I am constantly refining the model to give my patients the very best experience.

I believe that a patient that is relaxed, calm and comfortable, not starved for general anaesthetic, and who is familiar with the environment has lower blood pressure, lower circulating stress hormones and is in a far better place to start recovering from surgery.

My assistant Lucy discusses preoperative preparation with all my patients, and everything is considered. From hair colouring to diet sheets, pre operative medications, supplements and specifics to avoid such as blood thinners - Non steroid anti-inflammatories (Ibuprofen, Neurofen, Volatarol), Aspirin and Vitamin E.

Procedure

The facelift process begins at the initial consultation. I want my patients to truly understand all the options available and the risks before undergoing surgery. I take written consent for the procedure(s) we have mutually agreed and give a copy to take away and read at leisure. Any queries that might arise are welcome to be clarified at a second preoperative consultation. On the day of surgery patients are escorted to the surgical suite where they are given their own temperature controlled warming gown and thick comfy socks. After a relaxation tablet, I give numbing injections in the hairline. Once in the theatre, and connected to a monitor, overseen by a consultant anaesthetist, an anti-inflammatory medicine and a small amount of sedation is given through a drip. I then use a special water based anaesthetic solution to gently pre-elevate the facial skin and completely numb the whole face and neck. An incision at a very specific angle is then made in the hairline following the contours of the ear and then back behind the ear into the high hairline. The muscles of the face are repositioned to a more youthful position and fat deposits are refined if necessary. Very fine sutures are used to meticulously reposition the skin after any excess has been removed. A mirror is then offered just before a crepe bandage is applied.

What Is Different About My Facelifts

When it comes to a facelift, I do it very different from convention. No one face is the same, different techniques of SMAS lifting, volumisation and fat reduction are tailored for the individual face. I did not want to produce the same identikit facelift results that one sees everywhere. The slightly tight 45º backwards pull that is achieved when a patient lies recumbent and anaethetised. The prolonged recovery associated with general anaesthetic, artificial blood pressure management and breathing tubes. Post surgical drains that hang from the fresh wounds, black eyes and mummy type bandages as you stay overnight in a soul-less private hospital room with occasional morphine to pass the time!

I have completely reverse-engineered the process to modernise my facelifts. From incision technique and placement, to an atraumatic method of dissection. From the vector of lift, to the method of closure. I never use general anaesthetic, I never use drains and I never remove facial soft tissue (as in a normal SMASectomy). My patients rarely need painkillers post procedure and go home within an hour of the final stitch. Most are out socially within 48 hours. I do not facelift in hospitals ... these aren't 'sick' patients! I don't use facial nerve monitors - I ask my patients to smile directly. I don't have to guess the vector of lift of a supine patient, I sit them up and can see in real time the most appropriate position. I have recently further adapted my facelifts to minimise bruising using the patients' own stem cells.

Recovery

My patients literally walk out of the operating theatre into the recovery room where gentle reflexology may be performed, and are back home (if local) or at the hotel within an hour accompanied by a family member or friend. It is quite normal for the bandage to feel tight (the tissues are swollen with anaesthetic fluid) and sleeping propped up on a couple of pillows really helps. A little bruising is inevitable especially if brow or eyelid surgery has been performed at the same time for which Arnica is excellent.

The next morning the bandage is removed (no drains are used) before gentle lymphatic drainage of the facial tissues is performed to reduce the swelling. After washing the hair, I then place my patient’s under a near red infra red dermalux light to start the healing process.

Over the next few days a neoprene garment is worn on the face day and night to support the lifted tissues. No exercise or bending forward is advised and I suggest not drinking too much water. The jaw may feel tight where the muscles have been tightened. This is normal and subsides. Soft foods and a children’s sized tooth brush are ideal!

The stitches come out at a week by which time most of the bruising and swelling has settled. Most patients can return to work at this time but if adjunctive procedures have been performed such as liposuction, eyelid surgery and/or browlifting, bruising may persist for up to 2 weeks.


Risks

Risks are minimised with adherence to pre and post operative guidance They are fortunately extremely rare with recent anaesthetic and surgical innovation and when they do they are usually a temporary inconvenience rather than a permanent problem. I do literally everything I can to minimise risks but when they occur I treat them with first class care and attention. The single biggest risk factor in facelifting is smoking. So much so, I do not operate on anyone who has smoked for 2 weeks before surgery.

Bleeding

Excessive bleeding into the wound can develop a collection of blood called a haematoma. These usually happen within 12 hours of surgery which is why I ask my patients to stay the first night locally. The published incidence of this is 2-3% but my personal incidence is less than 1%. I believe this to be a result of my unconventional multifactorial approach to facelifting. After draining a haematoma, your recovery is not affected in anyway.

Numbness of skin

This is inevitable but temporary. When lifting facial skin some sensory nerves have to be disrupted. As they regrow over 3 months an area infront of the ear may feel a little numb and/or tingle like pins and needles.

Asymmetry and Scarring

Despite meticulous technique and planning, all surgery is at the mercy of one’s own ability to heal. Occasionally scars may over heal (hypertrophic) or spread beyond the incision line (Keloid). Generally wound healing in the face is fast, predictable and reliable. I review all my patients regularly during this phase and if the scar needs assistance in healing (with Laser and/or injections) I am ready. Asymmetry is rare, due to the precision of surgery and time taken over the initial procedure. As I have the ability to sit my patients up during surgery and ask them to smile, I can assess symmetry under gravitational pull in real time. This is a huge advantage of local anaesthetic facelifting. It is nigh on impossible to assess upright symmetry in a fully anaesthetised and paralysed recumbent patient.

Infection

Any surgery carries a risk of infection. Fortunately infection in facelifting is extremely rare but if it happens can be treated accordingly. I have yet to have a single infection in a facelift patient.

Nerve Injury

The face is the most dynamic and expressive part of our body. This expression is powered by a myriad of nerves and muscles. Any surgery within the vicinity of these nerves has the potential to cause damage through direct trauma, heat and/or compression. Injury to a branch of the facial nerve inactivates the muscles that branch supplies leading to facial asymmetry. Permanent nerve injury is thankfully very rare, the global literature quotes a 1% incidence. Temporary nerve injury, known as Neuropraxia, is where the nerve isn’t damaged but shuts down much like the limp mode of a car engine. This is more common but resolves by itself within 10-12 weeks. I have never had a case of permanent nerve injury which I believe is due to the techniques I have developed for facelifting.

Aftercare

My facelift care starts with the final stitch. In the days following facial surgery, I am in constant contact with my patients and review them regularly. This is an essential part of my practice and ensures that my patients feel confident, reassured and comfortable during their initial post operative recovery.  My team and I are on hand to help my patients' physical and emotional recovery. The first few days after facelifting can be an emotional time, it is not only the physical scars that are healing but, as is the case in the majority of my patients, they are moving on from another life event life - divorce, bereavement, ill health etc. We are passionate about caring for you, listening to you, and make sure you are emotionally and confidentially supported throughout your journey. I write further about this in Psychology of Facial Surgery 

Longevity

A facelift puts back the aging clock by 7-10 years but doesn’t stop it ticking. A decade after surgery you will of course look older but still 7-10 years younger than if you had not had surgery. Facelift longevity varies depending upon the patient. I tell my patients that looking after your face is much the same as looking after a new car. You have to look after it to keep it looking new. Clean it the right way, feed it the right nutrients, get plenty of rest and avoid damaging environmental factors such as smoking and sunburn.


Skin Care

I see facelift surgery as the start of my relationship with you and would hope to help you achieve longevity of your result by advising you on skin health, nutrition and treatments going forward. I use the analogy of a bed when describing how I rejuvenate a face. When we make a bed we fix the bed frame, plump up the mattress and shake out the duvet. If we then cover it in dirty crease sheets it will never look perfect. This is why skin care is so important. My approach to skin care is different from the beauty industry norm. 99% of over-the-counter skin health products are moisturisers. I rarely advocate these as healthy skin hydrates from the inside. Infact, applying external moisturiser actually fools the skin into thinking it is adequately hydated which slows down the skin cycle leading to dull, non radiant skin. Very simply by cleansing, exfoliating, repairing skin function and protecting, perfect skin is achievable for everyone.

MASTER DECK.300 Facelifting & Necklifting