Author: drngsw

Advancements in medical science, technology and techniques have made cosmetic surgery safer, more effective and the results more natural-looking.

Surgery is the gold standard for facial rejuvenation and imparts the most lasting and dramatic results. Since the 1900s, facelifts have been used to reduce the appearance of sagging skin, iron out wrinkles, tighten and return shape to the brow, cheek and jaw and lift loose folds in the neck.

Since then, surgical facelift procedures have advanced by leaps and bounds. There are many surgical options to choose from – each addressing a specific area of the face and neck. Techniques have also become more refined and safe, with less scarring and quicker healing.

Types of lift

The areas that droop with age include the brow, mid-cheek, lower cheek and neck. There
are several types of facelifts available and the choice of procedure depends on the issues to be addressed and the extent of skin laxity. It is ideal to perform conventional facelift with a neck lift or browlift for a more harmonious result.

Conventional facelift

A conventional facelift is ideal for older people or those with severe laxity. There are several classifications and terminologies which are often confusing to the patient. In a long scar full facelift, the incision starts from the temporal area, passing in front of the ear and curving backwards behind it. A short scar face lift dispenses with the temporal incision and minimises the cut behind the ear. The longer the incision, the greater amount of laxity to be addressed.

The skin is then separated from the underlying tissue layer (called SMAS), redraped and shifted. The SMAS layer
is sutured to provide strength to the lift and any excess skin is trimmed. This type of facelift is the longest lasting and achieves the most dramatic results.

In recent times there has been great interest in the mini facelift. This involves a shorter scar, less tissue separation, reduced swelling and bruising, and shorter downtime. The result may not be as drastic as a full facelift, and most patients can return to work within one to two weeks after the procedure.

Browlift

A brow lift corrects sagging skin in the forehead, upper eyelids, and eyebrows. Also called a forehead lift, the procedure restores the appearance by correcting a heavy, sagging brow, and smoothing out deep furrows, to the upper third of the face. It is usually done with the use of an endoscope via several small incisions behind the hairline. The forehead skin is lifted and secured with sutures fixed to the skull. The result greatly complements a facelift.

Threadlift

Patients with mild skin laxity and redundancy may opt for a less invasive threadlift procedure. Threadlifts last for up to two years and are repeatable as new threads can be attached or existing ones adjusted.

The procedure is done under local anaesthetic and sedation and involves placing specially designed surgical threads under the skin in different positions using a thin needle. These implanted threads have barbs or cones which are pulled in different directions to lift the sagging skin. Side-effects include bruising and swelling which may resolve within a week.

Non-invasive lifting procedures

Minimally invasive or non-surgical facelifts are increasingly popular though they do not offer the same results. They are a good option for those who do not wish to undergo surgery. They generate heat damage to the collagen in the deep dermis resulting in regeneration and lifting. Some of these treatments are based on infrared, focused ultrasound and radio frequency.

Filler injection has been inappropriately termed as a face lifting procedure. Strictly speaking, a lifting procedure is anti-gravity and has a single direction of pull with stable fixation of tissue. Fillers provide generalised multi-directional distension of tissue with volumisation effect.

There is no ‘right’ or ideal procedure as it all depends on an individual’s desired results, the shape of his or her face and the extent of laxity. It is important to speak with your surgeon on the most suitable procedure appropriate for your unique case.

The quest for youth has spurned a multi-billion dollar industry. Today, the multitude of rejuvenation options is bewildering. A person’s choice of rejuvenation technique is generally determined by his or her physical state, tolerance for pain and downtime, and financial constraints.

The clinical problems that we commonly address include pigmentation, superficial textural imperfections, wrinkles (dynamic or static), deep folds or contour deformities, and skin laxity.

Rejuvenation options are divided broadly into non-invasive (non-surgical) and invasive (surgical) procedures with a few options in the “borderline” zone. Patients should be aware that all these rejuvenation techniques have a common goal of causing controlled damage to the various layers of the skin in order to stimulate repair and regeneration. Sun avoidance and strict usage of sunscreen are the keys to maintaining the results and preventing hyperpigmentation.

NON-INVASIVE (NON-SURGICAL) PROCEDURES

The most common form of phototherapy treatment is Intense Pulsed Light (IPL) or Broadband Light (BBL), which is able to improve the general complexion, lighten pigmentation, improve fine wrinkles and mildly tighten the skin. It is also effective for permanent hair removal. IPL/BBL is a suitable option for regular maintenance without downtime.

To achieve further textural improvement to the superficial layer of the skin, laser resurfacing is more effective. Erbium Yag lasers or carbon dioxide lasers are commonly used to ablate a thin epidermal layer. Erbium Yag is more suited for Asian skin types than carbon dioxide laser. The treated area will be raw and require regular application of antibiotics; the downtime for microlaser peel is around 3 to 5 days, after which a patient can resume putting on makeup.

Various treatment modalities are available to further tighten the dermal layer to for lifting and improvement of static wrinkles. Profractional Erbium Yag (or carbon dioxide) laser, radiofrequency, focused ultrasound and infrared waves can be used to cause thermal injury to the dermal collagen and elastin in a controlled manner. This induces regeneration of new collagen with a skin-firming effect. The clinical results are best assessed 3 to 4 months after the procedure, though most patients would notice improvements after about a month.

Botulinum toxin injection is the standard treatment for dynamic wrinkles – i.e., wrinkles that are worsened by facial animation. Effects usually last for 3 to 4 months. Mild bruising may be present at the needle entry sites. Clinical judgement needs to be exercised to deliver the optimal amount of toxin to alleviate wrinkles without causing an unnatural mask-like appearance.
Filler is used to replace volume; it can correct static deep facial folds (e.g., tear troughs and nasolabial folds) and contour deficits (e.g., sunken temporal areas), and can volumise the cheeks for a more youthful appearance. Filler provides an alternative for those patient who wants augmentation of the nasal dorsum without undergoing rhinoplasty. However, very rarely, the injection of filler into the nose can result in blindness or tissue necrosis. The chemical composition of fillers can be biological (e.g., hyaluronic acid or collagen) or synthetic (e.g., polytetrafluoroethylene). Synthetic fillers may last for more than a year but there is risk of infection and granuloma formation. In the interest of safety, shorter-acting filler material is preferable.
Botox and fillers complement each other, and some patients require both for optimal outcome.

INVASIVE (SURGICAL) PROCEDURES

Fat transfer (grafting) has gained much popularity over recent years as a method of volume replacement. Fat is a good filler option because it is autologous and contains a small amount of stem cells with rejuvenating properties. Fat grafting has been shown to improve the healing of post-irradiated chronic wounds. The final result is firmer skin with increased volume and improvement in wrinkles; the procedure may be repeated for a better cumulative result.

A thread lift procedure provides added levels of skin lifting to the cheeks and temporal area. Several threads made of absorbable material are inserted skin deep and stabilised by suturing to the temporal area. Swelling and bruising can last for a few weeks. The initial appearance may appear over-corrected; this normally improves over a few weeks to months. The clinical effects may last for one to two years.

Common surgeries for facial rejuvenation include blepharoplasty (eyelid surgery), brow lift, temporal lift, facelift and neck lift. These procedures can be done as a single procedure or as a combination, depending on the clinical state.

Upper eyelid surgery (blepharoplasty) can be done to create or improve the configuration of double eyelid or remove excessive droopy skin. It is therefore suitable for young patients who wish to create upper lid folds or older patients with droopy and puffy eyelids.

Ptosis (drooping) of the upper eyelid can co-exist with excessive skin. Not all patients with excess skin have ptosis. The various methods of ptosis correction depending on severity include levator plication or advancement, and in more severe cases something referred to as the FOOM flap.

Eyebags are caused by excessive fat accumulation and also laxity of skin and the orbital septum containing the bag of fat. Lower blepharoplasty can address both eyebags and excessive lower lid skin. There are two methods to remove eyebags: subciliary lower blepharoplasty (external method) and transconjunctival lower blepharoplasty (scarless method).

Subciliary lower blepharoplasty is suitable for patients with excess lower eyelid skin and fat pocket. Removal of fat would result in the gathering of excessive loose skin. Transconjunctival lower blepharoplasty is suitable for young patients with no skin laxity/ excess. The fat pocket is removed via a small cut in the back of the lower lid leaving no scar on the exterior.

A facelift and neck lift would address the problem of a sagging chin and jowl. The contour of the neck can be further improved by dividing the muscle band of the neck (platysmal band division for turkey neck deformity).

Endotine facelift is done via small incisions in the hairline, into which Endotine fixation devices are inserted. These are absorbable strips with small claws to lift up the cheek, jowl and neck. They are absorbed in about 3 to 6 months. Thus, Endotine lifting is suited for patients who do not have significant skin excess.

I often counsel patients that surgery to rejuvenate one area of the face may cause the neighbouring non-operated structure to appear out of sync. For example, in severe ageing eyelids, surgery to improve the eyebags without an upper eyelid procedures may cause the upper lid to appear slightly out of place. It is essential to understand that all features of the face age together. To achieve a harmonious appearance, a combination of procedures may need to be done simultaneously to address the various ageing features.

What happens during the ageing process?

The skin becomes thinner with loss of ground substance, collagen, elastin fibres and, occasionally, fat. This is accompanied by uneven accumulation of pigments. The result is deterioration of skin texture and colour, wrinkles, skin laxity and loss of volume.

How do you formulate a rejuvenation regime?

Every patient requires a personalised regime.
I identify the most significant problems and the ones that bother the patient most. I plan the regime based on the patient’s work schedule, tolerance for downtime, pain threshold, risk adversity and financial constraints.

What are the simpler rejuvenation techniques?

For improvement of skin texture, pore size, pigmentation and fine wrinkles, I recommend intense pulsed light (IPL) or broadband light (BBL). This treatment is well tolerated and has no down time. Clinical results are usually seen within two to three treatments up to one month apart. Some patients report results as early as one week after treatment.
Botulinum toxin injection is the standard treatment for wrinkles which are worsened by facial animation. It can improve crow’s feet, frown lines and forehead wrinkles and its effects usually last for three to four months. Clinical judgement is needed to alleviate wrinkles without causing an unnatural mask-like appearance.
Filler replaces volume to correct deep facial folds and volumise the cheeks for a more youthful appearance. For non-surgical augmentation of the nose, fillers can be a temporary alternative. Most fillers are composed of hyaluronic acid which lasts for about six months. Long-lasting filler materials are associated with side-effects such as infection and granuloma formation.
Botox and fillers complement each other and some patients require both.
Several non-invasive therapies are available to tighten the skin moderately. These include the use of infrared wave therapy (Sciton SkinTyte®), radiofrequency (Thermage®), and focused ultrasound (Ultherapy®). Post-procedure oedema and erythema commonly resolve within a few days, but clinical results may not be as dramatic as ablative laser procedure.
Microlaser peel (resurfacing) can further improve superficial skin texture, and the patient can put on make-up about three to five days after the procedure.

What of moderately complex techniques before surgery?

Profractional laser is used to achieve further skin tightening. This ablates narrow channels into the skin, and is used to treat atrophic acne scars. The healing process is faster and patients can return to work in a few days.
Thread lift provides added skin lifting to the cheeks and temporal area. Several barbed threads made of absorbable material are inserted skin-deep and stabilised by suturing to the temporal area. The initial appearance may appear over-corrected but normally improves over a few weeks to months. The effects can last for one to two years. Fat injection (grafting) has become popular for volume replacement. Fat tissue contains stem cells with rejuvenating properties which are harvested from the abdomen or thighs and processed before being injected. Post-procedure swelling and bruising last for a few weeks, and the final result is firmer skin with increased volume and improvement in wrinkles.

How do you devise a surgical plan for facial rejuvenation?

Ageing affects each part of the face at different speeds and times and this must be understood in the context of the desire for facial rejuvenation.