Attempts  to make faces more attractive and to address the ravages of time have been on record for thousands of years. The real progress in cosmetic surgery has been made over the last 100 years and, most significantly, over the last twenty years.

Beauty and aging are two separate entities.  Beauty is about proportions and finer details, whereas aging is a progression of events which indicate a person’s age. A young person can be unattractive and an old person can be very attractive.

Youth does not worry about aging, but an older person can worry about being both, unattractive and old. Clearly, aging is a much more complex problem to solve.

Cosmetic facial surgery can range from very complex to relatively simple. It may require moving or reshaping facial bones to improve overall facial balance or alteration of individual facial structures, such as the nose.

Facial cosmetic surgery for aging is particularly important at the present time because of increased longevity and the perception of ageism in otherwise active and physically fit population.

Although facelifting is perceived as the universal answer to setting the clock back, it is not always the correct answer.

Much more important is attention to upper and lower eyelids which are often more important than sagging facial skin and contour. Their reshaping can make all the difference between a permanently tired look and fresh and youthful appearance, without looking odd and obviously operated on.

Over the last few years there has been a shift towards conserving fat around the eyelids, as opposed to removing it, in some cases resulting in the “hollow eye” look. This has come with the realization that, although the fat volume within the eye socket increases with age, the soft tissues, such as the muscles and skin become weaker and less able to contain it. This weakness presents itself like a hernia, resulting in puffy eyes, or eyebags. New techniques tend to conserve most of the fat and rely on repair of these soft tissues. Sagging muscle surrounding the eyelids and skin are also tightened with a more pleasing and natural effect. However, these techniques are more complex than the time-honoured “eyebag” surgery.

Facelifting has also made great strides towards more natural and significant results. One reason is the acknowledgement that stretching the skin is not conductive of a good result and the other is that the forehead and neck play an integral part in the process of facial rejuvenation.

The best results in facelifting depend on adequate and long-lasting tightening of subcutaneous soft tissue and muscle (the SMAS). Many of the “lunch-time” facelifts are inadequate in this respect and have a limited longevity.

Sagging forehead and brows must be corrected before or together with facelifting to produce an overall natural result. The greatest advance in forehead lifting is endoscopic surgery which allows the surgeon to lift or reposition the forehead and brows through small incisions behind the hairline. This procedure is safe, accurate and produces long term results.

Neck-lifting should be an integral part of facelifting but is currently frowned upon by most facial cosmetic surgeons, largely because it is technically difficult and can result in serious post-operative problems. However, with experience and attention to detail, these problems are largely avoidable.  A youthful-looking neck is an essential part of a successful facelift.

Aging often results in permanent loss of facial fat that is important in maintaining youthful facial contour and look. This loss of fat mostly occurs in the cheeks and its restoration is as important as tightening of sagging of facial skin and tissues, especially in thin patients.  Lost facial fat can be replaced with patients’ own fat, taken from elsewhere, and transplanted by a technique called fat-grafting. Donor fat is retrieved by liposuction, processed and re-injected using blunt needles. The fat cells are deposited in minute amounts and layered to produce a natural, irregularity-free fat layer. Some of the fat will be absorbed but approximately 40% of the transplanted fat will survive. This technique can be used with facelifting or as a separate procedure.

Rhinoplasty is one of the commonest facial cosmetic operations performed today. The reason is that the nose can significantly effect the overall appearance and balance and the surgery, if carried out correctly, is relatively straightforward and safe. There are two main advances in rhinoplasty. One is computer imaging, which allows the surgeon to communicate to the patient what can be done by changing certain parameters of the nose and also gauge the patient’s expectations.

Secondly, the introduction of the open-approach rhinoplasty has allowed surgeons to alter nasal structures much more accurately, safely and with predictable results. The operation of rhinoplasty is no longer a hit-and-miss affair, dependant on the surgeon’s perception of what should be done and without patient’s involvement.

Finally, without fresh-looking and youthful skin it is impossible to create a youthful look with surgery alone. Sun damage, smoking and unfavourable genes result in old-looking skin. It has been known for a long time that “burning off” the  epidermis (the superficial layer of skin), and beyond, will result in new and better-looking skin. Initially, this was done with peeling agents, dermabrasion in 50s and 60s, and laser resurfacing in 1990s.  Now, dermabrasion has been superseded by time-honoured chemical peeling and lasers. Modern chemical peeling is safe and effective, without producing a parchment-like skin and permanent loss of pigment. It can also be repeated without long-term consequences. Laser is used mostly in severe wrinkling or for acne scarring, where results of medium chemical peeling are not nearly as good. New type of laser, the fractional laser, relies on skin resurfacing of part of the skin surface. This reduces the downtime and risks of full laser resurfacing to an absolute minimum.

Facial cosmetic surgery has come a long way from its humble beginnings. It is safe, effective and, if done well, barely detectable. Further advances in this field will ensure even greater safety and results in days to come.

Jan Stanek
October 2008