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| 60
years old, Facelift, Forehead
lift, Lip Augmentation,
Upper & Lower Eyelids |
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As
a patient considering
rejuvenative or restorative
surgery of the face, you
probably have certain
concerns which you consider
to be more important than
others. The first thing
we do after we sit down
together in consultation
is to ask you what concerns
you the most.
You may have deep worry
lines above and between
your eyes sagging of your
cheeks, with a deep fold
running from your nose
down to your jawline,
the development of jowls
at the jawline, or may
have an aged and poorly
defined neck. You may
have a chronic angry,
sad or tired expression.
You may have heaviness,
or bags, under your eyes.
Each of these is caused
by a specific change in
anatomy and we will make
a proper diagnosis and
explain the right operation
for you.
In some cases this can
be achieved with minimal
incisions and scars. |
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| Dr.
Gelfant understands the
desire of patients who
seek plastic surgery for
aging. |
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YOUTHFUL
APPEARANCE |
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RAPID
CONVALESCENCE |
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LOW
RISK |
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NO
STIGMATA OF SURGERY |
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THE
BEST RESULTS ARE UNNOTICED
“DID YOU DO SOMETHING
WITH YOUR HAIR”
is a comment we want you
to hear rather than a
whispered “who did
her???” |
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A surgical plan
to rejuvenate the aging
face may involve one or
several procedures combined
at one session or in a
series of sessions, depending
on many factors. A facelift
is traditionally the operation
involving the cheeks and
neck, but is often combined
with other procedures
to give a more complete
and harmonious result.
We usually look at the
face and neck as made
up from the following:
Cheeks and neck
Eyelids
Forehead and Brow
Mouth and lips
Skin
Deep structures (Fat Pads,
muscle, Bone structure)
A facelift treats the
contours made by the soft
tissues, such as skin,
fat, some muscles, cheeks
and neck, and we add other
procedures to facial rejuvenation
as we see necessary. Sometimes
this may even include
changing bony structures,
teeth, and the nose. |
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How
Do We Do a Facelift?
It's like
making a bed! Wrinkles
in the bed clothes cannot
be smoothed by pulling
on the covers, and a facelift
isn't successful if only
the skin is tightened. |
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Most
of us remember making
beds with sheets, blankets
and bedspreads, rather
than the current fashion
of duvets. We all were
told either by parents,
camp counsellors, or armed
forces sergeants that
you can’t make a
smooth bed by pulling
hard on the bedspread,
without smoothing out
the underlying bedclothes.
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The
underlying structures
(in this case the sheets)
must be smoothed out before
the surface bedspread,
(skin) can be smoothed.
The same is true with
a facelift. Pulling the
skin tight only produces
tight and shiny skin with
unnatural movement.
We need to tighten and
reposition the deeper
structures to restore
youthful contour. Once
this has been done, excess
fat, if present, can be
removed and the skin tightening
is moderate and is used
as the finishing touch,
rather than as the only
support. |
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approach has the benefits
of less risk of problems
with healing, better scars
because of lack of tension,
more natural & youthful
contours, and longer lasting
results. Sometimes,
when a patient has severe
sun and weather damage
to facial skin, a second
skin tightening operation
may be necessary but this
is unusual. |
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Incisions
(the “approach”)
A facelift is approached
through incisions placed
at the edge of the ears,
because this allows us
to conceal the incisions
as much as possible. There
are many fine nuances
which are added to help
achieve inconspicuous
incisions; these include
the manner in which the
temple hair incision is
made, whether to go inside
or outside the ear canal,
and how the incision continues
or if it continues behind
the ear and into the nape
of the neck. Each surgeon
has certain preferred
approaches and the approach
varies depending on individual
patients as well.
It takes longer to stitch
the incision I typically
make at the edge of the
temple hairline, but the
result is there is no
loss of the temple hair
which typically occurs
with the incision most
surgeons make in the temple.
The result, after healing
of the incision has occurred,
is a more natural appearance,
without the “windblown”
change seen in so many
“Hollywood faces”
in whom the hairline is
moved up and back leaving
no sideburn and a temple
hairline which begins
above the ear. |
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| Hairline
Preserving Facelift Incisions
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| Facelift
incision at 7days |
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| 3
months after surgery |
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| Face
lift incisions early and
late showing minimal change
in the natural hairline,
and concealment of scars
along the natural contours. |
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Under
the skin (it’s what
you don’t see that
matters most)
Although healed,
inconspicuous incisions
are very important to
the success of the operation.
It is how the deeper structures
are handled that influences
just how much success
in reversing the changes
of aging is actually achieved.
Our better understanding
of the changes of aging
at least has made us aware
of what we must achieve;
how we get to that goal
is another matter. Every
surgeon has his or her
own idea of what is best,
weighing surgical skill
and experience, risk to
the patient, time factors
and cost (which, unfortunately,
sometimes is given too
much consideration) and
individual patient factors.
My approach to the deep
tissues has evolved over
the years and continues
to change gradually, but
the basic idea is one
which comes down to common
sense: I try to put things
back where they were in
youth.
Improving on that, by
thinning a heavy neck
which had been heavy even
in youth, may also play
a role, but the
basic aim is to try to
keep patients looking
like themselves, only
better.
Believe it or not,
many facelift operations
have been developed over
the past ten years which
do not have this in mind,
instead trying to achieve
some form of ideal shape.
Unfortunately, this too
often leads to bizarre
results in which the patient
may not be recognizable
to themselves.
The main cause of aging
of the face is drooping
of the fat pad in the
cheeks. This is the structure
which gives us full cheek
bones in youth; conversely
as we age it drops, leaving
a hollow behind and piling
up against the mouth (to
form the naso-labial fold)
and hanging over the edge
of the jawline as the
jowl. |
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We deal with the sagging
fat pads and muscle layer
by directly lifting and
tightening after carefully
identifying the affected
structures, separating
them as needed to allow
free movement, and lifting
with internal stitching
to secure them in the
youthful position: |
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| Removal
of a "dart"
from deep layer |
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| Internal
stitching to support deep
tissues |
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Loose and redundant muscle
bands in the front of
the neck require a small
additional incision under
the chin, and which allows
us to stitch the muscle
edges together forming
a “hammock”
which gives support and
structure to give the
neck firmness and shape: |
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The
combination of tightening
the platysma from the
front of the neck and
lifting the SMAS/Platysma
from behind gives a better
neck angle, firmer jawline,
and youthful contour to
the cheeks.
Sometimes fat is also
removed, above the muscle
and under the chin in
many cases; under the
muscle less commonly.
This can be done with
liposuction or by trimming
the fat directly.
Once the deep structures
are appropriately positioned,
the amount of skin excess
becomes clear, and this
can be trimmed away and
the skin carefully tailored
back into position along
the incision lines. |
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Chin
Augmentation
If you have a small
or receding chin, this
may accentuate the development
of jowls and poor definition
of your neck and jawline.
A chin implant placed
at the same time as the
facelift will often dramatically
improve the bone structure
and make what we do to
the skin and soft tissues
much more successful.
Lip
Augmentation
Most people lose fat and
the small saliva glands
of the lips as they age;
the lips begin to thin
and turn inward, showing
less pink. Reduced bulk
of the lips also makes
the small vertical lines
radiating outward from
the lips worsen, and although
these are mainly from
environmental damage such
as sun, wind and smoking,
the loss of bulk contributes
to their occurrence. Adding
bulk to the lips helps
to break the skin attachment
to the underlying muscle
and reduces these lines
without the side effects
of lasering or chemical
peeling. I often use some
of the fat and fibrous
tissue removed from the
SMAS to plump the lips
through tiny incisions
in the corners of the
mouth. These heal almost
without a trace. |
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| Pre-op
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Post-op |
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| Facelift
& Lip Augmentation
with SMAS |
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| At
8 Months |
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Post-op |
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| Facelift
& Lip Augmentation
with SMAS |
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| At
6Months |
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These
SMAS grafts may
also be used as a natural
filler elsewhere in the
face, especially for otherwise
difficult to treat deep
folds from the nose to
the corners of the mouth
(naso-labial folds)
Eyelid
Plasty (Blepharoplasty)
“The eyes
are the windows of the
soul”
Of all facial rejuvenative
procedures, the blepharoplasty
is the most commonly performed
and has a very substantial
benefit compared to the
extent of the surgery.
However, the eyes are
vital to our sense of
who we are and small alterations
can make large differences.
If there are changes making
us look different but
not like ourselves, this
may cause serious concerns.
With age, the eyes may
take on a tired or fatigued
look due to several factors.
These may not be related
to age and are very commonly
associated with your family
background but are often
interpreted as signs of
age. The upper eyelids
may develop considerable
redundant skin, so much
so that it may actually
hang completely over the
eyelids and rest on the
eyelashes and, in extreme
circumstances, may cause
some obstruction to vision
towards the periphery
of your visual field.
If this extreme is reached,
your medical insurance
may cover part or all
of the cost.
In order to explain what
goes on under the skin,
we have to consider some
of the anatomy of the
eye. The eye sits within
the bones of the face
floating in a cushion
of fat cells. Under normal
circumstances, this fat
is held in place by a
strong but thin membrane
or wall which runs from
the eyelid down to the
rim of the cheek bone
in the lower eyelid and
from the upper eyelid
up to the brow. In some
individuals who are predisposed,
this wall gradually loosens
and the fat begins to
bulge into the skin of
the eyelids both in the
lower and in the upper
eyelids. When we see bags
under the eyes, this is
usually the fat bulging
into the skin causing
a convexity below the
natural border of the
eyelid. This is often
also seen just above the
inner corner of the eye
in the upper eyelid.
In performing an eyelid
plasty or blepharoplasty,
the surgeon trims the
excess skin from the upper
eyelid and approaches
this bulging fat by splitting
the membrane, then trims
the fat and carefully
cauterizes any tiny blood
vessels which would otherwise
cause bleeding, allows
the remaining fat to return
to its place and closes
the incision with some
fine stitches. In traditional
surgery of the lower eyelid,
if there is excess skin,
this is trimmed via an
incision immediately under
the eyelashes which in
time becomes very difficult
to see.
It is uncommon to have
a lot of excess skin to
the lower eyelids and
any attempt to lift the
lower eyelid by means
of trimming skin may result
in the eyelid being pulled
downwards and outwards
creating a very unsatisfactory
appearance. I am always
cautious about removing
skin from the lower eyelids
and I emphasize this is
not a lift, nor a wrinkle
removal operation.
A more recent technique
of lower lid blepharoplasty
involves removing the
lower lid fat from an
incision on the inside
of the lower lid, leaving
no external scar. If skin
tightening is felt to
be necessary, this can
be done either with an
incision on the outside
of the lid, or a laser,
which create a very superficial
peeling of the skin. When
this heals, it does so
with some tightening of
the skin and with reduction
of wrinkles.
Fat conservation techniques:
Many surgeons now believe
that excess removal of
fat may lead to a rather
hollow and operated look
in later years. New techniques
involving the traditional
external incision but
with repair and repositioning
of the fat pockets, have
been developing. The weak
wall is repaired and the
fat is partially removed
with the remainder put
back into position. I
call this a hernia repair
blepharoplasty and use
it in over half of my
eyelid patients. There
are other methods used
to perform lower eyelidplasty
and conserve fat. Most
commonly this involves
moving the bulging fat
out and onto the upper
edge of the cheekbone,
to fill this area.
All lower eyelidplasty
runs the risk of the lower
lid getting pulled down,
either because too much
skin is removed or because
of the forces of healing
and scar formation. When
this occurs, the effect
may vary from excess white
showing under the eyes
to ectropion, a problem
involving tearing and
chronic irritation and
inflammation or worse.
To prevent these problems,
we now frequently use
a technique called cathopexy
in lower lid surgery,
in which a strong stitch
is placed from the outer
corner of the eyelid,
under the surface, to
the bone, supporting the
lid during the healing
phase. This may have a
temporary effect of making
the eyes look oriental,
but this relaxes in a
few weeks and the benefits
of preventing problems
are worthwhile.
The choice of what technique
should be used will depend
on your own anatomy and
the surgeon’s preference
and experience. I use
different techniques in
different patients.
This patient was treated
by upper eyelid plasty
with a lower eyelid hernia
repair and canthopexy: |
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Bulging
lower eyelid fat is best
seen in profile |
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And
is clearly improved after
Lower Blepharoplasty |
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| Bulging
fat in the lower eyelids
may not be very apparent
in photographs taken directly
facing the camera… |
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| Pre-op
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Post-op |
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| Sometimes
the changes in the lower
lids are very dramatic. |
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Forehead
and Brow Lifts
It is also possible to
confuse the brow skin
with skin of the upper
eyelids. If there is sagging
of the brows, the skin
below the eyebrows will
fall onto the eyelids
and this is not helped
by an upper eyelid plasty,
only by a forehead and
browlift. The facial features
treatable by forehead
lifting are:
Hooding of the upper eyelids
Chronic angry or sad expression
Deep worry or frown lines
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The
following is a patient
who had undergone previous
eyelid and facelift surgery
showing chronic worried/angry
expression… |
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Post-op |
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reduction in frowning
is dramatic. |
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Endoscopic
Browlift and Revision
Facelift
For years, caricaturists
have understood the link
between the emotions and
their expressions. In
the best of animation,
emotion is conveyed by
simple but easy to understand
lines. |
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Much
of emotional expression
relates to position and
shape of the brows.
Some of this may be helped
by the use of Botox®,
which works by paralyzing
the frown muscles and
preventing them from pulling
the brows down and into
a chronic frown. It is
a little like treatment
of heart disease: some
patients are well treated
with medicines and others
are better off treated
by surgery. With the brow
lift, some patients may
be well served with the
use of injections every
4-6 months whereas others
are better off, especially
if they are having eyelid
surgery or a facelift
done simultaneously, to
have a brow lift at the
same visit. |
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| 54
years old patient underwent
simultaneous facial endoscopic
brow lift, upper &
lower eyelid plasty and
lip augmentation |
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The
facelift, as it is known
to surgeons, is a procedure
on the cheeks, temple
and neck but patients
use the concept of a complete
facelift to include the
entire face so this also
refers to the eyelids
and the forehead. I refer
to a facelift as involving
the traditional areas
of the cheeks and neck;
a forehead lift is an
adjunct to this.
A traditional forehead
lift involved the extension
of the facelift from the
temple on one side to
the temple on the other
side by a route either
at the edge of hairline
in the forehead, or back
in the scalp, depending
on the shape of your hairline
and how high your forehead
is.
Since
1996, I have
been doing the forehead
lift via very small incisions
using the endoscope,
the surgical telescope-like
device that has
successfully reduced knee
surgery scars from long
unsightly incisions to
much smaller puncture
sites. In the forehead
lift this offers the advantage
of reducing the incision
from one which runs from
ear to ear across the
top of the head, to several
very short incisions.
The aims of this operation
are threefold: to reduce
the sagging of the brow,
(thus it is often also
known as a browlift);
to reduce the action of
the frown muscles at the
top of the nose and between
the eyes; and to reduce
the frown lines running
horizontally across the
forehead, if these are
significant.
The small incisions used
are easily concealed in
the scalp, and recovery
is quite rapid, usually
about one week before
returning to regular activity.
In my practice, approximately
75% of patients undergoing
a facelift also have a
forehead lift either simultaneously
or shortly thereafter,
and since I started using
the endoscope, forehead
lifts alone or with some
eyelid surgery have become
much more common, and
are often done in younger
patients. Sometimes we
also extend the forehead
lift under the surface
into the upper cheeks,
and combined with eyelid
surgery we are able to
get some significant upper
cheek lifting without
additional incisions.
Mid-Face
Lift or Cheek Lift
This approach to the sagging
below the eyelids and
above the jawline has
been promoted as a means
of dealing with limited
signs of aging through
minimal incisions, initially
through the lower eyelid
only, and then when serious
and overly frequent complications
involving pulled down
lower eyelids occurred,
it changed to using temple
incisions. It has been
modified many times in
an effort to create an
operation which does what
it is supposed to do without
excess risk of problems.
It still, in my opinion,
has not achieved the reliability
necessary to make it advisable,
except in special cases.
Sub-Periosteal
Facelift This
approach involves using
the same or similar incisions
as other approaches but
instead of separating
the layers of fat and
muscle and skin, lifts
everything from the surface
of the bones of the face.
There are advantages to
this, but prolonged swelling
is a feature, and I do
not feel it deals directly
with the signs of aging
and may cause distortion.
At times, however, it
may be the best choice.
What is the best choice?
This is something that
cannot be decided upon
without a proper discussion
of your concerns and the
possible treatment options
and the alternatives.
I sit with you and first
listen carefully to your
concern while we look
at you in a mirror. I
explain what I see is
causing these changes
(the diagnosis) and then
plan the treatment. Your
budget may also play a
role, but it is best not
to consider this until
after we have a full understanding
of the problem and the
best treatments.
How
Long will it Last?
We are often asked how
long the benefits from
surgery will last. A well
done facelift with eyelids
and forehead, either at
one session or spaced
in intervals, will often
be the only one done for
many years, often the
only such surgery in a
person's life. Surgery
does not make the face
“freeze” at
an age, nor are there
sudden losses of the effect
such that it suddenly
becomes time to do it
again.
The common way we describe
the longevity of the surgery
is that it sets the clock
of aging back; the clock
continues to run thereafter.
The following 50
year old patient
returned to our clinic
for a visit nearly six
years after her facelift,
endobrow lift, upper and
lower eyelid plasty and
lip augmentation. She
was certain she needed
nothing further done for
her face. |
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| Pre-op |
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(Six years post surgery) |
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| 56
year old patient |
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Here are two further
examples of what facial
rejuvenation, when carefully
done, for the right patient,
can do: |
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| Post-op |
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| 49
year old patient underwent
Facelift, Endobrow Lift,
and Upper Eyelids |
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| Pre-op |
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| Post-op |
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| 60
year old patient underwent
Facelift, Endobrow Lift,
Upper & Lower Eyelids,
and Chin Augmentation |
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Deciding whether Facial Rejuvenation Surgery is right for you starts with a personal consultation with Dr. Gelfant.
You are invited to contact us at our Vancouver offices to arrange a meeting.
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