The Way Forward – 5 Small Procedures

Five smaller alternatives to a Facelift.

Most people enjoy the uplifted feeling that comes with having an improvement of their facial appearance. Helping people who want that confidence, but not wanting a facelift, is a growing and satisfying part of my Aesthetic surgery practice. It is possible to obtain a worthwhile yet subtle change without having to resort to major surgery. Many people have a particular area of their face which is disproportionately ageing compared to their overall more youthful appearance. This is a fortunate situation to be in, because simply correcting that specific area improves the look of their face, and without the reason for the improvement being noticed by others. The five ‘smaller surgery options’ that can be extremely beneficial are described here. The eyes are obviously one such key area – but there are also some surprises. The key to obtaining good results in these smaller procedures is the use of precise surgical technique. These techniques have become possible through incorporating recent advances in understanding of the facial structure, and in particular, of the changes that occur with ageing. This knowledge is the cornerstone of tailored facial surgery of such a quality that it’s undetectable to others and yet provides the benefit of long term psychologic satisfaction.

The importance of shrinkage of some facial bones in facial ageing was not even a consideration until a decade ago. The 2012 paper ‘Changes in the Facial Skeleton with Ageing: Implications and Clinical Application in Facial Augmentation’, published in the journal, Aesthetic Plastic Surgery, by myself and my associate Dr Chin Ho Wong sparked considerable interest. It followed our 2010 study on ‘The Fate of Porous Hydroxyapatite Granules Used in Facial Skeletal Augmentation’ in the same journal. The use of Hydroxyapatite allows us to add replacement bone to individual needs, avoiding pre-formed implants. Bone correction has become an integral part of virtually every procedure I perform, even lower lids. From my unique experience with this, in over a thousand patients, I have no doubt that first correcting the skeleton is fundamental for a natural result.
Each of following five smaller solutions are explained in more detail in our Patients Notes on the specific procedure or in meeting with one of our Patient Co-ordinators for an information session.

Small Procedure 1. Restoring attractive upper eyelids

Eyes matter. Unfortunately, middle age brings a tired look to the eyes, whose impact is reflected in the face. Nicely shaped eyes inherently bring a bright, attractive face, but there comes a time when eye makeup no longer works.
Because the eyes are key to overall appearance, they deserve individualised surgical attention. Just a millimetre can make all the difference. Upper eyelids are of too much importance for a ‘simple and easy’ fix, in which the skin only is tightened for a quick result. Precise surgery using the best technique is needed to provide a truly aesthetically pleasing result. The upper lid technique I have favoured for over 20 years, called Tarsal Fixation, focuses on internal contouring of the lid fold to provide the structural support that exists in youth. In people born to have beautiful eyes, this support is maintained over the years, which explains why their eyes remain bright. After surgery the eyes look entirely natural because the focus is on the internal structure, avoids the need for skin tightness to obtain the result, which is not lasting. This commonly leads to an unattractive deterioration of the result within a few years. In fact, the time until requiring further lid surgery was only 8 years after a standard skin procedure surgery in my published series of 100 secondary Upper Lid Blepharoplasties
The eyelashes also regain their youthful curvature when the lid’s internal support is restored. Most importantly the benefit of restoring bright eyes when younger is enjoying the benefit of attractive eyes now – as well as enjoying it into the future.
Tarsal Fixation is a real solution for the ‘tired eye’ look, as it enhances and brightens the eyes with a lasting benefit.

Small Procedure 2. Enhancement of the Facial Skeleton using Hydroxyapatite

Beneath every attractive face is an attractively shaped skeleton.

As the shape of our facial skeleton is inherited, only a fortunate few are destined to have natural attractiveness. For the rest, this is unattainable without resorting to temporary cosmetic illusion, hoping to compensate. But now everyone can have enhanced facial skeleton, usually in small, but significant ways to create a more attractive shape and by extension, a naturally more harmonious face.

For most, it usually takes only a small enhancement of the cheeks, brow or jaw for an undetectable but attractive refinement in appearance that, being the skeleton, lasts forever. Hydroxyapatite is the name of the mineral our bones and teeth are made of. That is why I prefer naturally derived Hydroxyapatite particles that I shape exactly to each patient’s needs, rather than preformed synthetic implants. In time, the patient’s bone grows into the Hydroxyapatite matrix to become the new facial skeleton. The implant becomes incorporated in the underlying bone while providing the extra shape needed.

It is known that people who have good bone structure age less, which explains why enhancing the skeleton with Hydroxyapatite slows the rate of future ageing. In effect, Hydroxyapatite enhancement of your bone structure, obtains all the benefits that come to people who inherit a good facial skeleton.

Augmentation with Hydroxyapatite is a major advance in natural looking aesthetic rejuvenation. While I perform this with nearly every facelift, many of the benefits can be obtained from having this alone, often performed under local anaesthetic in the Office Day Surgery. I suggest everyone reads the Patient Notes ‘Facial Augmentation with Hydroxyapatite.’

Small Procedures 3. Enhancing lower lids with a touch of hydroxyapatite

The area extending from the lower lid down to the upper cheek is of paramount importance in imparting a look of freshness to the face. Ageing of this critical area ages the whole face. The upside is that quality surgery in this small area to remove bags, folds or sags provides a disproportionately fresher look.

While it sounds simple this anatomical meeting place of the lower lid and the upper cheek is actually complex. Ageing here involves bulging fat (eye bags), drooping muscle (distorting the upper cheek) and bone shrinkage (reducing much–needed projection and support).

A considered approach is required that takes each element into account. This explains why simply injecting fillers into ‘tear troughs’ or simply reducing the visibility of under-eye bags, the common ‘go to’ approaches, are often disappointing. When only part of the problem, the tip of the iceberg, is addressed it’s no wonder practitioners as well as patients become frustrated their results do not predictably give satisfaction.

It took many years for aesthetic surgery to appreciate the importance of this area, and to solve the problem. A breakthrough occurred with the realisation of the key role played by localised bone shrinkage. This was the missing link. We now understand that the facial bones, particularly of the inner eye and cheek area, start to shrink in the late teens; with another spurt of shrinkage in the late 40’s. Individualised bone augmentation here (using natural hydroxyapatite) to replace that loss, along with lid correction, can produce delightful, lasting results.

Filler injections have been used, looking for a quick result, but are now largely abandoned. Fat injections may be beneficial on the bone although not sufficient to replicate bone. This is truly an area where localised surgery really does impart widespread benefit.

In the previous, Procedure 2, you can read more about the benefits of quality bone augmentation using Hydroxyapatite as an adjunct to facial surgery.

Small Procedures 4. Fat injections using Lipogems and MAFT delivery

Fat injections have advanced into a new era. From early disappointment they have evolved to being a procedure that offers a quality and predictable result with a ‘stem cell’ benefit. Two major technological advances are behind this change.

The first advance is Lipogems, a system that treats the fat prior to injection. The treatment both purifies the fat and activates the stem cells in it. One of the key problems of the past, the appearance of tiny lumps, especially in the thin eyelid skin, is completely avoided.

The second advance is the injection process, using a MAFT gun! This is a precision instrument that provides precise control of the injection process, replacing the traditional hand-held syringes for injecting. It looks somewhat like a gun – hence the name – and the trigger control provides a new level of precision. The MAFT gun delivers fat in adjustable micro amounts, providing assurance that each area receives exactly what is needed in precise accordance with the underlying anatomy.

In the face where millimetres count, control is paramount. Simply adding fat can result in a puffy look, which is neither youthful nor attractive. But when the right amount of purified fat is placed in the anatomically correct position, the desired effect can be obtained. This fat restores the attractive youthful volume that is lost with ageing, especially on the all-important areas of the upper eyelids, cheeks and lips. As overfilling must be avoided, it is safer to slightly under fill at the initial treatment allowing a more precise smaller secondary procedure.For some people, especially those with early ageing, LIPOGEMS with MAFT delivered injection of their own fat may be all they need: a true non-surgical alternative. For many others, a LIPOGEMS treated and MAFT delivered fat injection is the perfect final polish to a surgical result. Lipogems is usually performed in day surgery using either local or a light general anaesthetic.

Small Procedure 5. Correction of excessive wrinkling of the outer eye area on smiling.

Some people become disproportionately affected by this wrinkling, which becomes exaggerated in their mind, especially when looking at selfies. Some people admit to consciously suppressing smiling to avoid these wrinkles! While for some it is the earliest sign of ageing, is it most often the concern of people who previously had the right preventative surgery, such as a facelift, lower lid correction and even a temporal lift.

Some drooping of the upper cheek tissues, just below the eyelid, adds to the wrinkles, while the fine skin of the lower temple and lower lid stretches. Anti-wrinkle injections temporarily improves the excessive wrinkling by reducing smiling! Ageing results in a thinning of the fat in the temples and the outer cheeks occurs, for which Lipogems is at the time the simple treatment.

A real correction is required for long term satisfaction. Through an extension of the invisible lower lid incision, the sagged upper cheek tissues are supported higher on the bone, allowing the excess lower lid skin to be removed. This is performed in the Office Day Surgery – using either local anaesthetic with or without light general anaesthesia.