Richard Baker Weekly Blog
My Thoughts on Facial Rejuvenation Surgery
This week I have been doing a bit of reading and thinking about aesthetic surgery of the face. By ‘face’ I mean the skin and underlying fat and muscles of the face and neck, but I am not really talking about the eyelids, the nose or the mouth as such because these areas have very particular anatomical features and require a discussion of their own. The tissues of the face consist of skin, fat, muscle and the underlying bone, and all four of these structures give the face its overall shape. Furthermore, all four of these tissues change with age and contribute to the changing facial appearance.
Skin is made of two basic layers – the epidermis and the dermis, and the dermis is the thicker, stronger layer that in cows is used to make leather. As we get older, this layer thins and loses its elasticity as well as stretching under the influence of gravity. This means that the skin starts to sag with age and creates jowls and wrinkles.
The skin itself can be rejuvenated in a myriad of ways, and it is perhaps in this area where non-invasive aesthetic techniques have had the greatest progress. All of these techniques work in some way by producing an inflammatory response within the skin that leads to collagen production.
Collagen is the main constituent of the dermal layer of the skin, and any technique that leads to collagen production will thicken and rejuvenate the skin. Microneedling and chemical peels are good at thickening the skin and reducing some of the very fine wrinkling, but not so much the deep wrinkles. Meso threads are slowly absorbing threads inserted under skin that cause an inflammatory response with their absorption and thus collagen production. They are very effective but the results are not immediate; they take three months for the effects to become apparent and so perhaps are best for those people who have a regular (yearly) aesthetic regime. Platelet-rich plasma (PRP), which is made from a concentrated sample of the patient’s own blood which is then injected under the skin of the face (vampire facelift), works by releasing naturally occurring substances in the blood that stimulate collagen production. PRP is also finding applications in other parts of the body and I’m considering injecting into arthritic joints in the hand and wrist.
The most effective non-surgical technique for lifting sagging skin is suspension threads (thread lifts). These are threads with little hooks or spikes that are passed under the skin which grip the skin and fat layer, and as they are tightened they lift the skin. They slowly dissolve over six months, so the result is not permanent (usually lasts for about a year), and I find them very useful for lifting the neck, defining the jawline, improving the jowls and rejuvenating the cheeks. They are inserted without leaving any scars and the downtime is surprisingly quick – the patient can return to work the next day and there is usually no bruising. The procedure is performed under a local anaesthetic just like at the dentist. As with the meso threads, this technique is ideal for somebody who has an annual facial aesthetic regime. Of course, thread lifts aren’t a replacement for traditional facelifts because excess skin is not removed with a thread lift alone. However, it is possible to remove some skin at the same time under a local anaesthetic for a fraction of the price of a full facelift. They are also safer than a facelift because a general anaesthetic is not required and there is less risk to the nerves that move the face, and no risk of poor scarring or some of the overlying skin not surviving the procedure. I suspect that over time that the thread lift technique, particularly if it is combined with the small skin excisions, will become more popular and will mean the age that people have their first facelift is later. However, there is no doubt that if a patient has a lot of excess skin then a well-executed full facelift does give a remarkably rejuvenating effect that will take 10 years off a patient’s appearance and last about 10 years.
The fat is the layer beneath the skin, and this is a more complicated layer than it sounds. The fat is arranged partly in layers under the skin but also in discreet compartments and is particularly prominent around the cheek. Not only do these compartments descend down the face with time under the effect of gravity, but they also reduce in volume with age, and that is why newer filler techniques target these fat compartments for injection to restore volume in a more natural way than before. Fillers can also be used to mask sagging skin, for example the jowls at the point of the jaw, by smoothing out bulges and wrinkles. Strategically placed volumes of fillers can also cause a lifting effect, particularly around the cheeks. The ultimate fat restoration filler is the patient’s own fat liposuctioned from the abdomen (most of us have some spare fat there after all) and then injected into the face. This not only permanently restores volume it also adds stem cells which have an ongoing rejuvenative effect. The disadvantage is that not of all the fat survives so there may be asymmetry or the procedure may need repeating.
The next layer of the face is the muscle layer, and the muscles of the face are unique compared to the rest of the body because they move the overlying skin, which allows us to have facial expressions. In the rest of the body there is a layer between the muscle and the overlying fat and skin which prevents the muscles moving the overlying skin. Because the muscles of the face have a constant movement effect on the face, the face develops more wrinkles than other parts of the body. Botox, of course, has been a revolutionary treatment for reducing wrinkles and simply works by paralysing the muscle. Its effect is most noticeable in the 30s and 40s before wrinkles are present even when the underlying muscle isn’t contracting. Once wrinkles become too deep, Botox is not sufficient, but it will help and it will stop the wrinkles getting worse. The disadvantage of Botox is that it wears off and needs to be repeated every three to four months, although there is some evidence that the more Botox treatments a patient has, the thinner the muscles become and the less often it is required. I suspect in the future there will be developments that allow the effects of a single Botox treatment to last longer than the current three or four months. New applications are being found for Botox all the time, and I use it in my hand surgery practice as well as my aesthetic surgery practice. The most recent thing I have learnt regarding Botox techniques is that injections at the very top of the forehead can achieve a brow lift for people whose eyebrows have drooped. Of course, there is some skill to botulinum toxin (Botox) injection, as a face with too little facial expression is unappealing even if wrinkle-free. A traditional facelift disrupts the attachment between the facial muscles and the overlying skin. This is why a facelift can sometimes give the appearance of Botox treatment in the lower part of the face.
The last layer in the face is the bone. You might think that the bone is an unchanging structure, but actually the facial skeleton shrinks with aging, which is partly why the cheekbones become less prominent with time. At the moment there are no treatments that rejuvenate bone, and in any case the effects of thinning bone can be reversed with fillers or specially designed silicone implants for the cheeks and the chin. In the future I suspect sophisticated hormonal cocktails will be available to maintain bone mass (for example HRT already does this to some extent) but also to slow the ageing process in the soft tissues of the face that I have already described.
What this all means is that the ideal facial rejuvenation regime would address each of the layers of the face to rejuvenate the face in a way that is natural, repeatable, safe and leaves no scars. To thicken the skin, microneedling should be performed at regular intervals throughout the year, with a chemical peel once a year depending on skin type, and particularly demanding areas treated with mesothreads yearly. The sagging of the skin can be addressed with yearly threadlifts and the lost volume replaced with strategically placed dermal fillers or, for a longer-lasting effect, fat injections. Three or four-yearly Botox injections are essential for smoothing the upper part of the face but can also be used to great effect in other areas, for example around the mouth and neck. All of these techniques are enhanced by the use of platelet-rich plasma injection and fat injections by giving a stem cell boost. Advances in the field of facial aesthetics are coming at a dizzying rate, and I think we will see a point in the next 20 years where facial aging, for those who can afford it at least, becomes practically a thing of the past.