- facelift (rhytidectomy)
- Botulinum Toxin Injections
- eye lid lift (blepharoplasty)
- nose reshaping (rhinoplasty)
- ear pinning (otoplasty)
- forehead lift
- liposuction (lipoplasty)
- tummy tuck (abdominoplasty)
- penis enlargement
- gynecomastia
- spider and varicose vein treatment (sclerotherapy)
- lipolysis
As part of the aging process which happens to all of us sooner or late, our skin progressively loses its elasticity and our muscles tend to slacken. The stresses of daily life, effects of gravity and exposure to sun can be seen on our faces. The folds and smile lines deepen, the corners of the mouth droop, the jaw line sags and the skin of the neck becomes slack. Around the eyes, the eyebrows droop and the skin of the eyelids gathers in loose folds. In the skin the first sign is fine wrinkles developing around the lips, at the outer corners of the eye and lines of expression. The rate at which this happens varies from one person to another and is probably determined by our genes. Aging of the skin of the face does not necessarily reflect the rate that the rest of our body and mind is ageing and many people feel frustrated that the face they see in the mirror is not the one they feel should be there. Substantial weight loss can produce similar changes in facial appearance to those of the aging process.
Who will benefit from a facelift?
The best candidate is one whose face and neck has begun to sag, but whose skin still has some elasticity and whose bone structure is strong and well defined. Most patients are in their 40’s to 60’s, but facelifts can be done successfully on people in their 70’s or 80’s. It should not be obvious that a patient has had a facelift, but instead they look younger, more vital and cheerful. It is a procedure that technically works well but also increases morale and is well appreciated by the patient.
What a facelift does not do?
A facelift works better for the lower half of the face and particularly the jaw line and neck. If you have sagging eyebrows and wrinkles of the forehead then you should perhaps consider an endoscopic brow lift. Loose skin with fine wrinkles, freckles and rough areas will benefit more by chemical peel or laser resurfacing.
What should you do before the operation?
If you are overweight and intend to lose it you should do so before the operation. This allows the surgeon to remove more skin and therefore achieve a more pleasing result. You should avoid taking tablets containing aspirin and non steroidal anti-inflammatory drugs such as Voltarol and Indocid for at least two weeks before surgery as they increase the risk of bleeding. You should stop smoking at least two weeks before surgery as this is the main cause of reduced healing. It decreases circulation of the skinflaps, particularly behind the ears. Have your hair permed and tinted, if you wish, before your operation as fresh scars are sensitive to these chemicals for a few weeks.
How long does a facelift last?
A facelift does not stop the clock, but it does put the clock back. The effect of the facelift is likely to always be there, in that you will not look as old as you would have done if it had not been carried out.
Botulinum Toxin Injections
(Botulinum toxin is commercially available as Botox® or Dysport®. However, these injections arecommonly referred to as ‘Botox injections’ whichever product is actually used. This leaflet will therefore refer only to ‘Botox injections’). Introduction Wrinkles are part of the ageing process. They can be attributed to sun damage, effects of gravity and muscle contraction resulting from facial expressions such as frowning and laughing. Wrinkles due to the effects of gravity represent natural sagging of tissue with age and are generally only improved by surgical tightening procedures. Wrinkles caused by muscle contraction such as frown lines, forehead lines and crows’ feet, can be improved by Botox treatment. The various wrinkles caused by facial muscle contraction are illustrated on diagram 1. Botox can also be used to treat excessive sweating of the armpits and palms of the hands.
What is Botox?
Botox® and Dysport® are the trade names for Botulinum toxin, produced by bacteria called Clostridium botulinum. Several types of toxins have been identified, but type A, which is used commercially, is the most potent. Botox acts by blocking acetylcholine, a chemical that is responsible for transmitting electrical impulses that cause muscle contraction. This results in muscle paralysis. The resultant paralysis, however, is temporary, as the new growth of nerves will re-innervate the muscles. Botox was first used in 1978 to weaken over active muscles in the eye, followed by other neurological conditions such as dystonia and hemifacial spasm with good effects and little side effects. Botox was first used cosmetically in 1990, to reduce facial wrinkles arising from muscle contraction.
What can you expect at the time of your procedure?
Botox is injected directly into the muscles that cause the wrinkles, using a very small needle. Several injections are usually needed at specific sites, depending on the area treated (see diagram 1). When used to treat excessive sweating in the armpits, Botox is injected directed into the axillary skin. Localised discomfort and bruises can occur, but no sedation or local anaethesia is generally required. Normal activities can be resumed immediately.
What are the results?
Botox usually takes effect 24-72 hours after injection, with maximum effect at about 1 to 2 weeks. Its effects generally last for approximately 3-4 months. When injected into the muscles that are responsible for expression wrinkles, it gives the face a more relaxed and smoother appearance. Sometimes longer lasting effects (9-12 months) are seen after treatment of excessive sweating. When a gradual fading of treatment effect is noticed you may return to have another treatment.
What are the limitations?
Whilst Botox can be very effective in reducing wrinkles due to muscle contractions, it has no effect in reducing the fine lines on the face caused by sun damage, and lines due to sagging of facial skin. In those patients with very heavy lines, repeated treatments may be needed for maximum effect. Too frequent or excessive dosing of Botox may lead to patient’s resistance to treatment due to antibody formation and Botox treatment may exaggerate any facial asymmetry.
What are the contraindications for treatment?
The use of Botox is contraindicated in people with neuromuscular disorders such as myasthenia gravis, those who are taking certain muscle relaxants and antibodies such as aminoglycosides, pregnant or breast feeding women, those with infection or inflammation at the proposed site of injections and bleeding disorders.
What are the risks?
No severe complications after cosmetic use of Botox have been reported in the literature. Very rarely excessive weakening of the target muscles and paresis of adjacent muscles can occur, resulting in facial weakness. This is self-limiting. When injecting above the eyebrows, upper eyelid ptosis or slight drooping may occur but only 1:100. This can be corrected with eyedrops but will also improve as the effects of the Botox wears off.
Eyelid Reduction
The skin loses its elasticity and our muscles slacken with age. For the eyelids this results in an accumulation of loose skin which collects as folds in the upper lids and forms deepening creases in the lower lids. At the same time there is slackening of the muscle beneath the skin allowing the fat, which cushions the eyes in their sockets, to protrude forward to give the appearance of bagginess. In some families there is an inherited tendency for bags to develop during early adulthood before any skin changes. The problem often seems worse in the morning particularly with prolonged stress and lack of sleep. Fluid that is normally distributed throughout the upright body during the day, tends at night to settle in areas where the skin is loose, such as the eyelids. Drooping of the eyelids is also an effect of the ageing process and aggravates the accumulation of the skin in the upper eyelids. Sometimes so much skin accumulates in the upper lids that it hangs over the eyelashes to obstruct vision. Bags are caused by an accumulation of fat and with age the skin stretches and the muscles around the eye weaken.
What can be done?
An eyelid reduction (blepharoplasty) removes the surplus skin and protruding fat to produce a more alert appearance and reduces the morning swelling. Sometimes it is only necessary to reduce the skin, sometimes the skin and the fat and sometimes just the fat. If only the fat is being removed from the lower eyelids, then this can be removed from the inside of the lower eyelid avoiding an external excision (transconjunctival blepharoplasty)
What are the consequences?
People who have the familial problem of bags beneath the eyes may well undergo surgery in their 20?s. Ageing effects of the skin are apparent earlier in the eyelids than elsewhere. A reduction of the skin can be carried out from the age of 35. Patients with thyroid disease often develop eye signs which can be helped by surgery. Where there is reduced secretion of thyroxin (hypo-thyroidism) there is an increase in fat and where there is an increase in thyroxine (hyper-thyroidism) there is often so much increase in fat that the eyes protrude. An extended eyelid reduction (Olivari?s procedure) can treat this satisfactorily.
What are the limitations?
It is important for you to understand that only the wrinkles which are in the skin which is cut away will be removed. We are only treating the eyelids within the bony margin of the orbit (eye sockets). Folds of skin extending on to the cheek (festoons) will not normally be improved. Wrinkles in the area of the crow?s feet will remain and although the skin is much tighter it is still necessary to be able to open and close the eyes freely. The skin has less elasticity with age and for proper closure of the eye the upper eyelid will need to have surplus skin when it is open. Descent of the eyebrow can be helped by endoscopic brow lift and an extension of this, the deep facelift, can be used to not only lift the eyebrow and the upper eyelid, but also lift and open the outer angle of the eye. Sometimes residual or recurrent wrinkles are suitable for treatment by chemical peeling or laser resurfacing. The operation has no effect at all on the dark colour of the lower eyelid.
The Operation
Both upper and lower eyelid surgery can be carried out under local anaesthesia or under general anaesthesia in a hospital. In a typical procedure the surgeon makes incisions following the natural lines of your eyelids; in the creases of upper lids and just below the lashes in the lower lids (see illustration). These incisions are extended a little way into the crow?s feet or laughter lines at the corner of the eyes. Through this incision surplus fat is removed and excess skin and sagging muscle removed. If you have a pocket of fat beneath your lower eyelids without surplus skin then the fat may be removed through the inside of the lower eyelid. The resurfacing laser can be used at the same time as a transconjunctival blepharoplasty to tighten the external skin and reduce wrinkles, although there is no external scar there is residual redness in the skin which will last a few months. Following surgery it would be best to keep your head elevated for a few days to reduce swelling. Cold compresses can also help. The surgeon will normally apply some suture strips or steri-strips as support to the eyelids after surgery and if these become crusted they can be replaced. Cleaning the eyes with water is useful and the surgeon may advise the use of eye drops or ointment. The sutures are usually removed after 3 to 5 days and soon after you will be able to use make-up. Sometimes you will be advised to use the suture strips or steri-strips as support to the lower eyelids for a week or so. The closure of the eyes appears tight after surgery because of the swelling and because skin has been removed. If closure is not complete at night the patient should apply some eye ointment before going to sleep. This sensation will settle as the swelling goes down. The eyes appear watery after surgery, partly because of swelling under the conjunctiva (chemosis) and partly because the tear ducts are swollen and do not drain as readily. This will last a few weeks. Although there is bruising it can quite readily be disguised with make-up and dark glasses. The scars will be pink for a few months, but eventually they become almost invisible.
What are the risks?
All surgery carries some uncertainty and risk. When eyelid surgery is performed by a qualified Plastic Surgeon complications are infrequent and usually minor. You can reduce the risks by closely following your surgeon?s instructions both before and after surgery. You should tell him of any thyroid disease, high blood pressure, diabetes or eye disorder such as detached retina or glaucoma. It may be that he/she will wish you to be checked by an Ophthalmologist. Occasionally a pool of blood can collect under the skin after the operation has finished (haematoma) this usually disperses spontaneously over 2 or 3 weeks but it may need to be drained if it is large. Quite commonly the margin of the lower lid is slightly pulled away from the eye during the first day or two after surgery due to swelling. This will settle on its own or with the help of suture strips or steri-strips. Very occasionally another operation is necessary. Sometimes tiny white cysts can appear along the stitch line. They are nothing to be concerned about but can be pricked out with a needle. Blindness is an exceptionally rare complication.
Rhinoplasty (nose jobs)
Surgery to reshape the nose is a very common plastic surgery procedure and it can both increase or decrease the size of nose. The shape of the tip, the bridge and also the nostrils can be changed as can the angle between the nose and the upper lip. Sometimes breathing difficulties can be corrected at the same time. The nose is the central feature of the face, many people are self-conscious of shape which they may regard as too big, too small or have some other feature which they dislike. The characteristics of the nose are inherited from parents and develop during adolescent years. They continue until the age of 16, when the nose stops growing. It is, therefore, unwise to operate before this age. Injury to the nose is a common cause of flatness. Occasionally, it is a characteristic which is inherited. This can also develop after surgery to the interior framework of the nose (septoplasty to improve the breathing). The owner of a flat nose may acquire the reputation of the profession of a fighter as opposed to a sports person which may have an adverse effect to self-esteem.
What can be done?
To improve the appearance of a flattened nose it is necessary to introduce some additional framework underneath the skin to raise and straighten the bridge-line. The operation is called Augmentation Rhinoplasty. Various materials are used for the additional framework such as bone, cartilage (gristle) and a range of manufactured materials which experience has shown are safe and well tolerated by the body. Each has its advantages and disadvantages which are too complex to discuss in this factsheet. The additional framework is usually introduced into the nose through a cut either inside the nostrils or in the strut of skin between the nostrils. If a bone graft is used for the additional frame it is taken either from the crest of the hip, from a rib, from the back of the elbow or from the outer surface of the skull without causing any weakness of the ‘donor’ bone. If cartilage is used, it is usually taken from the shell of one or both ears or from cartilage inside the nose, which is spare. When the nose has been flattened by injury, it is quite common for the plate of bone which separated the two halves of the nose to be buckled as well. This makes breathing difficult. It can often be corrected at the same time as an augmentation rhinoplasty by straightening the buckle out but sometimes it is advisable to have this done as a separate operation beforehand. In cases of severe collapse of the nose, skin grafts may also be necessary to achieve a satisfactory reconstruction. This is highly complex plastic surgery and outside the scope of this factsheet.
What are the consequences?
You can expect to have bruising and swelling of your face, particularly around the eyes, which will take up to three weeks to settle and during part of this time your nose is likely to be covered by a firm splint. Once the initial swelling has settled, you will find that your nose feels rather stiff and numb. The numbness will disappear slowly during the next few months but the stiffness is likely to be permanent. If it has been necessary to take a bone graft from another part of the body, you will be left with a scar which may be noticeable if it is on your hip or chest.
What are the limitations?
Although it is usually possible to make a substantial improvement to the appearance of the nose with the operation, the new frame may feel unnaturally hard. This is because it does not have the consistency and flexibility of the natural frame of the nose. You may also find that the additional frame can be moved about under the skin if it does not become fixed to the existing bony framework of your nose. These limitations need not worry you provided you bear in mind that the operation is done for the sake of your appearance. Particularly if a bone graft has been used, there is a tendency for it to gradually shrink in size during the first year or two after the operation. To help compensate for this, your surgeon is likely to put in more graft than you actually need so that to start with your nose may look over-bulky. There may be technical limitations to the perfection of appearance that can be achieved. For example, perfect symmetry may not be possible and it may not be possible to make the nose as large as might be desired. An experienced surgeon will be able to advise you what is possible in your own case.
What are the risks?
Like any operation that is carried out under a general anaesthetic, there is a small risk of chest infection, particularly among people who smoke. Very occasionally, the operation can be complicated by heavy nose bleeding either shortly afterwards or, after a week to 10 days which may require treatment in hospital. There is a small risk that infection could adversely affect the success of the operation. Were it to happen, it may be necessary to remove, temporarily, a manufactured implant if that has been used, or it may cause a graft of bone or cartilage to dissolve. In either event, it should be possible for you to have a further recontructive operation once the infection has cleared. Sometimes a manufactured implant will extrude through the skin of the nose or its lining and need to be removed. This can happen months or years later, and is more likely if a large implant has been used or if the nose is accidentally injured. Altogether, you can think in terms of there being about a 10% risk that you may need further surgical treatment for one or more of these complications were you to have this operation done.
What you can expect at the time of your operation?
If you need only a small implant, it may be possible to do the operation without a general anaesthetic, in which case you would have injections of local anaesthetic into your nose to make it numb and you would not need to stay in hospital. For larger reconstructions and if a bone graft from the hip or chest is needed, you would probably need a general anaesthetic and, maybe, up to a week in hospital. After the operation, you will probably have dressings in your nostrils for a day or so which will prevent you from breathing through your nose. You will also have a firm splint over your nose for the first week or two. There should be very little pain in your nose but, if you have a bone graft taken from your hip, you can expect this to be quite painful for about 10 days, particularly when you walk. You will be given appropriate painkillers to help with this. Conclusion You should by now understand that this is a delicate and complex operation which needs to be designed for the needs of the individual patient. You should only consider having this operation for yourself if you are genuinely self-conscious of the nose you have at present. Do not think of having it done either for someone elseÕs sake or if it is just a whim. If you do decide to go ahead, only go to a surgeon who is properly trained, and be guided by his or her advice as to what is possible in your own case. Cosmetic Surgery is carried out by members of several different organisations and therefore your general practitioner is the best person to advise you on whom you should see.