Facelift & Necklift

Introduction
As part of the ageing process the skin of the face and neck progressively loses its elasticity and there is loss of volume in the midface as well as descent of the soft tissues. The effect of this process is to cause the cheeks to become less prominent, the nose to mouth lines to deepen, the jawline to sag giving rise to jowls and the skin of the neck to fall into loose folds. This changes the appearance of the face from being heart shaped, as it is in youth, to more square as you get older. Around the eyes the eyebrows may droop and the skin in the eyelids tends to drape giving a hooded appearance.

These changes can be addressed surgically with a face and neck lift which may also be combined with surgery to the eyelids. Mr Grover’s approach to facelifting is to rejuvenate your face and neck with a fresh youthful look and certainly avoid a tight or operated appearance. He is particularly known for his artistic approach to achieving a natural look and has lectured on the importance of an artistic element to surgical technique and how this can improve surgical outcome at the Louvre in Paris. He will also be honest in informing you if he feels you are not ready for a facelift yet but should wait a few years.


Before and after photos of patient operated on by Rajiv Grover


What can be done?
What types of facelift are there?
Which facelift is best for you?
How long does a facelift last?
Can the scars be hidden?
Preparation for surgery
Where will my surgery be performed?
What type of anaesthetic will be used?
What does the operation involve?
What happens after the operation?
What are the risks?
Summary

What can be done?
There are several operations that can be done to rejuvenate the ageing face which are referred to as facelifting. In the facelift operation the scars are designed to be well hidden. The skin of the temples, cheek and neck is tightened upwards and backwards. In addition the layer of muscle-like tissue which lies underneath the skin (SMAS layer) is also lifted in a similar way to give a longer lasting and natural result. This also improves facial shape returning it to a more youthful outline without giving a pulled or tight appearance.

The decision as to which type of facelift is performed will depend on your particular requests, the anatomy of your face and the effect that ageing has played on your facial appearance. The latter may be assessed with the help of photographs taken ten years or so before and also from your youth which you will be requested to bring to the consultation.

Often the main concern is the neck area. If there is a lot of loose skin or separation of the muscles producing two bands, then a neck lifting procedure may be required. This can usually be performed through the facelift incisions so tightening the neck muscles to a more youthful appearance. Occasionally a small scar, hidden beneath the chin, may also be required to tighten the neck muscles centrally.

What types of facelift are there?
Cutaneous (skin only) Facelift
The traditional facelift has been performed for many years. It is a technique where the skin is lifted from the underlying tissues and tightened backwards and upwards. While the overall facial appearance will be improved there is no improvement to the deeper facial tissues. This technique does not give a very long lasting result and is therefore not used frequently by Mr Grover.

SMAS Facelift
Beneath the skin of the face lies a deeper layer to which the muscles and soft tissue is attached (Superficial Musculo-Aponeurotic System - SMAS). This can be used to elevate the soft tissues of the face to provide a longer lasting result than with the classical facelift where only skin is tightened. This can be achieved either by removing a portion of the SMAS and tightening it (the SMASectomy Facelift) or by folding a portion of the SMAS itself to preserve volume (SMAS plication Facelift). These types of facelift are useful when there is a need to restore fullness to the cheekbone area as well as removing jowls and redefining the neck. This is the facelift that Mr Grover performs on most patients however the direction in which the muscles (SMAS layer) is pulled is individual to each patient and so the result is natural and based on the appearance seen in photographs of you when you were younger which Mr Grover will have studied at your consultation.


Before and after photos of patient operated on by Rajiv Grover


The 'MACS' Lift (Minimal Access Cranial Suspension)
Suitable for patients with mild to moderate jowls but no loose skin in the neck. Permanent sutures are used to elevate the soft tissues of the face and suspend them in a more youthful position. This operation has a shorter scar behind the ears and a relatively quick recovery, although it may not be as long lasting as the SMAS type facelifts.

The Short Scar Facelift
All of the facelifts above can be performed with a shorter scar which means that in addition to the normal scar in front of the ear, the rest of the incision behind the ear is limited and does not extend into the scalp. This does mean that the ability to tighten the neck may also be somewhat limited. Anybody with a moderate amount of loose skin in the neck will be better served with a slightly longer scar to accommodate this. However for patients who need tightening predominantly in the face it provides a useful alternative. These patients are usually in the younger age group (early 40’s).

The Volumetric Facelift
Facial ageing often results in loss of fat in the face and a gaunt or hollow appearance. This procedure uses a different approach to restoring a youthful appearance. Volume can be added by either injecting a patient’s own fat into the face, or by moving the cheek tissues from a lower to a higher position over the cheek bone. Recent advances have made fat transfer a more predictable and reliable option than was previously the case.

Subperiosteal Facelift (mask lift) and Endoscopic Facelifting (endoface)
The mask lift is a completely different concept from other types of facelift. It was developed by a French plastic surgeon, Dr Paul Tessier with ideas which arose from reconstructive techniques which were adapted for cosmetic use.

The soft tissues of the face are released from their deeper attachments, lifted and repositioned to the site which they occupied before gravity produced its downward drift. The most suitable patients are in a relatively younger age group (35 to 45), and have heaviness of the brows, sagging of the outer corners of the eyes and cheeks but without changes in the neck or jowl.

The endoscopic facelift is exactly the same procedure but uses small incisions within the hair and an incision in each lower eyelid rather than a long incision in the scalp

Neck Lift and Platysmaplasty
All deep plane (SMAS) facelifts tighten the muscle of the neck to improve both the jowl area and jaw line. The aim of a neck lift however is to eliminate vertical folds in the neck, to tighten the skin and reduce excess fat beneath the chin. This can usually be accomplished through the incisions made for a facelift although a small incision under the chin may also be required for fat removal or to tighten the neck muscles centrally (known as a platysmaplasty). This will be discussed in detail with you at your consultation with Mr Grover.


Before and after photos of patient operated on by Rajiv Grover


Which facelift is best for you?
There are now a number of options for effective facial rejuvenation surgery and the various types of facelift will be discussed with you in order to decide which would be most appropriate to produce the result you desire. All are designed to give a natural fresh look and will not produce a tight, mask-like appearance. The focus of this kind of surgery should, for the most part, be upon facial shape. A youthful face will have full, high cheekbones with a well defined jaw line and neck contour. As the face ages it tends to become squarer. This trend is reversed by effective facial rejuvenation surgery. Mr Grover will give you clear guidance as to what will be most suitable for you.

How long does a facelift last?
This is one of the questions most frequently asked by patients. The answer is that this type of surgery puts back the ageing clock by seven to ten years, but of course, cannot stop it from ticking. Ten years after the surgery you will of course look older but will always appear 7-10 years younger than you would have looked without surgery.

How will Mr Grover ensure a natural look?
This is one of the most important concerns for anyone considering facial surgery. The foundation of a good outcome is a thorough consultation and analysis of how your face has aged which requires a review of photographs taken of you about ten years ago and from your youth. You will be requested to bring these with you to the consultation with Mr Grover (family photographs are all that is required). This will give an accurate impression of what anatomical changes have occurred and they will act as a “Roadmap” so that your surgery truly rejuvenates rather than recreates an appearance you never had.

The next step is the surgery where Mr Grover rejuvenates primarily by moving the soft tissues of your face (SMAS layer) so that rejuvenation of shape is achieved which is usually the main change from youth to middle age and not just by tightening skin. The skin will of course be tightened as well but now can be done without giving a “wind tunnel” appearance. The “Roadmap” (i.e. your previous appearance from photographs) helps Mr Grover decide the direction of pull of the SMAS so your procedure achieves a natural appearance maintaining the precise character of your face from youth. Of course, this also requires a certain element of artistic appreciation, so please take a moment to read the section in this website on the relationship of art & surgery so that you understand Mr Grover’s philosophy on how important an artistic element is to achieving a pleasing outcome.


Before and after photos of patient operated on by Rajiv Grover


Can the scars be hidden?
The scars for all the above types of facelift are mostly within the hairline and hidden around the ear. The incision for the face extends down from the scalp to the top of the ear and then travels for a short distance just inside the ear canal so as to be hidden from view in the cheek area. It then turns backwards at the bottom of the ear to lie deep in the groove between the back of the ear and the side of the head. When it reaches the top of the ear at the back it turns to enter the scalp where it is again hidden. These scars are designed in such a way that you should be able to wear your hair in any style that you choose once the scars have matured.


Three women who have undergone face & neck lifting by Rajiv Grover. The incisions around the ear are now over 4 months old in each case and illustrate that the scar is well hidden and allows the hair to be worn in any style


If I have had a Facelift before can I have another one?
Approximately 35% of Mr Grover’s facelift practice involves treating patients who have had facelift surgery before (usually the primary surgery was elsewhere). Patients come, firstly because they have continued to age following their previous operation which was 7-10 years beforehand, or secondly because of unhappiness with their scarring or residual signs of ageing which were not adequately dealt with. Please note Mr Grover’s personal revision rate for this second category of surgery is less than 1% so the overwhelming majority of patients he treats for scarring or residual signs of ageing have had their primary surgery elsewhere.

Repeating a facelift which was done over 7 years before is usually straightforward as there will be further laxity of the soft tissues and skin as a result of the ageing process so a further lift is technically feasible. One can have up to three facelifts before the tissues become difficult to operate. Secondary facelifting for unhappiness with scarring or residual signs of ageing is more demanding as to remove the unwanted scars requires the patient to have enough laxity in the skin for adequate excision and re-positioning of the scars in a favourable line. Mr Grover will give you an honest opinion if this is possible or whether you should wait a year or two so that a better result can be achieved.


Before and after photos of patient operated on by Rajiv Grover


Preparation for surgery
It is important to avoid taking any Aspirin or products containing Aspirin for 2 weeks either side of the operation since Aspirin has an adverse effect on bruising as it thins the blood. The same is true for non-steroidal anti-inflammatory drugs (such as Brufen, Nurofen and Voltarol) and vitamin E tablets. Some patients find homeopathic remedies such as arnica helpful to reduce bruising although it is very difficult to “prove” their efficacy scientifically. If you wish to use arnica you should begin 2-3 days before the operation and continue for a week afterward. If you are a smoker it is absolutely imperative that you to stop for 4 weeks before surgery and for 2 weeks afterwards so as not to restrict the circulation to the skin. This restriction applies to all forms of nicotine including patches, inhalers and nicotine chewing gum!

Hair tinting may be continued up to the time of surgery but strong bleach containing colorants should be avoided for six weeks afterwards. Please wash your hair thoroughly with a mild shampoo the day before surgery and come to the hospital with no make up on the morning of the operation.

While making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days at home.

Where will my surgery be performed?
The surgery is performed at the King Edward VII Hospital in central London where Mr Grover works as a Consultant Plastic Surgeon. You will be admitted on the day of surgery, and will need to stay at least one night. If you have travelled from outside London then Mr Grover may suggest staying an extra night before going home. You will need a friend or relative to accompany you home when you leave hospital after surgery.


What type of anaesthetic will be used?
Facelift surgery is carried out under general anaesthesia, so you will sleep through the whole procedure. Mr Grover employs the services of a skilled consultant anaesthetist who specialises in anaesthesia for facial aesthetic surgery since there is no doubt that this makes the procedure very much safer and improves the outcome.


Before and after photos of patient operated on by Rajiv Grover

What does the operation involve?

After the anaesthetic has been administered and you are asleep Mr Grover prepares the hair and face for surgery. He does not shave any hair at all during facelifting as it can easily be parted with hair gel. Mr Grover infiltrates the face with a salt solution containing local anaesthetic (tumescent infiltration) as this reduces swelling and bruising after surgery and has been proven to improve scars after facelifting. The incisions are then made around the ear and extending into the scalp. Sometimes an additional incision is made under the chin to allow for fat removal and specific tightening of the neck muscles centrally.

The skin of the face and neck is then carefully lifted from the underlying muscle and fatty tissue. At this stage fat may be trimmed from around the neck and chin to improve the contour of the jawline. Mr Grover then tightens the underlying muscle and fatty tissue (SMAS) before pulling the skin back, and removing the excess. Stitches are then used to secure the skin and close the incisions although metal clips may be used in the scalp as this is beneficial for hair growth.

A head bandage is applied around the face and neck for the first night but this is removed before you leave the hospital the following day. A certain amount of bruising will always occur and for this reason it is a good idea to take a scarf and dark glasses to the hospital to wear on your way home. An overnight stay in hospital is all that is normally needed. However, if you do not live locally Mr Grover may suggest staying an extra night in hospital for your comfort.


Before and after photos of patient operated on by Rajiv Grover


What happens after the operation?
In Hospital (1-2 days)
A light padded dressing will usually be applied at the end of the operation which remains in place for 24 hours. You will be nursed in a semi-sitting position in bed immediately after the operation, which helps to reduce swelling. There is not usually much pain or discomfort although this can be subjective. On the day after surgery, the dressings and bandages will be removed and your hair will be washed by the nurses before going home.


At home (2-10 days)
It is helpful to rest/sleep with three or four pillows for the first week after surgery in order for swelling to subside more quickly. Swelling will tend to increase during the first 3-4 days after surgery (this is normal) and then subside over the next two weeks. It may be a little slower to subside in warmer weather. Try not to drink too much water. This is not the time to be drinking 1-2 litres of water each day in the hope of “flushing” out the system. The brain releases a hormone after surgery which tends to retain water and so if you drink a lot you will retain fluid and create more swelling. Please just quench your thirst and then drink fruit juice or tea as these will give less fluid retention and swelling.

It is important to avoid bending forwards as this may cause more swelling. It is better to avoid washing hair unless sitting with the head back like at the hairdresser. This will be done before leaving hospital and can then be repeated after 3-4 days. You should also avoid very hot drinks for the first week as well as avoiding very chewy foods as this helps facial swelling to settle quicker. It is very helpful to rest as much as possible for the first five days and then return gently to normal activities over seven to ten days

After a week Mr Grover will arrange to see you to remove any stitches near the eye and then at between 10-14 days to remove the remaining facelift stitches and any clips. Any facial or eyelid stitches run beneath the skin and are not visible except at either end. They will therefore leave no stitch marks so do not worry!


The first 2-6 weeks after surgery
The face (and eyelids if they have also been operated on) may feel a little tight. This is normal and related to swelling and scar maturation. Occasionally the eyes may feel a little “gritty” after surgery and if this is the case then it is helpful to use a lubricating ointment at night. The cheeks and ears will feel numb for about three months after the operation; this is quite normal and recovers spontaneously. In general it is best to continue with your usual facial skin care regime as the risk of sensitivity to a new product is best avoided. You may visit your hairdresser after 10-14 days but as mentioned earlier no colorants should be used for 4 weeks.

You should not drive for at least one week after surgery or until such time as your neck movements are comfortable. Most patients can return to work after 2 weeks although you may wish to avoid major social events for 3-4 weeks until the fine swelling has settled. You may resume your usual sporting activity at 3-4 weeks but prior to that it is best to avoid exercise as it will prolong the swelling in your face.


Before and after photos of patient operated on by Rajiv Grover


What are the risks?
These are fortunately rare and when they do occur usually represent a temporary inconvenience rather than a permanent problem. Mr Grover will do everything possible to minimize your risk. He has a strong interest in improving safety and is responsible for the UK National Audit of Cosmetic Surgery & Safety for the Royal College of Surgeons.

  • Bleeding beneath the skin causing excessive bruising (haematoma) can occur and may, on occasion, require surgical treatment. The overall incidence is approximately 2-3% in all face-lifting procedures. The most common time for it to arise is within the first twelve hours after surgery when you will be in hospital. It normally does not influence the ultimate outcome of the surgery but is a temporary hiccup.
  • Infection is extremely uncommon in the face, the incidence being approximately 1-2%.
  • Some numbness in the area of surgery, particularly in the cheeks is to be expected for about three months. As this recovers you may notice some tingling or pins and needles.
  • Temporary hair loss particularly in the region of the temple is seen occasionally (usually only in smokers) although this invariably recovers over a period of three to six months.
  • The scars are normally very fine and well hidden but in some individuals a scar may tend to thicken after 6-12 weeks, such "hypertrophic" scars can be improved and curtailed by appropriate treatment.
  • Wound healing in the face is generally very quick and reliable. Occasionally a slow healing wound may be seen. This is usually behind the ear since the skin there is most fragile. Such problems are, fortunately, very uncommon indeed but are known to be more likely in smokers.
Summary
Procedure time 3 - 4 hours
General / Local anaesthetic General
No. nights in hospital 1 night
Time off work 14 days
Sensitivity period 10-14 days
Back to normality / sports 4 weeks

 

The modern facelift has reached a point where it is possible to tailor the operation to suit individual needs. For most patients it will produce a significant rejuvenation and improvement in facial appearance for many years without appearing operated or overly tight.

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