Lifted to perfection

Dr Parag S Telang shares comprehensive surgical strategies for facial rejuvenation and lasting facelift outcomes.

Aesthetic surgery, a key component of the plastic surgery industry, addresses the evolving demand for physical enhancement solutions. Procedures like gynecomastia correction, breast augmentation, liposuction, facelifts, rhinoplasty, and tummy tucks remain crucial in meeting the increasing need for cosmetic treatments. In India, the rising popularity of these procedures reflects changing lifestyle preferences and growing societal emphasis on personal beauty standards, driving demand for advanced surgical solutions within the professional healthcare and cosmetic industrys.

Dr Parag S Telang, Founder and Director, Designer Bodyz Centre for Advanced Cosmetic Surgery, elaborates on the surgical options for facial sagging in conversation with Shriyal Sethumadhavan.

Primary causes

Facial ageing or changes typically begin to appear in the late 30s or early 40s. However, this can vary depending on factors like weight fluctuations. For instance, if someone starts at a certain weight and then loses a significant amount, the sagging that would naturally occur later in life may appear earlier. Broadly, there are two key factors that contribute to looking older: sagging and loss of volume. It is the combination of tissue sagging and volume loss that creates the appearance of ageing, making one look older than their actual age.

Treating facial sagging

When assessing a face, regardless of whether the patient is in their 20s, 30s, or 40s, we first need to analyse which area is contributing to the sagging. It could be the midface, which includes the cheeks and upper face, the lower part of the face, or the neck, which might make the face appear older. Depending on the area and the patient’s age, we have different solutions tailored to the specific type of facial ageing.

For someone in their early 30s who is just beginning to experience midface sagging, this usually manifests as a laugh line, one of the first noticeable signs of ageing. This line, which was not visible in their 20s, becomes more pronounced by their 30s. In such cases, aside from non-surgical options like filling the area with HA fillers or using threads, a straightforward surgical procedure known as a midface lift can be highly effective.

A midface lift involves a small incision, approximately 1 inch long, starting in the hairline, curving around the sideburn, and ending nearby. A pocket is created under the midface tissues, and the tissues are fixed to a higher position. Any excess skin that results from this lifting is trimmed during surgery, which is not possible with non-surgical alternatives. This minor procedure can help younger patients look refreshed.

For more pronounced sagging that extends beyond the midface to include the corners of the mouth or early jowling, a max lift may be recommended. A max lift, which stands for Minimal Access Cranial Suspension, rejuvenates the entire cheek area. This procedure involves an incision starting near the eyebrow, curving around the sideburn, into the natural ear crease, and ending discreetly. The incision respects the natural facial creases, and after 15 to 20 days, it becomes nearly inconspicuous. Patients can tie their hair up and socialise without concerns about visible scars.

For advanced signs of ageing that affect both the face and the neck, a deeper procedure is required. This may involve a deep plane facelift combined with a deep plane neck lift. Ageing affects not only the skin but also the deeper layers, such as the SMAS (superficial musculoaponeurotic system) layer, which is tightened and repositioned internally during the procedure. For the neck, the platysma muscle may also need tightening through a procedure called platysmaplasty.

This approach addresses issues like sagging, bulkiness, and prominent neck bands – visible vertical lines caused by the breakdown of neck muscles. These bands are repaired through small incisions behind the ears or under the chin. The muscle is tightened and pulled sideways, creating a more defined jawline. This combination of a deep plane facelift and necklift is particularly suitable for older patients or those with significant sagging in both the face and neck.

Facelift vs. necklift vs. browlift

A facelift is primarily designed to target the front view of the face. It addresses the areas visible when looking straight on. In contrast, the profile view highlights the neck, which often becomes more noticeable due to factors like excess fat or a lack of definition in the neck angle. Patients with these concerns may benefit from a neck lift, a procedure that tightens the area beneath the jawbone and enhances the jawline’s definition.

“Ageing affects not only the skin but also the deeper layers, such as the SMAS (superficial musculoaponeurotic system) layer, which is tightened and repositioned internally during the procedure. ”

For patients experiencing sagging in the eyebrow area, where the eyebrow starts drooping or the eyelids become saggy, there are different procedures available. A brow lift targets the eyebrow area, with the incision typically made inside the hairline. For sagging eyelids, the procedure involves making an incision along the eyelid crease and is known as eyelid surgery or blepharoplasty.

Suitability for surgery

Clinical examinations are always conducted to assess the patient. Typically, this involves having the patient stand in front of a mirror while we lift the tissues upward to observe how much excess skin bunches up.

If the bunching of skin measures around 1 cm or less, it indicates early sagging, and we can recommend non-surgical alternatives such as threads or HIFU (High-Intensity Focused Ultrasound). However, if the excess skin measures more – 1.5 cm, 2 cm, or even more – surgical intervention is necessary to remove the excess skin. Without removing it, the face will not achieve a tight, youthful appearance.

Some celebrities have swollen or puffed-up faces, which often occurs when sagging tissues are not tightened properly, and excessive fillers are added to the cheeks. The face cannot handle the additional weight, resulting in a saggy and unnatural look. It is important to remember that youthfulness is closely associated with tightness. A face must be tight to appear beautiful and rejuvenated.

Results and outcome

The beauty of surgical treatments lies in their longevity. With a deep plane facelift or necklift, you can confidently assure patients that the results will last at least 10 to 15 years. The only maintenance they may require is a small amount of botulinum toxin for forehead lines or crow’s feet. Beyond that, the face and neck typically do not need additional interventions.

However, if a patient experiences significant stress or weight fluctuations, they might benefit from maintenance treatments such as RF (radiofrequency) or HIFU (High-Intensity Focused Ultrasound) to keep the tissues firm. These treatments can effectively prolong the results of a facelift or necklift for several years.

Complications involved

The first step is to evaluate the patient’s overall health. Unless the patient is healthy and fit for anesthesia, they may not be suitable candidates for surgical treatments. Once that is addressed, the next consideration is recovery time. All surgeries require a specific recovery period, and this is especially true for facial aesthetic surgeries. Unlike body contouring surgeries, where results can be concealed with clothing, the face is always visible. After a facial surgery, such as an eyelid lift, swelling may take 10 to 12 days to subside, and any bruising will need time to heal. Patients should plan their procedures carefully and allocate sufficient recovery time.

To minimise risks during surgery, we ensure two critical measures. First, we use excellent lighting for optimal tissue visibility. Second, we rely on magnification, using microscopic, enlarged vision to identify and avoid critical structures like nerve branches. Even in medical literature, the chances of complications such as facial nerve injury or trauma to other tissues are extremely low – less than 0.5 per cent, or fewer than 1 in 1,000 cases.

Ensuring natural-looking results

There are people who say that plastic surgery involves “plastic”. That is not true. The term “plastic surgery” originates from the Greek word plastikos, meaning “to mold”. We are essentially molding tissues. If you compare the results of anyone – whether a celebrity or someone else – you will notice that their faces appear much more natural when they have had proper plastic surgery compared to non-surgical procedures.

Non-surgical treatments are more like camouflage; they do not lift or remove anything. Instead, they mask the issue by filling it in so it is less visible. In plastic surgery, we address the root cause. Sagging tissues are repositioned, and any excess skin or tissue is removed. Properly performed plastic surgery can provide pleasing, completely natural results.

“One notable innovation is hyperbaric oxygen therapy, which is now routinely recommended for postsurgery recovery. ”

Recovery process and downtime

For face and neck tightening, the skin and tissues are relatively tough, so there is minimal swelling or bruising. On the other hand, eyelid tissues are thinner and more delicate, so there is a higher chance of swelling and bruising. For a face and neck tightening procedure, recovery usually takes about 10-12 days. For eyelid surgeries, it takes two to three weeks to achieve a makeup-free look where no concealer is needed.

After surgery, patients are provided with a chinstrap – a cotton belt with Velcro – to apply pressure on the operated tissues. This helps reduce swelling and ensures the tissues adhere to the underlying muscles faster. Post-surgery care also includes antibiotics and painkillers for about a week. It is not an intense recovery process.

Not following post-operative care can significantly impact the treatment results. I often compare it to buying a new car – you ensure proper maintenance to keep it in top condition. Similarly, even with a new “face,” patients must follow instructions, wear compression garments, and apply prescribed creams to ensure the best outcome.

Most patients understand this and comply, but there are always a few who don’t follow instructions, like “naughty children”. In such cases, we have to be strict and explain the importance of adherence to post-operative care for optimal results.

Advancements in technology and techniques

Facelifts today are vastly different from what was done 10 years ago. We have seen improvements in instrumentation, anaesthesia, and post-operative care.

One notable innovation is hyperbaric oxygen therapy, which is now routinely recommended for post-surgery recovery. Patients lie in an oxygen chamber to receive high-pressure oxygen, which significantly reduces swelling and bruising. This was unheard of a few years ago.

Additionally, surgeries have become less invasive. For example, procedures that required a 10-cm incision five years ago can now be performed with a 2-cm incision, resulting in shorter recovery times. These are exciting times for facial aesthetic surgery.

Maintaining the results

The key to maintaining youthful results is a healthy lifestyle. Maintaining a stable weight is crucial. Frequent weight fluctuations stretch the skin like an elastic band, causing sagging. A balanced diet and regular exercise also play a significant role in preserving results.

People who maintain a consistent weight from their 20s through their 60s tend to age more gracefully. While they may develop some wrinkles or minor sagging, it is much less pronounced. Maintaining your overall health is essential to prolong the effects of surgical procedures.