Dr. Dirk Lazarus
Plastic Surgeon

Tel: 021 424 1112
Fax: 021 424 1118

86 New Church St
Tamboerskloof
Cape Town, 8001
South Africa

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PLASTIC SURGERY NEWSLETTER
Facial Rejuvenation – The 4 R’s
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Patients frequently contact me seeking simple and inexpensive ways to achieve a facial rejuvenation. A facelift is no longer the complete solution for facial rejuvenation and plastic surgeons now have a whole armamentarium with which to deal with facial ageing. A greater understanding of the changes that occur with ageing have allowed great progress in this field.

We know now that not only do the skin and deeper tissues sag and droop with ageing, but also volume is lost. The bones become lighter, the muscle atrophies, the fat becomes less and the skin thins. In addition the skin undergoes changes due to ageing and sun exposure. Fine lines and wrinkles occur, some also due to the effect of muscle action.

So while elevation of drooped tissue still remains an important component of facial rejuvenation - we now have multiple ways to elevate tissue (not just facelift) - other components contributing the aged look can be dealt with. Volume can be restored, muscles can be relaxed and the surface of the skin can be improved. Facial rejuvenation can thus be said to comprise of four modalities – the 4R’s:

1. Re-positioning (lifting) and removal of tissue
2. Re-filling or replacement of volume
3. Relaxation of key muscles which cause wrinkles
4. Resurfacing of the skin

1. Re-positioning and removal of tissue
This includes conventional facelifts, brow lifts, and removal of excess eyelid skin and fat – the conventional (and sometimes less conventional) operations traditionally performed by plastic surgeons. Barbed sutures such as Aptos threads, Contour threads, Featherlift and a handful of others are currently becoming popular as a minimally invasive, truly lunchtime, lifting procedure for the face and brow (but how long do they last?).

Facelifts are classified according to:

a) incision - either classic or some form of shorter incision (I prefer short scars);

b) according to what one does to the SMAS (the Superficial Muscular Aponeurotic System - the fibrous and muscular layer in the face which lies underneath the skin). The SMAS my be tightened by removal of a part of it (excision) or by suturing it (plication). As the scientific literature shows no difference between excision and plication, I prefer to do the simpler and safer plication, but I do vary it according to each case.

I achieve brow lifts with a suture suspension technique. Up until now I have used smooth sutures, but barbed sutures may give a better lift. Endoscopic brow lifts are popular. This operation requires a number of scalp incisions to insert the endoscope (like a telescope) so that the structures holding the brow down can be divided and the brow suspended. Skin is not usually removed. Endo brow lifts are more complicated than suture suspension and long term evidence from Sweden has shown that the brows can continue to rise up over the years so that in time they may appear too high. With suture suspensions the brows tend to drop in time. Open or traditional brow lifts tend to leave unacceptably large scars and as a result are no longer popular.

Eyelid surgery (blepharoplasty) generally gives very pleasing results, especially of the upper lid. To avoid some of the problems of conventional lower lid blepharoplasty, I am now doing a very simple skin excision (pinch blepharoplasty); removal of fat, where necessary, using an approach from behind the lid (transconjunctival blepharoplasty) and leaving the muscle layer intact. Sometimes, to correct tear trough deformities, I am placing some of the lower lid fat into the tear trough instead of removing it. I am also keen on fat transfers to improve volume losses in this area. I am also less frequently removing fat from the upper lid to avoid a gaunt look which occurs with ageing.

2. Volume Replacement
If one looks at very old people the volume changes that occur with ageing are evident. The bones of the skull and face become less heavy, the muscles atrophy or thin, the fat disappears and the skin thins. The look thus becomes skeletal which is why very thin faces often look old and why when people put on a little weight in their face, their face appears younger. Although some people have very thin necks, more often the fat descends with ageing and the neck provides a ready source of your own fat which can then be moved to a number of areas in the face, but especially around the mouth: the naso-labial lines from the nose to the mouth, the marionette lines or down lines from the mouth downwards, the upper and lower lips. I use the technique of Sidney Coleman from New York to transfer fat and I believe that I get reasonable results. Fat transfers may be done in conjunction with a facelift or as an isolated procedure. The neck lipo not only provides me with a source of fat, but is also a very good way to dissect the neck and lipo causes skin retraction too - a triple benefit! The fat, once harvested, is treated and then re-injected into the problematic areas using a very small syringe. This allows optimal take of the fat. Because the fat is transferred as a graft (a transfer without its own blood supply), it needs to pick up a blood supply from its new site. This takes about 6-8 weeks and the fat which has picked up a blood supply will continue to live in its new site and not go away. How much of the fat takes is, however, a little unpredictable.

In patients who are not undergoing another procedure, I often use commercially available, injectable fillers for volume replacement around the mouth and in other areas. Traditional collagen is no longer used due to problems with allergy and inadequate duration of results. Isolagen is a new technique which requires a small biopsy of your own skin, the collagen is then grown in the lab and 6-8 weeks later a couple of syringes of your own collagen are available for injection. Isolagen's expensive limits its widespread use. I use a lot of hyaluronic acid products such as Restylane and Perlane. Hyaluronic acid is a naturally occurring body sugar and once injected it draws in water. It is very good for augmentation and volume replacement, especially around the mouth, and will generally last 9-18 months depending on the product and the patient. Fillers are in the region of R2600-2800 and can be repeated at any time.

3. Relaxation of muscles: Botox
Botox has received a lot of press. It is certainly one of the wonder drugs of recent times, yet some people feel negative about the fact that it is a toxin. Botox prevents the release of the neurotransmitter, Acetylcholine, from the ends of nerves and thus prevents muscle contraction. In huge doses (10 000 units or more), it paralyses the respiratory muscles and that is how botulism kills, but the doses used for wrinkle treatment and prevention are minor in comparison (15-60 units) and there have been no deaths due to botox. In fact the side effects are rare and usually minor. Its toxicity is a lot less than some commonly used drugs such as paracetamol, aspirin and penicillin!

Botox, in the doses used, relaxes (not paralyses!) muscles injected and in so doing lessens the causation of wrinkles that are due to muscle activity. It acts specifically on the muscles treated and has no generalized or systemic effect. It is very good for the upper face: frown lines, crow's feet, horizontal forehead lines and can be used to achieve some degree of brow lifting, to open the eyes a little more and to soften the features of a stressed face.

If you like the botox effect, then you can choose to have it again. In time, the dose of botox required to treat your frown lines, crow's feet, etc, may become less as the muscle undergoes atrophy like a leg in a plaster cast (becomes thin and weak) and also you get out of the habit of making that movement. Treatments vary from R1000 to R3000 depending on how much Botox you want/need and you will probably want it two or three time a year initially.

Although Botox is best for the upper face, I also use it occasionally around the mouth, to change the shape of a smile (some people have a smile which pulls across or down, rather than up) or for neck bands.

4. Resurfacing
Resurfacing techniques aim to damage the outer layer of the dermis. New collagen is then deposited which has a more ordered arrangement resulting in smoother skin. Dermabrasion, a technique for abrading the skin with a device like an orbital sander, has largely fallen out of fashion due to the danger of aerosolizing blood products. Chemical peel is the application of usually acid to the skin to burn it to a particular depth. Laser does a similar thing but in a more controlled way. Needling is a technique whereby multiple puncture wounds are made in the skin without removing the outer layer. It is therefore associated with a quick recovery, but the devices for needling are costly, the process is time-consuming and needling requires good anaesthesia. For patients who need it, I will do a chemical peel around the mouth at the time of facelift as part of the rejuvenation process. I do not do laser and for patients who want full face laser, I refer them to a nearby laser clinic.

Using the above techniques of facial rejuvenation it is often possible to turn back the clock 10 or even 15 years. Perhaps even more importantly, we now have techniques and products which can slow facial ageing. The importance of sun protection/avoidance and good skin care are also important.

Facelift is therefore not the only answer for those showing signs of ageing. In fact facelifts only really deal with the jowls, neck and cheek wrinkles and while a very good operation for these areas, it is often better to put some fat in around the mouth or eyes, perhaps add some resurfacing and certainly use botox for the upper face. In younger patients, I will often treat the eyes, lipo the neck and put some fat back in without doing a facelift. How do you know what will be best for you? The only way, really, is to consult with someone who knows.