Brow Lift

Brow, or forehead lift surgery is used to rejuvenate the forehead and eyebrows. It can also be performed for a receding hairline or a naturally high forehead.

If the lateral part of your eyebrows is too low, your whole face may have a tired, or even sad look and can also create the impression that there is superfluous skin on your upper eyelids.

Occasionally, depending on genetics, even young people may experience this problem. Brow lift surgery can be considered and will normally give you back a more youthful and pleasing brow shape and position.

• When the brow position is low, some people tend to raise their eyebrows, which leads to forehead lines.

• In addition, in many cases (particularly with younger patients) repositioning the eyebrow may refresh the appearance of your eyes without the need for eyelid surgery.

• Brow lift surgery also has the ability to address the frown muscles, and reduce the tendency that some people have to frown whilst they are focusing.

Your Brow Lift consultation

During your consultation, your surgeon will seek to determine the relationship between your upper eyelid, brow and the upper edge of the eye socket. Once this is clear, he will lift the lateral (outside) portion of your eyebrow to establish how much correction will be needed to place your brow in the ideal position.

• For women, this ideal position is between 5 millimetres and 1 centimetre above the rim of the eye socket for the lateral part of the brow.

• With men it has been found that raising the brow to the above measurements sometimes creates a feminine appearance, therefore the brow should be positioned at the rim of the eye socket or slightly above.

• For both men and women the inside corner of the eyebrows should sit either just below or just above the edge of the eye socket. Your surgeon should make this decision after he has taken measurements appropriate to you. In addition, he should evaluate the appearance of your upper eyelids. If significant excess skin would remain in the upper eyelid area even after brow lift, a combination of brow lift and upper lid lift may provide better results than either procedure alone. This is evaluated in the context of the forehead shape, as it will determine the type of procedure best suited for you.

What to expect from your operation

Brow, or forehead lift surgery is performed under a general anaesthetic and usually involves an overnight stay in hospital.
Historically, brow lift surgery involved a long cut across the scalp behind the hairline. This procedure, now termed an open or coronal operation, is much less common today, but may still be useful in certain cases.

Today, most brow lift surgery is performed through several small incisions in the hair behind the hairline. This procedure, known as the endoscopic brow lift, uses an endoscope (a tiny camera and light mounted on a tubular probe), which is inserted through these incisions. The camera images are magnified and displayed on a screen to guide the surgeon during the operation.

• During the surgery the tissues of the forehead are lifted from the bone and repositioned higher.

• Frown muscles may be weakened. (Generally they are not destroyed entirely as this could cause the position of the brows to change too much resulting in a startled appearance.)

• The skin is then supported in its new position with a variety of fixing techniques and the wounds are closed, most commonly with skin staples.

A more limited degree of brow lifting can also be done through the incisions made for an upper lid blepharoplasty (a procedure called browpexy), or through the incisions made at the upper part of a face lift (known as a temporal lift).

After your surgery

In the time after your surgery there are a number of things of which you should be aware.

• The staples used to close your incisions should be removed at your 7-10 day follow-up visit. Although anticipated by most patients with apprehension, removal of staples is usually a painless event, and staples have the advantage of protecting the hair follicles better than stitches.

• You will probably have some bruising around your forehead, therefore it is wise to limit vigorous activity.

• You may experience headaches for the first few days. Any discomfort you experience can be controlled by taking paracetamol or medication provided by your surgeon. It is important not to take aspirin or other anti-inflammatory medications as these can promote bleeding.

• In the first few weeks after surgery your eyelids may not close fully, which can lead to dryness and irritation of your eyes. Lubricants and eye moisturisers, like artificial tears, are useful to protect your eyes from drying out, particularly at night.

• The position of your eyebrows immediately after surgery will probably be a little higher than you had expected. This should correct over the first few months as everything settles down.

Risks

• The primary risk of brow lift surgery is decreased sensation in the forehead. This is usually temporary and is related to the stretching of, or injury to the nerves at the edge of the eye socket. If this persists for any length of time, you should contact your surgeon.

• There is also a relatively low risk of damage to the nerves that move the forehead, which can lead to asymmetry in the forehead lines and the position of the eyebrows.

• Rarely, there is reduced hair density around the incision lines. This is more common in people with fine hair and can usually be improved by scar revision.

Face Lift Surgery

Our faces age for many reasons. Heredity, gravity, sun exposure - these all play a role. A face lift is a procedure that is over 60 years old; it is intended to reverse the aging process by smoothing and redefining the contour of the neck and jaw line to create a younger, fresher appearance.

No other kind of cosmetic surgery allows the surgeon more creativity; and no other kind of surgery is more deeply personal for the patient.

Gravity pulls at soft facial tissues. In time our cheeks begin to sag, the crease running from the nostrils to the sides of the mouth (nasolabial fold) is accentuated, and our jaw line and chin lose their smooth, refined appearance. As we age we also lose some of our facial fat and our skin becomes less elastic, leading to wrinkling and sagging of our skin, which affects our features.

Sun exposure can be a major contributor to accelerated aging. People who live in climates where the sun is strongest often suffer from prematurely aged skin, irrespective of their ethnic characteristics.

Other factors, such as smoking and drinking alcohol, especially if done to excess from a young age, can speed up the ageing process.

Years of research, and the cumulative experience of surgeons, have led to an increasingly sophisticated understanding of the ageing process and the more subtle elements in the anatomy of the face. From this, techniques have developed to restore a more naturally youthful appearance.

A face lift can help refresh your appearance, but it will not erase permanent creases, particularly those around your mouth. There are additional procedures like dermabrasion, laser resurfacing and chemical peels which can diminish those lines and can be performed at the same time as your face lift.

Your consultation

When you meet with your surgeon, you have an opportunity to receive information and ask any questions about the results you would like to achieve. Your surgeon should tell you what will happen during your surgery and help design a procedure that meets your individual needs. It is often helpful to bring a photograph of yourself when you considered you looked your best.

Your surgeon should take a detailed medical history and ask about any previous facial surgery you may have had. If you are a smoker, please discuss this with your surgeon as it may delay healing and affect your recovery.

He may also speak about normal differences in your facial symmetry, some of which you may have never noticed previously. Your surgeon will, in all likelihood, gently manipulate your facial skin. This performs a dual purpose; assessment of your skin and to show you the type of result you may expect after surgery. You should receive a comprehensive explanation of the other effects of your facial surgery, namely that the position of your hair in front of your ear may be a little higher. For men the beard area may move so that it is slightly under and behind the ear, necessitating shaving in that area.

He should discuss with you the risks, which may include scarring, bleeding and infection.

Your surgeon may also explain about procedures that can be used to improve the overall results of face lift surgery. These can all be tailored to meet your individual needs and include; deep (SMAS) lifts; chin fat removal and; remodeling of the neck muscles.
In addition, there are additional procedures that can be done at the time of your face lift, such as:

• Blepharoplasty - this is reduction of loose skin around the eye
• Forehead lift
• The use of fat from other parts of your body to plump up particular areas in your face
• Midface endoscopic lifts for more definition of the cheekbone area

In most cases your face lift will be done under general anaesthetic and you will spend the following night in the hospital or clinic.
Once you are comfortably asleep, the surgeon will make an incision that starts high in the temple area that is, at this point, hidden by the hair, following the curves in front of the top and bottom of the ear and behind the middle part (tragus). The incision then continues round the earlobe and up behind the ear, it will then curve softly back into the hairline.

In some cases a second incision in made under the chin where it will also be well hidden. Its purpose is to assist with definition of the chin and neck.

Using these incisions on both sides of the face, the skin, fat and muscle is remodelled. The incisions are closed with stitches in front of the ear and metal clips in the hair. Small drainage tubes are inserted under the skin during the operation and are removed several days after your surgery. These help to minimise bruising and swelling around the face and neck so that you may return to work and resume your normal social activities without too much delay. Some surgeons also apply a light bandage around your head at the end of the surgery.

The day after your surgery

Your bandages will be removed the morning after surgery and your surgeon will check that everything is all right. After that, your hair may be washed and you will be able to go home. You should receive a complete list of post-operative care instructions before you leave the hospital and advice such as:

• The importance of not engaging in overly vigorous activity for a few days after surgery, as this will help to prevent post-operative bleeding;
• Aspirin should be avoided. If you do experience any pain or discomfort a mild analgesic such as Paracetamol can be taken;
• Washing of your hair is fine with a mild shampoo (such as baby shampoo), making sure that you do not disturb the suture area.

In the week after surgery

As you continue to convalesce, you can expect that:

• Your sutures will usually be removed around seven days after surgery. It is advisable not to apply any hair colour for four weeks following surgery due to the strong chemicals like bleach or ammonia in the product;
• Your scars will usually be very faint at first, but usually these thicken and redden for a few months after your surgery before they return to a more natural skin colour and texture;
• It is normal to experience some bruising, swelling and numbness after a face lift. These symptoms are temporary and should mostly disappear after two weeks. Numbness sometimes takes longer to go. It may be present for up to a month in the cheek area and three to four months for the underside of the chin.

To help lessen post-operative bruising, arnica may be taken for one week prior to surgery and two weeks after. Products such as arnica cream may also be useful to reduce and clear the bruises more quickly.

Possible complications

Bleeding, infection (<1% risk), damage to the facial nerves producing weakness/paralysis/numbness, abnormal facial contour, visible scars/heavy scarring, haematoma (3-4% risk), adverse drug reactions, early relapse, damage to the ear and ear canal, skin breakdown (necrosis), delayed wound healing, and a tight face.

As a whole, facelift procedures are carried out without any adverse effects but any surgery has some risks. Some of the complications associated with facelifts may require further surgery and some may cause permanent scarring, deformity, and discomfort. Your risks are always minimised if you ensure your surgeon is a certified consultant plastic surgeon who is experienced in facelift surgery.

Facelift scars

All surgical scars are permanent however, the incisions will be placed discretely so that they will not be noticed other than by very close inspection. The usual incision placement is running along the natural contours of the ear, extending into the hairline.

Nose Surgery

This is a surgical procedure to reshape the nose and is also one of the most popular procedures with men and women. There are 2 different types of procedure.

Most people considering rhinoplasty want to bring the size and shape of their nose into better balance with their face. Many have been teased about their noses since they were children, and are eager to correct what they consider to be an embarrassment, and better compliments their appearance rather than dominating it.

• Closed rhinoplasty - With this procedure the incisions should be placed inside the nostrils, so that there are no external scars, unless the size of the nostrils is also reduced (alar base reduction.) In this situation, there may be small scars in the furrow between the nostril and the lip. If the tip of the nose requires considerable reshaping, a small scar under the midline of the nose may also be necessary.

• Open rhinoplasty - In addition to the incisions inside the nostrils, there is a small incision placed on the columella (the small bridge of skin between the nostrils.) Some surgeons may prefer this approach because it gives them greater control if intricate reshaping of the cartilage in the tip of the nose is required. Some surgeons may use computer simulation in the preparation for surgery. This generally leads to greater accuracy of the planning process.

Your consultation

During your consultation, your surgeon should take a general medical history and ask about any previous surgery or injury to your nose. He should also want to know how well you are able to breathe through your nose.

He should be interested in why you are unhappy with your nose and what results you are hoping to achieve.

• It is very important that you are honest with your surgeon about what kind of nose you would like. People sometimes fail to describe their true expectations, but in reality have a specific size and shape in mind. Only by telling your surgeon exactly what you want can you and he determine whether it is possible and desirable.

• At the same time, you need to be aware that everyone is different and what may work well for one person may not work well for another. As skin thickness varies enormously a small, delicate nose can rarely be made from a large, thickened one.

• Feel free to bring photographs of noses you admire.

• Your surgeon may also use computer simulations to help you see what changes are feasible and what they would look like. These simulations can often help patients describe the results they want and the changes they would like to avoid. You need to be aware that computer simulation is not a guarantee of the result, as each person has their own healing pattern.

Types of rhinoplasty

Reduction Rhinoplasty - This is usually the kind of rhinoplasty most commonly requested by both men and women. It is worth bearing in mind that simply reducing the size of the nose may not always produce a positive outcome.

• It is important to appreciate that if chin projection is insufficient, the profile may seem to be dominated by a small or average nose. In this instance the solution may be to augment the chin and not to reduce the nose at all, or to do a small reduction only.

• In a significant reduction procedure, all elements of the nose are influenced, and the skin will take more time to redrape and settle down fully.

Augmentation rhinoplasty (ethnic rhinoplasty) - This is a procedure that involves increasing the projection of the bridge and the tip of the nose and is more commonly requested by patients from ethnic groups that have a less defined bridge. It may also be necessary for patients that have undergone significant injuries, or multiple procedures.

• Materials used to support the tip and augment the bridge may be artificial, or can be taken from the patient, i.e. cartilage or bone.

• Sometimes implants are used, but these unfortunately carry higher risks from infection and the need for revisional surgery.

Secondary or revision rhinoplasty - Sometimes the outcome is unsatisfactory. This could be due to surgical errors, healing problems, or injuries after the first operation. In other instances this could be due to a lack of communication between yourself and your surgeon.

In all these cases repeat surgery requires an experienced and dedicated surgeon, as well as an understanding of the type of changes that the first operation would have created. Revision rhinoplasty often involves use of grafts, commonly cartilage from inside the nose but also from other areas (rib, ear), and will often require a longer period of time to settle down.

Achieving a good result from rhinoplasty is dependant on thinking through your needs and communication with your surgeon. It is better to have more than one consultation rather than embark on costly surgery without being certain of the outcome.

What to expect from your operation

Rhinoplasty is typically carried out under general anaesthesia.

• The first step is the removal of any hump to provide a new profile.

• It is usually necessary to fracture the nasal bones in a carefully controlled way to allow them to meet at the midline and form a narrow bridge line.

• The cartilage that shapes the tip of the nose is adjusted in size and shape.

• When surgery is complete, small dissolving stitches are placed inside the nostrils and tapes and a plaster cast are applied.

• A small plaster cast is required for seven days to support and protect the bones while they set in their new position.

In some cases it may be necessary to implant tissue into the nose (a graft) to get the desired result. Usually tissue is taken from the nose or from cartilage in the ear, or occasionally the ribs or synthetic materials. As the risk of infection is slightly higher with man made materials, antibiotics should be prescribed.

Frequently, internal silicone rubber splints are used to ensure the lining of the nose sets correctly. This means you will probably need to breathe through your mouth until their removal around 1 week after surgery. This technique is more common in the correction of significant nasal deviation.

In any event, your nose may feel blocked up and be swollen post-operatively, therefore you will probably be unable to breathe through it fully. If the breathing passages have been operated on, it may take some time for the nose to clear.

After surgery

Because your nasal bones will have been re-set, you will probably have “black eyes” after surgery and your face may be swollen. This should settle within 2 weeks. Makeup may be used to hide the bruising when your dressings have been removed.
Any pain you experience can be relieved by your surgeon with an injection. Once you go home, mild pain killers such as paracetamol are fine.

After surgery you should be advised to:-

• Avoid aspirin for the next few weeks whilst healing, as it can promote bleeding.

• Avoid stooping or vigorous activity for 2 or 3 days to reduce the risk of a nosebleed.

• Avoid blowing your nose for 10 days after surgery. Any mucus, clots, or other obstructions may be loosened and removed with a little water, or Vaseline on a cotton bud, but do ensure that this is done very gently.

• Arnica may be taken for 1 week prior to your surgery and for 2 weeks after surgery. This can help reduce the swelling and bruising.

Over the following months

• Once the cast is removed the healing process will take at least 6 months. During this time your nose should settle as scar tissue forms and internal scars gradually change their shape as they mature. Generally, the thicker the nasal skin the longer the period of scar maturation. This process can sometimes be accelerated with small injections of anti-inflammatory steroid in the tip of the nose. All of these factors may have an effect on the final shape.

• If you have chosen an alar-base reduction, your sutures will usually be removed at 1 week. The scars may be a little red, but should be hidden in the natural shadows of the nose.

• The tip of your nose may feel a little numb, but full sensation should return as the nerve supply regenerates.

• You can gauge the progress of the healing process by gently squeezing the tip of a normal nose, then squeezing yours to compare the firmness.

• Very occasionally, a blind boil type of infection may occur in the nose tip. This can be treated with antibiotics.

• Significant bleeding is rare and is usually caused by infection. If this occurs, contact your surgeon.

Do not rush things

It is important to be patient. The final result of your surgery will not be properly visible for at least 6 weeks, and will take more than 6 months to settle completely.

In around 10% of cases, after the 6 months have passed, it is concluded by both the patient and surgeon that the shape of the nose is not quite what was intended. This problem is most common in cases where the patient has had a severe injury or a very large reduction in the size of the nose and a second procedure may be necessary.

Possible complications

Abnormal shape to the nose, problems with airflow through the nose, need for corrective surgery, bleeding (may require a nasal pack to control), nasal septum haematoma/perforation, infection (<1% risk), nerve damage with possible numbness, asymmetry, change in skin colour, skin loss (necrosis), prominent scars, loss of smell, extrusion (of implants), reaction to medications, loss of structural support to the nose, toxic shock syndrome, and internal nasal adhesions/scars.

It is important to realise that very few people who have a rhinoplasty by a reputable consultant plastic surgeon have any complications, and those that do occur usually only suffer minor problems. But all surgery does have some risk and you should reduce your risk of complications by closely following your surgeon's instructions, both before and after your surgery.

Bleeding

There may be some minor bleeding for up to a month after surgery. One should resist the temptation to blow or pick at the nose.

Alteration in skin colour

Following rhinoplasty there may be some small blood vessels under the skin that burst and appear as tiny red spots on the skin's surface. The area affected is usually small and the problem usually resolves spontaneously, but rarely are the changes permanent.

Abnormal shape

There are many factors that may influence the final shape of the nose, it is possible for the surgeon to create a shape you are not happy with, there may be trauma to the nose such as knocking yourself whilst sleeping, the dressings applied may not provide adequate support, as well as a multitude of other factors that are outside of our control.

Wound infection

Infections are rare following rhinoplasty, although the use of any implants increases your risk. Infections may require further surgery but are usually treatable by antibiotics alone. 

Smoking risks

Smoking significantly reduces the ability of your body to deliver oxygen to your tissues and this means that there is a much higher risk of complications. Skin necrosis (skin death) is 1500% more likely in smokers and there are much higher rates of delayed healing and infection as well. You should try to stop smoking at least 4 weeks before and after your rhinoplasty.

Toxic shock syndrome

This is a very rare condition that occurs in only 0.016% of rhinoplasty cases. However if it does occur it is a serious condition that may be fatal. Symptoms include a high temperature, vomiting, diarrhoea, and a widespread sunburn-like rash.

Rhinoplasty scars

Surgical scars are permanent but if you are having a closed procedure all of the scarring will be hidden inside the nose. If however you have an open procedure, you will have small scars on the base of your nose (between the nostrils). These scars fade with time and are usually not noticeable to others. 

 

Eyelid Surgery (Blepharoplasty)

What is eyelid surgery?

Eye bag and eyelid surgery, or blepharoplasty, is a popular and commonly undertaken procedure that can lift droopy upper lids and reduce puffiness of bags under the eyes by removing excess skin and improving smoothness and contours.

Why choose eye bag removal treatment?

Your eyes are probably the most important part of your face. They are the first thing that most people notice when they look at you, and offer a central focus point when we talk to one another. The appearance of your eyes, and the surrounding areas, often provide an insight into your age, and can have an effect on your vitality and attractiveness.

Over the course of your life, many factors can contribute to the condition of your eyes, eye bag or eye lid. Ageing, gravity, sun damage, muscle weakening and stress can result in puffiness, bags and folds, and wrinkles. These effects can often cause an unnaturally tired appearance, or make you look older than you are. This can lead to a loss of confidence and embarrassment. Eye bag and eye lid surgery in the UK offers a satisfying remedy for these symptoms and can greatly improve one’s self image.

Is blepharoplasty right for me?

If you are considering having eye bag removal treatment, then it’s very important to book a consultation with an accredited and highly experienced surgeon. A top surgeon knows that over-zealous removal of excess fat from the upper eyelid can sometimes lead to a hollow, doll-like appearance. He or she should also understand that a youthful appearance is not achieved simply by removing the bags, but from a complex reduction of volume and redraping of tissues that restores a smoother contour between the cheek and the lower eyelid. The surgeon must also be aware that totally eradicating all eyelid creases would result in excess tension on the eyelids, and would be an overcorrection.

Once you have found a suitable surgeon, and have communicated your needs honestly with him or her, you are then able to effectively formulate achievable and realistic goals. The surgeon will assess which technique is best suited for your individual case, and proceed from there.

It’s now possible to lift and support the lateral part of the eyebrow using an upper eyelid procedure, combining a forehead lift and an upper lid blepharoplasty in a smaller procedure. Additionally, it’s sometimes possible to reduce frown lines between the eyebrows during an upper eye lid blepharoplasty by accessing and weakening the muscles that cause the lines.

What does eyelid surgery involve?

Upper eyelid surgery involves an incision made roughly one centimetre above your eyelash in the natural crease line, and extending out to the crow’s feet area. The surgeon then trims excess skin and removes unwanted fat, before closing the area with fine sutures.

Lower lid surgery involves an incision below the eyelashes and out to the laughter lines or crow’s feet. The skin is elevated and any excess fat or tissue is removed or redraped, and the cheek is often carefully lifted for optimal results. The skin is then lifted upwards and outwards to make sure there is sufficient tension in the area before the incisions are sewn.

In certain cases a procedure known as transconjunctival blepharoplasty can be performed on the lower lid. This allows contouring of the lower lids and the circles beneath the eyes without leaving any external scars. This technique can be accompanied by resurfacing of the lower eyelid using a laser or chemical peel.

What happens after eyelid surgery?

You may experience various forms of discomfort after surgery. There may be swelling or bruising, but this should go within 2 weeks. Painkillers can be prescribed to manage symptoms, but aspirin should be avoided as it can promote bleeding.

Sometimes patients experience abnormal skin pigmentation on the eyelid or excess tears, but these are normally temporary conditions, and you should be advised about precautions.

You should apply antibiotic eye ointment for three or four days, and should avoid makeup for the first couple of weeks.

You may experience difficulties in closing your eyes, but this is normally temporary and can be managed with eye drops.

Large sunglasses should be worn after your procedure, and contact lenses are prohibited for some time.

It’s beneficial to avoid stooping or doing strenuous activity for five days as this reduces the risk of bleeding.

It’s best to sleep in a semi-reclined position at night as this reduces the tendency for retention of facial fluids and excess swelling.

Are this any complications or risks?

No surgery is completely safe, and eye bag removal for upper and lower lids can result in certain complications. Infection and bleeding can sometimes occur, and these can usually be dealt with by using antibiotics and drains. Other complications include:

• Corneal abrasion. This is a scratch on the eyeball’s surface leading to a gritty sensation. It can be treated with eyedrops.
• Double vision. Occurs in less than 1% of cases.
• Milia. These are small cysts that sometimes form along the scar lines. They may disappear of their own accord, but sometimes require surgery.
• Dry Eye Syndrome. This can potentially cause damage to the cornea and lead to impairment of vision, but is very rare and should be treatable with eye drops.
• Retrobulbar haematoma. An extremely rare complication where a blood clot forms behind the eyeball, requiring further surgery. If this complication isn’t treated it can threaten your sight.
• Blindness. Permanent blindness following surgery is extremely rare: less than 1 incident in 10, 000 cases. The common cause is bleeding following fat removal from the eyelid. Blurred vision is seen in less than 1% of cases and is usually a temporary problem.