“Lifting” is the new catchword, from highly skilled plastic surgeons to the purveyors of supermarket body lotions. Verne Maree talks with some of our most popular aesthetic doctors to get the real story.
It used to be clear what a facelift was: a surgical operation under anaesthesia that made incisions near the hairline, then pulled back and excised loose skin to take ten years off your face. Then came the revolutionary promise of upliftment through minimally or non-invasive modalities – Botox, laser, radiofrequency (RF), ultrasound and more. And now, to confuse us still further, many cosmetic brands have topical lotions and potions that purport to lift your skin – even old Nivea is on the bandwagon.
Most of all, a facelift was something that I knew I would never think of doing. Until I fell in love with Joan Rivers, that is. Chief Constable of the Fashion Police and perhaps the rudest woman in the world, she’s famous for being immoderately lifted, nipped and tucked, and looks fabulous – though she turns 80 this month.
Cost: From $20,000 to $28,000
Downtime: About two weeks
Duration of effect: Lasting
Plastic surgeon Dr Wong Chin Ho did his fellowship in facelifting, and lifts a lot of faces – who better to answer my questions? As it happens, he’s just done a great job of removing three small growths from my face (the legacy of sun damage in my foolish youth), so I’ve had personal experience of his incredibly fine stitching technique.
How would you describe your approach?
WCH: The decision to have a facelift might be one of the most significant decisions that you will make, and many patients instinctively know when the time has come for them.
I like to put things into perspective and to be clear about what is possible in terms of the degree of improvement that can be achieved, given his or her individual skin quality, skeletal structure and the severity of ageing-related changes.
Very good results can be achieved for Caucasian skin: it’s lighter, thinner and more delicate than Asian skin, so we can drape it more effectively. And when the correct technique is applied, facelifts can also be profoundly beneficial for Asians.
Who is a good candidate for a facelift?
WCH: Someone who is looking for a profound rejuvenation. But if you’re not keen on surgery and will be satisfied with a very subtle result, non-invasive techniques like Thermage and Ulthera can tighten and rejuvenate the skin to some extent.
Non-invasive methods don’t work for the jowls, as you can see by manually lifting your own cheeks: there’s excess skin above it, and that needs to be removed.
To remove sagging jowls and really get a fresh appearance, however, takes a surgical facelift. Ageing is not just a question of sagging, either; there’s also an issue of facial shape. The youthful shape is triangular or heart-shaped; now, with jowls appearing, it becomes square-ish.
What sort of facelift do you perform?
WCH: I do what is called a deep-plane or composite facelift, which addresses both the skin layer and the layer below it. From my pictures, you can see that it gives a completely natural result – these women simply look like their younger selves.
Because the tightening is done in the support layer of the skin, rather than in the skin itself, we avoid the stigmata of a traditional facelift – that wind-tunnel look. Now, with our better understanding of the anatomy of the face, we are able to achieve much better results.
Who developed the deep-plane facelift?
WCH: The deep-plane facelift was first described over 20 years ago by Dr Sam Hamra in Dallas, who achieved superb results. In those days, however, the technique was not popular, because it was considered dangerous: it works at the deeper plane where you find the facial nerves, so there’s a real risk of nerve injury.
The pioneer in the understanding of facial anatomy, who is also my mentor, is Dr Brian Mendelssohn from Melbourne, Australia. Together, he and I contributed a chapter on Facial Soft Tissue Spaces for the third edition of Neligan’s important Plastic Surgery Principles.
With this understanding, we can get into those facial spaces safely with minimal risk to the patient. The risk of nerve injury associated with the new, improved composite technique is the same as it is with other facelift techniques: one to two percent. The result is more natural and the effect is more long-lasting.
In my experience, it has been a real advance for Asian patients, who tend to have thicker, heavier skin that the traditional facelift is less effective in lifting.
To the point: What would you recommend for me?
WCH: You look very good for your age, and you’re lucky to have hardly any eye bags. You have a great skeletal structure and a good jawline and cheekbones, so you would achieve a great result with the composite facelift. I would recommend the full facelift – and for you, we could use the short scar technique.
Another component of ageing is deflation; to restore volume around the eyes and the forehead, I would harvest some fat from elsewhere on the body, and graft it into the sunken areas to revolumise them. This “lift and fill” approach is the essence of the modern facelift.
When is the right time to have a facelift?
WCH: If you have it done while your skin is still in good condition – before you obviously need a lift – you will achieve the best results. Once ageing is advanced, it’s more difficult to get a great outcome.
Only the patient knows when the time is right. Often, her decision is triggered by a life event such as a daughter getting married, or perhaps the death of a spouse. I always say that the main purpose of this surgery is not to please the eye, but to uplift the soul.
Cost: $3,500 to $6,000
Downtime: From one to two weeks; normal activities can be resumed after a day
Duration of effect: About 2 years
Call it vanity, but it can be heartbreaking to see a permanently tired-looking, lined face that does not reflect who you are or how you feel. Dr Donald Ng is my next port of call. He concentrates on non-surgical or minimally invasive face-lifts – for those who prefer not to go under the knife.
Apart from a surgical facelift, what’s the next most effective lifting procedure?
DN: Fortunately, there’s a whole range of possible options for lifting and tightening. Many patients are OK with injections or even small incisions, as long as they will not be visible afterwards. For them, there has to be almost no risk of scarring; this is especially true for Asians, as our skin is much more prone to visible scarring than a Caucasian’s.
I’ve been doing thread-lifts with good success for the past eight years. The analogy I use is that of a building with concrete walls. Like concrete is reinforced with a network of steel mesh and bars, so the skin is supported with threads that the surgeon introduces into the subcutaneous level, just above the SMAS (or superficial muscular aponeurotic system).
No cutting is involved: we use a long needle to feed the threads through. By using a combination of the several types of threads that are now available, we can achieve dramatic results, especially when we do this in conjunction with fillers.
What do threads look like and how do they work?
DN: There are two basic types. Firstly, anchoring threads that secure the tissues with either barbs, cones or knots. Anchoring threads can be either free-lying, or they can be attached to an area above the ear or temple, from where the lifted tissues are suspended.
Secondly, smooth embedding threads don’t anchor the tissue, but work to stimulate the production of collagen around them. Very popular, they’re known as PDO threads and come from Korea.
How is it done?
DN: A thread-lift is generally very simple to perform and complications are rare. Results are immediate and can be rather dramatic, though the effect is natural.
The key thing is to choose a doctor who is familiar with the different types of threads and the various brands – and one who has a lot of experience in this particular procedure. Though it’s fairly simple, an experienced doctor will have the detailed knowledge to ensure a good result.
Can fillers help to lift the face?
DN: They don’t actually lift; the effect is more that of filling an empty balloon. We use them on areas of the face that have lost volume, especially around the eyes and upper cheeks. This happens more to Caucasians, who have thinner skins and can become quite skeletonised around the eyes.
There’s a range of materials that can be used, including fat grafted from the patient’s own body. Fat is very soft, so injected correctly and in the right amounts – tiny little rice grains – it works well and looks natural. You may lose 30 to 40 percent of the fat filler over time, but most of what is injected will be retained; and as the fat has its own stem cells, it improves the quality of the skin in the area that is treated.
Cosmetic fillers such as Juvederm and Restylane can be either temporary or permanent. Temporary ones are usually used for the cheeks, temples or forehead; for around the eyes and in the tear troughs where the skin is very thin, we use the softest possible AHA (alpha hydroxy acid) type. Permanent types are thicker and are reserved for the nose and chin.
Sculptra is something different again. Instead of providing direct volume, it delivers a chemical into the skin to stimulate collagen production, plumping the skin over time and causing a subtle lifting effect.
How would you describe your approach?
DN: My approach is to look at each patient to assess what can be done to restore her facial appearance to what I think it was like ten years ago. Apart from threads and fillers, I draw on a wide range of other modalities to achieve that goal.
These include laser; radiofrequency (RF) such as Thermage; or ultrasound such as Ulthera; delivered by means of non-invasive devices placed directly on the surface of the skin. As the already huge market for non-invasive technology grows, the industry is moving ever closer to the golden aim: achieving an excellent result with minimal pain and little downtime.
I firmly believe that you can’t just be a “thread doctor” or a “filler doctor”; the best results are achieved by calling on the wide range of technologies available and using them in conjunction with one another according to the patient’s needs and desires.
My suggested treatment will depend on many things: firstly, what the patient feels she or he needs, and the areas I believe I can improve; secondly, their openness to undergo particular procedures; and thirdly, what they are prepared to spend.
Understanding the patient’s expectations is of paramount importance, and so is the level of trust between you.
THE BOTOX LIFT
Cost: $700 to $1,200, depending on extent
Duration: 4 months
Administered by injection, our best friend, Botox, falls squarely into the minimally invasive category. It’s not a permanent fix, but that’s an advantage in a way: if you don’t like its brow- and eye-lifting effect, you don’t have to live with it for too long.
How long does it last for? In my experience, a good four months, and perhaps one or two more as a bonus.
I’ve never actually regretted a Botox session, but be warned that each doctor has his or her own style and technique. Quite frankly, some are much better than others. As the gentle, excellent and thorough Dr Anita Soosay told me, while sharpening her needles, it’s as much an art as it is a science.
It’s not easy to understand how partially paralysing facial muscles can achieve a tightening effect: you’d think that it would have the opposite effect, wouldn’t you?
I’ve experienced the brow-lifting effect of judiciously administered Botox – but how does it actually work?
AS: Your face has some muscles that pull upwards and others that pull downwards. Botox contains a neurotoxin called botulinum. By injecting small amounts of it into the downward-pulling muscles, we prevent them from working so well, thus allowing the upward-pulling muscles to do their job far better.
On the forehead, the down muscles are located in an inverted pyramid from the hairline of the brow. That enables the upward-pulling muscles above each eyebrow to work more effectively, opening the eye-space beautifully.
What about the eyes?
AS: It’s the same principle: we can relax the muscles associated with the lines radiating from the outer corners, or crow’s feet, which achieves a lifting effect. I also inject from the edge of the eyebrow all around the eye.
For eyelids that are no longer as firm as they used to be, I inject into the muscles directly under the eyebrows that drag the eyelids down; this slightly lifts the lids, opening up the eye area and allowing you to apply your eye shadow properly again. And a tiny injection under each eye helps to obviate any under-eye creases that may be caused by smoothing out your crow’s feet.
That’s the clearest explanation I’ve ever heard. Just how complex is the muscle system of the face?
AS: It’s fairly complicated, but once you’ve studied and comprehended the anatomy of the face, administering Botox is straightforward. In time, and the more cases you do, the more you are able to analyse different faces and assess each one’s specific needs.
It’s vital to use the right amounts, though; I’ve had patients coming to me with unwanted side effects, such as drooping or over-arched brows, after being treated by other doctors.
I make sure not to use too much, especially for a new patient. I prefer to top up if necessary at our three-week follow-up session.
What’s this horizontal line across the top of my nose? Can you get rid of it?
AS: We call that the bunny-scrunch, caused by wrinkling up your nose. I can soften it for you by injecting a bit of Botox on either side of the nose; but because it’s become a static (permanent) line as opposed to a dynamic line (apparent only when you move your face), a bit of filler would be the way to get rid of it.
What about the lower face?
I don’t perform Botox on the lower face, because that would affect your smile. If you can’t smile fully and widely, you will feel weird and you won’t look like yourself. Fillers are good for any deep lines around the mouth and the naso-labial lines.
Your own face is flawless. Do you practise what you preach?
AS: Yes, I use both Botox and fillers, because I believe they’re a good way to prevent the signs of ageing. If we start treating dynamic lines early enough, we can prevent them from becoming entrenched and permanent.
I’m not a fan of invasive procedures, though. I tend to advise patients to go for the non-invasive or minimally invasive options for as long as they can. There’s almost no risk associate with these treatments, and they’re completely reversible through the passage of time.
In closing, how much of a lifting effect can be achieved with purely topical products? I’ve been using Strivectin each night for the past few months, and I do feel it’s done my skin good – it feels stronger, more resilient.
AS: Peptide-containing formulations such as Strivectin are super-effective moisturisers. Being protein particles that are small enough to penetrate the dermis, peptides plump up the skin cells by increasing their moisture content – so you can expect a very slight lifting effect. It may not give you long-term benefits, though, unless you use it every day.
It’s also been claimed that you can apply hyaluronic acid topically to achieve a lifting effect, but I’m not sure that actually works. In the same way, I don’t believe that micro-Botox – many tiny injections of dilute Botox into the dermis – has any kind of lasting effect beyond a temporary plumping action.
I only perform procedures that I am fully convinced are effective and worth doing, ones that I would happily perform on my sister or on my mum.
After 48 hours, my crow’s feet are greatly diminished, my brow is smoother and – best of all – I can clearly see the lifting effect around my eyes and forehead. Is Botox addictive? You bet!
THE PANEL’s DETAILS…
Dr Wong Chin
W Aesthetic Plastic Surgery
38 Irrawaddy Road
#08-42 Mount Elizabeth Novena Specialist Center
6570 2528 | waesthetics.com
Dr Donald Ng
Alaxis Medical and Aesthetic Surgery
360 Orchard Road
#04-02 International Building
6235 0880 | alaxis.com.sg
Dr Anita Soosay
The Aesthetics Centre
1 Kim Seng Promenade
#03-15 Great World City
6820 3308 | anitasoosay.com
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