Surgical Services

Meloplasty - Face Lift

We are all affected by ageing - that irreversible relentless process of tissue degeneration which results in the loss of elasticity and stretching of skin, its supporting suspensory ligaments and underlying soft tissues.

The rate of this ageing process varies from individual to individual and depends on the person's genetically determined constitutional clock. It is hastened by the effects of sun exposure (photoageing), smoking and the stresses of daily life. Because of gravity, it is uaually first noted by fine lines which go on to form wrinkles and then furrows in the forehead, about the eyes, lips and mouth. Bags develop about the eyes, deep creases form between the nose and mouth, and jowls with loose skin appear along the jawline and into the neck. Folds and fat deposits develop in the neck. The result - "a tired old depressed look".

What Is Ageing?

We are all affected by ageing - that irreversible relentless process of tissue degeneration which results in the loss of elasticity and stretching of the skin, its supporting suspensory ligaments and the underlying soft tissues.

The rate of this ageing process varies from individual to individual and depends on the person's genetically determined constitutional clock. It is hastened by the effects of sun exposure (photoageing), smoking and the stresses of daily life. Because of gravity, it is usually first noted by fine lines which go on to form wrinkles and then furrows in the forehead, about the eyes, lips and mouth. Bags develop about the eyes, deep creases form between the nose and mouth, and jowls with loose skin appear along the jawline and into the neck. Folds and fat deposits develop in the neck. The result - "a tired old depressed look."

What Can Be Done?

There is nothing magical about cosmetic surgery - it cannot stop the ageing process. It cannot turn the clock back to make you look twenty-one, but it can reset the clock and improve the most visible signs of ageing. It does this by removing excess fat, tightening underlying muscles and redraping the skin of your face and neck by a facelift (technically known as a meloplasty or rhytidoplasty).

Patients often say "I want a facelift but I don't want to change." The modern facelift (which is submuscular rather than subcutaneous) can accomplish either a change in appearance or the more common desired effect of a fresh rejuvenated look without alteration in the normal expression of the face.

The aim of cosmetic surgery is to make you look as good as possible and there are many available procedures to accomplish an individual patient's needs. In other words, cosmetic surgery is tailored to the individual. Commonly used techniques include the standard facelift which addresses the lower two thirds of the face and upper neck (as shown below). It can be specifically directed towards the correction of facial muscle and supporting ligament laxity or minimised (as in the S-lift or MACS lift) to remove a small amount of loose skin and correct early jowl formation. The facelift is often combined with an ancillary procedure such as eyelid surgery, a forehead or brow lift, lip lift or augmentation , suction liposculpture to remove fat (especially in the upper neck), nose reshaping, removal of skin blemishes, dermabrasion or chemical peel treatment of the skin or laser resurfacing of various areas. These surgical combinations can be performed in one or more stages.

Dr Olbourne will advise you of any combination procedures which may be relevant in your particular case.

What Is Done?

The original facelift as described over 40 years ago involved incisions placed inconspicuously in the hair of the temple and in the scalp behind the ear, as well as in the creaselines in front of, around and behind the ear. The skin of the temple, cheek and neck was undercut and pulled back, trimming off the excess before closing the incisions with sutures. The tighter the skin was pulled back the tighter and more mask-like the facelift. But being an elastic material, we were aware that the skin would stretch and become loose again. So a degree of over correction was built in to the surgical procedure. This often produced an unnatural "parchment like" appearance as the tension was taken fully by the skin. The tension was also more likely to result in thickened (hypertrophic) scars and the result - relying only on skin tension-was not long lasting.

The skin is undermined or lifted from the muscle layer.

To produce a more natural look with better quality scars and to avoid an excess of skin tension, newer techniques have evolved over recent years. These use similar skin incisions, but involve the dissection and tightening of the suspensory supporting soft tissue structures of the face and neck - the SMAS*, Superficial Musculo-Aponeurotic System and the muscles of the eyelids (orbicularis), face (zygomaticus), and neck (platysma).

The muscle layer (SMAS) is tightened in the direction shown to enhance the immediate and long term result.

Skin is redraped (with little tension) over the tightened muscle layer in direction shown. Excess skin is removed and sutured into position.

A consumer demand for even less invasive procedures has led to the development of the S-lift or MACS*, Minimal Access Cranial Suspension type of procedure. These operations have application in younger patients without neck pathology and result in shorter scars and more rapid recovery. If applicable, Dr Olbourne will discuss them with you and give you procedure specific information to consider. Recent developments involve endoscopic techniques, where part of the face and browlift can be performed endoscopically - almost by remote control-using special instruments and a magnifying telescope-cum-TV camera. Because the incisions can be far from the site of operation - and can be keyhole in size - the scars are very much smaller and less obtrusive. However endoscopic procedures are often attended by more swelling and a longer recovery than more traditional methods. Dr Olbourne will discuss the relative merits with you.

Fatty tissue, especially in the neck, can be removed by direct excision through a small transverse incision under the chin, or by very strong suction applied to an instrument which is passed back and forward through the fat under the skin - suction assisted liposculpture. This leaves a small unobtrusive scar in a fold beneath the chin.

In the SMAS procedure, the deeper supporting structures of the face and neck are tightened and the skin is gently redraped to give a natural, fresh, rejuvenated appearance with normal facial expression and a smooth jawline without jowls. The excessive fatty tissue is removed, restoring the neck contour to a youthful look. A major advantage of these newer techniques is a longer lasting result due to the tightening of the deep supporting structures of the face and neck. Because the skin is not subject to the same degree of tension, scarring is inevitably less obvious. However, these procedures require a high degree of specialised surgical skill and take much longer to perform. With the deeper SMAS dissection, the facial nerve (responsible for facial expression) maybe involved and extra caution is required. However, it is Dr Olbourne's opinion that the SMAS procedure is the gold standard that should be offered in modern face-lifting because of the numerous benefits this operation affords the patient. The lesser lifts such as the MACS lift have generally more specific application in younger patients without neck pathology. You should ask for more information about them if you are inclined towards this type of procedure.

How Can I Expect To Look?

If you stand in front of a mirror and lightly pull the skin upwards and backwards in the temples and in front of the ears, you will get an indication of what a facelift can achieve.

We aim for a harmonious, well-rested, fresh look from forehead to neck whilst maintaining normal facial expression. A facelift and ancillary procedures will achieve this. But not all wrinkles, furrows and folds will disappear - especially if they have been long-standing and permanent skin damage has occurred over the years.

A commonly held misconception is that cosmetic surgery is magical and not real surgery. This is of course, not true. You cannot expect to have a facelift and look and feel normal overnight. It is safe to plan about three weeks of social hibernation after the procedure, although many patients resume full activities within a fortnight. The amount of swelling and bruising varies and is maximal in the first 3-4 days. It gradually settles over the next 2-3 weeks with the blue to yellow skin staining of bruising occurring in this time. Make-up is a marvellous invention . Coupled with the fact that your stitches are inconspicuously placed within your hairline and about your ears (usually easily covered with hair) you will usually be able to venture out within two weeks of surgery. Your sutures (stitches) are all removed within this time.

Although you will look presentable within 2-3 weeks of surgery, the average healing time for skin and soft tissue is about three months. During this time your scars may go through the usual healing processes - initially appearing red and itchy, then red and lumpy, pale and lumpy and leathery, eventually softening to normal skin colour and texture. Individuals vary greatly in the time taken for scar resolution, but generally improvements in results occur in a subtle way over some months.

To help you achieve the goal of looking as good as possible during this time, other important people will be involved in your management. These include a beauty therapist/make-up artist and a hair stylist. Dr Olbourne will direct you to the appropriate people at the right time.

Face lift surgery is limited in results by the quality of your skin - a very important aspect is your pre-op and post-op skincare program. Once again our office will advise and direct you. Our interest is in achieving the best result for you with the least inconvenience and discomfort.

Will Everyone Know I've Had A Facelift?

It is usual to feel apprehensive about undergoing a surgical procedure to improve your appearance. The dilemma is that on the one hand you want to recapture your youthful appearance, but on the other hand you don't want people to think that you have had a facelift to achieve it, fearing that you are vain. The real situation is that in our society, we are all vain and care about how we look - our hairstyles, makeup, clothes and jewellery. It is interesting to observe that one of the fastest growing industries worldwide is the cosmetic industry, where in the United States over two billion dollars a year is spent on make-up. The vast majority of people are not discerning and surprisingly will not notice even quite marked changes to facial appearance. The usual comments you can expect are that "You look well!" or "Have you been on a holiday?" A recent patient reviewed several months after her facelift, explained that her twin sister had asked "How come that lately you get so many comments about how great you look and compared to you, I look like the older sister? What's your secret?"

When Should I Have One & How Long Will It Last?

There is no specific age that is best for a facelift - we all age differently according to our individual genetics and our environmental experiences - sun exposure, skin care and smoking.

Facelifts can be performed from early 30's to late 70's. Usually a more youthful look is maintained longer when a facelift is performed on a younger person. In an older person whilst perhaps a more dramatic change is noted, deep furrows and wrinkles have already made their permanent mark and may need to be accepted by the patient if they cannot be totally removed by surgery.

Facial cosmetic surgery will not stop the biological clock, but will reset it. Although there are many factors determining the overall individual result, on average one can expect about 5-8 years of improvement. With the SMAS - type procedures, the improvements are often maintained for even longer.

Unfortunately, as stated above, the ageing process is relentless and after a number of years you will again develop ageing facial features which if you wish, can again be improved by a further facelift, often not as comprehensive as the original operation.

Another misconception is that facelifts make you age faster and that once you have one, you need more. This is not true and although ageing proceeds, it is not at an increased rate. In the face, the overall effects of ageing may be slowed after a modern day facelift, as the deep supporting structures are tightened and the redraped facial skin adheres to these supports. There is also evidence that subjecting the skin to tension induces the development of new elastic-type fibres which prolong the improvement achieved by surgery.

Is It Painful And How Will I Feel?

We all fear pain and have different thresholds at which we perceive pain. Facial cosmetic surgery, like any operation, will produce some pain, but it is usually only mild to moderate and should be relieved by mild analgesics such as Panadeine or Digesic. Pain relieving injections are rarely required, particularly with the modern techniques of analgesia with utilise long-acting local anaesthetics and intravenous sedatives. Dr Olbourne and your anaesthetist will discuss these techniques with you and advise you of the suitability of them in your particular case.

Advancements in anaesthesia over recent years has meant more comfort for patients - less pain with minimal post operative sedation and nausea and a quick recovery to "feeling normal." Depending on the individual, either general anaesthetic, (in which you will sleep throughout the operation) or neurolept anaesthesia (commonly known as "twilight" anaesthesia or sedation) is used. This dissocation technique is administered by intravenous injection. You are sedated, but not anaesthetised and thus you are in control of your senses and vital functions. You breathe normally. The main advantage of this technique is that you have no recall or memory of the procedure and that your recovery is smoother and more rapid with less nausea and vomiting. The anaesthetist will talk to you prior to the operation and explain what is best. You will be able to choose the anaesthetic technique best suited to your needs after speaking with our anaesthetist.

A new face does not guarantee a new life and does not change your personality, but cosmetic surgery performed in patients with realistic expectations can do wonders for self esteem and self confidence.

A change in your body physically will also change your mental body image. This will always be associated with mood changes in the early post operative period. The effects of this change may or may not be noticeable, but are transient (over the first few weeks) and often associated with sleep pattern interference which can easily be controlled with a mild sleeping tablet taken for a few nights.

It is not unusual to become excited or withdrawn and mildly depressed in the early post operative days - the chances of this affecting you are reduced by being aware that it can occur and is a normal sequel of any operation, but slightly more likely following cosmetic surgery. Before long you will be back to normal and enjoying life with your new look.

What Are The Dangers?

Before you make a decision to undergo cosmetic surgery, it is important that you be informed of the potential risks, complications and side effects. Despite Dr Olbourne's experience, it is recognised that complications may occur even with the best surgical care. For this reason, and in order that you may be truly informed prior to making your decision about surgery, it is important that you carefully read and understand the risk factors.

The following is a list of side effects which accompany facelift surgery on a relatively common basis. Complications, although rare and unexpected, may occur despite any surgeon's best efforts. Whilst reading and carefully considering this list, please understand that thousands of successful cosmetic procedures have been performed and the occasional occurrence of these side effects may be a part of what is considered a successful cosmetic operation. Likewise, although much less likely, the complications listed herein do occur, despite optimal care and patient co-operation. You must understand that all these complications have occurred to some patient sometimes and may, ultimately, be part of your own clinical experience. With care and patience many of them can be repaired or mitigated - but these problems do occur and you must consider them.

Possible Side Effects

Swelling - this is normal following facelift surgery, reaches a maximum at about three days and usually lasts up to three weeks and very occasionally, six to eight weeks.

Pigmentation (discolouration and bruising) - bruising usually comes to the surface within a few days and then gradually resolves over two to three weeks. Occasionally extensive bruising can require many weeks or months to totally resolve. These problems can be common in patients with thin, hypo-pigmented, transparent skin. Patients with darker complexions would be aware of the possibility of residual brown pigmentation. Should this occur, there are treatments which will accelerate its resolution, but they take some time to have an effect.

Loss of or abnormal sensation, feeling of tightness, vice-like feelings, headaches - it is usual to have a reduction in skin sensation after a facelift procedure. This can include the skin around the cheeks, chin and neck and it is also possible to have numbness of the lower portion of the ear and the hairline, both above and below the ears. Feeling will usually return over a period of 8 - 12 weeks, but in some patients this does take a little longer. A feeling of "insects crawling under the skin" can be experienced while the sensations are returning and this should be considered normal. On rare occasions, sensation can be increased and this will slowly return to normal over a period of weeks to months.

When the superficial muscle layer of the neck is tightened, occasionally a feeling of tightness or choking can be experienced. This is not usually a permanent problem as the muscle layer and sutures do tend to loosen slightly and the feeling of tightness around the neck reduces. However, during the week or weeks that this is present it can be a disconcerting feeling. The same applies to the area around the upper cheeks and temple and occasionally behind the ear. A vice-like feeling in this area and headaches can be experienced. Again, these settle as the swelling reduces and the tissues soften and relax. Significant pain is not common after facelift surgery and if it is experienced, it is mostly temporary.

Alteration of the hair-line - may occur especially in the side-burn areas. Dr Olbourne will discuss with you his technique to minimise this often troublesome problem. Male patients should be aware that the hairless area in the front of the ear may be narrowed and that the beard pattern will possibly change, necessitating shaving closer to the ear at the front and maybe behind the ear. Dr Olbourne modifies his incisions to prevent as far as possible any alteration to the normal "geography" of the hair line. Ladies with close-cropped hair styles present problems in this area. The operation needs to be sufficiently flexible to allow for all these variations in hair style.

Hair loss - as a result of anaesthesia or the surgery may occur in the temple area or behind the ear. This is usually temporary with normal regrowth noted within several months.

Scarring - will occur whenever skin is incised and of course all effort is made to place scar lines where they will not be detected by the unknowing observer. Scar maturation varies from person to person and occurs over 3-12 months. Scars normally progress through red, itchy, lumpy, white and leathery stages before settling to their final state. Visible incision lines may tend to thicken, require steroid injections or pressure therapy and possibly additional revision surgery will be indicated to improve the result.

Broken capillaries - with any skin lifting surgery, it is possible to cause some broken capillaries in the skin. This is more so if this condition already exists and can be noticeable on the lower cheeks and neck area. Fortunately laser treatment is available for improving the appearance of broken capillaries and this would require referral to a specialist who deals with this problem.

Possible Complications

Infection - this is extremely rare despite the proximity of hair around the wound, as the face has an excellent blood supply. Antibiotics may be administered to further minimise this possibility where indicated.

Blood clots or haematoma - although all care is taken to minimise bleeding, occasionally a blood vessel will continue to bleed after surgery producing a swelling or mass of blood (usually clotted). This clot or haematoma is usually noted within the first 24 to 48 hours after surgery and may require further surgical exploration to drain the collection and stop the bleeding if it is sufficiently large. Small amounts of bleeding may leave an indurated or thickened area for a few months. This may respond to ultra-sound treatment, but should settle without affecting the long term result.

Skin death (necrosis) - fortunately skin death (or necrosis) is a very rare complication of facelift surgery. However, even with the best operating skill it can occur. The area most frequently involved is the non hair-bearing skin behind the ear. If this was to occur, the area would be allowed to heal. Occasionally small skin grafts are necessary to speed up the healing process. If skin death does occur, additional scarring would result and would appear as white scar after maturation has occurred. Usually as the skin becomes looser the scar can be reduced in size and the effects of this complication can often be minimised. This complication is much more common in smokers and has been estimated to be 12 times more likely than in non-smokers. You should therefore inform Dr Olbourne if you are a smoker. He may plan your operation to allow a nicotine-free period of two weeks or more. If you continue to smoke despite these warnings, you run the risk of having to deal with this complication.

Nerve damage - possible nerve damage involving the sensory nerves to the cheek, neck and ear area has been covered earlier. However, damage to the nerves which innervate the muscles of the face can infrequently occur and it has been estimated to occur in approximately 0.7% of all facelifts. This will cause facial distortion or weakness around the eyebrows or mouth. This is transient in most cases and usually returns to normal over the first 6 weeks to 6 months. Occasionally this can persist as a permanent complication which will compromise the beneficial goals of the procedure. Damage to these motor nerves is slightly more common when the SMAS procedure is used. This is why the operation takes longer and requires a greater degree of skill. Dr Olbourne will discuss this with you in some detail.

Routine Prior To Surgery

1. Avoid Asprin or aspirin-containing medicine (Aspro, Disprin, Alka-Seltzer, or any medicine containing acetylsalicylic acid) for 2 weeks prior to your operation as these medications can produce bleeding or bruising. Panadol is safe. Some herbal therapies such as St Johns Wort or Gingko Biloba should also be avoided.
2. Avoid vitamin E two weeks prior to surgery as this may also increase bleeding tendency. Vitamin B and C are safe to use.
3. Stop smoking to avoid post-operative coughing which increases the risk of bleeding and bruising. Smoking also decreases blood supply to the healing tissues, increasing the risks of delayed and poor healing. This recommendation is important and your smoking pattern must be discussed with your doctor.
4. Do not drink alcohol for at least two days prior to surgery as alcohol also increases the chances of bleeding and bruising.
5. Hair colouring may be used up to the week of surgery, but must be avoided for approximately two weeks after surgery. Prior to surgery you should consider hair styles that allow coverage of your ears and if possible the forehead to help conceal early bruising or incision lines.
6. Plea0se note that only minimal hair will be shaved during the operation. The area shaved is behind the ears and confined to that scalp skin that is to be removed during surgery. At the end of your operation there is no hair loss. Despite there being sutures or metal clips in the scalp following any browlift procedure these are rarely seen after the hair has been washed and dried.
7. If you develop any sign of infection such as cold, flu, or pimples on your face during the week prior to surgery - please notify Dr Olbourne's office so that we can treat this effectively.
8. On the night before of the day of surgery, shampoo your hair and cleanse your face thoroughly with Hibiclense. Do not apply any moisturiser, makeup or hair products after cleansing.
9. Bring to hospital your normal toiletries and any regular normal medication that you use. Loose night clothes are recommended. Also bring a pair of sun-glasses and a scarf to wear home. If your procedure is scheduled for the Carswell Clinic, we will advise on your special requirements.
10. If your operation is in the morning, you must have nothing to eat or drink from midnight. If your operation is in the afternoon, you must have nil by mouth from 8am on the day of surgery.

Routine After Surgery

Upon leaving hospital, an appointment will be made for you to visit Dr Olbourne's office for removal of sutures. By the end of 7 to 10 days, all sutures or staples will be removed.

Vitamin E cream or oil gently massaged into the scar lines should be commenced about one week following removal of all sutures. This helps to soften the scars and you should continue doing this for six to eight weeks. Remember to massage for five minutes as the friction of this action is important in scar maturation.

In the first week following surgery it is advisable to restrict your normal activities. Avoid smoking, alcohol and stress if possible, as this hinders the healing process. Analgesia or pain relief is often required to manage the discomfort - Panadeine Forte or Digesic may be given initially, but as pain settles, Panadeine or Panadol is usually adequate. Codeine, which is found in Panadeine or Panadeine Forte, can cause constipation, so it is important to drink lots of fluids, maintain a high fibre diet, and if required a gentle laxative (eg. Nulax) may be used. Avoid aspirin as this can increase your bruising and bleeding into the tissues.

Generally, visible bruising is present for up to two weeks. The swelling increases over the first 48 to 72 hours following surgery, stabilises, then generally subsides slowly, but it can take up to three to six weeks to fully settle. Often one side of the face is more bruised or swollen than the other. A facial support can be worn initially to help with this. You need to be patient and give yourself time to heal.

It is necessary to sleep elevated on a few pillows to help minimise swelling. However it is vital not to let the neck flex onto the chest at any time. Keep your chin up as far as possible. Occasionally this can be uncomfortable, so a folded towel under the upper back may be supportive and beneficial in keeping your neck extended. Sleeping tablets may be useful to regain your normal sleep pattern.

You may shampoo your hair as soon as the bandages are removed, usually on the second post-operative day. This helps keep the incision lines clean and dry. Careful drying is important - use a hair dryer on low heat around the suture lines. A dry cotton bud is particularly useful to clean behind the ears after showering. Ointment may be prescribed to keep the areas behind the ears soft and moist. Apply this twice daily, if so instructed.

It is quite normal to experience tightness and reduced sensations to your face during the initial healing process (i.e. over the first six weeks or so).

Often in the weeks following surgery, it can be a difficult time coming to terms with the "new you". Some patients when looking in the mirror will say, "What have I done?" and experience guilt and low self-esteem. Now is good time to seek the advice of your beauty therapist and/or a hair stylist who can provide useful hints about camouflage of bruising and makeup. This can help boost your confidence and maintain a positive state of mind. Try and increase your daily activities and start going out a bit more.

Post-operative appointments are made as necessary for you to visit our office for a check up. Photographs are usually taken to chart your progress. As time passes you will begin to see the positive effects of your facelift and you will gradually resume most normal activities and start feeling more confident.

CALL DR OLBOURNE IF YOU EXPERIENCE THE FOLLOWING:

• Excessive pain or bleeding
• Abnormal swelling of the forehead
• Fever during the first 24 hours or especially during the first 7 days

How Much Will The Procedure Cost?

The costs of this surgery relate to:

1. surgeon and assistant surgeon
2. anaesthetist
3. hospital
4. ancillary charge (pharmacy, brassiere, etc)

Dr Olbourne can tell you his fee and give you some indication of the costs of the other people involved in your care.

You must appreciate that the ultimate cost to you will depend on where you choose to go for your procedure and what rebates you will receive from your medical fund and Medicare. This in turn depends on who you may be insured with and what level of insurance you have chosen. Please advise Dr Olbourne if your insurance has a front end deductible cost or "excess". With all the relevant information the doctor's office should be able to give you a very close approximation of what your final costs might be.

Private insurance including Medicare may pay the cost of part of the operation itself, but not the cosmetic part. If so, they would also contribute to the anaesthetic and hospital costs.

It is always preferable to arrange all your finance prior to surgery to avoid unnecessary stress afterwards which will detract from your enjoyment of having achieved your goal.

Further Information

For further information on this or any other cosmetic procedure, feel free to contact our office. Our staff are dedicated to assisting you and will do all they can to make your surgical experience as comfortable as possible.

You can also assist us by advising us of any aspect of your experience that has not been adequately covered in this brochure. We are always seeking to improve the information we give to patients. Your input will help us achieve that goal.

Contact: Dr. Norman A. Olbourne
MB BS (Hon), BSc(Med), MHL, FACLM,
FRCS, FRCSEd, FRACS

Sydney Institute of Plastic Surgery
7 Help Street
Chatswood NSW 2067
PO Box 5010
Chatswood West NSW 1515

Phone: (02) 9411 - 3177
Fax: (02) 9411 - 3380

Email: info@sydneyplasticsurgery.org
Web: www.sydneyplasticsurgery.org