Through all your years of youthfulness, your facial skeleton is kept smooth and firm by three layers of tissue: muscle, fat and skin. Aging affects all three muscles lose tone, gravity pulls fat downward and skin becomes less elastic. The result: a craggy, sagging, jowly look as everything seems to go to pieces.

For long decades, the solution to this "all-falls-down" problem has been the face-lift (or rhytidectomy) a fairly aggressive scalpel procedure that involves separating the skin of your face and neck from underlying muscle, pulling it back and up, cutting off the excess skin, re-draping the skin over the face and neck, and then suturing it in front of and behind the earlobes. In the earlier years, this kind of cosmetic surgery often resulted in the waxen, tight look that Hollywood made famous.

Today, facial-contouring procedures are "made-to-order" packages, tailored to each individual's face. What's more, techniques have become more simplified and refined, involve less trauma and pain, and much shorter hospital stays and recuperation periods.

Some persons, such as those whose necks bulge out over their collars or who find themselves with one chin too many, may want to have only a neck lift (or a lower face-lift, as it's also called). That, too, is an option the surgeon will firm up the neck by tightening the cords of muscles, thus eliminating the vertical skin folds that create the turkey gobbler look, and "liposculpting" the chin area to restore firmness and a sharper angle.

Other cosmetic procedures may be super-added to the basic face-lift (although they can also be done separately, as and when they are indicated or desired). These include: a forehead lift, when both brows have gone into a noticeable slouch and when forehead furrows and crow's feet are deeply etched; a chin implant, inserted to correct a receding chin; liposuction to get rid of fat below the chin; blepharoplasty (eyelid surgery) to get rid of the eyebags that often are the first sign of aging. In fact, rather than considering a face-lift alone when it's obvious that you have more to be taken care of than just loose folds and sags, it is far better to discuss with your surgeon an approach that involves a total overhaul of your face. It seems foolish, for instance, to have a face lift to tone and tauten your face while neglecting the tired-looking puffy, eyelids that will compromise the results.

But the classical facelift is still the only option when facial sagging has become pronounced. That is because neither skin creams nor drugs, neither exercise nor chemical peels, can "uplift" skin that has stretched, or tone facial muscles that have gone slack.

  • Suitable Time

    The right time is determined not so much by your chronological age as by the extent to which your skin has given way to the ravages of time, the pull of gravity, the loss of the underlying fat layer, the shrinkage of the bony structure, and finally the stretch of muscles as you smile, laugh, talk or scrunch your face into your pillow at night.

    The usual age at which one becomes visibly aware of this downtrend is 45 to 55 years, but there is great individual variation. Factors such as premature menopause, hysterectomy or hormonal imbalance can accelerate the ageing of the skin. Sagging mainly takes place along the jawline (bringing on what are known as `jowls'), below the chin, around the corners of the mouth. The face-lift, in any particular person, needs to be adapted depending on which area or areas require the most attention. In younger patients, who show no sagging in the neck area, the so-called mannequin face-lift in which only the face is lifted is the procedure of choice.

    Once you notice that ageing has brought about noticeable and unwanted changes in your appearance, there is no particular advantage in waiting until sagging has become more pronounced. All that will give you is years of "looking old, while feeling young", which greatly negates your quality of life. What's more, if you wait too long until the skin has begun taking on the appearance of a prune, that is the results of a face-lift are certainly not going to be as good as (if you do it) when your skin still has good resilience.

    The greater the degree of sagging at the time of the initial face-lift, the earlier is another lift likely to be required. Those who have a face-lift done in their middle or late forties often need only a slight touch-up in later years. That's because the face-lift, far from accelerating the process of aging, as is commonly feared in fact, makes the skin less elastic, thus reducing its tendency to sag.

    Folds and sags that have been eliminated by a face-lift will not return; however, the normal process of aging will continue, although at a diminished rate, after the operation. As and when that happens, a second and -- if need be later -- even a third face-lift can be done. Age in itself is not a barrier to having a face lift.

  • Ideal Candidate

    Is someone in his or her mid-40s, of slim build, with high cheekbones, a strong chin and jawline. Fine skin, not too badly damaged by the sun, fares better than thick skin.

    To get a rough and ready idea of how a face-lift can change your appearance, stand before a mirror, place your open palms against your cheekbones and temples and lift upward. If your face gets an instant `lift' and looks more youthful, you're probably ready for a rhytidectomy. Of course, results will not be as dramatic as those suggested by your `hands-on' experiment. There are physiological barriers to achieving such a taut effect, especially in the nose to mouth area. The skin of the neck and jawline lends itselt to being pulled back somewhat tighter, and these are the areas in which the most dramatic improvements may be expected from a face-lift.

  • Cannot Be Done

    The face-lift is not basically a wrinkle-removing procedure. As excess skin is cut off and the remainder re-draped into firmer contours, the appearance of creases and lines will be softened somewhat, but they cannot be altogether obliterated. They include: crow's feet around the eyes; deep naso-labial furrows running from the nose to the corners of the mouth deep lines running from the corners of the mouth to the jowls.

    A face-lift also cannot do anything about: fine vertical lines around the mouth and lips; dark circles under the eyes; or droopy eyebrows. Separate procedures are needed to correct these. A chemical peel performed about a week after a face-lift, for instance, can significantly improve fine-to-medium lines on the face.

    (While a limited peel, such as in the forehead area or around the mouth, is feasible during the face-lift operation itself, a full-face chemical peel is contraindicated at this time.)

  • Pre-Surgery Preparation
    • If you are overweight, you will be advised to lose weight before the face-lift. This is because losing weight after the lift will cause the tightened facial skin to lose tone, become loose and start sagging again.
    • If you're male, its advisable to grow your sideburns and your hair; this helps to conceal the scars of the surgery until they fade sufficiently.
    • Avoid smoking and drinking alcohol and limit sodium intake for at least two weeks before the surgery: Because nicotine constricts the fine blood vessels of the face, it can delay healing; Smokers tend to have higher rates of complications after surgery. Similarly, it's important not to retain extra fluid or to be bloated during surgery.
    • You'll need to shampoo your head on the day before the operation.
  • How It Is Done

    Depending upon the surgeon's preference and the type of technique he's going to employ, either general or local anaesthesia or a combination of both may be used.

    The head does not need to shaved, If the hair is long enough, it is held back from the forehead with a rubber band; if it is short, as in men, it is trimmed with scissors and plastered upward.

    Although the line of incision follows the classical pattern of starting in the hairline above the ear, curving downward to the front of the ear, then skirting around the lobe to the back of the ear and then up again to the scalp, there are infinite variations on this basic pattern. The surgeon will adapt and alter the curve of the incision depending on factors such as a scanty hairline, existing baldness, the amount of facial skin that needs to be excised, whether the hair pattern is high. In men, the incisions are made so as to avoid, as far as possible, interfering with the growth pattern of the beard and side-burns.

    In younger patients, who may have no aging of the neck, only the face may be lifted (a procedure known variously as the upper face lift, the temporal face lift, or the mannequin face-lift.) In older patients, the surgeon will also lift and tighten the platysma muscle in the neck.

    The technique employed may be either the subcutaneous one where the surgeon dissects just under the skin surface, lifting and stitching lax tissues, or the sub-platysma technique in which the dissection is made under the facial musculature, lifting and tightening this structure too. The first technique is considered the safer one on the whole; in the second, if the facial nerve descends lower than usual into the neck, there is a risk of the surgeon cutting the nerve, resulting in subsequent denervation of the platysma muscle in the neck (if a combined face and neck lift is being performed).

    On the other hand, the risks of blood clot formation and of ecchymosis (bruises) are considered to be lower in the sub-platysma approach.

    A face-lift normally takes around three hours but may extend to more depending upon the individual case and also upon whether it is being combined with some other facial procedure such as chin liposuction or eyelid surgery.

    After the surgery is complete, an antibiotic ointment will be applied over the suture line and a suction-type drain placed below the dissected skin, enabling blood and serum to be aspirated during the first 24 hours. A moderately compressive dressing is also applied and it stays in place for at least the first 48 hours. The dressing keeps the patient more comfortable and prevents undue facial motion (which can aggravate bleeding and swelling, delaying healing and compromising the final 'look').

    At least a day's hospital stay is required. Bed rest is recommended for the first 24 to 48 hours, during which visitors are restricted. This is the most crucial period in the development of blood clots, and if the bleeding is severe, immediate corrective treatment will have to be undertaken.

    Sedatives or tranquillisers are helpful in the initial post-op period. You'll be allowed to move around a little on the second or third day; by this time, the drains and the dressing will also be removed.

    The stitches can be removed in stages during follow-up visits, beginning about a week after the surgery.

    You can do a gentle shampoo (no hair dryer) about five days after the surgery; and you can use make-up around the tenth day. Tinting and colouring can be done about three weeks post-op.

    Temporary swelling around the eyes often occurs after a face-lift, And, of course, you can expect around 10 to 14 days of bruising and swelling of the skin particularly of the lower face and neck. (The temporary swelling in the immediate post-operative period tends to obliterate all fine wrinkles, but as the swelling diminishes, the lines will generally re-appear).

    Because of the tightening of the tissues during the surgery, there will be a feeling of numbness and tension in the areas of the neck, cheeks and around the ears. These will gradually disappear in about 4 to 6 weeks.

    Because of this extended period of feeling "battered and bruised", face-lift patients often go through a depression phase, during which they require reassurance; the doctor-patient relationship therefore is very important.

  • Risk and Complications
    • The most common complication is the formation of blood clots under the skin. If the problem is minor (involving small collections of blood beneath the skin) it can be treated during the follow-up clinic visit. Such minor bleeding does not affect the overall results. But major post-operative bleeding, which causes painful swelling, needs earlier and more active treatment, often re-opening of the surgical sutures to remove blood clots or to close small bleeding points. Such bleeding (or hematoma, as it is called) is best controlled during the surgery itself by the use of adrenalin in the anaesthetic solution and by electrocoagulation or surgical suture ties. Post-surgery, avoiding excessive facial motion (heavy chewing, too much talking or laughing) can also help minimize bleeding. Care is also taken to avoid a rise in blood pressure which could again set off bleeding and jeopardize the final results.
    • Far less frequent is over-zealous cutting on the part of the surgeon which can lead to a loss of facial motion and a blank expression. This is more common among older patients who undergo a number of face lifts over short intervals, say, six months to a year. A temporary numbness and tightness of the face is, however, something you should expect in the early post-operative period; it is brought on by the bruising and swelling and not by over-correction on the part of the surgeon.
    • One of the most serious risks of a face-lift-though, fortunately it is rare-occurs if nerves are accidentally severed; paralysis can then occur down one side of the face.
    • If the incisions have been well placed within the hairline and behind the ear, they won't show.
    • You can anticipate a change in your normal hair pattern just in front of and slightly behind the ears. (Letting your surgeon know, before the surgery, how you like to wear your hair, may enable him to minimize this problem by placing his incisions accordingly. However, do remember that other considerations, some of them emerging on the operating table itself, may prevent him from doing this.)
    • Men may expect a change in shaving patterns if sideburns are elevated. They may also end up with hair-bearing skin behind the ear.
  • Mini Face Lift

    The Forehead Lift (or Brow Lift) : A face-lift alone cannot do anything for heavy frown lines in the forehead, or for droopy eyebrows that develop with age. When both these problems exist together, or when the first alone needs to be corrected, a forehead lift is the procedure of choice. It's also known as a brow lift or a temporal lift.

    The incision made for the brow lift is essentially an extension of that made for the traditional face-lift: it starts in the hair just above the ears and stretches from ear to ear over the top of the head, thus lying about two to three inches behind the front hairline. The skin of the forehead is then lifted tightly upwards, the excess skin is trimmed off, and the skin margins then sutured in place within the hair-bearing scalp. The effect is to diminish the appearance of frown lines and to raise the eyebrows. (In some patients, the upward stretch on the eyelid folds that results from a forehead lift does away with the need for separate eyelid surgery).

    However, the brow lift is not appropriate for all patients: Since scalp-bearing skin is moved upward, effectively extending the height of the forehead, men with receding hairlines would find that the area of baldness enlarges at the front. Also, as the process of natural balding continues, the incision scar in the head becomes gradually visible, which would be cosmetically unacceptable.

    Post-operatively, the main problem is numbness at the front of the scalp, caused by damage to nerves in this area during the surgery; recovery from such damage can take from six to 12 months.

    If hair follicles are injured, which can happen rarely, a small area of temporary baldness results; the hair starts to grow back spontaneously within about six months. Like the face-lift, the results of the brow lift are not permanent; they are subject to the continuing assaults of aging and gravity.

  • The Eye Brow Lift

    If your cosmetic concern centres chiefly around drooping eyebrows and you hair not seeking any improvement in the forehead area the answer is an eyebrow lift.

    Despite a blepharoplasty being done, a certain degree of fullness may still be present in the upper eyelids if the eyebrows too have drooped with time. To correct this, and to remove that look of a permanent scowl that drooping eyebrows seem to contribute, requires an eyebrow lift.

    An incision is made just behind the hairline, running across the top of the head, from ear to ear. Muscle and skin are then lifted away from the forehead and gently pulled up. Some muscle may be removed. The excess skin is cut away and the free edges of scalp are sewn together. The result : A smoother forehead (The procedure is, in fact, a combination eyebrow and forehead lift.)

    The eyebrow lift can also be done at the same time as blepharoplasty by cutting away an ellipse of the skin and muscle above the eyebrow (following the natural curve of the eyebrow, and then suturing the eyebrow in place at a higher point in the forehead than it originally was.) The scar left by the incision is minimal but permanent.

    Although the final scar is placed so as to lie as near the eyebrow as possible, it may need to be concealed for anything upto a year. If it does not settle satisfactorily, it may need to be dermabraded. (See the Chapter, "More Wrinkle Erasers"). The scar of the eyebrow lift remains the biggest drawback of this surgery, but in most cases it does settle down to an aesthetic finish.

    Sometimes the eyebrows can also be lifted in the course of a facelift, without separate incisions being made, thus avoiding visible scars.

  • Lip Lift

    As lips age, they thin, with the pink part becoming less visible. Filler materials offer only limited help: Collagen, injected into the border, can provide better definition, but no one really knows the long-term effects of injecting collagen into the body of lips. Auto-fat injections, as we"ve already mentioned, can leave you with lips that look unnaturally puffy.

    A lip lift can however restore youthfulness to peckers that have begun to do a disappearing act. One approach is to remove slivers of skin from the inside of the mouth underneath the nose; as the cuts heal, the lip rises up much as it would if you pulled up on your "moustache" area.

    Another technique involves advancing wedges of tissue on the inside of the lip.

    Either technique takes under half an hour.

    The end-effect can be as subtle or as dramatic as you wish.

    Significant swelling is present for three to four days. Complications include nerve damage and potentially lop-sided results.