Facial cosmetic surgery focuses on improving the appearance of the face. Common cosmetic surgery procedures include rhinoplasty, blepharoplasty (eyelid surgery), facelift, brow lift, chin augmentation, otoplasty (ear repositioning), liposuction, and fat transfer. Many patients may seek surgical treatment to reverse changes that occur with ageing, such as loose skin, decreased volume around the face and neck, crow’s feet at the outer part of the eyes, fine lines on the forehead, loss of jawline contour, sagging jowls, and a double chin.
Perhaps the most commonly performed and most difficult facial plastic surgery is rhinoplasty. It is performed to correct both intrinsic and extrinsic nasal pathology, to modify unsatisfactory aesthetic appearance, to reduce airway obstruction (due to septal deviation, inferior turbinate hypertrophy or deviated/fractured nasal bones), and to reconstruct congenital nasal anomalies present from birth. During a rhinoplasty, the nasal skin, subcutaneous soft tissue, cartilaginous and bony framework, and mucous membrane lining are manipulated surgically. The open rhinoplasty is differentiated from the closed or endonasal rhinoplasty in that the incision is made in the columella (fleshy tip of the nose that separates the nostrils) in the open approach. The general principle of a rhinoplasty consists of a separation of the nasal skin and soft tissues from the bony and cartilaginous nasal framework so that the underlying nasal framework can be reshaped to produce the desired nasal contours. Rhinoplasty is a technically challenging procedure that has complication rates from 4 to 20%. Postoperative scarring and swelling as well as patient dissatisfaction can lead to revision rhinoplasty (secondary rhinoplasty).
Over the past 10 years, rhinoplasty surgery has trended toward using structural techniques that require cartilage tissue to reconstruct shape, reinforce weak parts of the nose, expand the airway, and create an aesthetic contour as opposed to destructive cartilage removal techniques. Advances in this area include the broader use of cartilage for structural grafting. Traditionally, rib cartilage was used for only major reconstructive nasal operations, but more recently the number and type of grafts that are used in rhinoplasty have increased significantly as rib graft use became more prevalent in even primary cosmetic rhinoplasty. Digital imaging has become an increasingly important element of rhinoplasty planning, evolving to become an essential component of the preoperative consultation. Three-dimensional (3-D) imaging systems along with 3-D image morphing technologies are now widely used by most surgeons, though there is no universally accepted software platform.
Another popular facial procedure is blepharoplasty, or eyelid surgery. Blepharoplasty involves the excision of excessive eyelid skin and/or removal of prolapsed fat to treat ageing-related changes in the eye region and reduce excessive wafer thin skin. The impact of gravity on peri-ocular features, reduced strength in periorbital muscles as a result of soft tissue laxity, chronic sun damage, and changes in the skin thickness may cause aesthetically unappealing changes referred to as droopy eyelids,” “tired eyes,” or “bags under the eyes.” The usual technique for lower blepharoplasty surgery is through a lower eyelid incision with a raised skin and muscle flap, followed by identification and correction of prolapsed areas of fat.
The “skin pinch” blepharoplasty is the easiest to perform. In this technique, only excess skin is removed through the same approach as for a traditional lower blepharoplasty. This method avoids a heavy skin–muscle flap, which can create potential pulling on the lower eyelid leading to an ectropion. The pinch blepharoplasty of the lower lid also avoids violation of the orbicularis oculi muscle and the orbital septum to avoid nerve injury and to decrease scarring. This approach allows more wrinkled, thin skin to be safely removed and an aesthetic eyelid position to be maintained. Both upper and lower lid blepharoplasties are often performed under local anaesthesia with or without sedation. Of note, blepharoplasty is also performed to correct eyelid sagging, which can arise from several causes. The most common cause is weakness of the levator muscle..
The facelift also known as rhytidectomy, is a commonly performed surgical facial rejuvenation procedure performed by expert facial plastic surgeons. When facelifts were first developed over 100 years ago, the procedure itself involved making multiple incisions and pulling the skin on the face tighter. Now the traditional incision is made in front of the ear, extending up into the hairline and curving around the bottom of the ear lobe and then behind the ear. The skin is separated from the deeper tissues, and then the deeper tissues are tightened with stitches. In the final step, the skin is repositioned with the excess skin removed.
Advancements in facelift procedures have been largely driven by the demands and desires of patients. Patients today are looking for minimally invasive procedures with little to no postoperative downtime. Treatment of the ageing face has been profoundly impacted by the rise of so-called “lunchtime facelift” procedures. In the mid-1990s, facelifts and rejuvenation operations were becoming increasingly technically demanding and risky due to exposure of the facial nerve branches and extensive soft tissue dissections. These complex procedures gave Great results in expert hands. However, often patients operated on by more Junior surgeons experienced prolonged postoperative swelling, or potential facial nerve injury, and facial asymmetry. Today there are many facelift approaches, such as the deep plane facelift, composite facelift (which involves repositioning and fixation of the orbicularis oculi muscle), mid-facelift, mini-facelift, thread lift, skin-only facelift, and minimal access cranial suspension lift or MACS lift. Each can achieve outstanding outcomes but largely depend upon surgical skill and the anatomical variations between patients. In the early part of the 21st century, there was a rise in less invasive procedures, which could be performed under local anaesthesia with oral sedation. Overall numbers of facelifts have increased because of the marketing of the large UK cosmetic surgery chains. According to the British Society of Plastic Surgeons, the number of facelifts has increased. A major trend in recent years is the combination of facelift operations with facial fat grafting or autologous fat transfer, which also addresses the volume loss that occurs with the ageing face.
Brow lift or browpexy is a large part of a facial plastic surgery practice.
This procedure is relatively straightforward to carry out in terms of its classical approach where excess skin is resected and the forehead skin is repositioned to a higher level. The incisions are placed along a line within the hair-bearing scalp if the hairline is low. A hairline incision is used in patients with a high hairline. These two approaches are most commonly used in women. In men, a third option is the mid brow lift where an incision is made in a deep brow furrow on the forehead, and an ellipse of skin is removed. A direct brow lift, where the incision is made at the upper margin of the eyebrows, is rarely performed. Both mid- and direct brow lifts may leave a visible scar, and they are more commonly used for functional brow surgery in patients who have significant brow drooping contributing to a disturbance of vision.
The newest approach is the endoscopic brow lift where several small incisions are placed behind the hairline and an endoscope is used for visualisation during elevation of the forehead skin. With the endoscope under the forehead flap, the surgeon releases soft tissue from the lower brow, allowing repositioning and fixation of the skin more higher. The results are less dramatic, but it is an excellent technique in the younger patient who prefers more natural and less-defined changes.
Otoplasty also known as pinnaplasty or ear reshaping is the surgical procedure to treat congenitally prominent ears. Otoplasty can be either cartilage splitting or cartilage preserving. Cartilage-splitting techniques involve incisions through the cartilage and repositioning of large portions of ear cartilage. Cartilage-sparing techniques avoid full-thickness incisions but create angles and curls in the cartilage for contouring. Most surgeons now perform cartilage-sparing otoplasty routinely.