10 March 2016 March 2016 11 Expert guide: Aesthetics & Cosmetology 2016 Facelifting surgery has undergone both a revolution and an evolution in the last 25 to 30 years. Prior to the work of Mitz and Peyronie, which first highlighted the importance of the SMAS layer in re-suspending the musculature of the face, practically all facelifts were carried out simply by elevating a skin flap and re-draping it to take out the skin excess. Although in good hands this often produced excellent results there was a relatively quick relapse rate and the potential to over tighten the skin resulting in poor scars and less expression in the face. The SMAS facelift initially seemed to be the answer to this problem by taking the tension on the underlying muscular aponeurotic layer. Over the following 20 years the number and variety of SMAS techniques was limited only by the number of surgeons prepared to find a new way to reposition or tighten the SMAS and publish it. I include myself in this number. Early SMAS lifts however were found to produce their own problems and re-directing the SMAS with an unnaturally lateral vector often gave rise to the so-called lateral sweep deformity which was very stigmatic of a SMAS facelift. There were also surgeons who argued that by tensioning the SMAS there was a tendency to flatten the face and ignore the natural “ogee” curve with than expert hands the mask lift could often give a very stigmatic appearance of a different type to the over-pulled skin lift but stigmatic nonetheless.So, following this period and a careful analysis of long-term results there has been a trend back to conservatism with facelift surgery and currently the strong emphasis is on the additional gestures of replacing volume in the face. The so-called lift and fill facelifts consist of prominent cheek bones and softer nasolabial folds. There then followed a period where it seemed that the plane of facelift dissection got deeper and deeper. The work of Tessier in reconstructive surgery was adapted and popularised in aesthetic surgery by Darina Krastinova in Paris and the so-called mask lift enjoyed some years of popularity. It adhered to the idea that facelifting was not all about skin excision and that the improvement was achieved by re-suspending the entire face on the facial skeleton. I remember this era very well and was an enthusiastic proponent of the mask lift myself for particular cases. These included correction of problems related to lower eyelid surgery, transgender facelifts and so-called orthomorphic facelifts where the emphasis was on creating a better face shape rather than rejuvenating the face. At the same time a variety of deep plane facelifts also came into vogue. It is interesting that now in the middle of the second decade of the 21st Century the popularity of many of these techniques has dwindled largely due to the extended downtime and facial swelling which can be protracted and last for several months. In addition in less some form of SMAS gesture but in conjunction with 20 to 30 ml of fat harvested from the abdomen or the thigh and prepared in a variety of ways and re-injected into the face with the idea of replacing the volume of youth.The same trend to conservatism is, I think, also seen with contemporary surgery to the neck. Although the very extensive procedures, which involve opening the neck under the chin, removing the fat deep to the muscles, sometimes Norman Waterhouse www.theaestheticsurgeons.com info@theaestheticsurgeons.com +44 (0) 20 7636 4073 The Facelift Transformation: Industry Developments & Best Practice Techniques By Norman Waterhouse UK