Although it is generally thought of as being a recent phenomenon, the practice of cosmetic surgery dates back to the ancient Egyptians who were known to alter the shapes of their ears and ear lobes. Aesthetic surgery has been evolving ever since, and like all areas of medicine and science it has significantly changed over time as a result of continual developments and refinements in techniques and technologies.

‘In the past 25 years or so, there has been an explosion of interest and enormous advances in technique, combined with a much better understanding of anatomy,' says London-based plastic surgeon Dr Barry Jones. ‘This has facilitated the development of safer, more effective operations which limit the visibility of scars and reduce downtime. No where is this more apparent than in facial rejuvenation surgery where what once was a standard facelift has become a potential combination of many different techniques to address individual patient needs.'

‘There are, however, no quick fixes,' he continues. ‘I believe the ultimate aim of the aesthetics industry is to be able to reverse, prevent and modify the ageing process by some means other than an operation.'

‘While ancillary procedures such as botulinum toxin and fillers are very useful, it's important to be able to analyse what they do but also what they don't do; what we can achieve surgically and what we can achieve non-surgically,' he says. ‘We are moving forward all the time but it's important we do so on the basis of research and evidence.'

Queensland plastic surgeon Dr Craig Layt agrees. ‘There are continual modifications to procedures - both surgical and non-surgical - to counter the signs of ageing,' he says. ‘Importantly, however, you can't solve a problem or develop new methods of solving it unless you define and analyse it first.'

Facial aesthetic surgery in particular has undergone a series of paradigm shifts over the past few decades. Plastic surgeon Dr Claude Le Louarn from France says a new way of looking at facial ageing is emerging.

‘From clinical studies and research, we are finding that facial ageing isn't just about gravity and the descent of facial tissue,' he says. ‘There is now a focus not just on fixed anatomy but also the muscles and the way they affect the ageing process.'

The facial expression muscles typically run from the bone to the skin. In younger people the muscles are curved at rest. ‘The role of this convexity is two-fold,' explains Dr Le Louarn. ‘First, it means the muscle is more forward, or extruding. Second, the muscle is curvilinear and its contraction range is wider.'

‘With age and repeat contractions, the muscle can no longer totally relax when at rest. It is shorter, more rectilinear and therefore the difference between its contracted and relaxed states (the range) decreases and becomes visually apparent. Consequently the older person's face is more marked and tense,' he continues. ‘By examining the role of the facial muscles and their impact on the ageing process, we may be able to look at developing new ways of re-creating a more youthful face.'

There is also evidence that some of the facial bones, particularly around the eye socket, become smaller or more compressed as time goes by. ‘Again, this appears to be caused by the muscles around the eye area - as they contract over a period of time, they seem to shrink,' Dr Jones says.

Faster recovery

Research and new techniques have led to an overall shortening of the post-operative period. ‘The speed of recovery has significantly improved in more recent times,' says Dr Layt. ‘The concept that it takes six weeks of downtime after a facelift, for example, isn't true in most cases. For any given technique, over the years there has been a marked decrease in recovery time.'

‘The shorter recovery time doesn't necessarily correlate to shorter incisions in face surgery, for example,' adds Dr Jones. ‘Lots of minor things can make a big difference in reducing downtime. The summation of small things when put together can change the recovery time from five or six weeks to two weeks in some cases.'

‘The general trend is to try to have a recovery time which is as speedy as possible,' Dr Jones continues. ‘However, there are competing interests between performing what may be anatomically most correct and possibly most durable on the one hand and trying to have the quickest possible recovery time on the other. Frequently those two aims are almost mutually exclusive and we try to find a compromise between the two - to achieve the best possible outcome for the longest possible time in the shortest possible recovery time.'

According to Dr Le Louarn, newer techniques have meant the natural aspect of the patient can be better retained after surgical intervention. ‘In addition, a greater understanding of the human anatomy consequently leads to new ways we can correct ageing in specific areas of the body. A good example of this is cosmetic injectables such as anti-wrinkle injections and fillers,' he says.

Communication is key

‘Aesthetic surgery is very different to other areas of medicine in that it is elective and the surgeon should not sway the individual into undergoing a particular procedure,' Dr Jones says. ‘What the surgeon must do is make the patient aware of the options, benefits, limitations, risks and possible complications. I believe what is ultimately performed should be the patient's decision and not the surgeon's.'

Dr Le Louarn agrees: ‘It is a discussion between the patient and the surgeon. The surgeon knows what rejuvenation options are available and then needs to adapt these to meet the demands of the patient and to explain to the patient the possibility of complications and risks.'

The doctors also stress that there is no ‘one size fits all' and any aesthetic surgery should be customised to the individual patient.

‘Many experienced surgeons have a series of different approaches and techniques they use and they may mix and match for the specific individual,' explains Dr Jones. ‘In terms of facelift surgery, I advise patients not to get too hung up on the various acronyms and techniques but instead to focus on the skill and experience of their chosen surgeon when electing to undergo surgery.' acsm

Australian Cosmetic Surgery Magazine #47