Facial rejuvenation and refinement

Older-generation facelifts dissected mainly in the subcutaneous plane and tensioned the skin. The difficulty is that skin is not a load-bearing structure; tensioning it creates an unnaturally flat appearance, distorts the auricular contour, and relaxes quickly as the skin continues to stretch.

The true driver of midface ageing is not excess skin but descent of the deep fat compartments and the SMAS layer. The deep plane technique addresses that cause directly, so it improves the nasolabial fold and jawline, regions a superficial lift barely affects.

The trade-off: this is a considerably more complex operation with longer operative time, requiring detailed knowledge of facial nerve branch anatomy within the dissection field. Not every facility performs it, and the cost is higher than a conventional lift.

Factors that shorten longevity: smoking, unprotected sun exposure, large weight fluctuations, poor baseline skin quality and genetics. The first two are entirely modifiable.

A facelift addresses tissue laxity and descent but does not improve skin surface quality: pigmentation, telangiectasia, fine static lines or coarse texture. This is why most comprehensive rejuvenation plans combine surgery with resurfacing and regenerative treatments.

Volume loss is a separate axis of ageing. Many facelifts are combined with autologous fat grafting to restore temple, malar and periorbital volume, because lifting without volume restoration produces a taut but hollow appearance.

Maintaining periodic minimally invasive rejuvenation after surgery is what sustains the result longest. Surgery resets the starting point; regular light treatments slow the rate of decline from it.

Signs that surgery is worth considering: loss of jawline definition, jowling at the mandibular border, nasolabial folds that are deep at rest, and cervical skin banding. Once these are established, non-surgical options are usually insufficient.

Intervening too early does not deliver benefit proportionate to risk and cost, because there is little to lift. Intervening too late means the skin has lost much of its elasticity, giving a less durable result and higher wound healing risk.

RASA generally advises a staged pathway: maintenance and volume restoration in the earlier phase, moving to surgery once structural descent is evident. This avoids both premature surgery and the overuse of filler to defer an indication that has already matured.

Crease height is the decisive parameter. A high crease creates a larger-appearing eye but can look foreign on an Asian face, and once created it is very difficult to lower. RASA tends towards a conservative crease height, favouring natural over dramatic.

Excessive upper lid skin excision is the hardest complication to correct. It results in lid retraction, incomplete closure and chronic dry eye. The safe principle is to leave enough skin for complete closure: under-resection is preferable to over-resection.

In true ptosis, skin excision alone does not solve the problem and levator surgery is required. Distinguishing genuine ptosis from dermatochalasis is an essential preoperative step.

The two eyes rarely settle at the same rate; one side may remain swollen a few days longer. This is a normal course, not a sign of asymmetric surgery. Symmetry should only be judged from the third month onwards.

Cold compresses for the first 48 hours and sleeping with the head elevated reduce swelling substantially. After 48 hours, switch to warm compresses to help bruising resolve.

Factors that prolong swelling: rubbing the eyes, prolonged head-down posture, alcohol, early heavy exercise and sun exposure. Avoid these for at least the first two weeks.

A distinction you can make on your own face: lines visible only on expression are dynamic and respond to botulinum toxin. Lines still visible with the face fully relaxed are static and require filler or resurfacing.

Duration differs: botulinum toxin typically lasts 3 to 6 months, hyaluronic acid filler 9 to 18 months depending on product and site.

Neither addresses skin laxity or tissue descent. Using filler to compensate for structural descent produces a heavy, overfilled face, a recognisable and difficult-to-reverse appearance.

The forehead is where problems most often arise. Over-treating frontalis abolishes brow elevation and can cause brow ptosis, leaving the face heavier than before treatment. The principle is that forehead treatment must be balanced against the brow depressor muscles.

Onset is at 3 to 7 days with peak effect around day 14. Neither the result nor any top-up should be assessed before the two-week mark.

The effect is fully reversible. If the result is unsatisfactory, it returns to baseline within a few months. This is an important distinction from irreversible interventions.

The highest-risk areas are around the nose, the glabella and the nasolabial fold, because of anastomoses with the ophthalmic artery. Injection here requires detailed vascular anatomical knowledge.

Only hyaluronic acid fillers of verified provenance should be used. Permanent fillers and unverified injectable substances account for most of the severe, delayed and difficult complications RASA sees, because they cannot be dissolved enzymatically.

Signs requiring emergency management immediately after injection: disproportionate pain, skin blanching followed by dusky discolouration, and reduced or lost vision. If these occur, contact the injecting clinic immediately rather than waiting.

On long-term cost, fat grafting is usually more economical where multiple areas need volume. A full-face fat grafting session costs roughly the same as several extensive filler treatments, but the surviving fat persists indefinitely.

Fat grafting offers something filler does not: adipose tissue contains mesenchymal stromal cells, and clinically many patients show improvement in skin surface quality at the grafted site, not only added volume.

The drawback is less predictable final volume, since resorption rates vary between individuals, and a second session may be needed. Filler allows more precise volume control and immediate adjustment.

The limitation is mechanical: threads anchor into soft tissue rather than fixed structures, so lifting capacity depends on tissue quality. In patients with significant laxity, threads cheese-wire through the tissue and the effect is lost quickly.

A recurring problem in practice is that thread lifts are proposed to patients who genuinely have a surgical indication. The result is repeated expenditure without addressing the underlying issue, plus tissue fibrosis that complicates any later operation.

Possible complications include palpable or visible threads, dimpling at anchor points, asymmetry and prolonged discomfort. Most resolve, though some require thread removal.

Because it is not cross-linked, Profhilo does not hold shape and is not used for structural work such as chin projection or malar augmentation. Classifying it as a volumising filler misrepresents its mechanism.

The standard protocol is two sessions four weeks apart, then maintenance every six months. The clearest changes are in skin turgor and smoothness, usually evident from weeks 4 to 6.

Suitable indications: early loss of elasticity, dullness and fine static lines in patients aged 30 to 50. It is not appropriate where the principal issue is structural descent or significant volume loss.

A common misconception is that upper lid skin excess is always treated by blepharoplasty. In many cases that excess originates from a descended brow. Operating on the lid in that situation shortens the brow-to-lid distance further and makes the face look heavier.

A simple mirror test: place a finger at the tail of the brow and lift about 5mm. If the appearance improves markedly, the problem is at the brow. If little changes, the problem is at the lid.

Options range from a minimally invasive temporal tail lift to endoscopic forehead lifting. The choice depends on the degree of descent, hairline position and forehead height.

Using chin filler as a trial is a sound strategy: you see the new profile for around a year before committing to something permanent. The cost of that trial is usually justified.

For significant retrogenia, filler has clear limits. Injecting large volumes to compensate for projection widens the chin laterally rather than advancing it, and filler tends to migrate over time.

Occlusion should also be assessed. Some cases of apparent retrogenia reflect a jaw relationship problem requiring orthodontics or orthognathic surgery. A chin implant then masks the appearance without addressing function.

Distinguish early prejuvenation from over-treatment in young patients. Prejuvenation means maintenance and prevention, not injecting filler or toxin without indication. At 25 to 30, most of the value comes from sun protection and skincare rather than procedures.

The single highest-impact and least expensive factor remains sun protection. Ultraviolet exposure accounts for most visible skin ageing. No procedure compensates for years of unprotected exposure.

Once mild laxity appears, non-surgical options such as radiofrequency, HIFU or thread lifting can be introduced. These act on tissue firmness and belong to the preventive and maintenance phase, before structural descent becomes established.

RASA works from an individualised pathway based on skin condition and goals rather than fixed packages. The initial assessment establishes where you sit on the ageing trajectory and what is genuinely worth doing at this stage.