Face and Neck Lift

As part of the aging process which happens to all of us sooner or later, our skin progressively loses its elasticity and our muscles tend to slacken. The stresses of daily life, effects of gravity and exposure to sun can be seen on our faces. The folds and smile lines deepen, the corners of the mouth droop, the jaw line sags and the skin of the neck becomes slack. Around the eyes, the eyebrows droop and the skin of the eyelids gathers in loose folds. In the skin the first sign is fine wrinkles developing around the lips, at the outer corners of the eye and lines of expression. The rate at which this happens varies from one person to another and is probably determined by our genes. Aging of the skin of the face does not necessarily reflect the rate that the rest of our body and mind is ageing and many people feel frustrated that the face they see in the mirror is not the one they feel should be there. Substantial weight loss can produce similar changes in facial appearance to those of the aging process.

Who will benefit from a facelift?
The best candidate is one whose face and neck has begun to sag, but whose skin still has some elasticity and whose bone structure is strong and well defined. Most patients are in their 40's to 60's, but facelifts can be done successfully on people in their 70's or 80's.

It should not be obvious that a patient has had a facelift, but instead they look younger, more vital and cheerful. It is a procedure that technically works well but also increases morale and is well appreciated by the patient.

What a facelift does not do?
A facelift works better for the lower half of the face and particularly the jaw line and neck. If you have sagging eyebrows and wrinkles of the forehead then you should perhaps consider an endoscopic brow lift. Loose skin with fine wrinkles, freckles and rough areas will benefit more by chemical peel or laser resurfacing.

What should you do before the operation?
If you are overweight and intend to lose it you should do so before the operation. This allows the surgeon to remove more skin and therefore achieve a more pleasing result. You should avoid taking tablets containing aspirin and non steroidal anti-inflammatory drugs such as Voltarol and Indocid for at least two weeks before surgery as they increase the risk of bleeding.

You should stop smoking at least two weeks before surgery as this is the main cause of reduced healing. It decreases circulation of the skinflaps, particularly behind the ears.

Have your hair permed and tinted, if you wish, before your operation as fresh scars are sensitive to these chemicals for a few weeks.

The surgery
A facelift is carried out in a hospital and most surgeons and patients prefer a general anaesthetic. It is possible to carry out the procedure under local anaesthetic and intravenous sedation but the patient would still be advised to spend the night in hospital. The procedure, although long, can be combined with other operations of all sorts. The most common however would be an endoscopic brow lift and an eyelid reduction. Other extra procedures which can be used to enhance the face at the same time are malar (cheek bone) and chin augmentation and lip enhancement.

This is an extension of the forehead lift which is designed to tighten the skin of the upper half of the face, as opposed to the standard facelift which helps the lower half of the face. The Deep Facelift carried out endoscopically avoids the same ear to ear incision. It is usually carried out at a younger age than the standard facelift. It tightens the skin of the mid-face and freshens the eyes, opening and lifting the outer angle and reducing the wrinkles of the crows feet. There will be swelling around and below the eyes which gradually resolves in about a month. There will also be scars beneath the eyelashes of the lower eyelid and sometimes in the upper gum line. There is a slight risk of damage to the nerve which supplies the muscles of the forehead. This weakness is usually partial and temporary, on rare occasions it may be permanent.

Incisions are made above the hair line at the temples and extend in a natural line down the front of the ear, or just inside the cartilage at the front of the ear, and continue around behind the earlobe and up in the crease behind the ear and off into the lower scalp. Occasionally it may be necessary to make a small incision under the chin. Sometimes only the skin is lifted following separation from the underlying platysma muscle.

More usually however the platysma muscleand its fibrous attachments (S.M.A.S.) is dissected free and sutured tightly to the solid structures in front and behind the ear. At other times the skin and the S.M.A.S. layer are lifted together as a single layer, but will still be sutured separately. Fat along the jaw line and under the chin may be removed by liposuction or on occasion through an incision under the chin. The skin is sutured so that it is lifted upwards and backwards, just as when one lifts the skin when looking in the mirror. Sometimes drains are inserted. Most surgeons will bandage the face to minimise bruising and swelling. These bandages will stay for one or two days and the sutures are removed in 7 to 8 days.

At the beginning your face will look a little puffy and may feel rather strange and stiff. The scars can be very well hidden by women with their hair and disc shaped earrings so that they should be able to resume work and social activities within a couple of weeks. Camouflage make-up can be helpful in masking bruising.

Men find it more difficult to disguise the scars and will need to shave their beard closer to the ear in front and also behind the ear where the skin has been lifted.

The scars in the hair do not usually show except that the hair is cut shorter immediately around the wound. There may be some slight reduction in hair growth in the temples, but this is not usually a problem unless the hair is very thin and repeated facelifts are being carried out.

How long does a facelift last?
A facelift does not stop the clock, but it does put the clock back. The effect of the facelift is likely to always be there, in that you will not look as old as you would have done if it had not been carried out.

Choosing your surgeon
A facelift is a skilled procedure and we would recommend that you choose a surgeon who has undergone a full training programme for cosmetic surgery. These surgeons will be on the Specialist Register in Plastic Surgery at the General Medical Council. All members of the British Association of Aesthetic Plastic Surgeons (BAAPS) are on the Specialist Register.

Incision lines follow the natural crease, or tagus, in front of the ear and extend into the hairline above and behind the ear

Platysma muscle and its fibrous attachment (SMAS) are sutured tightly in front and behind the ear as an extra sling under the chin

Eyelid Surgery

The skin loses its elasticity and our muscles slacken with age. For the eyelids this results in an accumulation of loose skin which collects as folds in the upper lids and forms deepening creases in the lower lids. At the same time there is slackening of the muscle beneath the skin allowing the fat, which cushions the eyes in their sockets, to protrude forward to give the appearance of bagginess. In some families there is an inherited tendency for bags to develop during early adulthood before any skin changes.

The problem often seems worse in the morning particularly with prolonged stress and lack of sleep. Fluid that is normally distributed throughout the upright body during the day, tends at night to settle in areas where the skin is loose, such as the eyelids. Drooping of the eyelids is also an effect of the ageing process and aggravates the accumulation of the skin in the upper eyelids. Sometimes so much skin accumulates in the upper lids that it hangs over the eyelashes to obstruct vision.

What can be done?
An eyelid reduction (blepharoplasty) removes the surplus skin and protruding fat to produce a more alert appearance and reduces the morning swelling. Sometimes it is only necessary to reduce the skin, sometimes the skin and the fat and sometimes just the fat. If only the fat is being removed from the lower eyelids, then this can be removed from the inside of the lower eyelid avoiding an external excision (transconjunctival blepharoplasty)

What are the consequences?
People who have the familial problem of bags beneath the eyes may well undergo surgery in their 20?s. Ageing effects of the skin are apparent earlier in the eyelids than elsewhere. A reduction of the skin can be carried out from the age of 35. Patients with thyroid disease often develop eye signs which can be helped by surgery. Where there is reduced secretion of thyroxin (hypo-thyroidism) there is an increase in fat and where there is an increase in thyroxine (hyper-thyroidism) there is often so much increase in fat that the eyes protrude. An extended eyelid reduction (Olivari?s procedure) can treat this satisfactorily.

What are the limitations?
It is important for you to understand that only the wrinkles which are in the skin which is cut away will be removed. We are only treating the eyelids within the bony margin of the orbit (eye sockets). Folds of skin extending on to the cheek (festoons) will not normally be improved. Wrinkles in the area of the crow?s feet will remain and although the skin is much tighter it is still necessary to be able to open and close the eyes freely. The skin has less elasticity with age and for proper closure of the eye the upper eyelid will need to have surplus skin when it is open. Descent of the eyebrow can be helped by endoscopic brow lift and an extension of this, the deep facelift, can be used to not only lift the eyebrow and the upper eyelid, but also lift and open the outer angle of the eye.

Sometimes residual or recurrent wrinkles are suitable for treatment by chemical peeling or laser resurfacing. The operation has no effect at all on the dark colour of the lower eyelid.

The Operation
Both upper and lower eyelid surgery can be carried out under local anaesthesia or under general anaesthesia in a hospital.

In a typical procedure the surgeon makes incisions following the natural lines of your eyelids; in the creases of upper lids and just below the lashes in the lower lids (see illustration). These incisions are extended a little way into the crow?s feet or laughter lines at the corner of the eyes. Through this incision surplus fat is removed and excess skin and sagging muscle removed.

If you have a pocket of fat beneath your lower eyelids without surplus skin then the fat may be removed through the inside of the lower eyelid.

The resurfacing laser can be used at the same time as a transconjunctival blepharoplasty to tighten the external skin and reduce wrinkles, although there is no external scar there is residual redness in the skin which will last a few months.

Following surgery it would be best to keep your head elevated for a few days to reduce swelling. Cold compresses can also help. The surgeon will normally apply some suture strips or steri-strips as support to the eyelids after surgery and if these become crusted they can be replaced. Cleaning the eyes with water is useful and the surgeon may advise the use of eye drops or ointment.

The sutures are usually removed after 3 to 5 days and soon after you will be able to use make-up. Sometimes you will be advised to use the suture strips or steri-strips as support to the lower eyelids for a week or so.

The closure of the eyes appears tight after surgery because of the swelling and because skin has been removed. If closure is not complete at night the patient should apply some eye ointment before going to sleep. This sensation will settle as the swelling goes down.

The eyes appear watery after surgery, partly because of swelling under the conjunctiva (chemosis) and partly because the tear ducts are swollen and do not drain as readily. This will last a few weeks. Although there is bruising it can quite readily be disguised with make-up and dark glasses. The scars will be pink for a few months, but eventually they become almost invisible.

What are the risks?
All surgery carries some uncertainty and risk. When eyelid surgery is performed by a qualified Plastic Surgeon complications are infrequent and usually minor. You can check that your surgeon is on the Specialist Register kept by the General Medical Council (telephone 0171 915 3638). All members of the British Association of Aesthetic Plastic Surgeons (BAAPS) are on the Register.

You can reduce the risks by closely following your surgeon?s instructions both before and after surgery. You should tell him of any thyroid disease, high blood pressure, diabetes or eye disorder such as detached retina or glaucoma. It may be that he/she will wish you to be checked by an Ophthalmologist.

Occasionally a pool of blood can collect under the skin after the operation has finished (haematoma) this usually disperses spontaneously over 2 or 3 weeks but it may need to be drained if it is large. Quite commonly the margin of the lower lid is slightly pulled away from the eye during the first day or two after surgery due to swelling. This will settle on its own or with the help of suture strips or steri-strips. Very occasionally another operation is necessary.

Sometimes tiny white cysts can appear along the stitch line. They are nothing to be concerned about but can be pricked out with a needle. Blindness is an exceptionally rare complication.

Bags are caused by an accumulation of fat and with age the skin stretches and the muscles around the eye weaken.

Transconjunctival blepharoplasty- incision made inside.

In a typical eyelid reduction operation incisions lines follow the natural lines of the eyelids.

Rhinoplasty (Reduction)

Reduction Rhinoplasty "nose job" to reduce the size of the nose
Surgery to reshape the nose is a very common plastic surgery procedure and it can both increase or decrease the size of nose. The shape of the tip, the bridge and also the nostrils can be changed as can the angle between the nose and the upper lip. Sometimes breathing difficulties can be corrected at the same time.

The nose is the central feature of the face, many people are self-conscious of shape which they may regard as too big, too small or have some other feature which they dislike. The characteristics of the nose are inherited from parents and develop during adolescent years. It continues until the age of 16, when the nose stops growing. It is, therefore, unwise to operate before this age.

What can be done?
An operation called Reduction Rhinoplasty reduces the size of the framework of the nose over which the skin is draped. The skin itself is not touched. The frame of the nose which is made up of bone in its upper half and gristle (cartilage) in its lower half is approached from underneath the skin through cuts which are made inside the nostrils. Think of the frame of the nose as being like the roof of a house. In order to straighten the nose and bring its bridge closer to the face, its "ridge" is cut away. Then, to restore a new ''ridge'' or bridge-line, the two sides of the nose are bought together by cutting the bones of the nose where they join onto the cheek bones. The elasticity of the overlying skin allows it to shrink down on the smaller frame.

This operation effectively narrows the width of the nose. If doing so makes the nostrils seem too wide, it may be necessary to narrow them as well by cutting out a small piece of skin in the floor of the nostril which would leave a fine scar on each side. It is also possible to shorten the nose and to slim down a bulky tip by reducing the amount of cartilage which shapes the end of the the nose. If you have some difficulty breathing through your nose, it may be possible to improve this at the same time by adjusting the lie of the plate of the bone which separates one half of your nose from the other. This is referred to as a Septoplasty. Sometimes the size of the nose as a feature of the face is influenced by the proportions of the other features, such as the chin and the cheek bones, and to ''normalise'' the appearance of the face it may be advisable to alter these features as well, either at the same time as the rhinoplasty, or during a separate operation.

What are the consequences?
There is always some bruising and swelling, particularly around the eyes, which can take up to three weeks to completely disappear and you would need to wear a firm splint over your nose during part of this time. By the end of three weeks, swelling will have settled sufficiently for you to look normal to others and as if you had not had recent surgery. Indeed, it is likely that you will be surprised by the absence of other people's reactions to the fact that you have a new nose. They, of course, have not been self-conscious of your nose as you have been. If you have any anxieties about family and friends noticing a change in your appearance, change your hairstyle at the same time and they will think it is that which accounts for your new looks.

It is worth anticipating your own reaction to the first sight of yourself and your new nose. To start with, you will look rather strange in the mirror and not quite 'you' because of your different nose. Remember that it takes a few days for your mind's eye to adjust itself to your new appearance and to recognise it as 'you'. You should also bear in mind that it takes a good three months or more for all the swelling to settle out of the nose so, if there are any minor problems of shape soon after the operation, do not worry, they will almost certainly improve with time. Your nose will also feel rather numb and stiff for several months, particularly around the tip.

What are the limitations?
The object of the operation is to make your nose look right for your eyes so that you lose your self-consciousness of it. It is, therefore, most important that you are clear in your mind what it is that you dislike about the appearance of your nose and that you are able to explain this to your surgeon. He or she will then be able to tell you what is surgically possible and what is not. For instance, if the skin on the tip of your nose is thick and oily, it may not be possible to reduce its bulky appearance as much as you might like because, generally speaking, it is not possible to thin the skin without leaving scars.

If you are in middle age or if you have a very large nose, there may be a limit to the amount of reduction that can be achieved to the size of your nose within the limitations of the elasticity of your skin to shrink down on the smaller frame.

If your nose is bent from previous injury, it may not be possible you make it perfectly straight. Large nostrils can be difficult to reduce without cutting the skin and leaving noticeable scars.

What are the risks?
Like any operation that is carried out under general anaesthetic, there is a small risk of chest infection, particularly among people who smoke. There is a small risk that infection could complicate the operation. You can minimise this risk by ensuring that you are free from cough, cold or sore throat at the time of your operation and, if you have any doubts, you should contact your surgeon.

Occasionally, the operation is complicated by heavy nose bleeding either shortly afterwards or after a week to 10 days which may require treatment in hospital.

It is quite common for there to be some difficulty with breathing through the nose during the first week after the operation which disappears as the swelling settles. occasionally, though, the difficulty persists and can be permanent.

Sometimes (in about 10% of patients) the nose does not look right for the patient after all the swelling has settled. In these cases, it is usually possible for the surgeon to carry out a second operation to the residual problem of appearance but, not until all swelling has settled from the first operation. Most surgeons wait for a year for this to happen. Secondary surgery like this may involve additional expense.

What can you expect at the time of your operation?
Most British surgeons prefer to do this operation under general anaesthetic and you will need to be in hospital at least overnight. The operation is remarkably painless and it is unlikely that you will need anything other than mild painkillers afterwards. It is, however, uncomfortable because you will probably have dressings in each nostril for a day or two which prevent you from breathing through your nose. You will also have a firm splint over your nose to hold the bones in their correct position.

What you should do when you go home?
You can expect to have some minor bleeding from your nose for the first day or two after your operation and you should dab this away gently with gauze squares or a clean handkerchief. Keep your head up as much as possible and avoid having hot baths. Do not blow your nose and try your best not to sneeze through your nose. If you are going to sneeze, cough it out. Once the dressings have been removed from the nostrils, you can clear your nose by sniffing into the back of your throat if you wish. Unless you are advised otherwise, it is better to leave any crusts in your nostrils until you see your surgeon for removal of the splint 1-2 weeks after the operation.

Although there is no medical reason for you to stay away from work for more than a few days, you will probably feel more comfortable if you take two weeks off and go back when the bruising has gone. Cosmetic Surgery is carried out by members of several different organisations and therefore your general practitioner is the best person to advise you on whom you should see.

Rhinoplasty (Augmentation)

Augmentation Rhinoplasty "nose jobs" to build up the shape of the nose
Surgery to reshape the nose is a very common plastic surgery procedure and it can both increase or decrease the size of nose. The shape of the tip, the bridge and also the nostrils can be changed as can the angle between the nose and the upper lip. Sometimes breathing difficulties can be corrected at the same time.

The nose is the central feature of the face, many people are self-conscious of shape which they may regard as too big, too small or have some other feature which they dislike. The characteristics of the nose are inherited from parents and develop during adolescent years. They continue until the age of 16, when the nose stops growing. It is, therefore, unwise to operate before this age.

Injury to the nose is a common cause of flatness. Occasionally, it is a characteristic which is inherited. This can also develop after surgery to the interior framework of the nose (septoplasty to improve the breathing). The owner of a flat nose may acquire the reputation of the profession of a fighter as opposed to a sports person which may have an adverse effect to self-esteem.

What can be done?
To improve the appearance of a flattened nose it is necessary to introduce some additional framework underneath the skin to raise and straighten the bridge-line. The operation is called Augmentation Rhinoplasty. Various materials are used for the additional framework such as bone, cartilage (gristle) and a range of manufactured materials which experience has shown are safe and well tolerated by the body. Each has its advantages and disadvantages which are too complex to discuss in this factsheet. The additional framework is usually introduced into the nose through a cut either inside the nostrils or in the strut of skin between the nostrils. If a bone graft is used for the additional frame it is taken either from the crest of the hip, from a rib, from the back of the elbow or from the outer surface of the skull without causing any weakness of the 'donor' bone. If cartilage is used, it is usually taken from the shell of one or both ears or from cartilage inside the nose, which is spare.

When the nose has been flattened by injury, it is quite common for the plate of bone which separated the two halves of the nose to be buckled as well. This makes breathing difficult. It can often be corrected at the same time as an augmentation rhinoplasty by straightening the buckle out but sometimes it is advisable to have this done as a separate operation beforehand.

In cases of severe collapse of the nose, skin grafts may also be necessary to achieve a satisfactory reconstruction. This is highly complex plastic surgery and outside the scope of this factsheet.

What are the consequences?
You can expect to have bruising and swelling of your face, particularly around the eyes, which will take up to three weeks to settle and during part of this time your nose is likely to be covered by a firm splint. Once the initial swelling has settled, you will find that your nose feels rather stiff and numb. The numbness will disappear slowly during the next few months but the stiffness is likely to be permanent. If it has been necessary to take a bone graft from another part of the body, you will be left with a scar which may be noticeable if it is on your hip or chest.

What are the limitations?
Although it is usually possible to make a substantial improvement to the appearance of the nose with the operation, the new frame may feel unnaturally hard. This is because it does not have the consistency and flexibility of the natural frame of the nose. You may also find that the additional frame can be moved about under the skin if it does not become fixed to the existing bony framework of your nose. These limitations need not worry you provided you bear in mind that the operation is done for the sake of your appearance. Particularly if a bone graft has been used, there is a tendency for it to gradually shrink in size during the first year or two after the operation. To help compensate for this, your surgeon is likely to put in more graft than you actually need so that to start with your nose may look over-bulky.

There may be technical limitations to the perfection of appearance that can be achieved. For example, perfect symmetry may not be possible and it may not be possible to make the nose as large as might be desired. An experienced surgeon will be able to advise you what is possible in your own case.

What are the risks?
Like any operation that is carried out under a general anaesthetic, there is a small risk of chest infection, particularly among people who smoke. Very occasionally, the operation can be complicated by heavy nose bleeding either shortly afterwards or, after a week to 10 days which may require treatment in hospital. There is a small risk that infection could adversely affect the success of the operation. Were it to happen, it may be necessary to remove, temporarily, a manufactured implant if that has been used, or it may cause a graft of bone or cartilage to dissolve. In either event, it should be possible for you to have a further recontructive operation once the infection has cleared. Sometimes a manufactured implant will extrude through the skin of the nose or its lining and need to be removed. This can happen months or years later, and is more likely if a large implant has been used or if the nose is accidentally injured. Altogether, you can think in terms of there being about a 10% risk that you may need further surgical treatment for one or more of these complications were you to have this operation done.

What you can expect at the time of your operation?
If you need only a small implant, it may be possible to do the operation without a general anaesthetic, in which case you would have injections of local anaesthetic into your nose to make it numb and you would not need to stay in hospital. For larger reconstructions and if a bone graft from the hip or chest is needed, you would probably need a general anaesthetic and, maybe, up to a week in hospital. After the operation, you will probably have dressings in your nostrils for a day or so which will prevent you from breathing through your nose. You will also have a firm splint over your nose for the first week or two. There should be very little pain in your nose but, if you have a bone graft taken from your hip, you can expect this to be quite painful for about 10 days, particularly when you walk. You will be given appropriate painkillers to help with this.

What you should do when you go home?
You can expect to have some minor bleeding from your nose for the first day or two and you can gently dab this away with a gauze swab or clean handkerchief. Unless you are advised otherwise, it is best for you to leave any crusts in your nostrils for the first week and then gently cleanse them away with cotton buds. You should keep your head up as much as possible and avoid having hot baths. Do not blow your nose and try your best not to sneeze through your nose. If you are going to sneeze, cough it out. It is safe to clear your nose by sniffing into the back of your throat.

Stitches inside your nose will probably be of the dissolving type and do not need to be removed. If your stitches are outside your nose, your surgeon will advise you on their care and the time for their removal. You will also have a firm splint over your nose in order to protect the new frame and keep it stable whilst it is settling in. Once the splint has been removed, this protection is gone and you will have to be very careful in the way that you handle your nose for the first six weeks. You should avoid any activities where you might knock your nose and you should not move it from side to side between your finger and thumb. Try your best to sleep on your back.

How long you would need off work will depend on the extent of your operation. The initial swelling and bruising will probably have disappeared within the first two weeks sufficiently for you to feel confident to show your face in public again.

However, it will take at least three months for the reconstructed shape of your nose to mature and maybe a lot longer if you have had a lot done. Do not be too critical of your nose too early. Minor unevenness of contour is common during the first few months and usually settles with time.

Conclusion
You should by now understand that this is a delicate and complex operation which needs to be designed for the needs of the individual patient. You should only consider having this operation for yourself if you are genuinely self-conscious of the nose you have at present. Do not think of having it done either for someone else's sake or if it is just a whim. If you do decide to go ahead, only go to a surgeon who is properly trained, and be guided by his or her advice as to what is possible in your own case. Cosmetic Surgery is carried out by members of several different organisations and therefore your general practitioner is the best person to advise you on whom you should see.

Reshaping Chins and Cheeks

When we talk of 'normal' facial appearance, we imply that there is a 'normal' balance to the features of the face- particularly the nose, the chin and the check-bones. If one of these features is out of proportion with the others, a face can look out unusual or maybe 'abnormal' especially to someone who is aesthetically sensitive. As it is instinctive for most of us to want to look normal, it is understandable that a person can feel self-conscious if a feature of his or her face is out of proportion; either too large or too small. Disproportion of the nose is covered in other leaflets entitled; 'Reduction Rhinoplasty' and 'Augmentation Rhinoplasty'. This leaflet deals with chins which either jut out too much or are too recessive and cheek-bones which are too flat. It may be possible that are the position of your chin is wrong because the jaw as a whole is too large or too small so that your teeth do not meet properly. If so, you would need to get advice from your dental surgeon, as you would probably need a major operation by a maxillo- facial surgeon to reposition the whole of your jaw rather than a type of treatment which is described which is described in this leaflet.

What can be done?
A jutting chin can be reduced by removing some of the chin-bone and recessive chin can be built out either by sliding the chin forwards or by inserting an implant on the bone. Each of these operations is carried out through a cut made in the grove between the lower lip and the gum though if an implant is used, the surgeon may advise that the cut is made in the natural crease under the chin.

Flat cheek- bones can be built out by inserting implants over the cheek bones usually through cuts that are made inside the mouth where the cheek joins the upper gum. The implants which are used are manufactured usually from silicone or other non- biological materials and are safe and well- tolerated by the body. Sometimes it is necessary to use a bone graft, which would probably be taken from the crest of the hip and leave a noticeable scar.

These operations can usually be done at the same time as other facial cosmetic surgery, such as a face lift or an operation to reshape the nose.

What are the consequences?
If the cut is made inside the mouth, there will be no visible scar. If made the chin, the scar should be inconspicuous in the line of the natural crease.

There is always some swelling and sometimes bruising which settles within three weeks.

Temporary numbness of the lower lip after chin surgery and of the upper lip and the side of the nose after surgery on the cheeks is common. It usually disappears within a few days though you may have a period of pins-and-needles discomfort during recovery.

An implant, particularly when it used to build out the chin, may not become firmly fixed to the underlying bone and fell a bit unstable. However, this is unlikely to have any effect on your appearance. Sometimes though, the outline of the implant's shape can be visible under the skin. Because there may be some scarring in the muscles of the chin as a result of surgery, you may find that your chin creases unnaturally when you smile.

What are the limitations?
It is usually possible to harmonize the facial features with one or more of these operations. However, as the outcome of treatment must be an appearance with which you feel happy, it is essential that you have a clear idea in your mind about what is wrong with your present appearance and that you can explain this to your surgeon. He or she will be able to give a personal opinion about the changes that could be made for the better but, in the end, it is your face and how you see it that is important. Once you have established the ideal, your surgeon will be in the position to advise you on the possibilities of achieving it.

What are the risks?
If you require a general anaesthetic, there is a small risk of chest infection, especially among smokers.

There is a small risk that part or all of lip may be permently numb and there is an equally small risk of some weakness in one or more muscles around the mouth.

Occasionally, the pressure of an implant can thin the underlying bone and, if roots of teeth are nearby, they may be weakened.

Sometimes an implant can slip out of place and require a further operation to reposition it.

Occasionally, these operations are complicated by infection which shows up as painful, red swelling and it may be necessary to remove an implant in order to clear it up. Should this be necessary the implant can usually be replaced once the infection has cleared.

What should you do before the operation?
Because of the risk of infection, it is most important that your mouth is healthy and that there is no infection in your teeth. You are strongly advised to visit your dental practioner for a cheek-up if you have any doubts.

What you can expect at the time of your operations?
These operations are usually done under a general anaesthetic for which you would need to be in hospital at least overnight. You can expect a moderate amount of pain for the first two days and some soreness inside your mouth where the stitches lie. if you have had surgery to your chin, you are likely to have it strapped for a few days. It is sometimes necessary to stabilize a cheek implant with an out side stitch for the first 4 days.

What you should do after the operation?
The most important thing to do is to treat your face gently and avoid disturbing an implant by feeling it or, worse still, trying to feel if it will move. Don't rest your chin on your hand. Keep your mouth clean and have a mouthwash after meals whilst your stitches are dissolving. When brushing your teeth, you should take care not to damage your scars with the toothbrush. You will need at least a week off work.

Setting back prominent ears

Approximately 1 to 2% of the population in the United Kingdom consider their ears to be too prominent. In many cases the shape and lie of the ears is inherited, and a family trend can be seen. The most prominent ears often lack a normal fold, and sometimes one ear is more prominent than the other. People with prominent ears are sometimes teased, particularly during their school years, and this can lead to a loss of self confidence.

What can be done?
When an ear is noted to be prominent within the first few weeks of life, it is possible to reshape it by applying a small splint to the rim. The cartilage or gristle of a new-born?s ear is very floppy and easily remoulded and after several weeks of splintage a permanent correction can be achieved. The older the child, the more stiff is the cartilage and the longer the period of splintage must be. By the age of six months the cartilage is too hard to be remoulded and a surgical solution is required.

Pinnaplasty or Otoplasty is an operation which adjusts the shape of the cartilage within the ear to create the missing folds and to allow the ear to lie closer to the side of the head. Because the operation is carried out from behind the ears, a small scar is left close to the groove between the ear and the side of the head. The procedure can be carried out under local anaesthetic, but in young children a general anaesthetic is usually required. Where the lobe of the ear is especially large, a small procedure to reduce its size may also be required.

What are the consequences?
A small protective dressing is usually worn after the surgery until the stitches are removed at between 5-10 days after surgery. Once the dressing has been discarded, it is wise to wear a protective head-band or bandage when sleeping to avoid the ears being bent forward against the pillow. The ears are often sore and tender for several weeks and painkilling medication such as Paracetamol or Codeine may be required. Other drugs such as Aspirin or Nurofen can occasionally cause unwanted bleeding following the surgery and should be avoided. The scar behind the ear usually settles well, but on rare occasions it can become red and lumpy. A small number of patients, particularly those who are very sensitive about the precise shape of their ears, may require a minor adjustment procedure. The vast majority of patients, however, are well pleased by the result, and the procedure has a high satisfaction rate.

What you should do after the operation?
The hair can be washed after the dressing and the stitches have been removed. It is important to keep the grooves behind the ears clean.

What are the limitations?
The operation is most often done during childhood, but it is best to operate when the patient is 5 years old or more, as until then the cartilage is very floppy and does not hold the stitches well. It is recommended that although parents may feel that their child?s ears should be corrected to avoid teasing and stigmatisation it is best to wait until the child recognises the problem and wants the ears corrected. Children are generally more co-operative and happy with the outcome when they fully understand why the surgery is taking place. Pinnaplasty is also performed during the teenage years and in adult life, when either a local or general anaesthetic can be used.

What are the risks?
In children the operation is carried out under general anaesthetic, and this carries with it a very small risk. In a small number of patients (approximately 3%) the scars can become thick and red, and may require further treatment. Infection is not common, but should this occur it would require treatment with antibiotics and regular dressing changes. Sometimes the dressing can chafe the ears to produce a break in the skin which can take a long time to heal. There is a small risk that the repair may not hold properly, and further adjustment surgery is occasionally required. The ears are often a little numb after the procedure, and this usually takes several weeks to settle.

Cosmetic surgery is carried out by members of several different organisations and therefore your general practitioner is the best person to advise you on whom you should see.

Before operation

After operation

An incision line is made behind the ear close to the grove between the ear and the side of the head.