Face the Facts

Created on 24th February 2009

Leading surgeon in the field of aesthetic facial plastic surgery, Norman Waterhouse, has recently developed a new kind of surgical facelift that means goodbye to the ‘wind tunnel’ look

Development of a philosophy After twenty years of experience in facial reconstructive and aesthetic surgery, I have developed an algorithm for facial rejuvenation. During this time, the philosophy and execution of facelift techniques has undergone enormous changes. The vast numbers of operations have reflected a philosophical change in what the operation should achieve.

The emphasis on removing and tightening facial skin has now diminished. We all recognise that this can produce a taut unnatural result. Equally, it is understood that just operating on the neck and lower face can produce an unbalanced ‘operated’ look even if it technically achieves its goals.

Greater attention is now given to ensuring that the volume in the face is repositioned and maintained, to ensure that the shape of the face is feminine and soft (a male facelift has to be addressed quite differently).

Elevating and repositioning loose and drooped facial tissue has spawned many innovative procedures and, even now, the facelift community is obsessed with ‘mid-face mania’; the desire to restore full malar (cheek)
prominence and a more youthful appearance around the eyes.

For several years I used to do this with a deep technique developed in France and often referred to it as a ‘masklift’. This operation was very successful but the recovery period was often lengthy.

The appreciation of the need to preserve or enhance facial volume led to the development of the ‘volumetric’ facelift using quite large amounts of the patient’s fat to restore youthful features.

Despite all the new developments, it became gradually obvious to me that one fundamental principle has remained. The best method of repositioning facial fat and soft tissue is by using SMAS as the vehicle. SMAS stands for Superficial Muscular-Aponeurotic System and is the
medical term for the muscle Layer present underneath the skin layer. With the SMAS lift the muscle layer is lifted and refreshed before the actual lift. This provides a longer lasting result than with the classical facelift where only skin is tightened.

The Waterhouse Facelift

So, the next step was to determine the best technique of SMAS surgery that would achieve the following goals:a natural youthful, feminine,
soft appearance that did not look ‘lifted’, an operation that preserved rather than removed tissue, a short recovery time and, importantly, very low complication rates.

Perhaps the simplest SMAS procedure is an operation devised by New York surgeon, Dan Baker. He has been performing this technique for many years with consistently good results. Indeed, a famous study involving identical twins has shown that his operation worked just as well as the vastly more complicated ‘composite’ facelift.

The operation is called the ‘lateral smasectomy’ facelift. I started to use his over ten years ago for patients with thin faces or for those undergoing secondary or revision facelifts. I was so impressed that I started to use it for most of my patients. However, I still felt that the procedure could be improved in two areas: the neck and the cheek area. As a result of that I modified the technique to reposition more tissue back into the face and particularly the cheeks. I also tightened the lax neck muscles as part of the same manoeuvre. The real value of the modification was that I have almost never needed to carry out a separate ‘mid-face’ lift (although I do still use fat injections for patients with very thin faces).

I have used this ‘modified lateral smasectomy’ facelift for several years and published the results of the first 360 patients in the American Plastic and Reconstructive Surgery Journal.

Naturally, each patient is treated as an individual and there are other techniques I use in addition to the lift to achieve a natural appearance of the whole face.

I almost always combine the lift with a lateral endoscopic browlift. This is different from the traditional endoscopic browlift, which tends to give an unnatural shape to the eyebrow and a somewhat startled expression. The lateral browlift does not remove any of the frown muscles in between the eyebrows. These are best treated with Botox!

The procedure gives a natural and feminine shape to the eyebrow and takes away any ‘hooding’ of the upper eyelid. For some patients, I use the techniques to gently lift the corner of the eye, when the eyelid is rounded or lowered as a result of poor eyelid surgery.

All experienced facelift surgeons recognise the difficulty of achieving natural results for patients with very thin faces. Traditional lifts may result in tight, gaunt or hollow look, which is not youthful or natural.
In these situations I may use at transfer or I may choose not to remove any of the SMAS. Instead, the tissue is tightened in the same direction as the smasectomy.

Over many years, I have expressed anxiety about the potential complications of traditional lower eyelid surgery.(This is a complex subject nd beyond the scope of this article.) However, because the lateral smasectomy procedure elevates the tissue under the eyelid and gives this area more fullness, I have frequently found it not necessary to perform so many lower lid blepharoplasties.

For the past ten years I have been teaching this facelift to young plastic surgeons at the Wellington Hospital. It is very pleasing that they have almost all adopted it as their preferred technique and report excellent
results with short recovery times.

Plastic surgery never stands still and I am sure that further modifications and refinements will occur in the future.