The Demise of the Scalpel

By: Katharine Griffiths
Created on 09th June 2010

Mr Chris Inglefield of London Bridge Plastic Surgery takes a provocative look at how the rise of the non-invasive procedure could be the death of traditional cosmetic surgery

The desire to look younger or at least better for our age is now well established, and this goal is realistic for everyone due to the greater accessibility of treatments and extensive media exposure.

In order to reverse the signs of ageing, facelift surgery has been the gold standard for most of the twentieth century. A revolution occurred in the 1970s with the description of the SMAS lift technique and over the last three decades numerous modifications have evolved.

The goals of surgery were focused on improved results, reduced scarring, shorter recovery and reduced risks. However, despite the improvements in lifting techniques, all surgery results in significant scars, real risks and prolonged recovery.

Peeling back the years
Surgery also can't improve the complexion. Skin peels were therefore used to remove the signs of sun damage and ageing - mainly lines, wrinkles and pigmentation.

Peeling also carried significant downtime and side effects. Until the last 15 years, patients who desired facial rejuvenation were limited to facelift surgery and aggressive peels.

Dermabrasion was introduced as the first non chemical ablative technique to improve the appearance of the skin and was used extensively for facial scarring and skin rejuvenation.

Dermabrasion was a very crude technique, which was effective but carried with it significant risks of worsened scarring and de-pigmentation of the skin.

Lighting the way
Laser skin ablation using CO2 and Erbium-Yag lasers brought in a new era in accurately controlled skin ablation. This was used extensively for over ten years but, like dermabrasion, carried risks of scarring and depigmentation and a long healing time.

Despite these drawbacks, laser skin ablation became the gold standard in skin rejuvenation with effective removal of actinic damage and age spots as well as good skin tightening.

However, the limitations of lasers fuelled the pursuit of less invasive technology, resulting in the introduction of Intense Pulsed Light. This broad spectrum of light was able to target a range of chromophorbes in the skin to reduce pigmentation and activate fibroblasts.

With little downtime and encouraging results IPL was widely accepted. But it only induced modest improvement in lines, resulting in the continued search for an effective technology to address skin laxity.

Increasingly, patients have become less tolerant of the long healing time and side effects of facial rejuvenation. Improvements in technology have therefore been driven by patient demands.

Ablative lasers have been superseded by fractionated CO2 in the attempt to reduce downtime and side effects but maintain the effectiveness.

Energy savers

Other energy sources have been introduced in the last ten years including radiofrequency and ultrasound energy. The first non-invasive RF device was Thermage. This produced modest improvement in skin laxity but was a very uncomfortable treatment with significant risk of fat necrosis. A Bipolar RF device, Accent, proved to be better tolerated with few risks and is modestly effective in treating skin laxity.

The use of ultrasound for facial rejuvenation is in its infancy and is predicted to provide the most effective technology for nonsurgical facial rejuvenation in the future.

Filling in the gaps
Non-surgical facial rejuvenation took a significant step forward with the introduction of dermal fillers, beginning with collagen in the 80s and hyaluronic acid in the 90s.

It has not been until the last five years that the concept of facial volumising has been fully appreciated. Prior to this, loss of skin elasticity was considered the main cause of facial ageing.

The introduction of dermal fillers has brought about a revolution in non-surgical facial rejuvenation. Various attempts to introduce some form of cellular therapy have produced interesting concepts. Platelet rich plasma and fibroblasts seem promising and cellular therapy is likely to make a major contribution to the goal of true facial rejuvenation.

Facing the future
With all these exciting technologies, will there be a need for the surgeon's scalpel? Certainly, the generation of the 70s and 80s, who have been exposed to the explosion in non-surgical options as well as significant advances in the understanding of skin ageing, will be less likely to advance to surgical facelifting in later life.

This generation has benefitted from the development in skincare products designed to reverse the effects of ageing on the skin, reduce the accumulated DNA damage, and protect us from environmental insults.

The emphasis on prevention and protection which evolved when this generation was in their youth has resulted in significantly less extrinsic ageing changes and likely slowing of the intrinsic ageing process, both of which will ensure that these individuals look more youthful in their twilight years.

The continued advances in the science of ageing mean that the indications for surgical facelifting will continue to shrink. Advances in cellular therapy promise true regeneration of the facial skin, soft tissue and possibly even bones.

The age of the scalpel in facial rejuvenation is certainly waning and the future for patients looks exciting.