Facelift Surgery should be evidence based and not dictated by the hype of press or social media. Rajiv has a passion for innovation and research which is reflected in a 20 year history of scientific publications and awards for improving the safety, outcome, and recovery from Facelift Surgery. The following is a summary of the processes of facial ageing, facelift science and facelift safety through the lens of original research that Rajiv has performed and published over the past 20 years – what he calls “Faceology”.

Debate has raged whether the face ages primarily by gravity or volume loss. In 2005 Rajiv had the privilege to set up a research collaboration with the QMed Institute in Sweden to answer this question. Q-Med was the company that developed the first hyaluronic acid filler, Restylane. The owner of the company was the Swedish Scientist Bengt Agerup (short listed for the Nobel Prize) who created the world’s first ever hyaluronic acid filler. Hyaluronic acids are now the world’s most commonly injected fillers and all of them owe their existence to the scientific genius of Bengt Agerup. Rajiv was honoured to work with Bengt, and to be supported by the scientific team at Q-Med.

Studying the CT scans of healthy individuals over a range of ages revealed that there is a window between the late 30’s and mid 40’s (approximately 7 years) when the first sign of ageing is subtle volume loss (i.e., deflation) in the cheek which precedes the effects of gravity. 

From the late 40’s onwards, gravity kicked in to become the dominant mechanism. It’s pull on the facial tissues, especially the midface, was downwards and forwards so the face changed from heart shaped to square (referred to as “centrofacial ageing”). In the early window when there is pure volume loss, rejuvenation with fillers is feasible. However once gravity takes hold the inappropriate use of fillers will either make the face look overfilled (“Pillow Face”), or simply make you look older because of the weight of the filler and the lack of underlying support causes further descent which exaggerates the square look, turning it into a bottom heavy appearance. In essence, you can’t fill your way out of a gravity problem; the only real antidote to gravity is lifting.

Rajiv’s research crucially revealed a third mechanism which related to bone loss from the facial skeleton. This was focussed on the jaws (maxilla – upper jaw, and mandible – lower jaw). The effects of bone loss on facial ageing commence around 50 and often related to menopause. The loss of bony framework exaggerated the nasolabial folds (nose to mouth folds), exaggerated the jowls, and created a short sloping neck profile due to the loss of jaw projection. Essentially bone loss mimicked and exaggerated the effects of gravity in the lower face and neck.

In consulting with a patient prior to facelifting it is essential do some detective work to determine which combination of these three mechanisms of ageing have given rise to the change in appearance (is it soft tissue volume loss, gravity, or bone loss?). Only by doing this can Rajiv give you an honest and realistic idea of what can be achieved because some elements of anatomy cannot be changed, such as those related to bone loss. Lifting of course only targets the effects of gravity.

Ageing can be a slow and gradual process, but this is not what Rajiv frequently saw in his patients. To answer the question whether ageing could be a sudden event, Rajiv was supported by the Q-Med Institute in Sweden to perform a ten year prospective research study following the lives of 108 women aged 40-45 at the outset and taking precise measurements to assess ageing in the upper third of the face (forehead and brow), the midface (cheek volume and nasolabial fold depth) and lower third of the face (jowl formation). These were repeated every 6 months over 10 consecutive years – the patients got to know Rajiv well!

The results were fascinating and unexpected. For some women ageing was indeed gradual, and this was especially seen in the forehead and brow. However, 58% (i.e., over half the patients in the study) at some point suffered the equivalent of 5 years normal ageing in just one year. This was usually focussed in the mid and lower face. Statistical analysis revealed that these “Ageing Spurts” were associated with one or more of the following factors:

Factors associated with an Ageing Spurt

Menopause

Stress (caused by either Bereavement/Divorce/Job Loss)

Illness (e.g., Breast Cancer)

Sudden weight loss >6kg in 3 months

This study toppled the notion of ageing being just a gradual process as more than half of the women in the 10 year study (58%) aged as much as would be expected in 5 years over just one year. Even more interesting was that predictable factors were responsible, the commonest being menopause. At the conclusion of this study Rajiv coined the term “Ageing Spurt” to describe this observation which is now in regular use all over the world.

Traditional facelifting suffers from the risk of producing a tight or pulled appearance as tension is carried on the skin. The Deep Plane Facelift was developed by New York Surgeon Andrew Jacono and creates a more natural appearance by primarily moving the layer below the skin (the SMAS) which then carries the overlying skin as a passenger without tenson. This is achieved by dissecting below the SMAS layer and releasing its attachments so it can move more freely which then has the added benefit of also moving facial volume back to a more youthful position.

The Deep Plane Facelift has been the greatest advance in Facial Surgery during the last 20 years and Dr Jacono published his scientific work in the internationally renowned Aesthetic Surgery Journal. Rajiv was privileged to be invited to write a commentary alongside Andrew Jacono’s published work evaluating its use and significance. Rajiv was also invited by QMP Medical, the publisher of Andrew Jacono’s textbook, to write a review of Dr Jacono’s work. Rajiv is an experienced enthusiast of Deep Plane facelifting and specialises in this field.

The best way to deal with complications in facelift surgery is to avoid them! Rajiv undertook a landmark study into which risk factors were the cause of complications in facelifting looking at a large series of patients (1,038) treated at the Wellington Hospital, London just before he was appointed as a Consultant Plastic Surgeon. He used a unique mathematical technique called Multivariate Analysis which permitted different surgical risk factors to be analysed simultaneously and define which ones truly influenced the complication rate. Multivariate Analysis is powerful statistical research tool which at the time was being used by Microsoft, Apple, and NASA but this was the first ever study to use such methods in Facial Plastic Surgery. The study gave surgeons an algorithm when assessing patients to help reduce the risks of facelifting and clearly revealed which factors raised complication rates after facelift surgery: 

RISK Factors

Deep Neck Surgery, especially involving salivary glands

Male patients

Patients with raised blood pressure 

Type of facelift dissection

Patients on blood thinners or dietary supplements

Smokers

SAFETY Measures

It was clear that careful blood pressure control especially during surgery was critical. The use of light general anaesthesia which allows meticulous blood pressure control and reduction of carbon dioxide level (not possible with local anaesthesia and sedation) reduced risk during facelift surgery and enhanced recovery by reducing bruising and swelling.

This unique study remains one of the most referenced publications on facelifting complications in the scientific literature to date. Rajiv was awarded the Mike Hackett Prize from the BAAPS for this work and the Mentor prize by the British Journal of Plastic Surgery for the best paper published in the journal that year. This insight and research has helped Rajiv and other surgeons to develop a mental algorithm in planning facelift surgery for patients to make it as safe as possible. 

How to improve a facelift and recover more quickly is an area full of hype and seriously lacking in evidence. Rajiv with two colleagues carried out a systematic review of the all the authentic scientific literature ever published on facelifting to provide “evidence based” recommendations on helping to improve facelift safety and recovery. Now internationally accepted, these recommendations have helped reduce complication rates as well as reduce bruising, swelling, and improve recovery times for patients undergoing facelift surgery. 

Rajiv has incorporated all these evidence based elements in his practice protocol such that patients leaving hospital after a facelift take only paracetamol for pain relief and most have minimal bruising and swelling leading to an accelerated recovery.

The conclusion of this research was the importance of trying to make a small improvement in every little detail of the facelift process which then produces a more powerful improvement overall than the sum of the individual small changes. This mirrors the science of improving sporting outcomes. The legendary Cycling coach of Team Sky and the Olympic Team GB cycling team, Sir David Brailsford described the concept of the “aggregation of marginal gains”. If there is a process which seems efficient it can still be improved by breaking it down to its most basic individual steps and improving each one even by just 1%. The resulting overall improvement far exceeds the sum of all the 1% gains.

Einstein put this beautifully when he said, “sometimes one plus one is greater than two”. Similarly in facelift surgery by making a marginal improvement in each individual step, one achieves a much greater improvement overall than the sum of the smaller (marginal) gains. Hence why Rajiv always says – “When it comes to the detail of Facelift Surgery, Everything Matters” 

Every patient wants to maintain the results of their facelift for as long as possible. Facelift longevity is multifactorial, and much relates to the surgical technique. The Deep Plane Facelift has been scientifically proven to generate longer lasting results as shown by the work of Andrew Jacono who developed this procedure in New York. However, the status of the patient’s tissues can also play a significant role. Poor skin quality can lead to earlier relapse of the lift especially in the neck. Trying to improve and maintain skin elasticity and firmness is important. A discovery in 2006 by a research group in Canada found that hyaluronic acid injected just under the skin as a skin booster (and not as a filler) can stimulate the cells that make collagen and elastin. To explore this Rajiv performed a study over 5 years to investigate if injectable hyaluronic acid in the skin after facelifting could improve and maintain its firmness and elastic qualities. This would crucially help in finding a way to help maintain the results of facelifting.

A series of patients had hyaluronic acid injections to boost and hydrate the skin after facelift surgery. Please note these were NOT fillers, there was no need to add volume, these were skin boosters that just hydrate the skin and don’t add volume or make the face look puffy. Injections were administered every 6 months and took 10-15 minutes in the clinic. Skin elasticity was measured before and after surgery as well as comparing with a group who had surgery alone and no injections. An instrument called a cutometer (aptly named) was used for the scientific measurement of skin elasticity and firmness.

Facelifting alone actually improved the skin quality as well as restoring face shape, but facelifting and hyaluronic acid injections as skin boosters further improved elasticity by about 10-15% when repeated. This effect was cumulative and increased up to and beyond two years.

Rajiv often suggests the use of injectable hyaluronic acid after facelifting especially to the neck which is the area which relapses the earliest because the skin is so much thinner than that of the face. Rajiv currently uses Profhilo as his Hyaluronic acid of choice to boost the skin and performs the injections in his practice personally. 

Facelift Surgery should be examined with the same scientific rigour as any other medical discipline. Rajiv has had a 20 year history of performing scientific research to seek evidence rather than hype to help improve the safety and outcome of his facelift patients. His research has been published both in the UK and USA and in many areas remains the scientific benchmark.