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27.02.2015
IntroductionThe interaction of art and surgical aesthetics is essential to achieving a natural and pleasing result following cosmetic surgery.
IntroductionAgeing of the upper and lower eyelids is normally due to a combination of loose skin and protrusion of fat. The eyes may tend to water in cold air or windy weather during the first week or two until the swelling subsides. The lower lid may droop very slightly while the lid is heavy and swollen but this is self-correcting once the swelling has reduced.
Redness in the scars occurs occasionally during the initial three months and is more common in red haired people. IntroductionAgeing within the upper third of the face causes horizontal creases in the forehead and dropping of the eyebrows.
It is common to have a headache for the first few days following a browlift due to stretching of the nerves to the scalp. Some numbness over the forehead and scalp can also occur due to stretching of the nerves and this usually recovers within a few weeks. A small amount of hair loss in the region of the incisions is very occasionally seen although this will recover over a period of time.
Endoscopic Browlift is an excellent operation for rejuvenating the forehead and lifting the brows to give an open appearance and fresh look to the upper third of the face which are characteristics of youth and beauty. Charles is extremely experienced in aesthetic and functional plastic surgery of the nose (nose jobs, rhinoplasty) and is also an expert in nasal and sinus disease and how to treat it. Having graduated from the University of London, Charing Cross Hospital Medical School in 1980, Charles was awarded the Hallett Prize by the Royal College of Surgeons of England and continued his training in ENT at Oxford, University College Hospital and the Middlesex Hospital. He is lead clinician for the Rhinoplasty service at the Royal National Throat Nose and Ear Hospital and is also part of the craniofacial surgery team at University College Hospital Foundation Trust. He has served as UK Vice President of the European Academy of Facial Plastic Surgery and regularly lectures at national and international meetings. The extremely successful textbook, Ear Nose and Throat – Head and Neck Surgery was co-authored by Charles and he has also written chapters in the British national textbook “Scott – Brown’s Otolaryngology – Head and Neck Surgery”. He is currently a board member of the Rhinoplasty Society of Europe and an active member of the European Academy of Facial Plastic Surgery.
Nose job Scotland When considering a nose job (rhinoplasty) there are important questions that you need to consider. This crucial interaction was the subject of the Guggenheim lecture delivered at the Louvre in Paris by Rajiv Grover in 2009. As this causes the appearance of tiredness and eye bags the operation of eyelid reduction (Blepharoplasty) is one of the commonest procedures for facial rejuvenation. Repositioning the brow and forehead gives an open appearance and fresh look to the upper third of the face which are characteristics of youth and beauty. He formed Rhinoplasty London along with his partner Lydia Badia to provide specialist advice, treatment and surgery options for those suffering the misery of nasal and sinus problems.
He then went on to be a senior clinical and research Fellow in the University of Washington Seattle for 12 months studying Facial Plastic surgery. He has also been a faculty member at the Royal College of Surgeons for minimally invasive sinus surgery courses and is current Chairman of Facial Plastic Surgery UK, a committee at the Royal College, and is a specialty adviser to National Institute of Health and Clinical Excellence (NICE). We have listed some of the most commonly asked questions below with answers about our own practice: What is a rhinoplasty? He is the first surgeon to have been given this honour and has also lectured on the importance of an artistic element to surgical technique in order to improve the outcome of cosmetic surgery at The Royal College of Art in London as well as the University of the Arts (Central Saint Martins). In the upper eyelids ageing causes stretching of the eyelid skin producing a “hooded” appearance. It aims to compensate for the drop in brow position that occurs with age although this can take place at a relatively young age in certain individuals with a familial tendency. The central facial triangle, consisting of the two eyes and the mouth, is therefore a key feature of the face. These problems can be rectified surgically by operating on the eyelid itself and removing or adjusting excess skin and fat (Blepharoplasty).In some patients, the primary problem may be due to sagging of the eyebrows with age rather than the eyelid in which case a brow lift may be indicated. The chances are excellent that you'll be happy with your surgery but you must be aware that the results may not be apparent immediately. If the eyebrows drop it also creates the impression that the upper eyelid has excess skin as it all gathers between the eyebrow and the upper lid.The operation of Browlift is performed by Mr Grover using the Endoscopic ("key hole") technique. Even very young children look at faces this way long before they have learnt about facial beauty or perception.Artistic perception and the central facial triangleThe central facial triangle is the first area to draw the gaze of an observer.
This can usually be carried using “key hole” techniques leaving no visible scars on the eye or forehead. The freshening of your eyes and improvement in the tired appearance will benefit self-esteem, confidence and should last for years.
This utilises a surgical telescope (endoscope) to lift the brow and forehead without the need for visible scars. Andy Warhol used this to his advantage when creating flattering silk screen prints of his subjects. The need for brow surgery either alone or in addition to eyelid surgery will be discussed with you at your consultation. The incisions are short (12-15 mm) and kept within the scalp in order to keep them well hidden.


Mr Grover’s approach to eyelid surgery is to provide a natural appearance often guided by looking at photographs of your face when you were younger so any surgery ensures that you, still look like “you”.
The operation of Endoscopic Browlift is often performed in conjunction with surgery to the eyelids for removal of loose skin or bags (Blepharoplasty). Any feature which could distract from the central facial triangle such as the nose was minimised. He is particularly known for his artistic approach to achieving a natural look and has lectured on the importance of an artistic element to surgical technique and how this can improve outcome at the Louvre in Paris as well as the Royal College of Art in London.
This way he emphasized the youth and beauty of his subjects.Silk screen prints by Andy WarholIn the world of Photography the Vogue cover which was voted the most iconic of the 20th century was the January 1950 cover photographed by Erwin Blumenfeld which has distilled the face down to just the eye and mouth and yet we still can perceive it as a face. If you are a smoker it is helpful to stop for two weeks before surgery and for a week afterwards so as not to restrict the circulation to the skin.Where will my surgery be performed?The surgery is performed at the King Edward VII Hospital in central London where Mr Grover works as a Consultant Plastic Surgeon.
A face where the central facial triangle is emphasized may be perceived as more attractive.
Wide bright eyes and proportionate lips without features that could distract attention away such as a large nose, prominent nose to mouth lines or jowls mean that one can focus on the key features of the central triangle. While making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days at home.Where will my surgery be performed?The surgery is usually performed at the King Edward VII Hospital in central London where Mr Grover works as a Consultant in Plastic and Aesthetic Surgery.
He does not shave any hair at all during browlifting as it can easily be parted with hair gel. Particularly around the eyes the smooth junction between eyelid and cheek mean that the eyes stand clear as does the mouth so attention focuses on the central facial triangle. Mr Grover infiltrates the forehead with a salt solution containing local anaesthetic (tumescent infiltration) as this reduces swelling and bruising after surgery.
The fact that her central facial triangle is so clear makes her very beautiful.Brigitte Bardot age 25Can anatomical features enhance the central facial triangle?Although the eyes and lips themselves are the key areas of facial perception, they can be enhanced by certain anatomical features. What type of anaesthetic will be used?Blepharoplasty is usually performed under a general anaesthetic, so you'll sleep through the entire operation.What does the operation involve?On the upper eyelids the incision is carried out in the natural crease line that is located about 8-10 mm above the eyelashes.
Both the eyebrows and the cheeks “frame” the eyes and the cheeks in particular act as a pedestal for the eyes.
Enhancement of the cheek within the normal anatomical range therefore acts to enhance the appearance of the eyes which in turn improves our perception of the face.
After making the incisions, the excess skin and muscle is trimmed from the upper eyelids together with any fat. This interaction of the cheek with the central facial triangle was clearly understood by the great artists of the Italian Renaissance such as Sandro Boticelli. The incisions are then closed with very fine sutures which are passed below the skin therefore leaving no external stitch marks.On the lower eyelids, the technique very much depends on the patient's individual circumstance and requirements. At the time of the surgery the frown muscles can be weakened as well in addition to lifting of the brow.
The majority of his works are housed at the Uffizi gallery in Florence including “Primivera” which announces the arrival of spring.
If the problem is mainly prominent lower bags without loose skin, you may have what is termed as a transconjuctival blepharoplasty.
Mr Grover is always careful to judge the position of your brow carefully in order to avoid creating a startled appearance after surgery.
Although the painting is famous for the inclusion of the three graces the depiction of Primavera herself is a good example of how the cheek (i.e.
The skin is then supported in the new position and the wounds are stitched with dissolving sutures. Alternatively, when there is also some loose skin the incision is made just underneath the eyelashes where it is very well hidden. A more limited degree of brow lifting can be also achieved through the incisions made for an upper lid Blepharoplasty and if this is appropriate it will be carefully explained at your consultation.How long will the surgery take?Endoscopic browlift usually takes about an hour depending on the extent of the surgery. The skin is then lifted upwards and outwards, and after removing some underlying fat, the skin is carefully sutured after removing the excess.How long will the surgery take?Blepharoplasty usually takes between an hour and an hour and a half, depending on the extent of the surgery. Is it painful?For the first few days it is common to experience some headache in the forehead region after browlifting as the nerves to the scalp in this area are stretched.
Interestingly about 7 years before there is evidence of gravity causing tissues to descend there is a gradual LOSS of volume from the face particularly over the cheek which changes the form of the face from heart shaped to more square (Published in the American Journal of Aesthetic Surgery march 2006). Before and after photos of patient operated on by Rajiv GroverIs it painful?Your eyelids will probably feel a little tight and as the anaesthetic wears off and it is normal for this to continue for a few days afterwards. What can I expect after the Surgery?It is hoped that you will have only mild swelling and bruising following your browlift, however this does vary depending on whether any eyelid surgery was performed at the same time. By reducing cheek volume the “pedestal for the eyes” is diminished which reduces their prominence in the central facial triangle which we know to be important for youth and beauty. Whilst in hospital the nurses may apply cool soothing pads to your eyes in order to minimise this swelling further. In addition it is advised to rest for the first few days with your head elevated on 2-3 pillows as this also helps. The age at which this volume loss from the cheek begins is between 38 and 40 with gravity having an effect about 7 years later.Volume loss occurring 7 years before effects of gravity in facial ageingIs the concept of change in shape being the central factor of ageing something new?Absolutely not! This is normal and usually returns in a matter of weeks, although occasionally it may take a little longer.
During the first week you should avoid straining and bending down as this tends to increase the swelling.


Although the world of science may have thought this was a new discovery the world of art had known this for nearly 500 years.
What can I expect after the surgery?It is hoped that you will have only mild swelling and bruising following your Blepharoplasty, however this does vary from patient to patient. Mr Grover will arrange to see you after about 7-10 days to check all is well however as the stitches are dissolving and hidden in the scalp there will be no sutures to remove.Most patients can return to work after about 10 to 14 days although it will probably take at least 4 weeks before you would be ready for a major social event. In his teachings on how to draw the features of an older face Leonardo da Vinci commented that the most important determinant of age was face shape and second was facial features like the nose to mouth lines and last of all was skin wrinkles. It is better to avoid wearing contact lenses for at least two weeks after browlifting and in some individuals this is best avoided for about a month.What are the scars like?The Endoscopic Browlift is performed by Mr Grover using a "key hole" technique so all the small incisions are kept hidden in the scalp. The muscles of the forehead cause horizontal creases and similar creases are seen vertically between the eyebrows as the frown muscles fold the skin over time.
This means that there will be no visible scars.What are the risks?It is important to stress the possibility of risks although in practice these are rare and Endoscopic browlift is an operation with a high level of patient satisfaction and a reliable outcome. The eyelids age first by developing crepey skin which later develops into bags as the underlying fat of the eye socket protrudes forward.Middle Third Changes in midface volume lead to loss of cheek prominence and the combined effect of this volume loss and gravity then leads to deepening of the nose to mouth lines (nasolabial fold).
After about a week your stitches will be removed by Mr Grover and you will be able to wear make-up to hide any residual bruising.Most patients can return to work after about 14 days although it will probably take at least 3-4 weeks before you would be ready for a major social event. Lower Third Here the effects of gravity rather than volume loss are most noticeable with development of jowls due to loss of skin tone and eventually loose skin in the jaw line and neck. It is better to avoid wearing contact lenses for at least two weeks after Blepharoplasty and in some individuals this is best avoided for about a month.What are the scars like?In general, blepharoplasty scars heal well although variations in the healing process do occur from individual to individual.
A computerised research tool developed to study the science of ageing by Rajiv Grover in collaboration with the Qmed Institute.What happens to the Central Facial Triangle with age?In the youthful face the prominence of the eyes is enhanced by the cheek and midface volume whilst the appearance of the mouth is clear as it has not yet developed any nose to mouth lines which can distract attention from it.
The scars along the lower eyelashes and in the upper lid almost always heal with a near invisible line after several weeks have passed. As the face ages the loss of midface volume detracts from the eyes and the presence of nose to mouth lines distracts from the mouth as do the development of jowls.
Those extending out into the crow's feet area can become slightly reddened and may require a little longer to settle completely. The appearance of the central facial triangle therefore seems to reverse.The signs of ageing seen in the “real face” of Brigitte Bardot age 25 and 62. Massage of these scars speeds up their recovery and this will be discussed with you by Mr Grover once the stitches are out.What are the risks?It is important to stress the possibility of risks although in practice these are rare and blepharoplasty as an operation with a high level of patient satisfaction and a reliable outcome.
Loss of midface volume and jowl formation reverses the perception of the central facial triangle.How does all this help us rejuvenate and enhance the face in the 21st Century?The foregoing discussion has emphasized that beauty is to some extent dependent on the appearance of the central facial triangle. Certain features like a large nose, prominent nose to mouth lines or jowls take emphasis away from the central facial triangle and so distract from beauty. As we age the most important and first change is volume loss from the cheek which reduces eye prominence and through reduction in facial support deepens the nose to mouth lines. Modern rejuvenation should therefore address these changes in order to rejuvenate in a natural way and one which respects what is known from the work of the great artists.What was wrong with previous methods of Facial Surgery?The previous approach to facial surgery focussed on the fact that ageing lead to loose skin and therefore tightening of the face and neck was the main aim. The effects of tightening the skin alone rather than the underlying soft tissues lead to surgery which caused pulling of the cheek and flattening.
The tension in the skin distorted facial appearance including the ear which was often pulled forward. A biography of him shows a youthful face in his 40’s and later in life after an “alleged” facelift we see distortion around the mouth, flattening of the cheek due to pulling and because of the tension in the skin, there is an opposite reaction around the ear where it gets pulled forward (the so called “pixie ear deformity”). John Paul Getty in middle age and in his late 60’s after facial surgery that tightened the face by pulling only skin and paying no attention to volume.
This did nothing to enhance the central facial triangle and so did not rejuvenate in a natural wayThe Modern ApproachSurgery has changed a lot in the last two decades and appreciation that the soft tissues also require support rather than just pulling the skin has lead to the so called “deep plane” lifts where the underlying muscle of the face (SMAS) is pulled in addition to the skin.
The true appreciation that cheek volume is the key to beauty and also the key to a natural, artistic rejuvenation has only reached prominence in the last few years. Its recognition in the popular press lead to the cover of New York Magazine having a picture of Madonna emphasizing her beauty through the heart shaped face where volume in the cheek emphasizes the central facial triangle.Madonna at age 50 on the cover of New York magazine which had an article on how new beauty was about volume (500 years after Leonardo da Vinci had said the same!!)Volumetric enhancement to face shape and beautyWe can learn from this scientific work and the lessons of the great artists by using volume to enhance the cheek and so make the eyes a greater focus within the central facial triangle. The fact that volume in the cheek also creates beauty which is typical of youth gives it a double significance in trying to rejuvenate and give some artistic beauty to the face. Here the study of photographs taken about 10 years before and also from the patient’s youth allows the character and shape of their face to be studied so that a bespoke and natural surgical plan can be made.
These photographs (usually just family snaps) act as the surgical “Roadmap” for the planning.
Of course the surgery must be carried out meticulously and by an experienced surgeon but one who has at his disposal the many tools which can aid in making a facelift not an “off the shelf” procedure but a truly individual operation for each patient.
Focussing attention on adding volume to the cheek and midface enhances the perception of the central facial triangle which creates a beautiful and youthful face. The amount of volume and extent of the change can be guided by a “roadmap” of the patients own photographs.It should be humbling to all surgeons that this knowledge is actually over 500 years old and first documented by Leonardo da Vinci. However it is in fact intuitive in the minds’ of all great artists who have known this for centuries!




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