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Facelift by by Dr. BCK Patel MD, FRCS in Salt Lake City and St. George, Utah

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“Well, the last time I had a picture taken I could hardly see my eyes because of the weight of heavy eyelid. Then I paid attention to how I was actually using my eyes and I really noticed when I was looking at anything especially the computer I was straining my forehead to see better. Since I have had it done I no longer have to lift the forehead and tilt my head to see. It is amazing! I love…” D. Rock 63 Yrs Old with Fat Droopy Eyes – Salt Lake City, UT

Movement of our facial muscles (called animation) allows us to smile, frown and grimace. Movement of muscles moves the overlying skin, which results in dynamic lines or wrinkles. In our youth, these are not visible once we stop animating the face. However, over time, changes in skin where these lines of animation form result in more permanent lines. For example, the constant use of the forehead leads to horizontal forehead lines, and smiling results in radiating lines on the outer corners of our eyelids, commonly called Crow’s feet. Vertical lines between the brows are a result of overaction of our frown muscles and are commonly called elevenses. There are numerous other areas on the face where major or minor lines or wrinkles may form. With an accurate knowledge of anatomy and physiology of human facial muscles and skin, it is possible to modulate some of these lines and bulges with considered use of botox. This is not injection by the numbers: faces differ, sexes differ, the degree of overaction of muscles and the depth of lines and prominence of bulges also differ. This is where the careful use of toxins gives excellent results. Botox is one of such toxins. ​There are several different types of botulinum toxin on the market, including Botox, Dysport, Myobloc and Xeomin. ​

Natural smile lines in a smiling face of a northern Indian

HOW DO I KNOW IF I AM A CANDIDATE FOR BOTOX?

Walk-in, walk-out, injections by the numbers are the reasons why there are so many poorly performed botox injections. Not everyone needs botox for improvement of changes on the face. At times, other modalities like chemical peels, lasers, fractionated lasers, fotofacial lasers, or even surgery may be better for you. An assessment of your concerns and a careful examination of the dynamic and static lines, grooves and bulges, together with any discoloration of the skin from sun damage and other conditions allows us to determine what the best treatment might be. ​

WHAT IS BOTOX?

Botox is a one of a group of chemicals termed “neurotoxins”. Simply put, it is a chemical that blocks the transmission of impulses from a nerve ending to a muscle. Therefore, the muscle is not able to function when such

​an injection is administered.

WHAT IS THE EFFECT OF BOTOX INJECTIONS?

As the muscle is unable to contract after the injection of botox, several effects are seen. Where muscles tend to cause a bulge, like the frown muscles, these bulges are relaxed. Where the contracture of the muscle causes a groove, like forehead grooves and frown line grooves, these become shallow (during the duration of the effect of the injections). And because of the decrease in contracture of the muscle, the overlying skin wrinkles also look better.    The effect should be to leave you looking relaxed and rejuvenated, with fewer worry and frown lines, but at the same time leave you with the ability to still express yourself. This is very important so as to avoid the overly “botoxed” face, so common these days. ​
 
Appearance before and after botox injections and filling with filler to improve frown lines by Dr.BCK Patel MD, FRCS
Where can botox be injected to benefit the appearance of the face? A drawing by Dr. BCK Patel MD, FRCS
BUT ISN'T BOTOX A POISON?
Botulinum toxin is, indeed, a poison. However, when the toxin is modified and weakened to very accurate scientifically determined levels, the chemical is able to decrease the movement of the muscle without any systemic effect: that is the chemical that we inject: you should have no concerns about any systemic effects from the controlled injection of the botulinum toxin. Millions of injections of botox have been administered safely over more than 30 years.
 

HOW DO I KNOW IF I AM A CANDIDATE FOR BOTOX?

Walk-in, walk-out, injections by the numbers are the reasons why there are so many poorly performed botox injections. Not everyone needs botox for improvement of changes on the face. At times, other modalities like chemical peels, lasers, fractionated lasers, fotofacial lasers, or even surgery may be better for you. An assessment of your concerns and a careful examination of the dynamic and static lines, grooves and bulges, together with any discoloration of the skin from sun damage and other conditions allows us to determine what the best treatment might be. ​
WHAT AGE DO I HAVE TO BE TO ​GET BOTOX?

We use botox for medical reasons in patients of all ages, from babies to older patients. For cosmetic reasons, it is wise to only consider injections when you are an adult and able to comprehend the pros and the cons of such injections. ​

WHAT DO I EXPECT FOLLOWING TREATMENT?
The effects of the injections are usually seen three to four days after injections although some of our patients claim to see results almost immediately. When the chemical takes effect, the areas injected will show an improvement in fine lines as well as deeper wrinkles. Where the intention is to reduce the movement, one will notice such reduction in movement: for example in the brow area where injections are administered to reduce the movement of the frown muscles.
Results of botox injections combined with fillers for frown lines also called elevenses
Results of botox injections combined with fillers for frown lines also called elevenses
WILL I BRUISE?
Remember that the face is full of vessels. We use cooling of the skin to reduce the risk of bruising. Some areas are more likely to bruise than others: for example, the lower eyelids and the crow’s feet areas are vey vascular and may bruise more easily than the forehead or the frown muscle injections. After the injections, use of ice can reduce bruising.
 

I HATE NEEDLES: WILL IT BE PAINFUL?

None of our patients has ever jumped up and run away! We apply an anesthetic cream when patients want it. Our regular patients have an anesthetic cream prescribed which they apply before they leave home: this reduces the sensitivity of the skin sufficiently to make the injections almost pleasant! We also apply ice and we have a Zimmer cooling device which is very helpful in reducing bruising as well as discomfort. ​
 
Results of botox injections combined with fillers for frown lines also called elevenses

HOW OFTEN WILL I NEED INJECTIONS?

Most patients find that getting injections every three to four months is ideal. However, if your lines, wrinkles and bulges are not too prominent, you can easily go longer. We always assess your results after a month when we first inject you to ensure that you get the best possible result and also to guide you as to how long the effects may last. ​

HOW LONG WILL THE EFFECTS OF THE INJECTIONS LAST?

Although there are scientific studies that show that regeneration of the nerve endings allows the muscles to work again as early as two-and-a-half months after injections, we find that the benefits of the injections often last three to five months. Of course, the effects of the injections don’t just stop suddenly but wear off gradually.  ​
Before and after results of judicious use of fillers for nasolabial and melolabial folds, and botox for frown lines
IF I KEEP ON GETTING THE INJECTIONS, WILL I EVENTUALLY NOT NEED THEM ANY MORE?
There is no evidence that the nerves stop producing new endings: therefore, it is unlikely that you will achieve Nirvana. ​
I HAVE TRIED BOTOX BUT IT DOES NOT WORK ON ME?
We see many patients who tell us that they have been getting botox but that it does not work on them. When we have injected these patients using our strict attention to concentration and the number of units needed, we have never seen anyone in whom botox does not work! Also, it is not a matter of working or not working, but also subtleties of the effect of the injections have to be taken into account. When artistically injected, it is possible to leave expression but also a very pleasing relaxed and rejuvenated look. Injecting botox is like being an expert at playing a musical instrument: it is possible to achieve many effects with appropriate knowledge, skill and attention to detail!
Before and after photographs showing the result of microbotox to the forehead lines
Botox and fillers used to treat the frown lines caused by the corrugator and procerus muscles
WHO WILL INJECT ME?
​In many clinics, such injections are delegated to nurses or aestheticians. A detailed knowledge of the 43 facial muscles is vital, however, in order to inject in the right spot, to the right depth, and using the correct combination. The panoply of movements which are a result of groups of muscles acting in unison but also individually makes it easy to inject in the wrong group of muscles, or to get the balance wrong. As we not only learn the function and actions of these facial muscles in detail but regularly operate upon faces with facelifts, browlifts, blepharoplasties, etc, we believe that the most trained and knowledgeable person should inject: to that end, you will only be injected by Dr. Patel.  ​
 
“Well, the last time I had a picture taken I could hardly see my eyes because of the weight of heavy eyelid. Then I paid attention to how I was actually using my eyes and I really noticed when I was looking at anything especially the computer I was straining my forehead to see better. Since I have had it done I no longer have to lift the forehead and tilt my head to see. It is amazing! I love…” D. Rock 63 Yrs Old with Fat Droopy Eyes – Salt Lake City, UT
FACIAL MUSCLES
  • Occipitofrontalis muscle
  • Temporoparietalis muscle
  • Procerus muscle
  • Nasalis muscle
  • Depressor septinasi muscle
  • Orbicularis oculi muscle
  • Corrugator supercilii muscle
  • Depressor supercilii muscle
  • Auricular muscles (anterior, superior and posterior)
  • Orbicularis oris muscle
  • Depressor anguli oris muscle
  • Risorius
  • Zygomaticus major muscle
  • Zygomaticus minor muscle
  • Levator labii superioris
  • Levator labii
  • superioris alaeque nasi muscle
  • Depressor labii inferioris muscle
  • Levator anguli oris
  • Buccinator muscle
  • Mentalis
  • Platysm
Facial muscles
Facial muscles
Facial muscles
Facial muscles
WHY IS IT IMPORTANT TO KNOW WHERE TO INJECT?
As I am sure one would understand, the orchestra sounds good when everyone plays in harmony. Similarly, the 43 facial muscles have to work in harmony to give us a pleasing look, a beckoning smile, a genuine kind smile, a come-hither blink! If injections are not given with a proper knowledge of this orchestra of facial muscles, you get the many comments I hear: “she looked strange”, “wow, her brows have a diablo look”, “my wrinkles are gone but why are the brows so low?”, “I can’t smile!”, “my husband thinks I look weird now”, “nothing moves when she smiles or am surprised!”. “he looks like a woman now!”, etc. I have heard all these more and many more besides. Let us look at this orchestra of muscles:
 
WHETHER I GET INJECTIONS INTO THE FOREHEAD, THE FROWN LINES OR THE SMILE LINES, OR ALL THREE, CAN MY SMILE BE AFFECTED? HOW IS IT DIFFERENT?
Again, the orchestra must play in unison and must be synchronous. Ever noticed how there are basically two types of smiles: a genuine smile and a fake one? This distinction has been of interest to researchers for quite sometime now. In fact, the genuine smile has a name.
It’s called the “Duchenne smile,” named after the French physician Guillaume Duchenne, who studied the physiology of facial expressions in the nineteenth century.
The Duchenne smile involves both voluntary and involuntary contraction from two muscles: the zygomatic major (raising the corners of the mouth) and the orbicularis oculi (raising the cheeks and producing crow’s feet around the eyes).
A fake smile or, as I like to call it, a “Say Cheese” smile involves the contraction of just the zygomatic major since we cannot voluntarily contract the orbicularis oculi muscle.
The Duchenne smile

This is interesting, but why is it so? What’s going on upstairs that creates these two different smiles?Scientists have discovered that these two types of smiles are actually controlled by two completely different parts of our brain. When a patient with damage to the motor cortex on the brain’s left hemisphere attempts to smile, the smile is asymmetrical, with the right side of the smile not moving as it should. However, when that same patient spontaneously laughs, the smile is normal with no asymmetry. This means that the genuine smile is controlled by some other part of the brain. Now, when a patient with damage to the anterior cingulate (part of the limbic system) in the left hemisphere attempts to smile, there is no asymmetry. The smile is normal. However, when that same patient tries to smile spontaneously, the asymmetry appears.

Thus, the “Say Cheese” smile is controlled by the motor cortex while emotion-related movements, like the Duchenne smile, is controlled by the limbic system (the emotional center of the brain). But, does it truly matter if your smile is contrived or authentic?

Apparently, it matters a great deal to your life satisfaction (and quality of marriage, ability to make friends and how you are perceived in business and life!) “Say Cheese” smiles, and the non-smilers.

The researchers followed up with these women at age 27, 43, and 52 and asked them questions about their life satisfaction and status of their marriage. They found that the Duchenne smile predicted positive outcomes in marriage and well-being up to 30 years later.

So remember, a genuine smile will probably make you happier than you think! THAT is why it is important to know the orchestra members, the orchestra and the hall within which they play!

References:

  1. Damasio, A. (2006). Descartes’ Error. Vintage (Rand).

Harker, L. and Keltner, D. (2001). Expressions of positive emotion in women’s college yearbook pictures and their relationship to personality and life outcomes across adulthood. Journal of Personality and Social Psychology, 80(1):112-124.

BEFORE AND AFTER

Botox for crow's feet or smile lines before and after photographs
“I had a excellent eye lift done by Dr. Patel. He knows what he is doing and is very pleasant. Dr.Patel was easy to get an appointment and he works with you. The office staff was very pleasant and made you feel calm.” D. Gull Highly recommended for eye lift surgery – Salt Lake City, UT
Botox for masseters to slim the face
ARE THERE ANY SIDE-EFFECTS?
  • Bruising and swelling may occur, but that may happen whenever injections are administered.
  • Asymmetry: on occasion, you may notice a more or less effect of the botox on one or the other side. This is really not a side-effect and can easily be corrected. It is best to wait four weeks to ensure that one is not over-injecting.
  • Ptosis: this is a droop of the upper eyelid. This may happen in about 3% of injections when administered in the frown area for the elevenses. If this happens, the droop disappears within a few weeks. Although there is a drop that can be used to lift the eyelid temporarily, your pupil may look a little bigger after the use of this drop. Ptosis is not a serious side-effect and in most cases disappears in two to three weeks.
  • Allergic reaction: Although there have been reports of allergic reactions, I have never personally seen one. A few patients sometimes develop a tiny dot at the site of the injection which may be a little tender to the touch. These just disappear within a few days.
  • Oedema: this is swelling. Remember, our facial muscles allow us to pump fluid away from certain areas. It is because our lower eyelid and cheek muscles move that we are able to reduce the overnight lower eyelid puffiness that many people get. After botox injections in certain areas, especially the lower eyelids and the smile lines, some degree of puffiness may occur. Again, this is not severe and disappears within a few days.
  • Ache and headache: a few patients report a slight headache after the injections for a few hours or a few days. This is unusual. More often, patients notice that those that suffer from frontal headaches actually get relief. ​

ARE THERE ANY SIDE EFFECTS?

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FAQs

Facelifts are performed in an operating theatre for the sake of sterility and your comfort. We have a team of anesthesiologists and nurses who are trained to specifically look after patients undergoing these procedures.
 
 
General anesthesia is best for facelifts, although in some instances, sedation anesthesia may also be used.
 

With a 3-D procedure, there are several layer of sutures, accurately placed to give the lifting, tightening and filling, without leaving any tell-tale pull-lines. Some are slow dissolving sutures, others are more permanent. The skin sutures are generally removed between 7 and 14 days. ​

Lasers will be used to treat peri-oral lines, “sleep lines” on the cheeks and other skin irregularities. The advantage of using all the skills and modalities available to us, rather than performing quick or weekend or one-hour facelifts is that it allows us to give you a remarkable improvement not only in the structure and appearance of the face, but also the health and smoothness of the skin as seen here:
 
Facelift surgery can take between 3 and 5 hours of surgery time, depending upon the planned procedures, patient’s face-type, age and other factors. ​
 
Bruising and swelling are de rigeur! However, significant long-lasting complications are rare.
Bleeding is not common as we pay close attention to proper hemostasis. On rare occasions, a small hematoma may collect.
​
Everyone will experience some numbness in the face: this resolves over weeks to months. This occurs because of the dissection of the face. This is not a complication.
Because of the dissection and repositioning of the tissues, it is common for there to be small differences in the smile between the right and left sides: this is usually only noticeable to the patient and to Dr. Patel! It recovers over a few weeks.

All faces have asymmetry and there will be some degree of asymmetry. This is to be expected.
Permanent weakness of nerves and muscles is rare.
The scars are usually very well hidden. However, some patients may have a tendency to cause hypertrophic scarring: in such cases, certain lasers and treatments will help. By-and-large, scars are rarely a problem. With Caucasian skin, pinkness of scars is to be expected for several weeks. With darker skin, some hyperpigmentation may occur. 
 
Bruising around the jawline and upper neck is common for the first two weeks. The face itself usually will not get much bruising, but may be pink from any laser work. Swelling is to be expected because of the extent of the surgery: the swelling abates over about two weeks. ​
 
Only if insurance will buy you a Rolls Royce (Phantom, of course). ​
 
A sensation of firmness will be there because of the swelling: this is present for the first few days. Most patients do not need prescription pain medication after the first two to three days. ​
 
We will provide you with a special neck dressing which you will wear as much as you can for the first couple of weeks. You will also apply a moisturizer (any brand will do) to the face as healing skin and lasered skin requires moisturizer. Icing the face also helps for the first two to three days. Many of our patients will ice the face for longer as it feels good. You may be up-and-about the day after surgery. Gentle exercise (treadmill and stationary bicycle) may be commenced by day 3. More vigorous exercise like skiing and tennis may be resumed by about day 10. ​
 
Ideally, you should be within about 3 – 5 pounds of your desired weight. Whereas I can create the most beautiful angles and curves in slim patients, if you are able to get close to your ideal weight, we can wonders as can be seen in this patient who lost some weight before her surgery and is absolutely chuffed at her result:
 

In the first few days, everyone will experience some degree of dryness and blurry vision. You will also feel that your lids look a little tight on the outer corner where you will also feel some of the deeper sutures if you put your finger there: this is of no concern. The tightness and the bumps under the skin settle over a few weeks.
More serious complications which are very rare include excessive bleeding, hemorrhage and loss of vision. 

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    Contact Info

    ​Dr. BCK Patel MD, FRCS
    ​1025E 3300S
    Salt Lake City, Utah 84106, USA

    (801) 413-3599 (phone/text)
    E-Mail: bckpatelmd@gmail.com
    bckpatel.info

    Dr. BCK Patel MD, FRCS
    617 E Riverside Dr Suite 101
    ​Saint George, UT 84790, USA
    (435) 215-0014
    ​E: drbckpatel@gmail.com

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