"God has given you one face," said Shakespeare's Hamlet, "and you make yourselves another."

OK, so maybe the Bard wasn't talking about facial rejuvenation, but today, there are probably as many options for people seeking to turn back the clock as Will had sonnets. From facelifts to Botox(r) injections, there are many procedures that can help the face look more youthful or in proportion-and not all of them involve surgery.

People are taking advantage of these opportunities to look younger or improve a perceived facial flaw. Three of the five most frequently performed cosmetic surgeries in 2000 involved the face, according to the American Society of Plastic Surgeons: Nose reshaping was the most popular, with 389,155 procedures; followed by eyelid surgeries, with 327,514, in third place; and facelifts, with 133,856, ranking fifth.

While other medical specialists perform certain facial procedures (an ophthalmologist might do eyelid surgery, for example), plastic surgeons have the specialized, comprehensive training to work on all areas of the face. That's important, since patients often choose to have more than one procedure done on different parts of the face on the same day. A person might opt to have surgery to make her lower eyelids look less baggy and a facelift to improve the appearance of the lower two-thirds of her face, for instance. Dr. Mark Granick, professor of surgery at the New Jersey Medical School and chief of plastic surgery at University Hospital, who is board certified in both plastic surgery and otolaryngology (ears, nose, and throat, or ENT), says his dual specialty enables him to offer patients "the best of both worlds."

When choosing a surgeon, one item to look for is certification. A surgeon certified by the American Board of Plastic Surgeons has completed at least five years of residency training (typically three years of general surgery and two of plastic surgery); practiced plastic surgery for at least two years; and passed written and oral exams.

It's also in a person's best interest to ask a lot of questions about the surgeon and the procedure before committing to anything. Talk to friends and acquaintances who've had facial rejuvenation procedures about their experiences, or ask a primary care physician whom he or she would recommend. The surgeon should be experienced in the desired area and someone the patient feels comfortable talking to, never pressuring him or her to undergo a surgery.

Which isn't to say the surgeon won't offer recommendations. "If a person wants her nose reshaped, she might not realize that without also augmenting a weak chin with an implant, her face will not look balanced," says Dr. Granick. "My goals are to look at the face as a whole, use the simplest procedure to accomplish what the patient wants done, and to do all of this with safety as a top priority."

Most facial rejuvenation surgeries are same-day procedures that use a "twilight" intravenous sedation, or, in some cases, a local anesthetic. While some of these surgeries have been around for many years, the techniques are constantly being refined. The benefits can include smaller incisions, a faster healing period, or a more natural look.

Take the facelift. While Phyllis Diller's mask-like facelift provided fodder for late-night talk show hosts in the 1970s, this procedure has undergone a transformation. "Plastic surgeons have learned a lot about the structure below the skin since then and have adapted some techniques used by craniofacial surgeons," explains Dr. Granick. "Typically, we lift the tissue off of the skeleton, remove fat and tighten the muscle, and then reposition the skin. This results in a facelift that is more natural looking."

While the facelift addresses problems on the lower two-thirds of the face, such as sagging skin around the neck and jaw line, a browlift focuses on the upper one third. A browlift can help diminish the appearance of furrows in the brow and create a more youthful, pleasant look. For this minimally invasive procedure, button-hole-size incisions are made in the scalp. Using an endoscope- a thin, telescope-like surgical instrument attached to a tiny camera-the surgeon can tighten the underlying skin and muscle.

Eyelid surgery, or blepharoplasty, can help correct heavy, droopy-looking upper eyelids or lower lids that have "bags" beneath them. The surgeon can work on one or both sets of lids. "As with the facelift, there have been many advancements made in eyelid surgery," notes Dr. Granick. "What was one surgery for both lids now has evolved into several procedures. We can hide incisions within the lower lid so there is no visible scarring and tighten the lids without that 'pulled-down' appearance."

While most facial rejuvenation procedures and treatments are not covered by insurance companies, when the heaviness of upper lids is so severe that it interferes with vision, eyelid surgery is sometimes the exception.

The most popular facial rejuvenation surgery, rhinoplasty, is also one of the most complex, says Dr. Granick. "The nose is three dimensional and requires precision and artistry to produce the desired result. We're working on bone and cartilage, which respond differently to injury, and sometimes internal structures, such as the septum, as well." Chin or cheekbone augmentation-implants that can be inserted in these areas-can be done alone or in conjunction with a "nose job" to provide balance to the face.

Pre Procedure	Post Procedure

There's another facial surgery that, while it doesn't help people look younger, can correct an often-embarrassing problem: significantly protruding ears. Otoplasty is a relatively simple operation that can reshape the cartilage of the outer ears. Ideally, this operation is done when the patient is young-about first grade. "There are also adults who, having undergone years of teasing as children, now can afford to have their ears reshaped," says Dr. Granick.

Right Ear Before Procedure	Right Ear After Procedure
Left Ear Before Procedure	Left Ear After Procedure

All of these facial rejuvenation procedures usually have few complications. However, there can be swelling, bruising, and. as with any surgery, a chance of anesthesia-related problems or post-operative infection. Most people who undergo facial rejuvenation surgery are able to return to work within one to two weeks.

Non-Surgical Approaches to Facial Rejuvenation     

Sometimes people want a more youthful appearance, but don't want to have surgery. There are limits to what surgery can accomplish, also. While a lower eyelid lift can remove "bags," for example, it does not erase "crow's feet."

Botox is one of the most popular treatments to reduce the appearance of facial wrinkles. This diluted form of botulinum toxin blocks the nerve stimulation of muscles, forcing them to relax. As a result, the wrinkles "smooth" away. "Botox is very effective in areas where wrinkles result from skin being pulled by muscles, such as the forehead and around the eyes," says Dr. Granick. "While Botox is given by injection, it is not painful. The recovery time is immediate, and the results are long-lasting-about four to six months."

Eyebrows at rest	Eyebrows raised
Pre-Injection
1 Day Post Injection
8 Days Post Injection

There are other options that can be done by themselves or in addition to facial rejuvenation surgery. Collagen, a natural protein, can be injected to "plump up" wrinkled areas or add fullness to the lips. Chemical peels are solutions that can be applied to the face to help reduce fine lines and acne scarring and correct uneven pigmentation. Peels come in various strengths, and the healing time can be lengthy. Another non-invasive procedure, microdermabrasion, buffs, or exfoliates the skin, using a special crystal technique.

Dr. Granick offers a couple of caveats about facial rejuvenation procedures. First, most are considered elective and therefore not covered by insurance. Some people reach for the "plastic" to pay for hospitalization costs, surgeon's fees, and the anesthesiologist's bill. There are also financial organizations that specialize in making loans to plastic surgery patients.

One more thing. "Facial rejuvenation doesn't give back youth," he says, "but it does a great job of letting people borrow it."

For more information about the Cosmetic Surgery Center, visit our Web site at: www.TheUniversityHospital.com/plastics or call (973) 972-8071.