Scalping settlers may have been a gruesome business, but it was relatively simple, according to Jan Stanek, a cosmetic plastic surgeon. Once the knife had sliced through the skin, fat and fibrous tissue down to the membrane covering the skull, the scalp would 'lift up and peel off quite nicely'.
Mr Stanek is intimately familiar with the process. He will be using just such a deep incision himself, not to remove his patient's scalp, but to separate a good proportion of the upper face from the bone in a revolutionary new type of cosmetic face-and-browlift. It is called the Mask - or, slightly less chillingly, the Extended SubperiostealFacelift. Mr Stanek is shortly to perform the first such operation to be carried out in Britain.
Working in private practice in London, he does up to five ordinary facelifts each week, but by comparison these are relatively simple, skin-deep operations. They tend to need redoing eventually (up to a maximum half-a-dozen times), once the tautened skin has sagged and bagged to follow the forces of gravity and time.
The Mask is quite different. Pioneered in the United States, it tackles that world-weary look by tightening and reanchoring not just skin but muscle. It lifts the face directly upwards rather than outwards. The surgeon works at the level of facial bone, at one stage prising the fine membrane that covers the whole skull away from its underlying bone.
The result is dramatic - perhaps too startlingly youthful for some would-be patients, warns the brochure produced by one American private clinic. The Mask claims to lift the entire face by some 2 to 3cms, giving a natural effect that can knock 10 to 15 years off someone's visible age. Its practitioners claim that the surgery should never need repeating.
The operation is a purely cosmetic offshoot of work pioneered by Paul Tessier, a French surgeon. Over four decades, he has operated on people, particularly children, with severely disfiguring skull defects, often the result of the 14 bones of the face failing to knit together correctly.
In order to shift bones around and graft in new sections, Mr Tessier needed to be able to lift aside large areas of soft tissue and muscle, without damaging the nerves.
The Mask's drawbacks (apart from its cost, presently around pounds 3,500) are that it involves three hours under general anaesthetic and results in greater swelling and bruising than a standard facelift. But Mr Stanek, who studied the technique in Texas, says that the procedure is quite safe.
'The complication rate is a lot lower than for most common procedures carried out under the NHS,' he says. 'Even today, about 60 people a year die from appendix post-operative complications here and an 8 per cent infection rate is common on general surgical wards. If I had that rate among my patients, I'd be out of business tomorrow.'
He adds that if post-operative bruising later compresses the facial nerve or if it has been slightly pulled during surgery, the effects are normally temporary.
A suitable patient must fulfil certain physical criteria. The patient would need to be fit enough for general anaesthesia and must not have any kind of bleeding disorder. The face must also have aged in a particular pattern. Ideally, foreheads should be furrowed and their eyes be drooping and 'sad', with hooded lids. They should have sagging cheeks and deep creases from nose to mouth. Some loose jowling would not be amiss, either.
'All these things indicate that a standard facelift would be no good because it doesn't lift vertically,' says Mr Stanek. Thick, oily skin is best, too, 'skin that hasn't been sun-damaged'.
The first step is a stabbing cut inside the mouth, between cheek and gum, on either side of the upper jaw. The surgeon then works upwards 'to free all the space around the cheek'. Mid-face muscle and soft tissue are detached from the upper jaw, sides of nose and cheekbones.
The surgeon then moves to the top of the head, making a long 'Alice band' incision across the top of the scalp, about 5cms behind the hairline, slicing down to the membrane covering the skull. He peels away the flesh of the forehead, so that it can fall over the eyes. Then, from eyebrow-level downwards, a spatula-shaped instrument is used to lift the bone's membrane, the periosteum, from the cheekbone.
'I go around the nerves and get inside the eye socket,' says Mr Stanek. 'It's all actually quite bloodless. Then I move the instrument towards the zygomatic arch - the horizontal cheek-to-ear bone that Prince William fractured in an accident at school.'
The muscles of the upper face are then pulled upwards and reanchored, and its flesh redraped in more flattering positions. The lifted face is held in place internally, in several places, by non-absorbable nylon or prolene stitches, while any excess skin at the top of head is removed and the scalp scar closed by temporary metal staples. Provided that there is not too much tension placed on the wound when it is resealed, there should be no scarring afterwards, Mr Stanek says .
Injections of saline, of lignocaine, a local anaesthetic, and adrenaline, which constricts blood vessels, are given to reduce bleeding during surgery. Steroids are also given in fairly high doses both before and after surgery to reduce swelling, and antibiotics to cut the risk of infection. This aggressive anti-infection regime is particularly vital because an opening has to be left inside the mouth for fluid to drain out - and mouths are normally full of hard-to-eliminate bacteria.
Any fears of facial palsy as a result of nerve damage are unfounded, says Mr Stanek, since surgery is performed at bone level, far below the facial nerve.
The Mask will not help to improve crepey eyelids or below-eye skin, although a separate operation can be carried out on these areas simultaneously.
Mr Stanek believes the Mask is a 'superb operation, in the right hands and with the right candidates it looks very good, very natural, and it lasts so long. There is virtually no complication rate'.
More information about the Mask facelift is available from the Surgical Advisory Service, 23 Harley Street, London W1N 1DA. Tel: 071-637 3110. Operations are performed at the private London Welbeck Hospital.
We have received a number of letters from consultant plastic surgeons contesting claims attributed to Jan Stanek in the article 'The deeper the cut, the younger the look' (Health, 11 January). Among the points they made are: Mr Stanek will not be the first to perform the subperiosteal face-lift in the UK. The operation was first performed by a French surgeon, Paul Tessier, in 1980. It was wrong to compare risks with those in infected abdominal conditions. There is a risk of complications in all surgical procedures and to suggest otherwise is misleading.