| In the last 10 years, public interest
in the use of cosmetic surgical procedures has burgeoned. This interest
has paralleled a remarkable rise in media attention, which has ascribed
credence to certain practitioners and techniques while often disregarding
the current medical literature and the extensive postgraduate training
and rigorous examinations that plastic surgeons undertake to gain
acceptable qualifications. The internet is an expanding source of
both authentic and uncorroborated information: 25,000 websites are
now devoted to cosmetic surgery and available to inform - and confuse
- the public.
This article aims to provide up to date information about popular
procedures and to respond to increasing requests from GPs for reliable
information. An article that introduced the different procedures,
with emphasis on the risks, benefits and preoperative work up of
each, has previously been published by the author.
Facelifting
The major trends in facelifting have been the development and provision
of less invasive procedures in order to reduce residual scarring
and minimise morbidity for all patients. It is likely that many
younger patients who are now undertaking to have facelifts would
not have proceeded if not for the availability of current, less
invasive surgical techniques.
An individual's changes with natural ageing are largely influenced
by his or her degree of facial expression, amount of sun exposure,
genetics and lifestyle.
Normal ageing in the Caucasian population results in:
- laxity of the deep facial tissues beginning at the brow and
especially in the neck.
- loss of bone density in the facial skeleton.
- thinning of the subcutaneous tissues
- increasing fatty deposits in the neck and jowls
- skin wrinkling (to varying degrees).
Depending on the severity of each ageing component, a combination
of techniques can be used to re-establish a smooth, 'toned' appearance
without the surgical stigmata of scars, tension, hairline distortion
or ear lobe displacement. (Figure 1a and b).
Figure 1a and b. A woman shown before
and after a facelift.
A combination of techniques to was used to produce a toned appearance.
The amount of evidence of facial ageing in the upper, mid-face
and lower face differs in each individual and may occur at the same
or different rates in each area of the face. The upper face will
be dealt with in the section on browlifting.
The Mid Face
The mid face is comprised of the orbit and the cheeks. Ageing of
these parts results in:
- flattening of the cheeks
- deepening of the nasolabial lines
- widening of the orbit at the junction of the lower eyelid and
cheek.
Lifting of the mid face involves re-suspending the orbicularis
oculi muscle, possibly augmenting the cheek with fat or a cheek
implant and replacement or shifting of herniated orbital fat pads
into the 'hollowed' or lengthened orbit. Minor elevation of the
mid face can be achieved by a transconjunctival approach; however,
major elevation of the mid face requires skin resection with a separate
subciliary incision to achieve an optimal result.
Primary elevation of the mid face generally involves a lower blepharoplasty
or facelift either alone or in combination. A major drawback of
these mid face procedures is the possibility of damaging the orbicularis
oculi muscle function with a resultant ectropion ('round-eye') often
made worse in the post-operative period by swelling and scarring
in the orbital septum (see Figures 2a and b) .
Figures 2a and b. A woman with 'round
eye' after previous facelifts including an attempted
lift of the mid-face. The ectropion was corrected by secondary facelifting
and canthoplasty.
Endoscopic techniques also have an application in lifting the mid-face
through the browlifting approach and suspending cheek fat pads superiorly
on the zygoma.
The Lower Face
An accumulation of fat in the neck results in a double chin which,
in the younger age group (that is, under 40 years of age) can be
corrected by liposuction (see Figures 3a and b). In older patients,
accompanying laxity of the platysma muscle means that results from
liposuction are less satisfactory.
Figures 3a and b. A woman with a
fatty neck and double chin. The problem was corrected by liposuction
alone.
Many patients who have a "turkey neck" wrongly think
that the problem can be improved by liposuction alone. Neck lifting
procedures, however, address the problem of neck laxity due to muscle
ptosis and are performed either in conjunction with a facelift or
as a limited surgical 'stand-alone' procedure. Incisions can be
made behind the ear, just in front of the earlobe and under the
chin. The platysma through these incisions, is approached and tightened
centrally and laterally and surgical suture 'slings' can be put
across the neck in order to define the jawline. This is called the
Giampapa procedure. Laxity of the jowls and prominence of the labiomental
folds can be ameliorated by localised liposuction to improve the
appearance of the lower face further (Figures 4a and b).
Figures 4a and b. A patient before
and after a limited incisional lift of the lower face,
combined with endoscopic browlift, blepharoplasty and localised
facial liposuction.
Neck lifting is highly sought after by men over the age of 50 years
whose main concern is their double chin. Male patients' major apprehensions
are not only surgical scarring but also displacement of the natural
beard. The lower facelift currently in use improves the neck without
beard displacement or an obvious pre-auricular scar.
The 'S-Lift' which has been highly advertised and discussed in
the popular media, has not yet been authenticated by the scientific
literature. Unfortunately, the S-Lift in effect reverts to an older
technique in which a highly undesirable scar is situated in front
of the ear and includes a limited surgical dissection with several
sutures inserted into the platysma and the superficial fascial structures
of the face. This lift fails to address laxity of the mid face and
is likely to have a limited, short-lived outcome. Patient dissatisfaction
with the S-Lift is likely to be high, not so much because of the
scar (which will fade with time) but because of the transience of
the result.
The Upper face (browlifting)
One of the most successful procedures introduced since 1995 has
been the endoscopic browlift, which is used for brows affected by
central and lateral overactivity of the facial musculature. When
the muscles are released, a gentle ascent of the brow is achieved
with relaxation of the attendant scowl, the consequence of heavy
or overdeveloped hyperactive glabellar musculature (Figures 5a and
b).
Figures 5a and b. A patient before
and after a facelift, eyelid
surgery and browlift to provide upper facial rejuvenation.
Utilising the endoscopic technique for browlifting involves minimal
scalp scarring (an advantage over traditional brow lifting) with
four or five 1 cm incisions rather than one 25 cm incision. In addition,
there is no transsection of branches of the supraorbital nerve which
occurred with the long incision. The endoscope has also had a limited
but useful mid-face application - lifting can be achieved by applying
traction on the deep cheek tissues which can, in turn, be elevated
and fixed above through a small brow incision.
Blepharoplasty
Blepharoplasty is still popular for eliminating a tired, wrinkled
appearance and bulging fatty tissue in the infraorbital area. Herniated
infraorbital fat is removed from the lower eyelids and then replaced
in the orbit or moved to a more appropriate position. To reduce
the 'hollowed out' appearance, it is now preferable to remove less
fatty tissue than in the past - established techniques involve conservative
fat removal and laser resurfacing to reduce wrinkles in the lower
eyelids.
In lower eyelid surgery, it is extremely important to prevent 'round
eye' or 'scleral show' stigmata by avoiding excessive skin resection,
orbital septal scarring and orbicularis oculi denervation. Treatment
of 'scleral show' requires possible reattachment and tightening
of the lateral canthal ligament or, in extremely rare cases, skin
grafting and release of the scarred orbital septum. For a well-trained
and skilful surgeon, this complication should be avoidable.
All upper eyelid surgery aims to establish an attractive supratarsal
fold, reduce bagginess and smooth the pretarsal skin. A 'hollow'
look is averted by not overresecting fat (Figures 6a and b).
Figures 6a and b. A 50 year old
woman before and after upper and lower eyelid blepharoplasty.
The carbon dioxide ultrapulse coherent laser and Sharplan feather
touch laser are the cosmetic surgical industry's current standards
for resurfacing in the periorbital region. Laser resurfacing with
carbon dioxide results in a controlled burn, causing contraction
of collagen which effectively shrinks' the wrinkles in this area.
There is potential for a permanent skin hypopigmentation, and for
demarcation line to occur between the resurfaced skin and the normal,
sun-damaged skin.
The erbium laser has recently been introduced into cosmetic surgical
practice. Satisfaction with long term results is unknown, but it
has less likelihood of a pigmentary change in the skin than the
carbon dioxide laser therapy.
Rhinoplasty
There are still two standard rhinoplastic techniques, 'open' and
'closed'. The open technique involves an incision in the columella
to elevate the skin of the nose and expose the cartilages and septum.
The closed technique involves no external excisions.
Results have continued to be refined, and the term 'finesse rhinoplasty'
is applied to a higher quality result, rather than a 'cookie-cutter'
approach used to achieve a reduction or refinement (Figures 7a and
b). Note that, in a multi- cultural society such as Australia, an
appreciation of the different aesthetic requirements of different
population sub- groups is imperative for the successful outcome
of rhinoplasty.
Figures 7a and b. A patient before
and after 'finesse' rhinoplasty and chin augmentation.
In rhinoplasty, resection alone will not provide an optimal result
in all patients. For patients with traumatic deformities or certain
ethnic origins (such as Chinese or Thai), the nasal dorsum is deficient
and augmentation is necessary - this can be achieved by using silicone
prostheses or autogenous material (the patient's own cartilage or
bone). In my opinion, autogenous material is preferable because
it has less tendency to twist or distort with time, bonds biologically,
and is less likely to erode through the delicate tissues of the
nose.
Digital imaging technology has made pre-operative facial imaging
popular. Patients can see how changes in their nose and chin can
affect their overall appearance, especially their profile. Digital
imaging has been integrated into many corrective surgical procedures,
especially rhinoplasty. By viewing the possible cosmetic improvements,
patients can realistically appraise the potential benefits.
Over the last decades, teenagers have begun to seek advice on rhinoplasty.
A twisted nose or dorsal hump will often detract from one's appearance
and cause psychological stress that is reflected in dysfunctional
social behaviour. In such cases, surgical correction has been shown
to improve psychosocial skills greatly.
Facial Implants
Although there is scepticism regarding any silicone product, solid
silicone chin and cheek implants are quite popular. No systemic
side-effects secondary to the use of these implants have been alluded
to.
Other materials used for implant manufacture include porex and
hydroxyapetite - these are 'more similar to bone' and therefore
often favoured by maxillofacial surgeons. Porex and hydroxyapetite
implants are stiffer than silicone (making them less 'user-friendly'
for the surgeon) but they achieve the same objective of changing
the shape of the soft tissues around the cheeks and chin to strike
a better balance in the skeletal base of the face.
Silicone nasal implants are popular in Asia where a higher nasal
bridge is regarded as attractive (Figures 8a and b); however, these
implants generally do not bind to the nasal dorsum and have a disturbing
rate of exposure over time. Silicone nasal implants are available
in various sizes and shapes, but must be customised to the patient's
aesthetic desires. Ideally, the implants should not be too large,
or have an unnatural 'show'. The rate of infection from silicone
implants is very low -infected implants usually have to be removed
can be re-inserted at a later date.
Figures 8a and b. A patient before
and after nasal augmentation with a silicone prosthesis.
When the chin is asymmetrical or the patient suffers from microgenia
(i.e. chin too small) an implant can be used or alternatively a
segmental genioplasty. With the genioplasty, the bony mentum is
sawed from the body of the mandible, re- positioned and sometimes
augmented with hydroxyapetite, synthetic bone in order to stabilise
the new position of the chin. Patient acceptance of genioplasty
is not high because of the perceived complexity of the procedure
i.e. sawing of the bone and most cases who present clinically can
be significantly improved by the use of a silicone implant alone,
placed on the chin either through a submental incision or through
the mouth. (Figure 9).
Figures 9a and b. A patient before
and after rhinoplasty and genioplasty.
Injectables
There is a high demand for non-surgical procedures especially for
volume fill to wrinkles and soft tissues. Collagen, which has a
low rate of complications, has been the preferred nontoxic injectable
product for the last 20 years. The popularity of collagen has waned
even more recently as it is a bovine product and the negative press
regarding 'mad cow disease' has reduced its appeal further. Non-permanent injectible,
Perlane and Hylaform are newer, injectable hylauronic acid gels
that, when injected into wrinkles or deficient soft tissue, are
often efficacious for up to six months (compared with three months
for collagen). Non-permanent injectible and Perlane are non-bovine products and
after 3 years of use, help to 'plump out' wrinkles in patients who
are looking for a 'quick fix' and are prepared to have a temporary
result. The non-permanent injectible is usually more painful than Collagen
and will require a nerve block prior to injection when used for
lip enhancement (particularly in younger women).
Botulinum toxin was initially used to treat nervous tics
such as blepharospasm (i.e. eyelid twitching) and has gained considerable
popularity to treat overly prominent glabellar wrinkling, orbicularis
wrinkles and asymmetry around the mouth and nose (Figures 10a and
b). Botulinum toxin has been proven to generally last for three
to four months. Gore- tex, which gained some popularity as a strip
filler, tended to be palpable when placed in soft tissue and is
less acceptable in the long-term.
Figures 10a and b. A patient before
and after injections of
botulinum toxin to the glabellar area to reduce glabellar frowning.
Fat restructuring
Fat injections have received recently considerable media attention.
In many patients, however, the transitory and unpredictable nature
of fat injections and grafts necessitates repeat procedures and
leads to problems. Usually, the fat is harvested from the abdomen
and thighs, cleaned and then microdrops are injected into areas
of atrophy, 'bony' show or 'hollowness' to re-establish the smooth
contours of youth.
Lip enhancement, which is a highly popular procedure, can be achieved
through fat injections, but the unpredictable nature of the results
may detract from the popularity of the procedure (Figures 11a and
b).
Figures 11a and b. A patient before
and after fat injections to the lips.
Dermal fat grafts for enhancing the lips are more predictable than
fat injections because the dermis makes the fat less likely to be
absorbed. Grafts can be harvested from old scar tissue or a crease,
and the intact dermis attaches the fat to provide a more predictable
'take'. Dermal fat grafts are most useful for contour deformities
of the face that occur with ageing, after trauma and for hypoplastic
thin lips (a result of ageing or hereditary thinness).
Neck Liposuction
Patients in the younger age group (that is, less than 40 years
old) may have fatty deposits in the chin and neck area than can
cause a double chin. Pneumatic and ultrasonic liposculpture have
been introduced but traditional liposuction with an aspirator and
a fine cannula will allow the fat to be harvested under and along
the neck by access through three 2 mm incisions behind the ear and
under the chin (Figures 12a and b).
Figures 12a and b. A patient before
and after liposuction of the neck alone with chin augmentation.
Summary
The range of procedures offered by the plastic surgeon dealing
with facial cosmetic surgery has increased dramatically over the
last decade. The incorporation of digital technology, endoscopy
and the response to consumer demands for less traumatic procedures
has relegated the traditional facelift to antiquity. There is every
reason to expect because of the great demand there is for facial
cosmetic surgery that the developments will continue at the same
hectic pace.
This two-part article will conclude next month with
a discussion of cosmetic surgical options for body enhancement.
References
1. Hodgkinson D J - A place for cosmetic surgery: Part 1. The Face.
Mod Med Aust 1993; 36(3): 32-42
2. Hodgkinson DJ. A place for cosmetic surgery: Part 2. Body Contouring
- Mod Med Aust 1993; 36(4): 66-78 |
