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 injection 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 |
