by Eid B. Mustafa, MD, FACS

INTRODUCTION: Aesthetic plastic surgery, which is popularly referred to as cosmetic surgery has been and will remain a dynamic specialty. This article will highlight some of the advances that have taken place in the last few years.

FACIAL SURGERY

Facial surgery can be done either to reduce the effects of aging or to redefine facial features. The former refers to the facelift, eyelid, eyebrow and forehead rejuvenation procedures and to skin treatments in the form of skin care with different products, chemical peels and laser resurfacing. The latter deals with facial contour changes of the nose, chin, cheeks and ears.

FACELIFT SURGERY

A facelift is a procedure that addresses the sagging cheek, jowl and neck tissues. It started as a skin operation many years ago. The facelift of today is a rather complex operation that addresses most of the involved tissues in the aging process. The skin, facial muscles and fascia as well as the fat compartments are modified to achieve the desired rejuvenation. The operation is more customized to the individual needs of the patient and the results are superior to the skin only operation. Surgery is being done on relatively young patients. Endoscopic techniques for facelifting, which usually refers to rejuvenation of the upper face, will be addressed under forehead and eyebrow surgery. However, occasionally it is extended to the lower face. This is done in an attempt to tighten the deeper facial tissues and minimize the extent of the incisions around the ears. The indications for this type of surgery are very limited at this stage.

EYELID SURGERY

Eyelid changes affect people’s looks more than other parts of the face, since while communicating people look into each other’s eyes. Nowadays, the fat in the lower eyelids, which gives people a tired look, can be removed through the conjunctive, without external skin surgery. This has special appeal for younger and dark skinned people. If there is skin redundancy, it is addressed with surgery or with laser resurfacing. Some prefer to rearrange the lower eyelid fat by advancing it on the cheek to correct the tear trough. Upper eyelid surgery can be combined with reduction of the frown muscles and some upward repositioning of the eyebrow through the same incision. Eyelid surgery is often enhanced with intradermal tattooing of the eyelid margins in the form of a semi-permanent enhancement of the eyelashes.

EYEBROW AND FOREHEAD LIFT

A better understanding of the aging face and the occasional disharmony between the upper and lower face following standard facelift surgery have resulted in more emphasis on rejuvenating the upper face. This is done through repositioning of the eyebrow into a more youthful location, modulating its contour and reducing the frown and forehead line. These procedures have been traditionally done through incisions in the scalp or at the hairline, but occasionally through midforehead and direct eyebrow incisions. The resulting scars and sensory changes from such operations have often been of concern to the patient, prompting the development of endoscopic surgery for this part of the face. Endoscopic operations are done through multiple small incisions within the hairbearing part of the scalp, releasing the eyebrow attachments to the orbit and repositioning of the eyebrow and forehead tissues into a more desirable location. Minimal, if any, skin excision is performed. Different fixation techniques are currently in use and long term result have been encouraging. The procedure should be tailored to the patient’s needs and desire. It is sometimes done to address only the frown lines by reducing or paralyzing the frown muscles.

SKIN TREATMENTS

The above mentioned operations address the major skin folds and irregularities as well as the disproportionate fat distribution of the facial and neck tissues. They do not modify the quality of the skin and do not affect the fine skin lines or blemishes. Managing these changes should start with educating the patient about preventive measures and ways to maintain a healthy skin. Heredity is a factor that cannot be changed. However, the degree of sun exposure, alcohol consumption, inadequate and poor nutrition and particularly smoking are factors that can be controlled to the patient’s benefit. Treatment for the fine lines and other signs of skin damage and aging involves the use of Retin-A preparations, the use of Vitamin C and fruit acid peels and maintenance programs in various combinations. Chemical peels and lasers are more involved but certainly more effective.

Retin-A has been shown to help some patients improve the quality of their skin and reduce the fine lines if used on a regular basis. Most of these improvements, however, tend to disappear once the treatment is discontinued. Some patients benefit from and tolerate the treatment with this product more than others.

Vitamin C preparations are reported to produce more or less similar effects to those of Rein-A. Its use is still not widespread, though.

Fruit acid peels and maintenance preparations have been popularized in the last few years and tend to give patients a more youthful appearance and possibly some improvements in their skin tone and wrinkling. Their effects are not very dramatic, however, but for mild cases of skin aging, they can be appropriately used.

More aggressive peeling of skin using trichloracetic acid preparations or phenol has been used for many years.

The TCA peels can be effective for the fine skin lines and are particularly useful in addressing the pigmentary skin changes.

The phenol peels are some of the oldest and most effective ways to deal with the fine skin lines but would result in a lighter skin than what the patient started with. This in itself might not be as problematic for the lighter skinned person, but the line of demarcation may necessitate the use of cover cosmetics afterwards on a regular basis.

CO2 LASER RESURFACING

The carbon dioxide laser has been around for many years. It is only in the last few years that it has been used to treat facial skin wrinkles. The concept is not much different from that of chemical peels and dermabrasions and involves the precise removal of some of the outer layers of the skin. The laser energy has been shown to induce the production of collagen, which tightens the skin and helps reduce and in some areas, eliminate the fine skin lines. Laser resurfacing is not a painless operation and should not be taken lightly. The patient’s skin should be prepared for two to four weeks with certain preparations which will also be needed after the facial skin heals. Laser safety precautions should be strictly adhered to. The patient should expect several days during which the skin would be healing and sometimes uncomfortable. Some patients experience a sense of heat in the skin that may last for several days and is quite unpleasant. Close expert monitoring of the healing of the skin is very important to obtain a good result.

Scarring can develop but is usually treatable, especially if noticed early. Hyperpigmentation is common but is usually treatable. Redness or pinkish discoloration of the skin is a normal result for a few months after the operation. Hypopigmentation is less likely and tends to be of a more permanent nature. This is much less frequently encountered than with phenol peels. Dramatic improvement of skin lines is often noted with laser resurfacing. The continuous improvements in technology, the better understanding of the healing process of the laser burn, and the availability of longer term results with this new technique have resulted in a rapid increase in its use for the treatment of the skin lines. Its high tech appeal and aggressive promotional advertisements have a lot to do with its increasing use.

THE ERBIUM YAG LASER

This is a new laser that is gentler on the skin, less painful to the patient and results in a more rapid skin healing. It is introduced as an alternative, not a replacement for the carbon dioxide laser. It is less effective (as of today’s technology) in eradicating the skin lines and blemishes but is also less taxing on the patient in terms of the degree of pain, discomfort and period of healing than the carbon dioxide laser. It will probably prove to be a necessary tool in the overall armamentarium of skin rejuvenation equipment and time will tell on its degree of effectiveness.

OTHER MODALITIES

Dermabrasion remains an acceptable method of treating skin lines, especially around the mouth but does not have the high-tech appeal of the laser. Several products have been used to minimize the lines around the eyes and the mouth. The most recent of which are the use of the patient’s own fat instead of collagen or other products as fillers and the use of the botulin toxin to temporarily paralyze certain muscles, especially around the eyes. These are temporary measures and can be used only as ancillary procedures in the overall facial rejuvenation process. Detailed information about these procedures is beyond the scope of this article.

SURGERY OF THE NOSE, CHIN, CHEEK AND EARS

Rhinoplasty or nasal cosmetic surgery is one of the most commonly performed cosmetic operations. What seems to be a simple operation has been the subject of thousands of articles through the years. Current refinements follow our improved understanding of the esthetically perfect nose, and our attempts to take into account the patient’s desires, their features and their ethnicity. The use of the open rhinoplasty approach by modifying the nasal framework under direct vision has resulted in significant overall improvement in the results when such technique is indicated.

Computer imaging, which found a place in the consultation room is a clear line of communication between the patient and surgeon, has been a double-edged sword. While it helped some patients explain their desire, it has given others a wrong impression. Patients need to know that the computer imaging is nothing more than a way of discussion and the computer has nothing to do with how the operation is done. Changing the shape of the chin if often needed to balance the facial features and this is done either by modifying the framework of the mandible or adding an implant to improve its profile. Several different materials are being used for that purpose. The cheek has recently been the source of attention from the esthetic point of view with the increased popularity of the prominent cheekbones. Cheek enhancement is achievable by inserting an implant in that area, either through an eyelid incision or through an oral approach. Changing the shape or degree of prominence of the ear is often requested by our younger patients to avoid the ridicule at school. Techniques for this type of surgery are not much different from the standard ones that have been in use for many years except for minor technical detail.

BODY CONTOURING

This part of cosmetic surgery refers to operations on the breast, trunk, thighs, knees and legs.

Augmentation Mammaplasty

Breast augmentation surgery has been available since the mid-60’s. This is accomplished with the use of implants placed either under the breast or under the pectoral muscles. The controversy of the early 90’s regarding silicone implants has resulted in a significant public concern regarding the use of these implants for augmentation. The FDA restricted their use to breast reconstruction after mastectomy and to those who needed their implants exchanged. Many studies have been done to address the issue of safety of silicone implants and the results have been very reassuring. For practical purposes, however, silicone implants are being used very infrequently and only in studies designed to give the final word on their effectiveness and safety. Saline implants are the only ones available in this country. The technique of the operation has not varied significantly except for occasional use of the endoscopic techniques to conceal the scars in the axilla and to decrease their length. Implant fillers other than saline are not yet approved for clinical use in this county.

Reduction Mammaplasty

Breast reduction surgery is one of the most rewarding operations for those who need it. It almost always alleviates the shoulder, neck and back pain that patients present with and results in a dramatic change in the patient’s lifestyle, their ability to participate in athletic activities and in their ability to wear normal clothes. This surgery, however, results in long and sometimes significant scars. The Europeans have pioneered some techniques to reduce the length of these scars and although the initial results can be rather discouraging, as far as the shape of the breast is concerned, long term results are acceptable.

New methods to deal with the scars in the form of local application of silicone sheets and more modern suturing techniques have kept this problem to a minimum. An occasional scar revision is needed and usually gives satisfactory results.

Mastopexy

Breast lift surgery, addressing the normal sized but sagging breasts, uses designs similar to those of breast reduction surgery and trade the ptosis or sagging of the breasts with a more youthful and better shaped breast at the expense of having some skin scarring. Newer techniques have resulted in shorter scars for this type of surgery but these are based on the degree of ptosis and the patient’s desires.

ABDOMINOPLASTY

Abdominal cosmetic surgery removes the excess abdominal panniculus and tightens the relaxed abdominal muscles. It removes a fair amount of the abdominal skin and subcutanteous fat at the expense of a lower abdominal scar that is tailored to fit the patient’s anatomy and her choice of swim wear. To achieve maximum improvement, this is often combined with liposuction, either before or after abdominolplasty and if done in a limited fashion, sometimes at the same time of the abdominoplasty. The newer endoscopic abdominoplasty is a combination of muscle tightening through small incisions in the pubic area and liposuction. The indications are limited to young patients who have a moderated degree of muscle laxity, localized fatty deposits in the lower abdomen and minimal skin excess.

LIPOSUCTION OR SUCTION ASSISTED LIPECTOMY

Body contouring by removing unwanted subcutaneous fat was pioneered in Europe. It gained popularity in the United States in the early 80’s and has become the most commonly performed cosmetic operation. The ideal candidate for this procedure is a healthy, relatively young person with localized fatty deposits that do not improve with weight loss. Liposuction has a tremendous appeal because it results in minimal hidden scars. It is a very safe operation if done according to the accepted medical standards. Recent advances in liposuction include the more frequent use of wetting solutions as a method of obtaining local anesthesia and as a way to reduce blood loss. This is known as the tumescent technique, which is a variant of the wet and superwet techniques. The use of the ultrasonic energy to improve the results of liposuction has been the main development in this field within the last couple of years. Our European and South American colleagues have again tried this technique first. It is currently being studied to define its safety and effectiveness. It is known to be less physically demanding for the surgeon to perform but more time consuming and somewhat more expensive. The claim that it results in less bruising, less pain and better final contour has not been proven yet. Another claim that it is possible to remove more fat in one session using this technique also remains to be proven. It is used as an adjunct procedure to traditional liposuction, since the fat cells destroyed with the ultrasonic energy will still have to be evacuated using the standard liposuction techniques. The energy at the tip of the ultrasonic cannula can result in skin burns and the incisions needed to gain access are larger with the use of the ultrasonic probe. Difficult areas to treat with the traditional liposuction techniques are best suited for this new technology and these include the back, trunk and breasts. This technology might result in revolutionary improvement in our ability to contour the human body once it is refined and proven safe on a long-term basis. Newer methods to transmit the ultrasonic energy through the skin are currently being tested. If this technique works, it also might be a revolutionary development in our ability not only to correct the major contour imperfections but possible to address the difficult problem of cellulite or skin surface dimpling and irregularity.

This has been a review of the recent advances in cosmetic surgery. It is not meant to be comprehensive because of the scope of this article and it is not a substitute for a detailed and adequate informed consent before such procedures are contemplated. Patients should be advised not to depend on information obtained from promotional ads, the lay press or the talk shows for obvious reasons.

Cosmetic surgery is technically demanding, operator dependent and carries the usual risks of surgery in general. However, when performed according to the accepted medical standards, it is safe and rewarding.

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