MODERN MEDICINE

Vol.36 - No.3 Pages 32-42, March, 1993

A place for cosmetic surgery:
Part 1. The face

DARRYL J. HODGKINSON

MB BS (Hons) FRCS (C), FACS, DIP AMERICAN BOARD PLASTIC SURGERY

Dr Hodgkinson is Consultant Plastic Surgeon, Skin and Cancer Foundation, Darlinghurst, NSW; Clinical Instructor (Plastic Surgery), Medical College of Virginia, USA; and has a private practice in Double Bay, NSW.

Cosmetic surgery has established itself as a surgical subspecialty over the last two decades. The range of procedures is vast, encompassing rejuvenation surgery, such as facelift; facial aesthetic surgery, including rhinoplasty; and body contour surgery, such as abdominoplasty and liposuction. In this two-part article examining these popular procedures, I will outline the medical aspects, and try to predict the future trends of cosmetic surgery.

Over the last two decades, aesthetic surgery (cosmetic surgery) has established itself as a major subspecialty of plastic surgery. Although most procedures in plastic surgery have an aesthetic element, cosmetic surgery to improve the appearance has not been given the same credence that functional surgery enjoys. In fact, until the 1970s, cosmetic surgery was kept under wraps and was only occasionally mentioned as the part-time interest of some reconstructive surgeons. Prior to this, eminent plastic surgeons would not admit to performing cosmetic surgery, or would only undertake it for financial rewards to subsidise their endeavours in reconstructive surgery.

Cosmetic surgery is still scorned by some senior colleagues and still finds no kindly place in the academic teaching institutions. Thus, training in cosmetic surgery has been difficult to obtain and is mainly offered by private nonacademic surgeons in major cities in Western countries.

In the United States, some fellowships are offered in New York, Miami and Los Angeles. I was fortunate to gain additional training in cosmetic surgery in Newport Beach, California, with Dr Fred Grazer, past President of the American Society of Aesthetic Surgery. Over the last 20 years, societies for the dissemination of scientific information have blossomed and include the American Society of Aesthetic Surgery, the International Society of Aesthetic Plastic Surgery and the Society for Aesthetic Surgery in Orientals. These and other societies offer training courses in aesthetic surgery and a forum to discuss new technical advances and past experiences.

Indeed, just as so many surgical subspecialties have enjoyed a burgeoning - even a renaissance - in the last 20 years, so too has cosmetic surgery. Technical advances and dramatic new anatomical concepts of rejuvenation surgery and body contour surgery have greatly improved results over the last decade.

In Part 1 of this review I will discuss facial cosmetic surgery procedures including facelifting, browlifting, blepharoplasty, rhinoplasty and otoplasty. In Part 2, I will review aesthetic breast surgery: reduction mammoplasty, mastopexy, breast augmentation and reconstruction after mastopexy. Body contour procedures such as liposuction, abdominoplasty and muscle contour implants for males, including pectoralis and calf implants, will also be discussed in the second section.

Facelifting

Over the last decade, new facelifting techniques have been developed to give a longer lasting more natural, less pulled appearance

The number of people undergoing facial rejuvenation surgery is increasing worldwide as the baby boom post World War II generation reach middle age and, with the personal pressures imposed by a youth-oriented society, seek to maintain a competitive and youthful edge.

Facelifts have little to do with wrinkling but are most concerned with re-establishing facial muscular tone, and reducing or redistributing facial, neck and jowl lipoaccumulation of middle age.

As we age, the neck and jowls fill out as fat accumulates; this is often associated with a laxity of the facial musculature. Most noticeable in the neck are the platysma bands, referred to as 'chook neck' by Australian patients and 'turkey neck' by their American counterparts. Australian women seem to age more rapidly than American women, probably due to their, overexposure to the sun, the ozone depletion problem, and possibly due to a high proportion of women with a Celtic background, type 1 and 2 skin.

Over the last decade 'deep plane' facelifting techniques and the subperiosteal approach have been developed to give a longer-lasting, more natural, less pulled or 'operated on' appearance.1

Hopefully gone are the days of the overtight, drawn appearance feared by so many patients. Such a result was often accompanied by hairline abnormalities, heavy scarring, and an unsightly and obvious 'operated on' appearance.

Current techniques avoid tension on the skin closures, thereby minimising scars. Attention to the hairline and to the location of incisions has led to a more natural result which can be touched up secondarily as needed, perhaps in up to eight to 10 years.

In the early part of the century, European and American surgeons carried out facelifts using skin resection alone. These basic tenets remained until the late 1970s when French anatomists defined the SMAS (superficial musculoaponeurotic system). Later, it was found that correction of laxity of the SMAS and of the platysma muscle resulted in a redefinition of the jaw and neck, thus restoring a youthful appearance.

Appreciation of the role of muscle laxity and fatty accumulation in ageing of the face (Figure 1) resulted in the development of a variety of procedures aimed less at skin resection and more on the repair of lax facial musculature and on the resection of fat which accumulates in the neck, jowl and periorbital region.

The modem facelift referred to as composite facelifting' involves elevation and plication or resection of the SMAS (Figure 2) platysma complex, orbicularis muscle and cheek fat pad. Numerous SMAS flap designs (Figure 3) have been devised; the choice depends on which portion of the face has sagged the most. The neck alone may sag with prominent platysma bands, or the mid-face may degenerate and the cheeks flatten, resulting in heavy nasolabial folds and a downturning of the mouth.

These SMAS flaps are raised from the underlying deep cervical fascia and parotid gland (Figure 4). The facial nerve runs in this plane and must be avoided. Figure 5 shows the course of the nerve. The branches, especially the temporal and submandibular, are vulnerable, and if damaged could lead to permanent facial palsy.

Fatty accumulation in the neck and jowls may be dealt with by fat resection, or open or closed liposuction. Over-resection of fat may lead to a gaunt appearance or a skeletonised neck. Careful aesthetic surgical technique and development of a plan for the re-establishment of a more youthful face should enable these deformities to be avoided. The resulting appearance must be soft, not tight.

Trends in facelifting

The emphasis is less on skin resection and more on repair of lax facial musculature and resection of accumulated fat.

Two major trends have occurred over the last decade. Younger females (Figure 6) and males are more likely to seek surgery. Chemical peels using the newer agents, alpha hydroxy acids, to reverse the photoageing of the skin present in so many Australians are becoming more useful as an adjunct to, but not a replacement for, facelifting. These peels are an improvement on the previously used phenol peels, which were liable to damage the skin by causing hypopigmentation or scarring. Their use for actinically damaged skin is well documented.2

Younger patients are becoming motivated to seek aesthetic facial rejuvenation as they note prominence of the jowls, loss of the jawline and thickening of the neck - the early signs of ageing. In this group of patients, tone must be re-established in the face and fat resected, all without distortion of the hairline or excessive scar formation. The results are often subtle but can be striking (Figure 7). Because most of the surgery is concentrated on the deeper layers of the face, including the fascia muscles and periosteum, little tension is placed on the suture lines, which tend to heal with a minimum of scarring (Figure 8).

More men are seeking facial rejuvenation, especially those who work in competitive white collar industries in management, sales and marketing. For these men, image is very important. Hair restorative surgery is well-established and an integral part of rejuvenation. In males, facelifting must concentrate on restoration of the neck contour and reduction of heavy nasolabial folds and jowls (Figure 9). Techniques are similar to those used for females but incisions vary due to the beard and should be concealed within the hairline. Cheek implants may be combined with facelifting to give more strength and angularity to the mid-face.

Medical aspects of facelifting

The emotional stability of the patient must be ascertained and the motivation for surgery determined.

Many patients do not seek advice from their general practitioner about facelifting due to embarrassment or fear of rejection. However, a workup is important for patients undergoing facelifting. If hypertension is present, it must be under control. A bleeding diathesis should be ruled out. The emotional stability of the patient must be ascertained and the motivation for surgery determined.

The surgical procedure is carried out under local anaesthesia with intravenous sedation, or under general anaesthesia. It usually involves three to four hours of surgery and may be carried out as an outpatient procedure or involve one to two day's stay in a private hospital. Recuperation takes one to two weeks and patients can expect to return to their usual occupation in two to three weeks.

Chemical peeling

Chemical peels are not a replacement for facelifting when jowl and neck laxity predominate.

Ageing of the skin is accompanied by wrinkling and pigmentary changes which cannot be corrected by facelifting. For this reason, chemical face peels have been used to reduce perioral and periorbital wrinkling, and to give the facial skin a more uniform complexion by reducing age-related pigmentary changes.

Phenol in Baker's formula was used for the past two decades and satisfactorily reduced the deep perioral rhytides (vertical wrinkles); however, it often bleached the skin, caused unpredictable scarring and had potentially toxic cardiac side effects. Peels using alpha hydroxy acids, such as trichloroacetic acid and glycolic acid, have become popular over the last three to four years as dermatologists shared their experience and results. Improvement of fine lines and complexion is well documented.3 Figure 10 shows a patient before, one year and four years after facelift. The patient has received annual 30% trichloroacetic acid peels since the celi . ese peels are not a replacement or facelifting when jowl and neck laxity predominate; however, they are an invaluable adjunct to facial rejuvenation, improving the quality and texture of the facial skin. Pharmaco-cosmetics which combine these alpha hydroxy acids are available to continue the peeling process; this has a long term positive effect on photodamaged skin.

Blepharoplasty

Eyelid surgery is sought by patients who are concerned about excessive skin in the upper eyelid, wrinkled eyelid skin or herniation of periorbital fat pads which gives them a tired, bedraggled appearance. Excessive eyelid skin, blepharochalasis, may cascade over the eyelashes and obstruct the lateral visual field. Herniate t pads give the patient a tired, worn out, self abused appearance and the removal of these pads greatly improves the overall appearance of the patient. The removal of fat should not be excessive and skin removal should be especially conservative, as a hollowed out appearance from over-resection is unattractive, making the patient look gaunt. If too much skin is resected, the upper lid assumes a flattened appearance and lag ophthalmia can result.

Trends in blepharoplasty

Laser blepharoplasty utilises laser scalpels to excise skin and remove fat, possibly offering a more rapid recuperation due to less morbidity.

These days much less attention is directed to resection of skin (Figure 11). Newer techniques popularised by Flowers in the 1980s concentrated on re-establishing the cutaneous insertion of the levator muscle to the upper eyelid skin to re-establish a well defined supratarsal fold (Figure 12).4 Trans conjunctival blepharoplasty achieves removal of the fat pads without removal of skin or an excision on the outside of the eyelid.

Oriental patients seek blepharoplasty to establish a defined supratarsal fold (double eyelid operation). About 25% of Asians have a poorly defined or absent supratarsal fold. A hooded appearance and accompanying epicanthal fold is usual. Numerous procedures have been developed to reduce this fold, but all have the same principle of establishing a permanent connection between the dermis of the supratarsal fold and the underlying levator aponeurosis. A natural, attractive oriental eye, not a Westernised one, is the desired outcome of the surgery.

Laser blepharoplasty utilises laser scalpels to excise skin and remove fat. It has been suggested that there is a reduction in morbidity with this technique compared with the more traditional blepharoplasty procedures.

Medical aspects of blepharoplasty

The patient's visual acuity must be tested. Dry eye should be evaluated by a Schirmer's test. A visual field study may confirm visual obstruction secondary to eyelid blepharochalasis. Eyelid ptosis may be present as well as brow ptosis and should be evaluated and corrected. Lower lid laxity needs to be evaluated, as ectropion must be prevented by canthoplasty. The patient should be normotensive or, if hypertensive, controlled on medication. Any bleeding diathesis should be ruled out.

Browlifting

Replacing the brows in their original position above the orbital rims is an important step in rejuvenation of the upper face.

Brow ptosis is often an early sign of ageing and is accompanied by crow's feet in the periorbital region, heavy glabella lines and deep transverse forehead wrinkling. Patients appear permanently concerned or angry. Collagen injections temporarily improve the wrinkles but do not correct the underlying problem of muscle hypertrophy and eyebrow descent.

Replacement of the brows in their original position above the orbital rims and sculpturing of hypertrophied muscles is an important step in rejuvenation of the upper face. The surgical incision extends across the skull, usually behind the hairline. and the scalp galeal complex is dissected down to and over the supraorbital ridges (Figure 13). Care is taken not to damage the supraorbital sensory nerves or the frontal branch of the facial nerve. The hypertrophied glabella musculature is resected, the frontalis muscle is scored and, after scalp replacement, the excess scalp is trimmed. The procedure may be carried out under local anaesthesia with sedation, or under general anaesthesia on an outpatient basis or with a short hospital stay.

Trends in browlifting

Browlifting is often indicated when on first examination it appears that the patient has excess skin in the upper eyelids. Replacement of the brow above the supraorbital ridges will determine if an excess truly exists. Figure 14 shows a patient before and after browlifting, which takes away the concerned, serious appearance of brow ptosis.

Medical aspects of browlifting

Brow ptosis may contribute to visual field disturbance. Facial nerve function should be assessed. The scalp incision may raise the hairline, the position of which should be assessed and preserved. Any scalp disease may preclude incisions within the hairline, as Koebrier's phenomena may lead to alopecia within the scalp incision.

Rhinoplasty

Nasal deformity causes psychological distress in many patients. As young teenagers they often feel stigmatised from being taunted by peers. Patients often present for rhinoplasty in the middle or late teenage years.

Nasal trauma, if inadequately treated, can lead to deformity and result in accompanying nasal obstructions and septal deviation.

Two rhinoplasty techniques are popular: the closed and the open. The open technique (Figure 15) involves an incision in the columella and reflection of the nasal skin from the underlying cartilages and bones. This exposure allows for a precise remodelling of the nasal structures, the insertion of grafts, and fixation with a more predictable outcome. However, the majority of cases can be managed by the closed technique, in which there are no external incisions. These procedures may be carried out under local anaesthesia with sedation, or under general anaesthesia on an outpatient basis or with a short inpatient stay.

Trends in rhinoplasty

Nasal shape and size should be individualised to balance the overall facial structure (Figure 16). The conventional procedures involve resection and reduction, which often resulted in a small, scooped out appearance to the nose.

Careful measurement of the facial aesthetic landmarks can guide the surgeon to an anticipated ideal in shape and tip projection, dorsal height and length of nose. To achieve this ideal may require cartilage grafting of the nasal tip or dorsum, with autogenous septal or chondral cartilage or, occasionally, bone.

Communication with patients and an understanding of their expectations is most important. I have the patients bring photographs from glossy popular magazines and discuss with them which noses they like and which noses they think would suit their face. This 'reality test' helps determine if the patients' expectations are realistic. Videoimaging is another tool which may be useful in discussing the anticipated final result with patients, and determining whether or not it will satisfy their aesthetic goals.

The diversity of ethnic groups seeking nasal aesthetic surgery presents a challenge to the nasal surgeon who can hardly have a standard procedure to suit all. Patients of Mediterranean extraction often have generous noses and commonly seek aesthetic rhinoplasty (Figure 17). Importantly, the results must be attractive to the patient's own ethnic subgroup; the nose must not appear obviously operated on, too small, sculpted or be disharmonious within the family or peer group.

Medical aspects of rhinoplasty

Nasal obstruction should be assessed by internal examination of the airway. Bleeding disorders and hypertension should be evaluated and treated prior to elective rhinoplasty. The psychological stability of the patient should be evaluated. If the patient's motivation or expectations are questionable, counselling by the patient's general practitioner, or a psychological or psychiatric assessment might be considered. Sometimes numerous interviews are necessary to delineate clearly the patient's desires and expectations.

Facial implants

To improve deficient facial contour, shape or volume, alloplastic implants have become popular.

The beauty of a face is in part defined by the skeletal anatomy. Occasionally, major orthognatic or craniofacial surgery is indicated to achieve ideal skeletal anatomy; however, alloplastic implants may be used to improve deficient facial contour, shape or volume, and have become popular.

Nasal augmentation using silicone implants has been practised successfully for many years, especially for the nasal dorsum in oriental patients. Solid silicone implants can also be used successfully to augment the cheek bone, chin and mandible. Figure 18 shows a patient after rhinoplasty and chin implant.

These silicone implants come in various sizes and shapes, and can be contoured and inserted in the subperiosteal pockets to enhance the facial skeleton. Improving shape and volume of the skeleton augments the soft tissue by displacement and can achieve beautification of the face in profile and anterior projection. The variety of implants available allows precise facial skeletal augmentation, offering a tool to enhance the facial shape. There have been no reports of adverse reactions to solid silicone implants, unlike liquid silicone implants, which once were used commonly for breast augmentation.

Trends in facial implants

Bold, defined, dramatic facial features are the hallmarks of many fashion models and cinema or television idols. Aesthetic ideals change dynamically, constantly varying for the cosmetic surgeon. Newer shaped implants which significantly refine the facial skeleton are now available for the malar region, chin and premandible, and assist the cosmetic surgeon to achieve the goals of beautification and accentuation of the features of the face.

Medical aspects of facial implants

Dental occlusion should be assessed, and referral to an oral surgeon is appropriate if orthognatic surgery is anticipated. Cephalometric x-ray or CT scan can aid in diagnosis of skeletal disharmony. This workup is similar to that outlined above for rhinoplasty.

Otoplasty

A major trend in cosmetic surgery is to operate earlier on children with a deformity such as bat ears.

Bat ears (prominent ears) are unappealing features which attract scorn and ridicule from childhood peers. Although hairstyles can camouflage bat ears, stigmatisation will cause anxiety in children. These children are often brought for consultation five or six years prior to the period at which taunting might be expected to commence. Figure 19 shows the result of repair of bat ears.

The corrective procedure can be carried out safely in the infant years provided the child is co-operative. Other groups of patients present as teenagers or mature adults. Two problems usually coexist: there is a conchal excess and absence of formation of the normal curved concho-scaphoid angle.

Trends in otoplasty

A major trend in cosmetic surgery is to operate earlier on children with deformity. Appearance-impaired children can be socially stigmatised; in order to prevent this, consideration should be given to earlier surgical repair of bat ears or obvious scars or nasal deformities. Children are becoming more socialised earlier and accepting more responsible roles, and thus may request physical change at a younger age. Medical professionals often have trivialised the importance of appearance. However, appearance-impaired children may suffer embarrassment, depression or shame, which can be averted or prevented by judicious, early surgical procedures.5

Otoplasty is carried out on an outpatient basis or with an overnight stay. Incisions are kept behind the ear; the concha and scaphoid fossa are contoured to improve shape and the ear is positioned closer against the side of the scalp.

Medical workup

Ear deformities may be associated with first and second branchial cleft deformities. Occlusion and mandibular growth may be affected and any indication of facial asymmetry should be referred to our dental colleagues for assessment. Many children take a week out of vacation for otoplasty and return to school with more self confidence.

Part 2 of this article will appear in the April 1993 issue of Modern Medicine and will discuss body contour surgery, and breast surgery and reconstruction.

References

1. Hamra S. Composite rhytidectomy. Plastic and Reconstructive Surgery 1992; 90(l): 1-14 .
2. Brodland DG, et al. Trichloroacetic acid chemoexfoliation (chemical peel for extensive premalignant actinic damage in the face and scalp). Mayo Clinic Proceedings 1988; 63: 887-896.
3. Collins PS. Trichloroacetic acid peels revisited. Journal of Dermatological Surgery and Oncology 1989; 15: 933-940.
4. Flowers RS. The art of eyelid and orbital multiracial surgical considerations. Clinics in Plastic Surgery 1987; 14(4): 703.
5. Hill BA. Beauty is the beast. Pennsylvania: University of Pennsylvania Press, 1990. res 19a and b. A child with prominent ears (left). Correction involves changing the shape and position of the ear (right).