15 Cosmetic Surgery
Perception of cosmetic medical and surgical interventions has evolved significantly over time. In 1935, Gillies stated, ‘The operations for removal of eyelid wrinkles, cheek folds and fat in the neck are justifiable if the patients are chosen with honest discrimination’. Now aesthetic medical and surgical interventions are considered as norm. This chapter seeks to cover medical options including neuromodulators and injectable fillers and surgical options for facial rejuvenation: brow/forehead lift, blepharoplasty, rhytidectomy (face and neck lift) and otoplasty. The list is by no means exhaustive, as other available tools in the aesthetic surgeon’s armamentarium (
Table 15.1) such as dermabrasion, chemical peels and laser treatments for facial rejuvenation are beyond the scope of this chapter.
15.1 Biology of Ageing
Facial ageing is a three-dimensional process that results in devolumisation and descent, which are affected by intrinsic and extrinsic factors. Intrinsic ageing includes atrophy of facial skin and subcutaneous fat, and volume changes in the facial skeleton. The skin loses elasticity and capacity to retain moisture resulting in dryness and sagging. Laxity of retaining ligaments of the face results in descent. Remodelling of the craniofacial skeleton leads to changes in facial dimensions and relative proportions. There is rotation and reduction in height of the maxilla, along with contraction of the bony skeleton. The orbital width on the other hand increases. The combination of above factors ultimately accounts for jowl formation, sagging and rhytids. The primary extrinsic factor for ageing is sun exposure resulting in photoageing, and smoking accelerates this process.
15.2 Non-Surgical Treatment
15.2.1 Botulinum Toxins
Botulinum toxin exists as many preparations, including Botox (Allergan), Xeomin (incobotulinumtoxinA: Merz pharmaceuticals) and Dysport (abobotulinumtoxinA; Azzalure). It is a protein produced by the anaerobic gram-positive bacterium, Clostridium botulinum. Botox type A is the most clinically relevant of the seven serotypes (A–G). It works by causing flaccid paralysis of the muscle by inhibiting acetylcholine release at the neuromuscular junction. The weakened and relaxed muscle reduces the amount of unwanted lines of facial expression. Botox is used in various regions of the head and neck for aesthetic and functional reasons (
Fig. 15.1).
15.2.2 Fillers
Fillers are ‘products used to improve appearance and don’t impart any health benefits’ as defined by the Food and Drug Administration (FDA). They are considered as medical devices and may be referred to by trade names. They may be temporary, for example, hyaluronic acid, semi-permanent, for example, Sculptra (poly-L-lactic acid) or permanent, for example, polymethyl methacrylate. The use of permanent fillers is discouraged due to the adverse results that often require surgical intervention for removal, while hyaluronic acid fillers may be removed with hyaluronidase. Viscosity of products varies with higher viscosity products being used for volumisation versus fine wrinkle treatment with low-viscosity products.
Table 15.1 Guidelines and strategies for facial rejuvenation (combination of treatments should be considered to optimise results)Patient concerns | Structural change | Treatment option |
Superficial wrinkles, skin colour changes, telangiectasia, etc. | Mainly superficial dermal | Laser, IPL, chemical peels, medicated skin care programmes |
Mimetic wrinkles with or without volume loss | Deep dermal, subcutaneous | Botulinum toxins, fillers, free fat transfers, direct muscle excision, etc. |
Folds (nasojugal, nasolabial, jowls, neck) | Skin laxity, ligamentous laxity, soft tissue atrophy with volume loss, gravity, etc. | Surgery—face lift, neck lift, brow and forehead lift, blepharoplasty, etc.—based on location |
Folds, volume loss—malar, chin, etc. | Skeletal loss | Implants, bone grafts, etc. |
Abbreviation: IPL, intense pulsed light.
15.2.3 Complications
Botulinum toxin has limited adverse effects that may include swelling, bruising, asymmetric muscle paralysis and headaches. Filler complications include swelling, bruising, infection, ‘Tyndall effect’ (superficial injection resulting in a blue hue) lumpiness and nodules. The most feared complications are skin necrosis and blindness as a result of embolisation following inadvertent intra-vascular injection in the melolabial and peri-ocular or glabella regions, respectively.
15.3 Forehead and Brow Lift
The aim is to elevate the hairy brow to the bony supra-orbital rim, reduce width of the forehead if required, and reduce the upper eyelid skin excess. It should be considered before upper lid blepharoplasty surgery.
15.3.1 Anatomy
The layers may be remembered by the mnemonic SCALP: Skin, subCutaneous tissue, galea Aponeurosis, Loose areolar tissue and Pericranium. The frontalis is contained within the galea. The periosteum is continuous with the temporalis fascia at the temporal line and leads to a fascial condensation at superior orbital rim with the orbital septum known as the arcus marginalis.
15.3.2 Surgical Techniques
Various approaches are available for forehead and brow lifts.
• Endoscopic brow lift utilises small incisions within the hair-bearing area using standard 0-degree endoscopes and stack system. The procedure carries the risk of frontal neurovascular bundle injury. This approach should be used judiciously in high hairlines and male pattern baldness.
• In coronal lifts, the incision is made above the hairline with a dissection plane between the perichondrium and galea. It should not be used in high hairline or male pattern baldness patients. This technique is not effective for correction of brow asymmetry and there is a risk of raising the hairline.
• A pretrichial lift at the hairline can be utilised with a high hairline but can result in anaesthesia posterior to the incision.
• The midforehead lift may be utilised effectively in patients with high hairlines and prominent forehead rhytids, particularly men. Sensation may be preserved with subcutaneous dissection. It may leave a prominent scar and does not address the lateral brow or upper forehead.
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