Facial Aesthetic Surgery
Alexander Ovchinsky
Jon B. Turk
Aesthetic and functional changes in facial structures caused by genetic, traumatic, or environmental factors often are of concern to patients. Otolaryngologic training is focused on the regional anatomy and surgery of the head and neck and hence plays a primary role in the management of facial cosmetic deformities. Care often is provided in conjunction with a dermatologist, ophthalmologist, and oral surgeon. The contemporary world of cosmetic surgery includes lasers, endoscopes, liposculpture, and bioengineered implants. Technical advances in instrumentation, anesthesia, and biomaterials have brought facial aesthetic surgery to an unprecedented level of safety and predictability. Unfortunately, there are still complications and health risks to which patients must be alerted before undergoing surgical treatment. It is important to perform a psychological evaluation before scheduling an operation. Patients who believe cosmetic surgery will improve a failing marriage or move them up the corporate ladder often are poor surgical candidates and need to be counseled. This chapter provides an overview of some of the procedures commonly performed by an otolaryngologist-facial plastic surgeon.
RHINOPLASTY
Rhinoplasty is surgical correction of congenital or acquired functional and aesthetic defects of the nose (Fig. 38-1). Preoperative evaluation begins with the history and physical examination. The history of nasal obstruction, rhinosinusitis, nasal trauma, or nasal surgery is elicited. Patient concerns about nasal appearance then are assessed. The patient is asked to show the precise area of concern in front of a three-way mirror, which has been a very valuable tool in preoperative cosmetic consultation. Both the internal and external nasal structures are examined. Mucosal irregularities, quality of secretions, position of the septum, and patency of the nasal valves are evaluated. On anteroposterior view, the nose is inspected for disharmony with the rest of the face. The upper bony third and lower cartilaginous two-thirds are assessed. The nares are examined from below for symmetry, size, shape, and support mechanism that defines the patency of the external nasal valve. Finally, on the profile view, dorsal contour and projection and rotation of the nasal tip are evaluated.
In general, rhinoplasty involves correction of bony and/or cartilaginous abnormalities through a combination of intranasal and external incisions depending on the location and complexity of the problem. Bony and cartilaginous humps can be adjusted, and the size and shape of the nasal tip can be changed. Various nasal defects can be camouflaged or augmented with grafts. Autogenous tissue such as septal or conchal cartilage is preferred since implantation of biomaterials in the nose has a definite rate of complications. However, allogenic dermis (Alloderm)
has lately found widespread application in dorsal augmentation during rhinoplasty. Complications of rhinoplasty include epistaxis, infection, septal hematoma, septal perforation, nasal obstruction, persistence, recurrence, or even worsening of nasal deformity, and skin flap necrosis.
has lately found widespread application in dorsal augmentation during rhinoplasty. Complications of rhinoplasty include epistaxis, infection, septal hematoma, septal perforation, nasal obstruction, persistence, recurrence, or even worsening of nasal deformity, and skin flap necrosis.
RHYTIDECTOMY
Rhytidectomy and meloplasty are technical terms for the facial aesthetic procedure commonly known as a face lift (Fig. 38-2). Rhytidectomy involves redraping of the soft tissues of the cheek, lower face, and neck in order to achieve a more youthful appearance. The aims of rhytidectomy are listed below.
Tighten the jowl lines
Elevate sagging cheeks
Elevate facial expression lines to a more youthful, posterosuperior orientation
Reduce the prominence of nasolabial folds
Reduce redundancy and volume in the submental and cervical regions
Evaluation again begins with the history and physical examination. Patient concerns about facial appearance are assessed. A history of smoking or excessive sun exposure is ascertained. The face is inspected from the anterior and profile views for malar sagging, prominent nasolabial folds, jowling, redundant cervical skin, and excessive submental fat. Bimanual pulling of the face and neck soft tissue in the posterosuperior direction often simulates the ideal postoperative result.
Fig. 38-3 illustrates a common incision for rhytidectomy. It is important to understand that rhytidectomy is not an operation for wrinkles; rather it involves excision of redundant skin and resuspension of the superficial musculoaponeurotic system (SMAS). The SMAS is a fascio-muscular layer continuous with the platysma muscle below the mandible and the temporoparietal fascia above the zygomatic arch. Its resuspension is primarily responsible for the smoother, more youthful appearance following rhytidectomy. Excessive submental fat often is removed by means of either direct lipectomy or liposuction. Potential complications of rhytidectomy include hematoma, infection, hypesthesia, poor scar formation, alopecia, flap necrosis (more likely in smokers) and facial nerve injury.
BROW LIFT
Brow lift is a procedure aimed at surgical rejuvenation of the upper third of the face, also known as the forehead-glabella-brow unit. Downward displacement of the medial portion of the eyebrow can project anger, whereas similar displacement laterally gives the appearance of sadness. Complete brow ptosis portrays a fatigued appearance. Functional impairment such as obstruction of the superior and lateral visual fields may also occur. Brow ptosis is most often associated with forehead wrinkling.
Evaluation includes assessment of the frontal hairline, position of the brow, preoperative brow symmetry, and the presence or absence of brow wrinkles. The surgical approach is one of the
following: suprabrow incision, midforehead rhytid incision, bicoronal flap approach, or endoscopic brow lift through several small scalp incisions.
following: suprabrow incision, midforehead rhytid incision, bicoronal flap approach, or endoscopic brow lift through several small scalp incisions.
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