Issue #15 summary - GO BACK TO ARCHIVE

An age old problem
What happens to our skin as we age, and are these changes inevitable? Ageing arises from a continual imbalance between the formation and repair of DNA damage in cells, according to Chikako Nishigori, PhD, MD, professor and chairman of the Division of Dermatology at Kobe University Graduate School of Medicine.
   Two processes drive what we normally think of as ageing-related changes in the skin: intrinsic, or “normal,” ageing and extrinsic ageing, brought on by environmental damage. In the latter case, the primary culprit is UV radiation, and the process is described as “photoageing”. “Both intrinsic ageing and photoageing are related to oxidative stress,” said Dr Nishigori.
   In the normal ageing process, the epidermis becomes thinner and the amount of subcutaneous fat decreases over time. In the dermis, the architecture of the collagen and elastin networks changes, and there are fewer immune cells. Gradually the skin becomes thinner, finely wrinkled, dry, and less “elastic”. Cuts or bruises occur more easily and wound healing may be slower.
Photoaged skin has a different appearance from normally aged skin and is often dark, coarse and “leathery”.
   “Macroscopically, photo-aged skin shows thickening and roughness of the skin, coarse wrinkles, sebaceous hyperplasia and uneven pigmentation,” said Dr Nishigori. “Histological findings reveal that the dermal change in photoaged skin is characterised by a decrease in type I and III collagen and an increase in elastin fibre.” In addition, UV damage suffered by photoaged skin results in a higher incidence of skin cancers such as melanoma and basal cell carcinoma.

Vertical facelift
In the face, ageing causes atrophy of the skin and underlying layers while gravity causes the facial tissues to droop vertically, creating redundant skin and jowls. The end result is an absolute loss of volume of the face—“the deflation effect”—and a relative shift of volume from parts of the face to less desirable areas, such as the nasolabial fold, jaw line, and below the eyes and neck.
   Traditional facelifts attempt to correct the problem by pulling laterally, producing the so-called “wind-swept look”. By pulling the skin taut, this method also causes a flattening effect. Therefore, facial rejuvenation has been plagued for decades by two major mistakes: wrong direction of the pull vector—lateral vs vertical—and a bi-dimensional, skin-only, flattening approach.
   If you look at how Botticelli painted Simonetta Vespucci in his Primaveras, you can appreciate the ”volume theory” of a youthful, beautiful face. Basically, ageing causes volume loss: the ultimate goal of facial rejuvenation should be to restore the lost volume.
Planning is an important part of the procedure. A careful analysis of computerised, pre-operative images of the patient is made, including old pictures of the patient in his or her 20s and 30s. This results in a “road map” that we follow in the rejuvenation process.
   An important role in achieving this goal is played by new, state of the art endoscopic technology, which helps us to minimise scars. By attaching cameras to scopes introduced through tiny incisions, images can be projected to our operative room monitors. This allows us to access critical areas of the face with specially designed instruments, modifying and shaping underlying tissues in accordance with the patient’s aesthetic needs.

Titan march against time
Mother Nature can be cruel to us over time, causing the elastin in our skin to disintegrate slowly, resulting in ageing in our face, neck and body. The baby boomer generation is no longer content with cosmetic surgery as the only solution to sagging skin. Botox, Thermage and a host of wrinkle fillers and skin tighteners have been introduced, stimulating a new movement in cosmetic enhancement.
   The Titan procedure is a safe, new, US Food and Drug Administration (FDA) approved, painless skin-tightening approach to treating lax and redundant skin, including the abdomen, thighs and underarms, and is also used to tone, lift and tighten skin on the face and neck. The Titan is not just another non-invasive procedure. It stands out from the rest by stimulating long-term collagen rebuilding as well as integrating an effective cooling system that instantly numbs the treatment area while you work without any other outside anaesthetic, making it a comfortable experience for the patient.
   The Titan procedure uses a blended infrared light to tighten skin and reverse the signs of ageing. The Titan heats the dermis to cause collagen contraction while protecting the skin through continuous cooling. By creating significant heating in the dermis, the body is “tricked” into repairing the skin.

Lifting sagging thighs
Once thought of as a procedure to remove excess skin from men and women who have lost lots of weight, the ”total thigh lift” has evolved to treat patients who are at their ideal weight but want to rid themselves of loose, sagging skin. The procedure is used on patients with no excess fat, or minimal excess fat, but with significant droop of the thigh and buttock due to age, gravity or pregnancy.
   Both men and women who have experienced significant weight-loss are excellent candidates. These patients usually have loose skin in the thigh-buttock area that exercise cannot repair. The skin in these areas is usually saggy, has an orange peel appearance, with flab or dimples or both. This displays poor skin quality that will not respond to liposuction.
Technically, the procedure can be thought of as a fusion of medial (inner) thigh lift and the lower body lift. The entire thigh is lifted as a unit, anchoring the inferior skin flap to the tough, inelastic deep layer of the superficial perineal fascia. This aids in suspension so that the skin is not stretched with tension. This will help with the quality of the scar, as well as help avoid an unnatural pulling effect on the buttocks and genital region.
   There is a fairly lengthy incision, which spirals around the buttocks and the thigh and falls in the buttock creases for ease of camouflage. The scar is positioned in the bikini line. Two weeks prior to surgery, patients are instructed not to take aspirin, vitamin E, or to drink alcohol. Patients who smoke are instructed to stop smoking four weeks before. Post-surgery, patients are to remain off aspirin, vitamin E, alcohol and cigarettes for two weeks.
   Performed under general anaesthesia, on an outpatient basis, the surgical procedure takes about five hours. Before anaesthesia is given, a surgical marking pen is used to draw a detailed map on the actual area to be operated on. This plan is used to make the accurate changes from the standing to the lying position.

Correcting asymmetry
Minor asymmetries, due to the breast, the thorax or both, are corrected using prostheses of different sizes and shapes or with asymmetrical soft tissue envelope correction. I use only gel-filled textured implants. I am a strong advocate of the subglandular position, because it is the anatomically correct location for implants. The marking of the future inframammary line and the extent of the pocket dissection is important, especially for correcting tuberous breasts. Small asymmetries can be corrected with prostheses that are the same but with asymmetrical modifications of the dermo-adipose tissue. Asymmetries much more marked are corrected by means of prostheses of different sizes and shapes and with more marked modifications of the dermo-adipose tissue. In these cases it may be necessary to carry out secondary touch-ups.
   The preoperative marking must determine the inframammary fold, the medial and lateral pocket dissection, the exact size and location of the nipple-areola complex. The approach is always periareolar. For the elevation of the lower areola, I use a purse-string suture (round block). To correct the constricted breast, I release the lower pole surgically. To be able to correct the asymmetry in one stage I place a very small implant on the bigger side. Usually, a skin expander is not necessary to place the contralateral bigger implant.
   To choose the right implant for the smaller breast, keep in mind the position of the nipple-areola complex, the distance between sternal notch and nipple, and the width of the thorax. The implant has to be centered behind the areola. The principal guidelines for successful results are careful preoperative evaluation of the volume, consistency and dimensions, and careful operative planning.

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