Issue #16 summary - GO BACK TO ARCHIVE

Precise facial rejuvenation
The information age has thrust the spotlight on the field of aesthetic surgery. Television programming, print media and the internet provide patients with information about the latest and greatest innovations in cosmetic surgery. As a result, patients present to our offices armed with considerable knowledge of aesthetic surgery and the procedures available.
   The trend that has evolved equates more toward preventive medicine. Patients no longer wait for everything to “fall apart”. Today, patients are seeking rejuvenation procedures at younger ages in an effort to perform a pre-emptive strike against ageing. This attitude is especially prevalent in facial rejuvenation.
   The authors’ practice has seen a significant shift in the age distribution of patients seeking facial rejuvenation. Patients are presenting today in their late 30s and 40s. Endoscopic forehead and midface procedures can provide these patients with significant restoration of their youthful appearance without the stigma of a full facelift. This approach favours minimal access incisions and soft tissue transfer to provide a three-dimensional rejuvenation of the ageing face.
   Facial ageing does not occur in two dimensions. The ageing face can be characterised by defects in collagen repair mechanisms; atrophy of the facial skeleton; and loss and redistribution of the soft tissue volume in the face. Defective collagen repair mechanisms lead to increased rhytid formation and laxity of the connective tissue support. Bony atrophy leads to facial volume loss, especially noticeable in edentulous patients. There is a progressive loss of fat on the face.

Total Thigh Lift
Once thought of as a procedure to remove excess skin for those who had lost extreme amounts 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, have an orange peel appearance, with a flabby and/or dimpled appearance. This displays very 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, and it is important to anchor the inferior skin flap to the tough, inelastic deep layer of the superficial perineal fascia. This aids in suspension, so 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 in the bikini. The scar is essentially hidden in the bikini line. The Total Thigh Lift results can be quite long lasting-often up to 10 years or more-but are subject to change as a result of weight gain and/or aging.

Surgical tactics address battle of the bulge
Surgery of the abdominal wall is diverse. Each case is particular, and it is necessary to speak about abdom­ino­plasties, rather than an all-encompassing abdominoplasty. All cases are to be considered according to the anatomy and physiopathology.
   The abdominal wall consists of skin, fat and muscles. The skin can be of good quality, stretched, with an excess appearing above or below the umbilical point or both. Fat can be present, absent, median, or on the hips, which one treats often at the same time as the belly. The muscles of the abdominal wall can be distended, with a median disunion giving a soft belly, or to even present a hernia or even an eventration at the junction of the rectus muscles.
All these problems—more or less intermingled—make it possible to understand why there is such a variety of cases and treatments. A small excess of fat without cutaneous stretching can be treated by a simple liposuction in ambulatory, whereas a large belly distended with stretch marks requires a hospitalisation of a few days, incisions and particular post-operative care.
   Generally, abdominoplasties are treated by a low horizontal incision hidden in the “bathing suit” area, and a transposition of the navel , which remains attached in-depth to its vascularisation by the umbilical channel and which will be “brought out” in a new situation related to the retightened belly. The result is a final scar, often very acceptable—horizontal and low—but un­for­tu­nately inevitable.
   A strong liposuction always precedes the undermining of the skin. Deep stitches with absorbable thread between the deep part of the flap and the muscular plane prevent the classical seroma, which often occurred in the past but is now rare.

Genital enhancement
Social and medical acceptance of genital enhancement is increasing. It was taboo when I started performing these procedures in Canada more than 15 years ago—a view similar to that expressed about cosmetic surgery when I was in training in the 1970s.
   There are about 20 popular procedures of cosmetic genital enhancement surgery. For men there is penis lengthening, penis girth augmentation with fat autografting (fat injection), penis girth augmentation with dermal-fat grafting, circumcision with and without frenulum release, foreskin restoration, escutcheon lifting, pubic liposuction, scrotal reduction, testicular implants and repair of unfavourable surgical results (primary surgery done elsewhere).
Women choose from labia majora augmentation, labia majora reduction, labia minora reduction, clitoral repositioning, clitoral unhooding, hymen repair, vaginal tightening, pubic liposuction, escutcheon lift (mini-tummy tuck), and repair of unfavourable results, which soon may include FGM -- what does this denote??
   For men, fat injection is now more popular than penis lengthening. Labia minora reduction with unhooding is the most common female procedure.
   Penis lengthening is performed in an ambulatory facility under intravenous sedation and local anaethesia. I have performed more than 500 lengthening operations.
Incisions are made at the junction of the penis and pubic area. The penis is then released from its suspensory ligaments to the pubic symphysis. The space is closed with local tissue. Skin from the penis or the pubic area or both is used to cover the extended penis. Post-op traction is used to reduce the possibility of retraction and provide more natural shaft skin.
   Penis function, namely urination and copulation, should not be affected, but the angle of erection will become slightly less vertical. The operation causes temporary changes in sensation owing to swelling and bruising, but permanent loss of feeling is a rare complication. The procedure takes about two hours and the patient remains for observation for about three hours before discharge, after which they are advised to have someone stay with them for the first post-op night if they are single.

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