Issue #17 summary - GO BACK TO ARCHIVE

Stitch in time saves nine
Almost every patient who comes for a consultation desires minimal and discreet scarring, especially for facial procedures. The advances in minimally invasive surgeryand endoscopic equipment have led to smaller scars. Even with the most precise endoscopic procedure, incisions will usually be longer than 1cm, potentially visible.
   Another trend in recent years is that younger patients, when they are not ready for full surgical facelifts, opt for cosmetic facial rejuvenation. They desire smaller scars and a “refreshed look”, which has led to the thread-lifting procedure. Thread lifts involve specially designed or ordinary surgical sutures being passed into the subcutaneous tissues, where they grip the trabecular connective tissue network to elevate and reposition ptotic areas and, consequently, restore contours.
   Thread lifts can be combined with other rejuvenation procedures, such as dermal and sub-dermal fillers, botulinum toxin, laser resurfacing, chemical peeling, lipo-filling, liposuction or injections of phosphatidylcholine. Success depends on design of the thread, material of the thread, insertion technique (free floating or suspension), patient selection, and implementation of combination techniques when indicated
   In brief, the main candidates for thread lifts are patients who are not ready for a facelift but complain of “looking tired”; more mature patients who do not want to have the traditional, open surgical facelift; patients complaining of insufficient results shortly after a facelift; and patients who wish to improve more than one part of the face at the same time.
   Free-floating threads are endowed with directional cogs (barbs), for example, Aptos (Anti-PTOsis). After their insertion into the skin, the threads’ cogs open and prevent the threads from being pulled out from either direction. They form a supporting structure for the facial tissues.

Long-term fillers fail to live up to expectations
Facial filler materials have been approved in Europe for some time. Although most of these products have proven efficacious, some complications have been associated with their injection or inappropriate application. Moreover, the long-term effects of injecting into the face materials that often cannot be removed without surgical intervention is an issue that deserves serious consideration by both physicians and patients.
   Long-lasting or so-called permanent facial-filler materials have been marketed in Europe for several years. The new products include hyaluronic acid; hyaluronic acid and collagen combined with polymethylmethacrylate (PMMA) or hydroxyethylmethacrylate (HEMA); polylactic acid (PLA) and polyacrylamide injections.
   Hyaluronic acid and PLA eventually dissolve after injection. The duration of its effects varies, depending on the thickness of the material. The other filler materials remain permanently in the body’s tissues.
   There are three thicknesses of hyaluronic acid. Low-density hyaluronic acid products are designed to fill “smoker lines” of the upper lips, as well as crow’s feet; they dissolve after two to three months. Medium-density hyaluronic acid products are applied to the lips and generally last four to six months.
   High-density hyaluronic acid products are applied in the nasolabial folds and may last up to one year if injected properly. A new version of hyaluronic acid with even larger molecules, SubQ, is also on the market.
   We have treated 500 patients with hyaluronic acid facial injections and found that it provided longer-lasting results than bovine collagen products for volume augmentation of the lips, wrinkles, and folds. In contrast with collagen, hyaluronic acid contains no products of animal origin. Consequently, no skin pre-testing is necessary. We prefer to work with the thicker hyaluronic acid fillers because we have obtained more satisfactory results with them.

Developing budding skills
With some 600 UK surgeons performing cosmetic surgery, the Department of Health is increasingly concerned with quality control. Yet with the growing severity of rationing of such surgery in the NHS (even post-traumatic rhinoplasty is off the menu in the South East) learning opportunities have all but vanished. The speciality boards’ examination in plastic surgery still includes aesthetic surgery on the curriculum, so how can trainees gain expertise in aesthetic surgery?
   The McIndoe Surgical Centre in East Grinstead opened its doors two years ago for training in aesthetic surgery. A three-month fellowship is offered and has proven to be enormously popular. Fellows are given the opportunity to concentrate on aesthetic surgery away from the pressures of the NHS. The aim of the programme is for the fellows to shadow experienced aesthetic surgeons and, under their guidance and supervision, perform surgery. The apprenticeship is informal, unscripted, wide-ranging and encompasses:technical surgical advice, ethics, financial issues, running a private practice, hands-on operating and outpatient consulting.
   Furthermore, with the McIndoe Surgical Centre on the site of the Queen Victoria Hospital Foundation Trust—the largest plastic surgery centre in the UK—there is access to a huge volume of reconstructive work, especially the breast, a well-equipped library, IT and, of course, other trainees.
   Since its inception, there have been 16 fellows at McIndoe Surgical Centre. At present there are four three-month posts per year. Demand is so great that all posts are filled until September 2006. As a result of this demand exceeding availability, plans are in place to create a second post, subject to specialist advisory committee approval.
   Although the Department of Health is determined that training schemes in aesthetic surgery are constructed, there is an obvious reluctance to provide funding either directly or via the deaneries. The most likely source is from private companies holding an interest in related markets.

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