Issue #19 summary - GO BACK TO ARCHIVE

Rhinoplasty by injection
The standard method for correcting nasal deformities is rhinoplasty. However, as a result of the new trend in minimally invasive cosmetic procedures, many procedures can now be replaced by injectable treatments. Rhinoplasty is no exception.
   I shall describe my approach to the correction of minor nasal deformities, both static and dynamic, by the use of injectables (botulinum toxin, dermal fillers) and minor surgery (depressor nasi transection and surgical threads). Since starting to use these techniques I have found there to be more suitable candidates than I thought before.
   What is the perfect nose? This question has to be taken in the context of the rest of an individual’s face as well as race, sex and even changes in fashion. The aesthetic triangle of Powel and Humphreys is one analysis of the ideal relationship between the nose and the rest of the face. The necessary measurements are best done using photographs in full profile. A vertical line from the glabella to the most anterior point of the chin (pogonion) defines the vertical anterior facial plane. A line from the nasal tip is then drawn to the deepest depression at the root of the nose in the midsaggital plane (nasion).

Changing faces takes root
To a large extent, one’s face is one’s identity. The notion of radically changing one’s face, particularly by a transplant of facial tissue from someone recently deceased, is an uncomfortable concept for most, as if the transplant would somehow transfer to the recipient the identity of the donor. The naive assumption underlying this response is that the transplant recipient would take on the appearance of the donor. If that’s the case, why would someone choose to undergo a facial transplant, or permit donor tissue to be harvested from a deceased loved one? Should surgeries such as facial transplants be permitted?
   Facial transplants are not intended as cosmetic surgery for someone who already has a “normal” appearance. The intended recipient would be someone severely disfigured from extensive burns, trauma, cancer or birth defects, someone who likely would have already undergone numerous surgeries in an attempt to achieve an appearance that did not instantly provoke a negative reaction from strangers. Precisely because the face is such a critical component of one’s identity, those who experience rejection as a consequence of severe facial disfigurement often live in social isolation, with potentially devastating psychological consequences. For such a patient, facial transplant could offer the hope of reintegrating into society.
   A face is not a single tissue but a composite of multiple tissue types with different antigenic responses. Skin, subcutaneous tissues, blood vessels, nerves, hair follicles, and hair, muscles, and bone all combine to create a face. Thus, allotransplantation of the face—that is, transplantation of facial tissue from an unrelated donor—is a type of transplant known as a composite tissue allograft (CTA). Examples of CTA transplants include allograft transplants of the knee, hand, larynx, muscle and nerves.
Although CTA transplant is relatively uncommon, successful CTA transplants have been performed in the past decade, most notably hand allograft transplants. One of the greatest medical concerns facing CTA transplant recipients is immunosuppression.

Facial beauty ‘bone deep’
Size and shape of the facial skeleton affects how the soft tissues of the face are molded. The relationship between the bony framework of the face and its soft tissue envelope helps determine whether a face is unattractive or beautiful. The skeletal framework seems the most important in defining facial beauty.
   Looking from another perspective, it seems that facial beauty is “bone deep”. This is a common observation among artists, plastic surgeons and photographers. Flicking through any glamour magazine, the most beautiful people—regardless of age and sex—are those who have strong orbital rims, nice cheek bones and a strong mandible and chin.
   Facial ageing is also interdependent of the strength of the facial skeletal support. In other words, people with a stronger skeletal foundation seem to age more graciously and later in life. For those who do not have good support, all the soft tissues sag quicker and more severely. This is particularly true of the mandible, the framework of the lower face and, to a greater extent than previously appreciated, it exerts significant influence on the aesthetics of the neck.
   I developed the Mandibular Matrix Implant System (MMIS) for implant manufacturer Porex Surgical. MMIS addresses the absence of adequate mandibular contour from the tip of the chin to the angle of the jaw (gonial angle). The system provides an excellent construct to redefine the jawline, especially when combined with a neck lift or neck tightening procedures.
   MMIS is resistant to infection and has long-term stability, enabling rapid revascularisation and ingrowth of tissue. It can be fashioned to mimic the normal contour of the jawline. The multiple components of the implant system allow augmentation of the entire mandible or individual segments that may be deficient.
   The implants have been designed to provide “three-dimensional” restoration of the mandible. They wrap around the inferior border of the mandible, and because of this shape are self-stabilising and require minimal fixation with screws or sutures tunnelled in the bone. This is a significant advantage compared with two-dimensional onlay implants.

Malpractice insurance
Health and well-being are now enjoying a much higher lifestyle priority. A natural desire to look good, combined with the popularity of maintaining a healthy diet and lifestyle, has contributed to a significant increase in health practitioners covering a range of medical disciplines.
   Aesthetic practitioners, fitness centres and beauty salons are now commonplace and attract a growing number of visitors. As a result, many reconstructive procedures, anti-ageing and beauty enhancing products are becoming more accessible and affordable and are no longer the province of the privileged. These market developments have brought significant opportunities for cosmetic practitioners, but alongside these opportunities comes risk.
   We now live in an increasingly litigious society and every practitioner, regardless of competency, is vulnerable to allegations of malpractice and wrong doing. Dissatisfaction due to lack of knowledge on the part of the client is the most common route to a claim being made.
However, genuine accidents and errors of judgement can and do happen in every profession. Fortunately, these occurrences, despite occasional and sensational media reports, are relatively rare in the medical profession—and any subsequent claims are usually settled quickly and with comparatively little costs.
   In the most severe incidents, the consequences for the practitioner can be serious—both financially and professionally. Even if it appears that there is no case to answer, the claim must still be defended, often at considerable expense. That’s why it is advisable to have medical malpractice insurance. In the UK, if you are a doctor or dentist working in either the NHS or private sector, you may be able to rely on support from your defence organisation. However, if you are a practitioner involved in supplementary or complementary practice, you may need to arrange commercial malpractice insurance to protect yourself against claims for medical negligence. Commercial medical malpractice insurance responds to claims arising from bodily injury, which may include its more intangible forms such as mental injury, distress or psychological harm. The injury can arise from either treatment or advice or from a combination of the two.

Survival of the fittest
The past five years have seen explosive growth in Europe’s non-surgical aesthetic market. New groups of practitioners are opening their doors with different business models. Cosmetic dentists, in particular, are realising that selling injectable cosmetic treatments to their client base is both possible and profitable.
   Many specialist clinics are not highly visible geograpically, preferring to promote discretion and exclusivity. By contrast, others package their non-surgical medical procedures for consumers in a retail environment. One such company is a high street brand named Sk:n, which launched in Glasgow and other British cities to promote to consumers specialist skincare advice and treatment using injectables, peels, high-end retail skincare and light-based procedures.
   Another model is the medical spa, run by a medical practitioner but utilising a range of beauty and spa treatments to generate a loyal repeat business client base.
   Consumers can now find injectable treatments offered by general practitioners, nurse practitioners, dentists, accident and emergency consultants, neurologists and surgeons of all specialities at beauty salons, spas, slimming clinics, private consulting rooms, dental and GP surgeries, private hospitals, specialist laser and medical aesthetic clinics, cosmetic surgery clinics, hotels, tattooist shops and clients’ homes.
   With so many business models, it is difficult to determine which, if any, is the ideal business model to take best advantage of the growing demand for medical aesthetic treatments. Whichever the model, consumers will gravitate towards clinics that train their staff effectively.
Clinics will need to market themselves as experts that specialise in proven non-surgical treatments that really do work, which will generate repeat income. Proven products include botulinum toxin, dermal fillers, microsclerotherapy; laser and intense pulsed light, chemical peels and a medically proven topical retail line.
   Consumers are familiar with traditional dental clinics, beauty salons, spas and cosmetic surgery clinics. But their link with medical aesthetic treatments is not as transparent. As the market moves forward, those that promote and deliver a good, focused medical aesthetic service will be actively sought.

GO BACK TO ARCHIVE