Issue #22 summary - GO BACK TO ARCHIVE

Reconstructing the ears
The human ears are important organs in the aesthetic harmony of the facial contour. They may not be noticed when their size, shape, position and location are normal. However, any alteration in one, two or in all of these may cause unbalance of the organ itself and a significant, noticeable, aesthetic disturbance to the whole face.
   Any alteration to the facial contour due to a defect of the auricular skeleton usually causes dissatisfaction with one’s physical appearance combined with deep psychological damage. Those who are affected use a variety of artifices to hide the deformity and eventually show alterations in their self-image.
   Frequently a small deformity of the ear can cause an emotional reaction in child patients as well as in their parents. Even very young children feel uncomfortable when they recognise their own abnormality, leading to an inferiority complex.
   Taking all this into account, reconstruction of the ear is much more than a matter of surgery, because it should create the characteristic features essential to the patient’s physical and psychological recovery.
   The ear’s deformities may be classified in two major groups: congenital and acquired.
Congenital ear abnormalities occur in the earliest growth and development of the face and skull in utero and take place from the fourth to the eighth week of embryonic life. They are not hereditary disorders. In more than 500 patients in which we have performed ear reconstruction to repair congenital malformations, there have been only three brothers with similar imperfections (0.6%). The congenital disorders of the ear present a great variety of clinical forms, but the term microtia symbolises almost all of them, which means “small ear”. Most patients present other anomalies of the face, skull and upper and lower extremities as well the torso.

Beautiful lip service
The lips and the perioral area can be obvious markers of ageing in the face and can compromise attempts at facial rejuvenation if not addressed.
   Lip augmentation can be achieved by surgical and non-surgical means and seems deceivingly simple. It is a vital part of a cosmetic surgeon’s arsenal to beautify the face.
Achieving the best results needs a thorough understanding of the anatomy and pathophysiology of ageing of the lips and perioral region and an indepth knowledge of the techniques and materials used. This is not well described in the literature and benefits from further study and examination.
   The lip contours trace out an M shape superiorly and a W shape inferiorly. This contour is formed by the vermillion border or the white roll, which is a fine line of raised pale skin that accentuates the transition from skin to lip.
   The cupid’s bow of the upper lip is formed by two paramedian elevations of the vermilion. Two raised vertical ridges extend superiorly from these elevations to form a midline depression, the philtrum.The lower lip is somewhat fuller than the upper lip, and they come together laterally at the oral commissures.
   The dry–wet vermilion border refers to the transition area where the mucous membrane of the lip goes from squamous to columnar epithelium. The dry vermilion transitions to the wet vermilion which then becomes continuous with the mucous membrane of the oral cavity. This transition area can be found by everting the lip and drying it with a swab or cotton bud.
   The perioral region is bordered superiorly by the base of the nose, the nasolabial folds laterally and the free edge of the vermilion border of the upper lip. Inferiorly, it extends from the free vermilion edge of the lower lip, to the commissures laterally, and to the mandible inferiorly.
   The lips are another area of the face that tend to shrink and atrophy with age. The following describe the changes to the lips and perioral area as we age: lengthening of white lip, flattening of philtrum, flattening of Cupid’s bow, loss of lip projection, lip inversion, dermal and subcutaneous atrophy, marionette lines due to loss of maxillary dentition and bone resorption, atrophy of orbicularis oris, perioral wrinkles (smokers’ lines), and downturning of oral commissures.

Reshaping the face
The accumulation of fatty jowl tissue has been a subject debated since the beginning of the 20th century. Maliniak extolled the virtues of extracting tissue from the chin and neck areas in 1932. In 1955, Davis used a 1cm incision under the chin to remove fatty tissue. Later that year, Johnson used an elliptical incision to remove the same. In the mid-1970s, Kesselring, Mayer and Fischer used or proposed techniques using curettage instruments.
   In 1977, Illouz, using Fischer’s technique, injected a saline solution and used Korman cannulas and a vacuum or suction apparatus designed for abortions.
   Since then, liposuction has really progressed, extending to the inner thighs, the hips, the knees and the cervical region. The use of the Fournier syringes instead of the vacuum proved to be a simpler and more delicate operation, but it is a difficult method in the neck because of the rapid loss and void left behind.
   The pre-platysmal fatty tissue is the target of cervical liposuction. The target area is in a triangle at the back of the neck. The summit of the triangle is at the base of the neck above the sternal fork and its base joins the mandible centred on the hyoid bone. This ‘golden triangle’ is considered the region that gives particularly positive results.
   How the fatty tissue is likely to scar determines which technique is used. A total removal creates a large void that fills itself with a sero-hematic liquid combined with existing epithelium, causing a pseudo-pocket or purse, which makes healing impossible.
   Creating a tunnel produces a fibrous, concentric, regular, star-shaped tissue of a smaller diameter than that made by cannulas. The regular, concentric stars result in scar tissue that doesn’t stretch and shrink the surface. The consequence is that the skin retracts.

The one-stitch facelift
Well before the introduction of the barbed sutures (threads), “old Hollywood” had used tricks to make its stars look younger—temporarily— in close-ups. A simple but effective technique involved placing transparent tape in strategic positions of the face to pull the skin upward.
   In an effort to create a minimally invasive procedure that could mimic the results of transparent tape—but, of course, be more lasting—the one stitch face lift was developed. The procedure is based on a concept of moving the loose skin of the cheek area in a vertical vector towards the temporal area, using one’s own skin as the means to transmit the tension upward.
   The procedure requires two incisions: a curvilinear one at the sideburns; the other in the temporal area, each of about 2cm in length. Through the sideburn access, the skin of the cheek area is undermined: the extent depends on the degree of skin laxity.
   The skin is then pulled upward, in a vertical vector, to estimate the amount of pull needed. The excess skin is marked and then depithelialised, not excised. The temporal incision is made and deepened to the deep temporal fascia and a tunnel is created to the skin of the sideburn. then inserted through the tunnel and secured under adequate tension to the deep temporal fascia with 3-0 absorbable suture. The two incisions are then closed with semibarried 5-0 and 3-0 non-absorbable sutures. The entire procedure is done under local anaesthetic and the patient is able to drive herself to and from the facility.

Reducing perspiration
Hyperhidrosis is an excessive production of sweat beyond that required to cool the body and can affect a person’s quality of life. This excess sweat may affect the entire body (generalised hyperhidrosis) or be localised to the axillae, palms, soles or another part of the body (focal hyperhidrosis). It may be further divided into primary or secondary, such as hyperthyroidism, anxiety, obesity, drug withdrawal.
   A more scientific definition involves the measurement of sweat production gravimetrically over a fixed time, with the patient in a resting position. In clinical practice, the most useful indicator of severity of disease is a formal quality of life assessment.
   Hyperhidrosis is estimated to affect about 1% of the UK population; although, because of under-reporting, this is thought to be an underestimate. Therapeutic options include antiperspirants, anticholinergics, ionotophoresis, surgical intervention (sympathectomy) and, more recently, the injection of botulinum toxin type A (botox) into the sweat-producing areas.
   Botox’s efficacy in reducing sweat production is attributable to the way its inhibits the release of acetylcholine from the cholinergic neurons, which innervate the myo­epthelial cells surrounding the sweat glands via the sympathetic nervous system. It does this in three stages: binding of the toxin to specific neuronal presynaptic receptors, neuronal uptake of the toxin, and the intracellular inhibition of exocytosis of acetylcholine. This restricts muscle contraction and sweat release through the sweat ducts.
   The first report of botox used in a patient to treat hyperhidrosis was published as a letter in The Lancet (“Botulinum toxin for palmar hyperhidrosis”, Naumann M, Flachenecker P, Brocker EB, Toyka KV, Reiners K 1997 Jan 349: 252) and, thereafter, larger studies have been published resulting in the license being granted in the UK to Allergan Inc for botox type A to treat axillary hyperhidrosis.

How to make your skin glow
   The skin is the largest organ of the body and is certainly the most visible. It is continually repairing itself and maintaining its status, even though constantly exposed to the elements.
Ageing of the skin is divided into extrinsic ageing—which encompasses photoageing and the damage caused by various toxins such as alcohol, drugs and smoking—and intrinsic ageing, which refers to the breakdown of DNA at a chromosomal level, with a resultant loss of structure of the skin.
   Extrinsic ageing can be avoided; however, tackling intrinsic ageing is more challenging. There are many cutaneous signs of internal disease, and the paradox is that to maintain our skin in its best possible condition we need to have a healthy body. A holistic approach to anti-ageing is, therefore, essential.
   Ageing decreases antioxidant activity. It promotes a reduction in SOD (super oxide dimutase) and catalase, as well as leaving energy cell repair and renewal diminished and antioxidant enzymes less available.
   Dehydration is the most prominent, yet easily corrected, cause of accelerated ageing, particularly of the skin. An intake of two litres of water per day, and the exclusion of diuretics, such as coffee, will slow down ageing.
   Sunlight damage to the skin can be avoided with the use of SPF factor 30, as well as a high dose of oral antioxidants. Astaxanthins, together with vitamins A, C and E are also protective.
Collagen is particularly prone to free radical damage, which, in turn, causes the cross-linking of collagen proteins, leaving the skin stiff and less flexible. Sunlight can stimulate inflammatory products, skin collagen degradation and photo ageing. Skin ageing is accelerated by sun exposure, cigarette smoke, environmental toxins, poor diet, excess alcohol consumption, stress, and lack of sleep. One way of counteracting these ‘risk factors’ is to ensure the diet is rich in fruit and vegetables, increase the intake of antioxidants, as well as direct topical application of antioxidants.

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