Issue #7 summary - GO BACK TO ARCHIVE

Light at end of the tunnel
The ubiquitous word for the ‘90s and beyond in terms of beauty and plastic surgery has been “laser”. Lasers have become an integral and imperative part of cosmetic procedures and surgeries from the advent of laser hair removal to the use of lasers for scars, wrinkles, sun damage, and even veins. I decided that, if lasers can be used to improve such delicacies as the eyes and skin, I would explore some uncharted territory with the lips. With much success, I have pioneered the “laser graft and tunnel” lip augmentation, giving women fuller lips instantly utilising their very own skin.
   For years now, cosmetic surgeons — myself included — sought to feed the full-lip frenzy will filler substances such as Zyderm, Collagen, autologous fat injections, Alloderm and various lip-roll procedures. While all of these methods achieve a fuller lip, most are not permanent, produce unnatural results, and run the risk of allergic reaction or negatively inciting the immune system.
   I sought to use the existing technology in plastic surgery to invent a lip-plumping procedure for both aged and thin lips that would last a decade, produce no negative reaction, and could be done in 15 minutes under a local anaesthetic. The premise is simple and can be performed under two different conditions. For those who want to make the most out of a facelift, the laser graft and tunnel is easily incorporated. Gravity and age take its toll on various parts of the face, as well as the lips, which lose bulk over the years, becoming thinner and receding. This produces a much wider, less desirable gap between the lip border and the tip of the nose.

Smooth operator
It may be a relative newcomer to the cosmetic surgery lexicon, but microdermabrasion is already on the lips of millions of women and men worldwide. In the US alone, the American Society for Aesthetic Plastic Surgery estimates that 915,312 procedures were performed in 2001.    The society says microdermabrasion accounts for 10.8% of US cosmetic surgery procedures. Only Botox, chemical peels and collagen-type injections surpass it in popularity, a pattern pretty much mirrored in Europe.
   The attraction of microdermabrasion lies in its ability to give good results relatively quickly at a reasonable price. Fine lines, crow’s feet, age spots and superficial acne scars are only a few of the conditions that can be treated successfully in, say, six 30-minute to one-hour sessions, depending on skin condition. Many surgeons also administer maintenance programmes at three-to-six-month intervals. Prices start at about 100 euros per visit, with intervals between procedures lasting from one to four weeks.
   “The first time I had microdermabrasion I couldn’t understand what the excitement was. By the third of fourth, the unequivocal afterglow hit home,” says beauty consultant Wendy Lewis. “Women like the results they get with these treatments and keep coming back for more, even after they have completed an initial series.”
   The American Society for Dermatology, on a less-effusive note, says there is limited scientific data on microdermabrasion. “Several dermatologic surgeons are investigating the effectiveness of the treatment, but long-term clinical efficacy has yet to be determined. So far, preliminary experience suggests that the technique may be especially beneficial for Asian and dark-skinned patients who typically encounter skin discolouration with other facial rejuvenation treatments.    “As an adjunctive therapy, experts believe microdermabrasion may accelerate or maintain certain other skin renewal modalities, like laser treatment or Retin-A therapy.”

Time to adjust the volume
I have performed “refreshing” techniques for 10 years, offering patients an alternative to the classical facelift for facial rejuvenation. I have also treated faces that have been overstretched by the traditional facelift techniques. Refreshing does not give the same results as rhytidoplasty: it is a more gentle, facial recontouring procedure and complements other facial techniques.
   My technique of superficial syringe liposculpture uses the finest cannulas to recontour the jaw line and inject fat into the naso-labial, malar and glabellar regions. This postpones the first facelift or complements older patients’ facelifts. My concept of facial rejuvenation has altered. I was never happy performing facelifts on young patients aged 35–45, because I was reluctant to put an extensive and permanent scar on “borderline age” cases. I felt that there was another approach to stretching the skin to accomplish the “younger look”.
   Before liposuction, little could be done. The ‘so-called’ mini-lift of the temporal or cervical regions still has the stigma of rhytidoplasty. Blepharoplasty solves the problems of excess skin, muscle and fat within the orbital region. It is a wonderful procedure, made quicker and safer with a CO2 laser, giving a three–four day recovery time. It solves the eyelid problems thoroughly and leaves inconspicuous scars.
   Using the trans-conjunctival incision, I avoid the lower eyelids’ skin incision. After removal of the fat, skin retracts in 90% of patients. The fine wrinkles that do not disappear with the procedure can be treated with the light alphahydroxic peels, especially with 70% glycolic acid, or even with a CO2 laser peel. I rarely revise excess skin after the second post-operative month. In the early 1980s I started using liposuction to improve facial contours. Cannulas were thick in those days — 4–6mm. Results, as in all cases of liposuction then, were limited by the patient’s skin quality and the depth of suction. A patient was considered a “good candidate” for liposuction only if young with good skin tone.

Projecting into the future
Computer imaging systems continue to move on at pace. Since the early days of Photoshop and Apple Macs, software manufacturers have not been slow in harnessing the processing energy and wide-ranging ability of every advance in computer technology across all platforms. The versatility of 21st century digital image manipulation is apparent in cosmetic and plastic surgery. Patients can now see what they may look like before deciding to go ahead with, say, a rhinoplasty or abdominoplasty. For precisely that reason, increasing numbers of surgeons are investing in digital image manipulation systems.
   Unlike other professions and the trades, the application of image manipulation in cosmetic surgery raises ethical questions. Cosmetic and plastic surgeons treat people — all of whom are unique in their mental and physical make-up. So how can end results be formulaically previewed, and how accurate can these systems ever be? How realistic is the projected outcome? Will patients expect results to match their digital images? If the patient reacts badly to the procedure, could this later have an effect on his or her mental health?
   Dr Frank Meronk Jr, an oculoplastic surgeon based near Los Angeles, discusses the use of digital imaging by a practitioner to help persuade the patient to choose his or her services. “You’re half-way through a consultation with a patient whose anatomy makes him or her a challenging and less than ideal candidate for surgery. You’re doing your best to explain the limitations and risks of a particular procedure.

Implants with a difference
Breast implants have diversified dramatically since Dr Cronin, an American doctor, showed the first silicone implant in 1963. In recent years, breast enhancement surgery has become one of the most frequently performed cosmetic procedures. Today’s breast augmentation patients can choose from a wide range of implants that accommodate most needs.
   Although they account for only a tiny share of the breast implant market, adjustable breast implants have gained in popularity since their development in 1965 by Dr Arion of France. In 1998, 132,378 American women were reported to have chosen them. Inflatable implants have never been given formal FDA approval — only that they were retrospectively adjudged “approvable”. By virtue of being available before legislation introduced in 1976, they can be legally sold under the ‘grandfather’ rule, which allows the sale of goods to continue to be sold after legislation affecting new products is enacted.
   Board-certified plastic surgeon Dr Elliott Rose, who is director of the Aesthetic Surgery Center in Manhattan, says the advantage of inflatable implants is their adjustability. Dr Rose has been inserting adjustable implants since 1997 in patients ranging from 28–50 years old. “Often, women seek breast augmentation and merely know that they want to be ‘bigger’ or ‘fuller’.    Frequently, patients overestimate the size or underestimate the ‘ideal cup size’. It is often difficult for a patient to know exactly what she wants until she sees how a fuller breast actually fits her proportions. Without the benefit of an adjustable implant, patients often have to undergo multiple breast augmentations until the doctor and patient feel it is an ideal aesthetic result. Repeated surgery entails one or more post-operative recovery periods, which impedes a patient’s personal and professional life.

Positive necklifts
The ageing skin and the skin folds of the neck —especially below the Adam’s apple — cannot be elevated by means of a facelift. But I have used a technique where the submental and submandibular areas are liposuctioned. Through a postauricular incision close to the hairline, the whole neck is undermined up to the fossa jugularis, and the skin of the neck is lifted and sutured to the mastoid and occipital bone to apply a proper traction. To avoid a facelift and to correct an ageing neck, this technique is modified in younger patients, which helps to avoid facelift operations at an early age. This method elevates the submental region and corrects the results after neck liposuction. The advantages of this technique are fewer injuries, invisible scars behind the ears, short recovery time and low cost.
   A submental liposuction of the neck and a facelift alone will not be able to eliminate the skin folds and the skin damage at the lower half of the anterior neck. This angle differs between 105–120 degrees and makes a young appearance of the neck possible. The hypertrophied submandibular gland, or a ptosis of the platysma muscle which hangs down, causes a bad result when using liposuction alone. Up to now, surgeons have been performing a facelift, or operating on the neck, by removing a part of the gland or making a special platysmal suture — both resulting in terrible scarring. The advantage of the method I use is that it avoids the problem of an undesirable scar in front of and behind the ears. Nor is there is risk of hair loss because of incisions in the scalp.

Picking up the threads
Thread veins are a bane of the world’s population. Mr Brian Newman, FRCS, referring to statistics compiled on female sufferers, says they cause cosmetic discomfort and physical pain to more than 55 per cent of women at some point in their lives. In the UK alone this equates to about 15 million women. Thread veins in men are not nearly as common. Men who do have them often don’t consider them to be a cosmetic problem because they are usually concealed by body hair. However, treatment for thread veins in men is considered as effective.
   Much of the development of enlarged veins is due to the hormone oestrogen, seen as the main reason they affect women more than men. Pregnancy and obesity are also causes. As well as the higher oestrogen that women experience during pregnancy, the greater pressure on the venous system of the legs due to the weight of the baby can also promote thread veins. Genetics, of course, also plays a role. There is much evidence that the weak valves mainly causing varicose and thread veins is inherited.
   The visibility of thread veins on the face, thighs, ankles and feet clearly compels patients to seek an effective treatment. Stripping, in which an incision is made into the affected region and a hooked instrument is used to lever the inflamed vein out, is still a widely practised technique.
Sclerotherapy is a popular alternative. Basically it involves using a fine needle to inject the vein with a solution, such as saline, to cause the vein to swell and the blood to clot. In a study on sclerotherapy of the face, hands and chest, 14 patients were treated at 20 facial sites, seven on the hands and three five times on the chest. Follow-up treatment ranged from nine months to 15 years.

Breast nipple procedures
Features of inverted nipples are usually evident as a slit or hole in the nipple of one breast or both. It is usually a congenital situation but may be related to scarring from breast-feeding, infection in the ducts or previous breast surgery. Nipple inversion can cause functional problems such as irritation, rash and discomfort. It may prevent the ability to breast-feed. Correction is sought most often because it is a cosmetically undesirable condition and women simply do not like the way it looks and want it improved.
   The condition of inverted nipples occurs in about two per cent of women. It is anatomically related to the degree of scarring and retraction of the milk ducts, which pull the nipple down, and the amount of tissue bulk lacking at the base or neck of the nipple. There are varying grades of retraction:l Grade I — the nipple can be pulled out fairly easily and maintains its projection; Grade II — the nipple can be pulled out but not easily. It tends to want to retract fairly quickly; Grade III — it is difficult or impossible to evert the nipple.
   Treatment has involved many various procedures over the years, dating back to as early as 1888. The procedures are classified into two main groups: one preserves the milk ducts; the other divides the milk ducts. More than 20 surgical procedures have been described, the methods varying from tightening the neck or base of the nipple, adding more bulky tissue at the base of the nipple, incisions to release scar contractures, to internal cuts with sutures to hold up the nipple.

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