Aesthetic Surgery 1 (1)

Surgery 2 AESTHETIC SURGERY Stanley U. Kho, MD, DPBPS, FPAPRAS Aesthetic Surgery

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Reshape normal structures

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Improve appearance and self-esteem

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Surgery in the clear absence of a functional deformity

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The American Medical Association defines cosmetic surgery as "surgery performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.“ Nevertheless, there are patients for whom it is a priority to make surgical changes to their bodies in the clea r absence of a functional deformity. Performed on abnormal structures Improve function ; Approximate a normal appearance Unique challenge

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Most important outcome parameter is not truly appearance but

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 patient satisfaction satisfaction

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Optimally a good cosmetic outcome will be associated with a high

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 Aesthetic surgery patients present a unique challenge to the plastic surgeon, because the most important outcome parameter is not truly appearance, but patient satisfaction. Optimally, a good cosmetic outcome will be associated with a high leve l of patient satisfaction.

UPPER BLEPHAROPLASTY

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Laxity of skin & soft tissues

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Excessive skin, redundant orbicularis and orbital fat

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Restores eyelids to a more youthful appearance

level of patient satisfaction

Gunter and Gorney

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Patient's motivations

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Patient's goals and expectations

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Reasonable assessment

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Appropriately counseling

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Positive doctor-patient relationship

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The patient’s expectation level must be assessed prior to any operative

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intervention. Both Gunter and Gorney (4) have commented on “danger signs” that may be exhibited by certain patients. Those patients who fit these criteria should be app roached with caution,

as surgical intervention may not be in either the patient’s or the surgeon’s best interest.  

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Supratarsal crease incision

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Avoid overresection

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Excess skin and adipose deposits of the upper eyelid are approached through an incision based on the su pratarsal crease. Careful attention to marking will avoid the complication of overresection. A strip of orbicularis muscle is often excised to accentuate the supratarsal fold. Fat deep to the orbital septum is resected selectively.

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Excise a strip of orbicularis muscle

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Resect fat selectively

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Excess skin and adipose deposits of the upper eyelid are approached through an incision based on the su pratarsal crease. Careful attention to marking will avoid the complication of overresection. A strip of orbicularis muscle is often excised to accentuate the supratarsal fold. Fat deep to the orbital septum is resected selectively.

The “Gorneygram” comparing patient concern with the actual degree of deformity. For this to be the case, the plastic surgeon must do a careful analysis of the patient's motivations for wanting surgery, along with the patient's goals and expectations. The surgeon must make a reasonable a ssessment that the improvements that can be achieved through surgery w ill meet the patient's expectations. The surgeon must appropriately counsel the patient about the magnitude of the recovery process, the exact location of scars, and potential complications. If complications do occur, the surgeon must manage these in a manner that preserves a positive doctor-patient relationship.

PRE & POST-OP PHOTOGRAPHS

LOWER BLEPHAROPLASTY

MOST POPULAR PROCEDURES

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Subciliary incision

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In the lower lid, excess skin is removed through a subciliary incision. Lower eyelid fat may be either excised or repositioned. Complications can include hematoma, lower lid retraction, and injury to ocular muscles. If a hematoma forms in the retro-orbital region, a true surgical emergency exists. Permanent vision loss can occur if it is not immediately decompressed.

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Surgery 2 

Fat may be either excised or repositioned

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In the lower lid, excess skin is removed through a subciliary incision. Lower eyelid fat may be either excised or repositioned. Complications can include hematoma, lower lid retraction, and injury to ocular muscles. If a hematoma forms in the retro-orbital region, a true surgical emergency exists. Permanent vision loss can occur if it is not immediately decompressed.

BROWLIFT

PRE & POST-OP PHOTOGRAPHS

COMPLICATONS

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Hematoma

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Injury to ocular muscles

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Ectropion

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Resect corrugator and procerus muscles

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Preserve supraorbital & supratrochlear nerves

ENDOSCOPIC BROW LIFT

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Excessive skin excision

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Elderly w/ poor lid tone

PRE & POST-OP PHOTOGRAPHS

Sunken or hollow look o

Excessive fat excision

BROWLIFT BROW PTOSIS

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Grabb and Smith The goal of eyebrow elevation deserves spe cial comment. Ellenbogen (6) proposed five criteria for ideal eyebrow position and shape. The brow begins medially at a vertical line drawn perpendicular through the alar base. The brow terminates laterally at an oblique line drawn through the lateral canthus of the eye and the alar base. The medial and lateral ends lie at approximately the same horizontal level. The apex of the brow lies on the vertical line drawn directly through the lateralimbus of the eye. The brow arches above the supraorbital rim in women and lies at approximately the level of the rim in men.  Although commendable, these criteria may not always be achievable in the clinical setting. For practical purposes, postoperative eyebrow position is almost always satisfactory as long as the lateral eyebrow segment is simply higher than the medial segment in the female patient and level with the medial segment in the male patient.

BROW MUSCLES

RHYTIDECTOMY AGING CHANGES IN THE FACE 1.

Forehead and glabella creases

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Ptosis of the lateral brow

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Redundant upper eyelid skin

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Hollowing of the upper orbit

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Lower eyelid laxity and wrinkles

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Lower eyelid bags

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Deepening of the nasojugal groove.

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Ptosis of the malar tissues

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Generalized skin laxity

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Deepening of nasolabial folds

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Perioral wrinkles

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Downturn of oral commissures

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Deepening of labiomental crease

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Jowls

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Loss of definition and excess fat in neck

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Platysmal bands

FACELIFT

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Procerus

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Frontalis

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Corrugator

BROWLIFT INCISIONS  A, Temporal scalp incision;

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Preauricular with extension into the temporal hairline superiorly and into the retroauricular region posteriorly and inferiorly

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Grabb and Smith

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B, temporal hairline incision; C, midline scalp incision; D, mid-hairline incision; E, direct eyebrow incision; F, direct forehead incision.

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Standard facelift incision. Regardless of the technique chosen, some form of this incision is employed. In the temporal region the incision is shown within the hair. In patients with extremely thin hair, previous facelifts or if performing the minimal access cranial suspension (MACS) lift, the incision is made along the anterior sideburn and temporal hairline, rather than as sh own here. In this illustration, the incision is shown along the posterior margin of the tragus. In men, and in women with oily or hairy preauricular skin, an incision in the preauricular crease may be preferable.

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Surgery 2 

several structural problems. A deviated septum can severely impede airflow, as can problems with the internal nasal va lve. Obstruction at the internal nasal valve, which is the junction of the upper lateral cartilage and septum, can be identified by applying lateral traction on the cheek skin to open the valve and observing whether airflow improves (Cottle sign).  Airway obstruction can be addressed surgically at the time of rhinoplasty.  Aesthetic deformities of the dorsum of the nose are treated by a combination of osteotomies, which serve to reposition the nasal bones, and rasping of the bone. Aesthetic deformities of the tip of the nose are treated by reducing the width of the lower la teral cartilages and/or sewing the cartilages together to reduce tip width. Small tips can be augmented with cartilage grafts harvested from septum or auricle (Fig. 45-57). Complications of rhinoplasty include induction of new nasal airway obstruction and a variety of aesthetic deformities.

In the short scar technique, the incision is terminated at the bottom of the earlobe or just behind it, and the entire retroauricular portion of the incision is eliminated.

TURKEY-NECK

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The platysmal layer is continuous with the SMAS layer and ca n be plicated through a small neck incision to eliminate the appearance of vertical bands along the muscle edge.

PRE & POST-OP PHOTOGRAPHS

AUGMNETATION RHINOPLASTY

NASAL IMPLANTS

COMPLICATIONS

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Most common complication

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4%

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TIP PLASTY

Hematoma

Facial nerve injury o

Temporal branch and marginal mandibular branch

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1%

The most common facelift complication is hematoma, which may require operative drainage to prevent skin flap necrosis. Injury to facial nerves, most often temporal branch and marginal mandibular branch, is seen in approximately 1% of cases.

PRE & POST-OP PHOTOGRAPHS

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Interdomal sutures approximate the medial/middle crura and can affect both tip re finement and projection.  Aesthetic deformities of the tip of the nose are treated by reducing the width of the lower lateral cartilages and/or sewing the cartilages together to reduce tip width.

TIP GRAFTS

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The onlay tip graft is usually placed over the dome of the middle crura. Small tips can be augmented with cartilage grafts harvested from septum or auricle (Fig. 45-57). Complications of rhinoplasty include induction of new nasal airway obstruction and a variety of aesthetic deformities.

CARTILAGE EXCISION

RHINOPLASTY THE PERFECT NOSE

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BASE MODIFICATION

Symmetry is determined by drawing a vertical line from the midglabellar area to the menton.

ORIENTAL NOSE

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Broad and flat dorsum

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Deficient tip projection

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Wide lobule

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Flaring alae

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Thick alar margin

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The key to understanding rhinoplasty is app reciating the complex nasal anatomy (Fig. 45-56) and the way in which altering this framework will impact the appearance of the nose. Evaluation of the rhinoplasty patient not only should include the aesthetic complaints, but also should consider the function of the nasal airways. Nasal airway obstruction can occur from

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PRE-OP AND POST-OP

COMPLICATIONS

AUGMENTATION BY INJECTION

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Surgery 2

BODY CONTOURING

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Contour deformities o

Subcutaneous fat excess

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Skin excess

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Musculoaponeurotic laxity 

SUCTION LIPECTOMY

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Removal of adipose tissue through minimal incisions using a hollow suction cannula

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Excess fat deposits

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No significant skin excess

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No muscle laxity

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Liposuction involves the removal of adipose tissue through minimal incisions using a hollow suction cannula. Although the scarring is quite innocuous, a key principle of liposuction is that fat is being removed without skin tightening. Therefore, one relies on the patient's inherent skin elasticity to provide retraction over the treated adipose depot. Assessment of skin tone is a vital part of the patient evaluation. If there is skin laxity in the area to be treated, it may worsen after liposuction. Importantly, liposuction should be used as a tool for contouring prominent adipose depots and is not considered a weight loss treatment. The best candidates for liposuction are individuals who are close to their goal weight and have focal adipose deposits that are resistant to diet and exercise (Fig. 45-58). The suction cannula removes fat by a vulsing small parcels of adipose tissue into small holes at the cannula tip. With standard suction lipectomy, fat is removed only when the cannula is actively moved through the tissue planes. Minimal tissue effects are seen when the cannula is stationary. In general, larger-diameter cannulas remove adipose tissue at a faster ra te but carry a higher risk of causing contour irregularities such as grooving and uneven removal of fat. Newer liposuction technology uses an ultrasonic probe to emulsify the fat via cavitation before suction.  Advocates of ultrasonic liposuction report that the technique provides a more even and uniform removal of adipose tissue. Recognizing that no one technique is best for all p atients and all anatomic regions, many surgeons use ultrasonic energy selectively. For contouring

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Not a weight loss treatment

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Best candidates

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Individuals close to their ideal weight and have focal adipose

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dilute lidocaine and epinephrine (lidocaine 0.05% and epinephrine 1:1,000,000) in large volumes throughout the subcutaneous tissues. Tumescent volumes may range from one to three times the an ticipated aspirate volume. The dilute lidocaine provides sufficient anesthesia to allow the liposuction to be performed without additional agents, although many surgeons prefer to use sedation or even general anesthetic when large volumes of fat are to be removed. When general anesthesia is used, the lidocaine dose may be reduced or even eliminated. With tumescent anesthesia, the absorption of the dilute lidocaine from the subcutaneous tissue is very slow, with peak plasma concentrations occurring approximately 10 hours after the procedure.78 Therefore, the standard lidocaine dosing limit of 7 mg/kg may be sa fely exceeded. Current recommendations suggest a limit of 35 mg/kg of lidocaine with tumescent anesthesia.79 A very important component of the tumescent anesthetic solution is the dilute epinephrine, which limits blood loss during the procedure. Safety issues are paramount for liposuction because of potential fluid

shifts postoperatively and hypothermia. If Š5000 mL of aspirate is to be removed, the procedure should be performed in an accredited acute care hospital facility. After the procedure, vital signs and urinary output should be monitored overnight in an appropriate facility by qualified and competent staff who are familiar with perioperative care of the liposuction patient. SUCTION LIPECTOMY

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Crystalloid o

3:1 fluid-to-fat ratio

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150 ml fat: 1% Hct

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If  1500 ml fat removed, consider transfusion

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Large volume > 5 L

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2 cm of skin & subcutaneous tissue

deposits that are resistant to diet and exercise TUMESCENT TECHNIQUE

PRE-OP AND POST-OP

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Lidocaine (0.05%) and epinephrine ( 1:1,000,000)

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Two advantages of wetting solution o o

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 Anesthetic effect Hemostatic effect 

 A major advance in the field of liposuction was the development of tumescent local anesthesia. This method involves the infiltration of very

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COMPLICATIONS

EXCISIONAL BODY CONTOURING

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Significant skin laxity

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A trade of excess skin for scar

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Bariatric surgery

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When significant skin laxity is present, improvement in contour can be achieved only through skin excision. Therefore, all body-co ntouring

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Surgery 2 surgery represents a trade of excess skin for scar, and this must be emphasized during patient consultation. The patient willing to accept scars in exchange for improved contour is likely to be satisfied with the procedures. With the increased number of bariatric surgery procedures over the past decade, body-contouring surgery has become very popular and is emerging as a new subspecialty of plastic surgery. ABDOMINOPLASTY

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Most common body-contouring procedure

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Redundant skin o

Pregnancy

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Weight loss

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 Aging Surgery 

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Muscle laxity

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W/ or w/o excess fat

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 Abdominoplasty/panniculectomy is the most common body-contouring procedure and can range from a limited-incision skin removal in the lower abdomen to a major skin excision with transposition of the umbilicus and placation of the rectus muscles to further enhance contour.80 Some patients may benefit from a concurrent vertical incision to remove skin in two vectors (Fig. 45-59). Possible complications include skin necrosis, persistent paresthesias of the abdominal wall, seroma, and wound separation. Necrosis of the umbilicus may complicate preservation of that structure if the stalk is excessively long or an umbilical hernia is repaired.  Adding a vertical resection increases the incidence of skin necrosis, especially at the confluence of scars in the lower abdomen.

SURGICAL TECHNIQUE BREAST SURGERY BREAST PTOSIS Breast ptosis classification. A: Normal. B: Minor or first degree. C: Moderate or second degree. D: Severe or third degree. E: Glandular ptosis.

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Sagging breast

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Relative skin excess

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Causes o o o

Weight loss  Aging Postpartum atrophy

GRADE I PTOSIS

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Surgery 2 

Nipple ptosis is graded by the nipple position relative to the inframammary

fold (IMF). Grade 1 ptosis describes a nipple ≤1 cm below the IMF. GRADE II PTOSIS

BREAST AUGMENTATION

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Grade 2 ptosis describes a nipple 1 to 3 cm below the IMF.

GRADE III PTOSIS

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Grade 3 ptosis describes a nipple position >3 cm below the IMF.

PSEUDOPTOSIS

 Augmentation Mammaplasty  Although the use of prosthetic implants can successfully increase breast size, the surgeon must fully understand both the risks o f the biomaterials and the way in which a specific implant of given shape and size can be surgically integrated into the existing breast mound to achieve the desired result.84 To address the latter point, the surgeon must first consider the possible surgical approaches for implant placement. The three commonly used incisions for placement of cosmetic breast implants are inframammary, periareolar, and axillary (Fig. 45-63).85 A transumbilical breast augmentation technique has been advocated by some surgeons more recently, but critics of this approach point out that there is poor control over the dissection of the implant pocket and that direct access to the tissues of the breast is inadequate to con trol bleeding vessels. In addition, only saline implants can be used with transumbilical breast augmentation because the prefilled silicone implants are too large to pass through the incision and narrow tunnel. The implants may be placed in a subglandular or subpectoral position (Fig. 45-64). Many surgeons p refer the subpectoral placement because it provides greater soft tissue coverage in the upper pole of the breast and can hide contour irregularities related to the implant. This soft tissue coverage is especially important with saline implants, because visible rippling can occur. The next issue to consider is e xisting nipple position. If a patient has mild ptosis, the sheer volume of the implant may raise the nipple to an acceptable level. For more severe ptosis, a con current mastopexy is necessary. Some surgeons advocate performing the mastopexy as a second stage after the implant has settled into position.

HYPOMASTIA  – GENETICS

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Pseudoptosis or bottoming out is a term used to describe the descent of the breast tissue below the nipple and is a potential long-term complication of breast reduction.

INVOLUTIONAL

POLAND’S

SYNDROME

SURGICAL TECHNIQUE

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Similar to breast reduction o

Nipple repositioned superiorly 

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Excise excess skin

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No or minimal volume removal

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Mastopexy In contradistinction to breast reduction, in which patients are treated for symptoms related to heavy breasts, mastopexy is a three-dimensional reshaping of the breast performed with no or minimal volume removal. The principles are the same, however: The skin envelope is contoured and the nipple location optimized. Because the degree of ptosis may be less severe than in b reast reduction cases, the patterns of skin resection can vary widely. Minimal patterns may involve excision of just a crescent of skin from above the areola o r a periareolar ("donut") resection. The Wise keyhole pattern can be used for larger skin excisions.

PSYCHOLOGICAL

INCISIONS

PRE & POST-OP PHOTOGRAPHS

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Surgery 2

COMPLICATIONS

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Incisions for augmentation mammaplasty. A, Inframammary; B, axillary; C, periareolar  A transumbilical breast augmentation technique has been advocated by some surgeons more recently, but critics of this approach point out that there is poor control over the dissection of the implant pocket and that direct access to the tissues o f the breast is inadequate to control bleeding vessels. In addition, only saline implants can be used with transumbilical breast augmentation because the prefilled silicone implants are too large to pass through the incision and narrow tunnel. Placement of breast implant.  A. Subglandular. B. Subpectoral.  Although the use of prosthetic implants can successfully increase breast size, the surgeon must fully understand both the risks of the biomaterials and the way in which a specific implant of given shape and size can be surgically integrated into the existing breast mound to achieve the de sired result.84 To address the latter point, the surgeon must first consider the possible surgical approaches for implant placement. The three commonly used incisions for placement of cosmetic breast implants are inframammary, periareolar, and axillary (Fig. 45-63).85 A transumbilical breast augmentation technique has been advocated by some surgeons more recently, but critics of this approach point o ut that there is poor control over the dissection of the implant pocket and that direct access to the tissues of the breast is inadequate to control bleeding vessels. In addition, only saline implants can be used with transumbilical breast augmentation because the prefilled silicone implants are too large to pass through the incision and narrow tunnel. The implants may be p laced in a subglandular or subpectoral position (Fig. 45-64). Many surgeons p refer the subpectoral placement because it provides greater soft tissue coverage in the upper pole o f the breast and can hide contour irregularities related to the implant. This soft tissue coverage is especially important with saline implants, because visible rippling can occur. The next issue to consider is existing nipple position. If a patient has mild ptosis, the sheer volume of the implant may raise the nipple to an acceptable level. For more severe ptosis, a co ncurrent mastopexy is necessary. Some surgeons advocate performing the mastopexy as a second stage after the implant has settled into position.

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PLACEMENT OF IMPLANTS

Many surgeons prefer  the subpectoral placement because it provides greater soft tissue

Systemic connective tissue disorders

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coverage in the upper pole of the breast and can hide contour irregularities related to the implant. This soft tissue coverage is especially important with saline implants, because visible rippling can occur

Not proven by large epidemiologic studies

Rupture o

Saline implants  rapid deflation

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Silicone gel implants  confirmed by MRI

Potential complications related to the implant itself are numerous, and the patient must be fully informed of these possibilities before undergoing surgery. One important point is that there is a h igh likelihood that the patient will require a second operation to address an implant problem. The implant complications are essentially all local. Although there was concern in the past that implants might be associated with systemic connective tissue disorders, large epidemiologic studies have not supported such a link. The fears over implant safety were so strong that the Food and Drug  Administration (FDA) declared a moratorium on the use of silicone gel implants in 1992. At that time, saline-filled implants were still allowed for general cosmetic use. Data were compiled on silicone gel implants, and these devices were approved by the FDA for general use in 2006.86 Potential implant complications include rupture of the device. For saline implants, this results in rapid deflation. For silicone gel implants, the rupture may be not be obvious a nd can be confirmed by MRI. Another complication is capsular contracture, which results in a tight envelope of scar that can distort the shape of the implant and cause pain in severe cases. A complication more common to saline devices is the appearance of rippling in the upper pole of the device. Implant malposition can also distort the breast shape and require reoperation. Safety data printed on the official FDA-approved package insert from one of the device manufacturers show the incidence of reoperation to be 29.9% over 7 years in a study of 901 women undergoing primary breast augmentation with saline-filled implants (postapproval study). The rate of severe capsular contracture (grade 3 or 4 on a 4-point scale) was 15.7%, and the rate of implant rupture was 9.8%.87 For silicone gel –filled implants, the reoperation rate was observed to be 23.5% over 4 years in a study of 455 women undergoing primary breast augmentation. The rate of severe capsular contracture (grade 3 or 4 on a 4-point scale) was 13.2%, and the rate of implant rupture (evaluated by MRI) was 2.7%. The three most common reasons for operation, in order, were capsular contracture (28.9%), implant malposition (15.6%), and ptosis (14.1%). For secondary augmentation, complication rates were much higher, with the reoperation rate over 4 years rising to 35.2%. The rate of capsular contracture was 17.0%, and the rate of implant rupture was 4.0%.88  Another concern regarding breast implants is the issue of whether adequate mammography can be performed after augmentation. Displacement techniques can be used by the mammographer to view the breast tissue. Although patients are advised that implants may affect mammography, a study surveying women who did and did not undergo breast augmentation found no statistical difference in survival or detection of carcinoma between the two cohorts.89

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Surgery 2

BAKER’S CLASSIFICATION

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Class I o

Soft

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Breast absolutely natural 

PRE & POST-OP PHOTOGRAPHS

Class II o

Minimal contracture

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Implant palpable but not visible

Class III o

Moderate contracture

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Implant palpable and discernible

Ut In Omnibus Glorificetur Deus

Class IV o

Severe contracture

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Hard, symptomatic

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Sometimes distorted 

CAPSULAR CONTRACTURE

COMPLICATIONS

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Top three most common reasons for reoperation o

Capsular contracture (28.9%)

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Implant malposition (15.6%)

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Ptosis (14.1%)

Displacement techniques can be used by the mammographer to view the breast tissue

TEXTURED BREAST IMPLANTS

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 Incidence of capsular contraction

ROUND BREAST IMPLANTS

ANATOMICAL BREAST

IMPLANTS

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