Plastic Surgery Dubai

Each patient tolerates pain after surgery in different ways. I will prescribe the appropriate pain medications to help minimize any discomfort. In general, most facial cosmetic operations have minimal discomfort post-operatively. Liposuction is slightly more uncomfortable, and operations that require elevation or tightening of the muscles-such as an abdominoplasty or breast augmentation can cause discomfort equal to a C-section. Plastic Surgery Dubai FAQs

Yes. Depending upon what the procedure, it might make sense to sleep in a reclining (not horizontal) position for one week following surgery to minimize the collection of fluids in the face and eyelids. Follow the instructions you will be given about making and administering your cold and warm compresses. These will not only reduce bruising and swelling, but they will also maximize and promote healing. Plastic Surgery Dubai FAQs

The latest advances in liposuction provide patients with more effective results and a faster recovery time. These techniques include the tumescent technique, super-wet technique, ultrasound-assisted lipoplasty (UAL) and power-assisted liposuction. The tumescent technique involves injecting areas of excess fat with a large amount of anesthetic liquid before proceeding with liposuction. The liquid causes the compartments of fat to become swollen and firm or “tumesced.” Since the fat compartments have expanded, they are easier to distinguish, allowing for smoother and more even results. The tumescent technique may last as long as 4 to 5 hours. The super wet technique is similar to the tumescent technique, as it also requires the injection of anesthetic liquid. The difference is that significantly less volume is used – about a third as much. The surgery can be performed in about 1 to 2 hours. During ultrasound-assisted lipoplasty, the cannula emits high frequency sound waves to liquefy fat cells and facilitate low-level aspiration. The use of ultrasonic energy allows for more precision in less fatty areas that have high amounts of muscles and tendons, as it acts primarily on the fat cells and has no effect on the vascular, nervous, or connective tissues. Surgery time is longer than traditional liposuction but is shorter than the tumescent technique. Power-assisted liposuction uses a cannula that vibrates rather than one that is manually manipulated. This vibrating cannula whirs at a high enough speed to create a particularly high frequency vibration. This disrupts the fat cells, releasing them from the surrounding tissue and making them easier to suction out. Power-assisted liposuction is generally associated with fewer complications, more precise sculpting, smaller incisions, shorter surgical times, and less trauma to the surrounding tissues. It is most useful for smaller areas that need minimal fat removed such as the chin, under the arms, the outer breasts, the belly, hips, flanks, and thighs. There are some new procedures and techniques on the market called Smartlipo, laser lipo, vaser lipo, non-surgical liposuction, and others that are employed to reduce smaller areas of fat. Liposuction is also known as lipectomy, lipoaspiration, liposculpture and lipoplasty. In Britain, there was a 41% increase in liposuction cases in 2013 (The British Association of Aesthetic Plastic Surgeons, 2014). In 2013, the American Association of Aesthetic Plastic Surgery reported liposuction as the most popular surgical procedure, with an increase of 16% from the previous year. Initially, liposuction was most popular in women, but over the years liposuction has become increasingly popular in the male population and now tops the list of aesthetic surgical procedures for both sexes (ASAPS, 2014). Liposuction is a surgical procedure that involves the use of specialised cannulas to infiltrate and suction subcutaneous fat for the purpose of aesthetic body contouring and/or lipid transfer. Liposuction has evolved over the years to provide an adjunct to several other areas of reconstruction, including the breast, the head and neck area, and the upper and lower limbs. 2. BACKGROUND 2.1. History In 1926, a French surgeon called Charles Dujarier agreed to operate on a young female model to sculpture the lateral aspect of her calves. He used a sharp uterine curette. Unfortunately, this procedure ended up damaging the patient’s femoral artery, resulting in gangrene and subsequent amputation (Flynn and Coleman, 2000). Dujareir was sued for 200,000 Francs and died in the following months. The negative impact on the patient resulted in any form of body sculpture being boycotted in plastic surgery circles for decades (Glicenstein, 1989). 334 Textbook of Plastic and Reconstructi ve Surgery Most of the literature attributes the innovation of liposuction to Dr Yves-Gerard Illouz, a French surgeon, in the early 1980s. It was, however, first invented by Fischer, an Italian gynaecologist in the late 1970s (Flynn and Coleman, 2000). Illouz modified Fischer’s technique by infiltrating a small volume of saline solution into the subcutaneous fat prior to suction. This technique was coined the ‘wet technique’; Illouz was credited with the procedure, achieving global fame (Flynn and Coleman, 2000). Later that decade, an American dermatologist, Jeffery Klein, introduced the ‘tumescent technique’ which involved infiltration of larger volumes of local anaesthesia and adrenaline before aspiration. This reduced intra-operative blood loss and post-operative haematomas. A vast array of tools and techniques such as power-assisted liposuction (PAL) and ultrasound-assisted liposuction (UAL) soon followed (Iverson and Pao, 2008). 2.2. Patient selection Liposuction is an elective procedure in patients who are generally healthy. Careful patient selection is of utmost importance to achieve a satisfactory outcome. Other key factors include lifestyle changes (smoking, alcohol, recreation drugs), regular exercise and a well-balanced diet (Rohrich et al., 2004). Patients must be counselled so that they commit to these lifestyle changes, in addition to evaluating and discussing any concerns. Those who adhere to these lifestyle changes have shown significant improvements in their self-esteem and productivity (Stephan and Kenkel, 2010). Pregnancy, psychiatric history or body dysmorphic disorder, morbid obesity, unattainable expectations, co-morbidities, bleeding disorders and impaired wound healing should be addressed before the procedure is performed (Kenkel and Stephan, 2013). 3. ANATOMY AND AREAS OF CONSIDERATION Body contouring with liposuction requires a basic anatomical knowledge of subcutaneous fat and its relation to the underlying fascia to provide optimal results. Subcutaneous fat is variable in density, thickness and adherence throughout the body. It can be divided into three layers: the superficial, intermediate and deep layers (Kenkel and Stephan, 2013). As a rule, the superficial layer is avoided because of the higher risk of ecchymosis, bleeding, cutaneous trauma and body contour irregularities. Subcutaneous fat is connected to its underlying tissue through fibrous attachments within the layers that are continuous with the fascia inferiorly. Areas that have relatively thicker and denser attachments are responsible for the natural shape and contours of the patient, and are termed the zones of adherence. These zones may be traversed, but should not be directly suctioned. Head and neck liposuction has gained in popularity in the past decade owing to the development of appropriate techniques and safer equipment. Jowl and submental liposuction are the most popular in this region, and have high overall satisfaction rates (Doerr, 2007). The trunk is by far the most popular area for liposuction in men and women. Figure 15.1 shows the hypogastrium, flanks and lateral aspects of the chest, which are common areas of liposuction in the trunk. Limb contouring is an important aesthetic Liposuction 335 procedure in massive weight loss patients (Bruschi et al., 2009). Fat accumulates in the inferior aspect of the proximal upper limb, often referred to as ‘bingo wings’. The medial and lateral aspects of the upper thigh are frequently considered for liposuction. The surgeon should assess and advise the patient on the suitability of the requested area for liposuction, with regards to safety and the aesthetic outcome. Patients must be warned that formal surgical excision of the excess skin may be required after successful liposuction. Figure 15.2 shows common areas for liposuction in the upper and lower limbs. B C C B A A Figure 15.1. Common areas of liposuction on the trunk. A. Flank, B. chest and C. hypogastrium. A A B C Figure 15.2. Common areas of liposuction on the upper and lower limbs. A. Proximal upper limb, B. medial thigh and C. lateral thigh. 336 Textbook of Plastic and Reconstructi ve Surgery 4. PRE-OPERATIVE ASSESSMENT The pre-operative phase provides an opportunity to enhance rapport with the patient while obtaining a thorough history and examination. The surgeon should document the patient’s medical history, current medications, allergies, smoking, alcohol consumption, expectations and anaesthesia preferences. Establishing realistic aims and committing to lifestyle changes is essential for long-term success. Patients who present with symptoms of body dysmorphic disorder must be further evaluated. Success rates in these patients are low and psychological support is advised (Glaser and Kaminer, 2005). Co-morbidities, both past and present, should be thoroughly investigated because some conditions increase the chance of deep vein thrombosis and can lead to suboptimal outcomes (Iverson and Pao, 2008). An American Association of Anaesthesiologists (ASA) classification should be noted and, if necessary, followed by an anaesthetic review. Examination of the patient needs to be systematic and comprehensive (see Table 1.1). It is advisable to have a member of the nursing team present during the examination to offer additional support to the patient. Assessment of the aspirate estimation, skin laxity and fat deposition pattern is essential because these factors determine the success of aesthetic surgical changes. The patient is asked to relax all muscles for examination in a standing position, preferably in front of a mirror. This allows visualisation of the shape of the patient’s body in its natural state and helps in examining muscular integrity. Any signs of cellulite, asymmetry, scarring and dimples must be brought to the patient’s attention so as they are not attributed to the procedure post-operatively. Hernias must be thoroughly looked for and addressed if necessary. It is crucial to obtain formal medical photographs of the patient for record-keeping and future reference. 5. ANAESTHESIA OPTIONS Anaesthesia options vary in each case and are critical in the pre-operative discussion and assessment of the patient. Factors that influence the choice of anaesthesia include the patient’s general health (ASA Table 15.1. List of patient parameters to note during a physical examination for liposuction. Body Treatment area BMI Skin laxity and tone Obvious musculoskeletal deformities Cellulite Fat distribution (local or diffuse) Hernias Body curvature Posture Asymmetry Scars Striae Wrinkles Skin thickness Estimate volume of aspirate Dimples Liposuction 337 classification), the surgeon’s/physician’s preference, the patient’s preference, the estimated volume of aspiration, the optimal patient position, the length of operating time, intra-operative progress and the available facilities. The three forms of anaesthesia used are local anaesthesia, intravenous sedation and general anaesthesia. Lidocaine is usually the local anaesthetic of choice. It is preferable to bupivacaine because of its safer profile and faster reversibility. The normal recommended dose of lidocaine is 7 mg/ kg but, owing to vasoconstriction and the aspirate containing lidocaine, up to 35 mg/kg is accepted (Iverson and Pao, 2008). Lidocaine toxicity associated deaths are rare, but it is vital for the responsible physician to identify lidocaine toxicity peri- and post-operatively. Smaller volumes of aspirate are usually treated under local anaesthesia, intravenous sedation or a combination of both. Intravenous sedation is used to provide patients a degree of comfort peri-operatively and, for the physician, a conscious patient who is responsive to verbal and tactile stimuli. Patients who plan to have multiple areas treated or have severe co-morbidities, other surgical procedures planned, lengthy operations and estimated large aspirate volumes are more likely to receive general anaesthesia. Procedures using general anaesthesia are more costly, require trained personnel and warrant specific post-operative precautions. Administering anaesthesia requires good comprehension of the changes in physiology that occur during liposuction. An understanding of intra-operative fluid loss, its replacement, intra-operative physiological monitoring and post-operative pain needs is vital prior to induction (Sood et al., 2011). 6. INVASIVE LIPOSUCTION TECHNIQUES Various techniques are currently available for performing liposuction. Before choosing the appropriate technique, several factors should be considered. These include the body areas involved, amount of lipoaspirate, fibrous areas, possibility of revision liposuction and skin redundancy. The most commonly used options include suction-assisted liposuction (SAL), PAL, UAL, VASER liposuction, water-assisted liposuction (WAL) and laser-assisted liposuction (LAL) (Kenkel and Stephan, 2013). A new technique called power WAL has also gained in popularity. 6.1. Suction-assisted liposuction SAL was the first method described for liposuction and remains the one most commonly used (Ahmad et al., 2011). It mechanically removes adipocytes along with other tissue. After the desired site is injected with a wetting solution, a period of time is allowed for the infiltrate to take effect. At markings made pre-operatively on the body, small incisions (3–4 mm) are made with a sharp scalpel. The adipose tissue is then removed under negative pressure by a hollow cannula with a blunt tip. It is recommended to start with a larger cannula in a deeper plane and then use a smaller diameter cannula more superficially (Tabbal et al., 2013). The SAL technique is easy to use and a broad variety of cannulas are available. One disadvantage is that it can be considerably laborious, particularly in fibrous areas. 338 Textbook of Plastic and Reconstructi ve Surgery 6.2. Power-assisted liposuction PAL uses an external power source as opposed to the surgeon. The cannula moves back and forth in small oscillating motions. The small rapid vibrations break up the adiposites so they can be suctioned out of the body. The power settings can be altered to control the rate. PAL is useful for large volumes, fibrous areas and in revision liposuction. 6.3. Ultrasound-assisted liposuction UAL delivers fat-liquefying ultrasonic energy which breaks down the adipose tissue. The emulsified fat is then removed through a cannula. This is always a three-stage procedure because infiltration must be used. The ultrasonic energy is dispersed from the superficial to the deep layers, and there must be continuous movement to prevent thermal injury. The advantages of this technique are improved contouring and its suitability for revision and for fibrous areas. On the negative side, the equipment is more expensive, the operating time is longer and the risk of thermal injury is present if not used correctly. A newer type of UAL called VASER liposuction uses less energy because of more efficient probes. 6.4. L aser-assisted liposuction LAL is designed to achieve adipocyte removal and skin tightening from the thermal effect of the laser on the dermis (Matarasso and Levine, 2013). A small laser fibre is inserted through an incision in the skin. The four-stage procedure consists of infiltration, application of energy to the subcutaneous tissues, evacuation and, finally, subdermal skin tightening. 6.5. Water-assisted liposuction WAL is a technique in which instead of being destroyed, the adipocytes loosen, which facilitates a gentler removal. The process comprises a single step, with simultaneous injection and removal. It is considered to be gentle with less ecchymosis and a shorter recovery time due to less tissue trauma (see Figure 15.3). 7. APPLICATION OF WETTING SOLUTIONS Liposuction was initially performed without any wetting solution, resulting in high rates of blood loss. With the introduction of infiltrates, the operation is now performed with markedly less complications Liposuction 339 and with the removal of larger volumes. They may also provide some peri-operative analgesia. Wetting solutions are traditionally divided into four categories: dry, wet, superwet and tumescent (Sasaki, 2011). The most commonly used wetting solutions combine a crystalloid with lidocaine, adrenaline and, not infrequently, sodium bicarbonate. A common example is Klein’s formula, comprising 1000 ml normal saline, 50 ml 1% lidocaine, 1 ml 1:1000 adrenaline and 12.5 ml 8.4% sodium bicarbonate. In a recent study, Hatef et al. (2009) showed that varying doses of lidocaine did not affect intra- or post-operative analgesia requirements. It is generally recommended not to use marcaine because of its possible cardiotoxicity, although Failey et al. (2009) demonstrated no significant difference in the incidence of complications or length of hospital stay when comparing bupivacaine and lidocaine. Addition of adrenaline to the wetting solution adds a vasoconstrictive element which decreases blood loss. The addition of adrenaline to lidocaine results in less systemic absorption of lidocaine. The American Society of Plastic Surgeons has recommended that the total dose of adrenaline used in local anaesthesia should not exceed 0.07 mg/kg to limit the systemic effects (Iverson et al., 2004). Supplementing the wetting solution with sodium bicarbonate is known to decrease the painful sensation that lidocaine can produce. This occurs through reducing the acidity of lidocaine, thus making the pH more physiological. As previously mentioned, wetting solutions reduce the amount of blood loss during liposuction. For a dry technique, blood loss can typically be up to 50% of the final aspirate, whereas blood loss for the wet, superwet and tumescent techniques is reported to be 10–30%, 1–4% and <1%, respectively (Iverson et al., 2004). Water Suction Figure 15.3. Water-assisted liposuction. 340 Textbook of Plastic and Reconstructi ve Surgery 8. TECHNIQUES OF INFILTRATION The dry technique uses no infiltrate and is now very uncommon. The wet method uses 200–300 ml/ area and the volume aspirated is to the desired effect. The superwet technique applies 1 ml infiltrate to 1 ml aspirate. The tumescent method involves infiltrating to skin turgor and aspirating 2–3 ml aspirate/ ml infiltrate. 9. SURGICAL PLANNING 9.1. Pre-operative marking Prior to surgery, the patient’s body is marked by the surgeon, ideally when the patient is in an upright position in front of a mirror and with the patient’s involvement. The chosen areas for liposuction are marked with circles. The known areas of adherence should be delineated. These are the zones in which the more superficial structures adhere to the deeper structures (Figure 15.4). Zones of Adherence Areas of liposuction Figure 15.4. Zones of adherence. Liposuction 341 Pre-operative data sheets may be used to document the areas of contouring. Skin tone, asymmetry, cellulite and striae can also be included. 10. PATIENT POSITIONING Most liposuction can be done with the patient in the prone position, and it is important to use adequate padding for all pressure points pre-operatively. Repositioning to the supine position and re-preparation should be performed with multiple staff to minimise the time taken. The upper chest, face, iliac crest, bony prominences of the extremities and genitalia should be supported. Prevention of hypothermia is important, as is the use of lower leg compression devices in the prevention of deep vein thrombosis. The lateral decubitus position is not frequently used because it does not allow symmetrical comparison. 11. SURGICAL INSTRUMENTS Liposuction is achieved with cannulas through small access incisions. The three important features for determining the efficiency of a cannula are its tip, configuration and dimensions (diameter and length) (Mathes and Hentz, 2006). The tip of the cannula influences the speed and the efficacy of liposuction; most tips are blunt and have multiple openings. There are many different types of cannulas, which vary in both length and diameter. Cannula sizes are available from 1.8 mm to 1 cm in size, and the most common diameter is 2–5 mm (Kenkel and Stephan, 2013). The length of the cannula varies from around 10 cm to 30 cm. Longer cannulas provide further access but shorter cannulas enable more accurate control. Cannulas used for SAL and PAL have multiple openings set back from the tip. One of the most commonly used is the three-hole Mercedes-type cannula (see Figure 15.5). Cannulas used for PAL are similar to those used for SAL. As described earlier, they oscillate in a plane parallel to the long axis of the cannula. Power is provided by an electrical unit or a pneumatic hose (Mathes and Hentz, 2006). UAL uses a hollow cannula or a solid probe. The VASER probes are solid with rings around them. The tip of the ultrasonic apparatus oscillates 10 times faster than that used for PAL. These probes can be solid or hollow. The hollow probe allows some fat to be extracted, although the openings are rather small; therefore, further evacuation of the liquefied fat is needed. Figure 15.5. Mercedes type cannula (three holes). 342 Textbook of Plastic and Reconstructi ve Surgery 12. COMPRESSION GARMENTS Most patients should be able to go home within 24–48 hours, depending on the extent of the areas involved and their general fitness. Large volume liposuction patients should stay in hospital overnight. Compression stockings should be worn on the legs while in hospital to reduce the risk of thromboembolic events. Wearing compression garments is standard post-liposuction. Compressive bandages are often used in the first week if a customised garment is not available. Compression assists in contouring and decreases bruising and oedema. The recommended length of time for garment use varies among surgeons, but is usually a minimum of 6 weeks. 13. COMPLICATIONS Possible complications from liposuction vary from minor to major, life-threatening events. They may be divided into peri-operative (0–48 hours), early (1–7 days) and late (1 week to 3 months), as shown in Table 1.2. 13.1. Peri-operative complications In the peri-operative period, there may be complications related to the general anaesthesia, such as cardiac events. It is therefore strongly recommended that patients are classified as ASA 1–2 and, if there is any pre-existing cardiopulmonary disease, a medical review is warranted. Other anaesthesia complications may include local effects of the tumescent infiltrate such as lidocaine toxicity or direct cardiac effects of adrenaline. Organ or intestinal perforation is rare but well documented in the literature. The abdomen, thorax and retroperitoneum are all potentially affected areas, with perforations more commonly occurring through previous scars or hernias (Haeck et al., 2009). The surgeon must always be aware of the location of the tip of the cannula. Table 15.2. Complications of liposuction. Peri-operative Early Late Anaesthetic complications Venous thromboembolism Late seroma Perforation of organs Infection Oedema and ecchymosis Volume shift Skin necrosis Paraesthesia Bleeding Necrotising fasciitis Hyperpigmentation Hypothermia Seroma Contour irregularities Fat emboli syndrome Liposuction 343 Fluid shifts can occur intra-operatively, especially during large volume liposuction. This may lead to hypovolaemia or potentially pulmonary oedema. It is therefore important for both the anaesthetist and the surgeon to document fluid input and output. Bleeding during liposuction has become very rare after the introduction of wetting solutions. The risk of hypothermia is higher in patients having multiple areas treated. It is associated with an increased risk of bleeding, cardiac events and sepsis. Fat embolism syndrome (FES) is a rare complication of liposuction, in which fat becomes lodged in the small vessels of the lungs. The diagnostic criteria are at least two of the following: respiratory distress, cerebral involvement and petechial rash within 48 hours of the procedure. Hypoxia is often the first sign; others include fever, tachypnoea and bilateral X-ray changes. Treatment is mainly supportive. It is important to differentiate between a pulmonary embolism and FES. 13.2. E arly complications The incidence of venous thromboembolism in liposuction is thought to be relatively low, with a risk of <1%. It is important to review all pre-operative risk factors. The use of elastic compression stockings, intermittent pneumatic devices and low molecular weight heparin is recommended when necessary. Signs include lower extremity swelling, Homan’s sign, tachypnoea and/or chest pain. Prompt treatment with anticoagulation for deep vein thrombosis and possible thrombectomy or thrombolysis for pulmonary embolism is indicated. Small infections may occur within haematomas. Systemic infection is thought to be more likely in smokers, diabetics and immunocompromised patients. Local infection and fulminant necrotising fasciitis are well documented in liposuction. It is common practice to give one dose of antibiotic pre-operatively and to closely monitor and treat any post-operative fever and cellulitis. A large study of major and lethal complications of liposuction by Lehnhardt et al. (2008) showed that the most frequent complications were bacterial infection such as necrotising fasciitis, gas gangrene and other forms of sepsis. Skin necrosis appears to be more common in smokers and in patients who undergo superficial liposuction. 13.3. L ate complications Seromas appear to be more frequent in the lower abdominal area and usually become more noticeable at around 1 week post-operatively. They are thought to be more likely if adequate pressure garments have not been used and in patients with a high body mass index. Some studies have suggested there is a higher risk of seromas with UAL. They appear to be more common in overtreated areas. Oedema and ecchymosis are reduced with the use of compression garments for 4–6 weeks. There may be more swelling after UAL, and ecchymosis tends to be more frequently present in smokers or in patients on anticoagulants. 344 Textbook of Plastic and Reconstructi ve Surgery Post-operative aesthesia or dysaesthesia usually regresses within 10 weeks, but may infrequently last up to a year. Occasionally neurological pain may be associated with neuroma formation or damage to underlying fascia or muscle. Contour irregularities are the most common late complication. Surgical treatment consists of corrective liposuction or lipofilling. 14. NON-INVASIVE LIPOSUCTION The technologies used for non-invasive liposuction include ultrasound, laser, cryotherapy and injection mesotherapy. Mesotherapy involves a series of injections containing multiple ingredients which act in two ways: lipolytic agents stimulate lipolysis and ablative chemicals destroy adipocytes. This process is thought to increase blood and lymphatic flow in the mesoderm. The cells shrink, dissolve and are extracted (Rohrich, 2005). 15. CONCLUSION Maintenance of a healthy diet and exercise in conjunction with liposuction can enable patients to achieve their desired body shape and contour. To achieve a satisfactory outcome, it is paramount that patients adhere to the recommended diet and level of physical activity. Liposuction is under continuous development with regards to technology and instrumentation. It is deemed safe and effective but, as with all invasive surgery, is not without side effects. Diligent patient selection and realistic expectations will give the most rewarding results. REFERENCES American Society for Aesthetic Plastic Surgery (ASAPS). 2014. Cosmetic Surgery National Data Bank: Statistics 2013. Aesthet Surg J, 34, 1–20. Ahmad, J., Eaves, F. F., 3rd, Rohrich, R. J. & Kenkel, J. M. 2011. The American Society for Aesthetic Plastic Surgery (ASAPS) survey: Current trends in liposuction. Aesthet Surg J, 31, 214–24. Bruschi, S., Datta, G., Bocchiotti, M. A., Boriani, F., Obbialero, F. D. & Fraccalvieri, M. 2009. Limb contouring after massive weight loss: Functional rather than aesthetic improvement. Obes Surg, 19, 407–11. Doerr, T. D. 2007. Lipoplasty of the face and neck. Curr Opin Otolaryngol Head Neck Surg, 15, 228–32. Failey, C. L., Vemula, R., Borah, G. L. & Hsia, H. C. Intraoperative use of bupivacaine for tumescent liposuction: The Robert Wood Johnson experience. Plast Reconstr Surg, 124(4), 1304–11. Flynn, T. C., Coleman, W. P., 2nd, Field, L. M., Klein, J. A. & Hanke, C. W. 2000. History of liposuction. Dermatol Surg, 26, 515–20. Glaser, D. A. & Kaminer, M. S. 2005. Body dysmorphic disorder and the liposuction patient. Dermatol Surg, 31, 559–60; discussion 561. Liposuction 345 Glicenstein, J. 1989. Dujarier’s case [in French]. Ann Chir Plast Esthet, 34, 290–2. Haeck, P. C., Swanson, J. A., Iverson, R. E., Schechter, L. S., Singer, R., Basu, C. B., Damitz, L. A., Glasberg, S. B., Glassman, L. S., Mcguire, M. F. & Committee, A. P. S. 2009. Evidence-based patient safety advisory: Patient selection and procedures in ambulatory surgery. Plast Reconstr Surg, 124, 6S–27S. Hatef, D. A., Brown, S. A., Lipschitz, A. H. & Kenkel, J. M. 2009. Efficacy of lidocaine for pain control in subcutaneous infiltration during liposuction. Aesthet Surg J, 29, 122–8. Iverson, R. E., Lynch, D. J. & American Society of Plastic Surgeons Committee On Patient Safety. 2004. Practice advisory on liposuction. Plast Reconstr Surg, 113, 1478–90; discussion 1491–5. Iverson, R. E. & Pao, V. S. 2008. MOC-PS(SM) CME article: Liposuction. Plast Reconstr Surg, 121, 1–11. Kenkel J. M., Stephan P. J. 2013. Liposuction: A comprehensive review of techniques and safety. In: Warren, R. J. (ed.) Plastic Surgery. China: Elsevier. Lehnhardt, M., Homann, H. H., Daigeler, A., Hauser, J., Palka, P. & Steinau, H. U. 2008. Major and lethal complications of liposuction: A review of 72 cases in Germany between 1998 and 2002. Plast Reconstr Surg, 121, 396e–403e. Matarasso, A. & Levine, S. M. 2013. Evidence-based medicine: Liposuction. Plast Reconstr Surg, 132, 1697–705. Mathes S. J., Hentz V. R. 2006. Plastic Surgery, Michigan, Saunders Elsevier. Rohrich, R. J. 2005. Mesotherapy: What is it? Does it work? Plast Reconstr Surg, 115, 1425. Rohrich, R. J., Broughton, G., 2nd, Horton, B., Lipschitz, A., Kenkel, J. M. & Brown, S. A. 2004. The key to long-term success in liposuction: A guide for plastic surgeons and patients. Plast Reconstr Surg, 114, 1945–52; discussion 1953. Sasaki, G. H. 2011. Water-assisted liposuction for body contouring and lipoharvesting: Safety and efficacy in 41 consecutive patients. Aesthet Surg J, 31, 76–88. Sood, J., Jayaraman, L. & Sethi, N. 2011. Liposuction: Anaesthesia challenges. Indian J Anaesth, 55, 220–7. Stephan, P. J. & Kenkel, J. M. 2010. Updates and advances in liposuction. Aesthet Surg J, 30, 83–97. Tabbal, G. N., Ahmad, J., Lista, F. & Rohrich, R. J. 2013. Advances in liposuction: Five key principles with emphasis on patient safety and outcomes. Plast Reconstr Surg Glob Open, 1, e75. The British Association of Aesthetic Plastic Surgeons. 2014. Britain Sucks [Online]. BAAPS. Available: http://baaps.org. uk/about-us/press-releases/1833-britain-sucks [Accessed 31 October 2014]. 346 16 Facial Aesthetic Surgery Muholan Kanapathy, Niall Kirkpatrick 1. PATIENT SELECTION Facial aesthetic procedures have been rapidly growing in number across the globe over the past few decades. Globalisation and social media have played a major role in encouraging patients to undergo these procedures (The American Society for Aesthetic Plastic Surgery, 2010). Surgeons therefore have a greater responsibility to appropriately educate patients and use careful patient selection criteria to choose the appropriate candidates for the treatment. Considerations regarding patient selection and pre-operative counselling for aesthetic surgery include a clear understanding of the patient’s perception of their problem and their expectations of surgery as well as knowledge of a wide range of surgical techniques and their risks. While most patients have clearly identifiable concerns and appropriate expectations, care should be taken with patients that are overly expectant and demanding, those requesting multiple interventions (i.e. ‘the surgiholic’ patients), those with marital breakdown or job loss, those pushed into surgery by others, those with body dysmorphic disorder, and those with whom the surgeon feels incompatible (Gorney, 2010). Careful patient selection will avoid disappointment for those who may not have understood the procedure or have underestimated the limitations of surgery. 2. SURGICAL ANATOMY OF THE FACE A comprehensive description of facial anatomy is beyond the scope of this text. However, key anatomical points relating to facial aesthetic procedures will be emphasised. Facial Aesthetic Surgery 347 2.1. Soft tissue layer The soft tissue of the face consists of five basic layers which are arranged concentrically (Figure 16.1). Specific age-related changes occur in each facial layer; procedures to reposition tissues form the basis of facial rejuvenation surgery. In the skin, flattening of the dermoepidermal layer coupled with a reduction in the levels of collagens III, IV and VII, chondroitin sulphate, elastin, oxytalan fibres, melanocytes and Langerhans cells determine susceptibility to age-related changes (Gilchrest, 1989; Contet-Audonneau et al., 1999). Subcutaneous tissue consists of two important components: the subcutaneous fat and retinacular cutis. The retinacular cutis is part of the retaining ligaments that pass through the subcutaneous tissue to provide support. In areas with a thick subcutaneous layer, the retinacular cutis fibres are susceptible to weakening and distension with age. The superficial musculoaponeurotic system (SMAS) layer contains the mimetic muscles that are involved in facial expression. The SMAS is continuous with the platysma, temporoparietal fascia, frontalis and galea aponeurotica. Manipulation of the SMAS, as described by Mitz and Peyronie in 1976, has become a popular means of rejuvenating the face, with many later variations described (Mitz and Peyronie, 1976). In facelift procedures, greater tension can be applied to the SMAS than to the skin, and the SMAS may act as a carrier for other tissues such as muscle and fat pads. In addition, it forms a key landmark in facial nerve anatomy: below the zygomatic arch, all branches of the facial nerve are deep Bone 5 4 3 1) Skin 2 2) Subcutaneous 3) Musculo aponeurotic 4) Retaining ligament and space 5) Periosteum and deep fascia 1 Figure 16.1. Soft tissue layers of the face. 348 Textbook of Plastic and Reconstructi ve Surgery to the SMAS (Mendelson and Wong, 2013). Only the mentalis, levator anguli oris and buccinator muscles are innervated on their superficial surface. All other muscles are innervated on their deep surface. Therefore, dissection in the plane superficial to these muscles is considered relatively safe. The face also has a fibrous support system of retaining ligaments that prevents repositioning and fixation of facial soft tissues if not released. The retaining ligaments and soft tissue spaces make up the loose areolar tissue. This is an avascular potential space that allows the superficial layers to glide, enabling facial expression. This layer is safe for dissection because no structures cross within it. The retaining ligaments comprise both osteocutaneous ligaments and musculocutaneous ligaments. The osteocutaneous ligaments include the zygomatic ligament, which extends from the zygomatic arch and body (McGregor’s patch) through the malar fat pad to the dermis, and the mandibular ligament, which extends from the parasymphyseal region to the dermis. The parotid and masseteric cutaneous ligaments, formed by union of the superficial and deep facial fascia, attach these structures to the overlying dermis. 2.2. Nerve anatomy 2.2.1. Sensory The greater auricular nerve, a branch of the cervical plexus, is the symptomatic nerve most commonly injured during facelift surgery. The superior course of the greater auricular nerve falls within a 30° angle constructed using the vertical limb perpendicular to the Frankfurt horizontal and a second limb drawn posteriorly from the midlobule (Ozturk et al., 2014). Division of this nerve leads to numbness of the earlobe and lateral pinna and also a potential for problematic neuroma if not repaired. The midface receives sensory innervation from the zygomaticofacial, infraorbital and posterior maxillary nerves and motor innervation from the facial nerve. These nerves are at risk of injury during surgery. 2.2.2. Motor The facial nerve emerges from the stylomastoid foramen and passes through the parotid gland, dividing into five main branches which provide motor innervations to mimetic muscles. The temporal branch courses superficially after crossing the zygomatic arch, in the plane deep to the temporoparietal fascia. It travels along a trajectory known as the Pitanguy line from the tragus to a point approximately Plastic Surgery Dubai FAQs 1.5 cm superior to the lateral brow (Pitanguy and Ramos, 1966). The buccal and zygomatic branches form multiple interconnections which may conceal injury to the buccal branch, the branch most commonly injured during facelift surgery. The marginal mandibular branch courses approximately 1–2 cm below the border of the mandible before crossing the facial vessels, in the plane deep to platysma. The marginal mandibular and temporal branches are the most vulnerable to long-term dysfunction if injured. Facial Aesthetic Surgery 349 3. AGEING FACE Facial ageing is a dynamic, complex and multidimensional process whereby a complex interplay of several factors contributes to changes in each anatomical layer. The ageing process may vary dramatically between individuals and is thus influenced by genetic factors. When assessing the ageing face, it is important to consider the skeletal architecture, the soft tissue layers including anterior fat pads, the retaining ligament anchors and, finally, the overlying skin. 3.1. Assessment of facial ageingPlastic Surgery Dubai FAQs Surgical correction of facial ageing attempts to reverse gravitational changes to soft tissues and restore volume loss. In the context of the surgical management of facial ageing, the face can be usefully separated into three anatomical areas: 1. The upper face, including the forehead, upper eyelids and eyebrows. 2. The midface, including the anterior cheek and lower eyelids. 3. The lower and lateral face, neck and perioral regions. The upper face extends from the hairline down to the upper eyelids. Surgical procedures targeting the upper face include forehead and brow lifts, temporal lift, upper blepharoplasty and fat grafting to the brow. The midface is a triangular area below the eyelid bounded medially by the nasofacial angle, inferiorly by the nasolabial fold and corner of the mouth, and superiorly by the lower eyelid and tear trough and the lateral canthus at the superolateral aspect (Mendelson and Wong, 2012). Key elements of midfacial ageing are gradual ptosis of the cheek skin below the infraorbital rim, creating infraorbital hollowness, descent of the malar fat pad with loss of malar prominence, deepening of the tear trough and associated exaggeration of the nasolabial fold (Owsley, 1993; Stuzin et al., 1995; Hester, 2001; Paul et al., 2006; Saltz and Ohana, 2012). Surgical procedures directed at the midface may be approached via the temporal region or lower eyelid. It is important to emphasise that these procedures are complicated and involve dissection of the face at deep levels close to neurovascular structures (Hachach-Haram and Kirkpatrick, 2013). They may involve long downtimes and prolonged swelling for patients. Given the significant complication profile, these procedures should only be attempted by surgeons with a clear understanding of and thorough training in this area. Most commonly, facial rejuvenation is directed at the lateral cheek and lower third of the face and encompasses many modern facelift techniques and neck procedures. To achieve harmony in facial rejuvenation surgery, procedures to correct ageing within different zones may be performed simultaneously or in a staged fashion. 350 Textbook of Plastic and Reconstructi ve Surgery 3.1.1. Soft tissue changes in ageing face Ageing of the soft tissues of the midface is multifactorial and attributed to a combination of increased laxity of the orbicularis oculi muscle and orbital septum, horizontal laxity of the tarsal plate component of the lower lid, laxity of the zygomaticus muscles and elevators of the upper lip with subsequent deepening of the nasolabial fold, and fat atrophy. Most significantly, attenuation of the osseocutaneous ligaments, including the orbitomalar and orbicularis-retaining ligament, with descent and inferior migration of the soft tissues, including the malar and other fat pads, into the anterior maxillary hollow inferomedially, results in an apparent volume loss in the anterior cheek with visible lengthening of the lower eyelids, giving the face a more squared, vertical appearance (Owsley, 1993; Krastinova-Lolov, 1989; Nahai, 2005; Mendelson and Wong, 2012). In youth, the upper anterior cheek skin is firmly supported by the orbitomalar septum that allows little or no downward migration (Mendelson et al., 2007). Facial septa extending from the SMAS through the malar fat pad to the overlying dermis further support the malar fat pad (Owsley, 1993). The repeated movements of animation, as well as repeated zygomaticus and levator muscle contraction and shortening, result in pressure within the overlying cheek and prominence of the nasolabial fold (Owsley, 1993). Over time, the supporting fat pad facial septa stretch and weaken, resulting in downward migration Plastic Surgery Dubai FAQs of the malar fat pad and the appearance of infraorbital flattening or hollowing, and permanent prominence of the nasolabial fold (Figure 16.2). The fat pads, which include suborbicularis oculi fat (SOOF), temporal fat, malar fat pad and the buccal fat pad, form an important part of the facial architecture. They are partitioned into discrete compartments. Variance in ageing suggests that ageing of these fat pads is not entirely confluent but is instead characterised by how these compartments independently change with age (Krastinova-Lolov, 1989; Owsley, 1993; Rohrich and Pessa, 2007; McCollough et al., 2009). Disruption of the lower eyelid–cheek complex due to inferior migration of the malar fat pad and the SOOF results in a ‘double-contour’ deformity of the midface (Rohrich and Pessa, 2007; Ransom et al., 2012). The midface receives sensory innervation from the zygomaticofacial, infraorbital and posterior maxillary nerves and motor innervation from the facial nerve. These nerves are at risk of injury during midfacial dissection. Finally, skin changes and collagen degradation add to the ageing process by affecting the facial surface and skin thinning. 3.1.2. Skeletal architecture in the ageing face The inferior orbital rim is composed of the zygoma, the lacrimal bone and the anterior maxilla; projection of these structures determines the vector of the midface and the skeletal support available for the soft tissues of the midface. It is important to recognise that the anterior maxilla is significantly concave. Skeletal resorption, at both the periorbital level and maxillary level, has been attributed to the decreased Facial Aesthetic Surgery 351 malar projection and increased orbital aperture seen in ageing. This can have significant consequences on the projection and prominence of the maxilla and on the location of facial ligament attachments (Nahai, 2005; Mendelson et al., 2007). The maxilla may undergo significant skeletal resorption, with up to a 10° loss in the maxillary angle contributing to the typical ageing cheek stigmata associated with loss of maxillary projection and resulting in the development of a lid–cheek continuum deformity and a prominent nasolabial fold (Mendelson and Wong, 2012). 3.2. Photoaging Several factors accelerate the ageing process in the skin. Cumulative exposure to ultraviolet irradiation is an important factor that influences skin ageing. Clinical signs of photoaging include freckles, rhytides, telangiectasia, loss of elasticity and a sallow colour. The Glogau classification of photoaging is most commonly used to describe skin changes due to photodamage and aging (Table 16.1) (Nguyen et al., 2012). The Glogau scale is useful for estimating the overall amount of facial ageing and assists discussion of the potential outcome of cosmetic procedures. Transverse forehead line Tear trough Nasolabial fold Loss of fat in midface Marionette line Jowl Glabella frown line Figure 16.2. Features of the ageing face. 352 Textbook of Plastic and Reconstructi ve Surgery 4. SURGICAL AESTHETIC TREATMENT 4.1. Facelift The youthful face is often defined by malar and lateral cheek fullness with associated submalar concavity, giving a smooth contour coupled with an aesthetically pleasing convex lower eyelid–cheek continuum (Hachach-Haram and Kirkpatrick, 2013). The lower mandibular jawline is even and smoothly defined, and the eyebrow convex and situated on or above the supraorbital margin, with the eyelid having a well-defined crease. Facelift surgery started as early as 1901, and has evolved significantly since then (Warren, 2013). Since the mid-1990s, there has been increasing interest in the midface lift as a sophisticated component of facial rejuvenation, with the development of techniques other than the traditional pre- and post-auricular approaches (Berkowitz et al., 2005). Newer approaches are based on the principle of lifting in a more vertical or superolateral vector (Berkowitz et al., 2005). 4.1.1. Operative techniques of facelift 4.1.1.1. Subcutaneous facelift The subcutaneous facelift evolved from the first facelift involving a simple skin incision at the temporal hairline and pre-auricular region to a more extensive subcutaneous dissection with skin repositioned in a superolateral vector (Warren, 2013). The skin flap is created by dissecting in the plane immediately superficial to the SMAS, thus preserving the subdermal plexus for vascular supply (Hoefflin, 1998). Despite being a relatively safe procedure, the subcutaneous facelift is rarely performed today because it relies on skin tension to produce the desired lift; this often leads to widened scars and early recurrence Table 16.1. Glogau classification of photoageing. Group Age (years) Findings 1 20–30 No wrinkles Change in homogeneity of colour 2 30–40 Wrinkles on animation as expression lines Early keratosis 2 50–60 Wrinkles at rest Actinic keratosis Make-up provides homogeneity of colour but accentuates the wrinkles 4 60 or older Severe wrinkling Actinic keratosis and skin cancers Make-up creates ‘cracked mud’ appearance Facial Aesthetic Surgery 353 and an unnatural ‘pulled’ appearance. However, this technique may be useful in selected patients such as those with pseudoxanthoma elasticum or with multiple previous facelifts. 4.1.1.2. Subcutaneous facelift with SMAS manipulation Upon raising a subcutaneous skin flap, several different techniques can be used to manipulate the SMAS to restore volume to the malar region, thus creating a more youthful appearance. Plication uses sutures to fold the SMAS and reposition fat from the lower face. SMAS imbrication requires incision and overlapping of the SMAS with suture fixation. The SMAS is advanced in a different vector from the skin, thereby avoiding the use of skin tension alone. However, recurrence of facial ptosis may occur if sutures pull through the skin. The minimal access cranial suspension (MACS) lift, popularised by Tonnard and Verpaele (2007), uses permanent purse string sutures anchored to the deep temporal fascia to achieve superolateral suspension Plastic Surgery Dubai FAQs of the SMAS–platysma layer. Multiple small bites are taken during suture placement to create micro-imbrications of fat and SMAS. In the simple MACS lift, two purse string sutures are used to address the neck and lower third of the face. An additional third suture is included in the extended MACS lift to suspend the malar fat pad. The main disadvantage of the MACS lift is its reduced longevity of effect. MACS is most effective in younger patients who require minimal skin redraping. 4.1.1.3. Subcutaneous facelift with a separate SMAS flap (plus variations) Elevating separate skin and SMAS flaps provides greater flexibility in the direction and tension applied to each flap. The SMAS flap is usually advanced in a more vertical direction with firm suture fixation to immobile tissues, while the skin flap is redraped under minimal tension in a superolateral vector. This is crucial to avoid the ‘lateral sweep’ effect. 4.1.1.4. Skoog facelift In 1974, Skoog described raising the skin, subcutaneous fat and SMAS as a single unit (Skoog, 1974). Modifications of the technique have evolved to overcome tethering of the SMAS attachment to the lip elevators and thus improve the nasolabial fold (Barton and Hunt, 2003). 4.1.1.5. Lateral SMASectomy The lateral SMASectomy, as described by Baker, excises a strip of SMAS (obliquely from the angle of mandible to the lateral malar eminence) along with the overlying fat (Baker, 1997). The width of SMAS resection depends on the extent of laxity. The vector of elevation (perpendicular to the nasolabial fold) is not ideal and can produce an unnatural or ‘pulled’ appearance, otherwise known as ‘lateral sweep’ or ‘Nike swoosh’. Flattening, with loss of volume in the lateral cheek element, may also occur. 354 Textbook of Plastic and Reconstructi ve Surgery SMAS procedures can rejuvenate the middle third of the face by elevating tissues over the malar eminence with slight effacement of the nasolabial fold. The points of fixation for the most vertically elevated SMAS flap lie lateral to the orbit along the line of the zygoma and zygomatic arch. These techniques can address the jowls and produce an excellent jawline, as well as correcting laxity in the neck and the lateral cheek. However, these procedures do not address well the volume changes below the eyes and the problem of malar and anterior fat repositioning in its entirety. Consequently, they do not rejuvenate the true midface and their results on the midface are unpredictable. Enhancement of malar volume may therefore be achieved without adequately restoring the lower lid–cheek continuum. SMAS procedures may well produce acceptable results with a high satisfaction rate in younger patients, but in the older patient or those with more complex problems, SMAS procedures alone will generally fall short of ideal. Moreover, SMAS lifts can exacerbate the problem of the concavity and hollow appearance of the lower lid, giving a typical ‘lateral sweep facelift’ appearance. In contrast, re-elevating the midface using the orbicularis oculi flap as the primary vehicle, with or without subperiosteal dissection and re-suspension, can restore a more youthful convexity to the lower lid–cheek continuum; this is usually best seen in photographic three-quarter views. The recent development of volume-enhancing minimally invasive techniques such as autologous fat transfer has led some surgeons to opt for simpler techniques with minimal post-operative oedema. Filling midface contour defects enables a quick return to normal life. However, the fundamental problem of midface descent is not addressed and may even be made worse by further weighting of the tissues. Irregularity of the tissues may also become apparent once post-surgical oedema resolves; often, these results are not forgiving. These patients may subsequently benefit from corrective midface surgery. Although midface lifting techniques are more complex to perform and require careful patient assessment and choice of procedure, they can address ageing of the anterior cheek better than conventional facelift techniques. When performed either in isolation or in conjunction with other facelift or periorbital procedures, they produce harmonious and natural rejuvenation for patients. Furthermore, they can be used as powerful reconstructive tools for patients with soft tissue midface deficiencies. 4.1.1.6. Subperiosteal facelift Tessier advanced the subperiosteal approach for middle third facial rejuvenation and also highlighted the use of the coronal approach to achieve adequate lifting of the temporal and lateral canthal areas (Tessier, 1979). In the 1980s, Santana described the importance of subperiosteal dissection to allow traction of the deeper structures to improve the nasolabial fold and recommended resection of Bichat’s fat pad (buccal fat) to produce a more prominent malar appearance (Barton, 2002). Mendelson described the use of extended SMAS dissection and periosteal fixation that refined the process of elevating the ptotic malar fat pad, resulting in effacement of the nasolabial fold (Stuzin et al., 1995; Barton and Hunt, 2003). Ramirez et al., Ortiz-Monasterio, and Tapia et al., were concerned with the risk of neurapraxia; they independently demonstrated that careful subperiosteal dissection using multiple subperiosteal Facial Aesthetic Surgery 355 pockets minimises these risks (Barton, 2002). Furthermore, by dissecting beneath both layers of the temporal fascia, midface rejuvenation was achievable (Guerrerosantos, 1983; Feldman, 1990; Jones and Grover, 2004). Subperiosteal dissection can be performed via lower eyelid incisions, limited temporal incisions (often in combination with intraoral sulcus incisions) and the coronal ‘mask lift’ approach. The decision regarding which approach to use largely depends on the need to control the lateral canthus and brow complex. Some patients will also require release of the parotid–masseteric ligaments because these can restrict midfacial elevation. Subperiosteal dissection along the zygomatic arch with inferior dissection on the superior surface of the masseter muscle allows the release of these ligaments. Both subciliary and transconjunctival lower eyelid incisions can be used to elevate the midface in the subperiosteal plane alone. The subciliary approach is required to elevate the midface in the submuscular plane, allowing fashioning of the orbicularis flap as described by Hamra. This approach also allows separate subperiosteal dissection and elevation in a biplanar technique. The temporal approach utilises a short incision and careful dissection deep to the frontal branch of the facial nerve to avoid injury. Temporal supraperiosteal dissection using an endoscopic method has also been described (Byrd and Andochick, 1996). Berkowitz et al. described the use of the Endotine device (Coapt Systems, Palo Alto, CA, USA) for midface lifting (Berkowitz et al., 2005). Endotine devices are biodegradeable polylactide polymer devices that provide simultaneous elevation and fixation of tissue (Barton and Hunt, 2003). They are an excellent method of fixation for subperiosteal dissection because they provide a wide platform for purchase of these tissues, thus providing controlled and reliable fixation. These devices can be anchored either to the deep temporal fascia superiorly with sutures or with screw fixation to the inferolateral orbital rim and can be augmented with suture fixation to the inferior orbital rim where indicated. Among the advantages of subperiosteal face lift are en bloc mobilisation of soft tissue, which provides better exposure and better visibility, a low risk of facial nerve injury, and exposure of the bony skeleton, allowing skeletal contouring such as insertion of facial implants and synchronous lifting of the midface and brow (Warren, 2013). Its disadvantages include the requirement for additional equipment, a longer post-operative recovery period and minimal effects on facial skin. 4.1.2. Complications of facelift procedures 4.1.2.1. Haematoma Haematoma is the most common post-operative facelift complication, with an incidence of 3–4% in women, increasing to 8% in men. Development of haematoma is most likely to occur in the first 24 hours after surgery and requires urgent surgical evacuation. Prevention of haematoma may be facilitated by strict monitoring of blood pressure during the peri-operative period, with smooth awakening from anaesthesia avoiding valsalva manoeuvre. 356 Textbook of Plastic and Reconstructi ve Surgery 4.1.2.2. Nerve injury 4.1.2.2.1. Motor nerves Damage to the facial nerve is one of the most feared complications of facelift surgery. In the first few hours post-operatively, paralysis may be due to the effects of local anaesthesia. Subsequently, nerve injury may be related to cautery, traction, suture injury or division. 4.1.2.2.2. Sensory nerves The great auricular nerve is the one most commonly injured. Interruption of smaller, cutaneous sensory nerves may lead to self-limiting alterations in sensory innervation. 4.1.2.3. Skin necrosis Skin necrosis may occur in the central cheek or at the posterior edge of the skin flap. A watershed area is described in the central cheek between the zones supplied by the facial and superficial temporal arteries and may contribute to skin necrosis in this area. Other risk factors include haematoma, infection, thin skin flaps, excessive tension and smoking. Conservative management of skin loss is usually adopted. 4.1.2.4. Facelift stigmata Complications include distortion of the tragus and lobule, displacement of the hairline and bearded skin in men, the ‘lateral sweep’ effect and contour irregularities (as discussed previously). There are risks of asymmetry and lower eyelid inferior malposition. 4.1.2.5. Other complications Less common complications include infection (1%), hypertrophic scars, numbness, pigmentary changes, alopecia (up to 8.4%), parotid fistulae, and prolonged oedema or facial pain (Baker et al., 1977; LeRoy et al., 1994). 4.2. Upper third rejuvenation Age-related changes in the upper third of the face can falsely project an appearance of tiredness, sadness, anger or lack of interest (O’Doherty and Joshi, 2013). Evaluation of the upper eyelid must include the eyebrow, and it is important to tailor upper eyelid blepharoplasty and brow rejuvenation to the individual. Facial Aesthetic Surgery 357 4.2.1. Blepharoplasty The eye is perhaps the most important aesthetic unit of the face because it plays a major role in determining youthfulness. Blepharoplasty refers to excision of excess eyelid skin and muscles with or without the excision and manipulation of orbital fat for functional or aesthetic purpose (Biesman and Iwamoto, 2002). 4.2.1.1. Upper blepharoplasty 4.2.1.1.1. Relevant surgical anatomy for upper blepharoplasty The two main goals for upper lid blepharoplasty include restoration of a naturally sharp and crisp tarsal fold and a pretarsal show (O’Doherty and Joshi, 2013). In aesthetically attractive eyes, the pretarsal eyelid show is often only 2–3 mm (Figure 16.3) (O’Doherty and Joshi, 2013). The upper eyelid can be divided into tarsal and orbital portions at the level of the supratarsal fold. In Caucasians, this skin crease is located about 7–10 mm from the palpebral margin, which results from fusion of the levator aponeurosis, orbital septum and fascia of the orbicularis oculi into the dermis (Figure 16.4). In the ageing eyelid, orbicularis muscle becomes hypotonic and descends, accentuating the palpebromalar crease. Ageing leads to a higher fold, with or without upper lid ptosis and/or skin laxity of the lid (O’Doherty and Joshi, 2013). Loss of crease attachments may cause the skin to rest toward or beyond the upper eyelid–eyelash margin, which may cause interference with upper outer visual fields. This is accompanied by elongation of the lower eyelid and descent of the lateral canthus. Orbital septum laxity causes the fat to herniate anteriorly, leading to formation of prominent eye bags. 4.2.1.1.2. Clinical evaluation Prior to carrying out any procedure, the surgeon should obtain a good history from the patient. Medical conditions such as hypothyroidism and bleeding disorders need to be excluded. The upper eyelid margin usually rests 2 mm below the superior corneal limbus. Ptosis is the condition in which the upper eyelid drops further down. Ptosis can have a myogenic (affecting the levator or Müller muscle), neurogenic (myasthenia gravis), or mechanical or traumatic cause. The lower eyelid margin usually rests about 1 mm above the inferior corneal limbus. Visibility of white sclera below the inferior limbus is known as inferior scleral show. This inferior scleral show is normal in some populations. Evaluation of the upper eyelid must include evaluation of the eyebrow. Brow ptosis, which may be compensated by frontalis contraction, should be corrected to achieve repositioning of heavy eyebrow skin. Ageing also causes the eyebrow fat to descend over the upper lid, giving it a full appearance. Eyelid skin resection may cause worsening of the brow ptosis because elevation by frontalis muscle is no longer needed for the visual field. Plastic Surgery Dubai FAQs

Otoplasty, particularly ear pinning, can be performed at any age but is frequently performed on children. It is best planned after the ear nears full development at around 5 or 6 years old; therefore, that age is an excellent time to have a child evaluated by a plastic surgeon. Advantages of having the procedure earlier than later include less social trauma and softer ears to reshape. Plastic Surgery Dubai FAQs

There are several available facelift techniques and styles designed to meet your specific aesthetic goals. A full facelift, also known as a standard facelift, traditional facelift, or conventional facelift, is designed to lift sagging skin and at times, its deeper structures. This procedure is ideal for patients who have significant laxity of soft tissues of their face and neck. With incisions usually placed inconspicuously along or behind the hairline, the surgeon restores skin tissues by tightening and re-suspending the underlying fat and lax muscles. Depending on your aesthetic needs, a surgeon may also choose to consider a skin-only facelift. The mini facelift, short-scar facelift, or S-lift is a less-invasive procedure that utilizes a smaller incision and works on a smaller area of the face compared to a traditional facelift. It is an ideal procedure for those who are beginning to develop lines and drooping skin on their lower face and possibly laxity of their neck. These individuals may wish to address these issues before they become more obvious. A surgeon may also recommend a mini-lift as a secondary procedure for women who previously underwent a full facelift but are starting to notice visible signs of aging once again. The procedure involves an inconspicuous S-shaped incision from the sideburn, around toward the bottom of the hairline. The surgeon then tightens and elevates the underlying facial tissues, tightens the neck, and removes any excess skin. Depending on your aesthetic concerns, some surgeons may also make an additional short incision under the chin. A modified facelift is recommended for those who have moderate laxity of the face and neck but still do not have enough sagging to merit a full facelift. It is similar to the mini-lift in terms of incision placement, but it involves a longer incision that extends behind the ear, which allows for re-suspension of more fallen soft tissue as well as sagging neck muscles. Compared to a full facelift, a modified lift focuses on a more limited area of the face, such as the corners of the mouth or the nasolabial folds — the folds between the nose and the outer ends of the mouth. There is no one type of facelift that applies to everyone. Upon consultation, your surgeon will educate you on state-of-the-art techniques that would be ideal for your aesthetic goals. Plastic Surgery Dubai FAQs

Dr. Vigo will help you decide which surgical technique will best achieve your cosmetic goals: the classic or “open” method, or the endoscopic forehead lift. The classic forehead lift usually involves a coronal incision that follows a headphone-like pattern made behind the hairline, resulting in inconspicuous scarring. On the other hand, the endoscopic forehead lift involves three, four, or five short scalp incisions, each less than an inch in length. With the aid of a small camera in one of the incisions, the forehead skin is then lifted and the muscles and tissues beneath the skin removed or altered to produce a smoother appearance. The procedure may also involve lifting and repositioning the eyebrows. Plastic Surgery Dubai FAQs

Surgery of the upper and lower eyelids involves the surgical removal of fat just beneath the skin and loose skin around the eyes. For upper eyelid surgery, microscopic incisions follow the natural crease line of the upper lid. For lower eyelid surgery, the procedure is performed through a microscopic incision made just below the lower lash line. There is also an advanced procedure for lower eyelid surgery known as transconjunctival blepharoplasty that does not involve external excisions. It may be used for younger patients who only need fat removal beneath the lower eye area. The underlying fatty deposits may be extracted from the inside of the lower lid. Plastic Surgery Dubai FAQs

Yes. A breast augmentation can be performed in conjunction with breast lift. Your individual circumstances will determine if the breast lift and augmentation would be performed in one or two stages. If performed in one stage, the implants may be placed during the same surgery as the mastopexy is performed. Alternatively, the breast lift could be done on one day, with the implants inserted at a later date. You and your MAXiM-affiliated surgeon will review these options and make a decision during your consultation and pre-operative process. Plastic Surgery Dubai FAQs