The specialty of facial plastic and reconstructive surgery has undergone many changes over the past several decades. Some involve new perspectives on old procedures; some relate to evolving techniques; some concern advances in materials and technology. In addition, the patient base is changing, as are the reasons for undergoing such surgery.
Advances in Rhinoplasty
Possibly the most striking and important change in today’s plastic surgery is a new approach to rhinoplasty. “In the last ten to fifteen years, the emphasis in rhinoplasty has been on conservation,” said Russell Kridel, MD, a facial plastic surgeon based in Houston and past national president of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). “Previously, many surgeries were too aggressive; often, too much cartilage was removed in an attempt to make the nose smaller or to refine the nasal tip. After cosmetic nose surgery, the overlying skin can shrink down and lose some of its thickness, allowing you to see the changes underneath. If too much was removed, the cartilage can buckle and you can actually see the sharp edges of the cartilage underneath. If the structural support of the nasal skelton is weakened, the nose gradually tends to collapse and show irregularities. The late result often has been unnatural looking noses as well as nasal obstruction, both are common reasons patients may require revisions.
“In rhinoplasties done today we try to be conservative and cognizant of the nose’s structure—that is, maintaining good strong structure that supports breathing and the shape of the nose,” Dr. Kridel continued. “In most cases, the more conservative the rhinoplasty, the better the long-term result.”
Added Ira Papel, MD, of Baltimore, “As a mainly referral practice, we’ve treated people who’ve had as many as ten previous rhinoplasties and still are having problems. Many of these noses are similar: too much of the tip has been removed to make the noses thinner or the nose has lost its bony and cartilaginous support, creating nasal obstruction. Typically in these cases we’ve had to bring in new cartilage from outside the nose, such as the ear or the ribs, to do the repair.”
Thus, over the past 15 years, a new set of procedures for rhinoplasty has been developed. These conservation techniques involve very little removal of cartilage and bone and, instead, employ alteration of the existing nose using suture techniques and ensuring that key anatomic points, such as the valve, and structural support systems are maintained. Often, for example, when the nose is narrowed, spreader grafts are placed to make sure the lateral walls do not collapse. Alar batten grafts, frequently taken from the patient’s own septal cartilage, may be placed on the sides near the base of the nose. Or the shape of cartilage may be changed by moving some cartilage and suturing it to other portions of cartilage, usually with a monofilament nonabsorbable suture such as Prolene or nylon. Needed cartilage for grafts frequently is obtained from the nasal septum, the ear, or less often, the ribs.
Importantly, even recent patients are followed up for 5 and 10 years after surgery to monitor the effects of newer rhinoplasty techniques.
Regarding other types of nasal surgery, correction of septal perforations is unfortunately becoming more common, Dr. Kridel told ENToday. Some common causes for septal perforations are the use of impure “street” cocaine—talc or borax (products used to “cut” street cocaine) are very irritating to the nasal mucosa; long-term, nonmonitored use of certain medication such as nasal decongestants or nasal steroids; or chemical cauterization of the nasal septal mucosae to treat epistaxis. Some common symptoms associated with septal perforations include bleeding, crusting, and whistling. As the perforation becomes larger, there is increased likelihood of developing nasal obstruction.
Fortunately, in the past 20 years, consistent, successful techniques have been developed to repair the great majority of septal perforations. One specific technique favored by Dr. Kridel involves using bilateral sliding mucosal intranasal flaps. In the past, septal perforations were repaired with skin grafts, which often resulted in persistent nasal symptoms. “We incorporate nasal respiratory mucosal flaps to repair septal perforations which usually result in a return in normal respiratory function,” Dr. Kridel explains. “The interposition of a connective tissue graft between the two flaps may give the best technique. The connective tissue may come from the patient’s own temporalis fascia or acellular dermis may be obtained from a tissue bank. Inferior turbinate flaps are also used and are especially good for some very large, difficult perforations. This latter technique requires a second procedure to separate the connection and open the nasal passageway.”
The Aging—and Not So Aging—Face: Recent Modifications of Standard Facial Procedures
Even in the past 10 years, this procedure has undergone alterations. Now, according to Dr. Papel, rather than making an incision from ear to ear, peeling the forehead forward, elevating it, and dissecting and then excising part of the scalp in order to lift the brows, an endoscopic procedure is carried out via a very small incision behind the hairline. As in endoscopic procedures done elsewhere in the body, a camera is attached to the endoscope and images conveyed to a TV screen. “In this way we can see what we’re doing while we elevate the plane, avoiding small nerves and other structures while we do the dissection, and then use various methods to undermine and support the brow,” Dr. Papel said.
Patient recovery is easier and much faster, and complications such as loss of hair or of sensation on the top of the head are avoided.
Blepharoplasty of the Lower Eyelid
For people with fatty bags under their eyes, the location of the incision has been moved from just below the lash line to behind the lower eyelid, the so-called transconjunctival incision, and fat then removed. For patients with drooping lower lids and seemingly excess skin, there are new ways to correct the look with minimal incisions and very little excision of skin.
“We can also help patients who’ve undergone older blepharoplasty procedures,” Dr. Papel said. “Sometimes it requires skin grafts to replace that skin; sometimes it requires only tightening up of the eyelid, suspending it from the orbital bone. Again, it goes back to preservation of natural contours and anatomy, not just removing skin and fat as was done some years ago and which was part of my original training!”
Facelifts and Other Rejuvenation Procedures
For older patients who have more lax skin and can afford both the price and the “downtime” of a facelift, this procedure still reigns supreme compared with other techniques. According to most facial plastic surgeons, the newer techniques and materials will help older patients, but they do not achieve the results—in terms of final and long-lasting appearance—that a facelift does.
However, for other people who cannot afford the time or cost of a facelift or, especially, for the large numbers of younger people who are starting earlier in their attempts to maintain a youthful appearance or correct facial defects, there are new, well-publicized options that are much less expensive. However, for lasting results, they must be repeated from time to time.
To Jonathan Sykes, MD, director of facial plastic and reconstructive surgery and professor of otolaryngology at University of California, Davis School of Medicine in Sacramento, one of them, botulinum toxin type A (Botox), used to relax muscles in the forehead, between the eyebrows, and at the edges of the eyes, is “one of the most significant developments in the last twenty years.”
Botox has a relatively low cost, no downtime, yields high satisfaction rates and has very little risk. But it has to be repeated every four to five months. Some patients even get Botox injections for prevention of wrinkles, Dr. Sykes said.
Similar products, especially those that may last longer, are in clinical trials and not far from being approved by the FDA, he added.
Injectable filler agents are also being used in patients to augment lips and to address deep facial folds and wrinkles. Fine lines above the lips or the upper melolabial folds are often treated with Restylane (a gel composed of hyaluronic acid), which has essentially replaced the collagen that was formerly used for such problems. Beneficial effects of Restylane last for about six to nine months. Radiesse (a particulate made of hydroxylapatite) has been FDA-approved for nasolabial folds. This product has beneficial effects up to two years. Yet another filler agent is Sculptra (L-lactic acid), which, according to Dr. Kridel, can be especially effective in restoring a more normal appearance to the faces of some patients with HIV.
Another injectable filler agent is the patient’s own fat which sometimes, but not always, yields permanent effects, Dr. Papel said.
Still, the search continues for new filler agents that will last longer than those currently in use, or even be permanent.
Loss of Facial Volume
Because muscle can atrophy and even bone can change, facial plastic surgeons have recently begun to understand the aging effects of loss of volume in the face, Drs. Papel, Kridel and Sykes all emphasized. This is found most often in older people but also can occur in physically active people such as athletes with very low body fat who can have, according to Dr. Kridel, that “Abe Lincoln haggard look.”
In such a face, hollow cheeks can be corrected by submalar implants and/or by fat grafting. Dr. Kridel prefers to restore the volume to these faces, but he also may perform “suspension techniques where I elevate the skin subperiostally, taking tissue off its bony attachment, lifting it up and suspending it with sutures.”
Fat or other fillers may also be injected or grafted around the eyes of patients whose periorbital region has lost volume and the skin has thinned—a much different philosophy from the past notion in which fat was routinely removed from the eye area.
Where are the fat-harvesting sites? “We get it from the patients’ thighs or belly,” Dr. Papel said, adding: “Most of us have some to donate. And whenever you do it, everyone in the operating room says, ‘Take mine!’”
As for what eventually will be the preferred filling material, the jury is still out.
‘Cable Lifts’ or ‘Contour Threads’
Marketed over the past year and a half under various trade names, all these products are made of permanent suture material with barbs on them to hold and elevate facial skin. After they are placed via a stab incision, the patient’s skin is pulled over them. “The advantage is minimal downtime, some swelling and bruising, and less cost,” Dr. Sykes said. “Still, these lifts are unproven. We don’t know how long their effects last or whether this varies with the person. They’ve been on the market only about a year and a half.”
“When used correctly, these contour threads or cable lifts can accomplish minimal changes in people with minimal problems,” Dr. Papel said. “As with any other product, they should be used correctly with knowledge of their limitations.”
Dr. Kridel, however, feels that suspension alone without skin removed is not a worthwhile endeavor in patients with hanging skin.
Skin Resurfacing Modalities
For people with acne scars, considerable sun damage, or other problems afflicting primarily the facial epidermis, dermabrasion is still carried out and is very effective—when done correctly. “Dermabrasion is the most difficult of the skin resurfacing techniques,” Dr. Papel emphasized. “It requires the most practice, the most skill, and a good ‘feel.’ The number of surgeons who do it well is very small. Healing takes at least ten days.”
For others patients and surgeons, there are lasers. The CO2 laser and the erbium laser have been around for some time and are very effective, although the CO2 laser, because it has a greater depth of penetration, is more effective for deep resurfacing. Sometimes it is combined with dermabrasion, Dr. Kridel explained.
Now a new laser, called the Fraxel laser, yields resurfacing results nearly as good as those of the CO2 laser but entailing much less recovery time. Five treatments are given, with two to three days of recovery time after each, as opposed to one treatment with the CO2 laser. The Fraxel, although used over the entire face, actively treats only about 20% of the tissue at one time because the area around each changing “microthermal treatment zone” is said to remain untouched.
The device stimulates collagen deep in the facial tissue, stimulating the creation of new collagen which elevates depressed areas of skin, Dr. Kridel explained. “A lot of people who have wanted better looking skin but couldn’t afford the downtime are doing this. It’s not quite as good on wrinkles, but does improve the texture and coloration of the skin,” he said.
Still other light sources and lasers, generally termed “minimally invasive” or “nonablative,” are now available that only stimulate the skin. Long-term results on these new devices are not yet available.
Yet another modality, called the Thermage Therma-Cool system, sends radiofrequency waves, and thus heat, to deeper tissues. “Reportedly,” said Dr. Kridel, “through tightening of existing collagen and stimulation of new collagen development, it can tighten facial skin, although results are neither very predictable nor remarkable.”
He added: “But others have found—and I too, have seen—some cases of active acne in which Thermage has improved the condition. Presumably the heat penetrates into the deep pilosebaceous units, causing them to become less active.”
Advances in reconstructive surgery of the face have been aided by improved imaging of fractures and other defects, better biomaterials to hold parts of the face and head together while healing takes place, and the use of endoscopy in repairing facial fractures. Titanium plates remain the standard for helping to fix and reconstruct the face but in addition, according to Dr. Papel, there are now available absorbable facial reconstruction plates that facilitate healing of bones. One such material is Biosorb, a self-reinforced polyglycolide-co-polylactide 80/20 material used to make plates and screws to help fix osteotomies and fractures. Another is LactoSorb, a copolymer of 82 L-lactic acid and 18 glycolic acid.
“I think the absorbable plates are taking a bigger role all the time,” Dr. Papel said. “As long as you devote the time and attention to such surgery, you can do a good job.”
In 2006, many more people are seeking facial plastic surgery—and at younger ages—than previously. And, perhaps not surprisingly, a growing number of otolaryngology residents are entering the field. Dr. Papel, who serves as co-director of the facial plastic fellowship at Johns Hopkins Hospital in Baltimore, noted that there are now 50 fellowships in this subspecialty. With 200 residents finishing an ENT residency each year, about one-quarter now appear to be entering this ever-evolving field.
©2006 The Triological Society