Cosmetic Surgery of the Face

In the past, rhinoplasty has been our major tool in changing facial outlines, but we now do facial contour surgery. Mentoplasty often was done as an associated procedure for micrognathia We now work with our dental colleagues to realign the lower third of-the face through orthodontics and mandibular repositioning. Newer techniques for midface surgery allow significant improvements in severe midface deformities. For the most part, however, we are dealing with less severe facial defects in cosmetic surgery. Malar, as well as mental, augmentation is being combined with other cosmetic procedures. Implantable prostheses placed through intraoral incisions or small external incisions improve facial appearance. The surgery is relatively simple, adds little operating time, and the prostheses are well tolerated. Complications such as infection or rejection are rare, as are shifting or asymmetric place-merit. Repositioning or removal and reinsertion of a new implant may be accomplished without difficulty. Patient satisfaction has been great. Many patients re-quest rhinoplasty. which alone would produce only slight improvement. Small recontouring procedures plus rhinoplasty often can change ordinary results into excellent results (Figures 2A and 2B).

Suction lipectomy, the newest addition to facial con-touring, was first popularized in the United States by Newman and others.' The technique and instrumentation has been improved greatly during the past five years. In the face, it is used predominantly in the nasolabial folds, the jowls, and the submental region. Liposuction contouring of the nasolabial grooves through intranasal incisions has limited value, but may be augmented by injecting filling material. Liposuction for the jowls and submental region through a small submental incision has been of far greater value, especially in the younger patient with good skin elasticity. As skin elasticity is lost, liposuction combined with facelift and/or mentoplasty compensates for skin laxity (Figures 3A and 3B). Facial liposuction alone or in combination with mentoplasty is a quick, very safe office procedure. The blunt cannula of the liposuction device is riot likely to injure vessels or nerves. Liposuction with facelift has improved significantly the contouring effect in the jowl and submental regions and shortens operating time.

COVER STORY

Figure 1A. Traumatic nasal deformity. Note the asymmetry as well as the broad flat tip.	Figure 1B. Postoperative correction by open rhinoplasty.
Figure 2A - Preoperative view of patient who underwent revision rhinoplasty through open approach.	Figure 2B - Postoperative view of completed tip projection.

COVER STORY

Figures 3A and 3B - Pre- and postoperative view of patient treated with facial liposuction in conjunction with facelift and augmentation of the malar and mental regions.

Facial contouring with injectable materials such as collagen Zyderm and Zyplast may produce excellent short-term results. Long-term results with injectable silicone have been more reliable, but the earlier use of injectable silicone produced significant problems. The material fell into disfavor and has not been approved by the FDA. Orentreich and others have shown silicone to be safe and effective when used appropriately, i.e. in very small quantities over a long period of time." Webster has written on the silicone microdroplet technique. Those familiar with silicone feel it is safe and provides excellent long-term results: they hope silicone will gain FDA approval in the future.

Fat recycling involves the harvesting of fat by liposuction and reinjecting it to fill facial defects. Autogenous fat is a natural contour material and is easily obtained through small punctures under local anesthesia, but long-term fat survival with the present methods of recycling is questionable. Studies now are in progress on the basic nature of fat harvested from different areas of the body as well as the operative instrumentation.

Improved surgical techniques have reduced operating time, allowing performance of multiple procedures at one time, while advances in anesthesiology allow a greater margin of safety with both general anesthesia and local anesthesia combined with intravenous sedation.

The challenge to improve facial appearance continues to advance our surgical skills. As a result, we are able to offer patients better results with less morbidity.

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