lecture 1 facial cosmatic surgery

Historical Prespective
• Only in 2010 approximately 13 million cosmetic
procedures were performed only in the USA
• Of those 1.6 million were surgical procedures .
• According to the American Academy of Facial
Plastic and Reconstructive Surgery (AAFPRS) , the
most popular facial cosmetic surgical procedures
were Rhinoplasty, Face lift and blepharo-plasty .
• The most common non-surgical procedures were
botulinum toxin (Botox) and hyaluronic acid
injections

• More specifically, the combination of hard tissue
(osseous and Dental) and soft tissue (skin,
cartilage, fat and muscle ) management and
manipulation is truly unique to the field of
modern oral and maxillofacial surgery .
• Rejuvenation of the face must include a thorough
assessment and management of all these
components .

• The desire to achieve the best possible
physical appearance is as old as humanity .
• Roman Philosopher (Aulus Cornelius Celsus)
misquoted as the first to document
(Eyelid Correction)
Historical Perspective

Facial Aging and Analysis
Facial Aging :
• Facial Aging is not only restricted to skin but also
involves underlying subcotanous tissues, various fat
pads , the musculo-aponeurotic system and even the
facial skeleton itself
• The two main accelerators of facial aging that are
preventable are:
1. Sun Exposure
2. Smoking
• Both process accelerate collagen
and elastin degradation and disorganization .

• Sun Exposure leads to photoaging that
manifest as wrinkling , pigmentation changes ,
diminished skin tone .
• Ultraviolet (UV) radiation also leads to an
increased risk of skin Cancer .
Facial Aging

Facial Analysis:
Facial Analysis:
• Evaluation of the face should be done in a very
constant and systematic manner .
• Although no specific format exist for this analysis, one
effective format is to begin by performing a generalized
review of the entire patient (ethnicity, body habitus,
and general facial proportions) .

• The examination should focus on specific areas of
concern to the patient .
• Ethnicity is an important factor as a particular set
of racial norms will need to be used when
determining ‘’ideal’’ facial esthetics .
• This is followed by characterization of the skin,
and a ‘’top to bottom’’ evaluation of the face and
neck .
• Symmetry and facial proportion as well as soft
tissue characteristics should be carefully
evaluated .

Ideal Facial Angles in Profile Veiw

Vertically:
Symmetrical Face demonstrating
vertical fifths , with each fifth
approximating the width of one Eye .
Ideal Facial Proportions

Horizontally:
Horizontal thirds based on relatively
even measurements .
1. From the hair line to the glabella .
2. From the glabella to the subnasale
3. From the subnasale to the menton
Ideal Facial Proportions

Skin Analysis
• Skin is the most abundant tissue of the face .
• The degree of photo-damage and precancerous
or even malignant changes of facial skin are
factors to consider .

• Pigmentation greatly affects the degree of photo-
aging , as melanin is skin’s main defense against
damaging UV radiation.
• Patients with darker skin pigmentation tend to
resist or delay photo-aging compared with those
with lighter skin .
Skin Analysis

• Thickness and quality of skin greatly influence rejuvenate
techniques and their associated results .
- Thicker skin envelopes (layers)
will tend to hide or mask small
irregularities BUT are usually
associated with more problematic
scarring .
- Thinner skin generally heals more smoothly BUT at the
cost of more easily detectable contour changes beneath it .
Skin Analysis

• Detection of any aberrant (abnormal) scarring
(keloids or hypertrophic scaring ) should be
thoroughly evaluated
Skin Analysis

Non-Surgical Procedures
I. Skin care:
• Skin care is a vital part of any successful facial
cosmetic practice .
• The benefits are primarily
aimed at slowing the natural
progression of age-related
changes at the skin level .

• Stop smoking and adequate sun protection
are vital for skin care .
• Many skin care product are available with or
without prescription .

• The main uses for skin care products are
typically:
Sun protection .
Control of inflammation and pigment disorders .
 Increased collagen production .
 Improved cell turnover .
Exfoliation .

II. Dermal Fillers:
• If the lines, wrinkles or rhytids in the
face can be though of as a series of
hills and valleys , its easy to
understand that filling the valleys
( in skin will minimize the
appearance of wrinkles) .
• This premise has led to the
increasing popularity of the use of
cosmetic dermal fillers .

• In addition to minimizing the wrinkles , fillers has
become popular in treating areas of facial
atrophy either related to aging or disease .
• The most common type of Dermal fillers are:-
 Calcium hydroxyapatite .
Hyaluronic acid (HA) .
Autologous fat .
Silicon Oil .
Polymethylmethacralate (PMMA)

Typical Areas for Facial Filler
Application

• Hyaluronic acid and Calcium hydroxyapatite
• Are the most commonly used temporary fillers ,
because they are very safe and extremely low
allergic potential and don’t require allergy testing .
• Hyaluronic acid and Calcium hydroxyapatite can be
combined with local anesthetics to promote
patient comfort at the time of
injection .
Non Surgical Procedure
Dermal Filler

• Hyaluronic acid and Calcium hydroxyapatite
• They generally last from 6 months to 1 year .
• HA is clear and can be used more superficially
than calcium hydroxyapatite which is white and
generally reserved for deeper application .

 Autologous fat
can be harvested from another site
(usually the abdomen or thighs) and
placed in areas of atrophy in the face.
• Autologous fat is a semi-permanent filler in that only a
portion of the fat will remain viable for the life of the patient .
• The exact percentage of remaining fat is difficult to expect
and it is influenced by a number of factors:-
 how the fat is harvested and treated .
 Where the fat is placed .
Dermal Filler

• Roughly 30% to 80% of the fat may remain
permanently .
Dermal Filler
Micro-Autologous Fat
Transplantation Introduction

 Silicon Oil :
• Highly purified silicon oil is a permanent filler
that is reserved for use by only the most
experienced doctors .
• Given it permanence, over treatment must be
strictly avoided .
Dermal Filler

• It can be used to augment lip volume and treat
atrophic scarring .
• Silicon oil is well tolerated by the body and the
microdroplets once injected eventually become
encapsulated by collagen , which leads to volume
gain .

III. Botulinum Toxin (Botox):
• Botulinum Toxin (Botox) was the first neurotoxin
approved by the Food and Drug Administration (FDA) for
cosmetic use in USA, and become the most widely used
in the world .
• Botulinum Toxin (Botox)- is an endotoxin produced by
the bacterium clostridium botulinum and is responsible
for botulism or ‘’sausage poisoning’’
• In a high refined form and small dosage concentration
injections , it has proven to be an extremely safe
method for decreasing superficial muscle activity .

• Botulinum Toxin (A): works by weakening the
muscle which is injected into
Botulinum Toxin

• Botulinum Toxin is effective in lowering the smile
line if gingival show is excessive (gummy smile/
horse smile)
Botulinum Toxin

• Botulinum Toxin is typically effective for
3- 4 months and must be repeated to
maintain results
• The most common complication associated
with neurotoxin use are bruising , asymmetry
and brow or lid ptosis
Botulinum Toxin

IV. Facial Resurfacing:
• Is the controlled removal of the upper layers
of skin to treat pigment disorders, smooth
irregularities and promote tightening .
• Facial Resurfacing can be performed by:-
 Dermabrasion
Chemical peels
Laser resurfacing
Facial Resurficing

• All modalities must avoid penetration beyond
the mid-reticular dermis to prevent
complications as :-
Scarring and Permanent
pigment changes
Facial Resurficing

A. Dermabrasion:
• Is the mechanical removal of the outer layers
of skin with a diamond wheel or wire brush .
• This leads to new collagen formation and
resurfaced epidermis, which reduces facial
scarring , actinic changes ( (
‫الجلد‬ ‫على‬ ‫قشور‬ and
Dyschromias (alteration in the color of nails or
skin) .
Facial Resurficing

Facial Dyschromia
Actinic Changes

A. Dermabrasion:
• Control of the depth of treatment is based on
point bleeding at the papillary or upper
reticular dermis, this is mostly learned with
significant experience .
• Dermabrasion has been largely replaced by
chemical peels and laser resurfacing .
Facial Resurficing

B. Chemical Peeling:
• Chemical peeling involves the chemically
aided removal of the outer layers of damaged
skin to promote collagen tightening and
improvement of pigment disorder .
Facial Resurficing

• The degree of tissue removal depends upon the
chemicals used and techniques and may extend
down to the papillary or reticular dermis

B. Chemical Peeling:
• Deeper peels generally result in greater
improvement BUT needs more recovery time and
greater surgical competence and experience to
avoid complications .
• Typical chemicals used in facial peeling are:-
 Trichloroacetic acid (TCA)
Kojic acid
Salicylic acid
Glycolic acid
Hyrdoxy acids
Phenol
Facial Resurficing

C. Ablative Laser Resurfacing:
• Ablative lase resurfacing is
removing the outer skin layers
in a precisely controlled manner
to promote tightening and improvement of discoloration
or pigmentation abnormalities .
• By ablative laser resurfacing there's greater secondary
collagen tightening and more precision versus
chemical peels or derma abrasion
Facial Resurficing

• The addition of newer technologies to laser
systems have greatly reduced recovery time and
complications related to overaggressive
treatment
• The carbon dioxide (CO2) laser and the
erbium:YAG laser are the two predominant
ablative lasers in use today
• The carbon dioxide (CO2) laser is more aggressive
and typically yields greater results but requires
longer recovery time .
Facial Resurficing

• Darker skin types require more careful
treatment with any type of resurfacing, as
they are at higher risk for hyperpigmentation
postoperatively .
• This is usually treated with skin lightening
agents and may improve over time, but it can
be disturbing for both the patient and the
surgeon during the recovery period .
Facial Resurficing

• Patients generally require 7-10 days for
recovery , and several weeks for gradual
improvement of erythema .
• Resurfacing is commonly performed
simultaneously with face lift techniques and
fat transfers to yield maximum results .
Facial Resurficing

Complication of Skin Resurfacing:
1. Infection (bacterial, fungal , viral)
2. Scarring (deeper than expected penetration)
3. Pigment disorders
Facial Resurficing

lecture 1 facial cosmatic surgery

lecture 1 facial cosmatic surgery

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lecture 1 facial cosmatic surgery