An alternative approach to perioral rhytides

Facelift Without Surgery

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Facelift Without Surgery Overview

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Laser Resurfacing and Fillers

Both of these methods are indicated for the treatment of static wrinkles. The depth of the wrinkle, skin type, and recovery time after the procedure may influence the choice of either method. Usually, patients with a fair complexion benefit from laser resurfacing. Patients with a dark complexion may present hyper- and or hypopigmenta-tion. Due to skin quality, it is more common that patients with fair and sun-damaged skin may present full-face wrinkling and should be treated first with a skin resurfacing method to decrease the number of rhytides. After 3-6 months, biodegradable fillers may be injected into deeper wrinkles and folds. The degree of collagen remodeling that occurs following laser treatment varies according to laser aggressiveness and levels of enzymes, such as collagenases, which must have stabilized before any biodegradable product is injected. The appropriate time for commencement of collagen treatment is when the erythema subsides. Some patients who cannot schedule...

Chemical Peels and Fillers

Oral Commissure

Chemical peels are also an important tool for the removal of superficial wrinkles. Although patients may find the word laser more attractive, depending on the skin type and the time required from recovery, superficial or medium-depth peels are better suited for some patients. The rules are the same as for laser resurfacing there are advantages and disadvantages with laser, chemical peels, or dermabrasion. Combining any of these resurfacing methods may maximize the advantages of each and minimize the disadvantages. Fig. 7.2 a Patient before treatment to improve perioral wrinkles. b Dermal fillers were injected into the perioral wrinkles and into the oral commissure. BoNT-A was injected to block both the overcontraction of the orbicularis oris in the upper and lower lip and into the depressor anguli oris Fig. 7.2 a Patient before treatment to improve perioral wrinkles. b Dermal fillers were injected into the perioral wrinkles and into the oral commissure. BoNT-A was injected to block...

Thigh and Buttock Lift

The essential texts on biological implants (collagen), lipotransfer, botu-linum toxin, dermabrasion, ultrapulse CO2 laser, erbium-YAG laser, coblation, and chemical peeling can be found in Volume 1. As only ultrapulse CO2 laser treatment was shown in Volume 1, we have filmed short videos for Volume 2 on biological implants (collagen, hyaluronic acid), botulinum toxin, dermabrasion, erbium-YAG laser, and chemical peeling. For space reasons, these films have been kept very short and should show that adjuvant therapies should also be included in the repertoire of an experienced aesthetic surgeon.

Postoperative Care and Complications

Relative hypopigmentation can occur when removal of acquired sun damage has returned the skin to its normal nonsun-exposed color. A careful technique of feathering into the untreated, sun-damaged areas will minimize this demarcation. If it is still prominent, a touch up at the line of demarcation can help. Additionally, chemical peeling agents, hydroquinone preparations, or lasers which target melanin can be utilized to minimize the solar lentigines in the untreated area. Delayed hypopigmen-tation can arise in areas of significant erythema which may mask its earlier appearance. Although this hypopigmentation can be permanent, treatment with the excimer and other similar 308-nm light devices has been shown to improve this leukoderma (Friedman and Geronemus 2001)

Foreword by D Millesi

Many new techniques are at our disposition and the number is constantly growing. Apart from basic techniques, detailed technical points become more and more important for the successful outcome. It is nearly impossible to provide a complete survey of all techniques available today in a single textbook, not to mention the variety of technical details that are frequently not described. It is to W. L. Mang's credit that he elected the forum of a manual instead of a large textbook to present his great personal experience. In the first volume of his manual, W. L. Mang described his personal experience with rhinoplasty, rhytidectomy, eyelid surgery, and otoplasty. His techniques and his tricks are presented in the form of very instructive sketches, and any surgeon who wants to enter the field of aesthetic surgery can do this easily following the impressive illustrations. Now the second part of the Manual of Aesthetic Surgery is available. It covers liposuction, breast implants, hair...

Botulinum Toxin and Fillers

Depressor Nasi Resection

The use of BoNT-A has changed the way cosmetic procedures are handled. Nonsurgical treatment of wrinkles used to consist of filling or resurfacing methods, both of which were focused on static rhytides. Dynamic wrinkles could at that time only be treated by a surgical approach and only in a few areas, such as the forehead and glabella. Muscle action may affect the duration of biodegradable fillers so that the presence of wrinkles in areas of direct muscular action produces only partial results in treatments with fillers and skin resurfacing. Inhibition of muscular activity with BoNT-A has been the solution to this problem in various areas, especially in the upper third of the face. The aging process produces a change in muscular behavior. Continuous contraction of specific muscles may lead to dermal alteration and produces static rhytides. For such wrinkles, BoNT-A is injected before the fillers indeed in some cases it may even be the only method required. In some cases, however, the...

Nerve Exit Points Supraorbital Nerve Infraorbital Nerve Mental Nerve

Supraorbitary Nerve

If adjuvant therapies are not combined with operations (e.g., a facelift), they are performed under local anesthesia and as day-case treatment. Nerve block anesthesia with Ultracain 1 (articaine) and additional adrenaline have proved to be successful. When treating the entire face by laser or chemical peeling, light sedation also can be induced with Dormicum (midazolam) with anesthesiology stand-by. No more than 30 ml 1 local anesthesia solution should be injected. Particularly sensitive areas (e.g., lips) can be infiltrated separately, in addition to nerve block anesthesia.

Biophotonicsa New Frontier

As an increasingly aging world population presents unique health problems, biophotonics offers great hope for the early detection of diseases and for new modalities of light-guided and light-activated therapies. Lasers have already made a significant impact on general, plastic, and cosmetic surgeries. Two popular examples of cosmetic surgeries utilizing lasers are skin resurfacing

ErbiumYAG Laser Introduction

Skin resurfacing with pulsed CO2 laser treatment was explained in detail in Volume I of the manual, so only pulsed erbium-YAG laser treatment will be described briefly here. The advantage of using erbium-YAG laser treatment instead of CO2 laser treatment is that there is less necrosis and the treated area heals more rapidly because of the lower thermal impact on deeper tissue layers. The lack of a coagulation effect, however, limits the treatment of wrinkles as it is presumed that the collagen structure will not change because the ablation is virtually non-thermal.

Personal Laser Technique

Erbium Laser Day After

The first CO2 ablative laser pass is performed mainly to remove the epidermis and feather peripherally to minimize any demarcation with surrounding nontreated skin. The second laser pass, and, if used, a third pass is for heat deposition to promote tightening. Finally, the erbium laser (in the ablation mode) can be used to remove superficial thermal necrosis for further sculpting of deeper rhytides and or acne scars. In cases where deep rhytides or acne scars persist, the erbium laser in the ablative (shorter-pulsed) mode is helpful to sculpt the edges or to remove the superficial coagulative

Tissue Engineering with Light

This chapter covers three main types of laser-based tissue engineering (i) tissue contouring and restructuring, (ii) tissue welding, and (iii) tissue regeneration. Two specific examples of tissue contouring and restructuring covered in this chapter are used in dermatology and ophthalmology. Dermatological applications discussed here are (i) the treatment of vascular malformations, such as port-wine stains, (ii) the removal of pigment lesions and tattoos, (iii) skin resurfacing (wrinkle removal), and (iv) hair removal. Appropriate lasers used for these applications are presented.

Consent for Nonablative Resurfacing Collagen Stimulation

Other alternatives include microdermabrasion alone, chemical peels or laser resurfacing. Ablative laser resurfacing differs from nonablative resurfacing in that it physically removes the outer portions of the skin, and usually causes immediate tightening of the skin. With laser resurfacing you have more improvement in the outer layers with removal of sun damage changes and more tightening, but an additional 1 week period of down time. Both ablative and nonablative techniques lead to new collagen formation which continues for at least 6 months. Microdermabrasion alone will improve some of the fine lines on the surface of the skin and some of the pigmentary changes, but will not produce significant collagen remodeling or skin tightening.

General Remark

The aim of every operation, whether it is a facelift, rhinoplasty or a breast implant, should be a natural result. The patient should feel good and the surgery should not be conspicuous. Faces that are perfectly smooth, unnaturally augmented lips, and huge breasts are no longer the

What is Beauty

Madame de Pompadour said,The first requirement of a woman is to please. It is more and more difficult to fulfill this requirement with increasing age. This reminds me of an old woman who came to me and asked for a facelift. When I showed that I had little interest in performing this procedure because of her age, she said, in a quiet voice,When one has ceased to please, one doesn't have to displease for long.

History

Ablative resurfacing was first introduced in the mid 1990s. Technological advancements with carbon dioxide (CO2) lasers had emerged to minimize their thermal impact on tissue and, subsequently, possible clinical uses were explored. Two types of CO2 lasers were developed. The first utilized ultrashort pulse durations to minimize heat deposition in the tissue. The other utilized the laser beam in a continuous wave (CW) mode, in conjunction with a scanning device, to shorten the laser dwell time and, thereby, minimize thermal damage (Lask et al. 1995). These lasers were first used for the treatment of rhytides and acne scars however, investigators soon discovered that superficial sun damage changes, including lentigines, as well as actinic keratoses, fine lines, and other superficial imperfections also improved. Additionally, the deposition of heat was noted to cause a tissue-tightening effect, which softened deeper wrinkles (Fitzpatrick et al. 2000). The CO2 laser proved to be very...

Contraindications

There are few true contraindications. A personal or family history of vitiligo should be considered a relative contraindication. Theoretically, a Koebner phenomenon could occur and bring out vitiligo in the laser-treated areas. Scle-roderma patients should be counseled that ablative resurfacing could exacerbate their disease, although reports of successful treatment exist (T. Alster, personal communication). Darker-skinned patients need to understand the likelihood of hyperpigmentation, which is usually temporary but may be long-lasting. The use of hydroquinone preparations with vitamin A derivatives, glycolic acid and or topical corti-costeroids, and good sunscreen minimized this problem. Patients with very fair and fine-pored skin appear to be at greatest risk for delayed hypopigmentation, which can be permanent. Unrealistic expectations and inability or unwillingness to perform wound care are contraindications for ablative skin resurfacing.

Consent

CO2 & ERBIUM LASER RESURFACING PATIENT INFORMATION AND CONSENT WHAT IS LASER SKIN RESURFACING The carbon dioxide (CO2) laser has been used for more than 25 years for treating the skin. An intense beam of light is emitted, which heats and vaporizes skin tissue instantly. Recently developed Carbon Dioxide and Erbium Lasers are able to perform highly specific vaporization of tissue using powerfully focused light to precisely remove the layers of skin, vaporizing the ridges of scars and wrinkles and smoothing out the surface of the skin. In addition, the skin often tightens and collagen remodeling occurs with layers of new collagen replacing sun-damaged collagen. The CO2 laser tightens the skin more while the erbium laser is used more for sculpting. We may use both of these lasers to maximize benefit depending on each individuals'needs.

Plastic Surgery

Plastic surgery suites vary considerably, depending on the focus of the practice (cosmetic or reconstructive) and whether there is an intention to provide skin care or spa services (a recent trend). Skin care spa services may include microdermabrasion skin resurfacing, chemical peels, permanent hair removal by a diode laser, facials, body and cellulite treatments, as well as makeup tattooing of eyeliner or brows. These procedures are explained in greater detail, and room requirements discussed, in the Dermatology section of this chapter and at the end of this section. Another factor that will influence space planning is whether the plastic surgeon uses an advertising practice model. Some practitioners allocate a significant budget for advertising, publicity, or media consultants, and many offer educational seminars. As an example, a plastic surgeon in a building that contains a sizable breast care center may wish to conduct seminars on breast reconstruction for mastectomy candidates...

Dermatology

A dermatologist treats diseases of the skin. It is not uncommon to find a one-physician practice. Since dermatologists rarely make hospital rounds or emergency house calls, their appointment schedule is strictly adhered to without the sort of interruption that plagues many other physicians. A one-physician suite would be composed of three examination or treatment rooms, a waiting room to accommodate eight to ten persons, a small lab, a toilet room, a business office, a consultation room, a minor surgery, and a large storage closet for drug samples (Figure 4-107). Larger practices may include a surgery facility, as well as offer ancillary services such as laser hair removal, chemical peels, facials, Botox (botu-linum toxin) injections, sclerotherapy, Endermologie , and massage. The reader is referred to Chapter 6 for a decentralized plan of a group-practice dermatology suite and to Figure 4-108 for a centralized plan. Figure 4-109 shows the relationship of rooms.

The Future

Fig. 5.9. 69-year-old woman with acne scarring, telangiectases, and wrinkles, pre (a) and 4 months post (b) PDL treatment Fig. 5.11. 36-year-old woman with telangiectases and fine rhytides, pre (a) and 4 months post (b) IPL treatment Fig. 5.11. 36-year-old woman with telangiectases and fine rhytides, pre (a) and 4 months post (b) IPL treatment

Upper Arm Tightening

Axillary Fossa

Upper-arm tightening is requested increasingly by women over the age of 60. It is often surprising that women of this age do not have a facelift instead they are more bothered by their flabby upper arms when they want to wear a bathing suit or sleeveless clothes. The only way of eliminating the surplus skin and the wrinkles in the long term is cutaneous excision. The art of the surgeon in doing this is to position the incision in such a way that it is on the medial side of the upper arm and to ensure that the resection of the skin is carried out so generously that the entire upper-arm region is tightened.

Report Technique

Aciclovir 400

The most practical, most effective, and safest method of chemical peeling for the novice is to use 30 trichloroacetic acid. This removes the entire upper layer of skin, down to the reticular dermis. Nerve block anesthesia of the infraorbital and or mental nerves can be used in patients who are particularly sensitive to pain, but local anesthesia using an occlusive dressing is usually sufficient. Following disinfection, the skin is treated with acetone to remove superficial skin scales. This allows better penetration of the acid into the skin. After the acid has been applied, the area to be treated is marked. The acid is applied homogenously over the entire surface at a consistent pressure. This is the true art of any type of peeling. The application of the acid may be repeated several times, depending on the depth of the wrinkles, using slight pressure. Each area of skin must be treated with the same intensity so that the skin relief does not vary later. The typical blanching, which...

Wrinkle Reverse

Wrinkle Reverse

It's true, & deep down we all know it, there is no way to stop the natural aging process, not really. But you can take action to slow this process right down. And when done right you can even start to roll back the years as far as facial appearance goes that is! You know, Anyone can look younger when they know how. Skin rejuvenation is very real & It doesn't have to cost the earth!

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