Aesthetic Medicine: Surgical Pearls




Introduction


Aesthetic medicine comprises all medical procedures that are aimed at improving the physical appearance and satisfaction of the patient, using noninvasive to minimally invasive cosmetic procedures.


These aesthetic procedures consist of:



  • ▪

    injections of neurotoxins


  • ▪

    dermal fillers/fat grafting


  • ▪

    chemical peels


  • ▪

    radiofrequency


  • ▪

    cryotherapy


  • ▪

    lasers and intense pulsed light (IPL)


  • ▪

    ultrasound treatment


  • ▪

    platelet-rich plasma (PRP)



The author used a combination of these procedures for nonsurgical rejuvenation. This chapter provides an overview of each of these with their clinical implications, recommended indications, management, advantages, and disadvantages.




Multimodality Nonsurgical Rejuvenation With a Regional Approach


Botulinum Toxin (Botox)


In aesthetic medicine botulinum toxin (see Table 2.1 and Fig. 2.1 ) is the most commonly used nonsurgical treatment worldwide. In 2014, 4.89 million Botox treatments were done worldwide. Its popularity is due to its excellent safety record and predictable outcomes.



Table 2.1

Uses of botulinum toxin in aesthetic medicine












Dynamic rhytids

  • •

    Forehead horizontal lines


  • •

    Glabellar vertical lines


  • •

    Periocular rhytids (crow’s feet)


  • •

    Hyperdynamic orbicularis/pretarsal orbicularis (under the eyes)


  • •

    “Bunny” lines


  • •

    Perioral (smoker’s lines)

Diminishing the depressor activity of certain muscles

  • •

    Lateral fibers of orbicularis (brow elevation)


  • •

    Depressor septi (nasal tip elevation)


  • •

    Platysma (Nefertiti lift)


  • •

    Mentalis (chin deformity)


  • •

    DAO (for marionette lines)

Hypertrophic muscles

  • •

    Masseter


  • •

    Nasalis (alar flare muscle)


  • •

    LLSAN (“gummy” smile and alar flare)


  • •

    Masseter


  • •

    Deltoid


  • •

    Medial head of gastrocnemius


DAO, Depressor anguli oris; LLSAN, levator labii superioris alaeque nasi.



FIGURE 2.1


Combination treatment of hyaluronic acid to periocular midface and marionette areas with botulinum toxin to glabellar forehead and periocular area.


Commercially available botulinum toxin A are:



  • ▪

    onabotulinum toxin A (Botox)


  • ▪

    abobotulinum toxin A (Dysport)


  • ▪

    incobotulinum toxin A (Xeomin)



Dilution



  • ▪

    1 B.U. = 2.5 s.U




    • 1 vial of Dysport (500 s.U) + 2.5 mL saline = 20 U/0.1 mL



    • (can be rediluted in the syringe with 1 : 1 ratio to create a concentration of 10 s.U/0.1 mL)



  • ▪

    1 vial of Botox (100 U) + 2.5 mL of saline = 4 U/0.1 mL




    • 30- to 32-gauge needle (a smaller needle is preferred in sensitive patients)



    • 4 U Botox = 10 U Dysport




Preprocedure Management of Neuromodulators




  • ▪

    Conduct an assessment of the patient.


  • ▪

    Note the location and depth of rhytids.


  • ▪

    Obtain a history of the patient’s concerns.



    • •

      Brow position is important.


    • •

      Check for the presence or absence of compensatory brow elevation.


    • •

      Check for blepharochalasis and dermatochalasis.


    • •

      Check for collagen depletion.


    • •

      Measure the width of the forehead (a wide forehead would need more neuromodulator/Botox).


    • •

      Assess strength of frontalis muscle and length of corrugator.



  • ▪

    Take a preoperative photograph.


  • ▪

    Apply a eutectic mixture of local anesthetics (EMLA) 30 minutes prior to procedure.


  • ▪

    Give counseling about potential complications.


  • ▪

    Obtain consent.



Postoperative Care for Neuromodulators




  • ▪

    The lumps on the area injected will go down in 15 to 30 minutes.


  • ▪

    Do not rub or apply pressure on the area that was injected with Botox.


  • ▪

    For 6 hours, avoid bending or stooping down; instead lie down flat on your back.


  • ▪

    Do not go to the gym or do any sports until the next day.


  • ▪

    Follow up after 10 days.


  • ▪

    Take a postoperative photograph.



Hyaluronic Acid (Fillers)


Adding volume along with short-scar face lift has largely overtaken surgical correction for midface. The choice of filler is dependent on the anatomy of each individual and the specific treatment goals. Injectable soft-tissue fillers are durable, well tolerated, and potentially reversible in unfavorable clinical outcomes. Small-particle hyaluronic acid (HA) with lidocaine (Restylane Silk, Galderma, Uppsala, Sweden) is used for submucosal implantation for lip augmentation and dermal implantation for correction of perioral rhytids. Side effects are generally mild and transient.


Preprocedure Management




  • ▪

    Conduct a general assessment of the patient.


  • ▪

    The patient should avoid aspirin (any product containing acetylsalicylic acid), vitamin E, and other dietary supplements, including gingko, evening primrose oil, garlic, feverfew, and ginseng, for 2 weeks.


  • ▪

    The patient should also avoid blood thinners such as aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn) 1 week before the treatment.


  • ▪

    Enquire about history of cold sores (or fever blisters) prior to treatment.


  • ▪

    Optionally, the patient can start taking an Arnica tablet for 1 week prior to treatment and 4 days posttreatment. The standard dosage is three Arnica tablets (30 CH) three times a day 30 minutes before or after a meal.


  • ▪

    Enquire about allergy or sensitivity to lidocaine.


  • ▪

    Mild bruising is common and can last 7 to 14 days.


  • ▪

    Take a preoperative photograph.


  • ▪

    Apply EMLA 30 minutes prior to the procedure.


  • ▪

    Give counseling about potential complications and obtain consent.



Postoperative Management




  • ▪

    Follow up after 2 weeks for touch-up.


  • ▪

    Take a postoperative photograph.


  • ▪

    Counsel the patient that the volume will go down by approximately 20%.


  • ▪

    Give Voltarol for pain relief.


  • ▪

    Massage with Arnica.


  • ▪

    Avoid hot beverages after the dental block (for lip augmentation).


  • ▪

    Avoid cold compression to prevent headache (in the temporal area).


  • ▪

    Minimize movement of the treated area.


  • ▪

    Avoid applying heat to the treated area until bruising or any swelling has resolved.


  • ▪

    On the day of treatment, avoid activities that cause facial flushing including consuming alcohol, hot tub or sauna use, exercising, hot wax, and tanning. Avoid extreme-cold activities, like skiing or hiking outdoors.


  • ▪

    Gently apply a cool compress or wrapped ice pack to the treated areas for 15 minutes every few hours as needed to reduce discomfort, swelling, or bruising up to a few days after treatment. When bruising occurs it typically resolves within 7 to 14 days.


  • ▪

    Results last approximately 6 to 12 months.


  • ▪

    For more than 4 cc of filler used, prednisolone 40 mg with Nexium 40 mg daily for 2 days after meals may be considered.





Upper Face


Forehead and Brow Rejuvenation ( Fig. 2.2 )


Assessment ( Table 2.2 )




  • ▪

    Check the brow position (this is important).


  • ▪

    Check for the presence or absence of compensatory brow elevation.


  • ▪

    Check for blepharochalasis or dermatochalasis.


  • ▪

    Check for collagen depletion.


  • ▪

    Assess the strength of muscle.


  • ▪

    Measure the width of the forehead.




FIGURE 2.2


(A,B) Botulinum toxin to corrugator, depressor supercilli, and procerus muscle complex. (C,D) Botulinum toxin to frontalis muscle.


Table 2.2

Management of forehead and brow rejuvenation
































Indication/patient’s perspective Muscle Plane Treatment
Glabellar frown lines Corrugator Subdermal 4–8 injections in females
6-10 injections in males
10 s.U in each injection
Glabellar frown lines Procerus Deep subdermal
Glabellar frown lines Depressor supercilli Deep subdermal
Dynamic lines on the forehead Frontalis Subdermal One injection centrally and two laterally on forehead. (between 10 and 30 s.U in divided doses)
To maintain the brow position
To prevent lateral brow ptosis 		Orbicularis oculi (superior lateral fibers) Subdermal As a prophylactic measure, 10 s.U on each side to be given under the tail of the brow to inactivate the depressor action


Technique




  • ▪

    The brow elevator (frontalis) and depressors (corrugator, procerus, depressor supercilli [DSC] for the medial brow and the superolateral fibers of the orbicularis oculi for the lateral brow) should be treated as a single unit to prevent brow ptosis.


  • ▪

    Preventing brow ptosis should be the priority.


  • ▪

    This can be achieved by full treatment to the corrugator, procerus, and DSC, a conservative dose to the frontalis, and a later touch-up to the frontalis if required in 10 days.


  • ▪

    Treatment of the superolateral fibers of the orbicularis oculi will also help to maintain an elevated brow position.


  • ▪

    Assess the activity of DSC. If DSC overactivity is missed, the patient may come back with descent of the medial brow (an angry look).


  • ▪

    If there is previous history of heaviness of brow after treatment, inject only in the central forehead.


  • ▪

    For the technique, see .


  • ▪

    Injections placed above the midpupillary line for the corrugator should be at least 1 cm above the bony orbital rim to help prevent lid ptosis caused by diffusion of Botox to levator muscles.


  • ▪

    Some return for a touch-up in 10 days.



Complications




  • ▪

    Lid ptosis


  • ▪

    Brow ptosis



Periocular Rejuvenation (see Table 2.3 , Fig. 2.3 , and )




Table 2.3

Management of periocular rejuvenation

























Patient characteristics Management
Dark circles

  • •

    Mesotherapy


  • •

    Carboxytherapy


  • •

    Platelet-rich plasma


  • •

    Volumization



    • •

      Patient in upright position or semirecumbent position


    • •

      Low–G prime HA, Teosyal Redensity is my choice of product


    • •

      I prefer using a 30-gauge needle or a 25-gauge cannula, which gives accuracy of placement and less likelihood of irregularity


    • •

      Patient is instructed to gently close eyes or open in forward gaze to assess the depth


    • •

      Inject deep below the orbicularis. Delivery of small aliquots of low G prime HA subdermally is also possible


    • •

      Always withdraw plunger three times with slow delivery and do not overfill


    • •

      Inform the patients about upper eyelid heaviness because filler has some lidocaine and causes infraorbital anesthesia


Prominent eye bags

  • •

    In minimal extraocular fat, volumize between the periocular and cheek fat just under the orbital rim to decrease the disparity


  • •

    Volumizing may improve the look but the amount of volume required in the cheek to match the periocular area would result in swollen eyes


  • •

    If periocular fat is normal but looks excessive due to inadequate cheek volume and a disharmonious lid cheek junction then volumization would give a good effect

Prominent eyes

  • •

    Volumize the lateral orbital rim below the rim to create a harmonious lid cheek junction


  • •

    For patients who don’t have bulging eyes, volumization would make their eyes look smaller


  • •

    Volumization in the lateral orbital rim area gives the effect of higher cheek bones, but eyes become small; hence for bulging eyes, filling this area gives good results


  • •

    Test to assess extraorbital fat


  • •

    With the eyes closed, applying digital pressure on the globe would result in bulging of the periocular fat

Sleep lines

  • •

    Fractional laser (CO 2 laser)


  • •

    Volumize with low–G prime HA

Upper lid hollowness and brow position

  • •

    Small amount of local anesthetic is injected at two points:



    • •

      1 cm below the tail of brow, avoiding any superficial veins


    • •

      at midbrow area just above the orbital rim



  • •

    I use 27-gauge cannula 1.5 inch needle


  • •

    Enter into the subgaleal slide plane


  • •

    You will hear a pop as you enter


  • •

    I use a retrograde threading technique with very small amounts of volume placed above the orbital rim into and above the eyebrow. No more than 0.5 cc per eye


  • •

    Second access point tends to use a smaller 30-gauge cannula


  • •

    Product of choice is low–G prime HA


  • •

    Massage well

Periocular rhytids

  • •

    HA


  • •

    CO 2 laser


  • •

    Botox for dynamic lines ( Table 2.4 )



    • •

      Assessment of extent and depth of rhytids (into cheek or under the eyes)


    • •

      Laxity and excess of periocular skin particularly in the infraorbital area


    • •

      Avoid injecting too low over the zygoma to prevent diffusion to zygomaticus major, as it would inactivate cheek elevation upon smiling (masklike smile)


    • •

      Patients with excess lower eyelid skin, injections in the lower lid area can lead to descent of skin, causing a malar crescent at the level of the lateral orbital rim


    • •

      Treating the periocular area can result in exaggeration of bunny lines, which may be treated on subsequent treatment


    • •

      While treating the bunny lines, injection placed deep and low on the nasal sidewall can diffuse to LLSAN may lead to an asymmetric smile



  • •

    Complication



    • •

      Blurred vision


    • •

      Double vision


    • •

      Diffusion to the zygomaticus major leading to a asymmetric smile


    • •

      Bunny line exaggeration


    • •

      In redundant skin injection to the pretarsal area can lead to descent of the skin resulting an arc at the lid cheek junction



HA, Hyaluronic acid; LLSAN, levator labii superioris alaeque nasi.


Table 2.4

Neuromodulators for occular area




















Muscle Plane Treatment
Orbicularis oculi Subdermal 1 cm lateral to the lateral orbital rim
4–6 injections each side
10 s.U in each injection
Pretarsal orbicularis (bulge under the eyes during smile) Subdermal Infraorbital injection 5–10 s.U under the eyes into the pretarsal fibers on each side in divided doses
Bunny lines Subcutaneous One injection (5–10 s.U) high on each side of the nasal sidewall (form a bleb)



FIGURE 2.3


Tear trough and lateral orbital rim enhancement with hyaluronic acid.




Upper Face


Forehead and Brow Rejuvenation ( Fig. 2.2 )


Assessment ( Table 2.2 )




  • ▪

    Check the brow position (this is important).


  • ▪

    Check for the presence or absence of compensatory brow elevation.


  • ▪

    Check for blepharochalasis or dermatochalasis.


  • ▪

    Check for collagen depletion.


  • ▪

    Assess the strength of muscle.


  • ▪

    Measure the width of the forehead.




FIGURE 2.2


(A,B) Botulinum toxin to corrugator, depressor supercilli, and procerus muscle complex. (C,D) Botulinum toxin to frontalis muscle.


Table 2.2

Management of forehead and brow rejuvenation
































Indication/patient’s perspective Muscle Plane Treatment
Glabellar frown lines Corrugator Subdermal 4–8 injections in females
6-10 injections in males
10 s.U in each injection
Glabellar frown lines Procerus Deep subdermal
Glabellar frown lines Depressor supercilli Deep subdermal
Dynamic lines on the forehead Frontalis Subdermal One injection centrally and two laterally on forehead. (between 10 and 30 s.U in divided doses)
To maintain the brow position
To prevent lateral brow ptosis 		Orbicularis oculi (superior lateral fibers) Subdermal As a prophylactic measure, 10 s.U on each side to be given under the tail of the brow to inactivate the depressor action


Technique




  • ▪

    The brow elevator (frontalis) and depressors (corrugator, procerus, depressor supercilli [DSC] for the medial brow and the superolateral fibers of the orbicularis oculi for the lateral brow) should be treated as a single unit to prevent brow ptosis.


  • ▪

    Preventing brow ptosis should be the priority.


  • ▪

    This can be achieved by full treatment to the corrugator, procerus, and DSC, a conservative dose to the frontalis, and a later touch-up to the frontalis if required in 10 days.


  • ▪

    Treatment of the superolateral fibers of the orbicularis oculi will also help to maintain an elevated brow position.


  • ▪

    Assess the activity of DSC. If DSC overactivity is missed, the patient may come back with descent of the medial brow (an angry look).


  • ▪

    If there is previous history of heaviness of brow after treatment, inject only in the central forehead.


  • ▪

    For the technique, see .


  • ▪

    Injections placed above the midpupillary line for the corrugator should be at least 1 cm above the bony orbital rim to help prevent lid ptosis caused by diffusion of Botox to levator muscles.


  • ▪

    Some return for a touch-up in 10 days.



Complications




  • ▪

    Lid ptosis


  • ▪

    Brow ptosis



Periocular Rejuvenation (see Table 2.3 , Fig. 2.3 , and )



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Sep 8, 2018 | Posted by in Aesthetic plastic surgery | Comments Off on Aesthetic Medicine: Surgical Pearls

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