Saturday, August 5, 2006

The Face: Skin Augmentation

Small depressions in the skin may be caused by wrinkles, scars from acne, surgery or viral pox. Many times, these small depressions can be corrected without surgery through skin augmentation. In skin augmentation, materials are injected into or under the skin to raise the skin's surface and make it look smooth.


Collagen injections

Collagen is an animal protein found in skin, bones and connective tissues. Purified bovine collagen has been used for skin defects since the early 1970s. Once injected, it stays in the facial skin usually between six and 12 months. After that time, it begins to sink deeper into the skin and is removed by the body, so the correction is reduced or lost. Because the benefit of injectable collagen is temporary, reinjections will be needed on a regular basis. Allergic sensitivity is usually assessed in individuals prior to injection. Allergic reactivity can lead to redness and swelling which can on rare occasion compromise the aesthetic result.

Fat transplantation

In fat transplantation, small amounts of the patient's own fat are injected into or under the skin to fill out defects. Using liposuction techniques, local anesthesia and small incisions, fat is removed from a site of excess on the patient's body. The fat is then placed in a syringe and injected at sites of surface depression or atrophy. Allergic reactions do not occur because the fat comes from the patient's own body. A drawback is that the full extent of correction seen on the day of surgery is never fully retained due to atrophy and absorption of the fat. A good correction sometime requires two or three sessions of fat injections.
Since correction is temporary, retreatment may be needed as soon as six months for wrinkles around the mouth or as late as 12 to 18 months for acne scarring on the cheek, temple or forehead. Patients can receive retreatment as often and as long as they wish. There is no known limit to the amount of collagen or fat that can be injected.

The Face: Blepharoplasty or Eyelid Rejuvenation

Surgery to reduce the amount of excess tissue around the eyes (blepharoplasty) may be performed in conjunction with a face-lift operation or, more frequently, as a separate procedure. When a patient wants both a face-lift and a blepharoplasty, the operations may be performed together or in stages, according to the patient's personal preferences or financial considerations.


In most cases the right and left eyelids are operated on at the same time. However, it is not uncommon to do only the upper eyelids or the lower eyelids, as the patient wishes.


To remove excess skin and other tissue from the upper eyelids, incisions are made in the eyelid fold and extended laterally toward the smile lines. Fatty tissue from the lower eyelids may be removed either through an incision in the skin (just below the eyelashes) or through an incision in the back surface of the eyelid (the transconjunctival approach). Some patients have droopy lids from a weak eyelid muscle (with or without excess eyelid skin and fat). If this problem, which is called blepharoptosis, is diagnosed, it often is amenable to surgical correction.


The operation takes from 30 minutes to two hours and usually is performed using local anesthesia. Intravenous sedation may be given if the patient wishes. General anesthesia often is used if blepharoplasty is performed at the same time as a face-lift.


Sutures typically are removed four to seven days after surgery. Although discoloration around the eyes usually resolves in one to three weeks, swelling (edema) may persist for several weeks. The skin scars heal as inconspicuous thin lines in nearly all patients within a few weeks to months.


Some patients may experience dryness of the eyes after surgery. This symptom may be caused by incomplete closure of the eyelids during the healing phase and usually resolves within a few weeks. In the interim, the eyes may be soothed by using artificial tear drops and ointments. Because people who have dry eyes before surgery have a greater chance of experiencing this problem postoperatively, we recommend an examination by an ophthalmologist before blepharoplasty is performed.


Rarely, there may be other problems after surgery such as persistent drooping or retraction of the eyelids or darkening of the lids because of permanent retention of blood pigments in the skin. These undesirable side effects frequently can be treated satisfactorily.


Complete loss of vision in an eye is an extremely rare complication of blepharoplasty. Temporary visual blurriness occasionally may occur after surgery because of alterations of the tears, but the problem typically is short-lived.


Most patients indicate that their eyes look and feel more rested and youthful after blepharoplasty. In general, it is a relatively safe and straightforward operation.

The Face: Rhytidectomy: Face-lift, Neck-lift

The face-lift procedure is performed to tighten the skin of the face and neck and give the patient a more youthful and rested appearance. Face- and neck-lifting is pursued both by relatively young patients to preserve a more youthful appearance and by older individuals to attain a younger and more rested look. Correspondingly, the results of a face-lift can range from subtle to dramatic according to the extent of aging changes present in the individual.

As we age, our skin begins to wrinkle and lose elasticity. One of the first signs is "cheek creases" that appear without smiling. Further aging deepens the cheek creases and often creates "jowls" along the lower jawline. In advanced facial aging, skin and fat dangle from under the chin forming a "turkey gobbler" with vertically oriented bands and transversely running wrinkles.

Because it is unusual to find aging changes isolated in the face without accompanying changes in the neck, the neck and face are usually treated simultaneously. The face- and neck-lift, which is medically termed a rhytidectomy, is performed through incisions that are made in existing skin creases and hair-bearing regions surrounding the ear. Minimal or no hair is trimmed from the scalp along the incisions. Then, the surgeon retracts and advances the skin and its underlying tissues to affect a smoother and more defined contour to the neck and jawline.

If necessary, the surgeon will trim or suction focal deposits of fat along the jawline or under the chin. This occasionally requires an incision in the shaded area under the chin. Your surgeon tightens the tissue by moving both the skin and often the deeper subcutaneous tissues and muscles. The excess skin is excised and discarded as the incisions are closed with sutures and staples. The tightening is performed symmetrically on each side of the face.

Face- and neck-lifting surgery takes four to five hours and can be performed either with local or general anesthesia. Patients usually are hospitalized for one night postoperatively for observation and can wash their hair on the first postoperative day. Dressings are rarely worn beyond two days, but swelling and bruising may be considerable for two to three weeks. The surgeon will remove the sutures or staples in stages over the first five to ten postoperative days. Patients are generally encouraged to remain in Rochester over the early part of this interval. After the sutures are removed, patients are free to begin using cosmetics and usually return to their "routine" within two and three weeks.

Because the face-lift procedure restructures large areas of tissue, you should be aware of several risks: blood collecting under the skin and compromised blood flow or healing of the skin. These complications can lead to irregularities in the skin or scarring. Patients can minimize these risks by avoiding tobacco products and aspirin-like medications that "thin" the blood.

Because the skin is separated from the nerves and muscles which animate the face, you may experience numbness or weakness in moving the eyebrow or corner of the mouth postoperatively. Fortunately, this usually is resolved within two to three weeks, but it occasionally can take several months to subside.

Scars can require nearly a year to complete a cycle of fading and softening. Those in the scalp can occasionally be more visible due to thinning of the adjacent hair. You may be able to notice scars extending in front of the ear and around the earlobe if you look closely. However, all of these limitations can usually be minimized by using properly selected cosmetics, earrings and hairstyles. Rarely, poorly healed scars require additional measures to improve their appearance.

There are some limitations to a face-lift. First, a face- and neck-lift procedure alone will not affect aging changes in the eye or forehead region, which may require eyelid surgery or a forehead lift. Second, the redraping of the skin addresses skin laxity to a greater degree than wrinkling. Fine wrinkles, like those surrounding the lips and eyes, are due to alterations inherent to aging skin and usually must be addressed by a skin resurfacing procedure such and dermabrasion, chemical peeling or laser treatment. Depending on the area of the face in question, resurfacing can be performed in the same setting as face-lifting. The additional benefits of these skin resurfacing procedures to the skin quality and tone greatly enhances the rejuvenating effect of the face and neck lift procedure.

Finally, while the procedure renders a more youthful appearance, the extent of the enhancement will gradually diminish over time. The longevity of a face-lift is impossible to predict for a given patient since it is influenced by environmental factors like continued exposure to tobacco products and sun as well as factors genetically unique to the individual. It can be said that the face-lifted individual will never look as aged as if the operation had never been done. With sufficient continued aging, repeat face-lifting or "mini-lifting" operations may occasionally become necessary.

The Face: Laser Resurfacing or Wrinkle Treatment With Laser

Among the newest techniques to address aging changes within the skin is the use of the C02 laser. The laser has advantages over traditional resurfacing methods like chemical peels and dermabrasion including a quicker recovery period and reduced patient discomfort. "Laserbrasion" can be programmed to use specified amounts of energy and for that reason brings much more control and safety to resurfacing procedures designed to deal with changes within the skin such as complexion abnormalities and fine lines and wrinkles.

As we age, we acquire wrinkles around the eyes and lips and across the cheeks. These develop due to deterioration in the collagen and elastin fibers which connect the cells of our skin. These changes are accelerated by cigarette smoking, stress, and cumulative lifetime sun exposure. The laser is used to create a controlled burn of the most superficial layers of the skin in order to stimulate the formation of new fibers, which are more organized and plentiful in number. The result after healing is skin of better tone and a refreshed and more youthful configuration. Patients report a softer, silkier, and smoother appearance to their skin following laser treatment.

The technique can be used for regional treatment, for example around the eyes or around the mouth, or can be used to treat the entire facial region. The optimal number of sessions of treatment required depend on the severity of the problem. Laser treatment is not a substitute for formal surgical face-lifting which is done to redrape and reposition tissues that have become loose and sagging over time. There are, however, many patients who are candidates for laser resurfacing at an earlier age who have not yet become candidates for formal surgical face-lifting. Occasionally, surgery and a laser treatment are used in combination during the same sitting to simultaneously treat both loose skin and fine wrinkles.

Laser resurfacing may be done under local anesthesia with intravenous sedation as an outpatient procedure or under general anesthesia when combined with other cosmetic procedures or if the whole face is to be treated. Compared to alternate resurfacing methods, patients generally enjoy a shorter recovery. There is redness and swelling but minimal discomfort throughout the treated region.

Postoperative treatment includes cleansing and coverage with a moisturizer, bandage or some other wound care regimen, particularly during the first week. Within 2 weeks, the swelling has largely resolved and the redness has begun to fade to a color that can be easily controlled with cosmetics. Complete resolution of the redness may take several months. Patients are encouraged to aggressively apply sunscreen products since ultraviolet light exposure is counterproductive to achieving and maintaining a revitalized configuration for the skin. Occasionally, patients will develop irregular hyperpigmentation (brown spots) during their healing interval but this is typically self-limited and, if it does not resolve, spontaneously may be treated with a bleaching medication.

In order to determine whether the patient is a candidate for laser resurfacing in combination with or as an alternative to traditional surgical rejuvenation methods, a consultation with the physician is necessary. It is important to identify any previous viral infections that involve the facial skin or lips, sun sensitivity, the use of a medication called Accutane? within the past year, and any medical history that would suggest problems with healing.

The Face: Chemical Peel

Chemical peel is one of the most effective techniques available for alleviating fine wrinkles and giving the face a long-lasting youthful appearance. People with fine wrinkles, sun damage or color abnormalities of the skin are candidates for a chemical peel. A consultation at the Mayo Cosmetic Surgery Center can be arranged to determine the best type of peel to suit your individualized needs. The results of this procedure are often dramatic and usually long-lasting.

A chemical peel applies a controlled chemical burn to the top layers of your skin. Chemical peels are categorized into superficial, medium and deep peels depending upon the severity of the patient's wrinkles and the degree of sun damage present. The depth of the burn depends upon the concentration of acid that is used. The peel itself should take no more than 30 to 60 minutes and may be painful for the first few hours following the procedure. This pain is usually very well controlled with oral pain medicines.

After receiving a chemical peel, patients usually are sent home with supervision or to an outpatient nursing facility for a day or two. The skin will begin to peel 24 to 48 hours following the application of the acid. New skin will replace the peeled skin within seven to ten days. However, chemically peeled skin takes longer to look normal. A pink hue to the skin can be expected for six months, often necessitating blending with makeup.

The chemical peel procedure is usually done as a full face peel without ancillary procedures being performed about the face. If you would like a face-lift or eyelid surgery, these procedures must be performed three to six months before or after the chemical peel. An exception involves fine wrinkles around the mouth and chin which can be corrected at the same time as a face-lift.

Before you have a chemical peel, it is important for your surgeon to know if you have a history of cold sores. Medication may be administered to prevent them. Your surgeon may recommend two to six weeks of pretreatment with Retin A before your chemical peel. Also, notify your doctor if you've taken Accutane. Patients who have taken Accutane for acne can have problems with scarring following some peels.

The Face: Dermabrasion

Dermabrasion resurfaces the texture of the skin by removing its top layers. The procedure is most often done on the face to remove skin damaged by acne scarring. It is also done to lessen the visibility of wrinkles, tattoos and various other skin lesions. All or a small portion of the face can be done. Blotchy brown spots that occur on the cheeks, temples or forehead also may be treated with the technique. Dermabrasion has much the same effect as a chemical peel.

Dermabrasion results in a leveling or smoothing of the surface skin which makes scars less noticeable. It does not remove scars. Sometimes it is necessary to have a second procedure to get the maximum results.

Dermabrasion is considered the best treatment for improving acne scars. The procedure can be done in the office with a local anesthetic. A machine with a rotating wheel is applied to the face. The patient can go home after the procedure.

A scab normally forms on the treated area for five to seven days. When this comes off, the skin is healed but very pink. Makeup may be used to hide the pink skin. In several months when the skin has faded, it may have a slightly different color, usually lighter. This is more likely to happen with dark complected people. If this occurs, it can be balanced with makeup.

Discoloration and swelling usually occur for two to three months while the wound is healing. Infection and excessive bleeding are rare and can be treated easily if they do occur. Scarring within the healed skin is rare.

Before you have dermabrasion, it is important for your surgeon to know if you have a history of cold sores because medication may be administered to prevent them. Your surgeon may recommend two to six weeks of pretreatment with Retin A before your dermabrasion. Also, please notify your doctor if you've taken Accutane. Patients who have taken Accutane for acne can have problems with scarring following dermabrasion.

Infection and scarring can occur after this procedure, but these problems are not common. Occasionally, small white nodules will develop, but they are temporary.

Choosing Aesthetic Surgery

Candidates for Cosmetic Surgery

Your initial consultation will help you decide if cosmetic surgery is for you. A good candidate for cosmetic surgery is one who understands the procedure, is realistic about the expectations and risks for the surgery, and is motivated primarily to please oneself. In addition, good candidates are willing to tolerate unavoidable inconveniences such as healing time and to temporarily refrain from smoking and some medications that impede healing.


Choosing Aesthetic Surgery

Choosing aesthetic surgery is a personal decision that you should make after consultation at the Mayo Clinic. Combined with exercise and proper diet, an aesthetic procedure may provide the opportunity for you to feel better about the way you look.
Before making an appointment to see a physician about aesthetic surgery, take some time to think about the specific attributes accounting for your dissatisfaction with your appearance. Then, discuss your concerns at your doctor's appointment. He or she will recommend the most appropriate therapy to address your personal needs.

Many characteristics can be successfully altered through aesthetic techniques; others cannot. Your physician will help you understand what you can realistically expect if you choose surgery. Examine the benefits and limitations that aesthetic procedures offer and carefully weigh the options before making a decision to proceed.