Lecture 2 Facial cosmetic surgery Maxillofacial Surgery Dental Students Fifth Year second semester Al Azhar University Gaza Palestine Dr. Lama El Banna https://twitter.com/lama_k_banna

1. FACIAL COSMETIC SURGERY -2

2. Surgical Procedures
• The upper facial third is an often overlooked component of
the aging face despite its tendency to show age-related
changes prior to any other facial regions .
• The eyelids, brow, and forehead
together form the upper facial
esthetic unit , and the degree and
architecture of age-related
deformities can differ greatly among
patients .
 Upper Facial Third :-

3. • Rhinoplasty and Rhytidectomy (facelift) have
been the most publicized operations for facial
rejuvenation .
Rhinoplasty Rhytidectomy

4. • Successful performance of brow and palpebral
procedures often proceed correction of middle and
lower facial deformities .
• The reason for this is that the
brow and upper lids begin to show
age-related changes as early as the
third and fourth decades as opposed
to the fifth and sixth decades, which is
characterized by cervicofacial deflation
and deep rhytid formation.

5. • Ptosis of the brow and palpebral skin is an
inevitable part of the aging process and is the
result of a combination of static and dynamic
forces leading to descent of the brow and
malposition of the periorbital structures.

6. 1. Brow and Forehead Lift
• In some cases in severe ptosis, a long forehead ,
or receding hair line, the traditional mini-open
brow lift approach can be used to provide
generous access for mobilization and lifting of
the brow and forehead .

7. Technique:
• A trichophytic incision (avoiding damage to
hair follicles) is placed behind the hairline and
a full thickness scalp dissection is used to
undermine, mobilize, and elevate the
forehead and brow
1. Brow and Forehead Lift

8. • This has largely replaced the coronal incision
in terms of “open” brow lifting and allows the
brow lift to be performed without increasing
the forehead length

9. • Note the slightly increased forehead height in
this patient after coronal brow lift .
• So, patients who present with an increased
forehead length preoperatively, the
trichophytic approach is preferred.

12. • Most Brow lift and forehead procedures are
performed endoscopically
• Endoscopic surgery is performed by using
multiple small incisions within the hear
bearing area .

13. Endotrichophytic Approach

14. • The forehead and brow tissues are undermined
and suspended in a superior position with the
use of extremely small bone screws .
• Recovery from an endoscopic brow lift takes
typically 5 to 7 days.

15. • In females , its critical to lift the lateral third of
brow more than the medial third
• This should recreate the esthetically pleasing
arch intrinsic to the ideal female brow .

17.  The medial aspect of the brow begins tangential to a line drawn
from the alar base of the nose vertically through the medial
canthus of the eye.
 The tail of the brow ends tangential to an oblique line drawn from
the alar base of the nose through the lateral canthus of the eye.
 The apex of the brow falls somewhere between the lateral limbus
(junction between the cornea and the sclera) and the lateral
canthus of the eye.
“Ideal” Female Brow

19. • In men, more even elevation over the entire
length of the brow is necessary to recreate the
more typical masculine brow form.

20. Complications of Endoscopic Brow Lift
• Complication are rare but it can include:-
 Mild discomfort
 Hematoma
Asymmetry
Excessive elevation of the head of the brow
Relapse
Paresthesia
Temporal nerve branch weakness

21. 2. Blepharoplasty
• Age-related changes occur in periorbital structures as
early as the third or fourth decade of life, making
blepharoplasty or eyelid tuck one of the earliest
facial cosmetic surgeries many patients undergo.

23. • This is because the eyelid skin is the thinnest on
the body and constantly in motion.
• With skin laxity and pseudoherniation of orbital
fat due to a weakened orbital septum, patients
complain of baggy or puffy eyes or a tired look .

24. Dermatochalasis:
is defined as skin laxity of the upper or lower lids as a
result of aging .
Blepharochalasis:
which is laxity and thinning of the eyelid skin due to
recurrent episodes of lid edema from an unknown
etiology
- Both can lead to Lateral Hooding
2. Blepharoplasty

25.  Lateral Hooding:
which is prolapse of the upper lid skin over the
lateral aspect of the eye and the crow’s foot
area .

27. B
Old techniques :
• depends heavily on liberal removal of herniated
fat in the upper and lower lids.
• Extensive fat removal often provides initially
pleasing results but may lead to a hollowed
appearance that can be difficult to correct .
Blepharoplasty Techniques

28. Modern techniques:
• focus more on judicious removal or repositioning
of fat to preserve volume.
Blepharoplasty Techniques

29. Upper Lid Blepharoplasty
• involves removing the redundant skin and
occasionally muscle .
• If fat is to be removed, it must be done carefully
and is usually confined to the nasal fat
compartment only .

30. • Reduction of the medial or nasal fat pad in the upper
lid.
• Strict hemostasis must be ensured during this
component of the surgery to prevent orbital
hematoma.
• Over-aggressive resection of the orbital fat will result in
a treated and hollowed out effect of the upper eyelid
and should be strictly avoided.

31. • a drooping (ptotic) lacrimal gland may give the
appearance of fat herniation in the lateral aspect of
the upper lid. This will require repositioning of the
gland with suture techniques.
• The upper lid incision is hidden in the lid crease and
once fully healed is nearly imperceptible

32. • Although lower blepharoplasty is commonly
combined and discussed with upper lid
blepharoplasty, it is useful to consider it as
part of the middle facial third.
• With aging, both hard and soft tissues lose
prominence in the cheek and malar areas .
Middle Facial Third :-
1. Lower Blepharoplasty

33. • The lower lid itself may be treated in several
ways.
• Two of the most common techniques used are
the transconjunctival approach and the
subciliary approach.
1. Lower Blepharoplasty

34. 1. Transconjunctival
approach:
• The incision is made inside
the lower eyelid, and
prominent fat is sculpted
or repositioned.
• Skin laxity can then be
treated with either
chemical or laser
resurfacing versus actual
skin excision .
1. Lower Blepharoplasty

36. 2. Subciliary approach:
• involve an incision just
below the lash line of
the lower eyelid to gain
access to the prominent
fat compartments.
• the skin is then
redraped, and any excess
is carefully trimmed
away
1. Lower Blepharoplasty

38. • Postoperative recovery after a typical blepharoplasty takes
approximately 7 to 10 days, with minimal postoperative
discomfort.
• Significant complications are very rare but may include:
1. dry eye syndrome or xerophthalmia .
2. asymmetry
3. orbital hematoma, which, on extremely rare occasions,
can lead to blindness if not identified and treated
promptly.

40. • Midfacial or malar and submalar implants have
gained popularity in recent
years primarily because of
the difficulty and
unpredictability in restoring
midfacial volume through
Suturing or conventional
lifting techniques .
Middle Facial Third :-
2. Midfacial Implants

41. • As people age, the fat pads of the cheek region atrophy
and descend.
• This, combined with gradual loss of skeletal volume
and support, leads to flattening of the cheek.
• Some patients have congenital midface volume
deficiency, which can lead to a more aged appearance
as well .

42. • Types of Midfacial Implants;
1. High density porous polyethylene materials
2. Solid silicone implants
2. Midfacial Implants

43. • Advantages of midface implants:
1. Cheek implants are typically anatomic
(i.e., they adapt closely to skeletal norms) or
may be custom designed with the aid of three-
dimensional computed tomography (CT).
2. Midfacial Implants

44. 2. Solid silicone midface implants are popular because
of their safety and tolerance by human tissues.
3. Solid silicone implants are solid but flexible and
forgiving .
4. It’s easy retrievability
5. As with any implantable device, the body
encapsulates the implant. This collagen
encapsulation promotes stability of the implant.
Cheek implants may be placed into position either
through a lower lid incision or more commonly
through an intraoral incision in the maxillary
vestibule.
2. Midfacial Implants

45. 6. These implants are usually undetectable by the patient
once fully healed and immobilized by encapsulation
7. Many surgeons elect to fix the implants in position with
small titanium screws to maintain the proper position
until complete encapsulation occurs at 6 to 8 weeks.
8. Because the silicone implant is
smooth and flexible and not porous
like other facial implants which
promote soft tissue ingrowth, it can
be removed with relative ease
2. Midfacial Implants

46. • With removal of hard porous implants (porous
polyethylene), an increased risk of
fragmentation and injury to adjacent tissues
exists
2. Midfacial Implants

47. Rhinoplasty
• Rhinoplasty is one of the more commonly performed
cosmetic surgery procedures.
• Corrective nasal surgery is performed for a variety of
functional and cosmetic purposes and is performed
on patients as early as the teenage years.

48. Nasal anatomy

49. • When performed properly, rhinoplasty can
dramatically improve the appearance of the
patient.
• An elegant nose is one that is symmetrical
and proportional to the face.

50. • This allows the observer’s eye to focus on other facial
features such as the eyes or the smile, which are the
predominant conveyors of emotion among all the
features of the human face.

51. - In short, the ideal nose is hardly noticed.
- Patients who have undergone successful rhinoplasty
often remark that friends and family comment more
about the eyes or the smile than about the nose, even
if the results are fairly dramatic when compared with
the preoperative appearance of the nose.

53. • Rhinoplasty is traditionally performed either
through the 1-open approach or the 2- closed
approach.
• In the closed approach, all incisions are
intranasal, and much of the manipulation of
the underlying nasal skeleton is performed
blindly or with limited vision.

55. • The open approach incorporates similar
intranasal incisions with a columellar incision,
which allows full uncovering of the nasal
skeleton.
• This allows better visualization and more precise
alteration of the nasal cartilages

56. • Both techniques are useful, and their applications
are largely dependent on the surgeon.
• As a general rule, revision or more difficult
rhinoplasties requiring grafting or significant
cartilage-altering maneuvers are usually performed
with an open approach.
•

57. • Rhinoplasty allows the surgeon to reduce a
prominent nasal hump by reducing the bony
components, the cartilaginous components,
or both.

58. Septoplasty
• which is alteration of the nasal septum, is
commonly performed simultaneously to harvest
cartilage for grafting purposes, straighten a
crooked or deviated nose, or improve airflow
through the nose.

59. • Preservation or replacement of nasal support
is vital in rhinoplasty to avoid postoperative
breathing problems or nasal valve collapse .
• Nasal dressing usually includes taping of the
nose and placement of a rigid external splint
for 1 week.

60. • Intranasal packing is rarely required, which makes
recovery much more tolerable.

61. • Recovery typically requires 1 to 2 weeks of
recovery because of ensuing edema and
bruising.
• Subtle changes to the nasal tip, if modified,
can occur as late as 1 year; however, most
results are fully appreciated at 2 to 3 months .

62. A, Patient with prominent dorsal hump and inadequate tip
elevation. B, After rhinoplasty with reduction of a prominent hump
and tip elevation. She also underwent simultaneous mandibular
advancement. It is quite common to combine corrective jaw surgery
with rhinoplasty.

63. OTOPLASTY
• Prominent or “cupped” ears can be a source of insecurity
and awkwardness for many patients.
• This is especially a concern in school-aged children who
are ridiculed for having “big ears.”

64. •OTOPLASTY
• It is also common for a young female to be unable
or unwilling to wear her hair in a ponytail because
of prominent ears.
• Because of these psychosocial concerns, many
surgeons recommend having otoplasty at a fairly
young age to avoid some of the problems
discussed.

65. The etiology of prominent ears is usually a
combination of an underdeveloped antihelical fold
and overgrowth of the conchal bowl.

66. The external ear completes nearly all of its growth
by 7 to 8 years of age, which allows surgery to be
performed safely and predictably at that age.

67. - Surgical correction typically involves exposing the
ear cartilage through a postauricular incision.
- The excess cartilage is either totally excised or
thinned, and the ear is often reshaped by scoring of
the cartilage and suturing techniques to allow further
molding.

69.  After surgery, it is common to place a bolster dressing
and a mastoid wrap.
 This dressing helps protect the surgical site and reduce
swelling.