plastic surgery
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Problems of the cosmetic surgery. Wrinkle face and neck: etiology, symptoms,
diagnosis, surgical treatment. Paralysis of facial muscles: etiology, clinical features,
surgical treatments. Atrophy face: etiology, symptoms, diagnosis, surgical
treatment. Microsurgery of soft tissue and bone, maxillofacial area.
Plastic Surgery Rhinoplasty Breast Augmentation Liposuction Chin and Cheek Implants Blepharoplasty Brow Lift Abdominoplasty Etc.
Cosmetic Surgery is a Branch of Plastic Surgery Plastic surgeons repair congenital
malformations (e.g., cleft lip and palate), disfiguring wounds, animal bites, burn injuries, and perform reconstructions after surgeries for chronic and/or malignant conditions
Cosmetic surgery is largely elective and designed to augment “normal” appearance
Cosmetic Surgery:Other Procedures Face lift Chemical peel Forehead lift Upper arm lift Buttock lift Thigh lift Liposuction
Motivations for Cosmetic Surgery External: avoidance of ethnic prejudice; fear of
age discrimination; coercion by spouse/parent/boss
Internal: desire to diminish unpleasant feelings like depression, shame, or social anxiety; to alter a specific feature they dislike; desire for a more youthful, healthy look that signals fertility (women); interest in developing a strong, powerful look that may facilitate career advancement
Rhinoplasty One of the most
common cosmetic surgery procedures
Reduce or increase nose size, change shape of tip or bridge, nostril size, angle between nose and lip, or correct breathing problems
Cost: $5,700 “Modern Rhinoplasty Techniques and Facial Plastic Surgery” <http://ent.pote.hu/course12.htm> 22 March 2006.
RHINOPLASTY Reduce size, remove bump(s), shorten, tilt Procedure done inside = no scars Bones may be altered 90% growth 13/14 girls, 15/16 boys Chin often done at same time $ 6,000.00 Canadian (Van Sun)
RHINOPLASTY (con’t)
BEFORE AFTER
The Asian nose is naturally wide. Just how wide the nose should be is a personal choice. Notice how the nose was narrowed to fit her face.
The bones, cartilage, and nostrils widths were reduced.
(Bermant)
Facial Implants Used to improve facial
contours Implants made from different
materials including silicone Implant inserted into small
incision; often performed in conjunction with other facial surgery, i.e. face lift
Incision taped to reduce swelling and discomfort
Cost: $3,000-$5,000
“Facial Implants” American Society of Plastic Surgeons <http://www.plasticsurgery.org/public_education/procedures/FacialImplants.cfm> 22 March 2006.
Blepharoplasty and The Brow Lift Blepharoplasty: the removal
of fat, excess skin and muscle from upper and lower eyelids
Does not remove “crow’s feet”, wrinkles or dark circles
Brow/Forehead Lift: corrects drooping brows and smoothes forehead
Cost: $5,000
Left: “Blepharoplasty” and Right: “Brow Lift” American Society of Plastic Surgeons <http://www.plasticsurgery.org/public_education/procedures/Browlift.cfm> 22 March 2006.
Plastic Surgery and Recovery Scars may be pink for up to six months
after surgery Risk of post-operative infections and blood
clots Fluid loss Nerve damage
Microdermabrasion Sandblaster-like device
used to spray high pressure stream of aluminum oxide or salt crystals across face and suction used to remove dead outer layer of skin.
Stimulates skin cell and collagen production.
“Microdermabrasion” Skinet. <http://www.lasercare-clinics.co.uk/Treatments/Display.asp?ID=17> 22 March 2006.
Microdermabrasion Affects only outer layer of skin Used to reduce fine lines, “crow’s feet”,
age spots, acne scars Effective for all skin types “Lunch hour procedure” Multiple treatments required for visible
results 5 to 12 treatments 2 to 3 weeks apart
Microdermabrasion Few complications
Treatment extends only to outermost layer of skin and so scarring is unlikely and recovery is rapid.
Use of eye protection during procedure prevents ocular complications such as redness, sensitivity to light, and crystals adhering to the cornea typical of early microdermabrasion treatments.
Chemical Peel Uses a solution of
phenol (deep peel), trichloroacetic acid (medium depth peel) and alphahydroxy acids (light peel) to remove damaged outer layers of skin Wrinkles, blemishes,
uneven pigmentation or sun damage
“Chemical Peels” BGPMA Department of Aesthetic Medicine <http://www.bgpma.com/html/aesthetics/peels_main.htm> 22 March 2006.
Chemical Peel Side Effects
Temporary throbbing, tingling, swelling, redness, sensitivity to sun, whiteheads
With Phenol peel: permanent lightening of skin and loss of ability to tan
Risks Infection, scarring, flare-up of skin allergies, fever
blisters, cold sores In rare cases, heart irregularities with phenol peel New wrinkles may form as skin ages
Collagen Injections Plump creased, furrowed or
sunken facial skin Add fullness to lips and backs of
hands Risks and Side effects:
Stinging, throbbing, burning sensation, redness, swelling, excess fullness, allergic reaction, rash, hives, flu-like symptoms, infection, connective tissue or autoimmune diseases
Botox Botulinum toxin is a product of the bacteria Clostridium
Botulinum Wrinkles caused when a muscle tightens. Botox is injected through the skin into the muscle and keeps the
muscle from tightening; when the muscle can't tighten, the wrinkle is less prominent
Effective for about 4 months, after which wrinkles may reappear
Botox Side effects
Droopy eyelids, flu-like symptoms, headache, upset stomach, risk of botulism (a potentially fatal disease which often results in difficulty moving the arms and legs and difficulty breathing – risk is low if Botox is used properly)
Cosmetic Dentistry Whiten teeth Correct gum line Seal gaps Fix chips or cracks Correct rotations Replace worn down or discolored teeth
Cosmetic Dentistry blends function with beauty by combining
tooth reconstruction and plastic surgery procedures on the mouth tissues (gums, jawbones, facial muscles, lips, and skin) to result in a better-looking smile
Before After
Cosmetic Dentistry Crowns: artificial coverings for teeth made
from ceramic/porcelain metal composite, gold, or a tin/aluminum mixture
Veneers: similar to crowns except they cover the forward part of the tooth only and are used exclusively for aesthetic purposes
Beauty and Morality Certain images or ideas may be considered
inherently immoral and hence do not create a valid aesthetic experience Sexual content? Politically motivated? (That which does not
encourage adherence to dictates of the state)
Religious/Philosophical Views What does it mean to worship your body or
to view your body as a temple? Taking care of your body, doing what is best
for it Treating your body with respect, compassion
and care Not the same as being obsessed with
appearance
Cultural Considerations What is acceptable fashion/use of
cosmetics in one culture may be inappropriate or offensive to another Implications for a multicultural society?
Botox Many cases of botched Botox
Four cases of botulism poisoning occurred at a Fort Lauderdale Clinic and then expanded to California. Doctors received their materials form a biological
laboratory that supplied the botulinum toxin. How can doctors know for sure that what they are
providing to their patient does not harm them?
Plastic Surgery Medical evidence shows no correlation
between cancer and breast implants Should we be concerned about long term
health risks that we are not aware of for other procedures?
INTRODUCTION Elective surgery To improve appearance the pursuit of beauty
Vanity Severe defects
Most common: face (nose, chin, ears), breasts, fat reduction (liposuction)
For youth: nose, chin, ears, breasts Not without risks Careful research
OTOPLASTY Protruding or overlarge ears Build up or replace Pre-school children More common in males $4,000.00 Canadian (Van Sun)
FACIAL PROCEDURES Botox
Botulinum toxin injected into muscles to paralyze them 4 - 12 months $375 US
Chemical Peel liquid mixture of alpha-hydroxy acids exfoliates and unclog pores $600 US per treatment
FACIAL PROCEDURES (con’t) Photofacial
intense pulsed light repairs sun damage reduces redness, dark spots no harm to skin
Captique Injections for lips soft tissue filler gives fuller plumper appearance lasts 6 mos.
LIPOSUCTION Vacuum out fat: hips, buttocks, knees, upper arms, chin,
cheeks, neck, etc. Most common areas:
Females outer thighs/abdomen Males flank/love handles
Serious procedure, painful recovery Serious complications #1 Canadian procedure – men & women (Van Sun) $3,000.00 - $9,000.00+ Canadian (Van Sun) Appropriate for youth only very select cases
THE RISKS As with any surgery
Infection Bleeding or blood clots Reaction to anesthesia Scarring
Disfigurement, paralysis, death Carefully choose surgeon
Anatomy of Facial nerve1) Intracranial part Supranuclear segment Nuclear segment Infranuclear segment
Cerebellopontine angle Internal acoustic canal Labyrinthine segment Tympanic segment Mastoid segment
2) Extracranial part
Classifications of facial nerve injury
Seddon classification of nerve injury
Neuropraxia Axonotmesis Neurotmesis
Extracranial 1. Traumatic
Facial lacerations Blunt forces Penetrating wounds Mandible fractures Iatrogenic injuries Newborn paralysis
Extracranial 2. Neoplasm
Parotid tumors Tumors of the external and middle ear Facial nerve neurinomas Metastatic lesions
3. Congenital absence of facial musculature
Evaluation of Facial paralysis Clinical feature
Central VS Peripheral facial paralysis Complete head and neck examination Cranial nerve evaluation
Electrodiagnostic testing
Topographic diagnosis
Central facial paralysis Upper motor neurone lesion Movements of the frontal and upper
orbicularis oculi tend to be spared Because of uncrossed contributions from
ipsilateral supranuclear areas Involvement of tongue Involvement of lacrimation and salivation
Peripheral paralysis Lower motor neurone lesion At rest :
less prominent wrinkles on forehead of affected side, eyebrow drop, flattened nasolabial fold, corner of mouth turned down
Unable to : wrinkle forehead, raise eyebrow, wrinkle
nasolabial fold, purse lips, show teeth, or completely close eye
Management Extracranial
etiology Trauma Iatrogenic Neoplasm
Intratemporal etiology Fracture Iatrogenic Neoplasm Idiopathic (Bell’s
palsy) Infection
Idiopathic facial palsy (Bell's Palsy)
Most common cause of facial paralysis (>50% of case)
Most age 25-30 yrs. Male : Female = 1 : 1 Left side : Right side = 1 : 1 Unilateral > bilateral Increase risk in
pregnancy 3.3 times DM 4.5 times
Recurrent rate 10% 60% have previous URI
Etiology Unknown Microcirculatory failure of vasa
nervorum Viral infection (HSV) Ischemic neuropathy Autoimmune reaction
Entrapment theory
Diagnosis By exclusion Criteria :
Paralysis or paresis of all muscle groups of one side of the face
Sudden onset Absence of signs of CNS disease Absence of signs of ear or CPA disease
Medical treatment
Corticosteroids : prednisolone 1 mg/kg/day 7-10 days
Corticosteroids combine with antiviral drug is better
Acyclovir 400 mg 5 times/day Famciclovir and valacyclovir 500 mg
bid
Surgical treatment Facial nerve decompression Indication
Completely paralysis ENOG less than 10% in 2 weeks
Appropriate time for surgery is 2-3 weeks after paralysis
Herpes Zoster Oticus (Ramsay Hunt Syndrome) 3rd most common of peripheral facial paralysis
(10%) Aged > 60 yrs. or low immune (low CMIR) Virus travels to the dorsal root extramedullary
cranial nerve ganglion Infected of HZV at auricular, external canal or
face Prodromal symptoms very similar to those
seen in Bell's palsy but usually more severe
Herpes Zoster Oticus (Ramsay Hunt Syndrome) Symptoms include severe otalgia, facial
paralysis, facial numbness, and a vesicular eruption on the concha, external auditory canal, and palate
Facial paralysis + hearing loss + vertigo “canal paralysis”
Pathophysiology & treatment liked in Bell ’s palsy
Temporal bone fractures Longitudinal fracture Transverse fracture Mixed fracture
Temporal bone fractures Signs bleeding from the external canal hemotympanum step-deformity of the osseous canal conductive hearing loss (longitudinal fracture) sensorineural hearing loss (transverse
fracture) CSF otorrhea facial nerve involvement (20% of longitudinal
fractures and 50% of transverse fractures)
Treatment Surgery is treatment of choice Indications for facial nerve exploration
incomplete paralysis iatrogenic paralysis
Contraindications : any case have no poor prognostic factors
Complications Complications of facial nerve decompre
ssion dural tears conductive or sensorineural hearing loss vestibular function loss persistent CSF leaks meningitis injury to the anterior inferior cerebellar art
ery (AICA) or its branches
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