Facial Cosmetic Surgery

Introduction and Historical Perspective

From a historical perspective, cosmetic surgery in the United States has been primarily performed by plastic surgeons, including both facial and body cosmetic surgery. As time went on, with the introduction of competing specialties, such as otolaryngology, a shift in this practice occurred. Otolaryngologists, with their expertise in nasal surgery, began to expand the field and slowly entered the arena of facial cosmetic surgery. Over the past 25 years, other specialties, such as dermatology, oral and maxillofacial surgery (OMS), ophthalmology, and others have begun to routinely perform cosmetic procedures. As the practice of cosmetic surgery has expanded, so have the number of specialists who are trained and qualified to perform such procedures. Today, all OMS residents in training are expected to be knowledgeable and able to perform, to various degrees, facial cosmetic procedures. Postresidency training fellowships in cosmetic surgery, both facial and body surgery, are now available to oral and maxillofacial surgeons with an interest in cosmetic surgery. In addition, there are now recognized governing bodies, such as the American Board of Cosmetic Surgery, that can bestow board certification to any individual, regardless of specialty background, who has satisfied the necessary requirements.

There is a tremendous amount of money spent on cosmetic surgery in the United States annually. According to the latest data, in 2016, $10.5 billion was spent on surgical and nonsurgical procedures in our country. Prior to the recession of 2008, this number was close to $14 billion and each year since then has shown a steady increase in the number of consumers (patients) and the number of procedures. Another major shift, compared with 25 years ago, is the age distribution of patients seeking cosmetic procedures. Traditionally, patients opted to wait until they were in the fifth decade of life or older before seeking these types of procedures; recent data clearly show how this trend has shifted ( Fig. 27.1 ). Almost two-thirds of all patients seeking cosmetic surgery in the United States are between the ages of 19 and 50 years. Today, patients are more knowledgeable and motivated to pursue cosmetic procedures at an earlier age, almost in a preventative manner, to slow the effects of the aging process. This trend is also seen in other parts of the world.

Physiology of Aging

Before embarking on any discussion regarding surgical and nonsurgical management of a given condition, it is imperative to have a clear understanding of the disease process. This is no different when discussing facial cosmetic surgery; clinicians must have a firm appreciation of the aging process, both at the surface and deep within the tissues. The aging process includes two different categories: extrinsic aging and intrinsic aging. Extrinsic aging, also known as photoaging, is the cumulative effects of environmental factors under the control of the patient. These include habits such as smoking, lifestyle (individuals who work outdoors all day vs. those who work indoors), geographic location (individuals who live close to a power plant or areas with high pollution), and long exposure to sunlight. Intrinsic aging is the cumulative effect of physiologic and chronologic aging; it is the genetic and biologic action of cellular senescence. Intrinsic aging includes loss of collagen and elastin fibers, production of cytokines at the cellular level such as collagenase and elastase, impairment of DNA signal transduction, loss of tissue hydration and volume, selective resorption of bone, and descent and laxity of muscles and surrounding fascia. This process, coupled with extrinsic aging, is responsible for the visual depiction that most individuals associate with an aged person ( Fig. 27.2 ). Other pertinent considerations include ethnicity, hormonal differences between males and females, and anatomic variations (thickness of skin of the eyelids compared with the skin of the palms of the hands). Although intrinsic aging is difficult to manipulate, the focus of skin care and topical medications used in cosmetic surgery is extrinsic aging (photoaging).

In addition to understanding the aging process, each patient must also be evaluated in a systematic manner. Although there are individual, ethnic, and age-related differences between each patient, there are well-defined parameters in evaluating the face. This process attempts to answer the age-old question of what comprises “beauty.” Clearly, cultural norms of beauty have changed from the 1930s. A quick web search for “symbols of beauty” from the early part of the 20th century reveals how vastly different the current definition of beauty is. What is fairly standard is that the more symmetric one's face is, the more attractive the person appears. There are components of the face that clearly augment or detract from an overall image of beauty such as the eyes, smile, jawline, skin tone, and texture. When these features appear youthful, combined with symmetry, we tend to recognize the individual as attractive. Other parameters of facial evaluation deal with zones and subunits of the face and attempt to correlate a degree of symmetry and/or parity between each area. The face can be divided into equal horizontal thirds and equal vertical fifths ( Fig. 27.3 ). The upper third of the face is between the ideal hairline and nasion; middle third between the nasion and stomion; and lower third between the stomion and soft tissue pogonion. Ideally, there is a balance among all three horizontal sections. The middle and lower thirds of the face are the main target of corrective jaw surgery (orthognathic surgery), which is discussed elsewhere in this textbook. The vertical fifths of the face begin with the outer aspects of normally positioned and oriented ears and divide the face into five equal parts. Again, major disparity between these vertical dimensions can detract from symmetry of the face. In addition to horizontal and vertical divisions, there are well-known and recognized facial angles and measurements that can aid in evaluation of the ideal face ( Fig. 27.4 ). It is important to recognize that cultural and ethnic variations and norms play a major role in this arena.

Assessment of skin and the aging process can also be enhanced by using long-recognized classification systems such as the Glogau classification (aimed to determine the amount of photoaging and wrinkling), as well as the Fitzpatrick classification (aimed to determine how reactive one's skin is to sunlight) ( Fig. 27.5 and Table 27.1 ).

All of the aforementioned assessment tools must be taken into consideration when evaluating a patient for any type of cosmetic procedure.

Surgical Versus Nonsurgical Options

Facial cosmetic procedures can generally fall into two major categories: surgical and nonsurgical. Some clinicians include the term “minimally invasive” into the category of nonsurgical, although this inclusion is not always accurate (i.e., a minimally invasive endoscopic forehead lift is a surgical procedure, albeit with smaller incisions). Surgical options include any procedure in which an actual incision is made on or around the facial region (including inside the oral cavity). Nonsurgical options include any procedure in which incisions are not made and, rather, other modalities such as an injection of a medication or a source of energy (lights, lasers, etc.) is used to modify the appearance of facial structures.

Surgical Procedures

Lower Face and Neck

Surgical options in rejuvenation of the lower face include submental liposuction, neck lift (cervicoplasty), and chin augmentation.

Before determining the proper surgical option for a patient, a thorough evaluation of the facial region must be performed according to the previous section. Specific deformities such as loss of jaw definition, submental fullness, laxity of skin, lack of proper chin projection, evaluation of occlusion, and the status of the platysma muscle must be taken into consideration before finalizing the surgical options.

A younger patient with mild to moderate submental fullness may respond quite nicely to submental liposuction. This procedure removes the superficial adipose compartment above the platysma muscle ( Fig. 27.6 ). It does not include removal of any excess skin and completely relies on the contraction of the skin after removal of excess fat ( Fig. 27.7 ). Because the actual amount of fat between all individuals is identical (only the size of the fat cells differs between a thin and obese patient), removal of the fatty deposit should create a long-lasting result.

An older patient who shows evidence of skin laxity and submental fullness may benefit from more invasive procedures such as a formal neck lift. These patients almost always have laxity of the right and left platysma muscles, often manifested as platysmal redundancy or banding ( Fig. 27.8 ). A neck lift, also referred to as a cervicoplasty or submentoplasty, can be combined with a formal face lift and comprehensively addresses all of the aging components of the lower face and neck, including removal of submental fat, removal of redundant platysma, and possible excess skin removal. This procedure uses an incision in the submental area and incisions around the ears to address the cosmetic deformity ( Fig. 27.9 ).

Evaluation of the chin is also a critical component of lower face and neck rejuvenation. Obviously, occlusion plays an important role in the appearance of the chin. However, chin deficiencies, in an anterior/posterior vector as well as laterally, can certainly exist without an obvious malocclusion. Bone resorption and descent of soft tissue can certainly lead to the appearance of a “weak” chin. Augmentation of the chin can occur via a genioplasty in which the chin button is cut away from the remaining aspects of the mandible and simply repositioned into a more favorable location (described in Chapter 26 ). Chin augmentation can also be accomplished by placing alloplastic implants. Chin augmentation using an implant can be performed from inside the oral cavity or from a percutaneous approach from the submental region ( Figs. 27.10 and 27.11 ).