chapter 23 - cosmetic plastic surgery

8/11/2019 Chapter 23 - Cosmetic Plastic Surgery

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Chapter

Cosmetic Plastic SurgeryDouglas Sammer, MD, PhD, M. Haskell Newman, MD, andWilliam M. Kuzon, Jr, MD

Key Points

Males are opting for cosmetic surgery inincreasing numbers, with the 1.2 millionprocedures performed on male patients in2005 representing a 44% increase comparedwith data from 2000 (strength ofrecommendation: C).

The available literature demonstrates ahigher rate of personality disorders inpatients undergoing aesthetic surgery thanin the general population, including anincreased baseline incidence of anxietydisorders, neuroticism, depression, anddysmorphic disorders (strength ofrecommendation: B); males presenting foraesthetic surgery may have a higherincidence of these diagnoses than in femalepatients (strength of recommendation: C).

Because of the highly personal nature ofcosmetic surgery, there is no 1:1 relationshipbetween a physical finding and a surgical

procedure, and there is no ideal result forany given operation (strength ofrecommendation: C).

There is no evidence that autoimmune orother systemic diseases result from the useof silicone prostheses (strength ofrecommendation: C).

Introduction

The official definition ofcosmetic surgery,as statedby the American Society of Plastic Surgeons(ASPS) and the American Medical Association,1

is a surgical procedure performed to reshape

normalstructures of the body in order to improvethe patients appearance and self-esteem. Themost comprehensive source for demographicand statistical data on cosmetic surgery is theAmerican Society of Plastic Surgeons.2 These dataare compiled for ASPS members only, but theyclearly indicate that cosmetic surgery has becomea growth industry in the United States; the num-ber of cosmetic surgical procedures performed

annually has grown dramatically in the past 10years. In 2005, an estimated 10.2 million cosmeticprocedures were performed in the United Statesalone, which is an 11% increase over 2004. Thetarget market is no longer only the rich andfamous, but all socioeconomic groups. In addi-tion, males are opting for cosmetic surgery inincreasing numbers; 1.2 million procedures wereperformed on male patients in 2005, representinga 44% increase compared with 2000. Table 23-1summarizes statistical data on the prevalence of

cosmetic surgery in the United States.The news and entertainment media have sensa-tionalized cosmetic surgery, often providingmisleading or incorrect information. Our goals inthis chapter are to provide accurate and practicalinformation for primary care and other referringphysicians to assist patients considering cosmeticsurgery and to give a brief overview of the mostcommon aesthetic surgery procedures for men.Although this book focuses exclusively on malepatients, the major considerations for a prospectiveaesthetic surgery patient are the same for men and

women. Preeminent among these considerationsare the choice of a cosmetic surgeon and whatcomprises a good candidate for cosmetic surgery.

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in aesthetic surgery do not stem from complica-tions or from what the surgeon might consider asuboptimal result, but from a failure to meetpatient expectations.

The Aesthetic SurgeryConsultation

The preoperative consultation for cosmetic sur-gery is unlike most other doctor-patient interac-tions. Rather than trying to make a medicaldiagnosis and to effect treatment, the goals are todetermine what the patient desires, to judge hisor her suitability as a candidate for aestheticsurgery, and to provide education about risksand realistic outcomes. The diagnosis is oftencomplex and is a combination of a physical evalu-

ation of anatomy and an assessment of thepatients motivations, personality, and psychol-ogy. Although it was once believed that themajority of cosmetic surgery candidates mani-fested personality or psychiatric disorders, morerecent data indicate that the majority of patientsundergoing cosmetic surgery are free of suchissues.3 Nevertheless, the available literaturedemonstrates a higher rate of personality disor-ders in patients undergoing aesthetic surgery thanin the general population, including an increasedbaseline incidence of anxiety disorders, neurosis,depression, and body dysmorphic disorders;males presenting for aesthetic surgery may havea higher incidence of these diagnoses than thatseen in female cosmetic surgery patients.4,5 Bodydysmorphic disorder is a well-publicized, andfortunately rare condition in which attempts toimprove appearance through surgery become apathological obsession.6 Personality and psychiat-ric factors are primary reasons that a given patientmay not be considered as optimal candidates foraesthetic surgery.

Once a patient is deemed a suitable candidatefor a given plastic surgery procedure, the preop-erative consultation focuses on planning the pro-cedure and reducing complications. Preoperativephotographs are routine for all aesthetic proce-dures. Most aesthetic surgeons will decline toperform facelifts, abdominoplasties, and otherprocedures where tissue blood supply may becompromised if the patient is a current smoker.Use of medications, including herbal prepara-tions, many of which reduce platelet function orimpair clotting, must be discontinued.7 For someprocedures, pretreatments may be prescribedbefore an aesthetic procedure; an example wouldbe the use of isotretinoin (Retin-A) for patientsundergoing facial rejuvenation procedures.8

Many cosmetic treatments are staged, andtouch-up operations are very common aftergynecomastia procedures, liposuction, andbody-contouring operations. Patients must beprepared to accept the potential for multipleinterventions to obtain optimal results.

A necessary part of the aesthetic surgeryconsultation involves a discussion of the costs ofsurgery, including whether the management ofcomplications or touch-up procedures wouldincur additional cost. Most aesthetic surgeonsrequire cash in advance before performing anyprocedure; many have financing availablethrough their offices or through a multitude ofcompanies that specialize in loans for cosmeticsurgery. National data on the average cost ofthe most commonly performed aesthetic proce-

dures in men is summarized inTable 23-2.Clearly, the aesthetic surgery consultation

involves a significant level of complexity andsubtlety that has a major effect on subsequentoutcome. Managing this interaction is, even morethan technically virtuosity, what distinguishes asuccessful aesthetic surgeon.

Common Cosmetic SurgeryProcedures

In the paragraphs that follow, a brief descriptionof the most commonly performed aesthetic surgi-cal procedures in men is presented. The goalof these summaries is to give the nonplasticsurgeon a basic understanding of these proce-dures to provide accurate and appropriate adviceto their patients (and friends and relatives!). Foreach procedure the general indications, basicevaluation, general nature of the procedure, andpossible complications are discussed. For someprocedures, examples of results that could beconsidered average are presented. Because of

the highly personal nature of cosmetic surgery,there is no 1:1 relationship between a physicalfinding and a surgical procedure, and there isno ideal result for any given operation.

Body Contouring

Gynecomastia Correction

Gynecomastia, or male breast enlargement, is acommon condition resulting from a relativehyperestrinism, which can be due to multiple fac-tors including liver disease, aging (with increasedadrenal estrogen production), drugs (especiallyalcohol, antiviral agents, marijuana, steroids,and anabolic agents), genetic conditions such as

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Klinefelter syndrome, and testicular neoplasms.Preoperative evaluation for the patient withgynecomastia should include a thorough historyand physical examination and, if indicated, areferral to an endocrinologist or other specialistfor proper medical evaluation. Obviously, anyunderlying treatable causes of gynecomastiashould be managed appropriately, and only afterall other possible causes have been excludedshould the most common diagnosis of idiopathicgynecomastia be assigned.

The choice of a surgical procedure for gyneco-mastia will depend on the patients age, thedegree of excess breast parenchyma, the amount

of excess skin, and the size of the nipple/areolarcomplex. In young patients with good skin tone,a small amount of breast parenchyma, and nor-mal areolae, liposuction can often achieve a veryreasonable correction with an acceptable malechest profile (Figure 23-1). For patients with mod-erate degrees of excess skin and parenchyma andmoderate areolar enlargement, a combination ofliposuction with a circumareolar skin excisionand direct parenchymal excision works well. Thisleaves a scar at the periphery of the areola only,and the surgeon has reasonable control over theresection of the parenchyma. For patients withsignificant breast enlargement, especially olderpatients with poor skin tone, a circumareolarapproach is inadequate to allow the degree of

parenchymal resection, and areolar reduction isnecessary to provide an adequate correction. Forthese patients, a formal skin excision must becombined with areolar reduction and reposition-ing. There are many variations of this procedure(Figure 23-2).

In addition to complications that are genericfor any surgical procedure (e.g., infection, skinloss, scars), the feared complication of a gyneco-mastia excision is over-resection, creating a sau-cer chest.9 This deformity is difficult, if notimpossible, to correct. For this reason, the pru-dent surgeon will be conservative at the time ofa primary gynecomastia excision, and touch-up

procedures are exceedingly common. Gyneco-mastia excision, regardless of the technique used,is generally performed on an outpatient basis,usually with the patient under general anesthe-sia. Recovery time for patients undergoing lipo-suction only is 36 weeks; patients requiringdirect excision of skin and parenchyma will notbe able to fully return to normal activities for23 months.

Liposuction

Liposuction is the most commonly performedinvasive aesthetic surgical procedure and is usedas an adjunctive technique in virtually all body-contouring procedures. Developed in the 1970s,this technique involves making small, 1-cm-long

Table 23-2. Cosmetic Surgery Procedural Statistics

Procedure

Number of

Procedures 2004

Number of

Procedures 2005

% Change 2004 vs.

2005

National Average

Surgeons Fee*

Breast reduction in men(for gynecomastia)

13,963 16,275 17% $2981

Calf augmentation N/A 337 $2221

Ear surgery/otoplasty 25,915 27,993 8% $2437

Eyelid surgery/blepharoplasty

233,334 230,697 1% $2534

Facelift/rhytidectomy 114,279 108,955 5% $4484

Forehead lift 54,993 55,518 1% $2420

Hair transportation 48,925 47,462 3% $4755

Liposuction 324,891 323,605 0% $2323

Nose reshaping/rhinoplasty

305,475 298,413 2% $3511

Pectoral implants N/A 206 $3642

Thigh lift 8123 9533 17% $4181

Upper arm lift 9955 11,873 19% $3261

*Surgeons fee does not include anesthesia and facility charges.

Adapted from: American Society of Plastic Surgeons: Procedural statistics. 2006.

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incisions and introducing hollow metal cannulaewith side holes near the tip. By applying negativepressure to the lumen, small fragments of fat tis-sue are drawn into the cannula when it is movedin a reciprocating fashion, and the fragments offat in the lumen are transected and removed intoa suction reservoir. This simple concept has wideapplication in aesthetic surgery and has spawneda large body of literature on variations of thisbasic technique.10 The most commonly used tech-nique today is that of tumescent liposuction, inwhich a dilute solution of Xylocaine and epi-nephrine is infused into the target area beforeliposuction is performed. This has the advantageof more efficient removal of subcutaneous fatand excellent anesthesia and hemostasis.

The ideal candidate for liposuction is a patientwho is at or near their ideal body weight andwho has localized deposits of subcutaneous fatthat are recalcitrant to reduction via diet or exer-cise. In males, liposuction is most commonlyused in the abdomen, suprapubic area, andsubmental area. There are also patients whomay be candidates for large-volume liposuc-tion, in which the aspirated volume is greaterthan 1000 mL during a single procedure. Thistechnique can be applied to more generalizedsubcutaneous fat deposition, with reports of800010,000mL being aspirated during a singleprocedure.11

The preoperative evaluation of a patient forliposuction includes the pinch test, in which

A B

C D

Figure 23-1. Mild gynecomastia treated with liposuction alone. Anterior (A) and lateral (B) views before surgery; ante-rior (C) and lateral (D) views after breast reduction. (From Mladick RA: Gynecomastia, Clin Plast Surg 18:797822, 1991.)

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the amount of subcutaneous fat is estimated. Thisis especially important in the abdomen since

some male patients deposit the majority of theirabdominal fat in the omentum and intestinalmesentery, and not in the subcutaneous space.These patients are generally not good candidates

for liposuction and should focus on weightreduction over surgical removal of fat.

The most common complication of liposuctionis local contour irregularities, and it is commonfor patients to require touch-up procedures toimprove aesthetic appearance. For patients

A B

C

D

Figure 23-2. Moderate gynecomastia treated with parenchyma resection. Anterior (A) and lateral (B) views beforesurgery; anterior (C) and lateral (D) views after breast reduction. (From Mladick RA: Gynecomastia, Clin Plast Surg18:797822, 1991.)

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undergoing lower extremity liposuction, andespecially in the case of large-volume liposuction,deep venous thrombosis and pulmonary embolican occur.1012 Liposuction, when performed inisolation, is an outpatient surgical procedure.Patients typically have minimal pain, yet bruising

is common and often persists for 12 weeks.A compression garment is often prescribed tominimize swelling and to help with tissueremodeling. Depending on the number of areastreated and the aspirated volume, most patientscan return to work within 3 weeks.

Dermolipectomy

Dermolipectomy, or the resection of skin andunderlying subcutaneous tissue, is a broad cate-gory of body-contouring procedures that includes

tummy tucks, thigh reductions, and brachio-plasty. These procedures have in common anelliptical excision of skin and underlying subcuta-neous fat, with closure along a straight or curvedline once the excess tissue is removed. Individualprocedures differ mainly in the design of theskin excision patterns. There have been bothspeculation and case-report data asserting thatliposuction or dermolipectomy procedures mayameliorate the severity of diabetes and possiblyimprove risk profile for cardiac and peripheralvascular disease.13 Subsequent studies, however,have put this speculation in question,14 and atthe present time patients should be advised thatremoval of subcutaneous fat does not signifi-cantly alter their obesity-related risk factors. Inthese patients, weight loss to reduce visceral fatshould be a primary therapeutic objective.

Abdominal Procedures

Abdominal dermolipectomies or tummy tucks aredesigned to remove excess abdominal skin andfat, commonly referred to as a spare tire. This

procedure has a number of variations. A mini-abdominoplasty is appropriate for patients whohave only a small amount of excess abdominalskin and fat that is confined to the infra-umbilicalabdomen. In this procedure, a transverse ellipseof skin and fat is removed from the lower abdo-men, leaving a curvilinear scar in the lowerabdomen, where it is commonly covered byclothing. Liposuction is used to help removeexcess fat from the upper abdomen and flanks(love handles). Candidates for this proceduremust have good skin tone and should not requirea transverse reduction of skin to achieve a goodcontour.

A full abdominoplasty is a more complex andinvasive procedure and is indicated for patients

with substantial excess skin and subcutaneoustissue and who have laxity of the abdominalmyofascial structures. This procedure beginswith a transverse lower abdominal incision. Then,a flap of abdominal skin and subcutaneoustissue is elevated as far cranial as the costal

margin; the umbilicus is incised and left onits stalk. The abdominal skin is then re-draped,and the excess is excised. A vertically orientedexcision to address transverse skin excess canbe incorporated, leaving a midline abdominalscar. The abdominal musculofascial laxity can beaddressed by placating the midline with arunning suture from the xiphoid to the pubis.The umbilicus is brought through a new incisionin the re-draped flap (Figure 23-3).

The most extensive version of the abdominal

dermolipectomy is the circumferential abdomino-plasty or belt lipectomy. In this procedure, acircumferential excision of skin and subcutane-ous tissue is performed (Figure 23-4). For patientswho are morbidly obese, an abdominal pannicu-lectomy may be appropriate. This procedure isgenerally reserved for patients who experiencehealth-limiting ulcerations, intertrigo, folliculitis,and panniculitis caused by the pannus, as wellas limitations in physical mobility. The procedureconsists of a straightforward elliptical wedgeexcision of lower abdominal skin and fat withoutundermining. This procedure is limited byinfection, seroma, and wound dehiscence ratesranging from 30% to 70% in published series.15

Although this procedure is functional (or recon-structive) and is not considered cosmetic innature, it is mentioned as part of the continuumof dermolipectomy procedures for the abdomen.

The most common and problematic complica-tions after abdominal dermolipectomy includewound dehiscence and seroma formation. Themore extensive the skin resection, the more likely

these complications are to occur. Full and circum-ferential abdominoplasties are usually performedas inpatient procedures.

Thigh Contouring

Thighplasty refers to the resection of excess skinand fat from the medial thigh via horizontal orvertical ellipse excisions. Because the resection isperformed from the lower extremity and overly-ing the course of the saphenous vein, the risk ofdeep venous thrombosis is of greater concernthan for other dermolipectomy procedures, andpatients should receive appropriate prophylaxis(e.g., subcutaneous heparin). The major down-side of this procedure is the risk of significantmedial thigh scars.

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A B

C D

Figure 23-3. Abdominal lipodystrophy treated with full abdominoplasty. Anterior (A) and posterior (B) views prior to

surgery; anterior (C) and posterior (D) views after abdominoplasty. (From Pitman G: Abdominal contouring. In Marchac D,Granick MS, Solomon MP, Robbins LB, editors:Male Aesthetic Surgery, Boston, 1996, Butterworth-Heinemann, pp 301311.)

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A B

C DFigure 23-4. Circumferential abdominoplasty or belt dermolipectomy. Anterior view before (A) and after (B) sur-gery; posterior view before (C) and after (D) surgery; lateral view before (E) and after (F) surgery. (From Pitman G:Abdominal contouring. In Marchac D, Granick MS, Solomon MP, Robbins LB, editors: Male Aesthetic Surgery,Boston 1996, But-terworth-Heinemann, pp 301311.)

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Arm Contouring

The corollary of thighplasty in the upper extrem-ity is the brachioplasty. Excision of longitudinaland/or transverse ellipses of skin from the innerarm can eliminate redundancy at the expense ofsignificant medial arm scars that are not easilycovered by clothing. Because of this, this opera-tion has been reserved chiefly for patients who

have lost massive amounts of weight.

PostWeight Loss Procedures

The obesity epidemic in the United States hasbeen well documented and has spawned an enor-mous increment in bariatric surgical proce-dures.16 These procedures have resulted in alarge population of patients who have lost signif-icant amounts of weight, often in excess of 100pounds. These patients are typically left withsignificant excess skin in the arms, breasts, abdo-men, buttocks, and thighs after such a significantweight loss (Figure 23-5). With minor modifica-tions, the procedures described for abdominal,thigh, and arm dermolipectomy are applied to

this population, and the procedure to addressexcess skin in the breast region is similar to pro-cedures used in the treatment of gynecomastia.

Special considerations in this patient popula-tion include how to appropriately stage theseoperations if multiple body areas must beaddressed and the high incidence of concomitantincisional hernias in patients who have under-

gone an open gastric bypass procedure. Often,these patients have unrealistic expectations ofwhat can be accomplished with body-contouringprocedures, and their cases must be managedappropriately to avoid significant postoperativepatient dissatisfaction. In this population, skin-reduction procedures are in a grey zonebetween reconstructive and aesthetic surgery.For an abdominal dermolipectomy in a patientwhose weight loss exceeds 100 pounds, a pannusoverhanging the pubis and a health conditionrequiring treatment (usually recurrent intertrigo)are typical prerequisites for insurance companiesto consider these procedures as medically neces-sary, and thus for coverage under a patients ben-efits. Dermolipectomies in other areas of the body

E F

Figure 23-4contd.

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are rarely covered by health insurance plans andare generally considered to be cosmetic, evenwhen a significant deformity exists.

Implants

The term implant refers to any artificial materialthat is surgically implanted into the body. Inplastic surgery, implants are used to improvethe size and shape of various areas of the bodyfor either cosmetic or reconstructive purposes.Although implants have been used for manyyears for breast reconstruction and augmentationin women, the use of implants for cosmetic bodycontouring in men has only recently becomewidely accepted. Today, plastic surgeons

routinely use implants in men to improve theappearance of the chest and calves. Implants arealso used in other locations such as the buttocksor biceps, although augmentation of these areasis much less common. Although contour changescan be effected using implants, prospective

patients should be advised that any medicalimplant may need to be revised or removed inthe future. That is, implants are designed forlong-term use, but cannot be considered mainte-nance free.

Complications can occur with any implantoperation. Some of the more common complica-tions include contour irregularity or asymmetry,shifting of the implant out of the desired position,bleeding into the wound (hematoma), or infec-tion of the implant. If severe enough, any of these

complications can require a return to theoperating room for treatment. Periprostheticinfections generally require removal of the deviceto control the process. Under most circumstances,the implant could be reinserted once the infectionhas been cleared for 612 months. It should benoted that, unlike the breast implants used inwomen, which consist of a silicone shell filledwith a liquid or gel, the implants used for bodycontouring in men consist of solid yet soft sili-cone. Because of this, many of the complicationsassociated with breast implants, such as a rup-ture or a leakage of fluid, do not occur with theimplants used in men.

Pectoral

Pectoral implantsare used to increase the size andimprove the shape of the male chest for eithercosmetic reasons (Figure 23-6) or for reconstruc-tion of congenital or acquired deformities suchas Polands syndrome (a deficiency of subcutane-ous fat and muscles on one side of the body,often affecting the pectoralis major and minor).17

The implants commonly used are made of solidyet soft silicone and must be custom manufac-tured for each patient. In the weeks before sur-gery, a mold of the patients chest is taken inclinic, and a temporary wax version of the implantis created. The patient may need to return to clinicseveral times for sculpting and fine-tuning of thetemporary implant before the final customizedimplant is ordered and manufactured.

Implant placement is an outpatient operationrequiring general anesthesia and usually takes13 hours. An incision is made in the axilla, allow-ing the surgeon to create a pocket under thepectoralis major muscle. Creation of the pocketcan be performed either endoscopically or via anopen operation. Using an endoscope makes it

Figure 23-5. Resultant deformity after massive weightloss. (From Mladick RA: Gynecomastia, Clin Plast Surg 18:797822, 1991.)

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A D

B E

C F

Figure 23-6. Cosmetic chest augmentation with pectoral implants. Anterior (A) and oblique (B and C) views before sur-gery; anterior (D) and oblique (E and F) views after augmentation. (From Novack BH: Alloplastic implants for men, Clin PlastSurg 18:829855, 1991.)

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possible to perform the surgery through a smallerincision but is technically more difficult. Once thepocket is developed, the implant is passedthrough the incision into the pocket and lies deepto the pectoralis major muscle. A small drain maybe placed to reduce fluid buildup around the

implant (seroma). The patient is taught to carefor the drain and to measure the output at home.Once the drain output has decreased to anamount that can be absorbed by the body (usuallyless than 30 mL/day), the drain is removed inclinic. The patient can usually return to workwithin 23 weeks with limited upper extremityuse; full recovery takes approximately 6 weeks.

Common complications of pectoral implantsinclude hematoma and seroma formation, infec-tion of the implant, asymmetry, displacement of

the implant, and changes in nipple or skin sensa-tion. Some complications including hematoma,infection, or displacement may require a returnto the operating room for readjustment andappropriate treatment as described above.

Calf

Calf implants are used to increase the size andimprove the shape of the posterior leg and aregenerally used for cosmetic enhancement (Fig-ure 23-7). Like pectoral implants, calf implantsare made of solid yet soft silicone. One or twoimplants may be used for each calf, dependingon the size and shape of the patients legs.Although it is possible to use stock implants,the surgeon may prefer to create customimplants. This process takes place in the weeksbefore surgery and is similar to that of creatinga custom pectoral implant. A mold of the poste-rior leg is taken in the clinic, and a temporarywax version of the implant(s) is created. Sculpt-ing and fine-tuning of the temporary modelbefore the final implants are manufactured may

be necessary.The operation takes 23 hours and is per-

formed on an outpatient basis. A general anes-thetic is usually required, although a local orspinal anesthetic combined with intravenoussedation may be used. A transverse incision ismade in a natural crease behind the knee.A pocket is created deep to the skin and fat ofthe posterior superior leg, superficial to the gas-trocnemius muscle. The implants are theninserted into the pocket and the skin is closed.A drain may be placed to help reduce seroma for-mation, and it is removed in the clinic once theoutput has decreased sufficiently. The patientshould plan to stay off work for 36 weeks afterthis operation, depending on how much activity

is required. Physical activity is strictly limitedimmediately after surgery but is graduallyadvanced over the next 68 weeks, until thepatient can resume full activity.

Potential complications of calf implantsinclude hematoma, seroma, infection, displace-

ment, asymmetry, and visibility of the implant.Injury to major nerves or blood vessels can occurduring dissection in the popliteal fossa, althoughthis is quite rare.

Otoplasty

Cosmetic ear surgery or otoplasty is most com-monly performed to reposition prominent earsclose to the head or to reduce large ears. Theoperation, for the most part, is performed in chil-

dren older than 4 years of age when the ear isalmost fully developed; the earlier the surgery isperformed, the less ridicule the child will needto endure. Congenital ear deformities are genderequal, but because of the difficulties of hair cam-ouflage, otoplasty is more commonly performedon male patients. Ear surgery in an adult patientis also possible, and there are no additional risksassociated with the advancing age of the patient.Children and adults generally return to normalactivity within 1 week.

During an otoplasty, the ear cartilage isexposed through an incision on the back of theear. The cartilage framework is repositioned andsecured with permanent sutures, reduced withcartilage incision or expanded by cartilage graft-ing. The skin is re-draped over the modified car-tilage framework, then the incision is closed andcovered with an occlusive dressing. The opera-tive procedure usually takes 23 hours and is per-formed on an outpatient basis. In young patientsgeneral anesthesia is required, but in older chil-dren and adults local anesthesia with sedation

may be preferred.Postoperative complications are uncommon

but include infection of the cartilage, wound dis-ruption, excessive scarring, and hematoma for-mation that may require evacuation. Recurrenceof protrusion, contour distortion, or mismatchmay require repeat surgery.

Rhinoplasty

Rhinoplasty,or surgery to reshape the nose, is themost common of all aesthetic procedures per-formed in males.2 Rhinoplasty can reduce orincrease the size of the nose, change the shapeof the tip or dorsum of the nose, change theshape of the nostrils, enhance or reduce nasal

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projection, change the angle between the noseand lip, relieve nasal obstruction, or correct adeviated septum or crooked nose.

The best candidates for rhinoplasty are physi-cally healthy, psychologically stable patients withrealistic expectations. Most surgeons prefer notto perform elective rhinoplasty in teenage males

until they are emotionally mature and haveobtained full nasal growth, generally between 16and 18 years of age. Rhinoplasty can be performedeither with the patient under general anesthesiaor with local anesthesia and intravenous seda-tion. Depending on the extent of the procedureand patient/surgeon preference, rhinoplasty is

A B

C D

Figure 23-7. Cosmetic calf augmentation with calf implants. Anterior views before (A) and after (B) surgery. Obliqueviews before (C and E) and after (D and F) surgery. (From Novack BH: Alloplastic implants for men, Clin Plast Surg18:829855, 1991.)

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generally performed as an outpatient procedureand takes between 1 and 3 hours, although com-plicated procedures may take longer.

During surgery, the skin of the nose is sepa-

rated from the supporting framework of cartilageand bone. The skeletal support is modified to thedesired shape by reduction, augmentation, orsuture repositioning. The skin is re-draped overthe modified framework and supported for 1 oroccasionally 2 weeks with a combination of exter-nal splinting and intranasal plastic splints ornasal packing to stabilize the septum and reducepostoperative bleeding.

When rhinoplasty is performed by a qualifiedsurgeon, complications are usually minor and

infrequent. When they do occur, they can includehemorrhage, infection, nasal obstruction, or aresidual deformity, which may necessitate correc-tive surgery. Healing is a gradual process andsubtle swelling may be present for months, espe-cially in the nasal tip. The final result of a rhino-plasty may not be apparent for a year or more.A second procedure to correct a residual defor-mity is indicated in 1015% of primary rhinoplastyprocedures; an additional cost may be incurred.

Hair RestorationScalp hair loss in men is an extremely commonproblem and may occur for multiple reasons.For certain types of hair loss, effective nonsu-

rgical treatments exist that include various medi-cal therapies. These options should be exploredwith a dermatologist before surgical interventionis considered. If medical management is not

recommended or is ineffective, then surgeryshould be considered. All surgical techniquesinvolve moving existing hair from one part ofthe patients scalp to another to restore a morenormal hair pattern. For small areas of baldness,transplantation of small grafts of hair-bearing tis-sue from one part of the scalp to the bald area canbe effective. When hair loss is extensive, largerotation flaps, excision of bald areas, or even tis-sue-expansion techniques may be required.A combination of techniques is often necessary

to achieve the best result. In all cases, the resultsthat can be achieved surgically are limited bythe amount of hair-bearing scalp that patient stillhas. A patient who has little hair left on the scalpmay not be a candidate for hair-restoration sur-gery. It is best to perform hair-restoration surgeryonce hair loss has stabilized because ongoing hairloss after surgery can adversely affect the resultsof the operation.

Hair transplantation involves harvestingmany small grafts of hair-bearing scalp andtransplanting them to the bald area to restore a

more youthful hair pattern. Hair transplants areclassified according to the size of the grafts.Punch grafts contain approximately 1015hairs/graft, mini-grafts contain approximately

E F

Figure 23-7contd.

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24 hairs/graft, and micro-grafts contain only12 hairs each. A combination of punch, mini-,and micro-grafts is usually necessary to obtainthe best cosmetic result. Smaller grafts are bestused near the visible hair-line, whereas largergrafts can be used to fill in less visible areas. Slit

grafts and strip grafts are long, narrow graftscontaining 510 and 4050 hairs/graft, respec-tively, and these can be used as well.

Hair transplantation is an outpatient surgerythat can be performed in the office using a localanesthetic with or without sedation. If an exten-sive area is to be treated, the surgeon may harvesta sufficiently large strip of hair-bearing scalp,usually from the back of the head. The donor siteis sutured closed, and grafts of varying sizes aretaken from the harvested strip of scalp. If less

extensive transplanting is planned, the surgeoncan harvest grafts individually from the hair-bearing scalp without taking a large strip of tis-sue. The grafts are then transplanted into smallincisions in the bald area. Depending on the sizeof the bald spot, anywhere from 50 to well over500 grafts can be transplanted in one session.Approximately 1 month after surgery, the trans-planted hairs will shed, followed by regrowthwithin 46 weeks. This normal process may bediscouraging to the patient if he is not preparedfor it to occur before the initial procedure. Oncehair growth has stabilized, it is almost alwaysnecessary to perform repeat grafting to achievethe best final result (Figure 23-8).

Other hair restoration procedures includescalp reduction surgery (excision of bald areas),flap surgery, and tissue expansion. These techni-ques are more invasive than hair transplantation

but may be necessary to achieve an optimalresult. These operations, although usually per-formed on an outpatient basis, sometimes requiregeneral anesthesia.

Scalp-reduction surgery is the simplest ofthese techniques and can be used alone to treat

small areas of baldness or may be combined withother techniques to treat larger areas. Here, anellipse of bald scalp is excised, the surroundingscalp is undermined and stretched, and the ellip-tical defect is sutured closed in a straight orgently curved line. Because the scalp does notstretch like other areas of skin may, the resultsof a single scalp-reduction operation are usuallymodest. Scalp reduction can be performed seri-ally, allowing the surrounding scalp to relaxand stretch between operations, which ultimately

allows for a larger area to be excised.Flap surgery involves making large incisions

in the patients remaining hair-bearing scalp andelevating a flap of hair-bearing tissue. The flapremains attached to the surrounding scalp at itsbase, such that blood flow to the flap is pre-served. The area of bald scalp to be replaced bythe hair-bearing flap is excised, and the flap isrotated on its base into the recipient site andsutured in place. The flap donor site is closedwith stitches.

Tissue expansion may be necessary whenthere is a very large bald area and little remaininghair-bearing scalp. Tissue expansion involves theplacement of a plastic tissue expander (similar toa deflated balloon) underneath the area of hair-bearing scalp. Once the incision has healed suffi-ciently, expansion is initiated. This processinvolves injecting sterile saline into the expander

A B

Figure 23-8. Frontal hair loss treated with hair transplantation. Before hair transplantation (A) and after transplanta-tion (B). (From Barrera A: Hair restoration. In McCarthy JG, Galiano RD, Boutros SG, editors: Current Therapy in Plastic Surgery,Philadelphia, 2006, Saunders, pp 333337.)

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using a needle and syringe. A small amount ofsaline is injected once or twice a week for a num-ber of weeks. As the tissue expander fills withfluid, the overlying hair-bearing scalp stretchesand undergoes new tissue growth. The bulgingarea of scalp may be quite unsightly during the

expansion process, which is one of the main rea-sons patients do not like this operation. Oncethe hair-bearing scalp has been expanded, thepatient is taken back to the operating room forthe second operation. The tissue expander isremoved, and the expanded area of hair-bearingscalp is used to cover the bald areas.

Potential complications of hair restoration sur-gery include infection, bleeding, extrusion of thetissue expander (if used), and unsightly scarring.With hair-transplantation techniques, the donor

sites in the hair-bearing scalp are usually wellcamouflaged by the remaining hair. However, ifhair loss continues after surgery, the donor sitescars may become more visible. The other techni-ques described require larger incisions and mayresult in more extensive scarring. Scars on thescalp from flap surgery, scalp-reduction surgery,and tissue expansion may become widenedbecause of tension across the wounds as they heal.

Surgery of the Aging Face

Dynamics of Facial Aging

With aging, generalized facial and cervical laxitywith sagging are progressive and objectionableto many persons. Smoking and sun exposure arebelieved tosignificantly exacerbate skin changeswith age.18 Forehead and glabellar wrinkling,brow ptosis, lateral hooding and drooping ofupper eyelid skin, and lower lid puffiness appearin the upper face. Deepening of the nasolabialfolds, jowling,and cervical laxity affect the lower

face and neck.19

The major forces contributing tofacial aging include skeletal remodeling, subcuta-neous fat redistribution, hormonal imbalance, andgravity.

Aging of the craniofacial skeleton is aresult offocal bone atrophy and bone expansion.20 Thereis a reduction in facial height and a small increasein facial width due to changes in the maxilla andmandible. The orbits increase in size, whereas themaxilla decreases, accentuating the descent ofthe malar fat pad and deepening of the nasolabialfold. Alveolar bone resorption enhances perioralwrinkling and reduces lip fullness.

Facial aging is associated with loss of soft tissuefullness in the periorbital forehead, malar, tempo-ral, mandibular, and mental sites and persistence

or hypertrophy of fat in others (e.g., submental,lateral nasolabial fold, infraorbital fat pouches,and malar fat pad). Skin wrinkling appears in theperiorbital and perioral areas due to repeatedunderlying muscle action and volume loss. Jowland submental sagging occurs due to a relative

excess of skin or lack of elastic recoil as well asfat accumulation. Volume changes with the lossof temporal support, coupled with a reduction ofupper eyelid fullness, creates the impression ofbrow ptosis with the eyebrow descending to aposition at or below the supraorbital rim. In addi-tion, there is a relative excess of upper eyelid skinaccentuated by a reduction in periorbital volume.The loss of subcutaneous fullness and a down-ward displacement of intraorbital fat over a weak-ened orbital septum create a deeper and wider

orbit and convex deformity of the lower eyelid.Additionally, subcutaneous thinning of the lowereyelid confers a dark coloration to the thin infraor-bital skin, enhancing the tired eye appearance.Consequent to these structural changes, the facialconvexities of youth are altered. From the front,the jawline appears scalloped; the suborbital, buc-cal, and temporal areas are hollow; and the fore-head and brow lose their anterior projection.

Most conventional face, neck, and brow liftprocedures incorporate elevation and tighteningto reverse soft tissue descent that results fromatrophy and loss of skin elasticity. Current trendsin facial rejuvenation focus on deep aponeu-rotic and muscular manipulation plus volumerestoration.2123

Blepharoplasty

Cosmetic surgery of the eyelids (i.e., blepharo-plasty) includes a variety of operative proceduresdesigned to remove or reposition herniatedorbital fat or skin and muscle from the upper

and lower eyelids (Figure 23-9). The surgicalobjectives are to correct drooping upper eyelids,puffy lower eyelids, and eyelid malposition.Upper lid blepharoplasty, performed for the cor-rection of visual obstruction, may be consideredreconstructive, and the costs are often partiallycovered by certain insurance policies. Upperand lower eyelid surgery may be combined withbrowlift and cervicofacial lift procedures, whenindicated. Blepharoplasty after rhinoplasty is thesecond most commonly performed cosmetic pro-cedure in men.2

Upper and lower lid incisions follow the natu-ral lines of the lids to conceal resultant scars. Typ-ically, the scars lie in the natural crease of theupper lid and below the lashes of the lower

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eyelid, extending into the furrow at the outer can-thus. In younger patients with more elastic skin,transconjunctival blepharoplasty is performedthrough an incision inside the lower eyelid, leav-ing no visible scar. Depending on the rate of heal-ing, most bruising and swelling are resolved bythe second operative week, but the scars willremain pink for 6 months or more after surgery.

Browlift

A forehead lift or browlift is a surgical proceduredesigned to correct drooping brows and hoodingof the upper eyelids and to improve horizontalfurrows and glabellar frown lines (Figure 23-10).A forehead lift is often performed in combinationwith facelift to provide a more harmoniousresult. Blepharoplasty may also be performed incombination with a forehead lift if the patienthas brow ptosis with significant overhang of theupper lids.

The operative approach may be through anincision at or just behind the hairline. Alterna-tively, the procedure may be performed endos-

copically through small hairline incisions. Patientswith male pattern baldness are not ideal candi-dates for browlift procedures, but incisions canbe modified to accomplish the necessary brow ele-vation and reduce forehead creases. Workingthrough the incisions, the surgeon lifts the skinof the forehead to expose the underlying musclesfor modification, then releases, elevates, and

secures the forehead soft tissue to maintain thedesired forehead and eyebrow position.

Postoperative adverse effects may includetemporary swelling, forehead or scalp numbness,itching, or hair loss. Injury to the temporal branchof the facial nerve is rare and usually transient.Permanent injury can result in an ipsilateral lossof forehead motion.

Facelift (Rhytidectomy)

Face and neck lifting procedures are designed totighten the aponeurotic structures underlyingthe skin, reposition the skin, and remove skin suf-ficient to correct tissue laxity. The best candidateis a patient whose face and neck have begun to

A B

C D

Figure 23-9. Bilateral upper and lower lid blepharoplasty. Anterior (A) and lateral (B) views before blepharoplasty;anterior (C) and lateral (D) views after blepharoplasty.(From Ellis DS: Blepharoplasty. In Marchac D, Granick MS, SolomonMP, Robbins LB, editors: Male Aesthetic Surgery, Boston, 1996, Butterworth-Heinemann, pp 157170.)

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appropriate training before selecting a physicianto perform even minor procedures. Again, ABMScertification in a relevant specialty is a good signa-ture of a well-trained cosmetic surgeon.

Botox

The injection of botulinum toxin for wrinklereduction is an extremely common procedure,with over 2 million injections performed eachyear.2 Botox is the brand name of the only botuli-num toxin preparation that has been approved bythe US Food and Drug Administration (FDA) forcosmetic use. Botulinum toxin is a naturallyoccurring substance produced byClostridium bot-ulinum, a common anaerobic bacterium found insoil and other locations. The toxin binds to motornerve endings at the neuromuscular junction and

prevents release of the neurotransmitter acetyl-choline, resulting in muscle paralysis. It is thesame toxin that is responsible for botulism foodpoisoning, and it can be lethal. However, thetoxin can be purified and used safely in smalldoses for medical purposes.

The FDA has approved Botox for cosmetic usein the glabellar region between the eyebrows,although it is commonly used off-label in otherareas of the face. By paralyzing specific facialmuscles that cause the overlying skin to wrinkle,botulinum toxin causes wrinkles and fine lines tosmooth out. Botox begins to work within a weekafter injection, and maximum results are seenwithin 2 weeks. The results can last up to 4months, and repeat injections are often requested.With repeat treatments, the paralysis effect lastslonger.

When performed by an experienced surgeon,Botox injections are safe and effective; however,potential complications do exist. If injected incor-rectly, temporary numbness, drooping of the eye-lids, or unwanted paralysis of other facial

muscles can occur. Rare allergic reactions to thepreparation can occur and could be life-threaten-ing. In addition, some people develop antibodiesto the botulinum toxin after repeated treatmentsand are no longer able to benefit from injections.

Soft Tissue Fillers

Soft tissue fillers are injectable substances that areused to smooth out facial wrinkles, furrows, andcreases. They are also used to fill out focallydepressed areas in the face or to add fullness tothe lips. Many types of fillers already exist, andthe number of fillers entering the market isincreasing dramatically. However, not every fillerthat one may read or hear about is available foruse in the United States. Some of the more

commonly used fillers are discussed below,although the list is certainly not comprehensive.

Injection with soft tissue fillers is usually per-formed in the office or clinic setting and can takeanywhere from a few minutes to an hour to per-form. Although a topical anesthetic is applied to

the skin before the procedure, these injectionscan be quite painful. An injected local anestheticis much more effective for controlling pain, butits use in this situation is often limited becausethe injected anesthetic distorts the skin and softtissue in the area of interest. If the patient cannottolerate the filler injections, sedation or even abrief general anesthetic may be necessary. Theresults are often immediate, and the durationdepends on the type of filler used.

Fillers may be derived from naturally occur-

ring substances such as bovine collagen, or theymay be completely synthetic, like silicone. Otherfillers are a combination of natural and syntheticmaterials. For example, Artecoll is a filler com-posed of microspheres of polymethylmethacry-late imbedded in collagen. In addition,autogenous tissue may be injected as a filler.Most commonly, this is the patients own fat, har-vested by liposuction from another area of thebody.

Fillers can be classified as temporary, semiper-manent, or permanent. Temporary fillers usuallylast between 1 and 6 months and occasionallyup to a year. Semipermanent or permanent fillersmay last 5 years or longer. At first glance, it mayseem that permanent fillers would be preferableto temporary fillers because of the longer dura-tion of results. However, one of the complicationsthat can occur with any filler is the creation ofnew and unsightly contour irregularities.Although temporary fillers lose their effect overtime, they are more forgiving. When a bad resultoccurs with a permanent filler, it is extremely dif-

ficult to correct.Fat is the most commonly used autologous

filler, with more than 50,000 fat injections per-formed each year in the United States.2 Fat workswell to treat larger depressions or deep creases,but it does not work as well for fine wrinkles.The fat to be injected is generally harvested froma remote location on the patients body, often theabdomen, using a liposuction cannula insertedthrough a small incision hidden in the umbilicus.It is then prepared for injection by centrifugation,which separates the liquid and other tissues fromthe fat cells. The fat is then injected into the areaof soft tissue deficit. The area is initially overfilledbecause reabsorption of approximately 70% ofthe injected volume is expected. The best results

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are obtained with repeat treatments over a 612-month period. Occasionally there is some degreeof permanent improvement, but the results areusually temporary, lasting from months to a year.Because the fat is derived from the patients ownbody, the allergic reactions that can be seen with

other fillers do not occur.Collagen has long been the most popular soft

tissue filler. Over 500,000 people undergo colla-gen injections each year in the United States,2

and the number is growing. Collagen fillers areused to treat many types of facial wrinkles andcreases but are especially effective for lip aug-mentation and for treating perioral wrinkles andthe nasolabial folds. Collagen fillers are usuallyderived from bovine tissue (e.g., Zyderm),although human-derived collagen preparations

are available. Collagen is a temporary filler, andthe results generally last up to 6 months. Themajor drawback of bovine collagen is that it cancause a local or systemic allergic reaction.Because of this, a skin test is performed a monthbefore the actual procedure is undertaken. Thehuman-derived preparations have a decreasedrisk of allergic reaction but are more expensiveand may be more quickly reabsorbed than bovinecollagen, depending on the preparation. It is alsopossible to harvest the patients own skin andhave the collagen processed for injection, whichdoes eliminate the risk of allergic reaction. How-ever, since this process is time consuming andexpensive and requires the excision of skin, thisoption is very rarely chosen.

Hyaluronic acid is a chemical that is naturallyfound in human skin and soft tissue, as well as inthe skin and soft tissue of other animals. Thereare multiple hyaluronic acid filler preparationson the market, which vary significantly in termsof cost, permanence, and ease of use. Restylaneand Captique are the most commonly used pro-

ducts and are approved by the FDA. Both ofthese hyaluronic acid preparations are producedwithout the use of human or animal tissue. Thepreparations available in the United States aretemporary fillers, and results may last up to ayear. Allergic reactions to hyaluronic acid fillerscan occur but are much less common than withcollagen.

There are many other permanent and semiper-manent fillers used outside the United States thatare currently in various stages of FDA study orapproval.24 Artecoll and Radiesse are prepara-tions commonly used in Canada and Europe.Artecoll is a semipermanent to permanent fillermade of polymethylmethacrylate microspheresembedded in bovine-derived collagen. Radiesse

is a semipermanent filler made of hydroxyapa-titea chemical found in bonesuspended in agel. These products give long-lasting results butmay become lumpy over time and can result ingranuloma formation.

Silicone is sometimes used as a permanent

injectable filler and deserves special mention. Sil-icone is easy to use, is long lasting, and can givevery acceptable cosmetic results initially. How-ever, the complications associated with free sili-cone injection can be disastrous and disfiguring.Contour irregularities and severe granulomatousreactions can occur, and these are often impossi-ble to correct. Even though these problems donot occur in every patient who undergoes a sili-cone injection, we strongly recommend againstits use. It should be noted, however, that there

is no evidence to date that autoimmune or othersystemic diseases occur as a result of siliconeinjection.25

Peels

Chemical facial peels involve the treatment of thefacial skin with a solution that peels away theouter surface. As the injured skin heals after thetreatment, it becomes tighter, smoother, andmore evenly pigmented, resulting in a healthier,more youthful appearance. In general, chemicalpeels are most effective and have fewest compli-cations in fair-skinned persons. The two mostcommon types of chemical peel are the phenolpeel and the trichloroacetic acid (TCA) peel. Inaddition, lighter peels can be performed withalpha-hydroxy acids (AHAs) or beta-hydroxyacids (BHAs).

Phenol peels result in a deep chemical injurythat extends into the dermis. As the facial skinheals, it becomes tighter, smoother, more evenlypigmented, and lighter in color. The procedureitself is usually performed in the office under

light sedation and may take up to 2 hours. Thefacial skin is first cleaned, followed by carefulapplication of the phenol solution. After treat-ment, petroleum jelly is applied to the injuredskin to protect it and keep it from drying out.The skin takes up to 3 weeks to heal after a phe-nol peel. Crusting often occurs and can last upto 2 weeks after the peel. It is also common tohave facial redness that may take up to 6 monthsto resolve. The final results of phenol peels arepermanent, although as the body continues toage, new wrinkles and pigment changes willdevelop.

TCA peels are medium-depth peels and donot injure the skin as deeply as the phenol peels.Like the phenol peel, TCA peels are performed in

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the office but usually only take 2030 minutes tocomplete. Recovery is quicker than from a phenolpeel, and the skin usually heals within 710 days.There may be crusting, irritation, and redness fora few weeks after a TCA peel. Like phenol peels,TCA peels result in smoothing and tightening of

skin, although the results are not as dramatic asthose seen with phenol peels. To maximize theresults of a TCA peel, the surgeon may prescribeAHAs or hydroquinone treatments (a bleachingagent) in the weeks before the TCA peel. Unlikephenol peels, the results of TCA peels are usuallytemporary. The duration of results variesdepending on the skin type and the depth of thepeel, but it is common to need one or two repeattreatments to achieve maximum results. Becausethe TCA peel is not as deep as the phenol peel,

it results in less pigment change and is bettersuited to patients with darker skin.

Light chemical peels can be performed withtopical AHAs or BHAs. AHAs include glycolicacid, lactic acid, and various fruit acids. Salicylicacid is a BHA that is commonly used in lightpeels. Light peels with AHAs or BHAs take 1020 minutes to perform, and recovery time is min-imal. The results are much less dramatic thanthose seen with phenol or TCA peels. Therefore,patients usually undergo scheduled treatmentsevery few weeks or months. When treatment isstarted, patients often experience skin irritation,flaking, and redness. These are usually mild andresolves quickly.

Chemical peels are not without complication.All peels, especially phenol and TCA peels, causesome degree of erythema during the healing pro-cess. During this period, which can last up to 6months with phenol peels, it is extremely impor-tant to protect the skin from the sun through min-imization of exposure and judicious use ofsunscreen. Failure to do so can result in scarring

or permanent pigment changes. In addition,because phenol peels result in permanent lighten-ing of the skin, patients who have had a phenolpeel must be vigilant about sun protection forthe rest of their lives. Although lightening of theskin may be acceptable or desirable in fair-skinned persons, lines of demarcation betweentreated and untreated skin may develop, requir-ing coverage with makeup. In darkly pigmentedpersons, patchy depigmentation can occur, andthus phenol peels are contraindicated. Morerarely, TCA or phenol peels may result in skininjury deep enough to cause permanent scarring.Again, this is more likely to occur with a phenolpeel, which naturally penetrates the skin moredeeply. In addition, patients should be aware that

any peel can cause a reactivation of herpes virusinfections, including cold sores or shingles. Thiscan be prevented or minimized by pretreatmentwith oral antiviral medications. Finally, a compli-cation unique to phenol peels is cardiac arrhyth-mia, which can occur if too much phenol is

absorbed systemically during the peel. Cardiacmonitoring is therefore necessary phenol peelsare performed, and phenol peels are avoided inpatients with cardiac disease.

Lasers

Laser stands for light amplification by the stimu-lated emission of radiation. A laser is a veryintense coherent beam of light that can deliverfocused energy in a precise fashion. As such, itis a useful tool for facial resurfacing. The histo-

logic changes in skin after laser resurfacing aresimilar to those seen after chemical peels. How-ever, unlike chemical peels, the laser allows thesurgeon to more precisely control the depth oftreatment.

Laser resurfacing or laser peel is usuallyperformed with a carbon dioxide (CO2) laser.The CO2 laser can be used to improve fine wrin-kles and is especially useful around the eyesand mouth. It can also be used to treat unevenor patchy pigmentation and may be used in con-junction with a facelift or blepharoplasty. TheCO2 laser is used to direct brief bursts of high-energy light, vaporizing the outer layers of facialskin to a precisely controlled depth. During the12 weeks after treatment, the facial skin heals,resulting in smoother, tighter, more evenly pig-mented skin.

The erbium:yttrium aluminum garnet(erbium:YAG) laser, has recently become a popu-lar tool for facial resurfacing, although it has notreplaced the CO2laser. The energy of the erbiumlaser is absorbed by water in superficial skin

cells, resulting in their destruction and removal.As the skin heals after treatment, it becomestighter, smoother, and more evenly pigmented.The erbium laser is less destructive than theCO2laser. Because of this, it does not tighten skinas well as the CO2 laser does, and the results oferbium laser resurfacing are less long-lasting.However, patients experience significantly lessredness after treatment with the erbium laserand have a shorter recovery time. Because thereare fewer pigment changes with the erbium laser,it is better suited than the CO2 laser for use indarkly pigmented patients.

Laser resurfacing is an outpatient operationand is usually performed in the office or in anoutpatient surgery center. Treatment duration

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ranges from a few minutes to 2 hours, with varia-tions based on the surface area treated. Depend-ing on the duration of the treatment, lightsedation may be required. Afterward, patientsexperience mild swelling and discomfort for afew days. If the CO2 laser is used, the skin will

crust for 710 days and will be erythematous for34 weeks. If the erbium laser is used, there isminimal crusting, and the facial redness resolvesmore quickly. With both lasers, the skin reachesits final post-treatment appearance within 34months. The results of CO2 laser resurfacing arelong-lasting (up to years) but not permanent.The results of the erbium laser last for months,and repeat treatments may be required.

Laser resurfacing has potential complications.Burns and scarring are uncommon, but they can

occur. Permanent darkening or lightening of thetreated area can also occur, a problem more com-mon in darkly pigmented patients. Pigmentchanges occur more often with the CO2 laser,making the erbium laser better suited for use inpatients with darker skin. As with chemical peels,herpes virus infections including cold sores andshingles can be reactivated, and this risk can bedecreased by appropriate antiviral treatmentpreoperatively.26

Finally, there are many non-ablative lasers onthe market that, unlike the CO2 and erbium:YAG lasers, do not remove the top layer of skinbut rather deliver energy beneath the surface.These lasers are believed to stimulate collagenformation, resulting in skin tightening andsmoothing of wrinkles. These lasers certainlyhave fewer adverse effects and require lessdowntime after treatment. Their main disadvan-tage, however, is the slight degree of improve-ment that can be obtained, and the need formultiple repeat treatments to achieve results.

ConclusionCosmetic surgery has the potential to signifi-cantly improve the sense of well-being and qual-ity of life for male patients. A wide array of majorand minor procedures are now available to alter(and hopefully improve) virtually every part ofthe human anatomy. For referring physiciansand prospective patients, the preeminent consid-erations when considering cosmetic surgery arethe appropriate choice of a qualified surgeon,having realistic expectations of the outcomes ofcosmetic surgery, understanding and acceptingthe risks involved, and choosing the best proce-dure for each patient from the myriad of optionsnow available. Despite the fact that there is a

meager supportive evidence base for most aes-thetic procedures, there is every indication thatthe recent surge in the popularity of cosmetic sur-gery will continue and will increasingly involvethe activities of physicians from many specialties.

References

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2. American Society of Plastic Surgeons: Proceduralstatistics2006.

3. Hasan JS: Psychological issues in cosmetic surgery:a functional overview, Ann Plast Surg 44(1):8996,2000.

4. Kisely S, Morkell D, Allbrook B, et al: Factors asso-ciated with dysmorphic concern and psychiatricmorbidity in plastic surgery outpatients, Austr N ZJ Psychiatry36(1):121126, 2002.

5. Wright MR: The male aesthetic patient,Arch Otolar-yngol Head Neck Surg113(7):724727, 1987.

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7. Heller J, Gabbay JS, Ghadjar K, et al: Top-10 list ofherbal and supplemental medicines used by cos-metic patients: what the plastic surgeon needs toknow,Plast Reconstr Surg117(2):436445, 2006.

8. Graf RM, Bernardes A, Auerswald A, Noronha L:Full-face laser resurfacing and rhytidectomy,Aesthet Plast Surg23(2):101106, 1999.

9. Letterman G, Schurter M: Gynecomastia. In GoldwynR, editor, The Unfavorable Result in Plastic Surgery:Avoidance and Treatment, ed 2, Boston, 1984, LittleBrown, pp 779787.

10. Kenkel J: Practice advisory on liposuction, PlastReconstr Surg113(5):14941496, 2004.

11. Commons GW, Halperin B, Chang CC: Large-volume liposuction: a review of 631 consecutivecases over 12 years, Plast Reconstr Surg 108(6):17531756, 2001.

12. Trott SA, Beran SJ, Rohrich RJ, et al: Safety consid-erations and fluid resuscitation in liposuction: ananalysis of 53 consecutive patients, Plast ReconstrSurg102(6):22202229, 1998.

13. Giese SY, Bulan EJ, Commons GW, et al: Improve-ments in cardiovascular risk profile with large-volume liposuction: a pilot study, Plast ReconstrSurg108(2):510511, 2001.

14. Klein S, Fontana L, Young VL, et al: Absence of aneffect of liposuction on insulin action and risk fac-tors for coronary heart disease, N Engl J Med 350(25):25492557, 2004.

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17. Borschel GH, Izenberg PH, Cederna PS: Endoscopi-cally assisted reconstruction of male and femalepoland syndrome, Plast Reconstr Surg 109(5):15361543, 2002.

18. Ernster VL, Grady D, Miike R, et al: Facial wrin-kling in men and women by smoking status, Am J

Public Health85:7882, 1995.19. Zimbler MS, Kokoska MS, Thomas JR: Anatomyand pathophysiology of facial aging, Fac Plast SurgClin North Amer9:179187, 2001.

20. Bartlet SP, Grossman R, Whitaker LA: Age relatedchanges of the craniofacial skeleton: and anthropo-morphic and histologic analysis,Plast Reconstr Surg90:592600, 1992.

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22. Coleman SR:Structural Fat Grafting,St Louis, 2004,Quality Medical Publishing.

23. Little JW: Volumetric perceptions in midfacial agingwith altered priorities for rejuvenation, PlastReconstr Surg5:252266, 2000.

24. Rohrich RJ, Rios JL, Fagien S: A role of new fillers

in facial rejuvenation: a cautious outlook, PlastReconstr Surg112:18991902, 2003.25. Narins RS, Beer K: Liquid injectable silicone: a

review of its history, immunology, technical consid-erations, complications, and potential,Plast ReconstrSurg118(3 Suppl):77S84S, 2006.

26. Nestor MS: Prophylaxis for and treatment of uncom-plicated skin and skin structure infections in laserand cosmetic surgery, J Drugs Dermatol4(6 Suppl):S20S25, 2005.


chapter 23 - cosmetic plastic surgery

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