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” 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, 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 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 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. 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 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 BeforeAfter

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, Canadian (Van Sun)

FACIAL PROCEDURES Botox Botulinum toxin injected into muscles to paralyze them 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, $9, 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 nerve 1) 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 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) 3 rd 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 decompression dural tears conductive or sensorineural hearing loss vestibular function loss persistent CSF leaks meningitis injury to the anterior inferior cerebellar artery (AICA) or its branches

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