Archive for December, 2009
Restoring form and function is critical to excellent results in rhinoplasty surgery. The nose must be balanced in proportion to other facial features. In each individual patient, it should be considered in context to the relative size of the individuals facial reference points. Nasal tip projection is classically described as approximately 1/3 the height of the nose with several other specific and sophisticated methods used to describe ideal nasal tip projection. Chin projection can affect the perceived, relative tip projection; a recessed chin creates a nose that appears relatively overprojected, making a chin implant necessary. Additionally, the height of the nose is defined in relation to the height of the midface as well as the height of the upper and lower two thirds of the face, and disproportions in the vertical heights of any of these standard references, can result in facial disharmony. The length of the nose is measured from the root of the bridge to the nasal tip and is changed by affecting tip rotation. These measurements serve as a guide for changing the size of the nose in rhinoplasty surgery and can be tailored based on the patient’s personal ideal aesthetics.
Shaping the intrinsic characteristics of the nose involves changing features such as nasal humps or bumps, the shape of the tip, the angle between the nose and lip, and irregularities and asymmetries between the two sides. True humps are removed to create a straighter nasal bridge or a slight, feminine scoop. Tips that are bulbous and large can be contoured to create a more refined, elegant tip. Additionally weak, flat tips can be bolstered to create a more ideal, defined, aesthetically pleasing tip. The angle between the upper lip and nose is closer to a right angle in men, while in comparison, the angle in women can be up to 115 degrees. Correcting asymmetries between the two sides of the nose can require straightening the nasal bones as well as adding cartilage grafts to camouflage irregularities. Changing the intrinsic characteristics of the nose employs a multitude of techniques culminating in a more pleasing, harmonious, balanced nose.
There are two main approaches to gain access to the nasal structures for rhinoplasty. The first and most traditional way is through incisions contained on the inside of the nose and is called a closed or endonasal rhinoplasty. Not all surgeons are familiar with this approach and may not offer the technique. The primary limitation with the closed approach is with tip contouring and refinement. Although tip suturing can be performed by delivering the cartilages during closed rhinoplasty, the shaping is not performed with the cartilages in their native position making precise changes more difficult and less accurate. There are certainly patients who are excellent candidates for closed rhinoplasty, and patients should be judged on an individual basis with the goals of the patient and the familiarity of the surgeon with this technique in mind. Open Structure Rhinoplasty Surgery has become the most commonly employed technique in rhinoplasty surgery today. It involves a small imperceptible incision in the collumela, the structure that divides the two nostrils. With this additional tiny incision, the nasal envelope can be lifted to gain better access to the bony and cartilaginous structures of the nose, allowing for the absolute best control in shaping and reconstituting the structural elements. In many cases open rhinoplasty is the best technique to achieve the absolute best outcomes, particularly in revision rhinoplasty or when a significant amount of tip work needs to be done.
As with all facial plastic surgery, choosing a surgeon who is knowledgeable and familiar with several techniques is important to optimal surgical planning. Rhinoplasty can be performed in conjunction with other facial plastic surgery, such as a facelift. No single method or technique in rhinoplasty surgery is applicable to every situation. The patient’s goals for surgery are critical to developing an individualized plan. Digital morphing software allows photographic manipulation, making communication between the patient and surgeon easier in order to customize surgical results. Not every individual patient has the same aesthetic tastes and facial proportions. Some surgeons “give” the patient a nose, instead of discussing the possibilities of surgery, and developing a collaborative plan to achieve optimal outcomes with their rhinoplasty surgeon.
Post provided by: Rhinoplasty Surgeon Atlanta GA | Benjamin C. Stong MD
Skin rejuvenation can be confusing to even the most informed patients, and understanding how directed and combination therapies act to deliver results is crucial. In general, the degree of effect is directly related to the treatments depth of penetration into the skin. Skin can be conceptually divided into three zones: the epidermis, constituting the superficial zone, and the dermis, the medium and deep zones. Therapies are classified as superficial, medium, or deep based on the depth of penetration into these zones. The three most common treatment modalities used for skin rejuvenation are chemical peels, dermabrasion, and lasers. All three modalities can be used for superficial, medium, or deep rejuvenation.
Medical grade skin care products act to hydrate skin, increase exfoliation, build collagen, and treat superficial skin discolorations and blemishes. Topical vitamin therapy is a common, noninvasive therapy, of which, the most relevant to skin rejuvenation is tretinoin, a vitamin A derivative. Within months, it acts to rejuvenate the skin by thickening the deeper layers of the epidermis and diminishing signs of photoaging, which include: dyschromias and brown spots. With longer courses, it stimulates collagen production in the dermis, with mild to moderate improvement in fine wrinkles. Hydroquinone and Kojic acid are topical bleaching agents that inhibit melanin production, lightening age spots and improving melasma as well as other causes of hyperpigmented blemishes.
Superficial rejuvenation agents primarily consist of glycolic acid, lactic acid, salicylic acid and jessner chemical peels with various combination formulations commercially available. They act on the epidermis, decreasing discolorations and blemishes while allowing the germinal layer of the epidermis to regenerate. Additionally, they also act to increase superficial collagen formation in the dermis, improving fine wrinkles. Lasers can be used to perform “micropeels,” acting on the epidermis only, with benefits similar to the other superficial rejuvenation procedures.
Medium and deep rejuvenation procedures act down to the level of the dermis and are used to treat deeper photoaging elements and wrinkles. By increasing the depth of penetration the overall effect is increased due to improved recruiting of fibroblast activity and collagen deposition. Consequently, there is also an increased risk of complications with deeper rejuvenations, which can include hypopigmentation and scarring, along with prolonged healing times. Medium and deep chemical peels include jessner/TCA combination peels and phenol peels, respectively. Dermabrasion is an effective resurfacing technique that uses brushes or diamond burrs to remove skin, layer by layer. Today, it is largely used for scar revision resurfacing and the treatment of well formed wrinkles around the mouth. The depth of treatment with conventional lasers is primarily controlled by the type of laser used, the power settings, and the number of passes performed. In general, less aggressive settings and a decreased number of passes, result in less down time, a more superficial treatment, and subsequently, less impressive results. In addition to the benefits of a superficial rejuvenation procedure, deeper rejuvenation procedures improve photoaging elements in the dermis along with stimulating deeper, more robust collagen deposition and a more significant wrinkle reduction.
Fractionated laser resurfacing has been introduced to deliver results comparable to traditional lasers, but with decreased healing time. Fractionated lasers work by treating a percentage of the skin surface area, with spaced, deep penetrating, laser microcolumns that leave intact bridges of skin between the treated areas, decreasing the risk of complications associated with conventional full skin resurfacing techniques, while still maintaining the deeper benefits. Thermal energy is delivered to the deeper dermal elements to trigger collagen formation, while treating deeper dyschromias and brown spots, and allowing for faster recovery due to the intact bridges of skin. Today, the state of the art in laser resurfacing techniques combines conventional full skin resurfacing to remove the epidermis, improving the superficial elements, followed by fractionated therapies to treat deeper photoaging and stimulate deeper collagen formation and wrinkle reduction.
Skin rejuvenation therapy must be tailored by the patients, not the physician’s goals. Aggressive therapy can lengthen healing times and increase the risk of complications, but they also have the best results. Maintenance therapy with medical grade skin care products and superficial rejuvenation agents, with interval medium to deep rejuvenation therapy is ideal for optimal outcomes. Skin resurfacing and rejuvenation should be viewed as complimentary to, not a substitute for face lift surgery or midface lift surgery. The choice of resurfacing agents used to achieve the patient’s goal is collaborative and based on the comfort of the patient with the rejuvenation agent and the experience of the physician.
Post provided by: Atlanta Facial Plastic Surgeon – Benjamin C. Stong MD