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					      Special Feature | Surgical v Non-Surgical

      the brow. That’s fine for somebody whose brow is not too heavy, however it is                        that if you use Botox® for about eight to nine years it actually reduces the effect
      not going to work for someone who does have a heavy brow, those are the                             of ageing and the development brow ptosis because you are not constantly
      people that would benefit from a brow-lift.”                                                         getting those muscles to move the eye brow. Your brow height is a little higher
                                                                                                          and you haven’t loosened the ligaments as much, so you may prevent the
      Research has also shown that by having a non-surgical brow-lift with botulinum                      need for a brow-lift by having Botox® for a long period of time.”
      toxin can reduce the need for surgery long term. Mr Grover explains, “I did
      publish some research which was presented at IMCAS about three years ago




         LIPOSUCTION VERSUS VASER
         Liposuction has traditionally been one of the most popular cosmetic surgery
         procedures, however last year the popularity of the procedure saw a massive
         decline. In the UK there was a 29% reduction in liposuction procedures being
         performed and, across the Atlantic in the USA, the procedure was knocked off
         the top spot for the first time in The American Society for Aesthetic Plastic Surgery’s
         (ASAPS) history. Could this reflect the impact the recent influx of non-surgical                             A patient with a slightly droopy brow          After a botulinum toxin brow-lift
                                                                                                                    before treatment                               (Pictures courtesy of Dr Bob Khanna)
         liposuction techniques had an impact on the market?


         Liposuction has been used to remove stubborn areas of fat from the body in order to enhance aesthetic
         appearance since the 1970s however the early techniques used carried high risks. Over the years                                             RHINOPLASTY VERSUS NON-
         liposuction techniques have developed and many surgeons now routinely perform liposuction under local                                       SURGICAL NOSE RESHAPING
         anaesthetic.                                                                                                                                Rhinoplasty has always been one of
                                                                                                                                                     the top cosmetic surgery procedures,
         In recent years the introduction of so-called ‘non-surgical’ alternatives to liposuction has undoubtedly                                    particularly with men where it has
         seen the fat reduction market change direction. Most recently it has been VASER, a treatment that uses                                      ranked top in The British Association of
         ultrasound to break up fat cells, that has been causing a stir in the liposuction arena.                                                    Aesthetic Plastic Surgeons’ (BAAPS) stats
                                                                                                                                                     for a number of years.
         The VASER technique differs from traditional Ultrasound – Assisted Lipoplasty (UAL) procedures as it uses                                   There are two main techniques employed
         a patented probe, which delivers ultrasound energy from all sides, as well as from the tip, allowing the                                    for carrying out surgical rhinoplasty: closed
         practitioner to sculpt more precisely. This means there is less risk of damaging the surrounding structures                                 rhinoplasty and open rhinoplasty. Cosmetic
         such as blood vessels or nerves, as with traditional UAL. The treatment can be done in a minor surgery                                      surgeon Paul Banwell explains, “As a
         environment and is proving popular with physicians and patients alike.                                                                      plastic surgeon I do a lot of rhinoplasties.
                                                                                                                                                     They can be performed as either a closed
         Dr Ravi Jain said, “VASER offers patients all of the benefits of liposuction with much less downtime and                                     or endonasal procedure, or as an open
         increased skin tightening and it provides great results for patients thighs, tummies and love handles - pretty                              procedure. Closed rhinoplasty involves
         much all over.”                                                                                                                             making a small cut inside the nostril
                                                                                                                                                     that you then work through. This is how
                                                                                                                                                     rhinoplasty was traditionally always done,
                                                                                                                                                     however the results with this technique
                                                                                                                                                     can be variable because you haven’t got
                                                                                                                                                     very good access. There are some very
                                                                                                                                                     skilled surgeons who get fantastic results
                                                                                                                                                     with this method. The technique itself is
                                                                                                                                                     straight forward, however the results are
                                                                                                                                                     unpredictable because you don’t know
                                                                                                                                                     how the skin is going to re-drape. This is a
 Before VASER treatment to the thighs    Side profile of an abdomen before       Before VASER contouring on the stomach area                          disadvantage because you can get a high
(courtesy of Dr Ravi Jain, Riverbanks    VASER treatment (courtesy of Dr Ravi   (courtesy of Dr Ravi Jain, Riverbanks Clinic)
Clinic)                                  Jain, Riverbanks Clinic)                                                                                    level of patient dissatisfaction.
                                                                                                                                                     “The open technique really revolutionised
                                                                                                                                                     rhinoplasty procedures when it was
                                                                                                                                                     introduced 10-15 years ago. It involves
                                                                                                                                                     making an incision in the columella and
                                                                                                                                                     pulling the skin back, which gives you a
                                                                                                                                                     complete view of the anatomical structure
                                                                                                                                                     of the nose. The advantage is obviously
                                                                                                                                                     that the surgeon can see what he is doing
                                                                                                                                                     and can be more accurate, especially with
                                                                                                                                                     bone work, however the disadvantage
After VASER (courtesy of Dr Ravi Jain,   After VASER treatment to the           After VASER (courtesy of Dr Ravi Jain, Riverbanks Clinic)
Riverbanks Clinic)                       abdomen (courtesy of Dr Ravi Jain,                                                                          is the risk of scarring, a longer recovery
                                         Riverbanks Clinic)                                                                                          and more swelling. I have never had any
                                                                                                                                                     problems with scarring using the open



      28      cosmeticnewsuk.com
Special Feature | Surgical v Non-Surgical



approach but there is a risk.” Although Mr Banwell          lifted an re-sited using dermal fillers to essentially         of something rather than addition of something –
has carried out extensive rhinoplasty surgery he            create a new tip in an elevated position. You can             they are having a reductive rhinoplasty. The most
believes non-surgical rhinoplasty also has its place.       also correct slight deviations and asymmetries                common problems would be a slightly bulbous tip,
He says, “Recently I have started using dermal              very nicely. The combination of reshaping of the              which you can’t correct by adding something,
fillers for non-surgical rhinoplasty with great success.     dorsal hump and re-siting of the nasal tip means              or a bump on the bridge. Now the way in which
About five or six years ago I was speaking at a              that we can essentially mimic the effect of a                 most people non-surgically transform a bump
conference and had this misfortune to have to go            surgical rhinoplasty. In severe cases where you               on the bridge is by filling the bit above that, the
on after an American facial plastic surgeon called          have severe hump in the dorsum of the nose or                 root of the nose, so you get the illusion that the
Michal Cain who gave a fantastic presentation               quite considerable deviations of the septum and               bump is flatter. In my view that just gives them a
and really opened my eyes to what could be                  nasal bones, that would be better treated with                Roman nose, which comes right down from the
done non-surgically. Non-surgical rhinoplasty is            surgery. The benefits of course with a non-surgical            forehead. If you look at someone from the side
a very good treatment and has a number of                   procedure are that there are no scars whatsoever              and there is no difference between the forehead
uses within my practice. Firstly it is very good as a       and there is very little downtime if any at all. It is also   and the nose, it is just one line, I don’t think looks
corrective procedure post surgery. Quite often after        relatively pain free with the advent now of new               as attractive as when you take the bump away,
rhinoplasty you can have some lumps or bumps or             generation fillers such as Restylane® Perlane with             so I am not a fan of thinking you can treat people
asymmetries that the patient is not happy with and          lidociane, which makes it a lot more comfortable.”            with that. If someone came to me with just a
fillers can be used in this instance to correct any                                                                        subtle bump that didn’t need surgery maybe they
post-surgical deformities. They can also be used for        Both Dr Khanna and Mr Banwell agree that this                 are the right people to treat non-surgically but
a percentage of patients as a primary rhinoplasty           procedure is very specialist and technique is key.            in most cases I would think they are going to be
procedure. If they have got subtle dorsal deformity         Mr Banwell says, “Non-surgical rhinoplasty has got            better off having surgery.”
or a problem with the tip or asymmetry, non-surgical        to be done in the right hands as there is definitely
rhinoplasty is fantastic as the downtime is virtually       an artistic element. I’m not saying whether or                Dr Khanna actually agrees with some aspects
zero.                                                       not that should be a surgeon a doctor or a nurse              of this and says that patient selection and
                                                            practitioner, however you should not just enter into          maintaining the aesthetic appearance of
“I have a patient at the moment, a pretty young             it lightly.”                                                  the profile is key. He says, “With non-surgical
girl who was in a serious RTA and has a scar across                                                                       rhinoplasty it is important to maintain the nasal
her nose which has left her with a big divert, a bit        Dr Khanna adds, “As with most of these things it              frontal angle. There needs to be a slight concavity
like a boxers nose. I used a little bit of Juvederm         is very much technique driven because putting                 at the root of the nose. If that is totally obliterated
in her nose and she is delighted with the result. To        dermal filler just anywhere is not the answer, its             and it’s a straight line then that will look very
be able to treat her without having to do surgery           about knowing where to put it precisely to create             peculiar and unaesthetic. With a very extensive
is very rewarding. “Noses are also one of the               the right line angles and the correct contour.”               dorsal hump the temptation would be to totally
most common focuses for patients suffering from                                                                           obliterate that area to minimise the appearance
BDD. Many patients who come in for rhinoplasty              However Mr Grover is not convinced. He says, “I               of the bump, however that would give rise to a
procedures have an abnormal perception of                   have got a slightly different opinion. 95% of the             very unaesthetic appearance. That’s why case
how their nose actually looks. Whereas I might not          people I treat for nose correction need removal               selection is very important.”
think it is that bad it has a major impact
on their life. To be able to resolve that
quickly and easily with no downtime
and without doing surgery has huge
advantages and there is a high level of
patient satisfaction with the procedure.
The only disadvantage is that they
have to come back repeatedly for
treatment.


“As a surgeon you would think I would
be biased towards surgery, however I
think as a good surgeon you have to
consider the non-surgical solutions and
make the decision on whether or not to
perform surgery based on the patient’s             A patient with mild nasal deformities         The patient in profile before treatment     A patient with a nasal deformity
                                                   before treatment                                                                         following an RTA
best interests. If they can be treated
without having to undergo surgery then
I think we have a responsibility to do
that.”


Dr Bob Khanna adds, “A typical
presentation for non-surgical rhinoplasty
would be a patient who has what is
known as a dorsal hump. As long as
this is mild to moderate this can be
very nicely and easily rectified using
dermal fillers placed in precise areas to
minimse the appearance of this natural
bump. The other application is where               After non-surgical nose reshaping             The patient in profile after non-surgical After a non-surgical rhinoplasty
                                                   (Pictures courtesy of Dr Bob Khanna)          nose reshaping (Pictures courtesy of Dr (pictures courtesy of Paul Banwell)
the nasal tip has dropped. This can be
                                                                                                 Bob Khanna)




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