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Peter A. Adamson, MD, CCP
Cosmetic Facial Surgery
SUMMARY RESUMt
Canadians have committed themselves to a Les Canadiens ont developpe des habitudes de vie
healthier lifestyle, and many are seeking to plus saines et nombreux sont ceux qui veulent,
parallelement, soigner leur apparence. Pour les
look as well as they feel. For patients with patients dont les attentes sont realistes, les
realistic expectations, modemr techniques of techniques modernes de chirurgie esthetique faciale
cosmetic facial surgery can enhance peuvent ameliorer l'apparence et comporter certains
appearance and be of psychological benefit. avantages psychologiques. Aujourd'hui, la plupart
Today most procedures can be done under des interventions peuvent etre faites sous anesthesie
local anesthesia on an out-patient basis. locale en externe. Certains actes techniques tels la
rhinoplastie, l'otoplastie et la chirurgie correctrice du
Facial contour defects can be improved by menton et des joues peuvent corriger les
means of procedures such as rhinoplasty, imperfections au niveau du contour du visage. La
mentoplasty, otoplasty and malarplasty. Facial chirurgie de rajeunissement du visage dans le but
rejuvenation surgery to decrease the signs of d'attenuer les signes du vieillissement incluent le
aging indudes the forehead lift, eyebrow and lifting du front, la correction de la ligne ciliaire et
sourciliaire, la rhytidectomie, la liposuccion et la
eyelid lift, rhytidectomy, liposuction and dermabrasion chimique. II existe cependant de
chemical peeling. Newer controversial trends nouvelles tendances plus controvers6es au niveau de
in cosmetic facial surgery indude collagen la chirurgie esthetique du visage soit l'implant de
implantation and fat transfer for contour collagene et la reimplantation de graisses pour les
defects, and eyelid tattooing. (Can Fam imperfections du contour, et la dernopigmentation
Physcian 1987; 33:2121-2130.) des paupibres.
Key words: cosmetic facial surgery, rhinoplasty, facial rejuvenation surgery
Dr. Adamson is a cosmetic and This makes it difficult for the pri- against surgery. The degree of suc-
reconstructive facial surgeon who mary-care physician to advise patients cess that cosmetic facial surgery can
initially practised family medicine about procedures popularized in the offer depends not only on the sur-
in Barrie, Ontario. He now is in mass media. geon's skills, but also on the patient's
private practice at the Today, increasing numbers of indi- age, health, skin texture, bone struc-
Toronto-Dominion Centre and viduals are committed to a healthier ture, and specific needs. Good candi-
holds staff appointments at the lifestyle, including attention to diet, dates are persons who are outgoing
Toronto General Hospital and The regular exercise, and decreasing con- and have a positive outlook on life.
Hospital for Sick Children. He is an sumption of cigarettes and alcohol. A Poor candidates are persons who ex-
assistant professor at the University natural extension of this lifestyle is pect absolute perfection or unrealistic
of Toronto and is President of the the desire to look as well as one feels. changes in their lifestyle.
Canadian Institute of Facial Plastic Our society has embraced this con- The degree of psychological im-
Surgery. He is actively involved in cept, allowing more individuals to provement that a patient obtains from
teaching facial plastic surgery feel free to seek improvement in their cosmetic facial surgery bears no rela-
throughout the United States and facial appearance. A 1986 poll tionship to the degree of deformity
Canada. Requests for reprints to: showed that 45% of women and 33% corrected.' A patient may be deeply
Dr. Peter A. Adamson, P.O. Box of men would consider cosmetic sur- concerned about a minor defect such
47, Toronto Dominion Bank Tower, gery to improve their appearance.' as a nasal hump that appears to be of
Toronto-Dominion Centre, The goal of cosmetic surgery is to im- no consequence to others and may
Toronto, Ont. MSK 1B7 prove profile defects or reduce the achieve significant satisfaction from
signs of aging, thus improving facial having this slight defect improved.
harmony and enhancing appearance. Other patients may have significant
TH IS YEAR thousands of Cana- Absolute perfection or a complete deformities which their physician con-
dians will have surgery to im- transformation of the patient's appear- siders should be corrected, but which
prove their facial appearance. Yet the ance or lifestyle are unrealistic expec- they themselves are quite content to
family physician has little exposure to tations. Patients who express a desire live with. In the context of facial plas-
this type of surgery during training. for such results must be advised tic surgery, more than in any other
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987 2121
branch of medicine, the physician and make a physical examination of held so that the patient can make an
must be prepared to listen to the pa-the patient's head and neck. Polaroid unhurried informed decision about the
films are taken so that the patient can
tient's wishes and take a non-directive surgery.
be shown the defect and the proposed
approach in helping the patient to de-
correction. The patient is also shown
cide about surgery. This can be a dif- Anesthesia
photographs of surgical results
ficult task, as it departs from the more
achieved with other patients with sim-
traditional authoritarian behaviour of Local anesthesia is used for minor
ilar defects. The procedures that the
the physician/surgeon. Neither the pa- procedures such as removal of facial
patient is considering are described in
tient's spouse, family, and friends nor blemishes or scar revisions. For proce-
the surgeon can impose their own aes-detail. Special investigations include dures lasting up to three hours, local
medical photographs, nasal airflow
thetic standards on the patient seeking anesthesia combined with intravenous
cosmetic facial surgery. Rather, the studies for patients planning rhino- sedation is usually employed. This
surgeon must decide whether the pa- plasty, and an ophthalmology assess- allows almost any given costmetic fa-
ment for patients planning eyelid sur-
tient's expectations are realistic and cial surgical procedure to be done
can be met surgically. Table 1 out- gery. The patient is given literature to under local anesthetic if the patient so
lines the various surgical proceduresread and later returns for a second wishes. General anesthesia is used for
to recontour and rejuvenate the face.consultation to discuss the results of procedures taking longer than three
the investigations, ask any further hours, such as complete facial rejuven-
questions, and plan the proposed sur- ation, for younger patients, and for
Pre-Operative Assessment gery. For minor procedures only one those requesting it.
During the first consultation the consultation may be necessary, but Most patients who have local an-
surgeon will take a complete history for others several consultations are esthesia with sedation are able to
Table 1
Facial Plastic Surgery
Name of Duration Anesthesia Office Time Off Light Strenuous Contact Driving Sun When
Procedure (Hours) Out-Patient Work Exercise Exercise Sports Exposure Performed
or (Days) (Days) (Weeks) (Weeks) (Days) (Weeks) (Years)
In-Patient
Rhinoplasty 1-3 IV, GA O,l 10-14 2 3 6 7 6 16+
(Nose)
Mentoplasty 1 IV 0 5-7 2 1 4 1 N.R. 16+
(Chin
Augmentation)
Otoplasty 2 IV 0 5-7 2 2 4 2 N.R. 5+
(Ears)
Malarplasty 1 IV, GA 0 5-7 2 2 4 1 N.R. 16+
(Cheekbones)
ForeheadLife 11/2 IV,GA O,l 7-10 2 2 4 2 N.R. 30+
Eyebrow Lift 11/2 IV 0 7-10 2 2 4 2 6 30+
Blepharoplasty 2 IV 0 7-10 2 2 4 5 6 30+
(Eyelid Lift)
Rhytidectomy 3 IV, GA O, l 10-14 2 3 6 10 6 40+
(Face & Neck Lift)
Liposuction 1 IV, GA 0 7-10 2 2 4 5 N.R. 25+
(Fat Suctioning)
Chemical Peel 14 -1 LA, IV O,l 7-10 1 2 4 1-7 12 40+
Blemish Removal l/2 LA OFF, 0 0-7 1 1 3 1 6 16+
ScarRevision 1/2-2 LA,IV 0 0-7 1 1-2 3 1 6 PRN
Dermabrasion 1/2-2 IV, GA O,l 10-14 1 2 4 1-7 12 16+
(Skin Planning)
Collagen Injection 1/4 NIL OFF 0 N.R. 1 N.R. N.R. N.R. 30+
Legend Anesthesia LA = Local Anesthetic IV = Intravenous GA = General Anesthetic
Location OFF = Office 0 = Out-Patient I = In-Patient NR = No Restriction PRN = As Appropriate
Exercise Ught Exercise: walking, stretching Strenuous Exercise: jogging, swimming, sexual activity, aerobics,
weight lifting, bike riding Contact Sports: squash, tennis, baseball, hockey, football, diving
2122 CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987
have their surgery in a day-care facil- and return to work about two weeks she has a large nose and a retruding
ity and be taken home that evening. after surgery, but they should avoid chin. Chin augmentation with a pre-
After a general anesthesia lasting less strenuous activities and exercise for formed Silastic implant can be carried
than two hours, the patient may be three weeks and contact sports for six out by itself or at the same time as
discharged the same day. Patients un- weeks. The patient can expect signifi- rhinoplasty (Figure 1). It may be per-
dergoing a longer general anesthesia cant improvement in nasal shape formed either intra-orally or through a
require admission the day before the within two to three weeks, but the ul- small submental incision which re-
procedure and spend one night in hos- timate recontouring of the nose may sults in a virtually invisible scar. The
pital following surgery. take up to one year. Rhinoplasty is a extra-oral approach reduces the
Most patients have some discom- complex and intricate procedure that chance for infection and slippage. A
fort, but very little pain, following can generate significant psychological light Elastoplast dressing is used to
cosmetic facial surgery. Most do not improvement. ' secure the implant for several days
require analgesics after the first post- before the sutures are removed.
operative day. Mentoplasty (chin augmentation) Chin reduction can be effected
The chin is an important part of a through a similar submental incision
Facial Contour Surgery person's profile, especially if he or and removal of the surplus bone of
Rhinoplasty
A significant number of men and Figure 1
women would like to change their Rhinoplasty and Chin At
nasal profile. The most common com-
plaints are that the nose is too large,
crooked, has a bump, or is too bul-
bous at the tip (Figures 1 and 2). Fre-
quently there is a history of nasal
trauma with concomitant obstruction.
Such complications can be improved
by a septoplasty done at the same
time as the cosmetic procedure.
Usually the tip of the nose is nar-
rowed, set back, or projected further
from the face, and rotated slightly up-
wards to improve a drooping tip. The
nasal hump is removed, and osteoto-
mies of the nasal bones are carried out
to straighten and narrow the nose.
Narrowing of the nasal base is some-
times required to make wide nostrils
smaller.
The operation can be performed
through a. "closed" approach with all
incisions inside the nose. Many other
noses benefit from an "open" ap-
proach, which requires a small inci-
sion in the columella that heals almost
invisibly. This is a newer approach
and allows much greater exposure and
more accurate sculpting of the nasal
cartilage and bone. A small cast is
placed on the nose and plastic intra-
nasal stents are placed along the sep-
tum. These are removed after one
week. It is no longer necessary to
place large amounts of packing.
Bruising and swelling in the periorbi-
tal and lip *areas recede in approxi-
mately two weeks. Many patients feel
tired for several days after the sur-
gery. Patients commonly have little or
no pain, but do have a dry mouth sec-
ondary to nasal obstruction. This
usually resolves within two weeks. One-year result in a 21-year-old female who had a rhinoplasty and chin
Patients may resume social activities augmentation to improve a large, crooked nose and retruded chin.
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987 2123
the chin. If protrusion or retrusion is is performed to re-position the ears contour. Permanent sutures are placed
the result of a significant deformity ofcloser to the head and to correct other to maintain the new antihelical fold.
the mandible or maxilla, or if there is deformities and asymmetries (Figure There is very little, if any, pain asso-
associated dental malocclusion, more 2). The procedure can be performed at ciated with the surgery, and there are
extensive maxillofacial surgery or any time after the patient reaches the no sutures to remove. The thin scars
orthodontia may be necessary. An im- age of four, as the ear cartilage is then from the incisions are located behind
proved chin profile enhances the at- firm and has reached nearly adult size. the ear and are therefore well hidden.
tractiveness not only of the nose, but It is best to perform the surgery before There is some discolouration and
of the entire face as well. the child begins to attend school in swelling for up to two weeks, and the
order to avoid classroom teasing. The ears may be tender for several weeks
procedure can be done at any time in after surgery. A turban-like bandage
Otoplasty adults. is worn for several days. Then an ex-
Protruding ears are caused by a The surgeon makes an incision be- ercise headband is worn for two
Mendelian autosomal dominant trait hind the ear and sculpts the soft tissue weeks to protect the ears during sleep.
with variable penetrance.2' 3 Otoplasty and cartilage of the ear to improve As the ears are often not alike,
even in the normal state, perfect sym-
metry of both ears is not a reasonable
expectation. However, patients and
Figure 2 surgeons alike are very pleased with
the results of this procedure.
Malarplasty (cheekbone
augmentation)
It is becoming increasingly com-
mon for patients, especially females,
to request augmentation of the malar
bones (Figure 3). This gives more def-
inition to the lateral aspect of the face
and a heightened perception of beauty
for those with flat malar bones. The
procedure is performed intra-orally,
with development of a pocket beneath
the periosteum of the zygoma. Various
shapes and sizes of silicon implants
can be placed and secured with tran-
scutaneous sutures. The resultant
swelling and bruising are minimal.
Most patients can resume normal ac-
tivities within one week.
Facial Rejuvenation Surgery
Facial rejuvenation surgery in-
cludes lifting procedures involving the
forehead, eyelid, eyebrow, and face,
double chin removal, and chemical
peeling. Each individual ages at a dif-
ferent rate and in a unique fashion
because of the numerous factors af-
fecting the aging process. These pro-
cedures can be done at any time dur-
ing adult life, depending on the
person's requirements. The clock can
be turned back, but it will keep tick-
ing; thus a person who has undergone
this type of surgery will always look
better for his or her years, but will
continue to age. The earlier surgery is
done, the more subtle the rejuvenation
will be, and the more years the person
will have to enjoy the results. Secon-
oIj-IxImIUom resuIL ir female dary procedures in subsequent years
protruding ears. can provide the patient with a contin-
2124 CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987
ued look of youthfulness relative to facial expression (Figures 4 and 5). The minimal swelling and bruising are
age throughout life. This youthful ap- To perform a forehead lift, the sur- resolved within one week.
pearance tends to complement the ac- geon makes an incision across the top Removing the excessive scalp tis-
tive and outgoing lives that most peo- of the head behind the hairline. The sue makes the patient's eyes look
ple considering this type of surgery only hair removed is that on the ex- larger and more youthful. Forehead
enjoy. cised redundant skin. The muscles wrinkling and frown lines are re-
causing forehead creases are incised, duced. The eyebrows are elevated,
Forehead lift the forehead is elevated, and the ex- and loose skin between eyebrows and
With aging the eyebrows descend cess skin is removed. The incision is temples is smoothed.
over the bony framework of the eyes. closed with surgical staples. There is
Deep vertical and horizontal lines ap- little or no pain following surgery, but
pear at the junction of the nose and there may be some temporary numb- Blepharoplasty (eyelid lift)
forehead, making a person look angry ness in parts of the forehead or scalp. With relaxation of the forehead and
or unpleasant. Horizontal forehead Central forehead movement will be temple skin, "hooding" may occur in
wrinkling occurs secondary to constant decreased after the surgery, thus pre- the upper eyelids. Thinning and
elevation of the eyebrows and repeated venting the redevelopment of creases. stretching of the eyelid skin itself
causes further skin redundancy.
Pseudo-herniation of the periorbital
Figure 3 fat pads through the orbital septum
Rhinoplasty and Bilateral Malar Augmentation causes "bags" to occur. Repeated fa-
cial activity and sun exposure causes
wrinkling in the eyelids (Figures 4 and
5).
An ophthalmology exam is com-
pleted pre-operatively to ensure that
there are no ophthalmic contraindica-
tions to surgery. The upper-lid inci-
sion is made just above the tarsal
crease, and the redundant skin and fat
are excised. The lower-lid incision is
made just below the eyelashes in the
natural skin crease, and the redundant
fat is removed. The excess skin is re-
draped and tailored.
There is little or no pain post-opera-
tively, but there is a variable amount
of periorbital bruising and swelling.
The scars gradually blend with the
surrounding skin, and after several
weeks they are barely perceptible
even under close scrutiny. Slight blur-
ring of vision, eye irritation or dry-
ness can occur for up to one month
after surgery. Eyedrops and ointment
may be required during this time.
With the elimination of excessive
skin and sagging around the eyelids,
the patient has a more rested and
youthful appearance. However, a ble-
pharoplasty cannot remove the very
fine wrinkles, or ''crow' s feet",
which give every face character. The
eyelid lift cannot elevate the upper
cheek; a face and neck lift is required
for improvement in this area. The
upper-eyelid lift cannot completely re-
move the skin hooding caused by a
sagging brow; an eyebrow or forehead
lift may be required.
One-year result in a 25-year-old female who had a rhinoplasty and Eyebrow lift
bilateral malar augmentation to refine her nose and improve her flattened Drooping of the eyebrows, espe-
malar bones. cially laterally, is one of the first
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987 2125
signs of aging. It is more prominent forehead crease is the preferred proce- also has the advantage of allowing
in men (Figure 6). This causes the dure. It is effectively combined with a elevation of the glabella, thus reduc-
upper eyelids to bulge and descend blepharoplasty, imparting maximum ing skin redundancy between the
until they seem to lie on the eyelashes improvement. eyes. Lifting the eyebrows makes the
themselves. Patients complain that To perform an eyebrow lift, the eyes appear larger and more youthful.
their eyes appear to be getting smaller surgeon removes a wedge of skin It also lessens ""crow's feet".
or deeper set; women complain that above the drooping brow. The eye- Cosmetics can be used to cover
eye makeup usually ends up high on brow is lifted and secured by deep su- scars during the healing phase; men
the outer part of the eyelid. The fore- tures to its new, more youthful posi- may prefer eyeglasses. In some cases
head lift is often the best procedure to tion. The top row or two of eyebrow the scar is dermabraded several
improve this problem. However, in hairs may be lost. This is not a con- months later to improve it further.
female patients with very high hair- cern to women who pluck their brows
lines and in men who have male-pat- to contour them. Men's brows are Rhylidectoiny (face and neck lift)
tern baldness, the eyebrow lift or a usually thick enough to cover the Over the years the skin of the face
mid-forehead lift through a horizontal fine-line scar. The mid-forehead lift and neck loosens, thins, and sags.
Figure 4 Wrinkling develops, and pouches form
Female Facial Rejuvenation along the cheek and jaw line, while
cords may form in the anterior neck
because of weakening of the platysma
muscle. Rhytidectomy is designed to
remove the sagging excess skin and
smooth the deeper wrinkles of the
lower face and neck (Figures 5 and 6).
It can be combined with fat suctioning
(liposuction) to reduce jowls and the
submental "wattle" (Figure 5). It does
not reduce the signs of aging about the
eyes, forehead, or mouth, nor does it
remove fine facial wrinkles.
An incision is made from the temple
down in front of the ear, and up behind
the ear down into the neck hair. A
large superficial flap is elevated from
the underlying fascia, and the superfi-
cial musculo-aponeurotic system
(SMAS) fascia is then secured with per-
manent sutures at a higher level. This
is the point at which the true lift
occurs. The redundant skin is re-
draped, tailored, and closed without
tension. This two-layered lift gives a
natural-looking and long-lasting re-
sult.
There is little pain in the post-opera-
tive period, but there is a variable de-
gree of swelling, discolouration, and
tightness of the skin for a week or two.
Some numbness in the face resolves
within several weeks. Patients can re-
sume social activities within two to
three weeks. Hair colouring or perma-
nent-wave solution can be applied in
about three weeks.
The face and neck lift gives the pa-
tient a more refreshed appearance. If
there has been a great deal of sagging,
which is more likely in the older pa-
tient, the result will be more dramatic.
If sagging is less pronounced, the
Two-month result in a 47-year-old female who had a coronal forehead lift operation will keep the patient looking
and lower blepharoplasty, and face and neck lift with liposuction. Note young. He or she will always look five
the improvement in her facial ptosis, periorbital fat herniation, jowls, and to 10 years younger than his or her cur-
facial furrows. rent age, but aging will continue. Ap-
2126 CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987
proximately 50% of our facelift pa- piration of the buccal fat pad by way of skin. These are best eliminated by
tients will have a second lift or "tuck an intraoral approach, but this proce- chemical face peeling. This may be
up" at a later date. This allows further dure creates some risk of causing a ca- done as an isolated procedure for a re-
tightening of the underlying founda- daveric appearance in patients who do gional aesthetic unit of the face (for
tion of the face and removal of redun- not have a cherubic face.4 Further time example, lips, cheeks, and/or fore-
dant skin. In this way, a patient can will be required to assess accurately head), or it may be done in conjunc-
maintain his or her youthful appear- the technical merits and long-term re- tion with other facial rejuvenation pro-
ance throughout life. sults of these procedures. cedures. Different peeling compounds
are available, but essentially the tech-
Liposuction (fat suctioning) Chemical (Face) Peel nique causes a second degree burn to
In some people fat gradually depos- Fine wrinkles, weatherbeaten skin, the skin, which in turn causes exfolia-
its below the chin until a "double vertical wrinkles of the lips, and tion of the superficial layer of skin.
chin" forms. This deposit obliterates brown sun spots are all marks of aging This process results in a thinner but
the ideal chin-neck line, contributing
to the appearance of aging. Others Figure 5
have a "turkey gobbler" deformity, Male Facial Rejuvenation Surgery
which consists of vertical bands of pla-
tysma muscle, running from the chin
to the base of the neck. Jowls, an ex-
cess of skin and fat, may hang from
the lower jaw. Certain individuals
have a poorly developed cervico-men-
tal angle caused by an anteriorly
placed hyoid cartilage. If they also
have excess submental fat, they can
benefit from fat suctioning of the sub-
mental and submandibular region even
in their twenties (Figure 4).
To perform a liposuction, the sur-
geon makes small incisions under the
patient's chin and behind the earlobe.
Excess fat is removed with a suction
catheter in a cross-hatched fashion to
get a smooth result. A light pressure
dressing is worn for four days, at
which time all sutures are removed.
There is usually very little bruising or
swelling and minimal discomfort.
In patients who still have good skin
elasticity, liposuction may be the only
procedure required. Over several
months the skin will contract to give a
tighter appearing jaw and neckline. In
older patients who have decreased skin
elasticity, it is necessary to combine li-
posuction with a face and neck lift
in order to redrape the inelastic redun-
dant skin to achieve a more youthful
appearance. Patients with chin retru-
sion will realize an even greater im-
provement with chin augmentation
combined with lipsuction. Small
asymmetries and irregularities may oc-
casionally occur with healing, but
these are usually of little concern and
do not detract from the overall im-
provement.
Some surgeons have recommended
Z__. ~J
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fat suctioning of the nasolabial folds Three-year result in a 53-year-old male following direct brow lift, upper
and infraorbital regions. This proce- and lower blepharoplasty, and face and neck lift for facial rejuvenation.
dure, however, may result in ridging Because of numerous facial skin cancers, the patient also had a full-face
of the skin, which has been difficult to dermabrasion for therapeutic reasons, but also attained improved
correct. Others have recommended as- cosmesis.
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987 2127
r~ gi.NXS'1_-
smoother skin. A small patch test is cleansing of the face. The solution had been sunburned. Considerable
done several days before peeling the stings as it is applied, and the amount swelling may occur, and the patient
desired area in order to ensure that the of discomfort varies among patients. needs to be emotionally prepared to
patient has no adverse reaction to the The stinging is eased with steroids to accept the temporary distortion of his
peel solution. Chemical peeling will decrease swelling. Analgesics and or her appearance. Make-up may be
not improve larger creases and sagging anxiolytics are prescribed if necessary. used within seven to 10 days, once all
tissues, but will improve finer wrin- The patient immediately puts ointment the crusts are removed. The skin eryth-
kles and changes caused by sun expo- on the affected area. Loose crusts are ema fades over about three months,
sure. removed with showering, beginning during which time the patient should
Smaller areas may be peeled in the the first day. This greatly decreases the avoid prolonged sunlight.
office without sedation of the patient. discomfort which has been associated The result of this procedure is a de-
More extensive peeling requires hospi- with this procedure in the past. The crease in fine wrinkles and the patchy
tal care. The peeling solution is ap- underlying skin revealed after shower- pigmentation seen in older skin. Pa-
plied with cotton swabs after thorough ing is wrinkle-free and reddened as if it tients with fair complexions may
achieve more favourable results than
those with darker complexions or
Figure 6 thicker skin.
Z-plasty, W-plas
Additional Procedures
Growths and blemishes
Small growths and blemishes may
be present from birth or may increase
with aging. Removal of lesions such as
benign nevi and cysts reduces colour
and contour deformities of the face.
Telangiectasia or "spider veins" can
be cauterized in the office. Large
freckles or lentigos can be improved
with a light chemical peel. In each
case the method of treatment is deter-
mined by the type, size, and growth of
the blemish. The degree of improve-
ment depends on the extent of treat-
ment required and the individual's skin
characteristics. With increasing aware-
ness of the risks of ultraviolet irradia-
tion exposure resulting from depletion
of the ozone layer in the atmosphere,
all patients should be advised to avoid
excessive sun exposure or to use sun-
blocking agents.
Scar reilsion
Scars are characterized by location,
colour, line, and contour. Should a
scar be less than ideal with respect to
these characteristics, it can be im-
proved by surgical excision, derma-
brasion, collagen implantation, or
other camouflage techniques. Larger
scars can be excised serially over a
period of time. It is important to re-
member that a scar can never be com-
pletely eliminated, but can only be im-
proved. Furthermore, it may take up to
one year for a scar to mature, at which
time it will have reached its maximal
improvement.
A 26-year-old male with a severe chin laceration from an MVA. Fifteen Dermabrasion (skin planing)
months following Z-plasty, W-plasty and dermabrasion for scar revision, Dermabrasion is most commonly
the contour, line and colour of the scar are improved. used for acne scarring (Figure 6). To
2128 CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987
achieve ideal results the surgeon must becomes smoother and often slightly creases about the eyes and mouth are
surgically plane an entire regional aes- lighter. Scarring can be reduced, but difficult to correct with collagen.
thetic unit such as the cheek or fore- not completely eliminated. Face and
head, and not just the scarred area it- neck lifting may further reduce the Fat transter
self. "Spot" dermabrasion, except for deeper wrinkles and scars. There has recently been renewed in-
some contour irregularities in straight- terest in transplanting fat from areas
line scars, leaves a more prominent such as the abdomen and buttocks in
contour defect than the initial round Controversies and Trends order to correct contour defects of the
acne or chicken pox scar. Deep "ice- in Cosmetic Facial Surgery face. Investigators are currently study-
pick" scars are improved by a surgical Collagen Implantation ing the best methods of needle fat ex-
incision with a punch elevation of the traction, solutions for fat transfer, and
depressed area prior to the dermabra- Collagen, which is the structural re-injection techniques.6 Although the
sion. Accutane must be discontinued protein of the skin, is prepared from technique appears relatively simple
six months prior to dermabrasion, as it calf hide and purified so that it can be and there have been some encouraging
may decrease re-epithelialization. injected into the human dermis to im- early results, long-term results of these
prove contour defects. Three types of newer techniques are yet to be seen.
Surgical planing of the skin is car- collagen are currently available: Zy-
ried out with a high-speed diamond derm 1, Zyderm ii, and Zyplast. Zy- Eyelid Tattooing
fraize or wire brush, which removes plast is the latest and most commonly
the epidermis and superficial layers of Over the past few years, tattooing of
used form of collagen, as it is thicker the eyelids has been popularized. It
the dermis. The normal skin is taken and appears to last longer. has been recommended for busy
down to the level of the pitted scar,
thus diminishing the high-low junc- Before treatment begins, a test in- women who do not wish to take time
tions which cast shadows on the skin jection is made in the forearm. The pa- to apply makeup, for athletes, and for
when light strikes the face. The deeper tient is checked at 28 days after the more senior patients with visual,
dermis contains the epidermal appen- procedure for signs of adverse reac- arthritic or tremour problems that pre-
dages, which form new skin, and tions. About 3% of the general popula- vent the application of eyelid cosmet-
therefore the depth of dermabrasion is tion will react and should not be given ics. The patient chooses a pigment
limited. Before the procedure is collagen.5 Those at particular risk are which is then injected in a dot fashion
begun, the skin is frozen with Frigid- highly allergic persons and persons just above the upper, or below the
erm. This eliminates pain and allows with collagen-vascular diseases. Treat- lower, lash line. The effect will de-
the surgeon to sculpt the skin. Bleed- ment procedures are performed at least pend on the colour of pigment used,
ing is reduced so that the capillary two weeks apart, and most patients re- the width of the line placed, and the
loops in the dermis can be seen, which quire two to four sessions initially. In- density of the tattoo dots.
allows a more accurate assessment of jections are relatively painless, as Xy- There has been some concern about
the depth of dermabrasion. The patient locaine is placed in the syringe. After the irreversibility of this technique,
washes his or her face with cool water the implantations there is some swell- especially for younger women who
and applies medicated ointment. This ing, redness, and, rarely, mild sore- may wish to change their eyelid ap-
decreases crust formation, which re- ness. This reaction lasts only a few pearance later on. There have been
sults in more rapid healing and less hours. Some minor bruising occasion- rare reports of eyelash loss, infection,
ally occurs. and "bleeding" of the pigment.7 Pa-
discomfort. tients must be made aware of these po-
Touch-up injections are needed to
Most of the crusts fall off within 10 maintain maximum correction, as col- tential problems when they are consid-
days, leaving very erythematous skin. lagen is naturally metabolized by the ering this procedure.
Make-up may then be applied. The body. Most patients choose to receive
erythema subsides slowly over three touch-ups between six and 18 months Conclusions
months, leaving a smoother skin. Sun after initial treatment.
exposure must be avoided during this The great majority of patients un-
stage to prevent development of hyper- The most common use of collagen is dergoing cosmetic facial surgery are
pigmentation. Fair complexions are to fill in the deep facial creases of the very pleased with the results.' Nearly
less prone to pigmentation problems nasolabial folds, glabella and forehead all would have the procedure done
than are darker complexions. that are associated with aging. This again, and many do return for further
procedure may be carried out before facial rejuvenation surgery when other
It is generally thought that derma- facial rejuvenation surgery, or as a signs of aging appear. Patients increas-
brasion cannot be performed unless ac- touch-up to maximize results follow- ingly present for surgery at a relatively
tive acne has settled completely. It is ing such surgery. Collagen can be used early stage of life because they wish to
ideal to wait until acne is under con- to reduce certain acne scars, tissue loss maintain their youthful appearance and
trol, but absolute resolution is not nec- from disease or injury, or other depres- to enjoy the results of their surgery for
essary. Acne may flare for several sions. However, since collagen im- a longer period of time. Increasing
months following dermabrasion be- plantation does not yield a permanent numbers of men are requesting cos-
cause of the inflammatory response of result, the surgeon and the patient metic facial surgery.
healing. Following this response, must weigh the benefits of repeated in- There are, however, certain risks as-
however, most acne patients see their jections against more definitive surgi- sociated with any surgical procedure.
acne become less active than it was. cal management. Firm scars, or those In addition to hematoma and infection,
As a result of dermabrasion the skin with distinct margins, and very tiny more serious complications could in-
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987 2129
XNIZORAIq
K E T 0 C 0 N A Z 0 L E
ANTIFUNGAL AGENT
INDICATIONS
Serious or lite threatening systemic tuoigal intections in normal, predisposed or
interferes with steroid synthesis, the potential tor a deleterious ettect on
puberty andlor fertility must be carefully considered when long-term therapy is
contemplated. Calcium and phosphorus serum levels should be monitored in
long-term treatment since NIZORAL interteres with vitamin D metabolism:
hypoparathyroidism developed in a 6 year old during long-term therapy.
DRUG INTERACTIONS
NIZORAL + cyclosporin = Increases plasma concentrations of
cyclosporin.
Since the occurrence of nephrotoxicity as a side effect of cyclosporin is
clude visual loss associated with ble-
pharoplasty, and sensory or motor-
nerve injuries associated with facial
surgical procedures. Abnormal wound
healing may be a problem. Fortu-
immunocompromised patients where alternate therapy is considered inappro- correlated with high plasma trough levels, additional care is required when
priate or has been unsuccessful: systemic candidiasis, chronic mucocuta- they are used concomitantly. nately, none of these complications are
neous candidiasis, coccidioidomycosis and paracoccidioidomycosis, NIZORAL + warfarin = potantliation of the action of warfarin. common, and this is one of the reasons
histoplasmosis and chromomycosis. Severe recalcitrant dermatophytoses A sharp drop in the prothombin level may occur during concomitant therapy
unresponsive to other torms ot therapy. with antivitamin K type oral anticoagulants. More careful monitoring of antico- why these procedures are increasing in
When clinically warranted, therapy may be initiated prior to identitication of the agulant ehlect is necessary, with appropriate adjustment of the warfarin dose. popularity.
causative organismL NIZORAL + insulin = decreases insulin needs in diabetic patients.
N.B. NIZORAL is not recommended for lungal inlections ol the CNS. Due to a possible insulin-sparing effect, insulin needs should be assessed Patients considering such surgery
more frequently when NIZORAL is used concomitantly.
CONTRAINDICATIONS
NIZORAL + ritampicin and/or isoniazid = reduces NIZORAL levels. should first discuss their concerns with
Known hypersensitivity, hepatic dystunction, ini women of childbearing poten
tial unless etlective forms of contraception are employed. These drugs should not be used concomiantly. their family physician. He or she
NIZORAL + phenytoin = Increases or decreases plasma levels of
WARNINGS either drug. (Mediated via cytochrome P,50 enzymes). should be able to refer the patient to a
Idiosyncratic hepatocellular dysfunction has been reported and can be fatal
unless properly recognized and managed Liver function tests (SGGT. alkaline ADVERSE REACTIONS surgeon known to have expertise in the
Some deaths occurred in clinical trials which may or may not be drug related.
phosphatase, SGPT. SGOT. bilirubin) should be pertormed before, and at
periodic (monthly or more frequently) intervals during treatment, particularly in Gastrointestinal: nausea and/or vomiting (3%), G.I hemorrhage (<1%), area of the patient's concern. There are
patients with a history ol significant alcohol consumption, those expected to abdominal pain (1.2%), diarrhea (<1%).
Dermatological: pruritis (1.5%), alopecia, purpur, rash, dermatitis (<1% in
currently several specialties whose
be on prolonged therapy and those receiving other potentially hepatotoxic members exhibit expertise in facial
drugs, concurrently Minor elevations of liver enzymes usually normalize all capes).
during therapy and do not necessitate discontinuation of therapy, however, Central Nervous System: headache, dizziness, somnolence, tremors, ner
vousness, paresthesias (<1% in all cases).
cosmetic surgery. These specialties in-
symptomatic manilestation ol hepatotoxicity is an indication lor termination of
therapy Deaths have been reported following therapeutic doses of ketocona- Endocrinological: gynecomastia (<1%), dose-dependent decrease in tes clude otolaryngology-head and neck
zole associated with evidence of hepatotoxicity. tosterone serum levels, decrease in basal and ACTH-induced cortisol levels, surgery, general plastic surgery, ocu-
In man, single doses of 200. 400 or 600mg NIZORAL cause a dose-related increased serum levels of 17 OH progesterone and decreased urinary levels of
decrease in serum testosterone level,, which returns to baseline values 8 to 24 17-ketosteroids, hypoparathyroidism loplastic surgery, dermatologic sur-
Genitourinary: oligospermia and azoospermia, impotence, loss of libido,
hours later. During chronic administration of 200 mg daily, testosterone levels
were not signilicantly suppressed, Doses ol 1200mg/day have resulted in menstrual irregularities. gery, maxillofacial surgery, and den-
reduction ot serum testosterone to the castrate level within 24 hours This was Hematological: thrombcytopenia, ecsinophilia, decreased hemocrit, ane
mia, leuokopenia, neutropenia (<10%).
tistry. Patients should be confident that
maintained for the duration ot therapy. Oligospermia and azoospermia have they have identified their specific ex-
been reported at therapeutic doses and above. Hepatic: idiosyncratic hepatocellular dysfunction (<0 01%, see WARN-
In 6 healthy temales receiving 400mg once in the late tollicular phase and INGS), transient increases in liver enzymes. Three patirnts have died in
hepatic coma, two when ketoconazole therapy was continued despite icteric
pectations for surgery and have dis-
once in the luteal phase, NIZORAL produced a 380/0 drop in 17t -estradiol
along with a 500/o increase in progesterone during the lollicular phase as well symptoms and the third despite discontinuation ov therapy cussed these fully with their surgeon,
as a 610/n drop in 17(5-estradiol and a 940/o increase in progesterone during Miscellaneous: fever and chills, photophobia, idiosyncratic allergic re and they must be prepared to undergo
the luteal phase The potential for a deleterious eoIect on puberty andlor fertility actions, anaphylactic shock, pronounced dyspnea, arthralgia, sensation of
must be caretully considered when long-term NIZORAL therapy is contem detachment, corneal deposits, cataract enlargement (<1%/n) a surgical procedure with its attendant
plated in children DOSAGE AND ADMINISTRATION risks in order to achieve their desired
A single dose ot 200 mg ot NIZORAL had no efoect on human cortisol levels. The infecting organism should be identified although when clinically warranted
however. 400 or 600mg caused a slight non-signiticant tall in basal cortisol therapy may be initiated prior to obtaining these results goals. The burgeoning increase in pa-
levels and a signiticant but reversible blunting of cortisol response to ACTH tients desiring facial plastic surgery re-
Chronic administration of 800 or 1200mg NIZORAL impaired the ability ot the GENERAL GUIDELINES N.B. Refer to WARNINGS AND PRECAUTIONS
adrenals to produce cortisol although evidence ot frank adrenal insufficiency RECOMMENDED RESPONSE flects positively on the success of these
was not observed Cortisol levels should be monitored regularly in patients
predisposed to adrenal insutticiency, those with marginal adrenal fLinction. or
CONDITION TREATMENr TIMEb procedures.
during periods of prolonged stress, such as in the intensive care unit DERMAL AND CUTANEOUS
In males. 1200mg/day NiIZORAL produced a rapid and signiticant decline in MYCOSES
Derrnaromycoses 4 6 weeks 4 weeks
adrenal androgens (androstenedione and dehydroepiandrosterone), Since the
eftects on hormonal pathways are incompletely understood, tudicious consid Hair or scalp mycoses 4-8 weeks 4 weeks References
eration is recommended before prescribing NIZORAL on a long-term basis Pityriasis versicolor 3-6 weeks 3 weeks
Studies in rats indicate that ketoconazole leads to increased bone tragility in Oral thrush 1-2 weeks 1 week 1. Cash TF, Winstead BA, Janda CH. The
females. therefore, doses above 400 mg/day should not be used in susceptible Chronic mucoculaneous great american shape up. Psychol Today
patients (post-menopausal women and the elderly) Because ot ketoconazole's candidiasis 6-12 months 4 months 1986; 20:30-4.
ability to interfere with steroid synthesis and vitamin D metabolism, careful Onychomycosis 612 months 3 months
consideration should be given to use in children Calcium and phosphorus DEEP MYCOSES' 2. Goin JM, Goin MK. Changing the
levels should be monitored during long-term therapy
Animal studies indicate that NIZORAL crosses the placental barrier and is only Systemic candidiasis 24 weeks 4 weeks body: psychological effects of plastic sur-
eliminated very slowly from tetal membranes. This must be carelully consid
Paracoccidroidomycosis 2-4 months 2 months gery. Baltimore, MD: Williams and Wil-
ered in pregnant patients
Coccidioidomycosis >6 months 6 months kins, 1981; pp. 135; 127-9; 154-7.
Histoplasmosis 2-4 months 2 months
PRECAUTIONS Chromomycosis >6 months 3 months 3. Potter EL. A hereditary ear malforma-
Patients should report any signs and symptoms (unusual tatigue, anorexia,
nausea andlor vomiting. jaundice, dark urine or pale stools) suggesting liver a Base the duration of therapy on individual clinical and mycological tion transmitted through five generations. J
dystunction so that appropriate biochemical testing can be done. Liver func response
b If no response is seen, dosage can be increased up to maximum recomi
Heredity 1937; 28:255-8.
tion tests should be performed before and during the initial days of treatment
and at monthly or more frequent intervals during treatment in patients with a mended, 4. Rogers BD. Microtic, lop, cup and pro-
history of significant alcohol intake or suspicion of liver disorder, those treated c Continue treatment Ior at least 1 week alter apparent eradication of the truding ears: four directly inheritable defor-
concurrently with other potentially hepatoxic drugs, and those destined tor infecting oungus
long-term therapy (see WARNINGS) mities. Plastic Reconstruct Surgery 1968;
NIZORAL requires acidity tor dissolution and absorption Antacids. anticholin ADULTS 41:208-31.
200 mg once a day Dose may be increased to 400 mg in patients who do not
ergics or H,-blockers should he given at least 2 hours after NIZORAL For respond (see Table) Daily maximum dose of 400 mg should not be exceeded
achlorhydric patients dissolve each NIZORAL tablet in 4 mL aqueous 5. Keen M, Arena S. The surgical anatomy
0 2 N HCI, drink with a straw to avoid contact with the teeth and tollow with a CHILDREN and plastic surgical significance of the buc-
cup ot water <20 kg: 50 mg, 20 40 kg 100 mg, over 40 kg 200 mg Daily maximum dose
Anaphylactic reactions to NIZORAL with severe angiodema have been re- ol 100 400 mg should not be exceeded. cal fat pad. Presented at The American
ported in 2 cases Use NIZORAL cauliously in patienis with a known sensitivity NIZORAL should be taken once daily with a meal Since NIZORAL requires Academy of Facial Plastic and Reconstruc-
to micoiiazole as cross sensitivity may exist adequate gastric acidity lor dissolution, avoid concomitant use of antacids, tive Surgery, Spring Meeting, May 2,
Use in Women of Child-Bearing Age anticholinergics and H,-blockers or administer them at least 2 hours alter
An effective aorm of contraception must be used during NIZORAL theoapy NIZORAL. In achlorhydric patients dissolve each tablet in 4 mL 0 2 N HCI. 1987, Denver, Colarado.
Use in Pregnancy drink with a straw to avoid contact with the teeth and follow with a cup of water
In rats, NIZORAL is leratogenic. crosses the placental barrier and is eliirvinated AVAILABILITY
6. Zyderm collagen implantation: a sum-
very slowly trom tetal membranes, evidence oa malernal toxicity and embry- Tablets of 200mg ketoconazole, botlles of 100 mary of clinical investigation. Information
otoxicity was seen at doses of 10 mg/kg. Very careful consideration should be Frill Product Monograph available on request piece. Palo Alto, Calif: Collagen Corpora-
given to the implications tor mother and letus before using NIZORAL in tion, 1982.
pregnancy 'Trademark JANSSEN 1987 %-H]
Use During Lactation 7. Agris J. Autologous fat transplantation:
Nursing should be stopped before starting therapy since animal studios a 3-year study. Am J Cosmetic Surgery
indicate that NIZORAL is excreted in1 milk J ANSSEN JANSSEN Pharmaceucica Inc
Use in Children EZ PHRMCUTC 6535 Mill Creek Drive 1987; 4(2):95- 102.
Limited data dictates that caution be exorcised when NIZORAL Is given to 3 H R A ETC Mississauga, Ontario
children Carelul hepatic and hematotogicat monitoring is indicated NIZORAL L5N 2M2 8. Anderson RL. Eyelid tatooing: a sign of
the times. Arch Opthalmol 1985; 103
(10): 1469-71.
2130 CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987
