It has been said that facial aging can be summarized by referring to the 3 D’s Descent, Deflation, Deterioration.
By descent we mean the sagging of the facial tissue caused by gravity. The treatment for this would be pulling back the tissue to where it was many years earlier via a facelift, necklift, browlift or eyelid lift. By deflation we mean the gradual atrophy of the fatty tissue in the face, which had given it the attractive fullness… characteristic of youth. To reverse this, we transfer fat from another part of the body to areas of the face that are deficient. In some cases, we can even use synthetic implants.
By deterioration, we mean the loss of elasticity and collagen in the skin and the general degradation that we see from aging and exposure to the elements.
The treatment for this is resurfacing via laser, dermabrasion or chemical peels, and appropriate maintenance with moisturizers, sunblocks and other topical creams such as retinA and the alpha hydroxy acids like glycolic acid.
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By definition, a bulbous tip is one that resembles a “bulb” or appears as a rounded mass. And the two main components that establish this appearance are the structural tip cartilages and the overlying skin. One can have strong or flimsy cartilages as well as thick or thin skin. The most easily corrected combination is having strong cartilages, which allow for appropriate sculpting and repositioning, and thin overlying skin, which allows the cartilaginous contours to show through. The most challenging combination is having flimsy cartilages, which do little to express their shape externally, and thick skin, which masks the underlying structures. In this latter case, cartilage grafting is necessary to produce the appropriate contours. The grafts are usually taken from the nasal septum or ear or, rarely, a rib. Their shape and placement usually bear little resemblance to the normal anatomy in this area and is usually placed over it. The object is to create the external appearance of improved nasal aesthetics. In some cases, removing subcutaneous fat or scar from prior surgery may be necessary to help accomplish the desired result. Also, in many instances, the area is infiltrated with solutions such as steroids or fluorouracil to help prevent scar formation that may mask the final result. Finally, it is sometimes necessary to do nightly taping or even periodic casting to direct the healing and create the desired shape.
I have two examples, which illustrate these extremes. The first nose had strong tip cartilages with relatively thin skin. All that was necessary was to partially resect and then reconstruct and reposition the cartilages. In contrast, the second nose had flimsy cartilages, thick skin and scar tissue from prior surgeries. In this case, soft tissue debulking was necessary along with cartilage grafting. The judicious use of injectable kenalog with fluorouracil and post-operative casting and then nightly taping was also employed.
In rare instances, an irregularity will develop under the skin following a very successful rhinoplasty. It usually becomes apparent days or weeks after the procedure as the swelling subsides. In some instances, it is bony in nature and may present as a spicule of bone, resulting from the irritated periosteum (lining over the bridge) or a larger area of bone, if there is a shifting or displacement of the reconstructed bony bridge. The treatment for this may be a simple procedure under local anesthesia in a treatment room or a more involved procedure in an operating room. For a small spicule of bone, the area can be anesthetized locally and a tiny incision made in the club of the eyebrow. Through this incision a narrow chisel can be used to reduce the bony prominence…usually with one or two taps of the mallet. Unfortunately, if the bony irregularity is much larger in nature, a return to the operating room is usually necessary. In this case, rasping or even chiseling is needed and usually takes only a few minutes to accomplish.
If the irregularity noted under the skin is cartilaginous in nature from shifting of a graft or repositioning of the cartilaginous dorsum, an initial attempt at correction can be via a transcutaneous needle. In this case, the area is anesthetized and a small gauge needle is placed through the skin to fracture and progressively crush the cartilage. But, as with the larger bony deformity, if the cartilaginous deformity is large or unaffected by the transcutaneous approach, an intra-operative approach to trim it would be required.
I recently performed reconstructive surgery on a patient who had very large keloids of the ears secondary to ear piercing. Keloids of the ear are fairly common in African American patients, though I have removed keloids and reconstructed ears in Caucasian patients, as well. What distinguishes a keloid from a hypertrophic scar is its extension beyond the area of injury into adjacent areas.
Stephen J. Pincus, M.D., F.A.C.S., 421 N. Rodeo Dr., Second Floor South - Terrace Level, Beverly Hills, CA 90210
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