Facial aging

A new study by Dr. Howard Lanstein at the University of Rochester confirms long standing plastic surgeons’ assumption that changes in the shape of facial bones, specially the mandible, has a significant impact on facial aging.

In this study, CT scans of the facial bones were obtained in nearly 120 patients. The patients were then divided into three groups: young (ages 20-36), middle (ages 41-64), and old (65 and older). There were equal numbers of male and female patients in each group. Comparison of these groups showed that with aging, there is a significant reduction in length and height of the jaw. This leads to reduced chin projection, and loss of jaw-line definition.

The study findings confirm our updated understanding of facial aging, where multiple factors including loss of skin elasticity, soft tissue volume loss, and bony loss are responsible for changes that occur in the face. In regards to bony loss in the jaw, new treatments for tooth loss such as dental implants could help maintain more bony volume. Otherwise, chin implants have a long standing history as an adjunct to facelift surgery, and neck liposuction to enhance lower face and neck appearance.

This Saturday’s Wall Street Journal features a recent study from the Face Research Laboratory at the University Aberdeen Scotland. Nearly 4,800 women from around the world rated paired pictures of men for attractiveness. The pictures showed nearly identical men, with slightly altered facial features to make one appear more feminine. Alterations such as slightly narrower jaw, rounder eyes, or thinner lips.

The findings suggest that women from countries with healthier populations prefer more feminine-looking men. Women from Belgium had the weakest masculinity preferences. Women from other Scandinavian countries with healthy populations also showed a low preference for masculine features. Mexico, Brazil, and Bulgaria with low health care scores showed the highest preferences for masculine features.

Where did the United States stand in masculinity ranking? Number five out of the thirty countries studied. Interestingly, the US ranks twentieth in health index ranking amongst the thirty nations.

Amongst the explanations offered, was that masculine features indicate higher testosterone levels, and stronger healthier men, who could father healthier children. In countries with high health indexes, women prefer tendencies, such as cooperativeness, non-aggressiveness, and interest in parenting. Men with higher testosterone are usually more aggressive, philandering, and less interested in parenting.

If the study results are correct, with our epidemic of childhood obesity, and increasing incidents of diabetes and heart disease, women in the US are sure to continue preferring Clint Eastwood and Sean Connory over Rob Lowe and Hugh Grant.

I’ve heard the term “preventative cosmetic surgery” once too often lately and I wanted to address this subject.  Rejuvenative cosmetic operations are being touted to younger and younger patients. Smaller  operations, “mini facelift”, with shorter incisions are being proposed for patients as young as thirty five or forty. Midface lifting is espoused in even younger patients. Is that appropriate? I believe the answer is no.

Here is an example of a relatively young patient , I found on the web, who has undergone a facelift operation:

Besides having makeup, and perhaps a slightly improved upper neck contour, it is hard to see any effect from a facelift operation in this patient. The neck contour could have been improved with a simple liposuction procedure.

The concept of preventative cosmetic treatments took hold with popularization of Botox. Cosmetic doctors began to talk about Botox treatment in younger patients, as a way of preventing the development of frown lines or crow’s feet. Smaller procedures such as Botox or filler injections (Restylane, Juvederm), have relatively low risk, and they are temporary. As such, the risks are very low and the treatments may be justified. Surgical procedures carry real risk, they should be recommended in a more considered manner. There is no real place for a “preventative facelift”.

Rhinoplasty has been traditionally a cosmetic operation for younger patients, as young as fifteen. Rhinoplasty is a reshaping operation and not a rejuvenation procedure. Fat liposuction in the neck is appropriate for patients as young as their twenties when there is a clear over abundance of neck fat. Patients in their late thirties to forties are candidates for blepharoplasty or eyelid rejuvenation. However, facelift, midfacelift, and neck lift operations should be performed in patients who need rejuvenation, not in those who want to “prevent aging”. Facelift procedures are best suited for patients in their late fifties to sixties who show sings of aging such as jowl formation, nasolabial folds, marionette lines, and neck skin redundancy.

Although cosmetic surgery is safe and patient satisfaction surveys show high level of satisfaction in those who have had cosmetic surgery, as surgeons, it is up to us to maintain high standards in choosing the appropriate patient and recommending the proper procedures.

Insurance carriers often deny verage to patients with post traumatic and congenital facial deformities because these are not seen as “functional”. Recent facial transplants have proven that severely deformed patients are willing to undergo life-threatening surgery in search of a normal appearance. The researchers at the Robert Wood Johnson Medical School published a paper to assess the perception of the general population as to “appearance as a function” of the face.

210 people between the ages of 18 to 75 were questioned about the face and the important functions that it provides. Appearance was the fifth most important function of the face, after breathing, sight, speech, and eating. Half of those surveyed reported that normal facial appearance was very important to be a functioning member of the society. Majority of the respondents rated normalization of the face after facial nerve injury, birth defects, and scars from accidents or infections as functional. Whereas, normalization of a bumpy nose, baggy eyelids, or facial wrinkles was judged to be non-functional.

This study helps patients and their plastic surgeons in demanding insurance coverage for facial reconstruction following trauma, infection, or congenital anomalies.

A new animal study published in the prestigious Journal of Plastic and Reconstructive Surgery (March 2010) reports the benefits of Calcium Channel Blockers (a category of anti hypertension) medication in reducing the risk of skin necrosis and skin loss in animals who were exposed to cigarette smoke. Smoking has been shown to triple the risk of skin injury or skin loss during face lift surgery.  Most plastic surgeons refuse to perform elective face lift surgery on patients who actively smoke.

The adverse effects of cigarette smoking on tissue healing have been widely studied and published. Smoking-related skin necrosis is multi factorial and complex. In addition to reducing blood flow due to nicotine effect on blood vessels, smoking can cause increased blood clot formation and delayed tissue repair. Calcium channel blockers relax the muscles in the lining of blood vessels and partially counteract the spasm inducing effects of nicotine.

Although this finding won’t change my mind in refusing cosmetic surgery in smokers, these results will alter my treatment of smokers who require reconstructive surgery which can not be delayed.

Many people find cheek dimples as cute and endearing. Dimple creation has come into fore as our anatomic understanding of the cheek dimple has evolved.

In people without dimples, the cheek anatomy is comprised of skin, underlying fat, cheek muscle, and oral lining. Dimples are caused by close proximity of the cheek muscle to the overlying skin, without significant intervening fat. The close association of cheek muscle with the overlying skin causes the cheek skin to dimple when the muscle is contracted.

Dimple surgery is a small office procedure. The location of the dimple is marked on the skin. The location of the dimple is then identified inside the cheek and local anesthetic is injected into this area. A small incision is made inside the mouth and a dissolving stitch is placed from the cheek muscle unto the under surface of the cheek skin. The incision inside the mouth is then closed.

The recovery is typically easy and one can return to work the next day. Discomfort resolves within five days and the final result will be evident in two to four weeks.

Women with fuller and younger lips seem younger than they really are. This is the conclusion of a study funded by Unilever Co. in England. The study analysed the faces of 102 pairs of white Dutch female twins aged 59-81 and 162 individual British white women aged 45-75.

The study found that wrinkles, and age spots were equally influenced by genetics and environment. However, a receding hairline, greying hair, and most markedly lip volume was determined by genes. Interestingly, both men and women reach their maximum lip volume in early adulthood. The lips begin to shrink between the ages of 30 and 40. There was a large variation of the lip size among the study subjects.

The study author, David Gunn, said there was little to be gained by thin-lipped middle-aged or elderly women seeking lip augmentation. That’s because full lips on a patient with wrinkles and sagging skin will look out of place and unnatural.

The take home from this study is that conservative lip augmentationcan be very useful in enhancing the face in younger women. In my practice, I favor injectable fillers such as Restylane and Juvederm for this purpose. I have found fat transfer to be unreliable in terms of effect and longevity.  Facial rejuvenation in middle aged and older women will require attention to all facial features and not just the lips.

Botox

The Washington Post recently published an articlewhich raises the possibility of using botulinum toxin as a bio-weapon by terrorists. The article references a cosmetics trader who was selling a large quantity of a Botox substitute at suspiciously low prices. The toxic material is suspected to have been manufactured in Chechnya. The trader or a manufacturing site in Chechnya were never found. However, this event highlights the potential misuse of botulinum toxin as a terror tool by Al Queda or other terrorist organizations.

The commercially available Botox is a very diluted form of the toxin. It would take a hundred bottles of the Botox to kill a human being. However, the pure form of the toxin is one of the deadliest poisons. In fact, the US, the former Soviet Union, and Iraq have considered the use of botulinum toxin as a bio-weapon. All gave up on the idea because botulinum toxin degrades quickly when exposed to heat, making it poorly suited for delivery by missile or bomb. Al-Queda is reported to have sought botulinum toxin, which we presume was not for getting rid of smile lines on Osama’s face!

It appears that many illegal sites are manufacturing a selling Botox. China seems to be the largest location for these activities. The counterfeit drugs are sold online. Unfortunately, terrorists could potentially get a hold of a supplier or begin producing the toxin with the help of a knowledgeable scientist.  No laboratories for fake Botox have been found in the US. However, in 2004, the Justice Department raided a string of clinics in five states that substituted industrial-grade botulinum toxin for commercial Botox. The inferior toxin paralyzed four unsuspecting patients.

Facial Paralysis

In the US, over 40,000 cases of facial paralysis are seen every year. The large majority are due to Bell’s palsy or viral induced, and many recover spontaneously. However, in many cases the paralysis is permanent and may have devastating consequences. Facial paralysis repair is one of the most difficult and rewarding procedures for plastic surgeons.

The facial nerve, which travels through the middle ear space to reach the face in front of the ear canal, have several branches that control the upper, middle and lower facial muscles. Upper facial paralysis leads to an inability to close the eye (eye opening is mediated via a different nerve). If the eyelid fails to close properly, if can lead to pain in the eye, cornea irritation, cornea ulceration, and possibly visual damage.

The traditional treatment for eyelid paralysis has been placement of a gold weight in the upper eyelid. The weight of the implant causes the upper eyelid close by force of gravity. Eyelid closure in this way is slow (unlike a natural blink), and the gold wieght can fail to close the eye when the patient lays down. Recently, investigators in UC Irvine published an article on possible use of an artificial muscle to help restore eye blink in facial paralysis.

Electroactive Polymer Artificial Muscle (EPAM) is an electroactive polymer sandwiched between compliant electrodes. These electroactive polymers act like human muscels by expanding and contracting based on variable voltage input levels.  The investigators tested the force that can be generated with EPAM in cadaver eyelids, and found the force sufficient for adequate eyelid closure. The technology is still developing, and a functioning human model is not yet available. However, there is a high likelihood that EPAM may be available for live human application within five years.

For patients with facial paralysis, this new and innovative technology will have a significant and profound impact.

EMedicine is one of the most authoritative and accessible point of care medical reference available to physicians and helath care professionals on the internet. The site is part of the Medscape Professional Network that has a worldwide audience and recieves an average of 1.5 million physicians per month. The peer-reviewed, evidence-based site is updated regularly by provider authors and editors.

Dr. Khosh has been an author for several articles since the inception of eMedicine. This month Dr. Khosh was recognized by eMedicine for his contributions and continued involvement. The follwoing are a list of articles published by Dr. Khosh and the frequency with which those articles have been viewed: