Category: Procedures

Eyelid reduction or surgery can address excess of skin, bagginess, sun damage (fine wrinkles) and in people of oriental origin the absence of the eyelid crease in the upper eyelid or fold of skin in the medial corner.

Some patients may develop these problems earlier than expected due to an inherited tendency. Puffiness around the eyes can also be a sign of allergies or water retention. If you have any doubt concerning your eyes you should have them tested beforehand by an ophthalmologist.

The surgery

Can be performed in conjunction with other aesthetic procedures for example a facelift or brow lift. If the eyebrow is drooping it is also advisable to have that corrected first (see the section on browlift). The procedure can be performed under a general or local anaesthetic and sedation. The upper eyelid reduction can sometimes be performed under local anaesthetic without sedation.

The scar in the upper eyelid lies in the natural eyelid crease and just under the lashes in the lower eyelid extending slightly outward into one of the ‘laughter lines’. The bagginess in the lower eyelids can sometimes be addressed through an incision on the inside of the eyelid (transconjunctival) without any visible external scar.

The scar of eyelid surgery normally heals well and becomes invisible once the redness disappears after a few weeks. Sometimes resurfacing using a fractional CO2 laser can provide a certain amount of tightening of the skin (see section on laser resurfacing). The fine lines can be addressed by administering Botulinum toxin (Botox). The surgery can be performed as a day case and recovery take around two weeks.

Complications

There is a small risk that the operations could be complicated by any of the following:
• A collection of blood under the skin if one of the blood vessels open up after the surgery (haematoma) this will resolve if small but may have to be drained if large
• The eyelid margin may be pulled away from the globe in the early phase but will most of the time correct itself. In-patient undergoing secondary surgery or with very lax lower eyelids it may be necessary during the surgery to also perform an anchoring stitch to the eyelid margin (canthopexy) in order to prevent this being a permanent feature
• Influenced vision is extremely rare and mostly read about in medical textbooks only
• Small white cysts may form at the suture lines and will need to be drained with a needle. Sometimes they have to be surgically removed

After the surgery

The eyelids will feel sore and gritty for a few days. Natural tears may provide some relief as well as cold water compresses. You should sleep with a few pillows in the semi-upright position to improve drainage.

Sutures are removed at 4-5 days and it should be safe to apply eye make-up after 7 days. No heavy exercise should be undertaken for the first two weeks.

Rhinoplasty (aesthetic, correction of deviated nasal septum, cleft nose, revision rhinoplasty)

A nose can either be made bigger or smaller both from the front or the profile. In addition more subtle changes can be made to improve the projection of the tip, straighten the nose or improve the airway. The size and shape of the nostrils can also be altered. The changes made to a nose should always keep up with the patient’s cultural and ethnic origin as well as the overall balance of the face. Particular attention should be given to the size and shape of the upper and lower jawbone. The thickness of the nasal skin will also determine how much can be done. It is very difficult to make subtle changes in patients with very thick skin.

Surgery

It is done under a general anaesthesia although smaller changes, especially to the tip may be carried out under a local anaesthetic with some sedation. At least one day’s hospital stay is usually necessary.

Normally most of the scars are on the inside of the nose and not visible at all. In certain cases it may be necessary to have a small scar across the skin between the nostrils or in the fold at the side of the nostrils. Various materials may be used to augment the size and profile of the nose e.g. cartilage, bone, or synthetic materials.

At the end of the operation a small splint will be fitted over the nose to protect the nose from accidental injury and the nose will be packed with vaseline impregnated gauzes.
Complications

The undesired result is the most important potential complication. Therefore, a thorough discussion of you expectations and the limitations to your expectations is very important. Most patients considering rhinoplasty have at least two consultations and detailed discussions of possibilities with the help of photographs. Rhinoplasty is an operation often needing revision (18%).

The scars are most of the time on the inside of the nose and not visible. Spotting of blood is common in the first 10 days after the operation. The nose may feel numb but the feeling does improve within 6 months postoperatively. Swelling and bruising can be marked the first 5 days, especially under the eyes if the bones of the nose need to be altered. The swelling subsides gradually and might take up to 1 year.

After the surgery

You are normally able to go home after the first night in hospital. The splint will be removed after 10 days. Most of the bruising disappears after 2-3 weeks. The final result of the operation should only be judged after 6 months to a year when every thing has healed. Sleeping with a few pillows will help with reducing the swelling. The nose will be blocked for the first few weeks due to the swelling on the inside of the nose. Most patients easily adapt to breathing through the mouth in the early phase of the surgery.

Aging of the face results in a number of typical features and affect the forehead, eyebrows, eyelids, cheek, jaw and neck areas. It is due to loss of skin elasticity and the effect of gravity on the face. People that have had a lot of sun exposure will often show signs of facial aging at an earlier stage.

The most common effects are the loss of the youthful curve of the cheek and jaws, deepening of the lines running from the base of the nose to the corners of the mouth (nasolabial folds), loose skin and bands in the neck. Not all people age in the same way and therefore the proposed surgery has to be tailored to individual needs.

The operation

The extent of the surgery depends on the individual need. If the problem is the upper face or eyes then a browlift or eyelid reduction may be indicated. (See sections on blepharoplasty, browlift). Mild cases with wrinkles of the forehead, between the eyebrows and around the eyes can be also treated conservatively with laser resurfacing, microneedling, chemical peels, botox and hyaluronic acid. (See sections on laser resurfacing, chemical peels, microneedling, botox and hyaluronic acid).

For the mid-and lower face and neck problems the incision lines will start in or behind the temporal hairline, curve around the front and back of the ear and then extend into the hair at the back of the ear. This will allow the surgeon access to tighten the muscle layer (SMAS) of the face and neck as well as excising any extra skin.

Sometimes a small incision under the chin will allow removal of fat, and tightening of the muscle in this area. Surgery is performed under general anaesthesia and the patient typically stays in the hospital for one night at least.

Consequences and complications

The facial skin will feel numb in the first 6 weeks to 3 months after the surgery. Swelling and bruising can last up to 2-3 weeks. The temporal hairline may start higher up in front of the ear after the surgery and male patients may have to shave behind their ears as beard skin is transported to that area. Any of the following rare complications can occur:
• Collection of blood under the facial skin from a ruptured blood vessel
• Infection
• Rarely – damage to the nerve that moves a part of the face – this takes a few months to recover
• If you a prone to keloid (thickened scars) then this may happen on the face too
• Heavy smokers can have problems with healing of the skin in front and behind the ears

After the surgery

You carry 2 drains -one from each side of the face), which are usually removed 24 hours after the operation. The sutures are normally removed 12 days after the surgery at which stage most of the swelling and bruising will be gone. The postoperative result can be judged after 3 months postoperatively. Lifting of heavy objects or hard physical activity is not recommended during the first two weeks after the surgery.

You can wash your hair backwards in the shower or with a hand shower but do not bend forward. All aspirin and any other blood thinning tablets should be stopped before the surgery and avoided in the immediate period after the surgery.

Most of the discomfort after the surgery is due to the tightness of the skin caused by the swelling. Pain is normally moderate. Avoid hair dyeing during the first month after surgery.

Upper eyelid ptosi (blepharoptosis) is a common disease of the upper eyelid. It can occur uni_ or bilaterally. With the exception of congenital blepharoptosis, the most usual causes include laxation due to increased age, diseases affecting the muscles and nerves of the eyelid, e.g. myasthenia gravis and certain autoimmune disorders (connective tissue disorders).

Blepharoptosis can be classified according to the functionality of a muscle (levator palpebrae), responsible for eyelid elevation and is measured in mm: excellent 13-15mm, good 8-12mm, fair 5-7mm, poor less than 4mm.

The operation

In cases of severe blepharoptosis, the “frontalis sling” technique is used. In this method, fascial (or artificial) grafts are taken from another area (mainly temporal muscle or tensor fascia lata in the leg) and the are used as slings through which the thickest part of the eyelid (the tarsus) is anchored on the forehead muscle. In moderate blepharoptosis, a part of the relaxed levator muscle is removed so that its length is shortened (Fasanella-Servat procedure).

Complications

Over_ or undercorrection. Infection is rare in the eyelids.

After the operation

Swelling and bruising are usually prominent after any operation of the eyelids. Therefore, ice packing of the forehead is advised for the first 24 hours or cold compresses over the eyelid. It’s not advised to socialize for about 5-7 days. Sutures are removed after 5 days. Pain is moderate and can be easily controlled with tablets.

Ectropion is a condition in which your eyelid — typically the lower lid — turns out. This leaves the inner eyelid surface exposed and prone to irritation. Ectropion is more common in older adults. In severe ectropion, the entire length of the eyelid is turned out. When ectropion is less severe, only one segment of the eyelid sags away from the eye. Artificial tears can help relieve the symptoms caused by ectropion until you can have surgery to correct the condition.

Ectropion can be a result of muscular loss of tone due to ageing, facial paralysis, scarring, skin neoplasm, irradiation of the area, some medication or it can be congenital.

The operation

When the cause of ectropion is ageing or congenital, then it’s corrected according the Kunht-Szymanowski technique. In the rest of cases, the factor causing the ectropion has to be treated, whether this is a scar, a skin tumor. In most cases a full thickness skin graft is used, taken from the contralateral upper eyebrow or the skin area behind the ear.

Complications

Under_ or overcorrection needing re-operation to be restored. When it’s senile ectropion, there is a high possibility of recurrence within years following the reconstruction. Usually it takes about 1-3 months for preoperative symptoms to subside postoperatively. When a graft is used, the major complication is partial rejection of the graft (2-30%). Full thickness skin grafts shrink in time at about 20% of the total surface.

After the operation

If a skin graft was used, it’s covered with a tie-over gauze that has to be left in place for 5 days. You will be discharged from the hospital on the next day. Pain is moderate and controlled by tablets. You have to apply ophthalmic ointment on the area for 15 days. Sutures are removed after 7 days.

Protruding ears are a common problem causing stress and anxiety especially in children that are often teased by their school-mates.

The surgery to reposition the ears back can be performed from the age of 4 years at which stage the cartilage of the ear has developed enough for the surgery to be performed safely.

It is important that the patient should express his/her view regarding the proposed surgery and that it should not only be performed because of parental pressure. The surgical technique depends on the part of the ear involved in the condition.

The surgery

A single incision is made behind each ear in a hidden position and the technique appropriate for the specific ear employed to achieve an appropriate position in relation to the scalp. The surgery is normally performed under general anaesthesia although it is possible under local anaesthesia in adults. It is normally performed as a day case. Pain afterwards is moderate and can easily be controlled by oral medication.

Side-effects and complications

The scar is normally well hidden but can be pronounced in patients with a tendency to develop keloid scarring. A collection of fluid under the skin may require drainage at a later stage. Infections are rarely seen. The ear may regain its original position due to the elasticity of the cartilage in 10-15% of cases.

After the surgery

A bandage is applied around the ears to protect the position of the ears as well as the incision line. This is removed after 10 days when the sutures are also removed from the incision. At this stage the ears will still be swollen and tender to touch. It is recommended that a further head bandage is worn at night around the ears for 6 weeks to allow the ear to heal completely.

Sport or physical activity should be avoided for the first 4 weeks after surgery and contact sport should be avoided for three months.

Facial palsy is a devastating condition when the patient’s ability to produce a smile is altered and diminished on one or both sides of the face. In addition it can also affect eyebrow movement and lead to asymmetry. Lack of eyelid closure can lead to an inability of the eye to close in a normal way and leave the patient with a very sensitive, teary eye and chronic eye infections.

The condition can be due to a wide variety of causes, such as viral infections that affect the facial nerve (Bell’s Palsy), iatrogenic injury to the nerve or congenital, i.e. some patients are born with a malfunctioning nerve on one or both sides.

Surgical possibilities

A unilateral facial palsy remains one of the great challenges in reconstructive microsurgery. Various procedures are possible to improve function and appearance. Eyebrow asymmetry can be improved with procedures like dermadesis (elevating the eyebrow by removing a piece of skin above the eyebrow) or a unilateral eyebrow lift. The eye itself can be protected by placement of a specially designed gold-weight or closure of the eyelid by performing a canthoplasty. Other options are also available but less commonly used.

To improve the “smile” a two stage procedure using a nerve graft from the healthy side tunneled under the skin to the affected side and then six months later connected through microsurgical techniques to a new muscle imported into the face to replace the non functioning muscles achieves a good result.

This procedure is, however, not suitable for patients over the age of fifty-five. Experience has shown that the ability of the nerve to grow across the face is not optimal after that age. For the older patient group using sling type procedures whereby a graft of tissue from the leg or the transfer of a nearby muscle group to improve static function is used produces the best result.

In cases where both sides of the face are affected it may be possible to connect the new muscle imported into the face to another nerve in the same area (usually the hypoglossal nerve).

Consequences

Depending on the procedure or combination of procedures that you require achieving optimum improvement, the length of the procedure, number of procedures and hospital stay may vary. Most of this kind of surgery is performed under a general anaesthetic.

All surgery results in scarring although well hidden. The chances of success depend on factors individual to your case. Two stage procedures normally involve two operations six months apart.

The first operation takes approximately 2-2.5 hours and you are normally in hospital for two days. The second operation is more complex and lasts approximately 6-8 hours and you are in the hospital for a week. The various sling procedures and those improving the function and appearance around the eye involves surgery lasting approximately two hours and are day cases.

After the surgery

A period of rest is required and the face will be very swollen on the affected side. This can take six weeks and in the cases of importing a new muscle even longer. No heavy exercise should be undertaken for the first four weeks as this may aggravate the swelling and influence the ultimate outcome of the surgery.

Meticulous attention to the incision lines, massaging after a period and sun protection will maximize the appearance. Physiotherapy exercises of the newly transplanted muscle may be helpful once it starts functioning.

Summary

Facial palsy surgery can be very successful in restoring appearance and function but it is important to remember that the procedure suitable for an individual case varies.

Forehead lift ameliorates the horizontal forehead wrinkles, the position of the brows and the frown lines. It can be done with two different techniques. The classic forehead lift is performed through an incision extending from one ear to the other and hidden in the hair of the patient.

If the skin relaxation is excessive, then the incision should be placed at the hairline, in order to avoid transposing the hairline higher and thus in an unnatural position on the scalp. During the operation , the muscles causing the horizontal wrinkles and the frown lines are weakened.

The skin excess is removed and the brows are repositioned accordingly in a natural higher position. With the endoscopic technique, 5 small incisions are done in the hair of the patient. Through these the eyebrows are repositioned and the muscles causing the forehead wrinkles are weakened. No excess of skin can be addressed by this method.

Operation

It’s done under general anaesthesia and you stay in the hospital overnight. This operation is often combined with full face lift or blepharoplasty. After the open access operation you will have 2 drains that avoid fluid accumulation in the surgical area. They are usually removed after the first 24s. Stitches are removed on the 10th-12th day postoperatively.

Complications

The major complications of this procedure are edema and bruising that last about 2 weeks. Loss of some hair around the scar, infection of the wound, decreased sensitivity of the forehead skin and hematoma have been rarely reported (1%).

After the operation

You have to restrain from heavy exercise for at least 2 weeks. You can wash your hair after the 5th day but cannot dye them until after 4 weeks from the operation. The results of open access forehead lift are long lasting. There is no literature based proof for the same thing as concerns the endoscopic method.

It is always important to judge the chin in relation to the forehead, nose and upper jaws. An assessment of the relationship between the upper and lower teeth also important.

A chin implant can improve the appearance in certain cases but sometimes it may be better to move a part of the jawbone forward by an oral maxillofacial surgeon. The implant can be made from a variety of materials and is normally anatomically shaped to fit the lower jaw without producing a step.

The surgery

An incision is normally made under a general anaesthetic in the inside of the mouth between the teeth and the lower lip and a pocket created to fit the implant. It can be performed as a day case, you will be able to leave the hospital 12 hours postoperatively. Pain is moderate and can be adequately controlled by oral medication.

Complications

Infection is a small possibility and can be prevented by oral antibiotics. You will have small soft stitches on the inside of the mouth and oral hygiene is important to prevent infection. The lower lip may be numb for a period of up to 6 months, but will normally recover. The implant may move but this possibility decreases with time. You’re advised to avoid very hard food for about 6 weeks. Swelling and bruising are normally minimal.

Elevation of the brow improves the position of the eyebrow and facilitates ridding the upper eyelids of excess skin. The procedure can be performed using three different methods.

1)In an open brow-lift an incision in the hairline is made across the scalp from ear-to-ear. This allows direct access to the frown muscles as well as the horizontal forehead lines, which can be improved by surgically weakening of the muscles. A certain amount of skin is removed which will facilitate the elevation of the eyebrow.

2) Using an endoscopic method five small incisions are made in the hairline and the skin freed to allow upward motion and shrinking of the skin. The newly elevated position of the brow is then maintained by anchoring sutures to the scalp. The frown muscles can be addressed through surgical removal with the help of the endoscope. Horizontal lines on the forehead cannot be adequately addressed with this method and will come back after a short period.

3)Through 2 small incision hidden in the hair, blunt dissection is carried out till the eyebrow lateral edges. Lift is achieved by the help of specialized permanent sutures anchored to the periosteum of the skull (silhouette sutures)

The surgery

It is normally performed in conjunction with eyelid surgery or a face-lift. A general anaesthetic is normally required as well as an overnight stay in the hospital. In the first two methods, you will have one or two small surgical drains removing excess fluid that will be removed the next morning. Sutures or metallic clips in the hairline are removed between 10 and 12 days after surgery.

Complications

Swelling and bruising lasting around two weeks. You can have a small amount of hair loss around the incision lines but that is uncommon. Infection is a theoretical risk. Sensation of the forehead may be altered. A blood clot collecting under the forehead skin may have to be drained.

After the surgery

Avoid strenuous activity for at least the first two weeks. You can wash you hair under the shower after the 5th postoperative day, but avoid hair dye for at least 4 weeks. The result of the open method is long lasting but no data is yet available on the permanency of the endoscopic method.