Richard Baker Weekly Blog

My Thoughts on Facial Rejuvenation Surgery

This week I have been doing a bit of reading and thinking about aesthetic surgery of the face. By ‘face’ I mean the skin and underlying fat and muscles of the face and neck, but I am not really talking about the eyelids, the nose or the mouth as such because these areas have very particular anatomical features and require a discussion of their own. The tissues of the face consist of skin, fat, muscle and the underlying bone, and all four of these structures give the face its overall shape. Furthermore, all four of these tissues change with age and contribute to the changing facial appearance.

Skin is made of two basic layers – the epidermis and the dermis, and the dermis is the thicker, stronger layer that in cows is used to make leather. As we get older, this layer thins and loses its elasticity as well as stretching under the influence of gravity. This means that the skin starts to sag with age and creates jowls and wrinkles.

The skin itself can be rejuvenated in a myriad of ways, and it is perhaps in this area where non-invasive aesthetic techniques have had the greatest progress. All of these techniques work in some way by producing an inflammatory response within the skin that leads to collagen production.

Collagen is the main constituent of the dermal layer of the skin, and any technique that leads to collagen production will thicken and rejuvenate the skin. Microneedling and chemical peels are good at thickening the skin and reducing some of the very fine wrinkling, but not so much the deep wrinkles. Meso threads are slowly absorbing threads inserted under skin that cause an inflammatory response with their absorption and thus collagen production. They are very effective but the results are not immediate; they take three months for the effects to become apparent and so perhaps are best for those people who have a regular (yearly) aesthetic regime. Platelet-rich plasma (PRP), which is made from a concentrated sample of the patient’s own blood which is then injected under the skin of the face (vampire facelift), works by releasing naturally occurring substances in the blood that stimulate collagen production. PRP is also finding applications in other parts of the body and I’m considering injecting into arthritic joints in the hand and wrist.

The most effective non-surgical technique for lifting sagging skin is suspension threads (thread lifts). These are threads with little hooks or spikes that are passed under the skin which grip the skin and fat layer, and as they are tightened they lift the skin. They slowly dissolve over six months, so the result is not permanent (usually lasts for about a year), and I find them very useful for lifting the neck, defining the jawline, improving the jowls and rejuvenating the cheeks. They are inserted without leaving any scars and the downtime is surprisingly quick – the patient can return to work the next day and there is usually no bruising. The procedure is performed under a local anaesthetic just like at the dentist. As with the meso threads, this technique is ideal for somebody who has an annual facial aesthetic regime. Of course, thread lifts aren’t a replacement for traditional facelifts because excess skin is not removed with a thread lift alone. However, it is possible to remove some skin at the same time under a local anaesthetic for a fraction of the price of a full facelift. They are also safer than a facelift because a general anaesthetic is not required and there is less risk to the nerves that move the face, and no risk of poor scarring or some of the overlying skin not surviving the procedure. I suspect that over time that the thread lift technique, particularly if it is combined with the small skin excisions, will become more popular and will mean the age that people have their first facelift is later. However, there is no doubt that if a patient has a lot of excess skin then a well-executed full facelift does give a remarkably rejuvenating effect that will take 10 years off a patient’s appearance and last about 10 years.

 

The fat is the layer beneath the skin, and this is a more complicated layer than it sounds. The fat is arranged partly in layers under the skin but also in discreet compartments and is particularly prominent around the cheek. Not only do these compartments descend down the face with time under the effect of gravity, but they also reduce in volume with age, and that is why newer filler techniques target these fat compartments for injection to restore volume in a more natural way than before. Fillers can also be used to mask sagging skin, for example the jowls at the point of the jaw, by smoothing out bulges and wrinkles. Strategically placed volumes of fillers can also cause a lifting effect, particularly around the cheeks. The ultimate fat restoration filler is the patient’s own fat liposuctioned from the abdomen (most of us have some spare fat there after all) and then injected into the face. This not only permanently restores volume it also adds stem cells which have an ongoing rejuvenative effect. The disadvantage is that not of all the fat survives so there may be asymmetry or the procedure may need repeating.

The next layer of the face is the muscle layer, and the muscles of the face are unique compared to the rest of the body because they move the overlying skin, which allows us to have facial expressions. In the rest of the body there is a layer between the muscle and the overlying fat and skin which prevents the muscles moving the overlying skin. Because the muscles of the face have a constant movement effect on the face, the face develops more wrinkles than other parts of the body. Botox, of course, has been a revolutionary treatment for reducing wrinkles and simply works by paralysing the muscle. Its effect is most noticeable in the 30s and 40s before wrinkles are present even when the underlying muscle isn’t contracting. Once wrinkles become too deep, Botox is not sufficient, but it will help and it will stop the wrinkles getting worse. The disadvantage of Botox is that it wears off and needs to be repeated every three to four months, although there is some evidence that the more Botox treatments a patient has, the thinner the muscles become and the less often it is required. I suspect in the future there will be developments that allow the effects of a single Botox treatment to last longer than the current three or four months. New applications are being found for Botox all the time, and I use it in my hand surgery practice as well as my aesthetic surgery practice. The most recent thing I have learnt regarding Botox techniques is that injections at the very top of the forehead can achieve a brow lift for people whose eyebrows have drooped. Of course, there is some skill to botulinum toxin (Botox) injection, as a face with too little facial expression is unappealing even if wrinkle-free. A traditional facelift disrupts the attachment between the facial muscles and the overlying skin. This is why a facelift can sometimes give the appearance of Botox treatment in the lower part of the face.

The last layer in the face is the bone. You might think that the bone is an unchanging structure, but actually the facial skeleton shrinks with aging, which is partly why the cheekbones become less prominent with time. At the moment there are no treatments that rejuvenate bone, and in any case the effects of thinning bone can be reversed with fillers or specially designed silicone implants for the cheeks and the chin. In the future I suspect sophisticated hormonal cocktails will be available to maintain bone mass (for example HRT already does this to some extent) but also to slow the ageing process in the soft tissues of the face that I have already described.

 

What this all means is that the ideal facial rejuvenation regime would address each of the layers of the face to rejuvenate the face in a way that is natural, repeatable, safe and leaves no scars. To thicken the skin, microneedling should be performed at regular intervals throughout the year, with a chemical peel once a year depending on skin type, and particularly demanding areas treated with mesothreads yearly. The sagging of the skin can be addressed with yearly threadlifts and the lost volume replaced with strategically placed dermal fillers or, for a longer-lasting effect, fat injections. Three or four-yearly Botox injections are essential for smoothing the upper part of the face but can also be used to great effect in other areas, for example around the mouth and neck. All of these techniques are enhanced by the use of platelet-rich plasma injection and fat injections by giving a stem cell boost. Advances in the field of facial aesthetics are coming at a dizzying rate, and I think we will see a point in the next 20 years where facial aging, for those who can afford it at least, becomes practically a thing of the past.

Mr Richard Baker – Weekly Blog

Understanding the different type of wrist injuries

This week I have seen a number of wrist injuries and I have been thinking about their natural history of and my approach to them. There are two general mechanisms of wrist injury which divide the patients into two groups.

The first group tends to be young men involved in a high energy injury such as coming off a motorcycle, coming off a bicycle at speed, falling off a skateboard, throwing a punch of falling from a height such as a ladder at work, for example.

The second group tends to apply to women and children in particular and is a lower energy injury, typically tripping over and landing on the outstretched hands.

Both of these groups of patients present with significant pain and swelling in the wrist and loss of movement, but paradoxically I find diagnosis and treatment more straightforward in the first high energy injury group than the second group.

In the high energy injuries, you can usually identify a broken bone (fracture) such as a scaphoid fracture or a specific ligament injury, although this is less common. In the case of a scaphoid fracture, around six weeks of immobilisation in a plaster cast is sufficient, although there is a minority of patients in which the bone fails to heal and require surgery.

In the second group of patients who have the low energy injury, the x-rays are often completely normal with no sign of fracture, dislocation or ligament injury. The patient’s wrist is often tender throughout and all movements are painful and there is swelling, but there is often not any specific point that is painful or a specific anatomical structure that can be identified as the cause of the pain. In most cases, it is frustrating because it is not possible to tell a patient that structure X is injured and therefore we will do treatment Y and it will take X weeks to get better. The cause of pain and swelling in these patients is likely to be a general overstretching of the many ligaments around the outside of the wrist joint – a “wrist sprain” and so the best treatment is rest, elevation, splinting of the wrist and gradual resumption of normal activities as the pain resolves. Often, though, this period takes weeks to months. Patients sometimes ask about steroid injections for these injuries, and I generally use steroid injections for long-term chronic problems such as arthritis because the underlying problem is not something that is going to get better, whereas in contrast, in a wrist sprain, I have an expectation that the pain will get better as the tissues heal. Occasionally, though, if the process does take a long time a steroid injection can help to at least break the cycle of pain and allows the patient to return to normal activities sooner.

Patients also often ask about having scans of their wrist. The scan of choice would be an MRI scan because it is better at identifying the ligaments in the wrist than a CT scan. I am very careful about which patients I request an MRI scan for, by which I mean that I have to have a specific diagnosis in mind that I want to confirm or refute. It is generally unhelpful to request an MRI scan of a wrist when you have no idea of the possible causes of pain because it may well detect symptomless abnormalities (for example painless degeneration of the triangular fibrocartilage complex ligament (TFCC) is common in middle age) that can send the unwitting patient and surgeon down the wrong path of treatment.

The final investigation is a wrist arthroscopy (keyhole surgery) to look inside the wrist. Similar to an MRI scan, I would reserve this for patients in which I suspect a specific diagnosis that I want to confirm or refute. The patient should be chosen with care; it does involve a general anaesthetic and there are risks such as damaging tendons and nerves on the back of the wrist. It is useful for identifying specific ligament or cartilage injuries, which helps me decide what I am going to do next. I suspect over the years as the resolution of MRI scans improves, there may be less need for undertaking arthroscopies of the wrist. Wrist arthritis is a different concept to wrist injury and wrist sprains but can be the result of an injury many years in the patient’s past. Treatment of wrist arthritis is very different to treatment of wrist injuries and is the subject of another blog. The good news is that most wrist injuries get better by themselves without surgery, although the timing of resolution of symptoms is very difficult to accurately predict.

In conclusion, there are two main types of wrist injury, the high energy injury and the low energy injury, and paradoxically the high energy injuries are easier to diagnose, but fortunately in the low energy injuries very rarely do the patients need surgery.

Mr Richard Baker Weekly Blog

How to improve results in tummy tuck surgery?

This week I’ve been thinking about how to improve results in abdominoplasty, or ‘tummy tuck’, surgery. The commonest causes of dissatisfaction after abdominoplasty are residual excess skin, particularly when bending forwards, excess skin in the flanks and fluid collection under the skin (seroma). It is important to warn patients before surgery that though the skin can be very tight on the day of surgery, it naturally relaxes over the following weeks to months so that inevitably there is some degree of returning laxity over the following year. However, it is nowhere near to the same extent as before the surgery. In addition, the patient doesn’t get new younger skin, they simply have the excess removed. Unfortunately, aging, weight gain and pregnancy all have the effect of thinning the skin such that it loses the firmness and elasticity of youth. Liposuction helps in removal of loose skin because the suction of the fat layer allows you to stretch the skin further. Obviously, this is more effective the thicker the layer of fat.

Excess skin on flanks is difficult to address with a tummy tuck. The only way to remove a lot of skin from the flanks is to take the incision all the way around to the back in a so-called ‘body lift’. This creates a scar all the way around the waist and is a bigger operation with more risks, and therefore does not often appeal to patients. However, it is particularly suitable for people who have lost a great deal of weight following a gastric bypass, for example.

Lastly, fluid accumulation occurs because a tummy tuck, by definition, creates a large raw cavity under the skin of the abdomen on top of the muscles. I find putting dissolving stitches between the skin and the muscle can help to close off this cavity, although the stitches can sometimes cause discomfort. Drains are helpful for draining fluid in the initial few hours after surgery, although I don’t believe it makes a difference in the subsequent weeks. It varies enormously between patients, and I think different patients react differently to surgery and it is impossible to predict which patients will produce fluid and who won’t. Surgeons have tried spraying various chemicals into the wound to try to stop fluid production and no-one has found a good one yet. However, I am sure in the future research will generate an agent that will allow the skin to stick back down to the muscles and eliminate this problem.

 

 

Mr Richard Baker Blog

Some great new technologies – HIFU and Miradry

I attended the CCR expo in London which is the aesthetic surgery conference and exhibition.

I was particularly interested to hear about the new technologies such as HIFU, which is high frequency ultrasound treatments for tightening the skin and reducing the fat content which helps improve the contour of the face, neck and body; I’m thinking about introducing this to my patients.

The other technology that appeals to me was something called Miradry which is a device that turns off some of the sweat glands in the armpit so you have permanent reduction in sweating. Neither of these treatments require needles or incisions of the skin involved and no anaesthetic is required.

I was also interested that the British Association of Prosthetics Plastic Surgeon’s Council has issued guidance to its members, for which I am one, that they do not recommended aesthetic plastic surgeons in the UK to undertake large volume fat transfer to the buttocks in a procedure known as the “Brazilian Butt Lift”. This is because there is a mortality or death rate associated with this procedure of 1 in 3000 and this occurs because of fat getting into the blood vessels and travelling to the heart and lungs. I think BAPPS have made a sensible decision although, they haven’t defined what volume of fat they regard as “large volume”. In my practice, I think the buttock area can be reshaped very well with liposuction alone i.e. removing fat from where there is an excess, this means that the buttocks can be made into a more aesthetically pleasing shape, also at the same time reducing the overall size of the buttocks. If the volume of the buttocks still requires increasing, the alternative is to use special implants.