Sunday, December 23, 2012

Evolution of Lower Lid Surgery II

Although eyebags may be removed by making an incision below the eyelashes, the disadvantages of this approach are many including:
a. a scar extending along the length of the lower eyelids which may take time to heal
b. longer down time as the approach is associated with more bruising and swelling
c. risk of lower eyelid retraction especially if the skin and muscle are removed.
To avoid these complications, the fat may be removed from behind the eyelids (a transconjunctival approach) in suitable patients.
Julien Bourguet (1876-1952), a French surgeon was the first to introduce transconjunctival blepharoplasty. His results were described and published in 1924 with photographs (see photographs below).
One of the patients of Julien Bourguet who
had had transconjucntival blepharoplasty.
Bourguet's method is still in use and the steps are shown in the diagrams below.
Diagrams showing transconjunctival approach for fat removal.
Transconjunctival approach is used mainly in patients whose main problem is eyebag. This method does not address the problem of loose skin and therefore is not suitable for patients who need skin tightening. Most of my patients having this procedure are patients in their 20s and 30s.
Transconjunctival fat removal at one month post-operative.

Transconjunctival fat removal at two week post-operative.
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Tuesday, December 18, 2012

Evolution of Lower Eyelid Surgery I

Lower eyelid surgery is one of the most common surgery performed to rejuvenate the face. The first photographs of lower eyelid surgery were published in 1907 by Charles Conrad Miller, a plastic surgeon in Chicago. In this published article, the excess skin was excised from the lower eyelid between the cheeks and eyelids (very similar to the pictures shown here taken in early 20th century). Although the lower eyelids were tighten, there were obvious scarring and the lower eyelids were retracted causing exposure and tearings. Later on, Miller modified his technique so that the incision was made below the eyelashes (subciliary) very to the modern technique. However, the problem of eyelid retraction remain.
Early technique of lower lid blepharoplasty. a. Excess skin below the lower lids;
b. Removal of excess skin between the eyelid and cheek;
 c. Lower eyelid retraction after the excision;
d. Tightening of the lower eyelids but the lower eyelids were retracted.

Thursday, December 13, 2012

Complications of Tear Trough Treatment II

Ever since the invention of syringe and hypodermic needles, various substances have been injected into human faces in the name of beauty. Some of these substances were initially embraced with great enthusiasm only to be discovered later that they cause delayed and serious side effects. One of the these substances is liquid silicone as mentioned in the previous post. Unfortunately, it is still being used by unscrupulous unlicensed personnels due to their cheapness. Many of these gullible victims are left with disfigurements years later and when they tried to get answers from the perpetrators they  are often told that the problems have nothing to do with the initial injections as the complications did
not occur immediately.

The history of seeking the perfect filler began with miner oil (Vaseline). It was first injected in Austria in 1899 to replace a patient’s testicle removed because of TB infection. The initial report was favourable which led to the use of Vaseline and similar product such as paraffin in the first 20 years of the 20th century. However, even with initial good results, seoncdary or late severe complications appeared due to their dispersion causing nodule formations. The most famous victim of paraffin injection was Gladys Spencer-Churchill (1881- 1977), second wife of the 9th Duke of Marlborough. She was an American beauty and was regarded as the most beautiful woman in the West. However, she was unhappy with a kink on her nose and had paraffin injection. The paraffin later migrated to her chin producing paraffinomas (inflammation of tissues caused by paraffin) throughout her face. She became so distressed by her appearance that she did not permit any mirrors in her house. She became a recluse and develop ed mental illness.

Gladys before and after paraffin injection.

Incredibly, paraffin injection is still very much alive in the 21st century. A quick search in the medical literature yield reports of complications from  their uses to enhance various body organs such as penises and breasts. A few years ago, a woman consulted me because of progressively swollen cheeks after paraffin injection by an oversea “doctor”. She was persuaded by her beautician to have the injections to remove her tear troughs and make her cheek bones more attractive. The “doctor” reassured her that the injection was not silicone but the “safe” paraffin. Following the injections, the face appeared more pleasing but 9 months later the cheeks began to swell. She went back to the beauty saloon to seek help but was told the doctor had left with no forwarding address. She asked for removal of the swellings as they are causing discomfort and constant redness. However, such operation is often fought with difficulty because of the diffused nature of the swellings. The swellings were eventually removed after a lengthy operation and extensive reconstruction was needed to reconstruct the midface.

Swollen cheeks from paraffin injections.

Removal of the paraffinoma. This operation should not be
taken lightly as the reconstruction is extensive.




Saturday, December 1, 2012

Complications of Tear Trough Treatment I

Patients with tear troughs can be managed non-surgically with filler injection. The commonly used fillers are autologous fat and hyaluronic acid.

Tear trough (arrowed) was treated
with hyaluronic acid injection.
Unfortunately, some patients went to unlicensed personnels for dangerous fillers such as liquid silicone. Initially, the injections give dramatic and aesthetic improvement. However, over time, most of these patients develop complications such as foreign-body reactions, nodule formation, ulcerations, chronic cellulitis, and distant migration of the material. Patients not only suffer from facial deformity but also have psychological embarrassment with withdrawal behaviors. Treatment is fought with difficulties because the injected materials are diffusedly integrated into the facial tissue and radical resection is often needed leaving unsightly scars. Therefore, patients should go to licensed medical personnels for safe injections or live to regard their decisions.

Progressive swelligns of the lower eyelids two years
after silicone injection. Procedure done by a beautician.

Silicone migration causing asymmetry of the face.
Procedure done in a beauty saloon.

Progressive skin thickening and deformation and
chin elongation five years after silicone injection.
Patient had multiple silicone injections
in a beauty saloon.