Educating both adolescents and adults on the deleterious effects of sun damage and the proper daily use of sunscreen also is germane to basic skin care.

Facial skin resurfacing. Some of the most dramatic improvements in the aging face can occur through resurfacing procedures. Wrinkles, sagging skin, pigmentary changes and sun damage can all be dramatically reversed with various skin resurfacing procedures.

In the past, dermabrasion and phenol chemical peeling procedures were the most common resurfacing procedures. Due to its precision and control, laser skin resurfacing has become a popular resurfacing modality.

Dermabrasion. The results of dermabrasion are highly operator-dependent. The surgeon uses a larger version of a diamond laboratory bur to destroy the outer layers of the skin. This procedure can have unpredictable outcomes due to the lack of depth control, and it results in the splattering of blood and tissue. With the rise in bloodborne diseases and the advent of laser technology, dermabrasion is less frequently performed today.

Phenol chemical peeling. Phenol is a caustic chemical that is used to destroy the outer layers of the skin and can be unpredictable and toxic. Other compounds have become popular that are much more predictable and safer than phenol. For example, trichloroacetic acid, or TCA, and glycolic acid chemical peels are now commonly performed by oral and maxillofacial surgeons. These acids are used while the patient is under local or general anesthesia and are quite effective at rejuvenating the facial skin.

After two to six weeks of prepeel conditioning with tretinoin and bleaching agents, the patient is sedated in the office. Thirty-five percent TCA is applied to the face and the skin proteins begin to coagulate. This chemical change causes a temporary white color referred to as a "frost." The intensity of the frost is used to determine the correct depth of the peel. The skin will "defrost" in 10 to 20 minutes, and the patient is awakened.

The immediate recovery pain is consistent with that of a significant sunburn for several hours. Over the next three to four days, the skin takes on a leathery hue and texture and then begins to peel as with a sunburn. As the old skin peels, fine wrinkles and pigment spots are removed. The new youthful skin is tighter and without superficial pigmentary abnormalities. This procedure usually requires a five-day recovery period. Makeup usually can be worn at seven days. More dramatic results require multiple peels that are spaced three to four months apart.

Laser skin resurfacing. Laser technology has virtually replaced dermabrasion and phenol chemical peeling as the treatment of choice for facial rhytids (wrinkles), pigmentary problems and acne scarring. It uses the controlled burning power of amplified laser light. With the laser, a given power setting will produce the same depth from person to person. This reduces operator error and increases the operator’s ability to precisely reach the desired dermal layers. The precision of laser skin resurfacing is due to the fact that individual layers of epidermis and dermis can be removed almost cell by cell.

The most common skin resurfacing laser is the carbon dioxide, or CO₂, laser. A single pass of this laser usually will remove about 100 micrometers of tissue. Lesions or wrinkles can literally be wiped away with laser ablation.

Laser resurfacing produces a second-degree burn. The initial management consists of protecting the raw dermis until the epidermis re-epithelializes, which takes about 10 days. The affected area is weepy for three to four days and then progresses from red to pink over several weeks. Makeup may be worn at about 10 days.

The results of laser resurfacing on wrinkles and acne scars usually are much more dramatic than that of the chemical peel (Figure 1). The main drawback of the CO₂ laser is prolonged erythema, or redness, that can last from weeks to months.

View larger version (101K): [in this window] [in a new window]   Figure 1. Preoperative (A) and postoperative (B) photographs of a patient showing the results of Co2 laser skin resurfacing.

The erbium:yttrium-aluminum-garnet, or Er:YAG, laser is a newer laser that has a greater affinity for water and, therefore, does less thermal damage to the cells than does the CO₂ laser. The Er:YAG laser produces much less erythema than does the CO₂ laser, and the resulting redness usually resolves in less than a week. The laser provides less dramatic treatment of wrinkles and acne scarring and works better in younger patients who have less severe skin damage.

Complications of any facial resurfacing procedure include hyperpigmentation, hypopigmentation, hypertrophic scarring and herpes infection. The recovery time from full-face laser resurfacing procedures is usually one to two weeks.

Botulinum neurotoxin A treatment. One of the new esthetic treatments is the use of botulinum neurotoxin A, or BoNT-A, which is one of the toxins responsible for botulism food poisoning. In high doses, BoNT-A is the most potent toxin known to humans.⁷ The paralytic effect of BoNT-A is a result of its ability to block the release of acetylcholine at the myoneural junction.⁸ Minute doses of this toxin are used in esthetic facial surgery to selectively paralyze facial muscles that contribute to lines, folds and wrinkles.⁹

The most common areas treated with BoNT-A are the glabellar area (between the eyebrows and the nasal bridge), the frontalis area over the forehead where horizontal wrinkling occurs and the lateral canthal areas where "crow’s-feet" wrinkles occur.

Five mouse units of BoNT-A are injected in selected areas to treat the hyperfunctional muscles that contribute to wrinkling. About 72 hours are required for the paralytic effect to occur and the paralysis lasts for four to six months (Figure 2).

View larger version (97K): [in this window] [in a new window]   Figure 2. Wrinkles and hyperfunctional muscle lines shown during scowling before (A) and 72 hours after (B) the botulinum neurotoxin A injection into the procerus, corregator supercili and medial orbicularis oculi muscles. Note that in the postoperative photograph (B), the patient is attempting to scowl but is not able to.

BoNT-A is being evaluated for the paralysis or weakening of other masticatory muscles to decrease temporomandibular joint, or TMJ, dislocation.¹⁰

No major complications have been reported with BoNT-A. Minor bruising and transient headaches have been observed. My colleagues and I have observed coincidental improvement of migraine headaches; I am investigating this possibility. No recuperative time away from work is necessary in conjunction with the injections.

Blepharoplasty. The upper one-half of the face frequently ages before the lower one-half of the face; treating the aging effects on the eyelids and related structures can dramatically enhance facial esthetics.¹¹ Loose skin and orbicularis oculi muscle hypertrophy are two main effects from aging on the eyelids and cause droopy upper and lower eyelids. In many people, the upper lids become so droopy that they obscure vision by the loose skin overlapping the eyelids.

The eyeballs are surrounded by fat that serves as cushioning and allows free movement. The orbital septum is a structure in both eyelids that separates the fat from the eyelids. As we age, the septum weakens and the orbital fat herniates through the orbital septum and causes baggy eyelids. This herniated fat is the main cause of eyelid bags and gives people a tired and aged look.

In blepharoplasty of the upper eyelid, the surgeon excises a strip of excess skin and muscle to tighten the upper lid. After removing the excess skin and muscle, herniated fat also is removed. In the lower eyelid, surgeons frequently use a trans-conjunctival incision to access lower eyelid fat by incising through the inside of the lower lid. This provides excellent access to the herniated fat and eliminates the need for a skin incision.

The lower eyelid and infraorbital skin areas frequently are treated simultaneously with chemical peel or laser. This eliminates many wrinkles and tightens the skin, which dramatically enhances the blepharoplasty (Figure 3).

View larger version (72K): [in this window] [in a new window]   Figure 3. Preoperative (A) and postoperative (B) photographs of a patient who underwent upper and lower eyelid blepharoplasty. Note obvious reduction of redundant upper eyelid skin and exposure of natural eyelid crease in postoperative view (B).

The position of eyebrows may affect blepharoplasty. If the eyebrows are ptotic and the excess skin is removed, it will lower the position of the eyebrow and actually worsen the esthetic outcome. Endoscopic forehead and brow lift surgery is a new procedure that allows the surgeon to suspend the eyebrows and forehead through small skin incisions in the scalp using arthroscopic techniques similar to TMJ arthroscopic surgery.^12,13

This procedure elevates the eyebrows to a more natural position. The female eyebrow normally is arched and about a centimeter above the orbital rim; the male eyebrow is flat and level with the orbital rim. Previous brow lifting procedures required a scalp incision from ear to ear and the excision of scalp tissue. Successful endoscopic brow surgery will decrease the wrinkles in the forehead, elevate the position of the eyebrows, tighten the excess skin of the upper eyelids, and decrease the function of the scowling muscles between the eyes and above the bridge of the nose. Endoscopic brow and forehead lifting have made this surgery and recovery from it more tolerable for the patient and result in fewer complications, which include paresthesia, asymmetric lifting and surgical relapse of the brows. The recovery period for endoscopic brow and forehead lifting is five to seven days.

Facial liposuction. Liposis is a term used to localized fat accumulations in the body. In 1987, the tumescent technique of liposuction was introduced.¹⁴ Liposuction is a procedure in which the surgeon uses suction to evacuate fat from selected body areas. Liposuction is not a treatment for obesity, but more for localized, isolated fat deposits.

The tumescent technique of liposuction involves the injection of a dilute mixture of lidocaine 0.1 percent and epinephrine 1:1,000,000 into the fat deposits. The tumescent technique facilitates the liposuction technique by allowing hydrodis-section of the fat and allowing greater fat removal, as well as contributing to hemostasis. The added lidocaine allows this procedure to frequently be performed with the patient under local anesthesia.

Although fat usually is considered the enemy of cosmetic surgery, it also can be a useful material for augmentation of esthetic problems and defects.

The most common areas for facial liposuction are the submental region, the buccal jowls and the buccal fat pads.^15,16 If the platysma muscle is separated in the submental region, sagging and neckbands are apparent. The oral and maxillofacial surgeon will make a small incision underneath the chin and remove fat in an open manner, as well as reattach the platysma muscle in the midline or suspend it with sutures.

Figure 4 shows the dramatic results obtained by combining liposuction with augmentation genioplasty using expanded polytetra fluoroethylene, or ePTFE, (Gore-Tex, W.L. Gore) chin implant.

View larger version (91K): [in this window] [in a new window]   Figure 4. Preoperative (A) and postoperative (B) views of a patient who underwent submental liposuction and chin implant using expanded polytetra fluoroethylene. Note the distinct definition of the cervical angle and the improved chin and profile esthetics.

Autogenous soft-tissue augmentation (fat injection). Although fat usually is considered the enemy of cosmetic surgery, it also can be a useful material for augmentation of esthetic problems and defects. The surgeon harvests fat cells from the abdomen or lateral thigh and, after centrifuging them, reinjects the fat cells into specific areas such as the nasolabial fold area, lips, zygomatic areas or any other area that the patient deems necessary of filling or augmentation. The remaining fat that is not used may be frozen and used in the same patient at a later date.

Some of the fat cells that are harvested and reinjected lose their viability and are resorbed. For this reason, the surgeon must overcorrect the defects when injecting the fat. Each time fat cells are injected in the area, some fat cells remain viable; repeating this procedure several times will produce the desired permanent result.

Complications from this procedure include infection of the donor or recipient site, accelerated resorption of grafted fat, and over- or undercontouring from operator error. A weekend recovery period usually is sufficient, and missing work is not usually necessary.

	Alloplastic tissue augmentation (facial implants).

TOP ABSTRACT THE AGING FACE REJUVENATION STRATEGIES Alloplastic tissue augmentation... CONCLUSION THE ASSOCIATION’S REVIEW... REFERENCES

 
Enhancing facial features by using synthetic materials has been done for many years. Silicone, hydroxyapatite and methylmethacrylate are some of the more common materials used.

The material ePTFE, which commonly is associated with rainwear due to its hydrophobic and breathable qualities, has been used for more than 20 years for vascular grafts; more than 5 million grafts have been placed without a single case of rejection.¹⁷

The material ePTFE is used for soft-tissue augmentation and been used extensively in the face. Implants made from ePTFE frequently are used for augmentation of nasolabial folds, glabellar folds, facial scars, and chin and cheekbone augmentation. The ePTFE strips are threaded under the facial skin and serve to "plump" out the wrinkles or folds. Chin and cheekbone implants that are made from ePTFE now are available. The chin implants usually are placed through an intraoral incision and secured to the mandible with screws.

Complications include graft rejection, infection, and over- or underaugmentation. A weekend recovery period generally is required, and no time away from work is necessary for facial augmentation.

Augmentation or reduction cheiloplasty. Cheiloplasty, or lip enhancement, is one esthetic procedure that should be important to restorative dentists, as it serves to frame their work, much as an ornate frame will accentuate a fine piece of art. Today, as in the 1940s, thick, well-defined lips are considered voluptuous and stylish.

Lip augmentation. Various materials are available to augment lips, and they include ePTFE, fat and bovine collagen, as well as dermis (J. Niamtu, D.D.S., unpublished data, 1999). I frequently use a combination technique of an ePTFE cylinder implant at the vermillion cutaneous border with simultaneous augmentation of the lip body with the particulate fascia lata graft.

The previously mentioned autogenous harvested fat also can be used in the lips. Fat may be harvested from the submental region, abdomen, lateral thighs or buttocks and reinjected into the lips. The harvested fat is partially resorbed and several injections usually are required at one-month intervals to obtain permanent results.

Bovine collagen frequently is used to augment the lips, as well as better define the "white line" of the vermilion-skin interface. The collagen first is injected into the white line to accentuate the "cupid’s bow" configuration, and then it is injected into the parenchyma of the lip to increase thickness and fullness.

Although bovine collagen will produce predictable esthetic benefits, it is resorbed by the body and only lasts several months. A small percentage of patients may be allergic to bovine collagen and, therefore, all patients must undergo allergy testing at least one month before collagen injection. A newer product is human collagen (Fascian, Fascia Biosystems) that is harvested from cadaver tissue and sterilized. This product is less expensive, does not require allergy testing and has been shown to cause some permanent collagen formation.

Complications of lip augmentation are rare and include infection, graft rejection and overcorrection from operator error. A weekend recovery period usually is sufficient for fat augmentation and no time away from work is necessary for collagen lip augmentation. When using fat, the lips are usually overcorrected, as the body will resorb a portion of the injected fat. Multiple injections may be required for a permanent result.

Lip reduction. Many people are unhappy with the large size of their lips. Reducing large lips usually is a simple procedure that is performed by excising a wedge of tissue from the intraoral mucosal surface and suturing the incision. The excised tissue results in a narrower, less-full lip. Complication with reduction cheiloplasty include under- or over resection. A five- to seven-day recovery usually is adequate.

Rhytidectomy. Rhytidectomy, or face lift surgery, rejuvenates aging skin and is especially effective in dealing with saggy jowls and excess and droopy neck and submental region skin. Although this procedure is referred to as a face lift, it provides major improvement in the neck and submental areas and defines the cervicomental angle and mandibular border.

Many of the previously mentioned techniques—such as laser resurfacing, ePTFE augmentation of nasolabial folds and BoNT-A injections—may actually postpone rhytidectomy for many people. However, one can hold off the effects of gravity for only so long.

Rhytidectomy is performed using different techniques that produce varied results and chances of complications. It frequently is performed in the outpatient office environment with intravenous anesthetic. It involves conventional liposuction of the neck and lateral portion of the cheeks to undermine and dissect the subcutaneous tissues. An incisional flap is then made, which is very similar to the approach used in TMJ surgery, but the incision is extended around the back of the ear and into the posterior hairline. The soft tissues are further dissected and the superficial facial fascia is incised and plicated. This layer also is referred to as the superficial musculoaponeurotic system, or SMAS. This layer then is tightened by incision or suspension by suturing it to deeper structures. While suturing this layer, the surgeon suspends the SMAS in a vector opposite that of the gravitational forces and sagging skin.

A face lift provides major improvement in the neck and submental areas and defines the cervicomental angle and mandibular border.

The sagging skin and platysma muscle of the neck usually are addressed at the same surgical procedure. Excess submental fat is liposuctioned and the platysma muscle is tightened or suspended. Finally, excess skin is excised at the preauricular incision and sutured to tighten the previously saggy facial and neck skin.

Complications include hematoma formation, facial nerve injury, infection and hypertrophic scar formation. Rhytidectomy requires a recovery period of about two weeks.

Rhinoplasty. For decades, oral and maxillofacial surgeons who perform maxillary osteotomies have been working on the nose from an internal approach and have performed septal, turbinate, anterior nasal spine and alar base procedures to benefit their orthognathic procedures functionally and esthetically.^18–21

Various esthetic rhinoplasty, or nasal surgery, procedures are performed by oral and maxillofacial surgeons. Surgery to enhance the nasal tip and projection, as well as to reduce the nasal dorsum, are some of the most common esthetic nasal procedures.²² Many oral and maxillofacial surgeons also perform septal surgery and treat traumatic nasal fractures.

Complications of rhinoplasty include bleeding and infection and compromised treatment results. Patients usually require a seven-to-14-day recovery period when undergoing esthetic rhinoplasty.

Adjunctive facial esthetic procedures. Other common esthetic procedures performed by oral and maxillofacial surgeons include otoplasty (surgical repositioning of protruding ears); the removal of facial telangiectasia, or spider veins, with vascular lasers or radio-frequency ablation; the esthetic removal and biopsy of facial nevi; the repair of torn earlobes; and hair transplantation.

	CONCLUSION

TOP ABSTRACT THE AGING FACE REJUVENATION STRATEGIES Alloplastic tissue augmentation... CONCLUSION THE ASSOCIATION’S REVIEW... REFERENCES

 
Over the past century, the specialty of oral and maxillofacial surgery has continually progressed from exodontia to include functional and esthetic procedures of the hard and soft tissues of the oral and maxillofacial region. All dentists should be aware of the oral and maxillofacial surgeon’s abilities in providing esthetic treatment of the aging face, as well as the potential benefits to their patients from the enhancement of their esthetic dentistry.

	THE ASSOCIATION’S REVIEW OF ISSUES CONCERNING COSMETIC ORAL AND MAXILLOFACIAL PROCEDURES

TOP ABSTRACT THE AGING FACE REJUVENATION STRATEGIES Alloplastic tissue augmentation... CONCLUSION THE ASSOCIATION’S REVIEW... REFERENCES

 
Especially in light of recent legislative and legal developments regarding many of the types of procedures addressed in this article, dentists deciding whether to offer such procedures—or whether and how to make referrals to dentists who perform them—need to be mindful of a variety of considerations. One has to do with each state’s legal scope of practice: is the dentist licensed to perform the procedures in question? This may often turn on factors such as the dentist’s training and experience, the state dental practice act’s definition of dentistry and the actual license granted to the dentist by the state dental board.

State dental boards are increasingly sensitive to such issues. For example, reportedly in response to complaints by two patients against oral surgeons, the Dental Board of California recently sent a letter to all oral surgeons telling them they should not perform cosmetic procedures unrelated to a dental procedure.

Even if the state dental board has authorized the dentist to perform procedures such as those outlined in the accompanying article, the board’s actions—and hence the dentist’s licensure—might be challenged in court. In the sole reported decision in such a case, a court in Tennessee recently ruled that the state dental board had overstepped its authority by allowing a dentist to engage in certain procedures that the court viewed as medical in nature and not within the board’s purview. At press time, that decision was being appealed. Whatever the outcome of that appeal, the Tennessee case and others like it are reminders that dental boards and/or courts enforcing state dental acts will not always take as broad a view as to what constitutes "dentistry" as some dentists may want them to.

So when it comes to practicing in areas outside of "traditional" dentistry–particularly nonemergency, cosmetic services unrelated to a dental procedure—even if performed on "associated" structures—it’s important to know that there may be limits on what is deemed permissible.