by Camilla Jay Stewart
St. George’s Hospital, London
Facial aesthetic surgery is trending with significant popularity globally; rhinoplasty and facelifts being in the top five plastic surgery procedures performed in 2017. With social media and selfies being the day to day norm, patients are increasingly captivated by instant improvements to the face. 1,2
Istanbul has fast become a centre of facial aesthetic excellence, home to several internationally renowned certified plastic surgeons that serve the high demands and expectations of a large, multicultural population. This article highlights three key trends in Istanbul that have innovated the fields of rhinoplasty and face lifting.
The Preservation Rhinoplasty
Management of the nasal dorsum remains a challenge in rhinoplasty surgery, with many reduction rhinoplasties resulting in destruction of the key-stone area. This may require reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. Dr Baris Cakir, internationally renowned for his conceptualization of the “polygon rhinoplasty” in tip surface aesthetics with co-author Dr Rollin Daniel advocates the use of dorsal preservation via an (1) endonasal approach (2) removal of a septal strip in the subdorsal area whose shape and height are determined preoperatively (3) complete lateral, transverse and radix osteotomies and (4) dorsal reduction, utilizing a let down operation (LDO) or a push down operation (PDO) (Figure 1).3,4 The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4mm if lowering, whereas the PDO consists of downward impaction of the fully mobilised nasal pyramid and is utilized in patients with smaller humps (<4mm). This technique of dorsal preservation results in more natural postoperative dorsum lines, with fewer dorsal irregularities, inverted-V deformities or need for midvault reconstruction in selected primary patients.4
Furthermore, dissection is performed in a complete subperichondrial plane to minimise soft tissue disruption, resulting in less scar tissue formation and preservation of ligamentous structures.5Intra-operatively the scroll ligament and Pitanguy’s midline ligament are repaired to stabilize the internal valve and tip position, and long-term post operatively preserve tip definition and elasticity, respectively.
The Piezoelectric Rhinoplasty
The LDO and PDO can also be performed using an Ultrasonic Piezo or “Diamond” surgery technique, advocated by Dr Abdulkadir Göksel, member of the International Rhinoplasty Research Society and certified member of the European Board of Facial Plastic and Reconstructive Surgery. The use of Ultrasonic Piezo in the field of Rhinoplasty was first pioneered by Dr Olivier Gerbault, his fellow colleague in the International Rhinoplasty Research Society.
The key advantage of Piezoelectric surgery or “instrumentation” (PEI) is the inability of Ultrasonic Piezo to harm surrounding soft tissue: Piezoelectric vibrations generated by an electrically supplied piezoceramic transducer cut bone through a precise tip that emulsifies the bone selectively and removes it by suction irrigation without thermal or mechanical injury to the surrounding tissue. In this respect, the Ultrasonic Piezo tip has no potential to damage the nasal mucosa, membranes, muscles and vasculature, significantly reducing the degree of swelling and bruising post operatively. Suborbital swelling common on the third day post rhinoplasty tends to resolve within one week, and bruising is extremely rare.
Using an extended open approach, the bony nasal pyramid is completely undermined subperiosteally beneath the medial canthal tendon, piriform aperture and transverse piriform ligament so that osteotomy or osteotectomy can be performed under direct vision. The ultrasonic piezotome replaces the osteotome in contouring the osseocartilaginous vault, allowing precise analysis and surgical execution to perform the LDO or PDO as required for dorsal reduction (Figure 1). At the end of the operation, Dr Göksel uses a drain application through the inferior turbinate’s starting point to further reduce the risk of swelling and bruising post operatively. This is performed by excising a thin layer of a cannula and placing this between the bone and skin, removed one day post operatively.
The cost, increased operating time and learning curve associated with PEI limit its global use and availability. However, the greater precision that this technique offers, with preservation and protection to the soft tissues continues to give superior and natural results with reduced brusing and swelling post operatively. It has also advanced our understanding of the upper third of the rhinoplasty.6
The Midface Lift
Although the best way to perform a face lift has always been, and continues to be a matter of debate, there is even greater controversy when it comes to the best way to address the midface. The midface lift is one of the greatest technical evolutions in facial surgery, developing from lateral based rhytidectomy techniques with superolateral elevation to modern centrofacial approaches designed to achieve more vertical vectors of elevation.
Dr Serdar Eren, internationally renowned for his work in face-lifts and body sculpting, uses a transpalpebral approach to the midface. He emphasises the importance of midface lifting for a dynamic and youthful appearance at all ages, and tailors this technique carefully to the patient after a thorough preoperative evaluation of their facial aesthetics, anatomy, ophthalmic history, examination and individual expectations. The same method can be used to address many problems, including those requiring lower lid blepharoplasty, with android face and mid-cheek dysplasia, with lid/cheek deformity after lipofilling to the mid-face area, lid/cheek and tear trough deformity after orbital fat excision, ectropion scleral show, deformity after treatment with lipofilling or filler injections in infraorbital area and exophthalmos secondary to Grave’s Disease.
Under general anaesthetic, he performs this technique using a subciliary incision after pre- infiltration of local anaesthetic along the incision line. Dissection proceeds inferiorly developing a suborbicularis plane with a fine tipped colarado needle, elevating a skin muscle flap to expose the orbital rim. The medial part of the orbicularis oculi, levator labii superioris, orbitomalar ligament and zygomatic cutaneous ligaments are released completely, and dissection proceeds in a subperiosteal plane with care taken to preserve the infraorbital and zygomaticofacial nerves as they exit their respective foramina. Dissection boundaries are the gingivobuccal sulcus inferiorly, the malar eminence and medial insertion of the masseter laterally, and the nasomaxillary junction and pyriform aperture medially, elevating the periosteum as an island flap. Once full mobilisation of the midface composite flap is complete, with superior traction this can be easily elevated without excessive force. 7
A combination of suspension sutures are used to direct the lift in a superomedial or superior vector tailored to the individual patient’s aesthetic need: A vertical space lift can be achieved by pulling of the bucchal fat pad in the medial oblique direction and fixation to the medial orbital rim. If there is no need to use the Bucchal fat pad for volume, it can be removed to get a triangular shape. Transposition of the levator labii superioris with suborbicularis orbital fat (SOOF) and fixation to the medial orbital rim can be used to correct tear trough deformity. The orbital septum is further opened releasing suborbital fat to create better blending of the infraorbital area. The final step is to lift and secure the lower lid: The lateral canthal tendon is elevated superiorly to open space for orbicularis oculi muscle fixation on to the periosteum, with removal of redundant skin at the subciliary level dissected off the muscle. A thin muscle strip is then resected, and the orbicularis oculi is sutured and fixed just below the lateral canthal tendon without canthopexy or tarsorrhaphy ensuring the stability and shape of the lower lid are supported. The incision is sutured carefully with a subcutaneous 6’0 prolene suture and tape dressing for one week, for compression and immobilisation to avoid oedema.7
Like with all facial aesthetic surgical procedures, the success of this technique is guided not only by excellent surgical experience and skill, but also understanding individual patient concerns and expectations. Dr Serdar shares a holistic approach to beauty with his patients, integrating both mental and artistic ways of plastic surgery with a psychoanalytic point of view. He has innovated the “beauty concept”, understanding people’s individual approaches to beauty and reflections of beauty to their lives.
With acknowledgements to Dr Baris Cakir, Dr Abdulkadir Göksel, Dr Serdar Eren and Mr Mehmet Manisali.
New Plastic Surgery Statistics Reveal Focus on Face and Fat. The American Society of Plastic Surgeons (ASAPS) ©June 2018. Available from: https://www.plasticsurgery.org/news/press-releases/new-plastic-surgery-statistics-reveal-focus-on-face-and-fat
Worldwide Cosmetic Surgery Trends to Watch for in 2018! The International Society of Aesthetic Plastic Surgeons (ISAPS) ©June 2018. Available from: https://www.isaps.org/blog/worldwide-cosmetic-surgery-trends-watch-2018/
Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal Preservation: The Push Down Technique Reassessed. Aesthet Surg J. 2018 Jan; 38 (2) 117–131.
Çakır B1, Öreroğlu AR2, Daniel RK3. Surface Aesthetics in Tip Rhinoplasty: A Step-by-Step Guide. Aesthet Surg J.2014 Aug;34(6):941-55.
Cakir B1, Oreroğlu AR, Doğan T, Akan M. A complete subperichondrial dissection technique for rhinoplasty with management of the nasal ligaments. Aesthet Surg J.2012 Jul;32(5):564-74.
Gerbault O1, Daniel RK1, Kosins AM1. The Role of Piezoelectric Instrumentation in Rhinoplasty Surgery. Aesthet Surg J.2016 Jan;36(1):21-34.
Eren S. The Importance of Midface Lifting for Dynamic and Youthful Appearances at All Ages. Oral Presentation at the Royal Society of Medicine, May 2017, London.