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Misguided patients and prudent cosmetic surgery


Kyle S. Choe, M.D.
Patient-initiated and entirely elective, cosmetic surgery of the face is fundamentally different than medically necessary surgery. Therefore, patients have unique expectations about both the results of cosmetic surgery and the visible traces that a procedure has been performed, such as incisional scarring.

In the operating room, we cosmetic surgeons aspire to an ideal world in which every incision heals to the original histologic and gross state. In such a world, scars are undetectable; bruising and swelling are minimal; recovery time is negligible; restrictions around post-operation physical activity are limited. All the while, the patient's face emerges looking more natural and younger.

To be sure, our field is ever pushing itself to effect such a world. In recent years, the number of product introductions promising faster healing, quicker recovery or minimal downtime, or some combination of all three, has been overwhelming. Thermal-based skin-tightening systems and simple suspension lifts are just two of the many options available to satiate the ever-demanding cosmetic surgery patient.

Be selective But new is not always better. We owe it to our patients to be more thoughtful and selective about using the untried products continually flooding the market. The recently documented Florida misfortune caused by the use of unpurified botulinum toxin serves as a salient reminder of the possible consequences of using such products. We need to educate our patients, set realistic expectations, and choose the right technique and products for the right patient. Often, this will mean using not the newest technology, procedure or product available, but rather those that have stood the tests of time and peer review.

One of the greatest advances in the field of cosmetic facial surgery — one that has stood the test of time — is minimal-incision endoscopic surgery. First applied clinically well over 20 years ago, and today still applied in non-cosmetic fields such as otolaryngology and orthopedics, endoscopic surgery involves the use of a highly precise endoscope and very small incisions (usually a few millimeters in length) as opposed to the long scalp incisions and the removal of healthy, hair-bearing skin associated with more traumatic, less sophisticated surgical procedures.

Compared to classic approaches to upper two-third facial rejuvenation, minimal-incision endoscopic surgery offers several other distinct advantages: improved preservation of the scalp sensory nerves, better control of brow position, accurate resection of the brow depressor muscles, decreased post-surgical numbness and better effacement of nasolabial folds.

Since the introduction of this procedure, many authors have reported their personal experiences with it, and have offered various modifications to the technique. Over the years, this still-expanding body of literature has contributed to a refinement such that, today, the procedure is used to produce consistently reliable and natural results.

Cosmetic surgeons are fortunate to be a part of a very dynamic field of medicine propelled largely by technological innovation, and they are unique in the type of surgery they provide to their patients. Yet, with membership in this community comes both temptation and responsibility: temptation to yield to sometimes misguided patient demands, and the responsibility to ensure that our procedures and products serve our patients' overall best interests. And it will be those cosmetic surgeons who fulfill their responsibility and do not succumb to temptations who will be deemed prudent.

Kyle S. Choe, M.D. is a Director of Facial Plastic & Reconstructive Surgery Laser Skin & Vein Center of Virginia.

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