Cosmetic Procedures

It has been part of human nature for thousands of years to desire to alter one's appearance in some manner. This is a function not only of personal preference, but of culture, fashion, technology, pain endurance, lifespan, and affordability. Described below are various ways humans go about altering their appearance.

Using a suction device, the subcutaneous fat is selectively removed in specific areas to contour the body outline. Targeted areas can include: abdomen, thighs, "love handles" of lateral lower torso, arms, upper neck, back, and buttocks. The suction device is inserted through an incision about 1 cm in size, leaving very small scars. Removing subcutaneous fat may, as a consequence, highlight wrinkled or sagging skin. Complications are quite rare and can include: fat embolism syndrome, hemorrhage, and infection.

Also known as a "tummy tuck" this procedure is designed to remove excess skin and fat of the anterior abdominal wall and reduce the appearance of striae (stretch marks). The anterior abdominal musculature can be shortened and tightened.

In addition to liposuction, excess skin and fat can be excised to reduce sagging. The incision is made inferiorly to be hidden by the gluteal fold. In some cases, an implant or fat transplant may be used to augment the outline of the buttocks.

Hard silicone implants can be placed beneath calf muscles to increase the fullness of the calves. The incision is made in the lower popliteal region behind the knee.

Pectoral augmentation is performed for men wanting increased chest size. They can have implants (hard silicone, or implants similar to breast implants) placed beneath pectoral muscles of the chest.

This procedure can rehape the chin. In persons with a receding chin, an implant can be placed in front of the mandible through an incision below the lower lip, or through an incision in the skin below the chin.

Sagging upper arms can be remodeled by removing excessive skin and fat.

Implants can be placed over the cheekbones, usually through an incision inside the mouth.

With aging, particularly in women, the adipose tissue beneath the skin in the region of thighs, hips, and abdomen, and sometimes other places, becomes "lumpy" and irregular. Liposuction, fat injection, and removal of excess skin and fat can all be done. However, the cellulite is often widespread and difficult to treat completely.

Augmentation mammoplasty (breast enlargement) is performed to increase the size of small breasts and to match unequally sized breasts. Implants now consist of a plastic capsule and are filled with saline. The implant is placed either behind the breast tissue against the pectoral muscle, or behind the muscle adjacent to the chest wall. The incision can be circumareolar, beneath the breast, beneath the chest wall muscles, or in the axilla. Over time, some women will have scar tissue form that makes the breasts feel hard, or scarring that produces deformity and pain.

Mastopexy is performed to improve the appearance of drooping breasts. In this procedure, the nipple and areola are relocated superiorly, excess skin removed inferiorly, and the breast recontoured to a higher position.

Chemical peel: Designed to remove aging lines and wrinkles around the face, a chemical peel uses an acid-containing solution to remove part or nearly all of the epidermis. For superficial peels, alpha hydroxy acids (AHAs) such as glycolic acid are employed. Deeper peels use trichloracetic acid. For the most extensive peeling, phenol is used. The epidermis that regenerates may be smoother. In persons who have extensive sun damage and a condition called actinic keratosis (which can be pre-malignant), applicatiion of a cream containing 5-fluorouracil (a chemotherapeutic agent) can cause erythema and peeling and regrowth of skin that is less affected by the actinic keratosis process.

Dermabrasion: This procedure uses essentially the same equipment as a maker of model toys--a sandpapeer grinding wheel. The epidermis is abraded away in areas of wrinkling or of pitting from acne. The regrowth of epidermis may be smoother.

Laser resurfacing: A laser light is used to vaporize external layers of epidermis. No chemical is applied. The regrowth of epidermis may be smoother.

A solution containing collagen can be injected beneath the skin in subcutaneous regions in order to smooth out facial wrinkles. The solution is resorbed after several weeks, so the procedure must be repeated.

The exotoxin of Clostridium botulinum paralyzes skeletal muscle. A focal injection around the lateral eye will reduce muscle tone and reduce the appearance of wrinkles, particularly the "crow's feet" of older women. The effect lasts for about 3 months.

Augmentation: A dermal fat graft can be placed through an incision inside the mouth to advance the lip forward and make the lower lip more prominent.

Lip lift: A small wedge of skin can be removed from the corners of the mouth to raise the vermillion border of the lips at the corners. This improves sagging that gives some older persons a permanent frowning expression.

Lip reduction: A portion of the mucosa can be removed to reduce the size of large lips.

Drooping upper eyelids or bags beneath the lower lids can be excised to tighten up the skin around the eyes. The incisions tend to blend with the natural folds of the eyelids.

An incision is typically made behind the hairline of the scalp in order to remove excess skin of the forehead to remove wrinkles.

A portion of the earlobe can be excised to reduce the overall size of the earlobe.

This is the fancy name for a facelift. Incisions are made at the hairline and behind the ears and the facial skin pulled back and up. Excess skin is excised and the margins sutured. The resulting scars are generally hidden by hair.

The size and shape of the bridge and tip of the nose can be altered through an incision inside the nostrils. Cartilage can be removed to reduce the size of a "Roman nose". Wedges of skin can be removed to reduce the overall size.

Cosmetic tattoos are performed to create the effect of permanent facial makeup, often the appearance of a facial blush around cheekbones, or of eyeshadow, or of lip liner, or of eyebrow liner. Tattoos can reduce the effect of areas of vitiligo or of pigment loss following a burn injury. The problem is getting the right amount of pigmentation in an even distribution. Too much pigment, and the effect is that of a "clown" appearance.

Tattoos for body decoration and ceremonial and religious purposes have been performed for thousands of years in various human cultures. Most of the "traditional" tattoos are simple patterns on parts of the body (arm, chest, neck) that tend to retain shape with age, and with pigments such as blue and black that have minimal complications.

However, with time, the tattoo pigment, which is introduced into the dermis, tends to drift, and macrophages can engulf it and move it around as well. Thus, tattoos tend to blur and loose their sharp outlines with time. Throughout most of human history, most persons did not live long enough for this effect to become pronounced. In modern society, particularly fad conscious America, once the novelty of a tattoo wears off, the tattoo most certainly will not. Removal of a tattoo is best accomplished by laser ablation. The laser light is selected to reach the depth of the dermis and to selectively be taken up by the tattoo pigment, effectively vaporizing the pigment granules. However, the process is slow and costly.

Hair loss patterns are racial and hereditary, with Caucasians most affected, particularly those of northern European descent. In men, the most common pattern is "male pattern baldness" that affects the front and top of the scalp. Procedures for hair transplant include taking plugs of hair from the back of scalp (or elsewhere) to replace receding hairline. Microimplants of just a single hair can be done as well. The replacement of hair may proceed over 1 to 2 years. The success of transplants is unpredictable. The appearance of the transplanted hair may be different than expected.

The perception of unwanted hair is a cultural phenomenon that varies by place and time. Hair removal is a multibillion-dollar business in North America and Europe each year. Examples of hair removal techniques include shaving, depilatories, waxing, sugaring, epilation, electrolysis, and photo-epilation (laser).

In this procedure, a laser light strikes melanin pigment that is more selectively concentrated in hair follicles. A low intensity laser light (such as a ruby or alexandrite laser) is passed over the treated area. The light striking the melanin pigment produces heat that slows down or destroys the hair follicle. With repeated treatments, less hair grows. The procedure works better with darker hair containing more melanin. A variation on this method uses a suspensionof carbon particles applied to the skin that is more selectively concentrated within hair follicles, followed by application of laser light (usually neodymium:YAG) that disrupts the hair follicles through heat.

This method has been around for thousands of years. It is simple but must be repeated indefinitely. Hair growth does not become thicker with shaving. Instead, the ends of regrowing shaved hair shafts are coarser than the finer ends of naturally regrowing hair shafts. This also may cause problems, since the end of the shaft may retract beneath the skin surface to cause irritation ("bumps") and to produce ingrown hairs. Shaving may produce surface abrasions and lacerations.

These methods pull out hair shafts. A soft wax or thick sugar (like molasses) material is applied to a portion of skin surface and hardens around hair shafts. The material is pulled away from the skin, taking the hair with it (ouch!). Plucking (tweezing) is applied to individual hairs. Hair removed in this fashion usually takes 2 to 6 weeks to regrow, sometimes shorter. When hair regrows, it is often finer and lighter. Some hair bulbs may be removed, so over time the density of hair decreases. Uncommonly, some hairs become thicker and darker. Complications include hyperpigmentation, distorted follicles, and ingrown hair.

The process of electrolysis uses an electrical current applied selectively to the region of the hair follicle to destroy it. If properly performed, the effect is permanent. There are two forms of electrolysis. Galvanic electrolysis uses a direct current applied through a small needle to individual hairs. The current generates sodium hydroxide to chemically destroy the hair follicle. It takes about a minute per hair, so the method is very slow. Thermolysis uses a high frequency alternating current applied through a small needle to each hair, producing heat that destroys the follicle. Only a few seconds are required to destroy the follicle, but the current can be non-selective to destroy adjacent dermal structures and lead to scarring. A "blend" method utilizes a mixture of both direct and alternating current applied through the needle in order to localize the effect but make it faster. Electrolysis is very operator dependent--success depends on the skill of the needle operator. In addition to scarring, complications can include infection and, in darker skinned persons, hypopigmentation.

The most commonly used products contain agents such as mercaptans, including thioglycolic acid, which more selectively destroy hair than skin (though both have keratin). The chemical seeps down hair shafts and destroys hair below the surface, so the effect lasts longer than shaving. The major complication is skin irritation or allergy, which is not uncommon. Some products advertized as containing "natural" agents include a vegetable enzyme, such as papain from papaya, which breaks down protein. (Meat tenderizer used on a tough steak has the same effect). Trail tip: the effects of insect bites can be lessened with immediate application of meat tenderizer (or raw pineapple or papaya) which breaks down the protein of the venom.