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Cosmetic Surgery had its beginnings at the end of the nineteenth century. At first, the morality of people willing to undergo such surgery was questioned, but with time, the procedure gradually became more acceptable.

There were many factors affecting the growth of cosmetic surgery. The development of general anaesthesia was a key issue since, until the 1920’s, dripping Ether onto a rag covering the patients face was the most one could expect. The discovery of the first antibiotic and Sulfanamide, in the 1930’s was also a major factor, as the risk of infection in such operations was high. Antibiotics became more widely used after World War II. Most importantly perhaps, surgeons merely lacked knowledge or the appropriate techniques needed to perform effective cosmetic surgery. With the development of general anaesthesia, antibiotics and new techniques, reliable operations and instruments could then be designed to accomplish cosmetic changes and reduce the risks involved.

Throughout its history, cosmetic surgery has always attracted opportunists; surgeons seeking a quick and easy profit. At first, people were keen to believe in the promise of youthful looks and were prepared to pay handsomely for it. In the early days, patients seeking cosmetic surgery had merely wanted scars concealing, but by the 1950’s women were demanding their noses to be reshaped, purely to be in keeping with fashion and the popular image of beauty.

Reputable cosmetic surgeons are firstly general surgeons, plastic surgeons or otolaryngologists familiar with the body in general. They are therefore able to manage any surgical complaints which might arise. Traditionally, the best surgeons have actually been trained as reconstructive surgeons, helping patients to look normal.


RHINOPLASTY

One’s nose draws the observer’s eye because of its prominent position in the middle of the face. Surgeons have realized the anguish an obtrusive nose can cause to its owner and have developed ways to solve it.

Surgeons at first had to experiment in altering the shape of the nose. They trimmed nostrils that were too wide, elevated drooping tips and flattened humps of bone and cartilage to smooth humped noses. The real challenge was not the operation itself but leaving no obvious scars afterwards.

 

Johann Friedrich Dieffenbach (1794-1847), a Prussian surgeon,made the first recorded attempt to reshape a nose. He removed a wedge of flesh in order to raise a drooping tip and generally reduce the size of the nose. To slim the thick skin of a man’s nostrils, Dieffenbach removed wads of skin using a punch, an instrument similar to the tool used by a leather or metal worker.

John Orlando Roe (1848-1915), an ear, nose and throat surgeon from Rochester, New York, first addressed the problem of the elimination of all visible scarring. He recognized the importance of making the nose blend with the rest of the face and he proposedoperating on the nose through incisions hidden within the nostrils. Using this approach, he showed how he could reshape a pug nose, a deformity of the nasal tip resembling a dog’s stubby snout. Roe reduced an entire nose by removing excess bone and cartilage through an unobtrusive internal incision. The anaesthetic Roe used was cocaine. He applied it to the interior of the nose and injected it under the skin. Roe was unaware of the dangers of cocaine and was using it for his patient’s comfort. He appreciated the psychological benefits of cosmetic surgery. A well performed operation could relieve a patient’s embarrassment by eliminating a disfiguring feature.

Karl Koller (1857-1944), had introduced the use of cocaine in eye surgery while an intern at Vienna’s General Hospital. The world famous ENT Clinic in Vienna, Allgemeines Krankenhaus, was founded in 1884 by a surgeon unable to gain entry into general hospital. Robert Barany who received a Nobel Prize and George Von Bekesy practised at this clinic.

Robert Fulton Weir (1838-1927) of New York, introduced the subtle technique of reducing and refining a large, distorted nose. Weir operated through incisions hidden within the nostrils. To reduce the width, Weir chiselled the bones loose, moved them inward, and secured them by piercing them with a needle that was prevented from slipping by a metal shot

placed at either end. He also reported on how he narrowed the flaring nostrils of the wide, flat nose of an adult patient whose deformity typically accompanies a cleft lip. It is now routine to use Weir’s procedure of removing a wedge from the base of each nostril, then rolling the nostril inwards.

In Weir’s paper `On Restoring Sunken Noses` he identified the patient who is never satisfied with results and demands operation after operation, searching for perfection.

Jacques Joseph (1865-1934) Berlin, performed his first nose operation in 1896. Joseph tackled the problems of reducing a large nose while leaving as few offending scars as possible. He could shorten the nose, reduce its hump, straighten it and make the nostrils smaller by using incisions in the skin. Joseph performed the surgery through the inside of the nostrils. He had great success and, like his techniques, the saws, chisels and clamps that he devised for surgery are still in use today. Joseph was originally trained in Orthopedics. At that time cosmetic surgery was considered unimportant and unethical at Joseph’s University. He was temporarily suspended from his academic post for his unorthodox activities. He was not discouraged by this and continued to develop operations to correct abnormal features. In the year 1898, Joseph presented his procedures to the Medical Society of Berlin, where many local and American doctors were attending. He used intranasal incisions, removed nasal humps, performed lateral osteotomies and employed ivory for augmentation. (Joseph used to obtain ivory from a nearby piano factory). Joseph’s outstanding work enabled him to develop a worldwide reputation and people came from far and wide to have their rhinoplasty performed by him. Even more importantly, surgeons travelled great distances too in order to learn from him. Joseph, who was referred to as `Joseph Noseph`, specialized in rhinoplasty but also performed facelifts, otoplasty and general plastic surgery. In January 1934, Joseph performed his last rhinoplasty on the 16-year-old daughter of a Munich restaurateur. When Hitler rose to power, Joseph fled from Berlin to Prague. After his death, Joseph’s students brought his work to the attention of English-speaking surgeons. Among Joseph’s students were Gustave Aufricht, a Hungarian surgeon and Joseph Safian, both of whom became reputable as facial plastic surgeons in the United States. Safian was a careful and conservative surgeon who concentrated on how to avoid mistakes and how, if they were made, to correct them. Aufricht modified the Weir’s incision, and devised the Aufricht retractor which is still used in every rhinoplasty today.

 

The master rhinoplasty surgeons of the last twenty years (1980-2000) such as Robert Simons, Gaylon McCollough, M.E. Tardy, R.W.H. Kridel, Rollin Daniel, Webster, Dean Toriumi of the United States, and Tony Bull from the United Kingdom and others, have greatly contributed to the advances in our techniques today. The Tony Bull Course, London, has been operating for the last twenty years. The participants are surgeons from all over the world who are wishing to consider a career in rhinoplasty.

EARS
Giovanni Bathista della Porta, a sixteenth-century Neopolitan naturalist and philosopher, described a perfect ear as being neither too long nor too short. Johann Casper Lavater, the eighteenth century Swiss pastor who popularized the belief that external appearance is governed by inner moral qualities, devoted only three pages to ear size and shape and never once mentioned the criteria for judging the beauty of an ear. It is only in recent times that ears have been operated on to improve their aesthetic quality. Before this ears were only reconstructed if they had been partially damaged or completely destroyed.Ears placed closed to the head are recognized as desirable and surgeons have sought ways to make them flat. If one is unfortunate enough to have ears set at a right angle to the skull one is prone to be taunted as stupid or mean.

Edward Talbot Ely (1850-1885), Otolaryngologist at the Manhattan Eye and Ear Hospital pioneered the method for reshaping ears. However, this was not a problem free method since cutting out a strip of cartilage to flatten the ears left them with too sharp a crease. William Henry Luckett (1872-1929), New York, was the first to decide exactly what twist of anatomy made the ear protrude. A normal, visually pleasing ear gently folds back on itself and Luckett speculated that the protruding ear lacked such a fold. He set out to create a fold in the ear and after doing so he secured it with a line of stitches so that the ear was permanently rolled back toward the skull. Luckett took on the problem of setting back protruding ears as just one more in a long series of challenges. He also devised new methods of tying sutures, diagnosing skull fractures and removing diseased gallbladders.

 

The Aging Face

People do want to stay `forever young` and from the 1920’s onwards surgeons have worked hard to correct the difficulties of an aging face. Charles Conrad Miller (1880-1950), Chicago, is the man credited with making the first attempt at eliminating signs of facial aging. In 1906, he described removing lax folds of skin from the upper and lower eyelids. At first he cut away only the skin, he didn’t remove the bulging fat from around the eyeball that is standard procedure today. To correct the deep lines along the side of the mouth, Miller tried to burrow under the surface of the skin and cut muscles he believed to be the cause of the trouble. Miller blamed women for the unwanted creases, saying that they used these muscles improperly. He wrote the first book on cosmetic surgery `The Correction of Featural Imperfections`. By today’s standards Millers techniques for smoothing facial wrinkles were unsafe and unsavoury. In the 1920 edition of his book, Miller described some refinements to his facelifting technique. He recommended placing incisions unobtrusively, keeping them within the hairline while snipping and tucking to smooth the forehead. He recommended removing the skin and fat bulge through a long horizontal incision just under the chin for a double chin. Miller also advised surgeons to inform their patients of what to expect and to use fine suture material and fine technique.

Frederich Strange Kolle (1871-1929), suggested a remedy for the problems of loose, wrinkled skin on the upper and lower eyelids. His solution – removing large crescents of the skin from both upper and lower lids _ was fated to cause ectropion, contraction of the skin of the lower lids severe enough to show too much of the whites of the eyes and give the unfortunate patient a permanent, round-eyed stare.

Suzanne Noel (1878-1954), Paris, was the first woman to devote her practice exclusively to aesthetic surgery. In 1926, she published `La Chirurgie Esthetique: Son Role Social`, a book describing her ideas on the psychological impact of cosmetic surgery, as well as offering detailed explanations of her advanced surgical techniques. Noel believed that tugging on the skin alone was insufficient to achieve lasting results; lifting the skin off the underlying structures, then redraping it, provided a better effect.Reputable surgeons described other procedures, such as removing patches of the skin at the hairline and at the fold wherethe ear joins the face to smooth an aging face. Eugene Hollander (1867-1932), claimed he `lifted` the face of a polish aristocrat. Raymond Passot (1886-1933), France, carried out a similar operation. He predicted that cosmetic surgery would be viewed as reconstructive surgery had been in the past and that it would be accepted with enthusiasm by both the public and the medical profession. Albert Bettman (1883-1964), Oregon, U.S.A., presented the first before and after photos in 1919. His incisions in front of and behind the ear were closed with fine silk wire and horse hair and were almost identical to the standard incisions of today. Next Jacques Joseph published a photograph which showed his preoperative and postoperative results on a patient.

In the early days, the public were very gullible and believed in surgery that promised total rejuvenation. Charles-Eduard Brown-Seguard (1819-1894), France, decided that injecting an extract from dog testicles into an aging man could restore feelings and appearance of youth. Serge Voronoff (1866-1951), Russian, living in France, felt that he could achieve better results by transplanting entire testicles into the bodies of aging men. He felt that human organs would be best, but as it was difficult to get donors, young monkeys were used instead. Irradiating ovaries was the process used to attempt rejuvenation in women. The idea of irradiating ovaries and transplanting testicles was discredited but for a while these procedures had kept both public and surgeons hopeful of rejuvenation.

Moving into Facial Plastics

An ENT, head and neck surgeon who is familiar with parotid surgery, should not find a facelift difficult. Also, one who has practised osteoplastic frontal flap operations would find forehead lifting a relatively easy task. Therefore, it is a natural progression for otolaryngologists, once they have mastered rhinoplasty to move on to other parts of the face.

Ira Tresley, MD, President, American Academy of Facial Plastic and Reconstructive Surgery, 1969-1970, one of the best rhinoplastic surgeons. Otolaryngologists met with a lot of opposition as they tried out their new procedures. Many of them had their privileges from the hospital removed and suffered outright ostracism from the medical community. Jack Anderson scheduled his first rhinoplasties as submucous resections because a good friend and famous plastic surgeon called Neil Owens worked at his hospital. He knew that his friendship with Owens would be threatened if he put his procedure down as a rhinoplasty. Once the nature of Anderson’s work was discovered however, Owens never spoke to Anderson again and their friendship was lost.

Trent Smith, had a booming ENT practice before he decided to concentrate on facial plastic surgery. When he began doing facelifts he hired a young general plastic surgeon, who had just finished his residency to help him. Smith also met with a lot of opposition to his work. Morey Parkes was faced with a lot of resistance when he went on to do blepharoplastics and facelifts. He had no one to teach him and blepharoplastics was the hardest area to break into. Parkes commented that the move into facelifts and other cosmetic procedures was very gradual and sporadic. Anderson and Jesse Fuchs were doing it, other surgeons watched and learned from them, but it was a very gradual procedure.

Oscar Becker, Chicago, was a very accomplished plastic surgeon who was willing to allow others to come and watch his operations. One of his students was Sidney Feuerstein who often flew overnight to arrive at Weiss Memorial at six or seven thirty in the morning to watch Becker work and then listen to them discuss the procedure.

John Conley, head and neck cancer surgeon, was one of the first reputable surgeons to perform facelift surgery.

In the early days, surgeons did not have access to the kinds of seminars and courses that are available today. Despite this they were just as diligent in making the time to share their knowledge and hone their techniques.

Beekhuis explained that he had never done a facelift during his residency. To learn about facelifts he read and studied books about the subject, watched other surgeons performing the procedure, spoke to and questioned people about it and saw their results. Beekhuis found that the development of his skills in facelifts was not difficult, as he had already been working in the head and neck region.21

Nowadays, aesthetic facial procedures are practised by many specialists, including otolaryngologist, plastic surgeon, ophthalmologist, dermatologist and maxillo-facial surgeon. It is widely felt that the practice of facial plastic surgery by these varied communities, despite diverse experience and training, have very much attributed to the advances of the surgical techniques and upgraded the expertise and skills in facial plastic surgery.

 

Refrences
History of Facial Plastic Surgery

1.Aufricht G: The development of plastic surgery in the United States, Plast Reconstr Surg 1:3, 1942.
2.Weir RF: On restoring sunken noses, NYMJ 56:443, 1892.
3.Roe JO: The correction of angular deformities of the nose by a subcutaneous operation, Med Rec 40:57, 1891.
4.Joseph J: Operative reduction of the size of the nose (translated by G Aufricht). In McDowell F, editor: The source book of plastic surgery, Baltimore, 1977, Williams & Wilkins.
5.Joseph J: Nasal reductions (translated by F McDowell), Deutsch Med Wchnschr 30:1095, 1904. In McDowell F, editor: The source book of plastic surgery, Baltimore, 1977, Williams & Wilkins.
6.Natvig P: Some aspects of the character and personality of Jac`ques Joseph, Plast Reconstr Surg 47:452, 1971.
7.Safian J: Personal recollections of Professor Jacques Joseph, Plast Reconstr Surg 46:175, 1970.
8.Safian J: Failures in rhinoplastic surgery; causes and prevention, Am J Surg 50:274, 1940.
9.Safian J: Deceptive concepts of rhinoplasty, Plast Reconstruct Surg 18:127, 1956.
10.Goldwyn RM: Johann Friedrich Dieffenbach (1798-1847), Plast Reconstr Surg 42:19, 1968.
11.McDowell E: History of rhinoplasty, Aesth Plast Surg 1:321, 1978.
12.Davis JE and Hernandez HA: History of aesthetic surgery of the ear, Aesthetic Plast Surg 2:75, 1978.
13.Lavater JC: Essays on physiognomy (translated by T Holcraft), London, 1789, J Murray.
14.Ely ET: An operation for prominence of the auricles, Arch Otol 10:97, 1881.
15.Rogers BO: A medical “first”: Ely’s operation to correct protruding ears, Aesthetic Plast Surg 11:71, 1987.
16.Rogers BO: Commentary on “A new operation for prominent ears based on the anatomy of the deformity” by WH Luckett, Plast Reconstr Surg 43:83, 1969.
17.Mulliken JB: Biographical sketch of Charles Conrad Miller, “featural surgeon,” Plast Reconstr Surg 59:175, 1977.
18.Robbins HM: First is cosmetic surgery, Am J Cosm Surg 1:47, 1984.
19.Miller CC: Cosmetic surgery: The correction of featural imperfections, Chicago, 1908, Oak.
20.Rogers BO: A brief history of cosmetic surgery, Surg Clin North Am 51:265, 1971.
21.Simon R: Coming of age and thieme, 1989.
22.Romm, Sharon: The changing face of beauty, Mosby, 1992.

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