Bio-Lifting and Bio-Resurfacing

28.1 Introduction

Throughout history, men and women have always had the desire to improve their appearance beginning with improving the state of the skin, so that we could say that “Aesthetic surgery of the skin is as old as humankind” [1]. In primitive societies, shells and details stones were used for engraving and to smooth the skin. Egyptians used a cream of sulfur and resorcine to smooth the skin, and thanks to animal oils and alabaster, regeneration of skin was improved. In the Papyrus of Edwin Smith (1700 BC) and in the Papyrus of Ebers (1600 BC) magic prescriptions are found for the hair or for the cutaneous lesions. In Mesopotamia, the Babylonians became experienced in surgery as noted in the code of Hammurabi (2000 BC), in China medicine and Chinese surgery blossomed as noted in the “Canon of the Medicine” (2600 BC). In the “Rig Veda” (1500 BC), the Indian surgeons pointed out their particular interest in the reconstruction of the nose cut off in thieves. In ancient Greece, physician developed care of the skin and the hair with ancient physicians specialized in the art of cutaneous exfoliation. The Renaissance Europeans studied exfoliation of the skin through translating ancient Greek manuscripts giving a greater development to aesthetics in dermatology, medicine, and surgery.

Today, there is a tendency to confuse aesthetic surgery with plastic surgery that evolved after the First World War from dentistry and adopting techniques from ancient dermatology and general surgery. Plastic

P.A. Bacci

Via Monte Falco n. 31, 52100 Arezzo, Italy e-mail: baccipa@ntc.it

surgery is surgery for the recovery of form and function, while aesthetic surgery is more like dermatologic surgery and is surgery of the physical aspect and the desires to be better looking. Aesthetic surgery overlaps many disciplines and is not within any specific specialization.

28.2 Patient Desires

One of the principle objectives of aesthetic medicine and surgery is the rejuvenation of the face, where the years and the various pathologies have left the signs of tissue and metabolic alteration as wrinkles, loss of elasticity and skin tone, alterations of the hair, and the aesthetic pathologies tied to alterations of the quantity and quality of the fat tissue.

Alterations of the basal activities of cells and vital systems constitute signals sent by those structures, so that dysfunction of the regulation of metabolic exchanges constitutes the beginning of chronic and degenerative pathologies as well as the processes of aging. Maintaining the state of health from aesthetic pathologies belongs to “Medicine for the health and the comfort of the patient” through maintenance of the functional harmony of the whole body and of the patient’s own image.

28.3 Aging of the Face

The observation of an aged face asks for a careful reflection both on the trials that have provoked the various modifications and on the nature of the same alterations.

Reprinted with Permission of Springer, Berlin and revised

In aging, the face suffers changes in the principal structures: the bony skeleton, the adipose tissue, and the musculocutaneous system.

According to the rules of universal proportions [2], the face can be separated into three equal segments: the first one from the joining of the hair to the eyebrow, the second from the glabella to the subnasal furrow, and the third one from this line to the chin.

Aging provokes a slow but continuous resorption of the bony structure with reduction of mass so that an unbalance is provoked between bony mass and cutaneous tissue so that there is too much skin and subcutaneous tissue in comparison to its content. Such disproportion is most evident in the inferior part of the face from the retraction of the jaw and reduction of the dental structure.

Dzubow [3] noted that aging provokes alterations and degeneration (Fig. 28.1). The continuous hormonal and circulatory modifications induced from the style of life, particularly by the improper feeding, sedentariness, and smoking provoke alterations in the metabolism of all the tissues ending in the reduction of the quantity of water and subcutaneous adipose tissue (typical of the young face) as well as the muscular and cutaneous vascularization that their structural and metabolic reduction provokes. All these modifications provoke a change in the muscular structure that manifests in the reduction of the fibers with reduction of the tone and of tropism with consequent decrease in glide for the gravity of the tissues.

At the same time and in the same way, there is a decrease of the metabolic and vascular activities of the

skin and subcutaneous tissue that provoke reduction of the structure and the cutaneous tone, where we have a less soluble and more rigid collagen, a fragmented elastic net, and regression of the microcirculation with reduction of the “cells to veil,” that is of that lymphoadipose and microvascular system that surrounds and nourishes the same microcirculatory system. All of this provokes reduction and atrophy of the skin and the systems of support with consequent low glide in gravity. It is this low glide of the tissues, caused by the gravity and altered metabolism that increases the initial vascular, metabolic, and aesthetic alterations of the face (Fig. 28.2).

The process of aging of the face is from a series of mechanical, physics, and physiological chemical alterations induced by the stress of life that reduces the metabolic activities and vascular function that activates those alterations of chronic degenerations characterized by cutaneous excess, reduction of fat and the glide of the fat tissue, and atrophy of the skin.

Changes usually induced by feeding, smoke, hormones, and intestinal dysfunctions alter the equilibrium of the interstitial matrix with increase of free radicals, alteration of the systems of oxyreduction, alteration of the metalloproteasis, alteration of the production of collagen, reduction of the microarterial circulation, increase of the microlymphatic stasis, and finally activation of the processes that will bring degeneration of aging characterized by the fibrosis [4, 5]. Various degenerative changes due to gravity and loss of glide of the tissues evolve into the typical alterations of the aging (Fig. 28.3).

The process of evolution of the suborbicularis adipose bulge is typical. While cutaneous excess of the superior eyelid with relative adipose bulge depend, mostly, upon the yielding of the frontal structures and from reduction of the eyebrow fat, in

the lower eyelid the yielding of the malar structure with reduction of the adipose tissue and its prolapse stretches the ligament and suborbicular septum provoking formation of the bulge and the cutaneous excess.

While the tissues droop, there are some morphological alterations (in the temporal and spatial position) both of the microvascular systems of nutrition and purification of the tissues of the neurological and metabolic systems, that provoke signals and the production of the structural substances, among which are collagen and elastin. It is this association of metabolic alterations with the mechanical alterations induced by the droop of the tissues that is key to the interpretation of these changes [6].

Bringing the tissues to a more juvenile, more pleasant, and less severe appearance to the face reduces the annoying wrinkles and cutaneous excess folds (Fig. 28.4). Bringing the tissues to their best position means slowing down the processes of aging and improving oxygenation, decreasing the lymphatic stasis and the tissue toxicity, reducing free radicals and the oxidative alterations, reducing the alterations of the metalloproteasis as well as the process of fibrosis. It means to return the normal function to the extracellular matrix.

According to the type and degree of aging of the face, different treatments can be used such as surgical or dermatologic cosmetic treatments. A fundamental rule is to make a basic classification to plan the most correct therapeutic procedure (Table 28.1).

Cross-section of skin with cogged contour threads

Tension on free

distal end Gentle contouring of tissue

Table 28.1 Process of aging face and tissues

1.Prolapse and skin excess

(a)Correct by traditional surgery or surgery using threads

2.Reduction or glide in low adipose tissue with reduction of volume of tissues with juvenile cutaneous turgidity

(a)Correct with fillers or autogenous fat tissue to increase the volume and to offer the good fundamental hormonal substances activating the metabolism

3.Alteration of the skin structure with loss of substances and consequential aging

(a)Correct by nutritional dermoelectroporation and local mechanical, physical, and chemical treatments

1.Prolapse and excess of skin

(a)When the face has cutaneous excess, surgical treatment must be used to allow tissue recovery and elimination of the cutaneous excess. Traditional lifting, in its various modifications, provides a new position of the deep tissues with duplication and fixation of the superficial muscular aponeurotic system (SMAS) to guarantee a more lasting result, but not eternal. Aesthetic surgery results in about 5 years (between 3 and 8 years according to the type of skin, of the age,

Before

Facelift using sutures