Face Procedures

Anatomy and function of the nose

With several different compartments, the nose is an intricate network of bones, cartilage, cells, blood vessels and nerves. The nose's form and function are closely related and all parts of the human nose work together to warm, filter and moisten the air that goes into the lungs, as well as send messages to the brain to enable the sense of smell.

Consisting of skin, bone, cartilage, blood vessels and nerves, the nose can be divided into two main parts - the external and the cavity. A wall called the nasal septum, which falls between the two nostrils and extends back behind the nose and into the nasal cavity, divides these sections vertically.

External

This term refers to the actual structure (similar to a three-sided pyramid) that protrudes from the face. The ridge that leads down from the forehead to the tip of the nose is called the bridge, or dorsum. The top-third section is made of bone and skin, while the bottom two-thirds are made of skin and cartilage. The skin of the dorsum and sides of the nose is thin, but is thicker over the tip and the nostrils. The skin also has more sweat and oil glands than other parts of the face. The cartilage that makes up the tip of the nose and nostrils is the most complex, as it is actually five separate pieces that are connected by membranes, and has a specific shape that varies for each person.

External at a glance:
• The nasal bones are two small, oblong-shaped bones that lie side by side between the frontal processes of the maxillary bones and join to form the bridge of the nose. They vary in size and form for each individual.

• Located at the anterior margin of the ethmoid bone, the septal cartilage connects the nasal bones and forms the dividing wall of the nose.

• Situated below the inferior margin of the nasal bone, the lateral cartilage is flattened and triangular in shape. It connects the septal cartilage on either side.

• The greater alar cartilage is a thin, flexible plate that forms the tip of the nose and nostrils.

• Also known as the naris, a nostril is one of two openings to the nose.

• The columella is the strip of skin that separates the nostrils.

• The rhinion is the anterior tip at the end of the suture of the nasal bones.

Cavity

The internal structure of the nose can be thought of as a tunnel with an opening on the face and an opening at the top of the throat. This tunnel, called the nasal cavity, is divided into a right and a left side by a bony and cartilaginous divider called the nasal septum. The top of the nasal cavity is divided from the anterior cranial cavity by a bone called the cribiform plate. The lateral walls on each side border with the maxillary, or cheek, bones. The floor of the nasal cavity is separated from the top of the mouth by the palatal bones.

The internal nasal valve involves the area bounded by upper lateral cartilage, septum, nasal floor, and anterior head of the inferior turbinate. This comprises the narrowest portion of the nasal airway in the leptorrhine nose. An angle wider than 15 degrees is generally needed in this area.

Inside the nose is lined with a moist, thin layer of tissue called a mucous membrane, which warms up the air and moistens it. This membrane makes mucous, which captures dust, germs and other small particles that could irritate the lungs.

The nose, being an air filter and conditioner for the lungs, contains hairs to keep out dust and microscopic particles that could hinder the breathing process. If something does get trapped in the nose, a sneeze is triggered to clear it out.

Further into the nose, smaller hairs called cilia move back and forth to keep the mucous out of the sinuses and back of the nose. Cilia can also be found lining the air passages to help move mucous out of the lungs. As the lungs need to be supplied with air that is about 35 degrees centigrade and 95 percent humidity, noses have to deliver air to the lungs at the right temperature. Hence, the cavity is also complete with shelves, called turbinates, which warm the air and add moisture to it before it reaches the lungs.

Internal at a glance:
• Made of bone and cartilage, the septum is the wall that separates the nasal cavity.

• The olfactory nerve transmits the sense of smell from the nasal cavity to the brain.

• The hard palate separates the oral cavity from the nasal cavity, whereas the soft palate closes the nasal cavity from the oral cavity when swallowing.

• The passage that connects the nasal cavity to the top of the throat is called the nasopharynx.

• The Eustachian tube is the narrow channel that connects the middle ear and the nasopharynx.

• Also known as the superior nasal concha, the upper turbinate contains olfactory receptor cells.

• The middle turbinate is the spongy bone situated between the upper and lower meatuses.

• The lower turbinate, or inferior nasal concha, lies between the middle and lower meatuses.

• The upper, or superior, meatus is the nasal opening located between the upper and lower turbinates.

• The middle meatus runs from the anterior to the posterior end of the lower turbinate.

• The lower, or inferior, meatus is situated between the lower turbinate and the floor of the nasal cavity.

• A nasal meatus is one of the four portions (common, inferior, middle, and superior) of the nasal cavity on either side of the septum.

Sinuses
Humans have four major pairs of sinuses. This system of air cells called the paranasal sinuses are located above the eyes in the forehead (frontal), under the eyes in the cheekbones (maxillary), between the eyes (ethmois), and behind the nasal cavity and eyes near the centre of the head (sphenoid). The paranasal sinuses all communicate with the nasal cavity by a series of small holes called ostia.

The sinuses are hollow areas within the bones of the skull that are lined with mucous membrane, also known as mucosa. By creating air-filled chambers within the skull bones, the sinuses may serve to decrease the weight of the head. They also add resonance to the voice.

Importantly, the sinuses help to cushion the eyes and brain in a severe injury to the face. They also help to warm and humidify the air that passes through the nasal passage.

Sometimes, the narrow openings that run from the nose to the sinuses become blocked and the lining of the sinuses becomes inflamed, which leads to sinusitis. This can cause many uncomfortable symptoms such as:

• Headache

• Sensation of a build-up of pressure in the head

• Blocked or runny nose

• Feeling of nasal stuffiness

• Sore throat and cough.

Nasal septum
The nasal septum is a thin, vertical wall that divides the right nasal cavity from the left. Made of cartilage and bone, it is usually straight and lies in the centre of the nose. When an abnormal bend appears in the septum and causes problems with breathing, it is called a deviated septum.

A deviated septum may be caused by an injury or birth defect, and can be corrected through a procedure called septoplasty.

Functions

The nose has many physiologic functions, some of which include breathing, olfaction and taste.

Breathing
The nose serves as a conduit for inspired and expired air. When air is inhaled through the nostrils, it enters the nasal passages and travels into the nasal cavity whereby it is humidified and warmed by passing over the moist and warm nasal mucosa. This function is greatly enhanced by the turbinates for they increase the surface area available for humidification and warming. The air then passes down the back of the throat into the windpipe, or trachea, through to the lungs. The nose also acts as a two-way street for air; when exhaling new air, the old air leaves the body.

Sense of smell
The olfactory centres are situated high along the roof of the nose. In order for these centres to be stimulated, the odours have to be inspired into the nose and carried up to the roof of the nose. The process of olfaction involves the detection and perception of chemicals that are floating in the air. It begins by inhaling these chemical molecules. They are then dissolved in mucous with a membrane called the olfactory epithelium. This membrane, which is located around 7cm into the nose from the nostrils, contains millions of olfactory receptor nerves, which can differentiate between thousands of individual smells.

The nose is capable of distinguishing a large number of different odours. Some people have a great sense of smell, but others suffer from anosmia, a loss of the sense of smell.

Taste
Taste is perceived primarily on the tongue through the taste buds. There are four recognised tastes: sweet, salty, sour and bitter. The sense of smell plays an integral role in the flavour of foods. While chewing, the food releases chemicals that travel up the nose and trigger the olfactory receptors. When your nose is blocked, it's unable to receive the chemicals that trigger the receptors.

It is common for individuals who have a cold or blocked nose and lose their sense of smell to report that food loses its taste. This is incorrect; the food has only lost its aroma, and taste (sweet, salty, sour, bitter) remains intact.

Evolution of the nose

The shape of an individual's nose seems to have evolved in response to environmental factors. In desert areas where the air is already heated but isn't moist enough, noses tend to be large and narrow. This is t ensure that air travelling up the nose has plenty of time to absorb moisture from the mucous membranes. In northern Europe, where the air is more humid but colder, noses are usually long and narrow to restrict airflow and give the air the time it needs to warm up before reaching the lungs. In more humid environments, shorter, wider noses enable the air to reach the lungs more quickly.

Anesthetics explained

Anaesthesia is one of the most important medical discoveries of the 19th century. Here is a brief outline of how they work.

Before anaesthetics came into general use around 150 years ago, surgery was simply carried out as quickly as possible. The record for an amputation was 15 seconds, by Napoleon's military surgeon Dominique Laffrey, who used snow to reduce pain.

Of course, many patients just passed out. In fact, this was an advantage because they didn't have to be held down while they were unconscious. Many also died of shock.

Today, highly evolved techniques and state-of-the-art equipment mean modern anaesthetics have significantly reduced the trauma associated with surgical procedures. An anaesthetic is a drug or agent that produces a complete or partial loss of feeling. There are several kinds of anaesthetic: general, regional, local and tumescent.

When a patient undergoes a general anaesthetic, they lose sensation and become unconscious, sometimes requiring assisted breathing, while other types remove sensation from specific areas of the body.

Anaesthetic compositions

Anaesthetics can be composed of a number of agents, such as:

Gases

These should be non-flammable, non-explosive, non-irritant, lipid-soluble, possess low blood gas solubility and should not be metabolised or have end organ (heart, liver, kidney) toxicity.

Intravenous agents

These include sedatives, benzodiazepines and propofol which cause unconsciousness but not pain relief, as well as etomidate and ketamine which are often used in emergency settings. Only ketamine also produces pain relief.

Analgesic agents

Although they can cause unconsciousness, analgesics are normally combined with other anaesthetic agents for pain relief.

Muscle relaxants

These do not render patients unconsciousness or relieve pain but assist with intubation during general anaesthesia.

General anaesthesia

General anaesthetics can be administered by injection or as a gas by inhalation through a mask. Patients are sometimes given a ‘pre-med' that induces relaxation before they undergo general anaesthesia by inhalation. This can also help reduce salivation, particularly beneficial when a tube is inserted into the throat to assist ventilation after the patient has become unconscious and loses sensation.

An anaesthetist is a medical doctor with specialist training in anaesthetics. The anaesthetist controls the length of time the patient is unconscious and constantly monitors their pulse, breathing and blood pressure. If necessary, the anaesthetist administers intravenous fluids before, during and after surgery.

Once the surgery is completed, drugs that reverse the effect of the anaesthetic and any other drugs used during the operation (such as a muscle relaxant) are sometimes administered by injection When the anaesthetist is satisfied the patient's breathing and blood circulation have normalised, the patient is taken to a recovery area.

Local anaesthesia

Local anaesthesia is administered by injection to a small area and is commonly used in dentistry or for minor surgery such as stitching a wound. Local anaesthetic agents are also used in the regional and tumescent approaches.

Regional anaesthesia

This type of anaesthesia is also referred to as a nerve block, because the anaesthetic agent is injected into nerve bundles central to the area to be operated on. Traditionally administered as a single injection, recent developments include the use of an inserted catheter to allow for serial doses of local anaesthetic during surgery.

Common areas where regional anaesthesia is used include the shoulders, arms and legs, spine and lower body during childbirth (epidural).

Tumescent anaesthesia

Tumescent anaesthesia, which originated in liposuction surgery is now widely used in many procedures on subcutaneous tissues, such as the breast or abdominal wall.

The procedure uses a mixture of infiltrate containing local anaesthetic and adrenaline to help numb the area and prevent blood loss. Large volumes of infiltrate are steadily injected into the subcutaneous tissues until the area is swollen. A typical formula uses 25ml of 2 percent lidocaine and 1ml of 1:1000 adrenaline for each litre of sodium lactate intravenous infusion.

It is possible to use large volumes of fluid with higher doses of local anaesthetics, and a commonly recommended dose is up to 35mg per kilogram, although the dose depends on the site and the indication. This type of anaesthesia is combined with twilight sedation.

Twilight sedation

Twilight sedation is the state between wakefulness and complete unconsciousness, where patients are less aware of their surroundings. This is fairly easily accomplished with modern anaesthetic agents such propofol, which allow for rapid adjustment of sedation level and a quick recovery.

The anaesthetic is administered intravenously, intubation is not necessary and the risk of nausea during recovery is minimised.

How anaesthetics work

While modern anaesthetists are experts in understanding how many milligrams of which particular drug to administer depending on the patient's body weight and physical responses, at a cellular level the way these drugs work remains something of a mystery.

In broad terms, a general anaesthetic is carried in by the blood to the nerves in the brain. The nerve cells stop receiving and sending signals so the patient doesn't feel pain and remains immobile during surgery.

The general understanding is that the chemical agent acts on the cell membrane of the nerve cell. All cells are encased by a cell membrane which sandwiches layers of water absorbent and resistant molecules.

The pressure in between the different layers of the cell membrane is around 400 atmospheres, or roughly the pressure 4km under the sea.

The cell membrane has channels that admit or release certain chemicals such as chloride, sodium, potassium. Each channel passes through the sandwich of the cell membrane, with the pressure acting against it, but the channels are held open by cholesterol and other fats that are arranged into fairly rigid liquid crystals. As various chemicals flow in or out of channels, they change the electrical charge on the cell membrane that switches the nerve cell on or off.

There are a number of theories on how anaesthetics achieve this. One of the older theories postulates that anaesthetics can penetrate the cell membrane and interfere with the rigid liquid crystals that hold the channels open. If the shape of the channel changes, so will the flow rate of various chemicals to and from the cell.

A more modern theory is that anaesthetics adhere to little chemicals around the open mouth of the channel. These chemicals then can open or close the channel, leading to changes in electrical charge on the cell membrane that produces insensibility. Another theory says that anaesthetics alter the pressure inside the layers of the cell membrane, changing the shape of the channels and affecting the electrical charge on the cell membrane.

Botulinum Toxin

Botulinum toxin injections diminish facial lines by selectively limiting the movement of various facial muscles.

The appearance of frown lines and wrinkles can result in a prematurely aged appearance. Many people would like to alleviate the problem without having to undergo a surgical procedure. One of the biggest names in the facial rejuvenation business is botulinum toxin, an effective non-invasive alternative for reducing lines and revitalising the appearance.

Produced commercially under the brand names Botox and Dysport, botulinum toxin is a protein produced by the bacterium Clostridium botulinum. It is a muscle relaxant that is commonly used for cosmetic facial enhancement, particularly to treat crow's feet around the eyes, the frown lines between the eyebrows (glabellar lines) and the worry lines across the forehead. The marionette or sad lines, from the corner of the mouth to the chin, can be effectively treated with botulinum toxin. It can also be used to produce the effect of a brow lift by relaxing the muscles that drag down the brow.

In cosmetic procedures, botulinum toxin works by blocking nerve stimulation to wrinkle-causing muscles, which prevents the muscle from contracting and significantly reduces wrinkles and fine lines.
Botulinum toxin is used by thousands of women and an increasing number of men to help rejuvenate their appearances. In 2003, 2.2 million Americans had botulinum toxin injections and the procedure is becoming increasingly popular here in Australia.

History

While many people think of botulinum toxin as a new treatment for wrinkles, it has actually been used since the 1960s to treat a range of medical conditions.

However, it was in the 19th century that German physician Justinus Christian Kerner first recognised the potential therapeutic uses of botulinum toxin. An 1815 outbreak of botulism (a dangerous paralytic illness caused by the toxin, botulin) in southern Germany among people who had eaten uncooked blood sausage led Kerner to publish a precise description of botulism's symptoms - from blurred vision to progressive muscle weakness, culminating in respiratory failure. He postulated that minute quantities of the disease-producing substance might be able to treat disorders of the nervous system.

In 1895 Belgian bacteriologist Emile Van Ermengem was the first to isolate the bacterium, in much the same way that penicillin was first isolated from a mould that grows on bread. What was once known as Kerner's disease was renamed botulism from the Latin botulus for sausage.
In 1946 Edward Schantz succeeded in purifying botulinum toxin type A in crystalline form for the first time, providing scientists with the raw material necessary to study the molecule in greater detail.

In the 1970s Dr Alan Scott of the Smith-Kettlewell Eye Institute demonstrated that botulinum toxin was a powerful therapeutic agent that could be used to treat ophthalmic disorders associated with muscle over-activity such as lazy eye. Since then it has been used to treat a variety of involuntary muscle contractions or disorders. Its use as a cosmetic treatment was only discovered when people using it to treat facial muscle spasms noticed an improvement in their facial wrinkles.

Botulinum toxin is used in much higher doses to treat children two years of age or older suffering from cerebral palsy to help them walk. It can also be injected into the skin to block the action of the nerves that control sweat glands, and in this way treat excessive localised sweating (hyperhidrosis), especially severe underarm sweating.

In recent years Botox has been used to treat patients suffering from migraines and severe tension headaches, as well as to relieve teeth clenching and grinding. Researchers at the Royal Hospital for Women in Sydney have found that just one injection of Botox can stop chronic pelvic pain.

Cosmetic treatment

In cosmetic procedures, injections of botulinum toxin work by relaxing wrinkle-causing muscles, which softens existing facial lines and can also prevent the formation of new ones. A few tiny injections are administered just under the skin, reducing nerve stimulation to the targeted muscles. The procedure usually takes about 10 minutes but this can vary depending on the number of areas being treated. Because men tend to have larger and stronger muscles, they often require more injections to achieve satisfactory results.

Generally, no anaesthetic is required. The needles are very fine and only a small volume of the product is needed, so the procedure is relatively painless. If the patient is particularly concerned, the physician can numb the skin over the area before administering the injection.

After treatment for lines on the forehead, for example, patients are physically unable to frown. Over the next few days, the muscles gradually relax, and it often takes three to four days for results to become visible, normally reaching their full action by one week. Botulinum toxin is gradually reabsorbed by the body so in order to maintain results repeat injections are necessary every three to five months. With continued use, the effects may start to last longer because the targeted muscles have ‘unlearned' the response that originally contributed to the development of the lines.

Cosmetic treatment with botulinum toxin is considered safe in that there are no major or harmful side effects. Common side effects are generally restricted to minor temporary redness or bruising at the injection site. There is a very slight risk that it can cause a temporary weakness in nearby muscles, which can result in a slight drooping of an eyelid or eyebrow lasting from one to six weeks. Occasionally patients may experience a slight headache or nausea. Treatment with botulinum toxin is not recommended for women who are pregnant or breastfeeding. In its 10 years of cosmetic use, there have been no reported long-term or permanent side effects from the use of botulinum toxin

Brow Lift

Often the brow and forehead area can show the first signs of facial ageing. Deep creases across the forehead and between the eyebrows can become evident, even when the face remains in a static position. The effects of gravity, sun damage and the natural ageing process all contribute to a gradual descent of the brow, giving a ‘heavy' or ‘hooded' look to the upper face, which can make a person appear angry, sad or older than their years.

Also known as a forehead lift, a brow lift elevates a low or sagging brow to a more youthful position, minimises the creases and wrinkles that develop across the forehead, and improves frown lines that develop high on the bridge of the nose. It can also rejuvenate the upper eye area, reducing heaviness and sagging over the eyelid and at the outer edges of the eye.

Brow lift surgery can be performed using several techniques, depending on the patient's individual requirements and the surgeon's preferred method.

Generally there are two commonly used methods of performing a brow lift: the traditional crononal open incision brow lift and the newer endoscopic brow lift. The traditional brow lift procedure involves an incision made behind the hairline across the top of the head from temple to temple. The forehead skin is lifted from the underlying tissue and tightened using sutures under the skin. The incision is then closed with stitches. Surgery typically takes around one to two hours.

Instead of one long incision, the endoscopic approach to lifting the brow involves three to five short incisions above the hairline, each about 2cm long. An endoscope, a thin instrument with a tiny camera at one end, is passed through an incision and positioned near the brow. From there, surgical instruments are inserted through another incision to allow the tissue and muscle beneath the skin to be repositioned.

Gauze is placed over the closed incision and an elastic bandage may be wrapped over the area to reduce swelling for the first few days. Most patients can resume everyday activities within a week, although rigorous activity should be avoided for several weeks. Bruising and swelling typically subsides after around three to four weeks and some numbness of the scalp is normal. Healing is usually complete and the final results apparent within around two months.

A brow lift is often combined with a facelift or blepharoplasty to provide a harmonious rejuvenation.

Cosmeceuticals

Written by Bill Dunk

A new class of cosmetic products deliver pharmaceutical benefits, improving the skin's appearance by delivering necessary nutrients.

Just 15 years ago, Australian law prohibited the manufacturers of skincare products from claiming the benefits products might offer in their advertising. These days the efficacy of a new class of skincare product called cosmeceuticals can be scientifically proven, brushing aside that legislation with hard evidence.

Cosmo what?

The term ‘cosmeceuticals' refers to a class of cosmetic products with pharmaceutical benefits. Cosmeceuticals are topical skincare formulations containing active ingredients which enable them to act on the skin's cellular structure. In some cases such as exfoliants, this action is limited to the surface of the skin, while other formulations can penetrate to the cellular level and enhance or inhibit natural activities.

Cosmeceutical products are usually used at home and incorporated into a regular skincare regime. They can help alleviate the symptoms of ageing such as fine lines, pigmentation, skin tone and texture.

Many brands have poured millions of dollars into research and development, employing highly skilled biochemists to create new products delivered in formulations designed to enhance their capabilities and the appearance of the skin at the same time.

What to look for in cosmeceutical products are antioxidants, cell-communicating ingredients, exfoliants, skin-lightening ingredients and intercellular substances (that mimic skin structure). For the products to work, these need to be at sufficient concentrations and synergies to allow them to retain their active properties.

Key ingredients

Cosmeceutical products contain ingredients that induce healing and other changes in skin cells. Research shows that benefits for the skin can also be obtained from plant extracts and essential oils as well as vitamins, enzymes, phytochemicals and more.

Antioxidants reduce free-radical damage and inflammation, counteracting cellular damage, collagen destruction and immune suppression. Antioxidants in combination, studies suggest, can exert a cumulative synergistic action on the skin that is more effective than single ingredient formulations.

Cell-communicating ingredients use receptor sites or cellular pathways to interact with skin cells to signal them to function optimally.

Retinoids, which are derivatives of Vitamin A, are the best known. They act as antioxidants and neutralise the free radicals that result from exposure to ultraviolet light. In addition, they increase cellular turnover, stimulate a thickening of the epidermis and promote the removal of excess pigment.

Other cell-communicating ingredients include peptides, which were developed for use in skincare to either increase the production of collagen or to reduce the breakdown of collagen.

Niacinamide is a water-soluble B-complex vitamin that has anti-inflammatory properties and can assist with conditions such as acne vulgaris.

Exfoliants encourage surface skin cells to shed, mimicking the function of young skin and increasing collagen production. The primary reason for skin cell build-up is sun damage. Exfoliant ingredients include alphahydroxy acids (AHAs) such as glycolic and lactic acid, polyhydroxy acids (PHAs) such as gluconolactone and lactobionic acid, and beta hydroxyacids (BHAs) such as salicylic acid. Salicylic acid is also used as a skin conditioner and is especially useful in patients with oily skin and acne.

Skin-lightening ingredients inhibit melanin formation at a molecular level, reducing the appearance of brown discoloration, and include hydroquinone, arbutin, azelaic acid, some forms of Vitamin C, rucinol and glycyrrhetinic acid.

Intercellular substances are ingredients that exist naturally in skin and can be depleted by health, ageing and environmental factors. Ingredients such as ceramides, cholesterol, fatty acids and glycosaminoglycans are key to skin function and should be included in moisturisers if they are to be effective in promoting skin functionality. Hyaluronic acid is known to hydrate and moisturise the skin from the inside, helping to smooth out wrinkles.

Do they work?

This cavalcade of scientific terms may muddle the senses of the average consumer, who simply wants to know if what they are buying works. A 2008 study published in the Journal of Cosmetic Dermatology analysed several cosmeceutical ingredients to see how successful they are in targeting specific skin imperfections related to age. The study indicated, for example, that skin surface irregularity can be improved through the topical application of niacin, and that the appearance of fine lines can be diminished with the application of moisturisers containing engineered peptides and retinoids.

While it seems that this new class of skincare products can indeed improve the skin, there is still little to communicate this certainty to consumers. A lot of brands are now claiming their products are cosmeceuticals but there are as yet no regulations governing usage of this term. Natural cosmetics can by certified for content and production standards by the Association of German Industries and Trading Firms for pharmaceuticals, health care products, food supplements and personal hygiene products (BDIH) - recognised as the highest certification authority in the business - which affixes its ‘Certified Natural Cosmetics' seal on the packaging.

While the Australian Therapeutic Goods Administration regulates ‘products at the interface between cosmetic and therapeutic goods' (i.e. cosmeceuticals) and most manufacturers belong to self-regulating industry bodies, it is always safest to seek the advice of a dermatologist or skincare professional.

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