Forming an Alliance: The benefits of combining surgical & non-surgical treatment plans

By Mr Taimur Shoaib / 01 Oct 2015

Consultant plastic surgeon Mr Taimur Shoaib shares advice on incorporating both surgical and non-surgical procedures to complement aesthetic results

Introduction

As aesthetic practitioners, we are all aware that facial rejuvenation treatments include surgical options as well as non-surgical options. Most patients want to look fresh and less tired, and a thorough consultation will of course determine the most suitable approach to treatment. Although there are variations in the results that can be achieved with surgical and non-surgical options, many practitioners, such as myself, believe that a combined, holistic treatment approach can produce superior results.

From facials to facelifts

In 2014, my staff and I performed an audit of patients who attended our practice during the whole of 2013. I run a surgical and a non-surgical practice, so we considered these as two separate modalities. We looked at all our appointments over a calendar year and determined the crossover rate of treatment modality in patients who had more than three treatment appointments. These had to include at least two non-surgical appointments and one appointment for a surgical procedure. We found that 22% of patients who started off having non-surgical treatments subsequently underwent surgery, and that 80% of patients who started off having a surgical procedure subsequently underwent multiple nonsurgical treatments.
The patients who began by having nonsurgical treatments waited, on average, 18 months before they underwent a surgical procedure, and the patients who started off with surgery waited, on average, only four months before undergoing multiple nonsurgical procedures.
The study had its limitations; the most significant was the fact that practitioners from other clinics referred a number of non-surgical patients to me for surgery. The patients then returned to their non-surgical practitioners for continued treatments after surgery, meaning that the 80% figure may be significantly higher.

While there are some things that surgery will do that cannot be achieved through non-surgical treatments, there are many treatments that are best performed non-surgically

These results clearly suggest that there is a noteworthy crossover between surgical and non-surgical treatments, further supporting my view that there is a need for more combination procedures. In my opinion, surgeons and non-surgical aesthetic practitioners should work together to recognise how their work can be complemented by the alternative treatment method, and produce enhanced results for all our patients. Although there is some crossover in what each of the two different techniques can obtain, there is a wide variation in indication for different modalities of treatment. As such, I have detailed the considerations to bear in mind during your patient’s aesthetic journey.

Consultation

Many patients tell us that when they look in the mirror, they don’t see a reflection of someone who has the life, vitality, energy and freshness that they feel within themselves. Most patients who come in with these concerns are, therefore, looking for aesthetic treatments that will help them achieve those aims; they want to look as fresh on the outside as they feel on the inside.
When these patients attend our clinics, we should start with a thorough and in-depth consultation to assess the patient’s wants and needs. In my opinion, the aesthetic consultation needs to follow a specific order:

  • History
  • Examination
  • Investigation
  • Diagnosis
  • Discussion of treatment plan
  • Delivery of treatment
  • Follow up

As we become more skilled, the examination and history can sometimes take place simultaneously, but the principles still apply; practitioners should understand a patient’s medical history to ensure they are suitable for treatment before recommending any procedure.
While patients often come to us requesting a particular treatment, many will not understand what they actually need to improve their aesthetic concern. In the past I have had patients say “I would like some Botox to make my lips bigger” or “I think I need collagen injections in my lines”. However, the patient is starting the consultation at the bottom of the journey and, clearly in these examples, they can sometimes be misled in what they believe to be the best treatments for the concerns that they have. Therefore, it is our job to guide them onto the correct path for a successful patient journey.
To do this, I believe the two most important questions to ask at the beginning of the consultation are:

  • What do you not like about yourself?
  • What is it you’re hoping to achieve?

By asking these questions, and subsequently examining the patient, we can establish the starting point for treatment and formulate a plan that takes the patient from where they are currently, to where they want to be.

The treatment plan

Once you are confident that you understand your patient’s requests and have discussed appropriate options with them, it’s time to examine the patient and agree on an appropriate treatment plan.

How to examine the ageing face

Facial ageing is a complex process. If we want to simplify something that is complex, we break it down in to different components. Facial ageing is no different, and we should look at different parts of the face and tissue layers separately. Accordingly, our examination should break down the face into the upper third, the middle third and the lower third.1 We should also look at the face in its tissue component layers – the skin, the fat, the muscles and the bones – remembering that the layers do change in different parts of the face (for example, here there is skin and oral mucosa at either extremes of the tissue layers).2 It is very important for all aesthetic practitioners to understand that facial ageing takes place in all tissue layers. We must realise that even though we see, for example, dynamic glabellar lines, the reasons for them appearing lie in the skin, the fat, the muscles and the bones. When we see lateral brow ptosis, the reasons for this lies in changes that have occurred in the skin, the fat, the muscles, and the bones. Facial ageing occurs at all tissue levels and treatment must therefore be directed to all the tissue layers. Naturally, the tissue layer that shows most signs of ageing must be the first tissue layer to be treated (for example it is usually highly appropriate to use botulinum toxin for overactive muscles that are causing dynamic lines). Sometimes patients will be disappointed with results and the best solution to this is to address a different tissue layer. When we can see the effects of facial ageing and we know the reasons why the effects are being seen, we can treat the underlying cause and, hopefully, give our patients the best possible results.

Avoiding the ‘done’ look is possible with multimodality treatment

Multimodality treatment

At a simple level, we can perform multimodality treatment using multiple non-surgical techniques. For example, if someone dislikes the lines they have around the crow’s feet region, which worsen when they smile, we can treat these in many different ways. We get dynamic crow’s feet lines because our skin and fat layers become thinner and our muscles become stronger with repeated use.3 Additionally, the inferolateral aspect of the orbital rim undergoes recession posteriorly and inferor displacement laterally.4 To treat dynamic crow’s feet lines we can therefore reduce the power of the muscles with a neuromodulator, we can thicken the fat layer with a relatively thin and forgiving filler, we can thicken the skin with a CO2 laser, and we can address the bony loss with bony structural augmentation using fillers at the orbital rim, placed deep to orbiculares but inferior to the eyelid and orbital rim.

Fat or fillers?

If you have a surgeon based in your clinic, or work closely with a local colleague, the treatment plan will often take the form of surgical and non-surgical treatments. Both treatment types will work together not only to deliver the results we are hoping to see, but also to maintain surgical results with continuous non-surgical treatments. The best results from our aesthetic treatments are the ones where other people cannot tell that the patient has had significant treatment and avoiding the ‘done’ look is possible with multimodality treatment. For example, if a patient wants to achieve fuller cheeks and a lifted face, we might wish to recommend a facelift and fat injections (if these are indicated) and we may want to maintain the results with pre-jowl fillers, malar fillers and high intensity focused ultrasound treatment to the SMAS (the facial muscle that is tightened in a facelift). For the volume loss that we see in the lips and mid-face there are two options: fat injections or fillers. How should we decide what is best for the patients? As with most treatments, there are advantages and disadvantages to both. Fat is autologous tissue, which gains a blood supply, and so any infection can be treated with antibiotics. Fat injections are also permanent, however approximately half of the fat will fail to obtain a blood supply and will therefore disappear over a period of a few months. Surgery, however, has a longer recovery time and is usually more expensive. On the other hand, fillers are temporary but the recovery time is usually quicker and, until a certain volume is used they are usually cheaper. With fat versus fillers there is usually a tipping point at which fat becomes more desirable. The tipping point may relate to the financial issues associated with having repeated large volumes of filler injected versus the single treatment of a similar amount of fat, the magnitude of the clinical result desired, or the desire to use autologous tissue rather than a foreign material. However, even with fat injections I advise patients that they will inevitably want to have volume restoration into the fat-filled areas again at some point in the future. We can therefore, in some patients, consider fat injections to give us a better starting point for subsequent filler injections.

In practice

Case Study: Patient A

As part of our patient assessment, we ask patients how much of an improvement they are hoping to see, and attempt to quantify the magnitude of their facial ageing examination findings. In the example below, we can see that Patient A has signs of facial ageing: descent and atrophy of the mid-face fat pads, unwanted fat deposits in the submental region, a prominent jowl and hooding of the upper eyelids (Figure 1)The patient wanted quite a considerable improvement, so I suggested that the best approach to treatment was surgery. After taking time to consider this route, Patient A decided she was keen to go ahead. I informed her that she would need to maintain her results with non-surgical treatments, beginning approximately six months later.
Patient A underwent a facelift, followed by an upper-lid blepharoplasty. I elevated the malar fat pads and performed liposuction to the cervical and submental region (Figure 2). At the consultation I asked Patient A how she wore her hair, as she would have a prominent scar for a few weeks after surgery. Although this did not concern Patient A, it is important to prepare patients for all eventualities post surgery.

Although the scars are visible, they are likely to mature over a period of approximately one year. We can see the reduction in the prominence of her jowls, the improved definition of the jawline and the elevated cheek fat pads. We can, however, still see thinning of the lips, a marionette line, and nasolabial lines. While the facelift has improved her appearance, Patient A will benefit from further aesthetic treatment to enhance her results. Rather than recommending she undergo another facelift, which may be not indicated, it is worthwhile offering non-surgical treatments to further improve her aesthetic outcome. In this case, I would offer Patient A lip filler, laser skin treatments (CO2 fractionated resurfacing, green or yellow light IPL) and skincare products to help improve the appearance of her skin, the marionette and nasolabial lines, as well as the volume loss in her lips. Even after surgery, examination of the patient shows mild volume loss and persistent skin ageing. A multifactorial approach to facial ageing, combining surgical and non-surgical treatments, will therefore give her the best results.

Figure 1: Before treatment


Figure 2: Four weeks after Patient A's facelift (before her upper-lip blepharoplasty)

Case Study: Patient B

One of the side effects of fat injections into the fat pads of the face is that stem cells are imported to the tissues. These stem cells rejuvenate the surrounding tissues,and patients often report an improvement in the quality of the skin of the face. Apart from this, a facelift (and associated ancillary procedures) will do nothing to improve the skin. There are, however, many non-surgical options available to enhance skin quality.
Patient B sought treatment for her moderately sun-damaged skin, fine lines, loss of elasticity, and heterogeneous patches of pigmentation (Figure 3). Following three sessions of laser treatment we can see a significant improvement in the appearance of her skin (Figure 4). While Patient B was happy with her results, there is more we could do to improve the signs of ageing, using a combination of surgery and non-surgical treatments. For maximum results for the jowls, I would advise that Patient B undergo a facelift. For more subtle results, however, I would recommend CO2 laser treatment, Ultherapy and radiofrequency tightening. Although these treatments will not give as powerful a result as a facelift, the combination of treatments will all help to lift and tighten the skin and muscle layers of the face in this area. In Patient B, we can see she has loose skin and moderate jowls. The treatment plan should therefore be aimed at addressing the main salient features of the patient’s facial ageing, including her loose skin and jowls. Although non-surgical treatments will deliver a more modest result, when we ask the patient what they are hoping to achieve, and when we examine them, we can advise on the magnitude of effect likely to be delivered from the different treatment modalities, and suggest a plan accordingly. As with all patient counselling for facial surgery, we would also advise Patient B that she would need to continue with non-surgical treatments after surgery, such as regular radiofrequency and occasional laser treatment.

Figure 3: Before treatment
Figure 4: After three sessions of laser treatment

Summary

To be regarded as a trustworthy and reliable aesthetic practitioner, it is imperative that we be honest and keep our patient’s best interests in mind. While there are some things that surgery will do that cannot be achieved through non-surgical treatments, there are many treatments that are best performed non-surgically. As such, surgeons and non-surgical aesthetic practitioners should endeavour to work together to provide patients with the best possible outcomes and long-term, sustained results.

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