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The Plastic Surgeon's space-time map

Crisscross of time and space:
The human body is a dynamically balanced open system. The rhythm of movement for each organ varies, and it is just likes everyone has his/her own tempo. For the time and space factors that the experienced plastic surgeons think about, I can think of the following aspects:

Healing time of the wound

Wounds are disturbing, so everyone's goal is to have the wounds healed as soon as possible. However, having the wounds healed early does not always provide the best final results because it involves whether the scar is good or bad. Wounds always come with inflammation, and redness, edema, febrility, pain and bruising are common symptoms. Serious injuries will cause greater inflammatory reactions. These inflammatory symptoms are generally unwelcome, and it is best not to have any such symptoms if possible. However, the fact that "no side effect (inflammation) means no effect (healing)" is still the modern standard of wound healing. Most people think that medical treatments and handling have magical and secret medicines that can work wonders like "if there is illness, heal the illness. If not, make us stronger", but it is inaccurate. If we want immediate, lasting and significant improvements in the field of plastic surgery, it usually comes with longer down time (inflammation and scar maturation).

At present, aesthetic medicine often uses the shortest down time (recovery period) as the selling point, so the effects are less obvious and last shorter. That is why some treatments are introduced by "courses". Simpler injection beauty treatments sometimes require 1 to 3 days to recover, while the more complex injection beauty treatments may take 5 to 7 days of recovery period. Another common phenomenon that often comes with inflammation is postinflamatory hyperpigmentation (PIH), which is also known as "darkening" or "pigmentation." The general principle is that the larger the inflamed area, the more serious the PIH. Of course, the more invasive the treatment, the larger the PIH will be and the darker the skin or larger the PIH area the patient has. In terms of dermabrasion skin treatments, to a certain degree, the deeper the dermabeasion the better the effect, but the PIH will be more obvious and last longer.

There is currently a type of fractional laser that dermabrashes through punching 100μ holes in the skin. These holes are evenly and discontinuously distributed over the skin like a cardpuncher punching holes in the putting green. Its advantage is that the skin will recover quickly with a shorter down time (period when you cannot see others). This is totally using time to exchange for space: dividing the longer down time of traditional dermabrasion into several times. From my own experience, however, for the effects and down time that one traditional laser dermabrasion can achieve, it will take at least 5 or 6 fractional laser courses to do the same. Its advantage is that the down time can be divided, but the cost is the extended courses of treatment (the effects also need to be accumulated). Therefore, one significant factor for the selection of treatments will be "how much time you have for the recovery, that is, the down time."

The other thing that comes with inflammation is the "edema." Imagine that stitching double eyelid will cause edema for at least 3 to 5 days, and cutting double eyelid will cause edema for at least 5 to 7 days. The ideal situation is having only effects but with no edema, but this is an impossible task. There is a saying, "hit your own face until it swells to pretend to be fat," but the fact is that edema is not completely useless. Some rejuvenation treatments actually want your face to have edema, as with appropriate control it can reduce the wrinkles and make the skin look smooth and shiny. Most rejuvenation treatments, chemical skin peeling and face cares have immediate effects mainly due to the edema. The more invasive the treatment, the longer the edema. Currently, many of the rejuvenation practices are toward "slight but persistent edema", but if it is not properly managed it can trigger side effects. Therefore, if you do not see the expected effects a week or two after the treatment, you can almost conclude that "edema" plays the most important role here. Thus, if the rejuvenation treatment only uses edema as a tool, the patient must continue applying the treatment, just like having three meals a day to stop hunger.

The maturation process of scar

Scar maturity generally takes more than six months, and children or youngsters need an even longer time – even as long as several years. The so-called maturity refers to the color of the scar fades, area becomes smaller, and the hardness softened. The scar is the ugliest, the tightest and the hardest two to three weeks after the healing of the wound, and then it slowly improves from there. There are ways to improve or speed up this process, but you cannot skip this annoyingly maturity process.
The final result of a plastic surgery is usually stable only after the scar matures. It is a common mentality of patient's to be anxiously worrying about the results before the scar matures, and it is also the burden the plastic surgeon has to bear. The patients often ask: "Doctor, why my eyelids still look unnatural one month after my eyelid surgery? In fact, the answer is simple: the scar has not matured yet, and the tissues are still somewhat swollen and hard. If the patient can be educated before the surgery in this regard, the patient will be more accepting when the surgeon says the above.

Some patients feel their scars do not look ideal after the wounds healed and anxiously ask the plastic surgeon to repair their scars. Generally our opinion is that it is best to wait until after the scar matures before repairing them, which is about half a year after the surgery. This practice has several advantages as follows:
  1. Only after the scar matures, we can know what exactly its problem is – whether it is too wide, too convex, concave, tight or being bumpy (trap door deformity), so the surgeon can provide the proper treatment.
  2. The tissues are more brittle before the scar matures and bleeding can easily take place, which is not ideal for surgical procedures and might affect the results. In addition, the only major prerequisite for making improvement in scars is to provide it a more ideal healing condition than previously, so as to allow the wound to heal again.  Therefore, not all scars can be repaired to become better. For some patients who have the tendency of keloid scars, repairing the scar actually makes the matter worse. Scar reparation is to let the wound heal again, meaning that one must wait for the final result before repairing the scar, which is likely half a year later. The patients must understand this kind of time factor.

Most scars initially have tightness or contracture issue, but they loosen over time, and this is an example of using time to exchange for space. However, some scars, such as the keloid scars, do not improve over time, and there is a gray area between the two. Therefore, sometimes the surgeon has no control on where your scar falls. Experienced surgeons may advise you to dispel the idea of repairing your scars or ask you to wait and see. I hope you understand that he knows how to repair scars but does not want to waste medical resources.

When a sewed scar first heals, it is usually a flat and linear scar. However, as time goes by, some of these scars become less obvious, some become more convex, some become wider, and some become both convex and wide and may even be painful. Convex scars may gradually flatten over time, but widened scars do not usually narrow down. These phenomena might be caused by the tension of wound being too high or the genetic problems of the patient’s (the so-called constitution) and totally out of the surgeon’s control. Ideally, the surgeon shall, prior to the surgery, understand the condition and can tell the patient accordingly – especially when conducting the pre-operative consultation of a scar repair surgery.

Skin and soft tissue elasticity issues

Many people have "stretching" experience. With enough effort, the tightened ligaments can be loosened up over time. The skin also has the elasticity. With sustained tension or gravity, it will become longer and looser. Such phenomenon that changes over time has always been a topic in the field of plastic surgery. Perhaps you will hear that "Someone just did a facelift and ended up looking like a Beijing opera actress,", or "the result of facelift was good initially but the skin loosened up after a year." It tells us that the elasticity of the skin gives us a smooth and streamlined curve, but it can also make us look terribly old.

Removing the epicanthus is one of the most important means of rejuvenation surgery. Removing too much will make the skin look tight and unnatural, but if we do not remove enough, the skin will quickly become loose again. How much epicanthus should be removed is not just a personal preference of the surgeon. It is best to follow the consensus between physicians and patients and strike a balance between being natural and having longer effects. The surgeons have also been studying ways to achieve both, and currently there are indeed some approaches that can get close to this ideal, but usually these surgeries are more complicated and risky, meaning that there is no free lunch.

In terms of facelift, the subcutancous face lift, which uses only the means of skin removal, completely conforms to the principle of "if cutting too much it gets tight, whereas if not cutting enough the skin will look natural." It is simple, recovers fast, but the effect does not last long. The sub-SMAS face lift, which uses the means of stretching the fascia, is more risky, more difficult and with slower recovery, but the effects last longer. At that point the surgeon must discuss with you to decide which method should be used to meet your needs. These are choices about suitability but not comparison between good and bad. Some people care about the price, some care about the risk, some care about the outcome, and there is no so-called right or wrong about the selection.

Dr. Yi-Sheng Kao Director | Plastic Surgery Aesthetic Clinic

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