Not only nose

RHINOPLASTY

Septorhinoplasty

Duration of surgery > 60-120 min / Anaesthesia > general / Cost > 6000 Euro

Septorhinoplasty is universally considered the queen of facial plastic surgery. This is due to the difficulty of the surgery and the impact it can have on the appearance of the face. Nasal surgery often tends to make a clear distinction between aesthetics and function, but in clinical practice it is often impossible to correct one by neglecting the other. For example, a twisted nose often depends on a deviated septum and it would be unthinkable to correct the aesthetic alteration without performing a functional septoplasty. Conversely, a very high and narrow backed nose implies the presence of a stenosis in the internal nasal valve area and it is not possible to deal with the function without altering the appearance. Open rhinoplasty is the modern technique used by Dr. Marianetti in all his surgical procedures:  a small incision is made at the columella (anatomical unit that joins the upper lip with the tip of the nose) and, through it, the osteocartilaginous structures of the nose are exposed, which can then be modified under direct vision and in the absence of distortions. What has changed in septum and nasal pyramid surgery over the last 50 years is the philosophy of the surgical approach: from demolition to reconstructive, from subtractive to additive. Noses that showed clear signs of surgical interventions were considered as being "beautiful” 20 years ago, while today this has shifted and surgery is considered successful when it is impossible to distinguish a “remodelled” nose. In this perspective, the open approach is universally widespread, which enhances the architectural and anatomical aspect of nasal surgery, allowing the best combination of aesthetics with function. This concept is increasingly emphasized above all by the American authors, who have made the "Open structurerhinoplasty" the inspiratory principle of rhinosurgery.  The advantages of the open approach are the possibility to define the anatomical deformities under direct inspection of the osteocartilaginous structure, to carry out their correction in the absence of distortions and the greater guarantees of the result. These advantages explain why this approach is now used by the overwhelming majority of American nasal surgeons. The disadvantages of the open approach are the small columellar scar (which usually disappears within 6 months of surgery) and a post-operative swelling of the tip. nasal greater than the closed approach. Is the operation performed under general anaesthesia? Yes. Although in some cases it is possible to resort to local anaesthesia and this may vary in relation to the preferences of the surgeon and the patient, general anaesthesia is recommended. Are nasal pads necessary? The answer is no. Thanks to a suture of the septum, used by Dr. Marianetti and called "mattress suture", it is no longer necessary to apply the annoying post-operative pads, guaranteeing the patient a post-operative course without pain and discomfort. How long does the convalescence last after the operation? The patient is usually discharged one day after the surgery with only one night of hospitalization. The pads are removed the day after surgery or at most after two or three days. A rigid nasal mask is applied to the nose which is removed together with the columellar sutures (under the tip of the nose) seven days after surgery. After removing the mask, patches will be applied to the nasal back for one to two weeks. These patches are necessary to readjust the skin on the new osteo-cartilaginous structure created with the intervention. The nose remains edematous (swollen) for one or two weeks. The final result can only be appreciated three or four months after the operation. What is the surgeon's goal? It normally coincides with that of the patient and consists in carrying out the septorhinoplasty with the dual purpose of making the patient breathe and achieving a natural result. Noses that are "standard", "surgical", "French", "with an upward tip" or with a narrow and pinched, should now be a memory of the past and should never be realized even at the request of the patient. The goal must be to achieve a facial harmony and a naturalness that matches a beautiful nose, without appearing remodelled.
Revision septorhinoplasty

Duration of surgery > 120-180 min / Anaesthesia > general / Cost > 6500-8000 Euro

What is meant by revision septorhinoplasty? Revision septorhinoplasty refers to the need to perform surgery on a nose that has already been operated for residual aesthetic or functional problems. This can be referred to as secondary septorhinoplasty if there has been only one previous operation, tertiary if two interventions, quaternary if three, and so on. Is it common? Unfortunately, it is more and more common to operate patients that have already undergone septorhinoplasty. The main problem for which patients are not satisfied with the first operation is the innaturality of their nose following the operation, the so-called "redone" nose appearance, which was quite fashionable 20-30 years ago; but today has gone out of vogue. Is is technically more simple than the first operation? No! Secondary septorhinoplasty requires a high level of competence and experience. The main problem is that the anatomy is subverted by the first operation and it is often a full-fledged operation of anatomical reconstruction of the nasal osteocartilaginous structures in required in order to restore a pleasant, natural and functional appearance to the nose. At times during primary septorhinoplasty some surgeons remove too much cartilage both at the septum and cartilage level. This can lead to two problems: the first is aesthetic-functional, as for example an excessive resection of the alar cartilages leads to pinching of the nasal tip and failure of the external nasal valve, resulting in difficulty in breathing; the second is that in revision  nosoroplasty of there is no nasal cartilage available for the grafts necessary to rebuild the nose and repair the damage. Therefore, it is often necessary to resort to cartilage sampling from the ear canal (with a small incision behind the ear without any residual deformity of the ear) or resorting to the removal of costal cartilage. What if the nasal septum is perforated? Perforation of the nasal septum is the most common treatment in nose surgery. Because of the vortexes generated in the nasal cavities when it is present, it is associated with severe nasal breathing difficulties. The surgeon recognizes the following two causes: the first is the iatrogenic one, the second is connected to the use of cocaine or nasal vasoconstrictors. It is possible to close any perforations of 3-4 cm in diameter with very complex techniques that require operations that last at least two hours. Closed or open approach? In the case of secondary septorhinoplast, unless it is a very minor defect and the open approach is almost always necessary. Is the operation performed under general anaesthesia? Yes. Although in some cases it is possible to resort to local anaesthesia and this may vary in relation to the preferences of the surgeon and the patient, general anaesthesia is recommended.

MAXILLOFACIAL

Orthognathic surgery

Duration of surgery > 120-140 min / Anaesthesia > general / Cost > 6500 / 13000 Euro

Orthognathic surgery is the branch of maxillofacial surgery that aims at the correct dento-skeletal relationship between maxilla and mandible. Although the occlusion and function of the temporomandibular joint have a key role in the planning of the surgery, today the aesthetic and psychological factors related to the facial dento-skeletal malformation play a prominent role. Why perform surgery? The reasons for the intervention can be both aesthetic and functional. The functional alterations related to a malocclusionedento-skeletal are chewing problems, pain and noises in the temporomandibular joints, facial asymmetries, chronic pains in the jaw and neck and headaches, difficulty breathing during sleep (obstructive sleep apnea syndrome), inability to close lips and swallow. Should orthodontics be done first? Before being able to undergo surgery for repositioning of the maxillary and mandibular skeletal bases, correct pre-surgical orthodontic therapy is necessary. The latter has the task of preparing for orthognathic surgery and has different (often opposite) goals with respect to traditional orthodontics. When a malocclusion occurs, the first question to ask is: does it depend on the teeth or the underlying bone? If the factor is only dental, then classical orthodontics finds its field of application. If, on the contrary, malocclusion is secondary to an abnormal growth of mandibular or maxillary bones both in excess and in defect, then it is a serious mistake (unfortunately frequent) to try to "clench the teeth" looking for occlusal compensation. The purpose of prehurgical orthodontics, on the other hand, is precisely that of decompensating the occlusal compensation established over time or for previous incongruous therapies. To do this, the upper and lower dental arches are treated as if they were independent of each other and the tooth movements are programmed on plaster models. Surgery can be performed only when the plaster models of the two arches are perfectly occluded with each other, regardless of the momentary occlusion in the mouth. What does surgery entail? Surgery can involve either the upper jaw or the jaw or just one of them. It consists in the mobilization through standard osteotomies of the maxilla and/or of the jaw and in their repositioning according to a correct occlusal and aesthetic relationship. It is totally performed intra-oral and has a total duration of about two hours. The period of hospitalization is about 2-3 days after the operation. intermaxillary fixation is no longer used, except in outstanding cases, because the rigid synthetic means introduced to stabilize the osteotomized bones allow for early mobilization. The patient can then eat and talk as early as the day after surgery. The maximum swelling occurs at 24-48 hours and the final result can be appreciated at three or four weeks from surgery. Often this type of surgery is associated with other procedures, called ancillary, which have the objective of improving the aesthetic result. These include genoplasty, septoinoplasty, zygomatic or mental prostheses, remodelling of the mandibular angle, submental liposuction.
Salivary gland surgery

Duration of surgery > 60-180 min / Anaesthesia > general / Cost > 5000 / 8000 Euro

How many salivary glands are there and which ones are they? The salivary glands are divided into major and minor. The minors are many, the size of small grains and are located throughout the mucosa of the mouth. On the other hand, the major salivary glands are 3 on each side and include the parotid, submandibular and sublingual gland.   What is the most common disease? The major salivary glands are often affected by inflammatory pathology often on a lithiasic basis (calculations) or by neoformations that develop in their context. The parotid gland is often affected by the formation of benign tumours such as pleomorphic adenoma or Whartin's tumor. The calculations most frequently involve the submandibular gland.   What does therapy entail? It depends on the individual case. Surgical removal of the gland (scialoadenectomy) is however often foreseen. The intervention on the parotid gland must take into account that it is crossed by the facial nerve, which is the nerve that gives motility to the entire face. To preserve all the branches of this nerve it is essential to see and follow it from its point of emergence to the more peripheral branches. The neoformation can be either above the facial nerve (superficial) or below it (deep). In the first case (more frequent), it is necessary to perform a superficial parotidectomy, in the second case a deep parotidectomy is required.
Maxillofacial Trauma

Duration of surgery > 60-240 min / Anaesthesia > general / Cost > Executable in agreement with the NHS

Fractures of the maxillo-facial area are very frequent and require specialist treatment. They can affect, in an isolated or combined manner, different bones comprising the facial skeleton. The most frequent are fractures of the nasal bones, fractures of the orbito-maxillo-zygomatic complex with possible or isolated involvement of the orbital floor (blow out) and mandibular fractures. Among the latter, the most frequent fractures are the mandibular condyle, the mandibular angle area and the parasinfisi. Other fractures include upper jaw fractures (such as Le Fort I, Le Fort II or Le Fort III), fractures of the frontal, isolated fractures of the zygomatic arch, those of the medial wall of the orbit and of the orbit apex. The symptomatology is varied and depends on the type of fracture. The fractures of the orbito-maxillo-zygomatic complex are characterized by ecchymotic edema (swelling with subcutaneous blood collections), which at the beginning can mask the underlying aesthetic deformity. If they are associated with orbital floor fracture, diplopia (double vision) is often present. In the case of displaced maxillary or mandibular fractures there is in most cases an alteration of the occlusion. The treatment must be implemented promptly and in any case no later than 15 days of trauma to avoid consolidation of the fracture abutments in a defective position. Treatment of this type of fracture is the specific competence of the maxillofacial surgeon. It is divided into three phases: 1) exposure; 2) reduction and 3) containment. Exposure refers to surgical access to the fracture line by cutaneous or mucosal incisions. The latter are now performed in hidden regions, so that they can be almost invisible after healing. Reduction implies the repositioning of the fractured bones in their original position with realignment of the fracture lines. Finally, the term containment or fixation refers to the stabilization of the fracture with the use of titanium plates and screws. These are placed in contact with the bone and, with the exception of very rare cases, do not give any problem in the post-operative and must not be removed. Postoperative hospitalization depends on the type of fracture.
Maxillofacial oncological surgery

Duration of surgery > Variable / Anaesthesia > general / Cost > Executable in agreement with the NHS

Surgery is often the only radical solution for this type of disease, although in the cases indicated it may be preceded or followed by chemo and/or radiotherapy. The prognosis in these pathologies is closely correlated with the precociousness of the diagnosis. A medical check-up should be performed at the slightest suspicion as early detection of the disease is the best weapon that we have available today to fight cancer. Cigarette smoking and alcohol are the two major risk factors recognised for oral carcinoma. Surgical therapy has not changed conceptually over the years: in any case it is necessary to eliminate pathological neoformation in healthy margins and biological safety, together, if indicated, with the afferent lymph node stations. What has changed in recent years has been the advent of new reconstructive possibilities, which have allowed us to reach levels of oncological radicality in the demolithic phase not reachable in the past. Currently, reconstruction is in most cases entrusted to microsurgery, which allows, with the use of revascularized free tissue, a good morfo-functional restoration of the removed structures. These are bone flaps (fibula, iliac crest, scapula) or muscle-cutaneous (right muscle of the abdomen, radial), which are taken from their site after having identified their vascular peduncle. The latter is then anastomosed with microsurgical techniques to the vessels available at neck and facial area, thus allowing revascularization of the flap. Modelling of these flaps allows better morphofunctional rehabilitations than in the past.
Preprosthetic bone biopsy

Duration of surgery > 60-240 min / Anaesthesia > local or general / Cost > 2000 / 10000 Euro

Modern implantology is defined as prosthetically guided. In simple words, the implant should not be inserted wherever there is bone, but only in specific sites determined by where the tooth will then be placed. This ensures a batter aesthetic and functional result. Ample bone makes things easy; however, this must be replaced when missing. Although there are many synthetic bone substitutes, the autologous bone (of the same person) still remains the best material for reconstruction of the maxilla and mandible in bone atrophy. Where can bone be taken from? There are several autologous bone sampling sites, which will be selected based on the amount of bone needed and the preferences of the surgeon and patient. Schematically, atrophy that is not very extensive can be resolved with a bone graft taken from the jaw ramus, with incisions all made inside the mouth. When a large amount of bone is required, then it is better to remove bone from the iliac crest. Other sampling sites, such as the skull, the tibia, the maxillary tuberosity and the chin symphysis, can be evaluated from time to time, but are less recommended by the surgeon and less accepted by the patient. How much does the operation cost? It depends on the sampling site. General anaesthesia is usually not required for the mandibular angle collection. The incision is entirely inside the mouth. Drills and small osteotomes are used to take the sample which is then modelled in the same operative session and fixed with titanium screws in the area to be reconstructed. General anesthesia is required for iliac crest sampling. The incision is made quite laterally so that it can be concealed during the summer by a bathing suit. Passing between the muscular planes without tearing them, it is possible to reach the iliac crest bone, taking it in the medial portion, so as to leave the outer contour of the crest free of deformation. Normally no drainage is applied and the patient is free to move about the following day. Crutches should be used for a week if large amounts of bone material is taken. How long does the operation last? The average time taken from a mandibular angle is about 20 minutes, whereas the iliac crest biopsy takes about 40 minutes. Can you smoke after surgery? Bone graft surgery is contraindicated in smokers. Smoking exponentially increases the risk of exposure and infection of the graft, with consequent loss of the same. How long until implants can be inserted? It takes some time for the grafted bone to firmly attach to the maxillary or mandibular bone. This is usually 4-6 months. If 8-10 months are exceeded, given the absence of functional stimulation, the grafted bone tends to reabsorb.
Large maxillary sinus lift

Duration of surgery > The average time of the surgery is about 30 minutes / Anaesthesia > local / Cost > 1000 Euro

A large maxillary sinus lift means a bone graft that is placed at the level of the maxillary sinus floor in order to increase the posterior maxillary vertical dimension and to insert implants. Why and when should it be done? The large maxillary sinus lift should be performed when vertical posterior maxillary bone atrophy is in play. With the passing of years and with the loss of the dental elements, the maxillary bone gradually grades atrophy. The maxillary sinus, which is the air cavity located at the side of the nose and superior to the teeth, due to the loss of teeth and their functional stimulation on the bone, expands and reduces the amount of bone that can be exploited for the positioning of osseointegrated implants . Which substances are used? The substances used may be different and it has been shown that alloplastic (synthetic), heterologous (from animal origin) or autologous (taken from the same person) bone are almost equivalent in this type of procedure. How much does the operation cost? Is the operation performed under local anaesthesia? Surgery is carried out under local anaesthesia.The incision is traced at the mucosa of the alveolar ridge with small lateral incisions. A small hole at the side wall of the maxillary sinus is made with a diamond or multiblade drill, without damaging the membrane that covers it. The latter is then gently raised (sinus lift) and below it is inserted the graft material. Sometimes a collagen membrane is needed externally to protect the grafted material. At this point, sutures can be applied. What precautions should be taken after surgery? The main precautions to be observed in the post-operative period are basically two: 1) Do not smoke! 2) Do not blow your nose for at least two weeks, avoiding all other manoeuvres to compensate the airways (plane, helicopter, high mountain, extraneous efforts). It is also important to eat liquid/soft and cold food for a few days and avoid positioning the prosthesis so that it rests directly on the site of the lift. Cheek edema associated with mild hematoma are often present for a few days after surgery. How long until implants can be inserted? This takes time as the bone as grafted material must transform into the patient's bone structure. This is usually 6-8 months. If 10-12 months are exceeded, given the absence of functional stimulation, the grafted bone tends to reabsorb.
Implantology

Duration of surgery > 10-30 min / Anaesthesia > local / Cost > 1000-1800 Euro (implant and tooth)

Endosseous dental implantology is a surgical discipline that consists in positioning dental arches in the bone, partially or totally edentulous, with artificial roots in titanium. These, thanks to a process of biological integration with the patient's bone tissue (osseointegration), are then used as a support base for the replacement prosthetic dental elements. Is it a safe method? Since the 1960s, the use of implants has been documented in over 10,000 scientific studies. More than 400,000 patients are treated each year in Italy, for a total of more than one million implants. Long-term studies have unequivocally demonstrated that the success rate of dental implants after 15 years is over 96%. What are the benefits? From an aesthetic and functional point of view, the teeth supported by implants are often indistinguishable from natural teeth. The main advantage over conventional bridges is that with implants it is not necessary to file adjacent teeth to prepare them to support new teeth. The total prosthesis on implants is also more comfortable because there is no need to cover the palate with the prosthetic material, with obvious positive repercussions on the way people talk and eat. Are there any contraindications? Yes. Absolute contraindications to implantology are the presence of severe anaemia, immunosuppression, coagulation disorders and uncompensated diabetes. In the case of cardiovascular, respiratory or musculoskeletal diseases, the risks must be assessed individually. Cigarette smoking is a relative contraindication, but it is absolutely advisable to abstain from smoking for at least a week before a month after surgery, particularly if bone regeneration techniques have been used. Are there any age limits? The only age limitation is represented by the expectation of the term of growth of the maxillary bones (about 16 years for females and 18 for males). There are no upper age limits, compatibly with the general conditions. What is prosthetically guided implantology? Until a few years ago, the goal of implant surgery was to place implants in the jaws "looking for the bone", i.e. adjusting the implant axis based on the amount of bone available. Teeth supported by implants with incorrect axis and insertion depth were indeed functional, but often not adequate from an aesthetic point of view. Today, with the aid of dedicated software and special surgical guides, implants must be placed in pre-established bone areas and with precise axes. Implantology is therefore guided by the prosthesis and superior aesthetic results can be achieved thanks to a more precise programming. And if there is no bone? Traumas, surgical resections or atrophy may at times cause the absence of the maxillary alveolar bone for correct implant placement. Today there are numerous techniques of regeneration or bone reconstruction. It is possible to resort to autologous bone grafts, taken directly from patients, or the use of alloplastic material. Guided bone regeneration with membranes and biomaterials, large and small maxillary sinus augmentation, onlay and inlay bone grafts, the possibility of performing more complex jaw osteotomies (including orthognathic surgery), the possibility of widening the alveolar ridge (splitcrest) are just some of the techniques available to the surgeon to solve more complex cases. If the general conditions of the patient allow it and if there are no contraindications, endosseous implants can basically be inserted for all cases in play. Are the implants all the same? No. There are some manufacturers of implants that have invested in research and now offer implant coating surfaces that shorten the time of osseointegration up to 1 or 2 months (time necessary before the implant can be "loaded" with the final tooth). Unfortunately, companies producing implants are increasingly numerous and some of them, produce and market low cost implants that do not always offer scientifically validated and guaranteed products. What are the complications? It is classically a very simple operation with very little morbidity for the patient, but not free from complications. Implant failure is a possible event, but very rare in particular in non-smokers. The most serious complications are maxillary sinusitis, caused by implants partially or totally inserted into the maxillary sinus, and the lesion of the lower alveolar nerve, consequent to inexperience or to programming error.

AESTHETIC MEDICINE/SURGERY

Dermabrasion

Duration of surgery > 30 min / Anaesthesia > local/ Cost > 1000 Euro

Dermabrasion is a medical-surgical procedure that consists in removing the topmost skin conditions, allowing the regeneration of a younger and more regular skin. Which imperfections can be treated with it? Dermabrasion can be very useful in correcting many skin blemishes. The most common application is the possibility of reducing the visibility and extension of scars, be they surgical, trauma or acne. It can also be applied in larger areas of the skin to obtain "resurfacing", i.e. a removal of the superficial layers of the skin to allow its regeneration. Is it painful? Not usually, but the need for anaesthesia depends on the extent of the area to be treated or the extension of a scar. Usually the only anaesthesia applied is ice spray, sprayed on the area to be treated just before the dermabrasion. How is treatment performed? Treatment is carried out by gently passing a high speed diamond rotary cutter on the area to be treated. The surgeon slowly moves the cutter, caressing the skin with it and abrading its most superficial states. The depth is indicated by the appearance of small vessels of the dermis.
White peeling

Duration of surgery > 10 min / Anaesthesia > none / Cost > 100 Euro

Peeling is a dermo-aesthetic technique that involves the application of one or more exfoliating chemicals in order to cause selective and predictable damage to the skin. The Medical White Peel is a compound and combined peeling useful for the treatment of many facial imperfections. What is the difference between single-acid, compound and combined peeling? The first medical-use peels were created in the 90s, whose solution contained only one exfoliating agent, for example only glycolic acid: they were called single-acid peels. More recently, compound peels have been introduced, whose solution consists of a pool of exfoliating agents. The advantage over simple peeling consists in the fact that there may be synergy between the active ingredients and the concentrations of the single active ingredients can be reduced with a decreased probability of unwanted events. Finally, combined peeling is the temporal succession, during the same treatment session, of two or more peelings, in order to obtain a deeper effect, reducing however the risk of side effects compared to the use of a single peeling. Which substances are used? The Medical White Peel consists of 2 phases. The first phase is a flowing gel consisting of glycolic acid, salicylic acid and lactic acid. Glycolic acid has an epidermolytic effect and facilitates cell turnover. Salicylic acid is keratolytic and antimicrobial. Lactic acid is epidermolytic and antiseptic. The second phase is instead a white cream consisting of azelaic acid, salicylic acid, alpha-lipoic acid, alpha-bisabolol, arbutin and ascorbylpalmitate. Azelaic acid has an anti-inflammatory, skin-purifying, lightening and sebum-balancing effect. Alpha-lipoic acid and ascorbylpalmitate have an antioxidant effect. Alpha-bisabolol promotes skin tropism, has a lightening, regenerating and soothing action. Arbutin has a dual lightening action and anti free radicals. Which imperfections can be treated with it? It is indicated to restore the shine to aged skin (chrono or photo-ageing), to spots (melasma and chloasma) and to acne-prone impure skin. How many sessions are necessary? Six or more sessions are recommended depending on the imperfection to be treated within 15 days of each other. Once the desired result is achieved, two sessions per year of maintenance can be carried out. How is treatment performed? The first phase of the peeling is applied on the face with a small brush and made to act until you see a slight reddening of the skin. Patients then rinse their face with water. The second phase is then applied as a cream, which should be left to act for 6-12 hours. In the days following peeling, the skin must be protected with high degree sun protection (50+) and moisturising and soothing creams. Are desquamations and crusts formed? This rarely happens. In exfoliating peels, exfoliation is performed by the caustic action of the acid on the epidermis, with the formation of desquamations and crusts. White Peel has no caustic action, but stimulates the basal layer of the epidermis by increasing cell turnover.
Cutaneous bio-revitalization

Duration of surgery > The duration of the procedure varies according to the area to be treated and the quantity of solution to be injected. The average duration is 10-20 minutes. / Anaesthesia > none / Cost > 80-100 Euro

Skin bio-revitalization is an exogenous contribution to the skin of substances constituting the skin itself, in order to improve its hydration and appearance. The substances are injected by a doctor into the subcutaneous tissue. Which substances are used? The substances used may be different and may vary according to the commercial formulation. The main substance used is low molecular weight non-cross-linked hyaluronic acid. This is not the same hyaluronic acid used in fillers, which instead is high molecular weight and cross-linked in order to prevent degradation for months. The effect of low molecular weight hyaluronic acid is basically a hygroscopic effect, that is to say, of water. This means that it does not fill wrinkles but moisturizes the skin. How is it used in Aesthetic Medicine? Bio-revitalization is used to rejuvenate the skin, rehydrating it from the inside and giving it a brighter appearance. How long does it take for the result? The effect is practically immediate, but at the beginning it is slightly masked by the swelling coming from the infiltrations. After 2-3 days, hyaluronic acid draws water and therefore achieves maximum skin hydration. Hydration lasts as long as there is hyaluronic acid, which, however, is broken up within a few weeks due to its low low molecular weight. How is treatment performed? The bio-revitalization solution is injected into the subcutaneous tissue using an extremely fine needle. In the immediate post-treatment there may be a slight redness and swelling, which may persist for a few hours. No medication is required. Is it dangerous? The hyaluronic acid used in bio-revitalization is a natural constituent of the skin and is absolutely biologically tested and safe. Who is treatment indicated for? For those who want to restore a brighter and hydrated appearance to the skin of the face and décolleté. It is not a treatment that aims to fill wrinkles, but its goal is to restore the the shine and hydration of skin. Is infiltration painful? Usually not. Discomfort varies depending on the area to be treated and on the individual threshold of pain perception. Thanks to the use of very thin needles, there is only a slight annoyance. Are there any side effects? Immediately after treatment, slight reactions are common, which are the natural consequence of injections. Among these the most frequent are redness, swelling, pain, itching and haematoma. Generally these reactions resolve spontaneously in a few hours. What is the difference with skin biostimulation? In skin biostimulation, the precursors of the cutaneous constituents are supplied to the skin which stimulate the skin to produce hyaluronic acid and other constituent substances. Cutaneous biorevitalization externally supplies active substances to the skin (low molecular weight hyaluronic acid).
Biostimulation

Duration of surgery > The duration of the procedure varies according to the area to be treated and the quantity of solution to be injected. The average duration is 10-20 minutes. / Anaesthesia > none / Cost > 80-100 Euro

Skin biostimulation is an internal stimulation of the skin obtained with substances that are injected by a doctor into the subcutaneous tissue. Which substances are used? The substances used may be different and may vary according to the commercial formulation. The substances mainly used include: 1) glucosamine sulfate: it is a precursor of hyaluronic acid. Its presence in the subcutaneous tissue give fibroblasts a greater amount of substrate for the endogenous production of hyaluronic acid. 2) Polydioxyribonucleotides: are fragments of placenta extracts nucleic acids. They allow nucleic bases of fibroblast DNA to be reconstituted and reciprocated more frequently and consequently cell replication and rejuvenation is stimulated. 3) Local anaesthetic: to reduce pain during infiltration. 4) Sodium bicarbonate: to lower the acidity of the injection solution and consequently reduce burning during the injections. How is it used in Aesthetic Medicine? Biostimulation is used to rejuvenate the skin, regenerating it and providing a smoother and more lively appearance. The action takes place from the inside as the skin fibroblasts (which produce collagen and hyaluronic acid) are reactivated at the cellular and biochemical level. How long does it take for the result? The immediate effect is not the definitive one. At the beginning, in fact, there is swelling of the parts in which the stimulating solution is injected. In a few hours this oedema disappears and in its place often takes a little redness, a sign of skin reaction. The final result is appreciated only after 3-4 sessions of biostimulation. How is treatment performed? The bio-revitalization solution is injected into the subcutaneous tissue using an extremely fine needle. In the immediate post-treatment there may be a slight redness and swelling, which may persist for a few hours. No medication is required. Is it dangerous? All substances used in biostimulation are absolutely safe. However, the doctor should be advised of the possibility of adverse reactions to local anaesthetics. Who is treatment indicated for? For those who want to restore a brighter, compact, smoother and younger appearance to the skin of the face and décolleté. It is not a treatment that aims to fill wrinkles, but its goal is to restore the the shine and skin hydration and quality. Is infiltration painful? Usually not. Discomfort varies depending on the area to be treated and on the individual threshold of pain perception. Thanks to the use of very thin needles, there is only a slight annoyance. Are there any side effects? Immediately after treatment, slight reactions are common, which are the natural consequence of injections. Among these the most frequent are redness, swelling, pain, itching and haematoma. Generally these reactions resolve spontaneously in a few hours. What is the difference with skin biorevitalization? Cutaneous biorevitalization externally supplies active substances to the skin (in particular low molecular weight hyaluronic acid). With biostimulation the precursors are instead given to the skin and it is stimulated to produce its own constituents. The results of biostimulation therefore last longer.
Botulinum toxin

Duration of surgery > 10 min / Anaesthesia > none / Cost > 350 Euro

Botulinum toxin blocks the release of acetylcholine at the junctions between nerves and muscles (neuromuscular plaques). Acetylcholine is the substance that is released from the motor nerve to transmit the contraction impulse to the muscle. The procedure weakens the muscle in which the substance is injected. Is its use approved in the aesthetic field? In Italy the use of botulinum toxin was authorized in 2004 by the Ministry of Health. Only one type of drug called Vistabex can be used outside of hospital environments.. The authorized treatment specialists are maxillofacial surgeons, plastic surgeons, dermatologists, neurologists and ophthalmologists. What wrinkles can be treated? The maximum effectiveness is in glabellar wrinkles (between the eyebrows and at the root of the nose), in the crow's feet and in the horizontal wrinkles of the forehead. Who is treatment indicated for? It is indicated for the treatment of expression wrinkles (dynamic) that are formed as a result of the repeated and tonic contraction of the muscles of the forehead and of the eyebrow corrugators. By weakening the muscles, the folds of the overlying skin are no longer formed and wrinkles fade until disappearing. How is treatment performed? The protein is diluted and administered quickly and easily into the muscles responsible for wrinkles through a few micro-injections with a syringe equipped with a very fine needle. Is it dangerous? BTX is extremely safe when used in the treatment of facial wrinkles. No cases of allergies or systemic reactions have been reported. This drug has been used for over 20 years and, if used correctly and by competent specialists, is among the safest drugs known. Does it eliminate all wrinkles No. It is effective against wrinkles and does not eliminate wrinkles caused by prolonged sun exposure and ageing. It does not replace fillers and can be used in combination with them to achieve a better result. Is infiltration painful? No. Thanks to the use of very thin needles, there is only a slight annoyance and therefore no anaesthesia is required. Is the effect immediate? No. It takes about the affected muscles about 3 to 7 days to relax. Can it also be used to reduce excessive sweating? Yes. "Hyperhidrosis", or excessive sweating in the hands, feet or armpits can be effectively resolved with botulinum toxin. Can it be associated with other aesthetic treatments? Yes. The association with other treatments such as fillers, facelift or blepharoplasty often allows to obtain the best aesthetic results. How long does the effect last? The effect of botulinum toxin is temporary and lasts 3 to 6 months. Repeated injections increase the effect. What must I not do after treatment? The protein is injected into specific areas. Outside of these, its migration can give rise to problems such as the fall of the upper eyelid. Therefore, never massage the area, do not play sports and avoid makeup for the first hours after the injection.
Hyaluronic acid based fillers

Duration of surgery > 10 min / Anaesthesia > local / Cost > 250 Euro per bottle

Hyaluronic acid is a polysaccharide, that is, a type of sugar, which naturally exists in the body as the main constituent of the connective tissue. Thanks to its particular chemical structure it is able to retain water and gives the skin a hydrated and youthful appearance. Hyaluronic acid used as filler is a synthetic product identical to that present in the human body, but modified in chemical bonds in order to increase its stability. How is it used in Aesthetic Medicine? Hyaluronic acid can be used to fill furrows and wrinkles of the face or to reshape lips and/or cheekbones in order to increase their definition and volume. How long does the effect last? Hyaluronic acid is a completely resorbable filler. Today, non-absorbable fillers are inadvisable and largely prohibited due to the risks and complications they have shown over time. The resorption time is variable and individual and depends on various factors such as age, type of skin, type of life conducted (smoking) and the implant site. The average duration is 4 to 7 months. How is treatment performed? Hyaluronic acid is injected into the dermis with a very fine needle. The depth of injection is different depending on whether you want to eliminate a wrinkle, correct the volume or define the lip contour. In the immediate post-treatment appears a slight redness that persists for a few hours. No medication is required. How long does treatment last? The duration of the procedure varies according to the area to be treated and the quantity of filler to be injected. The average duration is 10-20 minutes. Is it dangerous? Hyaluronic acid is an absolutely safe natural substance. In recent years it has been used for aesthetic purposes in millions of patients and there are numerous histological and clinical studies that demonstrate its tolerability and effectiveness. Who is treatment indicated for? Anyone who wants to eliminate the wrinkles of the face, the eye contour (crow's feet) and remodel cheekbones and lips without resorting to plastic and aesthetic surgery. Is infiltration painful? Usually not. Discomfort varies depending on the area to be treated and on the individual threshold of pain perception. Thanks to the use of very thin needles, there is only a slight annoyance and many patients do not require anaesthesia. In sensitive patients local anaesthesia can be performed that totally eliminates pain (such as that applied by the dentist) or an anaesthetic cream can be used to desensitize the area to be treated. Are there any side effects? Immediately after treatment, slight reactions are common, which are the natural consequence of injections. Among these the most frequent are redness, swelling, pain, itching and haematoma. Generally these reactions resolve spontaneously in a few hours. Is the effect immediate? Yes. Although we must consider that the final result is seen at about 2-3 days from the treatment. Can it be associated with other aesthetic treatments? Yes. It can be associated both with other injecting treatments (botulinum toxin), and with surgical operations such as lifting or blepharoplasty, rhinoplasty, etc.
Lipofilling

Duration of surgery > 60 min / Anaesthesia > Local or general depending on the preferences of the surgeon and the patient and depending on the amount of fat required / Cost > 2000-6000 Euro

It is a surgical operation that aims to fill depressed or buried facial regions through the use of autologous fat, i.e. taken from the same patient. It is a non-invasive technique that guarantees reliable, long-lasting and natural results. Recently the interest in this technique is growing more and more due to the presence of abundant stem cells in the fat taken. It is a common experience that the skin of lipofilling is regenerated and revitalized after this procedure. The effect is often relevant both in terms of filling and cutaneous in the case of depressed scars. Where is the sample taken from? The fat is taken from areas with an excess of adipose tissue (thus obtaining a double advantage ...). Typically the most common sampling site is the abdomen, but the hips or thighs can also be used. The incision for the sample is minimal and entails tiny cuts inside the navel, necessary to allow insertion of the suction cannula. The fat drawn is placed into special containers and centrifuged for a set time and speed. Thus the fat and stem cells are separated from other substances contained in the sample. Where is the fat injected? Wherever necessary. The areas of the face that with age or due to particular diseases tend to "empty" out are the zygomatic areas and nasolabial folds. The fat sample can also be used to fill the  periocular area or used for profiloplasty The assessment of the site and the quantity of the transfer must be done on a case by case basis and planned before the procedure. How long does the post-operative period last? The surgery is not particularly painful and discomfort normally goes away within a week. At first, the result is partly masked by swelling and possible bruising, but within 2 weeks the final result can already begin to be appreciated.
Scar revision

Duration of surgery > 30-90 min / Anaesthesia > local or general depending on the scar / Cost > 500 / 3000 Euro

The revision of scars consists in the surgical removal of an unaesthetic scar. It is not about completely eliminating a scar, but replacing it with a more aesthetic one. The scalpel is not a magic wand and leaves a mark where it passes. However, an aesthetic suture and plastic details to redistribute the tension on the scar make it possible to improve its appearance in most cases. Peeling or dermabrasion can be used for superficial scars.
Lifting

Duration of surgery > 120-140 min / Anaesthesia > general / Cost > 10000 Euro

The lifting is a surgical procedure, more correctly called ritidectomy, which consists in the relaxation of skin and relaxed tissues due to the effect of gravity over time. How many types of facelifts exist? There are many types of lifts. They can be superficial or deep, involving only the skin or even the tissue made of muscles, fat and connective that comes in jargon called SMAS (superficial muscle-aponeurotic system). In addition, a lift can affect different skin areas: from the frontal facelift to the zygomatic-zygomatic facelift, from the cervico-facial to the mid-facial facelift. Which is the best lifting? Impossible to generalize. Each patient is different from the other and their clinical needs are different. The most classic facelift is the cervico-facial, which is indicated when cutaneous and muscle-cutaneous relaxation is more evident in the lower third of the face and neck. Nowadays, there is a tendency to limit the number of face-lifts today as, except for cases of extreme cutaneous overabundance, botulinum toxin offers results that are of comparable quality. A type of face that is growing in popularity is the mid-face facelift: it provides incisions similar to those of lower blepharoplasty and allows all relaxed tissues of the cheek to be repositioned upwards, with the double filling effect of the zygomatic region and of reduction of the sochinaso-genieni. Is the result natural? It depends on the surgeon. The unnatural results represent a failure and a bad publicity for all facial plastic surgery. Is it a simple procedure? Not at all. Often the patient tends to underestimate this type of surgery using expressions such as "pinch" or similar. Lifting s a complex operation that can have more or less serious complications, especially in smokers. The incisions are usually well hidden, but long (in the case of frontal and cervico-facial areas). Is it performed under general anaesthesia? Yes, unless minimally invasive techniques are performed on small skin regions. Is it painful? Usually not. For two or three days after surgery the oedema (swelling) is rather significant and bothersome, but resolves spontaneously in 7-10 days.
Zygomatic prosthesis

Duration of surgery > 120 min / Anaesthesia > general / Cost > 5000 Euro

Malarial hypoplasia, i.e. the projection deficit of the zygomatic region, sometimes represents an important imperfection, altering the harmonious proportion of the face. Zygomatic prostheses are alloplastic (synthetic) materials that increase the volume and the definition of the zygomatic region. What kind of material is used? The constituent materials of the prostheses are basically of two types: silicone and high density polyethylene (Medpor). The difference is in both consistency and surgical placement. While in fact silicone implants must be inserted in "pockets" made in the soft tissues of the zygomatic region, the Medpor prostheses are instead placed in contact with the zygomatic bone and fixed to it with titanium screws. While silicone implants over time can dislocate and move downwards following the gravity descent of the soft tissues of the face, the Medpor prosthesis is unable move because it is anchored to the bone. What does surgery entail? The operation is performed by making an incision inside the mouth, at the level of the upper gingival arch. In the case of the silicone prosthesis, it is inserted into the soft tissues and generally fixed with a point that protrudes outside the cheek (which is removed after a few days). In the case of the Medpor prosthesis, it is made to adhere to the underlying bone and fixed with one or more titanium screws. Can it be associated with other surgeries? Yes. Frequently facial aesthetic alteration does not concern only the zygomatic region, but it can be associated with aesthetic alteration of the nose and of the maxillary and mandibular region. It can then be associated with orthognathic surgery, and seporinoplasty. In general, the combination of several interventions tends to improve the patient's profile above all. In these cases one can speak of "profiloplasty”. How long does the post-operative period last? The patient can usually be discharged already the day after the operation. It is necessary to take specific antibiotics for a week to avoid infections of the prosthetic material. The endoral sutures are usually removed after about ten days. The oedema (swelling), a slight reddening, small hematomas and a momentary reduction in the sensitivity of the cheek region, are common consequences of the intervention, but they resolve spontaneously in a few days.
Profiloplasty

Duration of surgery > variable/ Anaesthesia > general / Cost > variable depending on the procedures to be carried out

Profiloplasty is an improper term that indicates a surgical alteration of the facial profile. It is the set of different surgical procedures that can also be associated in the same operation depending on the cases and needs. The operations that are most able to modify the profile of a face are: rhinoplasty, genoplasty, zygomatic prosthesis and orthognathic surgery. It makes no sense to talk about profiloplasty as if it were a specific surgical procedure: it is better to consider the individual interventions (associable) necessary to obtain a harmony of the face, which goes beyond its profile ...
Otoplasty

Duration of surgery > 120 min / Anaesthesia > local with sedation or general / Cost > 4500-6000 Euro

It is a surgical operation that aims to change the shape of the ears. Sometimes severe malformations of the auricle exist, but the vast majority of patients are referred to the surgeon for the correction of lop ears, i.e. big ears. When? Often the large protruding  ears represent a social disadvantage and a psychological problem. It is one of the few cases in facial plastic surgery in which it is morally licit to intervene on children (5-6 years) before entering primary school, so as to prevent them from being teased by schoolmates. In any case, most patients are adults. How is otoplasty performed? Although it seems simple to "attach" the ear, there is a great deal of techniques developed by different medical personnel. It is necessary to evaluate the portion of the deformed auricle (anthelix, lobe, auricular basin ...) and correct it. The incision is performed from behind the ear and is practically invisible. How long does the post-operative period last? Surgery can be performed locally or in general according to the surgeon and patient preferences. The surgery is not particularly painful and discomfort normally goes away within a week. The stitches are removed after 10-14 days. A rest period of at least 10 days is advisable. For 2 months (initially night and day, then only at night), a containment band should be worn. What are the possible complications? The main risk in the otoplasty is that perfect symmetry between the two sides is not achieved. This is sometimes only temporary as a post-operative haematoma could alter the shape of the ear. Hypertrophic infections or scars or keloids are extremely rare in this type of operation.
Blepharoplasty

Duration of surgery > The average duration of an upper and lower blepharoplasty is about an hour and a half / Anaesthesia > For local blepharoplasty, local anaesthesia is recommended. In the case of lower blepharoplasty combined with the upper one, it depends on the individual case and the patient's preferences. / Cost > 4500-6000 Euro (Upper and lower)

Blepharoplasty is eyelid surgery. It has both aesthetic and functional objectives.  From an aesthetic point of view, this type of intervention can eliminate important imperfections such as "bags" or under-adipose fatty hernias, ptosic or droopy eyelids and overabundant and wrinkled skin. As far as the function is concerned, the laxity of the lower eyelid can be corrected by eversion of the lower palpebral edge (ectropion) or by correcting a fall (ptosis) of the upper eyelid which may cause a limitation of the visual field. What are the objectives of the surgery? The primary objective of the surgery is the elimination of imperfections of function and facial harmony, avoiding the creation of "surgical eyes" or "unnatural glances". Which incisions are necessary? The operation is carried out by making incisions which, after healing, are practically invisible. As for the upper eyelid, the incision falls into the eyelid fold, while for the lower eyelid there are 2 possibilities: immediately below the eyelashes (subciliary incision) or from inside the lower eyelid (transconjunctival incision). How is the surgery performed? With regard to the upper eyelid it is almost always necessary to remove a portion of skin that is accurately determined just before surgery by markings made with a dermographic marker. The amount of fat to be removed can vary in amount. In the case of the upper eyelid, however, the quantity of skin to be removed must be extremely conservative in order to avoid that the scarring after surgery can "pull down" the lower eyelid margin and produce an ectropion. Even with regard to the removal of lower eyelid fat, today we tend to be fairly conservative. In fact, while eliminating the portion that makes up the bags, it can be partly used to fill the under brow furrow, which is almost always too accentuated and highlights the "dark circles" in patients who need blepharoplasty. What is the surgeon's goal? Improve, rejuvenate and lighten the patient's gaze, with the primary objective of obtaining natural and harmonic aspects, which do not seem “redone”.
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