Should Your Patients Consult a Dentist?
Carmen Schuller, DDS, of New York City specializes in integrative dentistry, a new approach that combines oral-cavity health with the balance between the head and neck, and the nervous, circulatory, and muscular systems. She says that some patients do not achieve their expected results after having facial plastic surgery because they lack proper oral health. Schuller advises patients to see a dentist to evaluate their dental health before seeking plastic surgery.
“It is clear that the two medical specialties are meant to collaborate so that the best possible natural results can be achieved,” Schuller says.
Before her patients undergo facial aesthetic surgery, Schuller adjusts the vertical distance between their nose and chin and restores their back teeth to their natural height and shape. Schuller then addresses the readiness of the connective-tissue matrix, which is distorted in the patient with inadequate dental support. These treatments, which are performed before and after surgery to help restore and improve muscle tone, complement the patient’s intraoral health and overall appearance.
“Decayed or infected teeth and or gums can contaminate adjacent surgery areas and can cause disseminated infections elsewhere in the body,” says Joseph Niamtu III, DMD, an aesthetic surgeon who practices in Richmond, Va (see page 30). “For instance, cardiac surgery patients are usually cleared with a preoperative dental exam to lower the chances of a septicemia from oral infection. From this aspect, preoperative dental health is important.
“In my practice,” Niamtu continues, “I pay more attention to the oral condition of a patient on whom I perform facelift surgery, and especially if I am placing chin or cheek implants from an intraoral incision. Missing teeth may make a small difference, but most patients that have the wherewithal to afford aesthetic surgery rarely have severe debilitating dental problems, in my experience.”
According to Schuller, some of the dental reasons for unfavorable facial plastic surgery outcomes are:
• The patient’s lower jaw is not equilibrated, and his or her core facial muscles are not strengthened and balanced before or after surgery.
• The patient may not be able to chew well because he or she is missing teeth in the back of the mouth, which can result in unnatural sinking of the cheeks.
• The distance between the nose and chin is not adequate.
• Patients that grind or clench their teeth exhibit vascular and lymphatic changes in the head and neck area, resulting in headaches, and neck and low back pain.
Niamtu agrees that any patient who undergoes surgery should have good health. However, he says, “As for the need to be cleared specifically for plastic or cosmetic surgery for neuromuscular, lymphatic, and vascular reasons or to prevent headaches and lower backaches is totally unfounded and not supported by any credible, mainline, standard-of-care scientific studies.
“There is no doubt that in severe cases, the teeth can affect the head and neck musculature, especially when there is severe night grinding or temporomandibular joint problems. But to try to attach the circulatory system, lymphatic system, and other remote maladies to the teeth is basically unfounded.”
New Skin-Cancer Therapies
At the American Academy of Dermatology scientific meeting held in July in San Diego, Hensin Tsao, MD, PhD, FAAD, an assistant professor in the department of dermatology at Harvard Medical School, discussed new therapies for skin cancer, including targeted therapies, immunotherapy, and stem-cell therapy.
“It is an exciting time in cancer biology, and new emerging therapies will undoubtedly challenge the old views of cancer and hopefully offer more effective outcomes,” Tsao says.
According to Tsao, targeted therapies detect the difference between cancer cells and healthy cells by targeting the genes or proteins that contribute to the development and growth of cancer. Targeted therapies were derived from a basic understanding of the cancer cell, he explains.
For cells to grow, divide or die, they send and receive chemical messages. These messages are transmitted along specific pathways that involve various genes and proteins in a cell.
Immunotherapy uses the body’s own rejection system as a method of treatment for skin cancer. Two types of treatment are cell-transfer immunotherapy and topical immunotherapy.
Cell-transfer immunotherapy uses the body’s natural defenses to fight the disease by stimulating the immune system to reject and destroy tumors. Studies have demonstrated that it can result in cancer regression in 50% of melanoma patients who do not respond to other treatments.
Topical immunotherapy was recently approved by the US Food and Drug Administration for the treatment of basal-cell carcinoma and actinic keratosis, the earliest stage in the development of skin cancer. A cream is applied to the skin every day for several weeks, helping to break down the lesion and regenerate healthy skin, essentially jump-starting the body’s immune system to fight the lesion.
Stem cells respond to cells such as fibroblasts—or connective-tissue cells—in the normal tissue, and they contribute to the development of an entire organ. A recent view of cancer is that the entire tumor mirrors the development of an organ.
In this regard, new blood vessels are formed in a process termed angiogenesis, which is known to be a critical event in the malignant transformation of skin cancer. During angiogenesis, new blood vessels feed diseased tissues, destroy normal tissues, and allow tumor cells to escape into the circulation. The cells can lodge in other organs, causing tumor metastases.
According to Tsao, researchers are trying to find therapies that will enhance cancer-cell death, minimize invasion, diminish angiogenesis, and increase the immune system’s attack.
Speaking at the American Academy of Dermatology meeting, Kimberly J. Butterwick, MD, FAAD, a dermatologist in La Jolla, Calif, reviewed the options available for lip enhancement, including collagen, hyaluronic acid gel, and fillers.
Purified collagen from cattle and humans is most often used to treat very fine wrinkles around the mouth—or classic “smoker” lines—and to add volume to thin lips, Butterwick says. Collagen products help add structure back to the skin; the results last 3 to 4 months.
Bovine collagen has been in use for more than 25 years. Nearly 5 years ago, human-bioengineered collagen, or collagen derived from human cells, was approved by the FDA. The advantage of human collagen is that it does not pose an allergy risk, whereas bovine collagen does and requires a skin test before use. Both types of collagen are formulated with an anesthetic to prevent any discomfort to the patient.
Another FDA-approved filler is hyaluronic acid gel. A natural component of skin, hyaluronic acid holds the collagen and elastin of the skin together. When injected into the skin, the gel binds to water and provides volume to plump lips and fill larger folds of skin around the mouth and cheeks. Results can last 3 to 6 months.
“A good lip enhancement can be achieved using both collagen and hyaluronic acid gel,” Butterwick says. “By using the collagen first, the skin is numbed, allowing the hyaluronic acid gel to be used pain-free. Additionally, each filler provides a different level of support, so the overall enhancement looks very natural.”
Other fillers, such as calcium hydroxyapatite and poly-L-lactic acid, often are used to enhance the areas surrounding the lips. Butterwick notes that although these fillers are not placed directly in the lips, they add to the overall effect by filling and supporting the lines and hollows around the lips. They can soften a down-turning mouth and restore fullness to the larger folds of skin around the mouth. Botulinum toxin Type A also may be placed in key areas around the lips to minimize muscle movement, such as frowning and pursing, that contributes to wrinkles.