Beverly Hills Rhinoplasty Surgery Blog

A patient recently asked whether lower facelifts can unnaturally pull her lips. She wondered whether she would be better off with a ‘vertical facelift’.

Here’s the answer. The so-called vertical vector facelifts that are done via incisions in the temple area or in the lower lids to address the midface cannot adequately address the lower face and neck. While there may be some improvement in jowling with these procedures, it is usually not substantial. Any excess tension in an attempt to get more improvement of the jawline can result in movement of the hairline and other problems.

A traditional incision around the ear is still the best approach to rejuvenating the lower face and neck when more repositioning is needed such as when there is noticeable jowling and . Most facelift surgeons today will modify the vector of repositioning on the deeper tissues so that it creates the most natural possible outcome. In the neck, the most appropriate vector often follows the jawline. A relatively more vertical vector is more appropriate higher up in the cheek. All of this can be done through the same incision and deeper plane techniques can often give a more dramatic and natural result. You do not need to worry about your lips being pulled horizontally in the hands of a good facelift surgeon. This shouldn’t happen.

A second really important aspect of facial rejuvenation to consider is volume restoration. We all lose some bone and fat/soft tissue volume as we age, especially in the cheeks and around the mouth. This can give us the effect of looking a little more gaunt and tired. Restoration of this volume along with a lift can really round out the procedure and restore a natural vibrant and youthful look. Our Hybrid Lift accomplishes this with micro fat transfer to the cheek, under eye area, and lower facial folds combined with a lower face and neck lift, and all via a small incision that does not extend into the hairlines.

Check out our Beverly Hills Facelift Surgery site for more details.

This is a great question that we get in our practice a fair bit and that we have looked into. In fact, we in association with our colleagues reviewed the largest series of injectible rhinoplasties (non surgical nose jobs, liquid rhinoplasty) done by anyone to date. In the study we examined all the patients over a year that had non surgical nose jobs with Radiesse to see how long it lasted and what if any problems occurred.

Side note- We will not make this blog a long diatribe about the merits of injectible rhinoplasty or about the aesthetics of the procedure, except to say that you should recognize that most people getting rhinoplasty want their nose at least slightly smaller whereas injectible nose jobs are by definition an augmenting procedure where the nose is made larger.

In short answer to the question, in our study we found that approximately 25% of patients required a touch up before 6 months, either due to partial resorption of the filler or because they wanted further augmentation.Over the remaining portion of the year, many more of the patients returned as the fillers dissolved. It is hard to say if the fillers dissolve completely because it partially depends on which filler material is use, but with the temporary fillers we suspect that the great majority of the filler dissolves with time.

For those wondering what about using other injectible fillers such as Sculptra, Aquamid Artefill, etc, it is true that they likely would stay longer in the nose but they can also cause inflammation, chronic infection, skin slough or a host of other problems. In fact, if you go to our blog a few weeks back we show an example of a patient in whom we did surgery who had had injectible nose job done some 7-8 months previously. (previous blog) In him, you can still see the injectible filler material that had to be removed. He is now very happy with his nose and he did great but it made surgery more difficult than it otherwise needed to be.

The point to all of this is that non surgical nose jobs, in our opinion, can be great to fill in minor defects or irregularities, but they should not necessarily replace or help achieve the goals that most people wanting a nose job want.

As most of you are aware by now, accutane can be quite abrasive to the skin. What some may not be aware of, is how damaging rhinoplasty can be to the skin envelope when not done by an experienced rhinoplasty surgeon. Sadly, we are very often presented with patients who in their previous surgery had either a hole made through the skin or because the surgeon was in an improper plane, massive amounts of scar tissue was created after surgery.

Luckily, in the majority of revision rhinoplasty cases the skin envelope is healthy and viable, allowing us to correct any other issues. As such, this particular question partially has to be made on a case by case basis. For those people wanting primary rhinoplasty (first time nose job) or in whom the previous rhinoplasty did not injure the skin envelope, waiting a month to 6 weeks after finishing accutane is likely enough time to proceed. If there is lots of scar tissue or other skin damage, the question has to be answered based on the extent of the problem. It may be wiser in those cases to either wait 3-6 months, or in the rare case it may be advisable not to operate ever because the risks would not outweigh the benefits.

The only further caveat is to make sure you see someone who does lots of revision rhinoplasty. This is particularly important in complicated cases like this so that you can feel safe in the knowledge your surgeon has the experience to make an honest appraisal.

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This is a great question that we get in our practice a fair bit and that we have looked into. In fact, we in association with our colleagues reviewed the largest series of injectible rhinoplasties done by anyone to date.I don’t want to make this a long diatribe about the merits of injectible rhinoplasty and if the aesthetics make a lot of sense, except to say that you should recognize that most people getting rhinoplasty want their nose at least slightly smaller whereas injectible nose jobs are by definition an augmenting procedure where the nose is made larger.

Getting injections done now can lead to distortion of what your nose really looks like and make it harder for your surgeon to know what your nose looks like originally. While it is true that injections can be temporary if done with restylane or juvederm, they can cause scarring or inflammation or infection  that can create further problems.

Moreover, other more longer lasting injectibles such as radiesse, sculptra, artefill, etc can and do stay longer in the nose causing further inflammation and needing to be removed at the time of surgery. In fact, if you go to our blog a few weeks back we show an example of a patient in whom we did surgery who had had injectible nose job done some 7-8 months previously. (previous blog) In him, you can still see the injectible material that had to be removed. He is now very happy with his nose and he did great but it made surgery more difficult than it otherwise needed to be.

I just read this article online regarding Lisa Rinna saying, “I always said I wouldn’t change my face, but I did it.”

We generally avoid discussing celebrity plastic surgery, but frankly I’m confused. Are her lips not part of her face and what do injections have to do with plastic surgery?

The article goes on to say, “Although she still likes Botox (”it doesn’t change the shape of my face,” she says), she has learned she doesn’t need so much surgery.”

I think the public gets misinformed about what is and isn’t plastic surgery. In this case, Ms Rinna went to someone who injected her with too much restylane in her cheeks- what does this have to do with surgery?  I mean there was a time when cheek enhancement meant you went in and had a cheek implant placed. And we still occasionally do this.  But this is not surgery, it is injection of a filler material- perhaps juvederm, radiesse, restylane, or any one of a host of other fillers on the market.

For those of you who follow our blog, you’ve heard our feelings regarding the filler craze that has been a huge part of “cosmetic surgery” over the last decade, so I won’t digress here. However, perhaps more than anything else the problem with this phenomenon is  that any type of doctor or nurse can buy restylane, juvederm or some other filler and with little or no training can start injecting patients. And unfortunately when things go wrong, the problem the media points to is not with the injector not having proper training or aesthetic sense but with “plastic surgery” in total.

We have no knowledge of who injected Ms Rinna- for all we know it was a plastic surgeon- but the point is that the media constantly hypes “minimally” invasive procedures like filler enhancement as though it is always better than surgery and that it has no or little risks.  And yet time and again when we see celebrities who have bad results from these minimally invasive procedures, it’s “plastic surgery” that is at fault.

To learn more about the facial fillers Botox, Restylane, Perlane or Juvederm, visit our Plastic Surgery website.

A recent Reuters Health article enjoyed a lot of coverage for its assertion that “women should consider looking beyond popular culture perspectives… before going under the knife for an emotional boost.” This conclusion was based on a study examining articles published over the last several years in popular women’s magazines such as Cosmopolitan and Chatelaine.

Of interest, the study seems to take a negative view of the fact that a majority of these women’s magazine articles link cosmetic surgery to an improvement in emotional health “despite the lack of scientific consensus” that cosmetic surgery has that effect. What’s worse, according to the study, is that male perceptions are commonly used to define standards of female attractiveness that are used to “justify undergoing cosmetic surgery,” especially body plastic surgical procedures it would seem.

This is a common opinion among plastic surgery detractors. It’s the age-old message, “You don’t need a facelift to feel good about yourself! That’s superficial. Embrace your wrinkles. Find your inner happiness.” Well, maybe that’s true and maybe it isn’t. Far be it from us plastic surgeons to ply and push our trade onto anyone. But, believe it or not, outer and inner beauty just might be more aligned than you think.  A recent study even suggested that plastic surgery can reduce dependence on anti-depressants.

What plastic surgery detractors should know is what we see every day. We talk to women who have and do look beyond cultural perspectives. They’re not having a nose job or eyelid tuck because their friend or boyfriend or husband told them to. In fact, many mates are opposed to the idea of surgery. They love these women as they are. Our patients are doing it for themselves, because it will improve an area of concern that has dogged them for years.

The idea that a woman having plastic surgery is somehow ‘giving in’ to pressures from the media and society is just plain wrong. A couple of my happiest patients have been strong, intelligent, self-proclaimed feminist intellectuals who used to be staunch opponents of plastic surgery…that is, until they realized the benefits for themselves.

But don’t take it from me, take it from them. There may not be “scientific consensus” about most things, but we just recently published one of the largest known studies of plastic surgery’s effects on quality of life. And, the results showed that facial plastic surgery had an overwhelmingly positive effect on perceived quality of life, as much or even more so than most any other medical treatment. So, the proof is in the pudding, folks. If you’d like to read about it for yourselves, here is the article.

Always on the forefront of beauty, Ms. Natasha Singer published a recent article in The New York Times detailing the fears that now surround nanotechnology as used in the cosmeceutical industry. For those unfamiliar, nanotechnology is the name designated for dealing with particles 100 nanometers or smaller [a nanometer being one billionth of a meter (10^-9 meter)], and in particular developing materials and devices of that size.

It was not too long ago when every cosmetic company was falling over itself in declaring its use of nanoparticles in their product- whether it was silver flakes to kill bacteria or gold flakes as antioxidants. However, more recently you see most companies shying away from bold declarations of their use of nanotechnology. Why?

Turns out when a particle is simply made smaller–macro to micro–the changes are not necessarily significant; but when you become nano, there are new quantam mechanical effects where the electronic properties of solids are altered. So, how do you test for these changes? For example, what happens to a nanoparticle of titanium dioxide in a sunscreen which can be as small as 15 nanometers? And if these particles are small enough to be absorbed through the skin, what happens to them once they get into the bloodstream or into the liver and kidneys?

Ms. Singer notes, “Indeed, some doctors, scientists and consumer advocates are concerned that many industries are adopting nanotechnology ahead of studies that would establish whether regular ingestion, inhalation or dermal penetration of these particles constitute a health or environmental hazard. Personal care products are simply the lowest hanging fruit.”

Truth is, I don’t know if anyone has concrete answers for these questions. Heck, I don’t even understand how the companies are making particles this small or checking for this. And, despite the recent blog posts, we are not out to be the bogeymen…we just think that when it comes to medical and cosmetic products, there should be enough studies to show that these things are safe before they hit the market–not after-market stories in the Times hinting that no one really knows…

The questions are deliberately controversial because the truth is most of the studies done in the US and throughout the world show that Permanent Fillers like Artefill and the possibly soon to be approved Aquamid are both safe and effective. However, despite being the only permanent filler on the market, Artefill went bankrupt in December. And the question is why?

 In addressing the topic a few weeks ago the NY Times was very vague in its analysis, instead posting a short article that for all intents and purposes just stated the fact that the company filed for bankruptcy.

There are many in the field who believe that dermatologists, “cosmetic surgeons,” and plastic surgeons who have heavy injectible practices utilize primarily temporary fillers because obviously it makes sense to them to have their patients coming back for more. Along the same lines, because these very doctors who have large injectible practices are then considered the experts in the field, they will also be the ones quoted in the media saying that while they think permanent fillers are likely safe, they are afraid of long term unknown consequences or as this article called them “ticking time bombs.” As a result, the general public and other less experienced injectors become wary of using permanent fillers.

So what do we think?

In our practice, as with the vast majority of practices, when most patients come to see us for fillers we generally end up using temporary fillers after we have gone through explaining the risks and benefits of the various fillers. And that is not because we believe that permanent fillers are unsafe. Unfortunately, however, the FDA and the manufacturers of these products are failing in doing the science required for us to really know how safe these fillers are. The problem is that most of these fillers get approval based on studies utilizing the nasolabial fold, where skin thickness allows you to inject deeper safely and as a result very few if any complications are seen. Longer range studies in Europe and Asia show the fillers to also be safe when utilized for the lips, under the eyes, and elsewhere. But these are usually not well controlled studies and in fact they are often done by a physician who is on the advisory board for the manufacturer of the fillers…so with the FDA doing an inadequate job, the local “experts” saying they are unsure, the rest of the physician base and the general population come to believe the product may not be safe…and a company goes boom…   

In the last month, Artes Medical, the makers of Artefill, formally filed for bankruptcy. Artefill had the distinction of being the first permanent filler that was approved for use in the United States. It had been used in other countries under a different formulation for some time.

There are probably a number of factors that have led to the problems Artes encountered, including market conditions and the current economic downturn. However, Bioform, maker of Radiesse, is also experiencing some loss of confidence in its stock.

For some time, we have been talking about the risks of using semi-permanent and permanent fillers (like Artefill and Radiesse) for facial augmentation. We are not big fans, and we have found fat transfer to be a fantastic natural alternative for lasting facial volume enhancement and augmentation. For those of you who would like to see the benefits of fat transfer, check out our youtube video at  http://www.youtube.com/results?search_query=bhprofiles&search_type=&aq=f.