Sorry we haven’t blogged in a while. We have just finished a tour of Las Vegas and New Mexico including a conference and consultations with patients. What was interesting to us was the similarities we see among patients’ desires and fears related to surgery. We have both practiced in big cities on both coasts but we have never had the pleasure of consulting with patients in the smaller cities of this beautiful desert country.

We talked to people who were generally well-informed and who had a great deal of interest in the latest and greatest in plastic surgery. Like our patients here in LA, they have justifiable doubts about some of the less invasive procedures that make over-the-top claims in the media. Some have had a Lifestyle Lift elsewhere and have been sorely disappointed. Most all spoke of wanting to look natural and of fearing an overdone appearance. All of them were very willing to consider surgical procedures to achieve their goals. Mostly, they were in need of doctors who would tell the truth about what they could expect from today’s surgical anti-aging procedures.

What we did not expect was the level of sun damage that a majority of patients exhibited. We probably shouldn’t have been surprised since many people in these areas spend much of their work and leisure time in the great outdoors. But, most also confessed that they did not use sunscreen at all, let alone effectively. As a result, we saw a lot of premature skin aging and most patients had had early precancerous lesions scraped or burned off. Many of these sun-related changes such as fine wrinkling, brown spots, and thickening can be treated really well with a series of peels, such as the ViPeel or Blue Peel, along with lifting and volume enhancing procedures such as our new Hybrid Lift to treat sagging skin.

But, the most important thing you can do is to protect your skin from the sun in the first place. We’re good about sun protection, yet UV-filtered photos of ourselves still show a fair bit of accumulated sun damage. So, we spent a lot of our time lecturing about sun protection. Avoidance of sun in the mid-day hours, wearing protective layers, and using a SPF 30 or greater sunscreen liberally and often (especially after water exposure) are all sensible things everyone should do, regardless of skin type. If you want to take skin anti-aging to the next level, then use of a good skin care regimen that incorporates antioxidants and bleaching agents can give your skin a healthy glow that you haven’t seen since grade school. Check out our website for more details.

Welcome to the no spin zone: no, you have not found your way to the O’Reilly blog, however when we read a recent article in the Daily Mail-UK we couldn’t help but wonder why these things would be reported in a newspaper. Do they actually research or do they decide a story they want and then find a number of people who will agree with them?

The story begins by telling us that the popularity of facelifts and anti-aging/ facial rejuvenation surgery is growing year after year, but then takes an abrupt turn by quoting a number of “cosmetic doctors,” who happen to have non surgical cosmetic practices (comprised of fillers- juvederm, restylane, perlane- and botox) who believe that surgery is bad.  What a surprise.

If you have been reading our blogs, especially those regarding the Hybrid Lift, you know by now that our Beverly Hills facial plastic surgery practice is dedicated to bringing natural looking results, and this means that we are strong advocates of a balanced approach utilizing volume enhancement, i.e. fillers, and lifting procedures in concert.

We recognize that potential patients are constantly bombarded by spin and hype from competing physicians and corporations [Allergan- Botox, Juvederm; McKesson- Restylane, Perlane, Myobloc; Artes- Artefill; Bioform- Radiesse, to name a few] and it is important for doctors to be advocates for their patients (not the corporation), so they can honestly explain all the risks and benefits of every available procedure. This is perhaps most important in plastic surgery and cosmetic surgery where we are talking about elective procedures.

The truth is that surgery works brilliantly when done correctly and for the right reasons. Let’s face it, if you have sagging skin and jowling, fillers are not the answer, though they may play a part. On the other hand, if you have hollowing in the cheeks or under the eyes, volume enhancement with a skin pinch may very well be better than traditional blepharoplasty (eyelid surgery). The key is understanding the difference between what a mini lift (lunch time lift) can do and how long it lasts as opposed to a lift that involves the deeper tissues.

Does anyone really believe you can correct these wrinkles by just filling under the skin without making this face look completely different?

We believe that for facial rejuvenation to work that lifting and volume must be coupled. Volume enhancement, for us, has come to mean fat, because some of it will last permanently and, perhaps more importantly, it is natural and safe. We remind you that none of the fillers to date have FDA approval outside the scope of the nasolabial folds (and perhaps lips but we have to check on that). As far as surgery, mini lifts occasionally are indicated, but we have found that patient satisfaction and long term results really depend on addressing the underlying, descending tissue (the SMAS).

The point of all this is that the story begins by telling us how the number of women and men having anti-aging surgery is growing rapidly. There is a reason for that: when it’s done correctly, it works.

Reading the New York Magazine we came across an interesting article that goes over a “new” phenomenon among New York’s higher echelons that involves volume enhancement using fillers and occasionally fat to restore the lost volume that many patients experience as they grow older. The article goes on to highlight a number of dermatologists and facial plastic surgeons in New York that are on the forefront of the phenomenon there.

Composite picture of Demi Moore, Angelina Jolie, Madonna, and Michelle Pfeiffer courtesy of the New York Magazine showing the natural aesthetics which are ideal when volume enhancement and facelifts are combined such as in the HYBRID LIFT

As we read the very well-written article trace the history of facial aesthetics and volume enhancement, we could not help but notice that many of the doctors and quotes noted that as patients age there is a descent of tissue, sagging of skin, wrinkles and jowling, but then they glossed over the fact that volume enhancement alone fails to correct all of these issues. The idea that adding fillers or fat can correct jowling and redundant skin is simply not true.

We don’t normally like to brag here on the post, but in this one instance we hope you permit us a minute to gloat over our HYBRID LIFT.  What we do for our own patients is a minimal incision deep facelift—this is tailored individually depending on how much skin descent and jowling there is—and then add the patient’s own fat back (as in the “new new face”) to recreate the volume so many patients lose as they age. The aesthetic results have been fantastic and our patients love that they can be up and around after only a few days.

While we respect the claims in the article and are proponents of volume enhancement, we find it disingenuous to claim that by replacing volume you can somehow correct the tissue and skin which descends with time. The  problem is that too many people with hammers begin to see everything as nails.

The key points of our HYBRID LIFT are:

1. By doing a deep lift we are able to first replace the patients’ own fallen deep tissue (the SMAS) back into its proper position

2. By using a minimal incision, we never get into the hairlines, move hair tufts, or get a windswept appearance

3. Unlike mini lifts, because we do the work in the deep layers; the results last

4. By then adding fat and restoring volume, we fill out the concavities that lead to an aged appearance and we restore the youthful heart-shaped face that people are drawn to

5. By using your own fat, we are confident that the results last and are natural. Temporary fillers unfortunately are just that: temporary. Permanent fillers are all too often not tested for safety in these other areas, are not approved for these uses by the FDA, and are used in “off- label” procedures whose safety is unclear.

For us, the HYBRID LIFT represents the culminant evolution of facial rejuvenation.  Stay tuned for the HYBRID LOWER EYELID LIFT…

Here’s a typical scenario. You’re considering facial plastic surgery to take care of a bump on your nose, a droopy tip, or a sagging jaw line. The feature may be subtle, but it’s definitely there. And you’ve been thinking of doing something about it for so long.

 You’ve finally worked up the courage to tell your husband/mother/sister/brother/best friend (insert loved one here) about it and, instead of uncompromising support, you hear something like “Your nose is fine. Why would you mess with it?”. Other reactions are “Whatever makes you happy, honey” or, “I was wondering when you were gonna take care of that honker”. But, the overwhelming #1 reaction is the first one.

You’re crestfallen. You start to second guess yourself. You think “I’m not imagining this. There is a noticeable bump on my nose. Why doesn’t anyone else see it?”. Well, the answer is, they do and they don’t. They can see the feature you’re pointing to just as well as you can. The human eye is capable of incredible feats. Our eyes can discriminate between two objects down to 1/25th of an inch or about 1 mm. So, if we show you a photo of your nose and another photo with your bump shaved down just one millimeter, you’ll be able to see the difference every time. And, we all also have a built-in, hard-wired aesthetic sense of proportion, symmetry and ‘belonging’ness when we compare one feature to the rest of the whole. So, they know deep down that the bump is there.

But, your family or friends may not “see” what you’re talking about because they don’t wish to and they don’t attach the same level of importance to it as you do. They care for you as you are, as they should. And, they’re afraid for you. Afraid of the risk, even if it’s very small. And, afraid that you’ll change too much. After all, you may want a subtle change or a dramatic change, but they don’t necessarily see what you see.

 Some of our patients who are REALLY close to family and friends and look to them for advice are really freaked out by this. We’ve even had a few patients recently who’ve nearly psyched themselves out of their decision. The important thing here is not to try to force your loved one to feel about your proposed surgery the way you do. Family are never quite as enthusiastic as you may be. Instead, you should let them know how important this decision is to you, and how much better you’ll feel if you have a positive outcome. That will often turn them around because what’s important to you is often what’s important to them. The decision to have surgery is a very personal one and is ultimately yours. You can reassure them that, if you’ve chosen the right surgeon, your results will look natural and won’t remove your identity.

 What’s interesting is that the most resistant family member or friend is usually your most astonished and glowing supporter after the surgery once they see how happy you are with the change. This is just something to consider when you sit down to have “the talk”.

We’ve had doubts for a long time about the effectiveness of thread-lifts for revitalizing the face. For those who don’t know, this procedure involves a bunch of barbed sutures or threads that are placed under the skin under local anesthesia to lift sagging brows, cheeks, and necks.

That just doesn’t make sense to us. You can’t expect a thread to do what a real lift should without pulling through the tissues over time. More involved lifts work because the sagging tissues are widely lifted away from underlying tissues and allowed to reheal in a new desirable position. Thread-lifts aren’t even anywhere near the same ballpark. The threads can’t support the weight of the tissues and when they break and fragment, a whole host of problems can arise.

It’s one thing for guys who don’t like the idea and who’ve never used them to trash these threads. But, when docs who embraced the technique start raining on the parade, that’s a reason to take notice. In the latest issue of Archives of Facial Plastic Surgery, a report on thread-lifts by an experienced surgeon indicated that a whopping 30 out of 75 patients treated experienced a complication. In 14 patients, the thread was extruding, meaning it was popping out of the skin! They all required procedures to repair or remove the thread. Three patients needed threads removed for visible puckering or dimpling of the skin. Another 17 patients on top of that were unhappy with the result and had to undergo repeated or alternate procedures to achieve the change they were hoping for. Even in the patients who didn’t have a problem, the surgeon wasn’t impressed with the longevity of the results and has stopped offering the procedure.

Sounds like he’s not the only one. Recently, at least 1 manufacturer has removed their thread product from the North American Market. Are we finally hearing the death knell of this overhyped procedure? We think so. It’s about time plastic surgeons got back to procedures that work, even if their names aren’t on them…  

With the growing trend toward more permanent results, we are surprised that more than 6 months after receiving FDA approval, Glabella Furrow Relaxation(GFX), or “No-Tox”, has received little hype.

The minimally invasive procedure uses radiofrequency thermal energy to “shock” the nerves that allow you to frown (and only those nerves, avoiding the all-over frozen look that many women are scared of when considering Botox). The results appear to last at least 2 years, and essentially replace those painful Botox shots between the eyes.  Of course that doesn’t mean no more Botox because the procedure is only for the frown lines and does not replace Botox in other areas, such as around the eyes.

GFX sounds like an ideal alternative for those who get Botox routinely or those too scared of being injected with a toxin. There are, however, two drawbacks:

1. Only two doctors in the entire United States are performing the procedure right now, and…

2. For the $2000-3000 price tag, you may be able to just get a brow lift.

There was an interesting article in the New York Times yesterday by Natasha Singer about the effect of the economic slump on Plastic Surgery. After all, you would think, with a “luxury item” like plastic surgery, how can it not be tied to the economic cycle?

And, sure enough, when Ms. Singer called around to all of the “top Plastic Surgeons” in major cities (if being on TV makes you one of the top plastic surgeons), the wait list to see the surgeon or to book a surgery date was shorter than it has been for a long time. This was the main thrust of the article.

Worse yet, according to the Times, are the recent 2007 statistics which supposedly show that actual facial surgical procedure numbers are down everywhere in favor of non-surgical procedures like Botox or dermal fillers because, so the argument goes, people just can’t afford surgery.

Funny thing is these stats are compiled by the American Society of Plastic Surgeons, which represents only General Plastic Surgeons in the US. So their numbers show a 64% increase in breast augmentation and a whopping 137% increase in tummy tucks since 2000, yet there were double digit declines for facial plastic procedures being done by general plastic surgeons.

HOW DO WE EXPLAIN THAT?

Well, that is the most interesting thing about the article. You just have to read carefully because they only briefly touched on it.

The fact is that people aren’t having body surgery in record numbers and simply avoiding facial surgery. Not at all. Facial plastic procedures are keeping pace, only it’s not the General Plastic Surgeons who are doing them any more. Facial plastic procedures, including nose jobs (rhinoplasty), facelifts, forehead lifts, and eyelid tightening (blepharoplasty) procedures are simply being done by Facial Plastic Surgeons, not general plastic surgeons.

You need only look at other statistics compiled by the American Academy of Facial Plastic Surgery, our professional organization, to see the other side of the story. According to them, the average number of eyelid lifts performed per surgeon was up 11% over 2 years earlier while forehead lifts were up 29%. To top it off, Facial Plastic Surgeons, on average, each did 79% more facelifts in 2007 over 2005. That’s more than increases in Botox and Fillers combined.

So, facial plastic surgery isn’t going the way of the Dodo. Just the opposite, gains in these procedures are outstripping many of the more publicized non-surgical procedures. Why?? Because they work. And people are coming around to that realization, and they’re also figuring out that super- specialists in the face (facial plastic surgeons) are the ones they trust to work on their faces.

Dark circles under the eyes have always been understood to be largely a function of pigment, and as a result there really has never been a good treatment for the problem.

There is the occasional patient who we find who has allergies which result in blood pooling under the area, or the even more rare patient who has noted the problem since starting birth control pills; but for the vast majority of patients presenting with this problem there has always been few treatment options. So we were surprised to see the NY Times tackle the subject in a recent article.

As we read the article we were first somewhat surprised at the sheer magnitude of the numbers quoted as being bothered by this phenomenon, but also the money involved in addressing the issue. The NY Times quotes a Clinique company survey of 13,000 Clinique users in 2006, of whom roughly 53%  cited under-eye circles and puffiness as their No. 1 beauty concern. Almost as fascinating was the fact that sales of “anti-aging” skin care treatments have nearly doubled over 6 years to a whopping $1.08 billion dollars in 2006. Sephora alone is noted to now sell more than 50 products designed to specifically treat under-eye circles.

While all of this was interesting because the article itself goes on to note that, “The problem is that few, if any, of the creams on the market are formulated for people with excess pigmentation or dilated veins,” we were more bothered by the fact that the article then goes on to tout how a number of physicians and patients have gone on to  use restylane or juvederm off label under the eyes for treatment.

What is disconcerting is that though they do note the off label nature of this treatment, we think that they under state the number of problems encountered by patients who have undergone this treatment. In our own experience we have had a number of patients who presented after being treated elsewhere who noted that the circles actually appeared either darker after injections of restylane/ juvederm or who noted a blue tint under the skin from the injected material.

There have been others who had lumpy/ bumpy appearances after the injections. But perhaps the most disconcerting problems are left for those patients who then had injection of products meant to break down the filler in trying to resolve these problems. These patients have presented with significant thinning of the overlying skin and a resulting crepe appearance which usually can only be treated with a lower eyelid blepharoplasty to remove the now excess skin.

Unfortunately the number of people who read this will be far less than those who read the NY Times article and go running to whichever doctor they can find who is promoting this off label treatment.

As a final note to the article we wanted to note that one doctor quoted regarding all the products available for treatment of under eye circles said, “If there are that many of them available, that usually means they’re not terribly successful.”

PS COME BACK SOON WHEN WE GO ON TO DISCUSS WHAT GOOD OPTIONS ARE AVAILABLE

Plastic surgery journals are filled with pseudoscience, “How I do it”, and “Me too” articles, so when the odd actual attempt at science comes around, we like to give it a little attention. Such is the case with a recent article in this month’s volume of Plastic and Reconstructive Surgery about the anatomy of the fat pads in the cheek area. “Medical News Today” has summed up the key points of the article here.

In the study, researchers better described the complex anatomy of this area by injecting dye into cadaveric cheeks. They were able to identify a discrete deep fat compartment that is associated with aging of the midface, as it loses volume with age. Restoring the volume in this area can reverse these signs of aging.

This photo of Angelina Jolie highlights the appearance of a youthful cheek. This area should be the widest point of the face. You can see how the cheek has a smooth dome-like shape with a fullness in the center, gradually smoothing out towards the eyes and the lips.

This is a useful finding because the cheek area has always been the hardest area to improve with traditional face lift procedures. That’s why we’ve had the opinion for some time that some sort of volume is often needed as part of any procedure that deals with the cheek area. So, we’ve incorporated micro fat transfer as part of our Hybrid Lift™ for many of our patients who are face lift candidates. This can give the entire face a smooth, cohesive youthful look without the usual stigmata of a traditional face lift such as pulled skin, visible scars, and sagging cheeks that don’t fit with the windswept jawline.

We all age, but how the aging process takes its toll on us physically depends upon a host of factors ranging from our genes to our sun exposure, eating and smoking habits. There was a fascinating recent slideshow titled “Classic Beauties: How They Aged” which showed how some of Hollywood’s most iconic beauties looked as young women and how they looked in later life.

As you scroll through the images, you notice some of the classic signs of aging- the wrinkled skin, jowling neck, bags under the eyes, falling brows. For some of these women aging seemed to have taken a smooth natural road, but for others the process was more harsh making some of the women unrecognizable.

The point is simple: we all age and how we choose to deal with that process is our own. For some aging without doing anything seems natural and “as it should be,” for others they want to do the things that keep them looking as young on the outside as they feel inside- yes its cliched but we all know its true.

Luckily for those who want to look younger, there is an ever wider array of safe alternatives ranging from minimally invasive injectibles and fillers to more dramatic lasers and surgical options. So you decide…