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.

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.  

Recently, the Archives of Facial Plastic Surgery reviewed the progress made and things learned regarding brow lifts by facial plastic surgeons over the last 10 years.

For many people reading this blog you may be wondering why do open forehead lift when endoscopic techniques are available?

For some people, when they hear about open browlift, they think back to their mom or grandmother who had the traditional coronal brow lift that spanned from ear to ear. And they fear the potentially longer scar and even hair loss they heard about. Luckily, we can now do a different lift called a trichophytic lift that allows us to elevate your brow without moving your hair line higher while making an incision that is completely hidden.

Notice that a few weeks after trichophytic browlift, the incision line is inconspicuous in the hair line

Since the early ‘90s, numerous authors have reviewed their experiences with the endoscopic technique and have reported that the endoscopic technique allows surgical access through small incisions, resulting in quicker recovery times, less morbidity, greater patient acceptance of surgery, and satisfactory results. Unfortunately, some reports question the effectiveness of the endoscopic forehead rejuvenation and characterize it as being cumbersome and not as effective long term.

In our experience, most of the flaws associated with the endoscopic technique are the result of a surgeon’s inexperience. However, that is not to say that there are not potential downsides to the endoscopic technique which need to be addressed.  The study points out, and we agree, that the main flaws with the endoscopic treatment include:

1. inadequate arcus marginalis release- this is the lining overlying the bone  just over the brow that has to be released to allow for permanent upward movement of the brow
2. inadequate frontalis muscle weakening- this is what allows us to weaken the muscle so you do not need as much Botox after,
3. lack of fixation, especially in the lateral eyebrow- in the endoscopic technique since no skin is removed, there are numerous ways surgeons attempt to “fix” the brow into the new elevated brow position
4. thick skinned patients with deep frontal and glabellar wrinkles- generally we recommend these patients strongly consider open techniques because it is simply very difficult to get the heavy skin to stay in the new elevated position

So if you are considering a brow lift, it is imperative for you and your surgeon to evaluate and accomplish:

1. Do a thorough preoperative evaluation of the upper face- including discussion of asymmetries;

2.  Wide release;

3. Complete periosteal release at the arcus marginalis;

4. Variable transection of the depressor musculature;

5. Maintenance of the integrity of the frontalis muscle;

6. and,  in endoscopic cases, adequate fixation of the forehead tissues to the elevated position, especially in the lateral portion of the eyebrow.

The truth is there are still many unanswered questions when it comes to the endoscopic technique. The study points out that there is a dearth of meaningful blinded trials with long-term follow-up to evaluate the plane of dissection, method of fixation, and muscle manipulation in endoscopic browlift techniques.

With all the interest in dark under eye circles and injectible fillers used under the eyes, we decided to post a little youtube video.  For those interested we review why we prefer fat to other fillers in this area and show one of our patients who underwent the procedure.

www.youtube.com/bhprofiles

We welcome your thoughts and questions. And for more information you can read more in our other blogs on the topic

Why do many people who have eyelid procedures often look like a deer caught in the headlights? Are their surgeons just pulling their lids a little too tight or is it something more? Recent studies have shed some light on this issue and shown us that the whole concept of eyelid aging has been wrong and is in need of an overhaul.

             For a long time, it has been thought that as we age, the support structures that ‘hold in’ the eye weaken allowing for fat from around the eye to protrude and cause baggy pockets. As a result, the “correction” for heavy and tired eyelids for decades has been to remove this so-called ‘extra’ fat.

Unfortunately the results of this approach are eyelids that look smoother for a time but eventually, due to removal of the fat, the eyes can often come to look aged and hollowed. In actual fact, studies show that the fat and bone beneath the eye and over the cheek shrink over time. So, the cheek flattens and the lower eyelid loses its foundation and ‘folds down’ like an accordion. This accordion-like folding is known as the “concertina effect”, the same kind of rippling we see in a caterpillar’s movement or in traffic clogs long after the blockage has cleared.

              The answer is not to remove or reposition the fat from inside the eye to make a flatter eyelid to fit a flatter cheek. That’s not youthful at all. A youthful look is all about convexity when it comes to cheeks and eyelids. We don’t remove fat from the eye at all. Instead, we restore a truly vibrant convexity by replacing the fat volume where it is needed, in the hollows beneath the eyes. By combining this with trimming of the stretchy skin over the eyelid, we have seen a real change from very good results with older techniques to remarkable results with our new Profiles Eye Lift. We welcome you to see the evolution of eyelid procedures for yourself. You won’t believe your eyes.

A  few months back we posted a blog titled:

Why is the NY Times promoting off label usage of Fillers for the

Treatment of Dark Eye Circles?

In the blog we ruminated that while they noted the off label nature of this treatment, we thought that they understated the number of problems encountered by patients who have undergone this treatment.

A few things we noted included the lumpiness some patients had encountered as well as some patients complaining about a blue hue after being injected. This blue hue arises due to the Tyndall effect which is the blue light we notice when light is scattered by a colloidal particle.  The same phenomenon explains why the sky is blue and why our veins appear blue even though we all know our blood is red.

As to problems with lumpiness,  we noted that due to the thinner skin overlying the eyelids patients were much more prone to have problems with fillers under the eyes as opposed to in the nasolabial folds and cheeks.

So we lamented that unfortunately the number of people who read our blog would be far less than those who read the NY Times article and go running to whichever doctor they could find seeking this “cure” for under eye circles.

Thankfully we noted that this last week Ms Natasha Singer  posted a new article-Questions on Using Fillers Near Eyes. In the article she not only expounds on the off label nature of these uses but the growing number of patients having problems with these injections.

We want to be clear that doctors use medicine off label all the time. Most antibiotics get approved to treat one problem- say sinus infections- and then get used for other needs. So off label by itself is not the problem. We believe that the skin around the eyes by its very nature is more fragile and thinner and as a result, in less experienced hands injections can cause problems like lumpiness. We believe that doctors should be more clear in the potential problems. However, the quote by a doctor saying any injection can cause blindness is also unfair. It is technically true, but its like saying anyone crossing the street can be hit by a car.

Our next blog will be on our use of fat for under the eyes and the concertina effect.