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…

It’s funny how you don’t really notice noses until you notice them….and then you can’t stop yourself. Most people can meet you, have a nice conversation, and go on their merry ways without ever really noticing your nose. Our eyes tend to be attracted to other people’s eyes. After all, they are the so-called windows to the soul. Next, we notice lips and smiles, especially when talking. These are the features that tend to be important in communicating and building a rapport with people. And finally, placing a distant fourth, other striking or not so striking features come up on the radar. Unless your nose is very out of place with your other facial features, it will tend to melt into the background even though it is smack-in-the-middle of your face.

People who tend to see noses everywhere are usually either very concerned with their own noses, have had or are planning to have a rhinoplasty, or are facial plastic surgeons. Most other people just don’t pay that much attention, until you point it out to them. And that’s why a lot of imperfect noses are walking around on some of our most iconic beauties. Take supermodels and celebrities as perfect examples.

Adriana Lima and Gisele Bundchen are known for their exotic beauty and are two of the most highly sought after supermodels in the world. Granted, they have a lot of other things going for them; but, try for a moment, to take all those positives out of the equation and concentrate on their noses. Adriana’s tip is decidely wide and boxy. And Gisele’s profile has a prominent bump and a droopy tip. But, that defines their looks.

Paris Hilton is another pop culture icon whose nose is a prime example of a thin, pinched, and hanging tip. Of course, that doesn’t stop her from being a tabloid media darling.

These noses aren’t perfect but, then again, they don’t have to be. And, the one thing they all have in common is that they add some character to their owners. Now, many of you are thinking that, sure, these women have so many other stunning attributes that noone would ever notice their noses. Maybe so. But, the same thing applies to the rest of us. Your nose doesn’t have to be perfect, it just has to blend in. And, that’s where we come in.

So, be careful of asking for a too-generic nose. A good nose job shouldn’t sacrifice your identity.

We’ve been doing a lot of lip augmentations lately with dermal fillers such as Restylane and Juvederm. It’s a popular procedure for women, young and not entirely young, to augment volume to thin lips or just to add a little bit of that pout to their look.

But, in the land of movie stars, some people take their cues from what they see the stars doing. Well, the stars should definitely not be setting the trends when it comes to lip augmentation. In fact, we wish so very much that they would stop. We won’t be cruel enough to point out these mistakes. You know who they are.

If you’re considering adding volume to your lips, consider these few pointers to get the best natural look:

1. Don’t ask for too much volume in the upper lip.

Many young women come in and tell us that they just want upper lip augmentation. They say “I don’t want you to do anything for my lower lip”. Most of the time, we advise against this because your upper lip should always be about 20% smaller than your lower lip. So, that proportion should be maintained. Isolated upper lip augmentation, if overdone, is probably the most common dead giveaway that someone’s had someone else near their lips with a needle. Check out the photos below to get an idea of what we’re talking about.

Below we see Liv Tyler on the left and Carla Bruni on the right. Many people think that both are beautiful women but, exotic Photoshopped image aside, Carla’s lips look naturally shapely and sensuous while Liv’s lips just look ‘top heavy’. What’s the difference?? Carla’s lips maintain the natural ratio mentioned above. Now, we’re not saying that either celebrity has had lip augmentation, we’re merely highlighting a point….

2. More is NOT Better.

A lot of people think that if a little enhancement is good, then a lot must be better…not the case. Overdoing it where lips are concerned is a sure way to have people talking about your new look, and not in a flattering light. Lip augmentation should be just that, an enhancement… a subtle addition to your feminized look, not the dominating force that overshadows all other features.

3. Technique matters.

Many people, including doctors (sadly), treat Botox and fillers like they are childs’ play. Yes, they’re minimally-invasive. But, that doesn’t mean that someone at the end of a syringe can’t mess things up just as much as someone at the end of a scalpel. A lot of doctors or nurses who’ve had filler training over a weekend treat lips and faces like they are all the same. A cookie cutter approach to lip augmentation is guaranteed to create an unnatural look just as it does for surgical procedures. A very experienced injector knows to work with what you’ve got. Some people need a little drop here but not there. The key is to sculpt your lips, not just balloon them out.

4.  Some areas need more help than others.

The area of the lips that benefit most from augmentation is the area in between the corner of the mouth and the philthrum (or the line where the upper lip begins to descend into that cute depression in the center that we call the “cupid’s bow”). Too much filler in the center of the lip gives a pulled down look. Too much filler near the corners of the upper lip gives the lip an unnatural overhang. Your upper lip should not hang over your lower lip. And the worst offender of all is filler placed mostly at the lip edge where it borders your skin. This gives the lips a ‘ducky’ look or ‘trout lip’ appearance where the lip is pulled too far forward. When your lips enter the room before you do, that is not a desirable look.

5. Be very careful about permanent lip enhancement.

A bad lip enhancement with a temporary filler is bad enough, but at least you know it will go away with time. But, a bad lip enhancement with a permanent filler or implant is a whole different story. There are a number of permanent options out there…permanent fillers such as Artefill or silicone and implants such as Alloderm or Goretex and other surgical procedures. Artefill can be an option, but you should recognize that these are off-label uses and long-term safety has not been proven completely. We’re not big fans of implants in the lips because they can give an artificial look and feel. So, be REALLY careful if you’re going to go this route. ALWAYS try a temporary filler first with the doctor you are considering to make sure you like the look and you’re both on the same page. And, even then you should go slowly because it’s almost impossible to go back.

These are just some of our thoughts on lips…

Plastic surgery, and rhinoplasty in particular, in Beverly Hills has become ever more concerned with aesthetic perfection. Unfortunately, rhinoplasty is a particularly demanding procedure that demands the most exacting attention to detail and technique if you want long term great results.

Finesse rhinoplasty is the name we give to the patient who needs or desires the most subtle of refinements. In some cases, these are the patients whose family or friends tell them that there is nothing wrong and that they should leave well enough alone. Many are very attractive and have good noses to begin with… but they wish to get even closer to their ideal.

You may wonder why operate at all, but for those of us who love this procedure, these are the cases that challenge us to be our very best, to pay heed to the most refined details… these are the ones that beckon us to be even better. Counter- intuitively, while small changes are sought, these are the most demanding cases because the window for improvement is likewise small. In other words, when you show up with a big bump, it’s pretty easy to get you a dramatically better result; it’s much harder to explain that to correct that little bump (bossae) at the tip of your nose permanently and safely, may necessitate a couple hours of surgery.

Jessica Biel is a spectacularly beautiful woman, but due to her thin skin you can see a number of irregularities in her nose in this picture

Often the patients wanting finesse rhinoplasty have a professional persona that demands that they look their best- models, actresses, entertainers. And most recently, we have had a number of very thin skinned patients (and we don’t mean metaphorically), who presented to us after having had surgery elsewhere. Unfortunately, they had been left with subtle but distinct tip asymmetries and bony irregularities.

Occasionally, in some instances we can recommend a non surgical nose job (see our blog on liquid rhinoplasty) in those patients with the minutest of surgical concerns. In these cases, the run is not worth the slide, ie the results achievable with surgery can be closely approximated by injection of a small amount of soft tissue filler such as Restylane, Juvederm, or Radiesse.

Unfortunately, when the irregularity is more pervasive, as was the case with these patients, we do not recommend fillers because they do not last long enough and have potential risks that we do not want to expose our patients to. In these cases, we found that after rasping (sandpapering) away as much of the irregularities as possible without bringing the bridge down, a thin layer of alloderm resulted in a fantastic cover for any minute palpable irregularities that we would otherwise be afraid could show years later in these very thin skinned patients.

Hope everyone had a great memorial day.

Very recently we saw an article saying that Aquamid just published new 5 year follow up on this new product and so far the results including patient satisfaction seem to be great.

For those who don’t know Aquamid is a polyacrylamide hydrogel- a facial augmentation filler that has been on the market in Europe and Australia for many years now.

We’re pretty excited about this product because we were one of a few centers around the country that were part of the FDA trial that has been ongoing for the last year.

We don’t know all the results from all the centers but so far it seems pretty exciting. I think we can tell you it injects about as easily as Juvederm but based on the European experience lasts for years with relatively few side effects and adverse outcomes. Of course, we’ll let you know when we are allowed to tell you more…

In the NY Times Magazine last week we came across these stunning pictures of Yasmine Warsame, a beautiful East African model from Somalia who grew up in Canada.

We looked her up since we had never seen her before and we came across her myspace site where she’s quoted as saying:

“I believe that ’Black beauty’ is understated and isn’t appreciated, so that’s what I want to represent in this modeling industry. I want to inspire young girls and women all around the world to follow their dreams, especially women of color.”

When Jennifer Hudson was featured on the cover of Vogue last year, a controversy arose because she was one of a small handful of black women ever to appear along on the cover.  It got us thinking about all of our ethnic patients who ask if we have expertise in ethnic rhinoplasty and facial plastic surgery. It’s a fair question, but one that requires a nuanced response. Yes, we do have expertise in working with a variety of ethnic patients…but truthfully, that’s less important than an understanding of aesthetics and anatomy in each individual.

No ethnic group can be pigeonholed into one group, though broad generalizations can be made (see our online book). You, your face and your nose are unique and individual to you, regardless of race or ethnicity.

So, getting back to black beauty - here are just a few of the beautiful black women who grace the landscape of our media world. You’ll note they’re all very different and yet stunning in their own way…

In the last two posts we have taken care of imaging for a poor rhinoplasty result to address problems with the nasal bridge. Now it’s time to take a look at the tip. A frequent problem after an overaggressive rhinoplasty is a tip that becomes distorted and lacking in support. This usually happens when too much of the tip cartilages are removed in trying to narrow and refine the tip. Instead, you just end up with a tip that is unstable.

The diagram below shows the area of the tip cartilages (in red) that is commonly removed during a rhinoplasty. The key of course is not to remove too much.

If too much cartilage is removed in this area, the tip can start to collapse. It can often look asymmetrical with formation of bossae or little deformities and bumps in the cartilage that show through the skin. Also, the tip can start to rotate up too much. This gives the nose an upturned and shortened “Ms. Piggy” appearance that is positively despised by everyone who is unfortunate enough to inherit this problem.

This problem can be exaggerated when surgeons also remove the nasal spine (the bone at the bottom of the tip) and the bottom part of the septum. To figure out which part of your nose we’re talking about, you can feel around just inside your nostrils. First, look around and make sure no one is looking. Now, if you pinch the skin between your nostrils and advance your finger and thumb back a bit, you will feel a firm but wiggly piece of cartilage that is the bottom part of the septum. Are your eyes watering yet?

Maintaining the integrity of this anatomy is critical to ensuring a good, strong result over time. If the above mistakes are made, the columella or structure separating the nostrils can appear to hang down too much, called a hanging columella. Also, the rim of the nostrils can appear pulled back or retracted. Ideally, the distance between the edge of the nostril and the bottom edge of the columella should be no more than a few millimeters. Anything more creates a very unflattering look that resembles a snarl. What’s worse is that breathing can also be affected. These problems can be fixed but it can take a lot of effort including complex cartilage grafting.

Take a look at the imaged photos below to see the final step in improving the appearance of this nose. The photo on the left has only the bridge imaged while the photo on the right also addresses the tip. You can see that the columella is pulled up, the nostril rim is pulled down, and the angle between the tip and the upper lip is better. Notice that the tip still projects outward by the same amount, but it looks so much less dominant and heavy when these problems are corrected.

So there you have it. We have illustrated a handful of the most common rhinoplasty mistakes and how we can fix them. There are a lot of sticky details that go into this, and a case such as this can take us many hours to perform.

The photos below show the original post-rhinoplasty picture on the left, the planned changes in the middle, and the imaged ideal result on the right. The green shaded areas are areas to be augmented or built up. The blue shaded areas are areas to be shaved down. This image has obviously been heavily doctored and we make it imperfect on purpose so that we don’t over-sell the possible results. But, you can at least get an idea of what needs to be done to bring this nose back into a balanced and harmonious state.

We hope this was a helpful exercise! Best of luck with your rhinoplasty and let us know if you have any questions or suggestions for future lessons….

So, what is a pollybeak deformity? Well, that’s the unpleasant and unkind name we give to a nose in which the area just above the tip is too full. Normally, there should be a little dip or depression just above your nasal tip that defines the transition from your bridge to your tip on profile. When that area is high or filled in, we call it a pollybeak.

When it is very full, it can even make the nose look down-turned like a parrot’s beak, thus the name. The reason for this is that the area above the tip often becomes the part of your nose that sticks out or projects the most from your face. This is not the way it should be. Your tip should be the most projecting point of your nose.

Check out the photo below to see a pollybeak deformity indicated by the arrows.

OK, what causes a pollybeak deformity?

Well, a few things can and they are all preventable. First, a surgeon may not reduce the cartilage enough in the area above your tip. Second, the surgeon may be overaggressive in reducing that area too much in someone with thick skin. In this case, the skin doesn’t contract and flatten out as much as it should and, instead, the area fills in with thick scar tissue. Finally, a surgeon may not provide enough support to your nasal tip. Over time, your tip may droop and make the area above the tip look too full.

Look below to see the plan for fixing this pollybeak deformity. The green area is the area of the bridge that was built up in the last blog post. The blue shaded area shows the cartilage that has to be shaved down to correct this appearance. Notice how the tip itself also has to be deprojected or brought in closer to the face.

See the two photos below for a simulation of this correction. On the left, only the pollybeak was taken down but the tip was not brought in so it looks too high and too pointy. This is not a good look but it is something we also see a lot after first-time rhinoplasty because tip correction is harder to do. On the right, you can see how much more balanced the tip looks now.

This is by no means a final image. Even the picture on the right doesn’t look right yet because we haven’t addressed the other problems with this nasal tip. It still looks pulled down and rounded and the nostrils have to be addressed. Tune in to our next post to see us pull together the final imaged picture.