Beauty in Balance: A Common Sense Approach to Plastic Surgery & Treatments-Less Is More

BEAUTY IN BALANCE A Common Sense Approach to Plastic Surgery & Treatments— Less Is More

ALLEN D. ROSEN, MD VALERIE J. ABLAZA, MD

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DISCLAIMER The information contained in this book represents the opinions of the author and should by no means be construed as a substitute for the advice of a qualified medical professional.The information contained in this book is for general reference and is intended to offer the user general information of interest.The information is not intended to replace or serve as a substitute for any medical or professional consultation or service. Certain content may represent the opinions of the authors, Drs. Allen Rosen and Valerie Ablaza, based on their collective training, experience, and observation; other physicians may have differing opinions. All information is provided “as is” and “as available” without warranties of any kind, expressed or implied, including accuracy, timeliness, and completeness. In no instance should a user attempt to diagnose a medical condition or determine appropriate treatment based on the information contained in this book. If you are experiencing any sort of medical problem or are considering cosmetic or reconstructive surgery, you should base any and all decisions only on the advice of your personal physician who has examined you and entered into a physician-patient relationship with you. This book is designed to provide information of a general nature about cosmetic procedures. The information is provided with the understanding that the author and publisher are not engaged in rendering any form of medical advice, professional services, or recommendations. Any information contained herein should not be considered a substitute for medical advice provided person-to-person and/or in the context of a professional treatment relationship by qualified physician, surgeon, dentist, and/or other appropriate healthcare professional to address your individual medical needs.Your particular facts and circumstances will determine the treatment that is most appropriate to you. Consult your own physician and/or other appropriate healthcare professional on specific medical questions, including matters requiring diagnosis, treatment, therapy, or medical attention.The information contained in this report is delivered “as is” without any form of warranty expressed or implied. Any use of the information contained within is solely at your own risk. MDPress, Inc. assumes no liability or responsibility for any claims, actions, or damages resulting from information provided in the context contained herein. ISBN: 0-9748997-4-7 Copyright © 2006 by Allen D. Rosen, MD & Valerie J. Ablaza, MD, All Rights Reserved The contents of this book including, but not limited to text, graphics, and icons, are copyrighted property of Allen D. Rosen, MD & Valerie J. Ablaza, MD. Reproduction, redistribution or modification in any form by any means of the information contained herein for any purpose is strictly prohibited. No part of this book may be reproduced, stored, or introduced into a retrieval system, or transmitted, in any form, or by any means (electronic, mechanical, photocopying, recording, or otherwise), without the prior written permission of both the copyright owner and the publisher of this book. Printed in the United States of America. Book design by StarGraphics Studio

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About the Authors ALLEN D. ROSEN, MD One of Americas Top Docs, Allen Rosen, was named one of the finest plastic surgeons in New York and New Jersey, by both New York Magazine and New Jersey Monthly Magazine. For eight years running, peer surveys by Castle Connolly Medical have recognized him as one of our countries premier plastic surgeons. Good Morning America, MTV, Eyewitness News, and NBC, have profiled his work, and he has been an invited guest on News 12 New Jersey and numerous other network media events. He has been quoted in Allure, Shape, and Self magazines, New York Daily News, The Wall Street Journal, and the Washington Times. For over a decade he has been a distinguished spokesperson for the American Society of Plastic and Reconstructive Surgeons and is the founding partner and medical director of the Plastic Surgery Group. Having finished his surgical training at Columbia Presbyterian Medical Center in New York, he relocated to New Jersey where he serves as Assistant Clinical Professor in the Dept. of Plastic Surgery at the University of Medicine and Dentistry of New Jersey. Dr. Rosen believes in balancing the demands of a busy professional life with that of volunteer service. He was honored in the spring of 2005 for ten years of dedicated service to Heal the Children, a charitable organization which helps children from around the world who need reconstructive surgery. The American Cancer Society of New Jersey, for which he served as unit president, honored him for his efforts to help women in the fight against breast cancer, and both the American Red Cross and the National Congressional Committees’ Business Advisory Council have singled him out to honor his outstanding contributions to community service. Most recently he has been involved in fund-raising activities to support Juvenile Diabetes Research.

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VALERIE J. ABLAZA, M.D. A partner and the Corporate Vice President of The Plastic Surgery Group, Valerie Ablaza is unique in her profession, noting that just one out of ten plastic surgeons are women.“I know that my perspective and sensitivities are different than my male colleagues,” she says.“Of course, there are things that my female patients will tell me that they would never tell a man, but surprisingly, many men also prefer the insight and perspective of a female plastic surgeon.” Dr. Ablaza is board certified by the American Society of Plastic Surgeons and is a Fellow of the American College of Surgeons. She is also a member of the American Society of Plastic Surgeons, Phi Beta Kappa, and the Alpha Epsilon Delta honor society. She received her medical degree from the Medical College of Pennsylvania, completed her residency in plastic surgery at the New York Hospital/ Cornell Medical Center, and finished her training with a fellowship in breast and aesthetic surgery in Nashville,Tennessee, with the internationally renowned plastic surgeon G. Patrick Maxwell. Frequently quoted on Internet websites including PlasticSurgery. com, Cosmeticsurgery.com, and awcancer.com, Dr. Ablaza has been featured on CN8 One on One with Steve Adubato. She was also a guest author of “Fifty Things To Do When You Turn Fifty,” a book about self-help and personal growth. She has had numerous articles published in medical journals, written chapters for plastic surgery and orthopedic textbooks. Dr. Ablaza has donated her time and expertise to Healing the Children, an international charity that provides reconstructive surgery to children from low-income communities and thirdworld countries. She has been an active participant with leadership roles in plastic surgical societies on the state and local level and sits on the executive committee of the New Jersey Society of Plastic Surgeons.

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Acknowledgements We would like to thank our families, whose love and pride in our work make all we do meaningful. We would also like to recognize the wonderful staff of The Plastic Surgery Group for supporting us in our pursuit of excellence. We could not do it without you.

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We would like to dedicate this book to our patients—past, present, and future. They have been, and will continue to be a constant source of inspiration and joy for us as we fulfill our life’s calling. It is only through you that we are fully able to realize our dreams.

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Contents Introduction

Chapter

11

1

The Plastic Surgeon’s Role as Navigator

13

Body Image

15

The Natural Look

17

Who Is Having Cosmetic Surgery?

18

Do I Need Cosmetic Surgery?

19

Choosing the Right Time for Your Surgery

20

Chapter

2

Make-Better Instead of Make-Over: What Is Not Real in the Reality Shows

21

Combining Procedures

24

Staging Surgery

26

Chapter

3

So You Want to Have Cosmetic Surgery

27

Choosing a Surgeon

28

The Consultation

28

The Value of Computer Imaging

30

Where to Have Your Surgery

32

Financial Considerations

33

Tissue Glue

36

Implantable Materials

36

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Chapter

Getting Ready for Surgery

37

Details Before Surgery

38

Medications

38

Do I Need Blood Work or Tests?

39

Vitamin Supplements

40

Skincare Strategies

40

Diet & Exercise

41

Risks of Surgery

41

Smokers Beware!

42

Managing Your Discomfort

43

Recovery Time

43

Travel Guidelines

44

Chapter

5

Anesthesia for Cosmetic Surgery

45

Local Anesthesia

47

Twilight Anesthesia

47

Regional Anesthesia

48

General Anesthesia

48

Chapter

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4

6

Surgery on Your Face

49

Restoring Your Youthful Face

51

Improving the Contour of Your Neck

56

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Rejuvenating Your Forehead and Brow

59

Eyelid Rejuvenation

63

Nose Reshaping

69

Changing the Shape of Your Face

74

Ear Reshaping Surgery

78

Combining Procedures

80

Chapter

7

Recontouring Your Body

83

Removing the Fat

85

Tummy Tuck

92

Plastic Surgery Following Massive Weight Loss

97

Body Lifts

98

Arm Recontouring

100

Tightening Your Thighs

102

Combining Procedures

103

Chapter

8

Breast Reshaping

105

Breast Enhancement

106

Breast Implants Past and Present

109

Rejuvenating Your Breasts

114

Reducing the Size of Your Breasts

116

Areola and Nipple Reduction

120

Correcting Nipple Inversion

121

Combining Procedures

121

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Chapter

9

Non-Surgical Options for Cosmetic Enhancement Botulinum Toxin

124

Soft Tissue Fillers

128

Resorbable Filling Substances

130

Non-Resorbable Filling Substances

135

Lip Enhancement

137

Skin Resurfacing

139

Types of Peels

140

Lasers and Light Sources

144

Non-Ablative Lasers

147

Permanent Cosmetics

151

Chapter

10

The Waves of the Future

153

Combining Procedures

154

The Youth Window

155

Surgery with Less Scarring

156

Pump Up the Volume

156

Lifting with Sutures

157

Beauty in Balance

157

Chapter

11

Frequently Asked Questions

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123

159

Glossary

168

Resources

183

Index

184

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Introduction Psychology of Body Image Change We live in a time of momentous events—dangers and possibilities heretofore undreamed of. Yet, interestingly, as events unfold that will have consequences for years to come, and we search for ways to cope in a complex, uncertain world, cosmetic surgery has emerged as an increasingly popular way of dealing with issues of self-confidence, self-esteem, and feeling good about ourselves. If we cannot easily change the world, we can, with greater ease than ever before, change how we look. There seem to be new procedures almost daily, most of which promise us increasingly greater benefits that can be achieved in increasingly shorter time periods. This comes as no surprise, given that we live in a society which tells us—indeed, virtually implores us—to strive, as much as possible, for physical perfection. In the past, handed down from each generation like family heirlooms, have been our expectations of greater health, prosperity, and fulfillment. Now, in addition to these goals (or rights, some believe) is the expectation of ever-increasing physical perfection, as plastic surgery becomes available to virtually every group in our society. Almost nightly, now, we can sit down and watch, on our TV.screens,“surprise” make-overs,“instant” make-overs,“extreme” make-overs and “ultimate” makeovers. It is oh-so-seductive and seems oh-so-easy. As new technologies beckon, who among us can resist? In a society that is so focused on how we look, who among us would not choose beauty over perceived unattractiveness, or perfection over perceived imperfection? As a psychotherapist, these issues come up routinely in my practice. And, to my mind, the question that needs to be asked is this: How can we achieve satisfactory balance between our outer selves and our inner selves? In fact, many people are discovering that enhancing and/or changing the outer self, does not necessar-

Introduction

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ily change or enhance the inner self. The right balance, it turns out, can be difficult to attain, or even define. Webster’s New World Dictionary defines the word balance as “a state of equilibrium … to make or be proportionate.”This concept is important because psychological research strongly suggests that happiness, or “well-being,” is very much tied to achieving a balance between our spiritual, emotional, and physical needs. That’s why a book like Beauty In Balance: A Common Sense Approach to Plastic Surgery—When Less Is More is so needed. Unlike many other books on the market, which explore cosmetic and surgical enhancements, Beauty in Balance does not try to promote a particular agenda and is not linked to a specific product line. It presents the facts—and only the facts—and lets the reader decide what is best and makes the most sense, for him or her. In an age of high tech, and high pressure, it is nice to have a book on this subject with a distinct absence of hype and an abundance of practical information and common sense. These days, that is something to be thankful for. —Janice I. Cohn, DSW, ACSW

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1

CHAPTER

The Plastic Surgeon’s Role as Navigator “Our ultimate goal is to get you to a place where you feel that you are the best you can be.”

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Almost every person wishes they could change something about their face or body. It is common for people to spend a lot of effort and energy—through makeup, hairstyle, clothing, diet and exercise—to conceal or change the things they do not like about themselves and to emphasize the things they do like or want to highlight. Vanity is an easy accusation, but body image is more complicated than that. What one person thinks is vain, may be considered by another person to be a necessity. And there are people who think that cosmetic surgery is only for those who lack self- worth and have low self-esteem.Yet, surprisingly, most people who undergo cosmetic surgery are actually very confident about themselves. Cosmetic surgery has become mainstream; many people now consider it acceptable to make improvements in their appearance to feel better about themselves and to create a physical form more in line with their inner self-image. While the current focus in the media is on drastic body changes through multiple and lengthy surgical procedures, it is not a realistic, practical, or safe approach to cosmetic plastic surgery for most people. This book discusses the modern trend of extreme makeovers and highlights appropriate combinations of procedures and a practical method for staging plastic surgery.

There are numerous issues to understand and to consider before undergoing surgery, including: • the safety of performing several procedures in an outpatient setting • the appropriate timing for surgery • the advantages and disadvantages of combining multiple procedures • the psychology of dramatic body image changes

We will offer information and practical advice to help you navigate the many options, avoid the pitfalls, and help you better understand what you see on television, what you find on the internet and

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what you read in newspapers, magazines, and books. We will also give you important background information on specific procedures, including facial aesthetic surgery, non-surgical techniques for facial rejuvenation, breast reshaping, and body contouring. As aesthetic plastic surgeons, it is our job to educate you about the changes that are possible, and the safest and most sensible way to undertake these changes. All your needs must be considered individually, because there is no single formula that applies to everyone. Although you may watch the physical transformations that are carried out on plastic surgery shows in awe, do not automatically assume that the same procedures would be recommended for you or that they would give you the same results. We encourage each person to consider the surgery that is best suited for their age, body type, skin type, and bone structure. It is our job to help align your external appearance with the person you feel like on the inside. Plastic surgery is serious business: it permanently alters your appearance, it involves risks, and it can be costly. We think it is important for you to have a clear understanding of what is involved with the surgery before agreeing to it. The results of plastic surgery are rarely satisfying for people who want to look like a particular celebrity or for people who are trying to please someone else. The people who have plastic surgery to look and feel better for themselves are usually the most satisfied. The mission of this book is to enlighten consumers who are considering cosmetic plastic surgery. Surgery should only be performed when you and your surgeon completely agree that a specific procedure offers realistic changes or enhancements in your appearance and can be carried out safely. We believe surgery is only appropriate when it is done by the right doctor, in the right place, at the right time, and for the right reasons.

Body Image

“Body image is the mental picture we have of ourselves.”

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Body image is much more than physical appearance, attractiveness, and beauty. It is a complex perception of appearance involving emotions and physical sensations that develops over time through interactions with people and the social world. Cues about what we should look like come from our parents, our peers, and the media. Body image is our mental picture of ourselves and is connected to personality. It is much more influenced by self-esteem than by actual physical attractiveness as judged by others. Body image is not static but is constantly changing depending on mood, environment, and physical experiences. When your body changes, whether naturally or by surgery, so does your image of yourself. Loathing your body makes it difficult to live a happy, healthy, normal life. A negative body image can be crippling if you worry incessantly about weight and appearance. Some people may become obsessed with a specific flaw or a perceived defect.

“Performing cosmetic surgery on people with unrealistic expectations all but guarantees dissatisfaction.”

Body dysmorphic disorder (BDD) is a type of anxiety disorder in which people have a distorted body image, and it has become a growing concern among women and even men. BDD is thought to be associated with a chemical imbalance in the brain that may have a genetic basis. Some people suffering from BDD can function and cope with daily life, but others experience paralyzing symptoms of depression and anxiety. Undergoing cosmetic surgery and treatments becomes a type of addiction for these people.

The signs of BDD vary and may include: • frequently comparing the appearance of the perceived defect with the appearance of others • frequent examination of a specific body part • excessive grooming • paralyzing feelings of self-consciousness

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People may also go to extreme measures to camouflage the perceived defect, and they will spend an inordinate amount of time attempting to convince others that something about them is unattractive. Although cosmetic surgery seems to be the easy answer, people suffering from BDD cannot be “cured” through surgical changes. The primary treatment for BDD includes a combination of antidepressants and psychotherapy. If you suspect that you or a family member may be suffering from this potentially life-threatening condition, we advise you to seek medical attention from a doctor or mental health professional. We take BDD very seriously and insist on a psychiatric evaluation before surgery in anyone who shows signs or symptoms of BDD. Performing repeated cosmetic surgery on people who have an unhealthy obsession with their appearance is no different than providing drugs to a drug addict.

The Natural Look

“The best facelift may go unnoticed, but a younger, refreshed look never does.”

The images of celebrities on television and in magazines who look too tightly pulled, with lips that are too plumped up and showcasing other exaggerated and distorted features have everyone wondering what they had done to make themselves look so radically different. It may be surprising to know that these “plastic surgery nightmares” are not examples of surgical mishaps or complications, but rather they are usually deliberate changes requested by those people. Our patients no longer want an “operated” or “done” look. Today, it is all about making changes that look natural. People are interested in being the best version of themselves. They would like to make changes on the outside that match the person that they feel on the inside, and they do not necessarily want to “announce”

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their surgery to the world. As we always say,“the best facelift goes unnoticed, but your younger, refreshed look never does.”

Who Is Having Cosmetic Surgery?

“When it comes to cosmetic surgery today, there is no such thing as a typical candidate.”

Women and men of all ages, ethnic backgrounds, professions, and income levels are interested in taking advantage of the new techniques and recent advances in cosmetic surgery. It is difficult to find someone in a major metropolitan area or surrounding suburb who has not had or does not know someone who has had some type cosmetic surgery or treatment. Business people, artists, teachers, soccer moms, and college students are some of the many types of people who have become regular consumers of cosmetic surgery procedures.The old days when only wealthy women in their 50s with a lot of time on their hands had cosmetic surgery are over. In a recent study conducted by the American Society of Plastic Surgeons, 644 people from all over the country who were considering plastic surgery within the next two years were surveyed. The study found almost 30 percent of the participants reported average household incomes of less than $30,000. Forty-one percent had annual incomes of $31,000 to $60,000, and 16 percent had annual incomes of $61,000 to $90,000. Only 13 percent reported average household incomes of more than $90,000 per year. The participants’ age ranges also varied; 26 percent were 18 to 29 years old, 38 percent were 30 to 49 years old and 36 percent were 50 years or older. Eighty-one percent of respondents had not undergone plastic surgery while 19 percent had already had at least one cosmetic procedure. More than 85 percent were Caucasian and 85 percent were women, according to the study. With the advent of new techniques and safe outpatient surgical facilities, we can now perform many different procedures efficiently, in order to maximize change and minimize recovery time.

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Do I Need Cosmetic Surgery?

“Everyone has a different threshold for tolerating things about their appearance that they would like changed.”

There are many different reasons for people to entertain the idea of changing their appearance with surgery. Some of our patients say that having cosmetic enhancements was something that they had thought about or wanted for a long time, but it took some type of “trigger” event for them to decide to go through with it. In fact, there are a number of common scenarios that begin the thought process about cosmetic surgery. Relocating, milestone birthdays—30th, 40th, 50th, and 60th—and events such as high school or college reunions and weddings often trigger the thought of altering one’s appearance. Of course, there are the physical signs that may lead you to consider plastic surgery, often noticed for the first time when you see a photograph of yourself. The physical changes associated with aging, child-bearing, and major weight loss gradually begin to become more obvious. A different kind of sign may also be present as early as adolescence, when a young person is unhappy with the shape of their nose, contour of their chin, or breast size. It is common for people to consider facial or body enhancements after major life changes, such as the loss of a partner through separation, divorce, or death, and career change. We do not recommended having cosmetic surgery during times of emotional upheaval. There may even be occasions when we feel it is appropriate to have a patient’s mental health formally evaluated by a psychiatrist before surgery, to make sure your judgement is not clouded by your emotional state.

“No one can tell you that you need cosmetic surgery. It has to be something you want to do for yourself.”

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When it comes to rejuvenation procedures, there is no specific formula or age when you “need” or “should have” certain procedures. Every person has a different awareness of body image and assigns a different degree of importance to appearance and physical characteristics. As a result, it is impossible to make a specific rule or develop a guideline for when certain flaws, deficiencies or perceived deformities are “worthy” of change with cosmetic surgery. When you have a feature that you do not like and want to change, whether it is a hook nose, a weak chin, small breasts, or “heavy thighs,” it is reasonable to at least have a consultation with a cosmetic surgeon to help put your thoughts into perspective.

Choosing the Right Time for Your Surgery There is no medical reason that should determine what time of year to have a cosmetic operation or treatment. The “best time” for each person will depend on the type of surgery, how long it takes to recover, lifestyle issues, type of work, work schedule, and family commitments. It is not surprising that most people would like to recover from plastic surgery procedures in private. The fact is that many people do not want their family, friends, neighbors, and co-workers to “know” about their surgery even if they would like people to notice the changes afterward. As a result, they may choose times for surgery when there is less of a demand for social appearances. On the other hand, some people use their holiday vacation for surgery so that they do not have to take extra time out of work. There are certain procedures that seem to be more popular during a specific season. For instance, it may be more convenient to wear turtlenecks and scarves after having a facelift or neck lift procedure during the winter months. And tummy tucks, breast surgery, and liposuction are common during late winter and spring so that people can be “ready” for the summer months, when bathing suits are more fashionable and clothing styles are more revealing in general. Abdominal binders and compression garments are also well-hidden under heavier clothing.

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CHAPTER

2

Make-Better Instead of Make-Over: What Is Not Real in the Reality Shows “Extreme make-overs require extreme recoveries.”

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The proliferation of popular cosmetic surgery reality television shows has changed how the public thinks about the field of cosmetic medicine. Indeed, plastic surgery has become a hot topic around water coolers and in many households today, but not all the talk has been positive. In its first season, Extreme Makeover (ABC) captured tremendous ratings and helped fuel the public interest in cosmetic procedures, but some of the programs that followed, including The Swan (Fox), were considered to be very exploitative. The Swan finale featured 16 women who were transformed from “ugly ducklings” into “swans” after undergoing multiple procedures. For several months during the healing process, these women were forbidden to look in a mirror or to see their families. They were then paraded around and judged against the other participants for the grand prize. Many of these reality shows about cosmetic surgery create the wrong impression about what we do. They foster the myth that plastic surgery is a quick and easy fix. The extreme aspect of the “make-over” involves performing lots of procedures in one stage and making drastic changes that alter peoples’ appearances to the point that they are almost unrecognizable to family and friends. We feel it is far better to take the “extreme” out of cosmetic surgery changes, and to focus on what we call the “make-better” rather than make-over. Balanced, realistic, and reasonable changes are our goal. The ever expanding laundry list of options that exist today becomes a temptation for people to have cosmetic enhancements without enough thought. On many cosmetic surgery reality programs, plastic surgeons can be seen telling people what they need or should have done, and the audience is not shown a “realistic” interaction between the doctor and the patient. Although the current media blitz on cosmetic surgery has made viewers much more savvy about plastic surgery compared to years past, the fact remains that many consumers are not even aware of what is available, what changes can be made, and what is a reasonable and prudent amount of surgery to have at one time.

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“Beware of the surgeon willing to perform multiple, lengthy procedures in one surgery session.”

These programs give viewers an incomplete and unbalanced view of the benefits and risks of cosmetic surgery and treatments. Since the objective of many producers is to showcase people who make the most drastic changes in appearance, consumers get false and dangerous impressions that all cosmetic surgical procedures are simple adjustments that will prepare them for a walk down the red carpet. Performing as many procedures as possible in one sitting ignores safety, psychological issues, and the correct way to combine specific procedures in order to have the maximum benefit.

“Less can sometimes be more with the not-so-extreme make-over.”

The “extreme make-over” concept involves people undergoing several lengthy procedures simultaneously over the face, trunk, and extremities, leaving them wrapped like a mummy from head to toe, and making it impossible for them to return to “a normal life” for many weeks. Although “extreme make-overs” remain a fascination for the television viewing public, the reality is that it is not normal to remain in seclusion and to have around-the-clock private nursing care for several weeks after cosmetic surgery. Cosmetic surgery should not become a contest to see how many different procedures can be performed in one day.

“Balanced, reasonable, and realistic changes are our overriding goal.”

Aside from the financial burden of having plastic surgery, there is a social cost in terms of time away from work, family, and friends.

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Most people are unable or unwilling to be secluded for two to three weeks after surgery. A very common question for many of our patients is,“When can I go back to work?” and there are very few procedures or combinations of procedures that we perform that require more than a week or ten days out of work.

Combining Procedures

“There are distinct advantages of performing more than one cosmetic surgical procedure at a time.”

We understand the modern public’s desire for maximizing outcomes as well as minimizing their downtime. However, the ultimate decision to combine procedures versus perform procedures in stages is based on whatever is the safest and most reasonable choice for each individual. The obvious advantages of performing more than one surgical procedure at a time include a single session of anesthesia and one recovery period. Recovery after multiple procedures is usually shorter than the total expected recovery time when the procedures are done separately, although this depends on the compatibility of specific procedures. By combining procedures, you are in essence “piggybacking” the recovery of one procedure on another. For example, the recovery time for someone having a tummy tuck and liposuction of the hips and thighs during the same operative session will be based on recovery from the tummy tuck and not the combined recovery time of each procedure. Discomfort related to the liposuction, when you have had a tummy tuck, will seem to resolve more quickly and be less significant. There are also distinct advantages of combining certain plastic surgery procedures in order to achieve the best result and keep your body balanced. For instance, liposuction of the flanks at the same time as a tummy tuck can give a better definition to the waistline than either procedure alone.

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In other cases, shape or feature imbalance can be avoided by performing certain procedures at the same time.This phenomenon of creating potential incongruence, when improvements in one area may “unmask” problems in other areas, can often be anticipated by us. In these cases, we would suggest whichever additional simultaneous treatments would be needed to avoid this problem. As an example, liposuction of your hips without liposuction of excessive fat on your outer thighs may give the illusion that your outer thighs are even larger. It is also common to perform an eyelid lift at the same time as a facelift, since a newly, more youthful looking face will make untreated aging eyes seem more obvious. Although the hype seems to support combining many plastic surgery procedures at one time involving a variety of body areas, we usually suggest that only two major procedures can safely be performed at the same time, or one major operation can be combined with two to three minor procedures. For example, a facelift (major) can be done at the same time as upper and lower eyelid lifts (minor), while a breast lift (major) can be performed with liposuction of the flanks (minor) and fat injections (minor) into facial creases. Now, if the facelift and breast lift were to be done simultaneously, additional procedures would not be advisable. There may be exceptions to this general rule, depending on the complexity and length of each procedure and your age and general health. Part of the general principle of limiting the number of procedures performed relates to the amount of time it takes to do the surgery. For safety reasons, we like to keep the operating time to within a five to six hour span. But also, by taking the extreme out of the equation, we as surgeons can maintain better focus throughout the surgery to maximize our performance and give you the best result possible. We are professionals, not machines. The disadvantage of combining procedures is more overall pain, swelling, and bruising all at once, even if you have saved time on your length of recovery. Also, when multiple different areas of the body are treated together, practical issues such as maintaining hygiene and finding a comfortable position to sleep may become a problem.

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Staging Surgery

“There are definite scenarios when performing cosmetic surgery in stages is desirable.”

While it is advantageous to perform two major procedures together at one time, beyond that, the law of diminishing returns applies. At that point, more is not better and the recommendation would be to have surgery in stages. Always remember that when making a decision about the timing and combination of procedures to be performed, safety is the most important consideration. Certain procedures need to be staged, either for practical reasons or due to safety issues. For instance, people who need both liposuction and a skin-tightening procedure in the abdominal area to look their best, it is most prudent to perform the procedures several months apart to avoid interfering with the blood supply to the tissues that could cause problems with healing. Similarly, when we do facelifts, we generally do not perform laser resurfacing in the same areas where your skin is lifted and tightened. Financial considerations may also play a role in whether plastic surgery procedures are combined or staged. Some people may be “forced” to stage procedures over months or years due to financial issues, and your surgeon should suggest an order for performing procedures that is most appropriate. In certain procedures that are best performed together, you may opt to delay having any surgery at all until you can afford to do both at the same time. Many plastic surgeons offer a 10 to 20 percent discount on the surgical fee when more than one procedure is performed at the same operative setting, and there are just as many who offer discounts on additional cosmetic surgery if you were a previously treated patient.

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CHAPTER

3

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Choosing a Surgeon “Make sure your plastic surgeon is board certified by the American Board of Plastic Surgery.”

Take your time to find a competent plastic surgeon who you like and trust. Any licensed medical doctor can legally perform cosmetic surgery, but surgeons certified by the American Board of Plastic Surgery are the only ones uniquely qualified to perform cosmetic procedures on both the face and body. The American Society of Plastic Surgeons (ASPS) is the largest organization of board-certified plastic surgeons in the world. With more than 5,000 members, the society is recognized as a leading authority and information source on cosmetic and reconstructive plastic surgery. ASPS comprises 94 percent of all board-certified plastic surgeons in the United States. A board-certified plastic surgeon located near you can be found by clicking on www.plasticsurgery.org.

“Generally, the people who have the most positive experiences with cosmetic plastic surgery are the most well-informed.”

The Consultation A personal consultation with a surgeon should be your first step when considering cosmetic surgery. We commonly see people in the office who have already “diagnosed” their situation and “prescribed” their own treatment. For instance, they may have already decided they “need” a tummy tuck or “would like” a facelift. While it is of the utmost importance to listen to your thoughts and desires, it is up to us as surgeons to evaluate the entire situation objectively in order to give you the best advice, even if our

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recommendations are not what you want to hear. Our job is to decide what procedures or treatments will help you achieve your goals most effectively and efficiently. The initial meeting gives you a chance to describe in your own words the changes you are interested in and to discuss your ultimate goals for surgery. It is also an opportunity for you to tell us about pre-existing medical conditions, current medications, and lifestyle choices and habits that may impact the surgery. During this meeting, we assess your physical and emotional health by taking a thorough medical history and examining the areas or body parts that you are interested in modifying. After listening to your goals and thoroughly recording the exam findings, we will come up with a list of recommended procedures and treatments that we consider to be ideal for your specific condition. We sit with you in a comfortable office setting to review these findings and to have an open discussion about the possible treatments, including both the surgical and non-surgical treatment options available. At this time, you may also have an opportunity to see before and after photographs of other people who have had similar procedures. Depending on your level of interest in proceeding with surgery, we may outline a plan of treatment for you and discuss details such as the length of surgery, where the scars will be located, the approximate amount of skin or fat to be removed, and the expected recovery time. Our discussion will also include the possible risks and adverse consequences associated with the surgery.

“The doctor-patient relationship is a bond that should provide you with a sense of security and confidence in the surgeon.”

While it is an important time for you to have a complete understanding of the facts relating to surgery, it is during the initial

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consultation that the doctor-patient relationship is established. Ideally, a bond is formed that provides you with a sense of security and confidence in the surgeon. There should be a comfort level that allows you to communicate your wishes and talk about expectations openly so that we can have a clear idea of your goals. In order for us to give the best advice to people considering cosmetic surgery, it is necessary to understand your goals, and understanding comes from listening to you. Your satisfaction is maximized when the lines of communication between us remain open. If you have a positive feeling at the end of the consultation, it is not necessary to continue to “shop around” for a surgeon for comparison. But of course, if you do not like the doctor after the consultation, the surgeon is not “right” for you, and it would be best to meet with another surgeon.

The Value of Computer Imaging

“Computer imaging has become a powerful tool when discussing patient expectations and devising a surgical plan.”

During the consultation, we may take digital pictures of the areas you are interested in treating so that they can be viewed on the computer when we discuss treatment options with you. Using the Canfield Mirror® Imaging System, we take digital photographs during the consultation and then we can digitally make modifications of your image on the computer to give you a general idea of what you may look like after your surgery. Although the computer imaging is only a simulation, it gives us another excellent opportunity to have an in-depth discussion about your goals and expectations of surgery. Computer imaging is one of the most powerful tools that we use

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in discussing patient expectations. Before and after pictures of other people are very helpful in understanding the effects of surgical procedures, but since every person has different body shape, skin type, and bone structure, it is difficult to draw conclusions about your own outcome from these pictures. Computer imaging is meant to help you to visualize the changes in your own body that may be possible, but it is not an absolute guarantee of outcomes. We believe that three-dimensional imaging will replace twodimensional imaging in the future as it allows both you and the surgeon to visualize the anticipated results in a more realistic fashion. Three-dimensional imaging can provide data that is not just a simulation, but may be able to predict actual results. A single photograph is taken with a sophisticated camera that provides data to a computer that processes the information. The image is then rotated and manipulated with the mouse on a computer screen so that the results can be viewed from all angles. The ability to simulate changes following surgery and also show actual changes based on real data will better help us discuss expected outcomes. This is another example of how techniques and technologies are helping us better meet your expectations.

“It is recommended to meet with your surgeon at least twice before having surgery.”

It is a good idea to return to the surgeon’s office for at least one additional visit after the initial meeting—and certainly before a planned surgical procedure—to ensure that all your questions have been answered and you completely understand the plan. When several weeks or months have passed between the initial consultation and the scheduled surgery, a pre-surgical visit refreshes everyone’s memory and is the best way to ensure that the surgery meets your expectations.

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We believe the role of the aesthetic plastic surgeon is to be a partner with you, our patients. Vitally important to successful surgical outcomes is listening to you, answering your questions, and addressing your concerns. We understand that even the most minor procedure is of major importance to you and your family members. In cosmetic plastic surgery, happy and satisfied people are the most rewarding outcome.

Where to Have Your Surgery

“Outpatient surgery centers are the overwhelming trend in cosmetic surgery.”

Outpatient surgical care has been proven to be safe, convenient, and cost-effective. Cosmetic treatments and surgery are now routinely performed in accredited office-based surgical facilities, free-standing ambulatory surgery centers, or hospital-based ambulatory facilities. In fact, we do most of our cosmetic procedures at our own fully accredited state-of-the-art ambulatory surgery center, staffed with a full-time board-certified anesthesiologist, so that we can provide patients with the best care in a warm, friendly, and safe environment. For many cosmetic procedures performed in the United States, it is common to go home the same day or at least within 24 hours. If your surgery will be performed outside of a hospital, make sure that your doctor has privileges to perform the same procedure in an accredited hospital. People needing or requesting an overnight stay must have their surgery in a hospital or in an ambulatory surgery center that is part of a hospital. Accreditation is an important piece of information to determine when researching a surgical center. You should check the credentials of any outpatient surgery center that you are considering to make sure it is safe and reliable. Look for centers that have a wellestablished track record good results and high-quality service.

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Make sure that documentation of accreditation by one of the following nationally recognized accrediting organizations is clearly visible in the facility: • The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) • The Accreditation Association for Ambulatory Health Care (AAAHC) • The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) • Medicare To check a facility’s accreditation status, you can contact the American Association for Accreditation of Ambulatory Plastic Surgery Facilities (847-949-6058), the Accreditation Association for Ambulatory Health Care (847-676-9610), or the Joint Commission on Accreditation of Healthcare Organizations (847-916-5600).

Regulations for freestanding clinics and surgery centers fall under federal as well as state and local standards, and you should find out which standards are in place in your particular state. More states will likely pass regulations covering office-based cosmetic surgery that make it necessary for doctors who perform any cosmetic surgical procedure in an office-based facility to have privileges to perform the same procedure in an accredited hospital.This regulation is a way to add more safety to outpatient cosmetic surgery, since physicians who do not qualify for staff privileges at a hospital would not be allowed to perform procedures in their office. Cosmetic surgery is elective, so there is no reason to make hasty decisions without research and planning and certainly do not feel pressured to make a quick decision. It is important to get as much information as you need to feel comfortable about your decision.

Financial Considerations Fees for cosmetic surgery vary widely depending on the surgeon, the complexity of the procedure, the number of procedures being performed at one time, and the amount of time needed

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to perform the procedures. There are also regional differences in surgical fees with major metropolitan areas generally having higher fees than plastic surgery practices located in suburban or rural areas.

“As a rule, cosmetic surgery is not covered by health insurance plans. However, in cases where there is truly a functional component to your problem that can be documented, insurance may pay for some or all of the cost of surgery.”

True cosmetic surgery is considered elective and is almost never covered by health insurance plans. However, some conditions may have a functional component and are therefore considered reconstructive, such as breast reduction in certain people with neck pain, back pain, and other symptoms; nasal surgery for people with difficulty breathing through their nose; or eyelid surgery in cases where visual field cuts can be documented. In these cases, the insurance company may cover all or a portion of the surgery fee, the anesthesia fee, and the surgical facility expenses. Procedures that may fall under the category of reconstructive surgery need to be pre-certified in advance of the surgery. Each insurance company has different criteria for covering these procedures and we recommend that you contact the company in order to find out the specifics in your particular case. When calculating the cost of cosmetic surgery, there may be a number of separate fees involved. Our surgical fee for a procedure is generally inclusive of all post-operative office visits needed until you have recovered or are completely healed. In addition to the surgeon’s fee, there will be a fee for the use of the operating room in either a surgery center or a hospital. The anesthesia fee may be a fixed amount determined in advance for specific procedures or may be based on the length of the procedure.

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“Never shop for a bargain when you are considering cosmetic or any other surgery.”

While it is never recommended to select a surgeon or procedure based on cost alone, we know the financial impact of cosmetic surgery is an important consideration for many people. Inability to comfortably afford cosmetic surgery can certainly be a limiting factor in the choice or timing of procedures. Like other appearance related investments such as manicures, hair styling, and teeth whitening, you must weigh the cost of the procedure relative to the improvements that you can expect.

COSMETIC SURGERY FEES Fees for procedures will vary according to geographic region, the surgeon and the procedures being performed. The table below is a basic guideline for the most popular procedures. NOTE: These fees DO NOT include anesthesia fees, surgicenter fees or the cost of implants when they are needed.

PROCEDURE

SURGICAL FEE RANGE

Upper eyelid lift

$ 2,200–$3,200

Lower eyelid lift

$ 2,200–$3,200

Facelift

$ 8,975–$10,975

Browlift

$ 3,950–$5,350

Chin reshaping

$ 1,500–$2,500

Ear reshaping

$ 3,000–$4,000

Breast enhancement

$ 4,200–$5,600

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PROCEDURE

SURGICAL FEE RANGE

Breast lift

$ 4,200–$6,100

Breast reduction

$9,500–$11,500

Upper arm lift

$3,000–$6,000

Liposuction

$2,000–$3,400 per area

Body lift

$14,000–$16,000

Restylane® Injections

$400–$600 per cc syringe

Botox® Injections

$350–$500 per cc syringe

Tissue Glue Tisseal® is a sealant used to glue surfaces together. On occasion, we use Tisseal® in addition to sutures and other fixation devices. It is often used during facelifts, forehead lifts, and tummy tucks to fix the tissues in place along with standard fixation techniques. When Tisseal® is used, it does add an additional expense to the surgery ($500–$1000) because the product is relatively costly.

Implantable Materials If you have a cosmetic surgical procedure that requires the use of an implant such as chin, cheek, or breast enhancement, there will be a fee for the product in addition to the surgeon’s fee to perform the procedure. Silicone gel filled breast implants are generally more expensive than saline breast implants by about 30 percent per pair.

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CHAPTER

4

Getting Ready for Surgery “The finer details of preparing for surgery play a key role in ensuring a smooth road to recovery.”

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Details Before Surgery It is our policy for you to return to the office within two weeks of your scheduled surgery, if it is to be performed under general anesthesia or intravenous sedation. At this time, we review the plan for surgery with you and have you read the surgical consent forms and sign them after all your questions have been answered. This visit is also an opportunity to take standard “before” photographs to document pre-existing asymmetries and as a comparison for later use. Implants for chin, cheek, jaw, and breast surgery are chosen and ordered and all garments that you will need after surgery are fitted including bras, upper and lower body compression girdles, and chin straps. We give you prescriptions for antibiotics, pain medication, and muscle relaxants, if needed, so that you can get the prescriptions filled ahead of time and avoid stopping at a pharmacy on the way home from the surgery center or hospital.

“The pre-surgery visit is a time to review details of the plan and to get practical advice to help make the process as smooth as possible.”

A nurse or physician assistant will also spend time with you during the pre-surgery visit and cover other practical issues related to surgery such as the appropriate clothing to wear on the day of surgery, the best way to bathe afterwards, tips on sitting and sleeping and positions, instructions on bandages, and the best way to take pain medications. If surgical drains will be needed after the surgery, they will also show you what they look like and how to take care of them so that you know what to expect.

Medications Like any surgical procedure, it is important that you tell your doctor about your complete medical history and all prescription and over-the-counter medications you are taking, including aspirin, Motrin, birth control pills, hormone replacement medications, vitamin supplements, diet pills, and herbal remedies.

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You will be advised not to drink alcohol and to avoid taking aspirin and aspirin containing products, non-steroidal anti-inflammatory products, and vitamin E, as these medications and substances can disrupt the clotting process and lead to excessive bleeding. Women who smoke, have a history of varicose veins, or are more than 10 percent over their ideal body weight should stop taking birth control pills and hormone replacement therapy one month before surgery to decrease the chance of developing blood clots. In general, if you are taking medications to treat problems such as high blood pressure or thyroid conditions, these should be continued up to the time of surgery. We may specifically prescribe antibiotics to be taken prior to surgery if you have a history of mitral valve prolapse, a heart murmur, or have had previous joint replacement surgery.

Do I Need Blood Work or Tests? The pre-surgical testing requirements for in-office surgery are the same as if you were having surgery in a hospital setting. The requirements for blood work and other tests are based on your age, your general health, and the type of anesthesia that you will be having. When necessary, blood tests are performed within two weeks of surgery and may include a blood count, electrolyte levels and/or a profile of the blood elements that regulate bleeding. If you are age 40 and over, an electrocardiogram is usually required. For women of childbearing age, a urine pregnancy test is requested. A chest x-ray may also be ordered, especially for people with a significant history of cigarette smoking. We suggest that you get medical clearance by a family doctor or internist for any major surgery, and it is required if you have a medical condition such as diabetes, high blood pressure, or lung disease. If you are taking prescribed psychoactive medications, we recommend that your psychiatrist or other mental health professional provides clearance before surgery. Even with normal test results and medical clearance, a markedly elevated blood pressure or a common cold on the day of surgery, are grounds to reschedule your procedure.

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Vitamin Supplements There are a number of companies that have developed comprehensive pre- and post-operative nutritional supplement systems specifically designed for people undergoing surgery. The vitamins and nutritional supplements can boost the immune system, help to prevent infection, minimize inflammation, reduce bruising, and enhance wound healing; we highly recommended them. You are given the opportunity to learn about the vitamin programs at the pre-surgical visit.

Skincare Strategies A comprehensive skincare regimen including the use of skincare products, regular facials, light chemical peels, and microdermabrasion is highly recommended both before and after facial rejuvenation surgery. In general, it is advisable for you to limit sun exposure and the use of tanning salons to minimize skin damage and the acceleration of aging changes in the skin, but we insist on the use of liberal sunscreen and avoidance of direct prolonged sun exposure on all surgical sites for a period of six months after your surgery to minimize scar darkening. Tanning outdoors or in a tanning salon in the first few months after surgery may cause a surgical incision to become “tattooed” with brownish pigmentation. You also have a higher chance of getting sunburned in the first few months after surgery in areas such as the breasts and abdomen that may have temporary sensory changes. With regards to application of creams, lotions, or ointments to surgical incisions for the purpose of improving the appearance of scars, there are a variety of options that may help minimize scarring. The final appearance of a scar, however, is determined by a number of factors including your age, skin type, the location of incisions, and the closure technique, with only a small benefit gained by the use of topical products afterwards. In general, your initial scars will remain somewhat thickened with a dark pinkish coloration for weeks and often months. Gradually, the scars will become less obvious, ideally fading to thin white lines. Silicone gel sheeting helps to flatten and

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lighten scars to some degree but unfortunately, we do not know of any products that can “erase” scars.

Diet & Exercise Exercise and generalized conditioning is highly recommended prior to cosmetic surgery but is just as important after surgery, once we have given you clearance to resume physical activity. Just as body contouring procedures are not treatments for weight reduction, the improvements that result after liposuction, tummy tucks, and breast reductions need to be maintained with a regular exercise program and a healthy, well-balanced diet.

Risks of Surgery

“No surgery or procedure is completely free of risks.”

As with any medical or surgical procedure, there is always a possibility of unexpected or unwanted events. No surgery or procedure is completely free of risks, and the risks vary according to the type of procedure being done, your general health status, smoking history, and the length of surgery. It is in everyone’s best interest for you to understand all of the potential complications prior to the surgery. The risks of cosmetic surgery can be divided into two main groups; those that are common after all operations and those that are unique to a specific technique or procedure. It is also important to factor in the variables of your age, gender, general health status, skin type, and medical history. Clearly, a younger person in prime health will have less risk than an older person with a history of high blood pressure. Males are more prone to facial bleeding after facelifts because they have a rich blood supply in their thicker, bearded skin. Thin skinned people may be more prone to bruising, and heavier people are at a higher risk for developing blood clots in their legs.

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The most common risks of cosmetic procedures include swelling, bruising, bleeding, and infection. Depending on the specific procedures performed, other adverse consequences may include the development of a hematoma, which is a blood collection, or a seroma, which is a collection of clear fluid. Sensory changes, asymmetries, and contour irregularities can also occur. Infections are rare and are typically treated with a course of antibiotics. If you are having surgery that involves placing an implant, there is always the unlikely possibility of extrusion, which means that the implant works its way through the surface of the skin, or capsular contracture, which is an excessive tightening of scar tissue that forms around the implant. More specific adverse consequences are unique to the body area being treated or the technique used. For instance, you may develop difficulties with breast feeding after breast reduction surgery or have slight asymmetries of eyebrow position after a brow lift. The possible risks associated with specific procedures will be covered in more depth in the chapters that follow.

Smokers Beware!

“Smoking greatly increases your risks of delayed healing, poor scarring, increased bruising, blood clots, and skin loss.”

We advise people to stop cigarette smoking for at least two to three weeks prior to surgery. There are many surgeons who will not even perform a facelift on a person with a significant smoking history, even if they are not currently smoking, due to the extremely high risk of poor wound healing. People who are actively smoking, people with a strong smoking history, and people who have had long-term exposure to second-hand smoke, all have a higher chance of problems after surgery. Nicotine causes blood vessels to become narrow, which causes decreased blood flow to tissues, and ultimately oxygen delivery is impaired. In some

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cases, smokers can actually lose a portion of skin due to a lower level of oxygen in the operated tissues. All forms of nicotine, including nicotine substitutes and smoker’s aids, can increase the risk of poor healing, skin loss, scabbing, and crusting. These risks are significantly reduced, but not eliminated, if you stop smoking at least two weeks, but preferably four weeks, before surgery.“No Smoking” includes avoidance of all forms of nicotine that infiltrate the bloodstream such as patches, gum, tablets, chewing tobacco, cigars, pipes, and exposure to heavy amounts of second-hand smoke.

Managing Your Discomfort Your discomfort level is based on many factors including the length and location of the incisions and whether or not muscles were stretched, cut, or tightened. The more extensive the surgery, the greater amount of discomfort you will feel. You will be given pain medications by mouth or injection in the recovery area after surgery. Sometimes we numb the area around the incision at the end of the surgery to give you longer lasting pain relief. For the first 24 to 48 hours after surgery, you may need prescription pain medications. We generally prescribe Percocet,Tylenol with Codeine, Darvocet N100, or Vicodin ES. For surgery involving muscle manipulation or tightening, we usually also prescribe Valium for muscle relaxation. After the first few days, most people switch to an over-the-counter pain medication or take nothing at all.

Recovery Time

“The specific length of recovery after surgery is dependent on a number of factors including your age, pre-operative activity level, and the number and type of procedures you had performed.”

A good general rule about recovery from cosmetic surgery is that you should be mobile enough to stand and walk around within a

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few hours of surgery, whether the surgery was performed in an outpatient facility or in a hospital setting when an overnight stay is planned. The goal is to return to public life within about seven to ten days, even if it requires the use of sunglasses, putting on camouflage makeup, or wearing a compression garment underneath your regular clothing. Recovery following cosmetic surgery can be considered in three phases. There is the immediate recovery that determines when you can stand, walk around, and resume a regular diet either in the hospital or at home. Procedures involving muscle manipulation, such as a tummy tuck or a breast augmentation with implants under the muscle, will be associated with more discomfort and a tight sensation in the first few days after surgery compared to procedures where only the skin and soft tissues are involved. The next phase of recovery determines when it would be possible for you to appear in public without drawing unwanted attention to yourself. By this time, most of the swelling and bruising will have subsided and the majority of people will have returned to work if they do not have an overly strenuous job. This is the “recovery” that most people are referring to when they ask us, “How long is the recovery?”. The last phase of recovery marks the time when you can resume all normal daily and work activities including exercise without restrictions. By the end of this phase, there should be no swelling, discomfort, or tightness. It is during this last phase, when scars fully mature by becoming flatter, softer, and lighter in color.

Travel Guidelines It is a good general rule not to travel on a plane within a few days of planned cosmetic surgery due to the increased risk for blood clot formation before surgery that may lead to problems at the time of surgery or afterward. If you are having surgery at a distance from your home, we always recommend that you stay in the area for at least a few days before and after surgery.

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CHAPTER

5

Anesthesia for Cosmetic Surgery By Dr. James Gentile, Director of Anesthesia and Pain Management at North Fullerton Surgery Center, Montclair, New Jersey

“The type of anesthesia used for cosmetic surgery is based on a combination of your desires, the needs of the surgeon, the type of surgery being performed, and the discretion of the anesthesiologist.”

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Anesthesia for cosmetic surgery is similar to anesthesia administered for other types of surgery, but often shorter acting agents are used so they clear out from your system and allow you to go home the same day. People who have cosmetic surgical procedures are usually healthy, and since the surgery is purely elective, it is usually carried out under the best possible conditions in a comfortable environment. As a result, we put more emphasis on avoiding even minor inconveniences and small problems like bruising at the site of an intravenous line or beneath a blood pressure cuff. Methods of blocking pain sensation from specific areas of the face and body have improved so much in recent years that most minor cosmetic procedures are done using some form of local anesthetic, with or without sedation. The specific choice of anesthesia depends on agreement between you, your surgeon, and the anesthesiologist. We may recommend the bare minimum type of anesthesia required to perform the procedure comfortably and successfully, but you may opt to have a higher level of anesthesia, and we will usually do so if it is reasonable. Even if you have been given medical clearance for surgery by your medical doctor, the final decision to proceed with surgery actually rests in the hands of the anesthesiologist who will interview and examine you, as well as review your medical chart before the surgery. As all cosmetic surgery is elective, it does not make sense to proceed when your blood pressure is elevated or if you have signs of a viral syndrome or upper respiratory infection, no matter how inconvenient it may be to reschedule your surgery. You may experience drowsiness and minor after-effects following anesthesia, including muscle aches, a sore throat, and occasional dizziness or headaches. You may also have nausea, but vomiting is less common. These side effects usually improve rapidly in the hours following surgery, but it may take up to 24 hours before they are gone completely. New protocols are being developed to bring the incidence of nausea and vomiting down from 40 percent or more, to less than 5 percent incidence when treated.

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Local Anesthesia Local anesthetic agents temporarily prevent the nerves from carrying pain messages to your brain. During local anesthesia, you are awake and are thus able to communicate with the physician. An anesthesiologist is usually not present for procedures performed under local anesthesia. Local anesthetics may be applied topically in the form of a gel, cream, or spray and in this form may require application at least 30 minutes ahead of time to take effect. Local anesthetic may also be injected directly into the surgical area or around the main trunks of the nerves that carry sensation to the area. Local anesthetics may be short acting and subside over the course of one hour or may be effective for up to six or eight hours. The choice of local anesthetics depends on the preference of the surgeon, and the procedure being performed, in terms of anticipated length of the surgery and which area of the body is being treated.

Twilight Anesthesia (Monitored Anesthesia Care) Cosmetic procedures are often performed under twilight anesthesia, which is local anesthesia with the addition of a sedative medication given intravenously, such as Valium or Versed to provide you a more relaxed feeling. This type of anesthesia is usually chosen for procedures lasting longer than one hour, for a few minor procedures that are being performed in different body areas, or when areas are being treated that cannot be well anesthetized with local anesthesia. The intravenous sedatives supplement the local anesthetic injections given by the plastic surgeon. People who have intravenous sedation will feel drowsy and with the combination of sedation and local anesthesia they will certainly feel comfortable during the procedure. People who are given intravenous sedation in addition to local anesthesia will usually be monitored by an anesthesiologist so that the medication dose can be properly adjusted to keep you comfortable. In the event that local anesthesia with sedation does not allow

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the surgical procedure to be carried out safely and comfortably, the anesthesiologist may switch to a general anesthetic.

Regional Anesthesia Anesthetizing an entire region of the body, such as the hands, feet, arms, or legs by injection of a local anesthetic around specific large nerves, is rarely indicated for cosmetic plastic surgery procedures. Other types of surgery such as reconstructive plastic surgery, hand surgery, orthopedic surgery, podiatric surgery, and vascular surgery commonly utilize regional anesthesia such as spinals, axillary blocks, or ankle blocks.

General Anesthesia A general anesthetic provides complete loss of pain sensation and loss of consciousness, and is often used in longer surgical procedures where a substantial amount of tissue manipulation is required, or when multiple smaller procedures are being performed in different areas of the body. A general anesthetic is administered by injection, gas, or a combination of both which causes you to fall into a deep sleep. Other medications are simultaneously used for pain relief and muscle relaxation. Advances in anesthesia have made this type of anesthesia better than ever, and for some procedures, general anesthesia is more controlled than using local anesthetics with intravenous sedation. The risk of significant complications from general anesthesia is less than that of having a serious auto accident while driving. The incidence of death from general anesthesia falls within the range of 1 in 185,000 to 1 in 300,000 for all people, including the elderly and those with serious medical illnesses. Presumably, healthy people undergoing elective cosmetic procedures would have a significantly lower risk.

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CHAPTER

6

Surgery on Your Face “The goal of rejuvenation surgery on the face is to look like a younger, more refreshed, and more relaxed version of yourself.”

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There are a number of trigger events that plant the seeds and may cause you to seek consultation for facial rejuvenation. There are the subtle signs of aging that begin to set in during the late 30s and early 40s which are hard to ignore: • looking like you pulled an “all-nighter” when you had a full night of sleep • needing more makeup and concealer to look your best • people commenting that you look angry when you are in a perfectly good mood • wearing more turtlenecks and high collars • walking past a mirror and seeing your mother’s or father’s image out of the corner of your eye

People generally say that they just want their external appearance to match the way they feel on the inside and not surprisingly, most people feel much younger than their age. Rejuvenation surgery will help ensure that you will look as good as you can at any age. People’s faces age in different ways and at different rates depending on variables such as genes, sun exposure, and history of smoking. In addition, skin type, ethnic background, and underlying bone structure all play a role in the surgical outcome making it impossible to have a standard formula to predict results. The choice of rejuvenation procedures or surgery to change shapes and contours on the face is made based on a thorough evaluation that takes into account all of the variables. A facelift tightens loose skin and muscle and repositions excess fat to restore a youthful look. The jowls, lower face, and neck are rejuvenated through a combination of procedures that make the entire face appear balanced. Eyelid surgery can give your eyes a brighter, refreshed, and more relaxed look, and your nose can be reshaped to make it shorter, narrower, or more defined. You can also have implants placed in your cheeks, along your jawline, and in your chin to create better harmony with the rest of your face. It may be necessary to “relift” your face 10 to 15 years later due

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to the natural effects of tissue relaxation, gravity and the ongoing aging process. However, it is less common to perform additional eyelid lifting surgery, and repeating a browlift, even decades later is usually unnecessary.

Restoring Your Youthful Face (Facelift or Rhytidectomy)

“There is no garden variety facelift technique that applies to everybody.”

A facelift is a surgical operation for the purpose of making your face and neck look more youthful. Skin type and tone, degree of skin laxity, and basic bone structure all factor into your choices for facial rejuvenation and contribute to your outcome. We look at each person on an individual basis to customize a surgical plan that meets their needs and desires. A facelift is not a specific procedure anymore. It has become a more generic term, as newer methods continue to evolve. In years past, large incisions were made and the skin alone was tightened. Nowadays, smaller incisions can be used and the skin and muscle layer (SMAS) are tightened, which results in very little tension on the skin and ultimately, improved scarring. To keep your facelift un-extreme, we reshape the underlying tissues by removing, repositioning, and adding soft tissue rather than just pulling the skin tight. Adding volume back to the face instead of simply removing loose skin, is another very important aspect of a rejuvenated, more youthful look. Facelifts mainly address the lower two thirds of your face and neck, but do very little to improve the eye and brow area unless the operation is specifically designed to address aging changes on your upper face. Unfortunately, facelifts do not address overall skin texture, skin thickness, or the presence of fine wrinkling and deeper creases near your nose and around your mouth. Conse-

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quently, we often do facelifts along with other procedures such as eyelid lifts or browlifts. It is also very common to add non-surgical treatments to a facelift including injections with botulinum toxin (Botox®) or soft tissue filler substances, and skin resurfacing techniques to give the best result possible.

Different Facelift Techniques

“The universal concept in facelifts is to correct loose skin, tighten stretched-out muscles, and reposition fatty tissue.”

We are continually devising new facelift techniques, with smaller incisions, and building on older methods. No one technique works for everyone so we have to customize our approach for each person taking into account age, gender, skin type, and bone structure. The universal concept, however, is that loose skin, weakened muscles, and drooping fat, like in the cheek or jowl area, must all be corrected to rejuvenate the face fully. Facelift techniques can be categorized by the tissue level where the work is being done, whether it is a more superficial technique in which we are working with the skin and the underlying muscle layer or whether we are working at a deep level, just above the bone. The different facelift techniques can be performed through access incisions which differ in length and location.

SMAS Lift This type of facelift not only repositions and removes excess skin, but also isolates and tightens the thin but strong underlying connective tissue layer know as the SMAS (superficial musculoaponeurotic system). As a result of tightening the foundation beneath, the skin over the cheeks, jawline, and neck are more easily redraped to give smooth and improved contours without visible tension. An extended SMAS lift includes more extensive isolation of the con-

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nective tissue layer, to take up the additional loose skin in people who have deeper folds between their nose and the corners of their mouth.

Subperiosteal Lift A subperiosteal type of facelift liberates and releases tissues off the bony layer and is sometimes done endoscopically. This technique is performed to get a more thorough release of the facial tissues. It usually causes significantly more swelling and takes longer to recover, but some surgeons feel the lifting effect is longer lasting. We do not believe, however, that the subperiosteal approach adds any additional advantage over the SMAS technique, which has become the gold standard in facelift surgery today.

Deep Plane Facelift This technique is used to reshape the entire face—including the upper and lower eyelids, the brow, and the neck—by lifting the facial tissues, fat, muscles, and skin in one continuous section. It is more invasive than other methods, and may require a longer recovery. This technique is used infrequently as most people are well served by the less invasive techniques.

“Everyone now recognizes that reshaping, elevating, and fixing the underlying structures is crucial for achieving natural, lasting, and satisfying results over skin tightening alone.”

How We Perform Facelifts Traditionally, an incision is made that starts two to three inches above your ear behind the temple hairline and extends down in front of your ear for two to three inches and around the ear lobe, and then into the crease behind your ear with an extension into the scalp hair behind the ear. Modified techniques are becoming

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popular which reduce the length of the incision behind the ear and into the scalp. We like using the modified facelift approach, also known as the “minimal” facelift,“mini” facelift or the “S-Lift”, on younger people who generally have less loose skin to correct and are thus able to have a shorter scar. In another modified approach, we can stop the incision short of your hairline and extend it around and in front of your sideburn area to minimize changes in your sideburn or temporal hairline location. This technique also works well for men who may not have thick enough hair to cover scars.

Mid-Facelift There are several signs of aging that begin to appear in the middle section of your face; the hollow of your eye begins to appear more defined and the natural smooth transition between your cheek and the area below your eyelid becomes very distinct; the deep folds which extend from the sides of your nostrils down to the corner of your mouth (nasolabial folds) become heavier as the cheek tissues descend. The mid facelift or “Cheek Lift,” improves loose or hanging skin and soft tissue along the middle of your face but does not improve the contours of your forehead, jawline, or neck. Mid-facelifting has taken on a new focus in the past several years. Plastic surgeons began to notice that despite all efforts at traditional facelifts and improvement of the jawline, neck, and side of the face, the mid-face area just to the side of nose and below the eye was not greatly improved by a facelift alone. Detecting the presence of aging signs in the mid-portion of the face and making a plan to correct the problem is more important than which fixation technique is ultimately chosen. When this area is overlooked by you and/or your surgeon and not properly addressed, a satisfying rejuvenation may not be achieved.

How are Mid-Facelifts Done? Several access points can be used to perform mid-facelifting. When a mid-facelift is combined with an eyelid lift, we use the lower eyelid

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incisions for access. When performed during a traditional facelift, we make an additional incision inside your mouth to help to release the mid-face tissues.The tissues are then suspended by use of sutures or dissolvable devices.The Endotine® is an example of one of these dissolvable devices and is made of an absorbable material that acts like a carpet tack in holding up the elevated tissues and then dissolves over the course of a few months.

Threadlift™

“Barbed sutures represent a breakthrough in minimally invasive techniques that can be used for an instant lifting effect through small incisions. “

Contour Threads™ is a patented self-anchoring thread technology that permits a minimally invasive surgical approach for the elevation and fixation of skin that was approved by the FDA for use in the United States, October 2004. The threads are made from clear polypropylene, a material that has been safely used for decades inside the human body as a suture material. Contour Threads™ are specially designed with dimensional barbs that attach to the underlying tissue, lifting, suspending, and fixing in place the contour of the brow, midface, and neck areas. A procedure with patented Contour Threads™ is a safe, conservative approach, and offers subtle, natural-looking results. While this procedure does not replace a conventional facelift, it does offer people an innovative, minimally invasive option. In general, the best candidates for the suture suspension technique include women and men in their 30s through their 60s who want a more youthful appearance, but who do not want a conventional full facelift, browlift, or necklift procedure. Since the technique is relatively new and surgeons are just beginning to explore the technology, it may take several years to gather data on how long the results last.

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Performing a Threadlift™ For the suspension suture technique that addresses the middle portion of your face, we make a tiny incision close to your ear and advance the threads along the previously marked contours toward your chin and jawline so they create a firm hold on the underlying tissues. The cogs do the work of holding, as they are affixed to the tissue and are softly contoured into place. Once in position, your body generates new collagen bundles that surround each thread to maintain the lifting effect. The exact placement of the threads will vary from person to person. The procedure is quick and usually performed under local anesthesia, and if desired, light intravenous sedation. The actual length of time will depend on the number of threads you need and the quality of your tissues. A typical procedure usually takes about 60 minutes to perform. In most cases, there is minimal discomfort, bruising and swelling. We recommend ice compresses for the first 24 to 48 hours. People can usually return to work or normal activities in a few days to one week. The suspension procedures using threads can be performed alone or in combination with botulinum toxin to reduce facial muscle activity, soft tissue fillers to plump up deep creases, or peels and laser therapy to improve skin texture. As mentioned earlier, no one can predict how long the results of the thread suspension procedure will last but generally this should be considered “a short term fix.”.

Improving the Contour of Your Neck (Neck Lift or Neck Suspension)

“The most important factors in deciding which neck contouring procedure is best for you are the looseness of the skin and muscle and whether excess fatty tissue is present.”

Signs of a youthful neck include a defined jawline and a deep

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angle from the chin to the base of the neck. You may have noticed changes in your neck as you get older such as loose skin and wrinkling, loss of the defined angle between your chin and neck, and the development of prominent vertical bands of muscle in the midline of your neck. We can approach an aging neck in several ways, but if jowls and loose skin are your chief concern, a surgical procedure will be recommended. The most important factor in choosing a particular treatment is whether the changes in your neck contour are related to the skin, muscles, and/or the fatty layer. In younger people with good skin tone, unwanted fat in the neck and jowl areas can be removed with liposuction. This procedure can give the neck a sharper line with more definition and better contour. Liposuction alone works best on young, toned skin that is elastic and will shrink back after the fatty deposits are removed. The key is in the quality and quantity of your skin. If you have loose skin or a “turkey gobbler” neck to start with, liposuction alone will not give you satisfactory results. If you do not want a complete facelift, and you have minimal loose skin but visible muscle bands, a smaller procedure can be performed by sewing the muscle bands together in the center through an incision under the chin. Special sutures can then be used to stretch the muscle and secure it at a point behind the ear. This method allows for tightening of your neck muscles, usually with a small amount of skin removal and a scar that is hidden behind your ear. You can have a neck lift by itself or in addition to other procedures on your upper face. Botulinum toxin can be used in the neck area to soften your muscle bands, but it will not significantly improve your jowls and it will definitely not tighten the loose skin. A facelift can soften, but will not totally eliminate, the creases between your nose and the corners of your mouth.

Joanne’s Turkey Gobbler Neck Joanne is a pretty lady who is 63-years-old with a big family and three grandsons. She had dreamed of having her

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face and neck done since she turned 50, but somehow the timing was never right. She told us the story of when her three-year-old grandson was recently sitting on her lap, and looked up at her while tugging at the hanging skin on her neck. Joanne did not know whether to laugh or cry. That was the trigger event she needed to get going. Joanne had a neck suspension procedure performed two months later. Within a few weeks of her surgery, she looked ten years younger. Her “turkey” neck was gone and there was no hanging skin for her grandson to tug on anymore. She also had her eyelids lifted to give her a balanced look. She is thrilled with her new look and is the envy of her friends, many of whom are now considering rejuvenation surgery themselves.

What to Expect After a Facelift or Neck Lift To minimize bruising and swelling, your face and neck may be wrapped with an elastic bandage, and it is important to keep your head elevated above the level of your heart when lying down. A small drainage tube may be inserted under the skin behind your ear for a day or two to collect fluid that accumulates. Expect some discomfort for several days that should be easily controlled by the prescribed pain medication. Severe pain is unusual and should be a warning sign to alert your doctor. During the early period, you may look pale, bruised, and swollen, but the effects of the surgery should be noticeable within a few weeks. Dressings are typically removed within one to five days and stitches are removed after five to seven days. Once the dressings are off, you can shower and gently shampoo your hair. The hair around your temples may be thin, but typically regrows within four months. Avoid steam baths, hot tubs, and saunas for several weeks to minimize swelling. Your scars will initially be red then fade to pink, and may take a full year to fade to white. You should expect some tightness and numbness of the skin but this should clear up in a few weeks. Firm areas—especially around the chin and neck—and irregularities in the cheeks may develop

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after three to four weeks but should gradually subside. (We call this the “lumpy bumpy phase.”) Swelling and bruising usually improve enough to allow you to make public appearances in two to four weeks. If major social functions like weddings or extensive travel are planned, you should have surgery when there is at least six to eight weeks of recovery time. Strenuous activities such as heavy lifting and rigorous exercise should be avoided for at least three to four weeks.

What Are the Possible Adverse Consequences? A blood collection or hematoma may develop beneath the skin and should resolve spontaneously if the collection is small. For larger hematomas, drainage is required and involves a return visit to the office or operating room to open the incision line and remove the excess fluid. Another potential complication is injury to the nerves that control facial muscles. This is very rare, and usually resolves itself within six months. Typically, numbness after this type of surgery is temporary and to be expected. Skin peeling or scabbing around the incisions may occur, especially if you smoke cigarettes. Poor or delayed healing of the skin can occur in people with very thin skin and is most commonly seen behind the ear where the most tension is placed during closure of the incision. This usually resolves on its own with good wound care, but may require scar revision. About 5 percent of people will request (or we may recommend) a touch-up or minor revision. This is not a complication, but rather a normal part of the healing process.

Rejuvenating Your Forehead and Brow (Brow Lift of Forehead Lift)

“The position of your brow has a major impact on facial expression. An elevated, smooth, youthful looking brow conveys a positive, uplifted state of mind.”

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As you get older, deep creases across your forehead and between your eyebrows develop and may be visible even when you are not actively raising your eyebrows or squeezing them together. And there is also a gradual descent of your normal brow position that gives your eyebrows a “heavy” look. Ideally, the eyebrow sits above the bony rim around your eye. If you place your finger on your eyebrow and it falls below the bony rim, you may consider having your brow lifted. A brow lift helps to reverse the aging changes by tightening a sagging forehead, removing and softening some creases, and lifting falling eyebrows. Younger people should also consider this procedure if they have inherited traits such as low eyebrow position or deep frown lines. To temporarily halt wrinkles, you can have botulinum toxin injections to your forehead area and between your eyebrows, and you can also plump up some of the creases between your eyebrows with soft tissue fillers. Brow lifts are commonly performed in conjunction with facelifts or eyelid surgery. When performed in the same operative session as an upper eyelid lift, the browlift should be performed first as it will tend to minimize the amount of upper eyelid skin that needs to be removed. There are two basic techniques that we use for lifting the brow: the older, more traditional coronal brow lift and the more commonly used endoscopic brow lift. We prefer the endoscopic technique for a browlift because the scalp incisions are minimized, there is a lower chance of permanent scalp numbness, and the recovery is shorter. This technique is also recommended for people with thinning hair. As with all surgery, there are many ways to achieve the same goals. We tailor our technique to the needs and particulars of each person.

How Is It Done? Typically, a browlift can be performed under local anesthesia, combined with an intravenous sedative to make you drowsy. The surgery can also be performed under general anesthesia. Your hair

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does not need to be shaved but is typically tied back with rubber bands on either side of your head where the incisions will be made.

Coronal Lift With the coronal technique, we make a cut through your scalp slightly behind your natural hairline which runs from ear to ear across the top of your head, in the location where a headband or headset would sit. For people with a high hairline, this incision can be made where the hairline begins to avoid moving the hairline back any further. After making the incision, your scalp and forehead skin is lifted away from the underlying tissue and pulled tight, causing elevation of the eyebrows. The excess scalp tissue is trimmed away and then the incision is closed with stitches or staples. Usually, the suture line is covered with gauze and your head is wrapped in an elastic bandage.

Endoscopic Brow Lift Instead of one long incision, the endoscopic technique requires three to five one-inch incisions and is our technique of choice.To see the underlying muscles and tissues, we insert an endoscope (a wand with a small camera on the end) into one of the incisions. In another incision, we insert a different instrument to lift the skin and release the underlying muscles and tissues. Next the eyebrows are lifted and secured underneath the skin. We have incorporated the Endotine™ device (Coapt Systems) into our browlift procedures for added fixation. Gauze and elastic bandages are then applied.

Transblepharoplasty Browlift The ENDOTINE transblepharoplasty is a revolutionary device that allows a browlift and eyelid lift to be performed through the same incision during the same surgery. This small absorbable device which holds tissues in place, is positioned underneath the brow

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through a single upper eyelid incision and anchored directly to the underlying bone for secure brow elevation with minimal surgical manipulation of the tissues. A transblepharoplasty brow lift also eliminates the frown lines between the eyebrows. Regular suture material can also be used to do the “lifting.” When we use an upper eyelid incision as access to perform a browlift, you can have the combined procedure of removing upper eyelid skin and repositioning of your brow in a single surgical session with a minimal amount of scarring.

Temporal Lift By making a limited incision just behind the natural hairline in the area of the temple, the outer part of your eyebrows can be elevated. This technique is mainly intended for people with slight droopiness, specifically on the outer aspects of their eyebrows, who do not have a general overall lower position of their eyebrows.

Threadlift™ for the Brow We can also place two to three barbed sutures on each side as another way of lifting the outer part of your eyebrows. We make small incisions along a natural forehead crease or behind your frontal hairline. Although this is a much simpler approach than an endoscopic brow lift, the results may not be as long lasting.

“As with most cosmetic surgery, there are many ways to achieve the same goals, and we tailor our technique to the needs and particulars of each person.”

What to Expect Afterward To reduce swelling after a browlift, you will need to keep your head elevated. Bandages are removed within a few days and stitches or staples are removed within a week. Within a couple of

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days you can shower and shampoo your hair. Numbness, tightness of the forehead and temporary pulling around the stitch line are common. Your cheeks and eyes may also swell and bruise, but these effects should resolve within a week or so. Most people are up and about in a few days, but you should rest for at least the first week after surgery. Rigorous physical activity should be avoided for several weeks. Most of the visible signs of surgery should fade within the first three weeks.

What Adverse Consequences Are Possible? There is a possibility that the nerves that control eyebrow movement may be injured on one or both sides, which may result in an inability to raise your eyebrows or wrinkle your forehead. This is usually a temporary condition, but may be long-term or permanent in rare cases. Loss of sensation along or just beyond the incision line is common, especially with the coronal type of brow lift. Scalp numbness is temporary and usually resolves in six months, but may be permanent in some people. Another possible adverse consequence is the formation of a widened scar after the coronal type lift, which may require another surgical procedure to create a new, thinner scar. You may also experience hair loss or thinning hair in the vicinity of the scar. Hair growth should resume within a few weeks or months. A small degree of unevenness in eyebrow position may occur, and despite all efforts, may remain after surgery.

Eyelid Rejuvenation (Eyelid Lift or Blepharoplasty)

”A beautiful eye is one that is well-framed by the brow, and the contours of the skin around it. It is well rested, attentive, and defies its true age”

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Your eyes are a focal point on your face and give others clues about your age, mood, and whether or not you are tired or well rested. When beginning the process of facial rejuvenation, many people choose eyelid surgery as a starting point. One of the main reasons may be that your eyelids often show the effects of aging, gravity, sun exposure, and smoking before the rest of your face or neck. Protruding fatty tissue from your eye sockets that causes bulging above or below the eye can be an inherited trait that shows up early in life, but can also be the result of gravity and aging that occurs in men and women. Generalized sun exposure over the years will have a direct effect on the weakening of your elastic fibers that keep eyelid skin taut. At first, bags or sagging may be most noticeable when you are particularly tired. Eventually the signs become visible all of the time. Bulging fat pockets result when fat pads that cushion your eyes begin to fall forward, pull away from the bone of the lower eyelids, and sag. Eyelid skin and muscle thin and stretch with time.

“There are many factors that contribute to the gradual changes in the delicate tissues of the eyelids.”

As you age, your upper eyelids become heavier and fuller and may form a “hood” over your eyelashes. Women often complain about having trouble applying eye shadow, or finding that mascara ends up on their upper eyelids. People also notice decreased peripheral vision, especially while driving or playing tennis. You can feel an added heaviness to your upper eyelids as a result of bulging fat pockets and excess skin. Blepharoplasty can get rid of droopy or hooded eyelids, and eliminate the protruding fat bags above and below your eyes. In some cases, cosmetic eyelid surgery may be combined with surgery to correct a functional problem such as weakness of upper eyelid muscles called “ptosis” (pronounced toe-sis) that can decrease the range of upward vision. The goals of eyelid rejuvenation techniques are to remove

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excess skin, reduce fat deposits or reposition them, tighten loose eyelid muscles, and re-establish a natural crease in your upper lids. A decade ago, we removed more skin, fat, and muscle. Today, we preserve fat whenever possible to avoid creating an operated look or causing hollows around your eyes. Eyelid surgery does not directly correct the dark circles under the eyes, but can eliminate the dark shadowing effect caused by bulging fat pockets and loose and redundant skin. And an eyelid lift will not lead to any improvement in sagging eyebrows.This requires a brow or forehead lift that can be performed in tandem with your eyelid surgery. Botulinum toxin injections, peels, and laser therapies can reduce fine lines and wrinkles around your eyes. Cosmetic eyelid surgery may need to be revised in the future if there is very loose or thin skin, but the rejuvenation effect of blepharoplasty generally lasts ten years or more and often times does not need to be repeated. Since the eyes are a central feature of the face, rejuvenating them is critical to achieving a more youthful appearance.

How Is It Done? In blepharoplasty, excess fat, skin, and, if needed, muscle are removed from your upper and/or lower eyelids. The procedure is performed on an outpatient basis under local anesthesia with intravenous sedation or under general anesthesia, especially when it is combined with another surgical procedure. First, eye drops may be used to anesthetize your eyes, and then an ointment may be placed in your eyes to protect your eyeballs during the surgery. We use very fine electrocautery throughout eyelid surgery to minimize bleeding.

Lower Eyelids The most common methods of performing lower blepharoplasty are the external approach—also called a skin-muscle flap—and the transconjunctival approach. For the external approach, we make

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an incision at a point near the inner tear duct of your lower eyelid, approximately 2 to 3 mm below your eyelash line, which typically extends into the crow’s feet area where wrinkles already exist so that the scar will be less noticeable. We lift the skin and muscle to remove a small amount of fat. Excess skin and muscle are then trimmed from your lower lid. If you have a pocket of fat beneath your lower eyelids but do not have any loose skin, we may recommend a transconjunctival blepharoplasty. It is usually performed on younger people with fatty lower eyelids and taut skin. The transconjunctival method utilizes an incision hidden inside the lower eyelid which leaves no visible external scars. Through this incision, we can expose and trim the excess fat. The incision is closed with dissolving sutures or, more commonly, it is left to heal on its own. A lower eyelid tightening procedure may also be performed with an eyelid lift using either surgical approach, but if significant skin and muscle laxity are present, the skin muscle flap (external) approach is advisable. Another aspect of lower eyelid surgery addresses the “tear troughs” or deep grooves that can result when there is an obvious demarcation at the junction of the lower eyelid area and the cheek. The main methods for improving the tear trough area are fat removal, fat injections, or fat transposition to move around the existing fatty deposits to create a smoother look.

Upper Eyelids Upper blepharoplasty involves making an elliptical incision across the eyelid crease, in the natural skin fold. We draw a line to identify the lower edge of the skin to be excised, which will eventually become the scar that remains. The loose and redundant skin of your upper eyelid is then marked out. Excess skin and fatty tissue are removed along with a thin strip of muscle to give your eyelid crease more definition. We close the incision with a single layer of fine sutures. When correctly planned, the scar is well hidden within the natural fold of your upper eyelids.

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What to Expect Afterward Thin surgical tape will be applied to your stitch line after the surgery. An ointment to prevent dryness may be applied but it is not necessary for your eyes to be covered.Your eyelids will feel tight and sore as the anesthesia wears off and you may feel a slight burning sensation along the suture lines. Head elevation with extra pillows above the level of the heart is important when you are lying down to help minimize swelling and applying cold compresses or ice packs for the first 48 hours will also help to reduce your swelling. Although you will be able to read, use a computer, and watch television the next day, these activities should be limited because they tend to dry the eyes and your eyes will tire easily. The stitches are removed three to five days after the procedure. For seven to ten days, the eye area will need to be cleaned and your eyes may feel sticky and itchy. In some cases, we recommend using artificial tears for lubrication that will help the gritty or scratchy feeling in the first few days after surgery. You should not wear contact lenses for one to two weeks and you may feel uncomfortable for a while when you resume wearing them. We recommend wearing sunglasses in the first few weeks after surgery since your eyes will be sensitive to sun, wind, and other irritants. For the first two weeks, it is important to avoid any activity that increases blood flow to the eyes or surrounding area including bending, lifting, crying, and exercising, or sports. Some swelling and bruising is to be expected for several weeks, depending on the extent of your procedure. Although your scars can remain slightly pink for six months after surgery, they should eventually fade to a thin, barely visible white line. Eyelid scars generally heal very well because of the thinness of the skin.

What Are the Risks? Certain medical conditions including dry eyes or lack of sufficient tears, thyroid problems such as hypothyroidism and Graves’ disease, hypertension, cardiovascular disease, and diabetes may increase the risks associated with eyelid surgery. Depending on

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your medical history and exam findings, we may have you see an ophthalmologist before surgery, to perform glaucoma testing and measure tear production. A dry eye condition or blepharitis can inhibit healing and possibly result in injury or infection of the cornea. In mild cases of dry eyes, a more conservative surgical approach is generally better. But if your dry eye condition is very severe, surgery may not be recommended. Other than expected bruising and swelling after blepharoplasty, minor adverse effects may include temporary double or blurred vision, burning, stinging, gritty sensation in the eye, excessive tearing, and a slight asymmetry. Severe complications may include decreased sensation in the eyelid, dry eyes, difficulty closing your eyes completely, or an ectropion where the lower lid is pulled down. A more serious but extremely rare complication is bleeding behind the eye, called retrobulbar hematoma that can be successfully treated once it is recognized.

Catherine’s Eyes Catherine was 48-years-old when she became interested in procedures to improve her aging eyelids. Even though “heavy eyelids” were a family trait, she definitely noticed more bulging and loose skin over the past five years or more, and she also thought that her peripheral vision was not as good on the tennis court. After a restful night of sleep, Catherine still felt that she looked tired. And she was tired, but only of people telling her that she looked tired. She basically gave up trying to wear eye makeup since it was difficult to apply, especially eye shadow and mascara. Once bulging fat pockets were removed and excess skin from the upper and lower eyelids was trimmed, Catherine could finally see her upper eyelid crease and the “bags” under her eyes were gone. She described feeling that “a weight had been removed” from her upper eyelids and “the horse blinders had been taken off.” She now has purchased several new shades of eye shadow and uses very little lower eyelid concealer. Most importantly, her improved peripheral vision has rejuvenated her tennis game. 68 BEAUTY IN BALANCE

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Nose Reshaping (Rhinoplasty)

“The nose is one of the most defining characteristics of the face; even a slight alteration can greatly improve one’s appearance.”

The most common complaints people have regarding the appearance of their nose include large-size, crookedness, a nasal hump, a wide bridge, a droopy or ill-defined thick tip, and excessively flared nostrils. Your nose may need to be lengthened, augmented, or narrowed to give you your best look. Rhinoplasty can be used to correct a variety of conditions including the appearance of your nose and whether it is in proportion to your other facial features, as well as functional problems including breathing through your nose and traumatic injuries. Breathing problems related to a “deviated septum” or other internal nasal structures can be corrected at the same time as procedures to reshape your nose. When we evaluate your nose, we study both the frontal view and the profile, in addition to taking note of the shape and projection of your chin, cheekbones, and upper lip. Since the nose may not be fully developed before the age of 16 or 17, we usually recommend that young adults wait until they are at least that age—and possibly older for boys—before undergoing rhinoplasty. Assuming you are in good health, there is no upper age limit for having your nose reshaped. With age, gravity, and the gradual weakening of the supportive structures of the nose, the shape and position of your nose will ultimately change. Your nose may appear longer as the tip gradually droops. Thus, it is not unusual to have nasal refinements performed later in life or at the time of a facelift procedure. A simple elevation of your nasal tip will result in a younger and more attractive appearance to your nose.

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“Modern nasal reshaping techniques have made the typical overdone looking ‘nose job’ a thing of the past.”

The concept of nasal refinement and reshaping has changed dramatically over the past few decades. In former years, the operation was considered a “reduction rhinoplasty,” thereby effectively reducing the size and projection of the nose. A large amount of cartilage was removed which led to the typical “nose job” look of the past. Today, we limit the amount of tissue that is removed and focus more on repositioning the existing cartilage into a more pleasing shape to give a more natural looking nasal correction. Modern rhinoplasty techniques for suturing cartilage, molding existing cartilage, and adding cartilage allow us many more options for reshaping the nose. Instead of erasing all signs of ethnic origins, many people today prefer to preserve some of the character and ethnic qualities of their natural noses while undergoing only subtle refinements. The major limitations in terms of what you can expect as a result of a rhinoplasty procedure have to do with your skin type, skin thickness, the thickness and position of your nasal bones, as well as the skill of the surgeon you select. We first examine the nose externally and make note of deformities, deficiencies, and asymmetries. All details about the shape of you nose and its relationship to the chin and lips are important and will be taken into account. Next, we perform an internal exam using a lighted nasal instrument which will allow us to look into your nostrils and see the shape and position of your septum, as well as the presence and degree of your nasal airway blockage.

How Is It Done? Rhinoplasty can be performed under general or local anesthesia with intravenous sedation. The incisions are usually made inside the rim of your nostrils. In some cases, tiny, inconspicuous incisions are also made across the bridge of skin separating your

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nostrils. The soft tissues of your nose are then separated from the underlying structures, and the cartilage and bone causing the deformity are reshaped. The exact nature of the sculpting depends on your particular problem and what you would like changed. If your nose is being reduced in size, your nasal bones will be carefully fractured inward at the conclusion of the procedure. If your nose needs to be built up in certain areas, grafts using nasal cartilage, ear cartilage, rib cartilage, or bone may be used. Other materials can also be used to build up the shape of the nose if necessary, including synthetics like silastic implants, human tissue grafts like AlloDerm®, or cartilage grafts from a tissue bank.The skin and soft tissues will redrape themselves over your new bony and cartilaginous framework. Breathing problems may be corrected at the same time by a procedure called septoplasty, in which the obstructed airway is opened. Generally, a splint is placed on the bridge of your nose to maintain and protect the newly positioned tissues and structures. You may also have a small bandage placed under the tip of your nose. Packing or soft internal splints are sometimes placed inside the nostrils for additional support and to minimize bleeding. The two basic methods of performing a rhinoplasty include the closed and the open technique.

“There are advantages and disadvantages to both techniques for nasal reshaping, and your surgeon will choose the method best for you based on your nasal anatomy and the changes you want .”

Closed Technique The closed technique does not require any external incisions. All incisions are made along the internal aspects of your nostril or septum. We use instruments that are passed into your nostrils to do the work of resculpting the bones, cartilage, and nasal structures. This is the preferred surgical approach for people who do not require extensive reshaping, especially involving the nasal tip.

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The width of the base of your nose can also be reduced by removing a small amount of tissue along the inner aspect of each nostril flaring during either the open or closed technique.

Open Technique The open technique includes an incision across the columella which is the small strip of skin that rests between your nostrils. One major advantage of this technique is that we can completely expose the internal structures of your nose, and place sutures precisely where they may be required. In general, this method allows us to better visualize the inner structures of the nose and makes it easier to reshape the cartilage so that we can produce a better, more predictable final result. With this technique of rhinoplasty, however, nasal tip swelling may take longer to subside.There is also an external scar associated with the open technique, but it is usually small and relatively well hidden along the underside of the nose.

Jason’s New Nose Sheila brought her 17-year-old son Jason in to see me for a consultation about his nose. When I asked him what he did not like about his nose, he answered very simply, “I just hate it.” Sheila almost cringed at the tone of his voice, but she knew how much it was affecting him. It was too large for his face, overhanging, and had a hump. I reduced the width of Jason’s nose, took the bump off the bridge, and raised the tip slightly. Later, Jason’s mother confided to me that Jason seems more outgoing and confident since his surgery. She said, “Dr. Ablaza, I cannot believe how much of a difference it made in his personality.”

The Recovery Period If your nose is being reduced in size or is being straightened, an external splint will generally be applied for five to seven days. Your

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nose may be packed lightly with gauze that will require removal in one to two days. In most cases, the bridge of your nose and the tip will be taped to help minimize swelling. If your nasal bones were fractured, you may have bruising around your eyes or your eyes may be bloodshot. Bruising usually peaks at 72 hours and subsides within 10 to 14 days. We recommend keeping your head elevated above the level of your heart for the first few days to reduce swelling and make breathing easier. You will be instructed not to get your splint or tape wet. You will also need to be careful about blowing your nose in the first few days. Usually by the end of the first week splints, bandaging, and external sutures will be removed. Internal stitches are self-absorbing so they do not need to be removed. You will have some swelling, pressure, and stuffiness for several weeks, but you can usually resume light activity after a few days. Activities that would cause blood to rush to your head such as bending, lifting, or strenuous exercise should be avoided for several weeks after surgery as they may stimulate bleeding. Contact sports or any activity that may risk inadvertent trauma to the nose should also be avoided for four to six weeks Your nose may be numb, and we recommend the use of broad spectrum sun protection for several months as numbness of your nasal skin will make it more prone to burning after surgery. The swelling will take the longest (up to 6 to 12 months or longer) to settle down in the tip. If your nose has been operated on previously, the swelling may take even longer to settle down completely. In general, the thicker your skin, the longer it will take to see the final shape, especially at the tip.

What Are the Risks? A small amount of nasal bleeding or oozing is common after rhinoplasty. In the rare occasion when it becomes excessive, you may be required to return to the office or the hospital to have your nose packed or a blood vessel cauterized. Infection is also possible but unlikely. Some irregularities of cartilage and bone are to be

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expected and are present in all noses. Secondary nasal surgery to correct small irregularities or asymmetries should not be done for a period of at least 6 to12 months after the initial surgery, so that swelling is completely resolved and all the tissues have healed.

Changing the Shape of Your Face

“When there is a weak chin, adding projection can greatly enhance the contour of the facial structures and bring the face into better balance.”

Facial lines and contours are determined by the skin and tissues beneath it, including the thickness and quality of fat, the thickness of muscle, and the shape of bone. Facial implant surgery is performed to build up various facial features to give your face a more balanced appearance. Implants are placed under the skin, or bone is moved to build up contours, or bone is shaved down to modify contours. Typical regions of contour change include the cheekbones, the jawbone and chin, as well as the lips and the nasolabial creases. More than one region may be treated at one time. To augment a facial contour, a non-reactive synthetic material is implanted deep below the skin’s surface and secured with permanent stitches into surrounding tissues so it does not move.There are a wide variety of implant materials, shapes, and sizes available including silicone-based materials and human tissues. Facial implants are typically made of solid and semi-solid materials, as opposed to gel or saline filled implants used in breast augmentation.

How Is It Done? Chin, cheek, and jaw reshaping is an outpatient procedure performed under local anesthesia along with intravenous sedation or general anesthesia, especially if other procedures will be done simultaneously.

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Cheek Augmentation Malarplasty is the term for the augmentation or reshaping of the cheeks. In cheek augmentation surgery, implants are used to enhance the underlying structure, which affects the overall balance of facial features. Cheek implants may sometimes be used together with other facial implants, particularly chin implants. In some cases, prominent fat pads in the cheek area may be removed to improve facial contours. This can be done in addition to or as an alternative to adding cheek implants. Cheek augmentation involves placing the implant over your cheekbone through an incision made inside your mouth, the outer part of your cheek, or through an opening in your lower eyelid just beneath the lower eyelash line. We create a pocket in the tissue and then place the implant directly on the cheekbone. The incisions are closed with resorbable sutures that dissolve in a week or two. At the conclusion of the surgery, your face is usually dressed with an elastic bandage to reduce swelling.

“Beauty is not only skin deep. The underlying bony contours contribute significantly to facial beauty, balance, and harmony.”

Chin and Jaw Reshaping Mentoplasty and genioplasty are terms used to describe chin surgery that involves the augmentation or reshaping of the chin. Adding a chin implant to your facial profile is particularly effective when it is done in combination with facial recontouring surgery such as face and neck lifts, rhinoplasty and liposuction of your neck and jowls. Chin augmentation is usually performed by inserting a silicone implant under the skin. Most often, the incision is made beneath your chin in a natural crease and closed with sutures that are removed in five days. The access incision can also be made inside your mouth, where the lower lip meets the teeth, and then closed with resorbable sutures. The intra-oral approach does not leave an

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external scar but there may be a higher incidence of infection as the implant is placed through a non sterlile field. At the end of the surgery, your chin is often taped to minimize swelling, and a compression strap is worn. To insert jaw implants we make incisions inside your mouth on either side of the lower lip. The incisions are closed with dissolving sutures. The size of your chin can also be increased without using an implant by modifying the underlying bone contour. This involves using power instruments that cut the bone, and then moving the bone of the chin forward to reshape it. This operation can also be performed in conjunction with nose surgery as well as liposuction of the face and neck. Chin reduction is accomplished in a similar fashion by cutting and repositioning the bone farther back. Another way to approach reshaping of your chin and jaw is with orthodontics, which can correct malocclusion and misaligned teeth that will significantly change the overall shape of your face. Fat transfer and other filling substances can also be used to augment your cheeks and chin. Sculptra® is soft tissue filler that has had more widespread use in filling large deficit, and for enhancing the contour of the cheek and temple area.

Tina Gets a New Chin When we met Tina, she was turning 30 and was very shy. She had her nose operated on when she was teenager, and at the time, the surgeon suggested a chin reshaping procedure which really frightened her because it involved breaking her jaw and advancing her bones to add the projection that she was lacking. Even though she did not like the idea at the time, she regretted not doing it because she still hated having a small, narrow chin. She felt that it made the rest of her features look too small. For her 30th birthday, her boyfriend, who was tired of hearing her talk about her chin, decided to give her the surgery as a present. Tina came to see us with the idea of undergoing major surgery in mind. When we explained that we could just place a solid silicone implant through a 76 BEAUTY IN BALANCE

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tiny scar under her chin, which would take half an hour in the operating room under twilight anesthesia, she was delighted. It made a big difference in Tina’s self-confidence and for the first time, she actually felt pretty.

What Are the Risks? Possible adverse consequences of facial implants include: implant extrusion, capsular contracture, asymmetry, infection, bone erosion ,and sensory changes. An implant that is too large or has inadequate soft tissue coverage may gradually resurface through the original access incision or through a new site. Capsular contracture, which is abnormal tightening of the scar tissue that normally forms around the implant, can cause distortion of the implant. A facial implant is sometimes placed improperly or may shift slightly out of alignment, and a second operation may be necessary to replace it in the proper position. If an infection occurs, you are given antibiotics and the implant is temporarily removed and replaced at a later date. There may be instances where underlying bone may gradually erode and become thinner under cheek or chin implants. An area that is operated on may also develop numbness that resolves after several months, although long-term numbness is a potential complication. In rare cases, nerve damage may occur if the implant is resting on one of the facial nerves.

What to Expect Afterward After facial implant surgery, swelling can be significant and usually peaks 24 to 48 hours afterward.You will be instructed to keep your head elevated as much as possible in the first few days after surgery. Applying cold compresses will reduce swelling and discomfort. Swelling and bruising can also be minimized with the application of tape or an elastic band for about a week after surgery. The treated area may feel tight and stiff and moving your mouth may be difficult initially following the surgery. It is normal to have some difficulty talking, eating, and smiling for several days followSurgery on Your Face

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ing the surgery. If you have surgical incisions inside your mouth you will need to be on a liquid diet for several days. Removable sutures are used for incisions under the chin and are taken out after five to seven days. You can return to work in one to two weeks, and resume exercise in three weeks. We recommend avoiding contact sports or any activity that may result in your face being jarred or bumped for several weeks. Although most of the significant swelling will subside over the first several weeks, mild swelling may remain for months before you can see your final facial contours.

Ear Reshaping Surgery (Otoplasty) Ear surgery, or otoplasty, is usually performed to reposition prominent ears closer to your head or to reduce the size of one or both of your ears that are too large in proportion to the size and shape of your face. Ears are considered to be almost fully developed by the age of five. The operation is most commonly performed on children between the ages of five and 14. In some cases, the surgery is done by age five or six so the child avoids teasing and ridicule from other children before entering school. Ear surgery is also performed on adults, however the firmer cartilage of fully developed ears does not have the same capacity for reshaping as children’s ears do. When the surgery is performed at a young age, the pliable cartilage is easier to reshape. A variety of other ear problems can be improved surgically. We can reconstruct under-developed ears and ears which have been physically damaged due to injury or trauma. Surgery can also improve large or stretched earlobes or lobes that have large creases due to aging or from years of wearing heavy earrings. It is very common to have an earlobe repair or earlobe reduction done in conjunction with facelift surgery.

Michael’s Ears Michael is an adorable eight-year-old boy whose ears were ringing with all of the name calling and mean-spirited 78 BEAUTY IN BALANCE

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taunts he heard on a daily basis from his classmates. He was tired of being called “Dumbo,” and Michael’s parents were distraught. When they came to see us, we immediately addressed their fears and explained that he was a great candidate for otoplasty and that many children have it done before entering school to avoid the teasing. He was scheduled for surgery over winter recess, and he was able to recover at home and return to school with a new energy and a real sense of confidence. Michael is a perfect example of how a cosmetic procedure can change the quality of a person’s life, which is especially important at an early age.

How Is It Done? Otoplasty is usually performed as an outpatient procedure under general anesthesia or local anesthesia with intravenous sedation. The surgical technique recommended will depend on your anatomy and the specific cartilage excess, deficiency, or deformity. One of the most common techniques involves making a small incision on the back of your ear to expose the ear cartilage. The cartilage is bent back toward your head, and sculpted into the desired shape. Excess cartilage may need to be removed. When the procedure is complete, there is a more natural-looking fold to the ear. Sutures are put in to anchor your ears until healing occurs. Permanent or dissolvable stitches may be used to help maintain the new shape of your ears. When only one of your ears appears to protrude, we usually perform surgery on both ears to create a good balance. Even after undergoing an otoplasty, there is no guarantee that your ears will be perfectly symmetrical.

What to Expect Afterward Both adults and children are usually up and about within a few hours of surgery. Your head will be wrapped in a bulky bandage immediately after the surgery to promote the best molding and healing. Soft dressings put on your ears will stay on for a few days Surgery on Your Face

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and then the bulky bandages will be replaced by a lighter head dressing similar to a headband. We recommend wearing the headband continuously for two weeks after the procedure to hold your ears in the correct position. Stitches are usually removed, or will dissolve on their own, in about one week to 10 days. Most people have mild to moderate discomfort following surgery. Your ears may throb or ache a little for a few days. You will be instructed not to put any pressure on your ears when sleeping, if possible. Any activity in which the ear might be bent should be avoided for one month. Children can go back to school after one to two weeks, but they should avoid physical activity and sports for at least a month. Ear surgery will result in a faint scar on the back of your ear which will fade with time. The scar is placed along a natural crease behind your ear and is usually well hidden and difficult to notice. Most people can wear their hair back or up without a problem after surgery.

What Are the Risks? A small percentage of people may develop a small collection of blood underneath the skin on their ear. It may dissolve naturally or can be drawn out with a needle. Occasionally people develop an infection in the cartilage, which can cause scar tissue to form. Infections are usually treated with antibiotics, and in rare cases, surgery may be required to drain the infected area. It is always possible to have an asymmetry between the ears, with one being higher than the other, or one being closer to the head than the other. In these cases, additional surgery can be performed to adjust the position of your ears.

Combining Procedures

“The whole effect is always greater than the sum of its parts.”

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Facelift and eyelid surgery are a natural pairing to be performed together because the beneficial effects from one enhances the other. Working in the same area of the body keeps surgery time down and the recovery time is no longer than for either procedure alone. Dressing changes and head elevation are required for both procedures so most of the instructions after surgery are the same. Rhinoplasty and chin enhancement surgery are another classic combination. In fact, it is quite common for people who are interested in nasal reshaping surgery to have a “weak” chin, and many people that come to the office for chin augmentation have a large “hook nose,” often with a hump. A small chin often leads to an unbalanced facial profile whereby your nose appears larger and longer. When these surgeries are done together, your entire facial profile becomes balanced. When necessary, neck liposuction also can be added to complete your profile correction. Brow lift and eyelid lift can be performed in combination when you have excess eyelid skin and droopy brows at the same time. The same area of the face is being addressed which makes the surgery more efficient. The care and instructions after surgery are also similar. When both your eyelids and eyebrows are lifted, your entire upper face can be rejuvenated at the same time. For people choosing less invasive options, Threadlifts® are great to do in combination with non-surgical procedures such as Botox® to relax the muscles, soft tissue fillers for fine lines and folds, and skin resurfacing treatments. Here too, the combination of new techniques and technologies helps strengthen the effectiveness of your rejuvenation.

A Letter From Gail Dear Dr. Rosen: When I entered your office three years ago I had little knowledge of what to expect. My eyes had become so heavy it was difficult to feel “awake” by the afternoon. Little did I know, that day was the start to a whole new outlook on life. It was at that meeting that we decided to do a facelift and eye lift. I will never forget the day of surgery when you came Surgery on Your Face

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into the room with your “marking pen,” when you started to mark my face for the surgery I could see the excitement and anticipation on your face. It was at that moment that I knew I was going to be very happy with the results. That day started the transformation. Your staff has always been so attentive and kind. No question I asked was too trivial, and I could always feel the caring. Well, that surgery was so successful it prompted me to take a look at the rest of my body—from the neck down. It jump started me on a diet and exercise program and a new outlook on turning 50. One year later and I was back in your office talking about ways to remove the excess stomach which my last two children had left me with. That led to a tummy tuck and a breast lift. After a swift recovery, I could not believe how terrific I felt. Not only did I look good, I felt great. I could wear clothes that I could only dream about before. That surgery prompted me to become the best I could be. I got a personal trainer and really started to pay attention to detail. Here I was, 51-years-old, and I felt better than I had at 30! This past year saw even greater improvement. A little liposuction, some Botox, some additional fine tuning and I finally reached my goal. I went from a size 16 to a size 8 in three years. But that was not the best part—I have changed my whole lifestyle. I have more energy and confidence in myself now. Your continued encouragement helped so much throughout this wonderful journey. Thank you so much Dr. Rosen for all you have done for me. Sincerely, Gail Gail’s story is so compelling because she took charge of her process. She was an active participant through a series of staged procedures that were carefully thought out and planned appropriately. Each stage involved a combination of procedures and they fit in well with her lifestyle changes. Diet, exercise, and healthy choices together with surgery make it a winning proposition for the patient and surgeon alike.

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CHAPTER

7

Recontouring Your Body “Body contouring and liposuction are all about shape and inches, not about weight.”

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The emphasis that modern society has placed on physical attractiveness and a lean, youthful body is largely responsible for the increased demand we have seen for procedures to trim excess fat and get rid of unsightly bulges. Genetics, life-style, disease, and diet all influence body shape and appearance and explain the diverse body configurations we see around us. In addition to these factors, pregnancy, weight fluctuations, and changes associated with aging have effects on body shape, skin tone, and skin elasticity. This chapter will cover the methods of modifying your body shape by removing unwanted fat, tightening loose skin, or both. Liposuction and tummy tucks are not meant to be substitutes for weight loss. In general, you do not lose a significant amount of weight as a direct result of body contouring surgery. Actually, it is unusual to remove more than five pounds of loose skin from the abdomen or thighs during tummy tucks or thigh lifts, and the fat removed during even a large volume liposuction procedure never weighs more than a few pounds. You do get some indirect weight loss from these procedures though, as visible contour improvements can be a strong motivational factor for you to stick to a diet and exercise regularly. It not usual to quote people the number of dress or pants sizes that will be lost with a given procedure, but rest assured that body contouring procedures will trim inches from your hips, abdomen, and thighs, which translates into clothing fitting and looking better and to you feeling more comfortable. Results after body contouring surgery are always better when you are closest to your ideal body weight, and it is a good idea for your weight to be stable for several months before surgery. If you are planning to lose a significant amount of weight later, you should also discuss this plan with your doctor since losing a substantial amount of weight after body lifts, tummy tucks, and thigh lifts may negate the tightened and lifted appearance that was achieved by surgery. In general, it is also best if you can get rid of as much extra fat as possible with diet and exercise before undergoing liposuction as it makes contouring easier.

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Removing the Fat

”Liposuction is the surgeon’s method of sculpting the body contours.”

Liposuction is the most common cosmetic surgical procedure performed in the United States today and works best for getting rid of localized fat deposits and unsightly bulges from many different areas of the body to improve shape and contour. Liposuction has come a long way since its introduction in the mid 1970s and modern techniques have made it safer and simpler for both surgeons and patients. Fat cells play numerous roles in metabolism. Fat cells serve as a storage depot and an energy source, and they interact with insulin and participate in hormone synthesis. Adult fat cells are thought to be incapable of multiplying. There are a fixed number distributed in a genetically predetermined fashion throughout the body when you are born. As you age and gain weight, these cells expand. As you lose weight, the cells become smaller but the number and distribution remain essentially unchanged. In rare cases of extreme obesity, new fat cells may be produced. Ideal candidates for liposuction are people at or close to their ideal body weight who want to improve specific contours of their body that they have not been able to change with traditional diet or exercise. We commonly see people in our office who exercise regularly and are in relatively good shape but who cannot get rid of the “love handles,”“saddle bags,” or “spare tires.”These areas are what we call exercise and diet resistant fat that are the result of your genetic makeup.You may have noticed the same pear-shaped bodies, heavy thighs, and full rounded tummies in several members of the same family.These “genetic” fat deposits respond well to liposuction.

Laura’s Love Handles When Laura came to our office, she assured me that I had never seen a pear-shaped body like hers. At 28, she had

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spent most of the last ten years becoming creative with her wardrobe to hide her large hip and thigh area that did not seem to match the rest of her body. She was always a good weight for her height but still worked out regularly. The fat just seemed to be in the wrong places. When she lost five or ten pounds, she noticed her breasts became smaller and her face looked thinner, but it did not change what seemed to be the enourmous size of her hips and thighs. She felt most comfortable wearing blazers and long sweaters in the winter and loose fitting tunics in the summer. And she would always wear a sweatshirt tied around her waist at the gym. Wearing a one piece bathing suit in public was out of the question unless she wore a long, loose fitting T-shirt on top of it. With liposuction I removed nearly a total of five liters of fat from her flank area, outer thighs, and lower abdomen. Even with the swelling and garment in place after the surgery, she could already see the difference in her proportions. She was so happy she wanted to cry, but I told her that was just the beginning. Six weeks later she understood what I meant. At two months after surgery, Laura was no longer a slave to her wardrobe and she was beginning to replace her long blazers and sweaters with cropped jackets and cute tops. She finally felt like her body “fit her.” She left the office saying, “Dr. Ablaza, you’re my hero.” Liposuction can slim the hips and thighs, can flatten the abdomen, and can remove excess fat from the chin, upper arms and breast area of a man. Liposuction can also help to create a more shapely contour to the inner knees, calves, and ankles.The treated areas will retain their new contour as long as you do not have large weight gains.The most popular areas for liposuction in women are the abdomen, hips, and outer and inner thighs. Men most commonly have liposuction on their breast area, abdomen, and love handles. The results of liposuction are permanent, as long as you keep

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your weight stable. If you gain weight after liposuction, you will tend to gain it back uniformly throughout the body. A large weight gain will negate the new contours you achieved with liposuction. There are certain areas of the body, such as the upper arms, abdomen, and inner thighs, that may develop loose or hanging skin following liposuction. The flanks, and outer thighs are areas that respond very well after liposuction and it is uncommon to develop loose skin in these areas. The degree of skin retraction and tightness after liposuction depends on your age, the amount of fat that was removed, where the fat was removed, and your general skin tone and skin elasticity. If there is a good chance that you will have loose skin after liposuction in a certain area, we may recommend a skin tightening procedure such as a thigh lift, tummy tuck, or upper arm lift instead of liposuction. If you do develop loose skin after liposuction, you can have a skin tightening procedure at a later date.

Gina’s Fatty Pockets A former dancer and personal trainer, Gina struggled with weight gain for many years. She had an attractive figure, but at 36 she was unhappy with the excess fat on her hips and thighs, which did not seem to change with diet and exercise. “I cannot tell you how frustrating it is to have spent so many years of my life keeping my body in shape— and helping other women do the same—and to know that no matter what I do, I cannot get rid of these bulges.” Gina was the ideal candidate for liposuction: fit, healthy, and at her ideal weight with large fatty deposits in her hip area and along her outer thighs. We removed more than one and a half liters of fat with liposuction, and because she was young and had good skin tone, she had no problem with excess or loose skin. Now Gina looks great and feels great, and she has begun to dance again. Although liposuction is an effective method for removing localized fat deposits, it does not eliminate wrinkles, it is ineffective

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in removing cellulite, it does not tighten loose skin, and it cannot remove the fat that lies underneath the muscle layer. We will first look at your general body shape and the location of excess fatty deposits and bulges. We must be able to pinch at least an inch of tissue in order to expect improvement in an area. The reaction of your skin to pinching also indicates your skin elasticity: inability of your skin to rebound when it is pinched means it has poor elasticity. We will make notations of stretch marks, indentations, irregularities, and asymmetries. At the initial evaluation, we will also discuss your lifestyle, including eating habits, exercise routine, and weight. If you are mildly or moderately overweight, it is best to have liposuction of multiple areas in stages but if you exceed your ideal weight by 50 percent or more, you need to lose weight prior to undergoing a liposuction procedure. Liposuction of multiple areas should not exceed five liters of total fat removed in the outpatient setting and 10 liters for people who plan to stay in the hospital overnight.

Tumescent Liposuction Compared to decades ago, all modern liposuction is performed using a technique that involves injecting fluid containing a local anesthetic and epinephrine, a medication to minimize bleeding, into the targeted collection of fat before performing liposuction. This fluid causes the area to be numb and also creates a wet environment for the fatty tissue that has now been expanded, making it easier to remove with the vacuum apparatus. The epinephrine constricts blood vessels in the place where we are working so there is less blood loss. For a small amount of fat removal, the tumescent solution injected into the treated area may be the only anesthetic you are given, but it can be supplemented with intravenous sedatives if necessary to put you in a sleepy state. General anesthesia may also be used for longer procedures involving large fat collections or when multiple smaller areas are treated in the same session.

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Traditional Liposuction (Suction Assisted Lipectomy or SAL) The original method for removing fat through small incisions using hollow metal tubes attached to a vacuum system is known as traditional liposuction or suction assisted lipectomy. The metal tubes or cannulas are blunt-tipped to prevent cutting through the skin or damaging tissue beneath the skin. They come in various shapes, lengths, and sizes and have highly polished surfaces to slip through fatty tissue with minimum friction or damage.

Ultrasound Assisted Liposuction (UAL) Ultrasonic sound waves, like shock waves, are transmitted into the fatty tissues from the tip of the solid cannula probe. The fat cells are first melted or liquefied by the ultrasonic energy and then vacuumed away using hollow metal tubes. Ultrasonic liposuction is usually reserved for more difficult areas to contour where the fat is denser, and thus harder to extract; i.e. back rolls, breast area in a man, and previous areas treated with liposuction that may be scarred. It can be combined with traditional liposuction when both the deeper fat and more superficial fat are being removed.

Power Assisted Liposuction (PAL) One of the latest advances in technology for liposuction is the addition of power. The cannulae used are motor-driven and move back and forth, creating a “double-action” mechanism which makes removing fat easier and faster for us. The primary advantage of this technique is that there is less physical exertion required for us to remove the fat and therefore, sculpting of the fatty bulges is more controlled.

VASER® Assisted Liposuction The VASER® system utilizes probes with a grooved design and continuous bursts of ultrasonic vibrational energy to selectively target fat cells which are then removed by suction. All of the modern methods of liposuction are equally effective

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in removing fat. Whichever technology is ultimately used is less important in the overall result than the aesthetic eye and expertise of the surgeon.

How We Perform Liposuction The principle of liposuction is very simple: excess fat is “vacuumed away” from target areas through small skin incisions using a hollow metal tube attached to a suction apparatus. First we make small incisions through the skin approximately one-quarter-inch long at the sites where fat is to be removed and a wetting solution is infused to provide anesthesia, reduce bleeding, and make fat removal easier. We use different sized cannulae, which are the hollow, tubular instruments with holes at the end to trap the fat. The cannula is attached to suction tubing through which the excess fat is evacuated. In the ultrasonic technique, a solid metal cannula or probe first delivers the energy to liquefy the fat, and then a hollow cannula aspirates the liquid fat. The cannula is inserted through the skin openings and moved in a back and forth and criss-cross fashion while the fat is suctioned through one or several holes at the tip. The blood vessels and nerves are usually pushed out of the way of the cannula and are thus protected. We frequently stop during the procedure to check for the smoothness of the contour and symmetry. The procedure is completed when the desired contour has been achieved. A major benefit of liposuction as a method of contouring your body is that the scars are small and usually located in inconspicuous areas. The small slit-like openings for the liposuction cannulae can be placed in hidden areas like the upper skin fold of the navel, in the crease under the buttocks, and inside the knee, so they are well concealed. These scars generally heal well and they are rarely a problem.

What to Expect After Liposuction Most people have liposuction on an outpatient basis and go home the same day. For large volume procedures, it may be recommended that you stay overnight in the hospital. The discomfort

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after liposuction feels like deep bruising and aching, similar to the feeling of a hard gym work-out when you are out of shape. Swelling, bruising, and numbness occur to a varying degree in all treated areas but gradually improve until there is complete resolution. Swelling travels down toward your feet with gravity so it is not uncommon to be bruised and swollen in places where liposuction was not performed. You will have snug fitting compression garments on treated areas to help control swelling and bruising that should be worn full time for at least two weeks and maybe longer for more extensive procedures.Your face, feet, and hands may swell up from the fluid you receive during the procedure, but this should resolve in a few days. Many people can return to work or limited activity within a week, and can resume an exercise program in 10 to 14 days. Depending on the amount of liposuction, you may not be able to completely see your new contours for 6 to 10 weeks.

What Are the Potential Adverse Consequences?

“High volume liposuction procedures, in which a large volume of fat is removed at one time, involves a higher risk of all the potential adverse consequences.”

There is a small risk of developing a blood clot in your leg, called a deep vein thrombosis or DVT, after liposuction in any body area. If a clot forms, your calf or thigh will get tender and your entire lower leg may swell. The danger is that this clot may break free and travel to the lungs and impair your breathing, called a pulmonary embolus or PE. Specialized inflatable stockings that massage your legs are used during surgery to prevent a blood clot from forming in the deep veins of your legs. A fat embolus can occur when a bit of fat travels in the bloodstream to the lungs and blocks breathing. A fluid collection called a seroma, can also develop especially after the ultrasonic technique, and is more common in the abdomen and male chest area. In rare cases, we may need to drain the

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excess fluid in the office to relieve pressure. Infection is extremely unlikely and is treated with antibiotics and local care. Specific risks from the tumescent technique include rare occurrences such as pulmonary edema, which is a collection of fluid in the lungs that builds up if too much fluid is given. Another potentially serious complication can arise from high levels of local anesthetic when a large amount of the solution containing lidocaine is used. In about 10 percent of people, minor touch-ups and revisions may be done six months later for skin irregularities, asymmetries, and residual bulges. Rarely, you may need the addition of some of your own fat to areas that are depressed or indented.

Tummy Tuck (Abdominoplasty)

“A tummy tuck eliminates excess skin and fat, narrows your waistline, gets rid of stretch marks on your lower abdomen, and improves the appearance of your navel.”

Abdominoplasty, commonly known as a “tummy tuck,” is a way to contour your body by removing excess skin and fat from the middle and lower part of your abdomen while also tightening your abdominal wall muscles. At the same time, your waistline becomes better defined and a large floppy navel or one that has the appearance of a horizontal slit or a frown can be converted into a small oval-shaped navel. Stretch marks and old scars that are located below your navel will be eliminated since they are part of the abdominal wall tissue that is discarded. The best candidates for a tummy tuck are people who are in relatively good shape, with loose abdominal skin. Women whose abdominal muscles and skin have been stretched out from multiple pregnancies, as well as older women and men who have a loss of skin elasticity due to age or weight fluctuations, are excellent candidates for abdominoplasty. If there is a thick layer of fat on the abdominal wall, especially along the upper part, liposuction may be required at a second

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stage after an abdominoplasty removes loose skin and tightens muscles. Liposuction can also be performed at a separate procedure before abdominoplasty to thin out the fatty layer. We recommend that women who are planning future pregnancies should wait to have a tummy tuck, as the vertical muscles in the abdomen that are tightened during surgery will tend to separate again during pregnancy. Also, newly tightened skin will be stretched out with future pregnancies. We first look at the shape of your abdomen and take note of your skin tone, the thickness of your fatty layer, the presence of overhanging skin, and the condition of your underlying muscle layer. At the same time, the contours of your upper back, hips, and thighs are assessed. Following the initial consultation, we may suggest other treatments or procedures that will more effectively meet your ultimate appearance goals, even if you came to the office for a tummy tuck. For instance, liposuction of the abdomen may be all that is needed or perhaps a more limited procedure such as a mini-abdominoplasty would be more beneficial than a full tummy tuck.

Relative contraindications to abdominoplasty due to increased risks for impaired skin circulation include: • previous surgery with extensive scarring above the level of your navel • a history of heavy cigarette smoking or long term exposure to second-hand smoke • heart or blood vessel disease • morbid obesity

How We Perform Tummy Tucks A tummy tuck is nearly always performed under general anesthesia, but under special circumstances may be performed under other types of anesthesia. We usually perform abdominoplasties in our surgicenter as an outpatient, but some people may prefer a hospital setting where they can stay overnight for recovery. Recontouring Your Body

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Traditional or Full Abdominoplasty The most common technique involves an incision made across the lower abdomen, just above the pubic hair line, extending from one hip to the other. This incision can be angled higher or lower on the sides to make it easier to conceal, depending on whether low rise pants or high cut bikinis are more desirable. We make another incision around the navel to free it from surrounding tissue. We then separate the skin from the abdominal wall all the way up to your ribs and lift a large skin flap to reveal the vertical muscles in your abdomen. These muscles are tightened by pulling them close together and stitching them into their new position. The skin flap is then stretched down and the extra skin and attached fat is removed. A new opening is made for your navel to keep it in the same position. The incisions are closed with dissolvable sutures, and surgical strips are placed over the incisions followed by a gauze dressing.

Mini-Abdominoplasty People who are good candidates for a mini-tummy tuck usually have excess skin and fat only below the navel and otherwise have firm, flat abdominal muscles. In a partial or modified tummy tuck, the incision is much shorter and the navel may not need to be moved. The abdominal skin is lifted up only from the top of your pubic hair line to your navel. We stretch the skin flap down, remove the excess tissue, and then stitch the flap back into place. There are only a limited number of people who qualify for a miniabdominoplasty. Most women after pregnancy have stretched out their muscle and skin above their navel, as well as the skin and muscle below their navel. Unfortunately, a common mistake is made by people who want a mini-plasty who would have a better result with a full abdominoplasty.They request a “smaller” procedure in an effort to avoid what they perceive to be a more invasive procedure. In fact, a more complete procedure (full abdominoplasty) will be the most satisfying for them which includes repair of the abdominal wall muscles and removal of excess skin above the navel. The scar length and location usually ends up being very similar for both procedures. Unfortunately, limited incision mini-plasties usually leave excess skin on either end of the incision site which gives the

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appearance of what we refer to as “dog ears.”This is an example once again of matching the right person to the right procedure as the only way to achieve a satisfactory result. Sometimes doing less is more, but other times it may not be the correct choice.

Jessica Gets a New Shape and Gets Back Her Old Confidence Jessica was a 28-year-old mother of 14-month-old twin boys who worked in an office full time. She had gained more than 60 pounds with her pregnancy and had lost 25 to 30 pounds since the twins’ birth with diet and exercise. Her main concern was her protuberant abdomen with overhanging skin and the bulging areas around her hips. She thought she still looked pregnant! A tummy tuck tightened up the stretched out abdominal muscles and got rid of the overhanging excess skin and fat. Simultaneous liposuction of the hip area accentuated her slimmer waistline. I was pleasantly surprised when Jessica showed up in the office approximately 15 months later looking fabulous in her low rise jeans. She was motivated enough after her surgery to lose another 25 pounds and she has a personal trainer twice a week to help keep her toned. Now she was ready to lift her sagging breasts. A breast lift gave her tighter, uplifted breasts that looked much more youthful and balanced with her tighter abdomen and thinner waist. Jessica’s figure has been transformed and she finally feels that she has returned to her pre-pregnancy shape.

A Letter From Jessica Dear Dr. Ablaza, I can never thank you enough but hope you will know how much you have done for me. You always have been kind, reassuring words for me and make me feel good about myself. You gave me so much confidence back. I never thought I would want to look at my body in the mirror again and now I cannot stop! My husband thanks you also. He has his confident wife back! Sincerely, Jessica

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What to Expect After Abdominoplasty After surgery, you will have soreness and discomfort that can be controlled with pain medication and medication to ease muscle spasms. Bed rest is recommended with your legs bent at the hips in order to reduce the strain on the abdominal area. At first you may not be able to stand up straight without feeling a tugging sensation, but it is important to be up and around the next day to decrease the chance of developing a blood clot. Within three to five days of the surgery, the dressing will be replaced with an abdominal supporter that you should wear for at least several weeks. The stitches are self dissolving but we like to keep the stitch line covered with surgical tape for a few weeks to protect it. Two or three drains are usually placed beneath the abdominal skin flap to collect small amounts of blood and serous fluid that may be secreted. The drains are easily removed in the office about five days after the surgery. Post-operative bruising is minimal, but swelling may take up to three months to settle. You may also experience a loss of sensation in the abdominal skin that may take several months to return. If you start out in top physical condition with strong abdominal muscles, recovery from abdominoplasty will be much faster. Most people are able to return to work after 10 to 14 days. Heavy lifting and vigorous exercise should be avoided until you can do it safely and comfortably, at about four to six weeks. It may take nine months to a year before the scars completely flatten, soften, and lighten, but it may be sooner in fair skinned individuals. Avoidance of direct prolonged sun exposure and the use of liberal sunscreen is important for several months after a tummy tuck to decrease the chance of burning the abdominal skin that may have diminished sensation for a while and to minimize darkening of the healing scar.

What Are the Risks? Possible adverse consequences associated with tummy tucks include infection, bleeding, adverse scarring, skin loss, asymmetries, and the need for a secondary procedure. This procedure does produce a permanent scar, which can extend from hip to hip

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but the scar is usually placed so that it will not show under most clothing, lingerie, and bathing suits. Everyone heals differently, and in some cases, the scar may be thick, raised and irregular. Occasionally, you can develop a projection of bulging tissue on the ends of the scar called a “dog ear” which can be easily revised at a later date if necessary. Infections are rare, but when they occur, they are treated with drainage and antibiotics. The risk of blood clots can be minimized by moving around as soon as possible after surgery.

Plastic Surgery Following Massive Weight Loss

“The goal of body contouring in people who have had massive weight loss is to remove as many traces of the previous obesity as possible in a safe manner, and with a minimum of scars, even if it may take a few stages.”

Obesity is measured by Body Mass Index (BMI). BMI is calculated by dividing your weight in kilograms by your height in meters squared or multiplying 703 by your weight in pounds divided by your height in inches. A BMI between 27 and 30 indicates mild obesity, while a BMI of 30 or above indicates more severe obesity with possible health risks. Morbid obesity is indicated by a BMI of 40 or above. The accuracy of BMI as an indication of obesity may vary depending on your muscle mass. Morbid obesity can lead to many other life-threatening conditions including high blood pressure, heart disease, diabetes, and arthritis. Bariatric or weight loss surgery reduces the size of your stomach and/or digestive tract to limit the intake of calories, or to bypass certain parts of your intestinal tract to limit absorption of calories, resulting in massive weight loss over the course of several months or years. Candidates for bariatric surgery include people who have a body mass index (BMI) above 40—approximately 100 pounds overweight for men and 80 pounds overweight for women. But some people with a BMI between 35 and 40 who suffer from adult onset

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diabetes, high blood pressure, severe sleep apnea, or obesity-related heart disease may also be candidates for weight loss surgery. Following substantial weight loss for any reason, people typically have multiple areas of significant skin excess including the breasts, upper arms, abdomen, back, and thighs that can be treated with breast lifts, upper arm lifts, tummy tucks, lower body lifts, and thigh lifts, respectively. Many of these people are also candidates for facial cosmetic surgery including neck recontouring and facelifts. Due to the large amount of excess skin to be removed, usually from several different areas, it is common for people to require at least two or three surgical stages if they want to achieve the best result in the safest manner.

Body Lifts Body lifts are ideal for people who have a significant weight loss and have been left with unsightly loose rolls of excess skin. It is the most effective technique to restore firm, youthful contours to the body. While exercise is an excellent way to burn calories and lose weight, and to improve muscle mass and tone, it has no effect on loose, hanging skin. Body lifts are essentially “facelifts for the body.” Lower body lifts can address the thighs, buttocks, abdomen, waist, and hips all in one stage. The added benefits are an overall improvement in dimpling and cellulite, as well as an elevation of the pubic area to a more youthful status. Body lifts may also be performed after previous liposuction. If there is skin excess after fat removal, a thigh or body lift may be performed to reduce the amount of loose tissue.

How We Do It Body lift surgery is usually performed under general anesthesia because it involves a large surgical area and can be quite extensive. Simultaneous lifting of the thighs and buttocks is done using incisions that follow a slightly higher line on the hip than a high cut bathing suit. We lift and remove the excess skin and fat down to the muscle. Drain tubes may be placed at the incision to draw out fluids. The lifting surgery can be combined with limited liposuction. Some

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of the scars can be hidden in the natural skin creases and others are at least located in areas normally covered by clothing.

What to Expect Afterward The recovery from a body lift procedure is very similar to a tummy tuck, however, people routinely stay in the hospital for one or two nights after surgery. It is important to walk as soon as possible after surgery to reduce the chance of blood clot formation in your legs. The swelling is mild to moderate, and peaks at two to three days. Surgical drains may be placed for several days following the procedure. For the first week following surgery, you must avoid bending or lifting. Usually the incisions are covered with adhesive steri-strips and surgical gauze. Due to the location of the incisions, it may be impossible for you to avoid lying on them. Changing position at least every 30 minutes and moving around carefully will limit stress on the incision lines. You will likely have several layers of stitches with body lift procedures. Some will be resorbed by the body and some may need to be removed by your surgeon. You will usually be able to shower on the third day after surgery. Moderate pain can be anticipated after this procedure. Areas of numbness near the incisions may occur but usually disappear gradually over several months. Although most bruising and swelling will disappear within three weeks, some swelling may remain for six months and up to a year. After thigh and buttocks lifts, you cannot resume rigorous aerobic exercise for approximately six weeks.

What Are the Risks? Bleeding, infection, delayed wound healing, and skin loss may occur after body lift procedures. In some people, fluid can collect beneath the skin that may need to be aspirated with a needle. Blood clots are also possible after body lift surgery. Most lifts require fairly lengthy incisions and scarring is an important consideration. Even though we attempt to make fine line scars that can usually be hidden under clothing and most bathing suits, thick or wide scars are always possible.

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Ellen’s Body Lift Ellen is an inspirational young woman who has battled with obesity in her late teens and early 20s. She lost 100 pounds and was able to reach a healthy weight of 145 just in time for her 26th birthday. She was very proud of her accomplishment. But when the weight was gone, she was left with a tremendous amount of loose skin that could not be toned with exercise. Ellen was ready to do whatever it took to finally have a body she felt comfortable in. Ellen had not worn a bathing suit since she was 14, so I knew how important it was to her that she be able to show off her new body. We performed a full body lift and an arm lift. Today, Ellen still does a double take when she looks at herself in the mirror. She has never been so comfortable in her own skin.

Arm Recontouring (Arm Lift or Brachioplasty) Arm Lift or Brachioplasty is performed to surgically eliminate loose, hanging skin from the upper arms. Aging, long-term excessive sun exposure and significant weight loss can all lead to a loss of skin elasticity. We will evaluate your upper arms to assess the amount and location of the fatty tissue as well as the degree of skin laxity. In patients with relatively good skin tone, liposuction alone may be all that is recommended for contour improvement. While liposuction can be performed to reduce the amount of fatty tissue in the upper arms, there will be little if any skin tightening effect. Excess fat is generally only removed by liposuction from the inner aspect of the arm through small incisions located along the inner elbow and the posterior aspect of the armpit. If the skin is loose and has poor tone, an arm lift is the only procedure that will lead to a significant contour improvement. Liposuction is commonly performed prior to brachioplasty to maximize the aesthetic result.

Carla’s Batwing Arms Carla came to see us after having lost 80 pounds on her own. She was a 38-year-old college professor at a prestigious university in upstate New York. She had been self-

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conscious about her weight all through her adult life. Through the support of family and friends, and a local nutritionist on campus, Carla won her battle with excess pounds and was determined to keep it off. She had gone from a size 16 to a size 10, and surprisingly, the skin of her hips and thighs had contracted nicely. What she now hated most were her arms. Because of the loose and hanging skin on her upper arms, Carla always wore long sleeved tops and blouses, even in warm weather. She said she would “not be caught dead” in a sleeveless shirt or tank top. During a mid-winter break, she had an arm lift. Although it took months for the pink scars to gradually fade, they are now fine white lines and hardly noticeable. Carla now wears short sleeves and no sleeves whenever possible. She never knew how much fun it could be to shop for clothes.

How Is It Done? In the standing position, we mark the area of excess skin to be removed.We usually place the incision on the inner surface of the upper arm, where it extends from your elbow to your armpit.The pattern of the tissue to be removed is designed in such a way that the resulting scar cannot be seen from the front or back view when your arms are held at your side. Of course, the scar may be visible when you raise your arms. Incisions are sometimes made on the inner and under surface of your arm in a zigzag pattern for better healing. In some cases, skin excision may be limited to the axillary or underarm area. After the excess skin and fat is removed, the remaining skin is brought together and sutured and the incisions are covered with adhesive strips. We usually put drains beneath the skin before closure to eliminate excess fluid, depending on the amount of skin and fat removed. While you are still in the operating room, elastic bandages or some type of a compression garment is applied to help control swelling.

Recovering After Surgery During the first week after the procedure, your arms should be

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elevated as much as possible. Some type of compression garment should be worn at all times except when showering for three to four weeks. We also advise waiting at least three to four weeks before engaging in aerobic exercise and six weeks for any upper arm workouts. Some tightness could remain in the area for up to three months. The scars may remain pink for nine months to one year or longer.

What Are the Risks? The scars from an arm lift are permanent and may be visible in any position other than when the arms are hanging at the sides. Women who have had a mastectomy are advised not to have an arm lift, since the surgery interrupts some of the lymphatic drainage and the combined procedures may cause the arm to swell permanently (lymphedema). People with a history of phlebitis or inflamed blood vessels in either arm should not undergo brachioplasty.

Tightening Your Thighs (Thigh Lift) The skin along your inner thighs typically has less tone and elasticity than the skin along your flanks or even your outer thighs. As a result, aging and weight loss cause the inner thigh skin to become loose. If you have also had excessive sun exposure for many years, the skin on your inner thighs may even be redundant and hanging. Even when you have a thick layer of fat along your inner thigh as well, liposuction alone will not make the skin in this area tighter.

How We Do It We usually perform liposuction of the inner thigh area first to loosen the overlying skin. Then we make an incision along the groin crease where the front of your thigh meets your lower abdomen. The incision continues around your upper, inner thigh and ends in the crease below your buttock. The skin and tissue underneath are then pulled upward until the skin is taut, and the excess tissue is trimmed off. A deep layer of stitches is placed in the strong connective tissue of your thigh and then dissolving stitches are used to close the skin.

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What to Expect Afterwards You will usually have a lower body compression garment in place after thigh lift surgery that you will wear for at least 2 weeks full time, except when showering. There will be generalized discomfort all along the thigh area with a burning sensation along the stitch line in your groin crease at the top of your thigh. As far as positioning, you will find it most difficult to bend forward or sit in a chair as this will put the most tension on the stitches. Standing or reclining flat will be the most comfortable position for the first few days to a week.There may be a tight feeling around the top of your thighs for several months. We recommend avoidance of strenuous exercise or activity for three to four weeks.

What Are the Possible Adverse Consequences? In addition to the unlikely possibility of infection and bleeding, the scars associated with thigh lift procedures may widen if they have not been securely attached to the underlying tissue since there is a lot of tension on these suture lines. Slight indentations, bulges, or skin irregularities are always possible and can usually be addressed with minor revisional surgery.

Combining Procedures When large volume liposuction is performed, it is best to treat specific areas of the body at the same time to maximize the result. For instance, it is best to combine liposuction of your back, love handle area, and abdomen during one session, and your hips, inner and outer thighs, and knees during another session. Liposuction can be performed alone or in combination with skin tightening procedures such as tummy tucks, thigh lifts, and body lifts. Traditional abdominoplasties and mini-tummy tucks are often performed with liposuction of the hips and thighs for complete rejuvenation of that area, both front and back. Thigh lifts are nicely complimented by liposuction of the hips and abdomen. It is relatively common for women to want breast and body contouring procedures after their childbearing years to address the changes in both their breasts and abdomen. We frequently

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perform breast lifts with or without implants at the same time as a tummy tuck. As previously mentioned, we recommended having tummy tucks and breast lifts performed after you have your last child, as future pregnancies and breast feeding may “reverse” some of the tightening and lifting effects of the surgery. It is also a good idea to have returned to your baseline weight and breast size before having any type of cosmetic surgery that involves making changes to your breasts or tummy.

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CHAPTER

8

Breast Reshaping “Skin quality and the amount of breast tissue are important factors to be considered when choosing the most appropriate breast reshaping procedure.”

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Women commonly seek consultation for breast reshaping surgery with stories of spending an enormous amount of money on padded bras, push-up bras, water bras,“chicken filet” inserts, and self-adhering bra cups. Women often complain about limitations in their clothing choices when they feel their breasts are too small, too saggy, or too large. Breast augmentation, lift, and reduction will give you greater freedom with fashion and will usually give your self-image a boost as well. It is always better when you have breast reshaping procedures for yourself rather than to make your spouse or significant other happy. For the purpose of illustration, let us say that breast tissue is represented by a baseball and the surrounding skin envelope is represented by a sock. A breast augmentation means the baseball is exchanged for a softball and the sock remains the same size, resulting in a larger breast. In breast reduction, the baseball is converted to a tennis ball or golf ball while at the same time a smaller sock is created.The end result is a smaller, uplifted breast. A breast lift involves designing a smaller sock for the existing baseball which means that the same sized breasts assume a higher position on the chest wall. All types of cosmetic or reconstructive breast surgery involve possible inability to breast-feed after the surgery, depending on the extent and type of surgery. There may also be temporary or permanent sensory changes ranging from decreased sensation to hypersensitivity. Pre-existing breast asymmetry is common and may also be possible following any type of breast surgery. Patients who are over the age of 35 and are undergoing surgery to reshape the breasts in some way, should have a mammogram prior to surgery (if it has not been done in the past year) to rule out existing abnormalities and to be used as a baseline for future comparison.

Breast Enhancement (Augmentation Mammaplasty)

”The goal of breast enhancement surgery is to achieve improved body proportions and balance, as well as an aesthetically pleasing result.”

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The main reason that women want breast enhancement surgery is a feeling that their breasts are too small. They may have always had inadequate breast volume or they may develop small breasts after pregnancy, breast-feeding, and significant weight loss. Increasing your breast size with implants not only improves your body proportions when you feel your breasts are too small, but can also balance pre-existing differences in your breast size. Implants can rejuvenate breasts that have “deflated” after pregnancy with or without breast-feeding. Breast augmentation is able to correct breast shrinkage from small to moderate weight loss, however massive weight loss almost always results in a large degree of loose skin and sagging that is best treated with a breast lift procedure in addition to implant insertion.

There are a number of issues about breast implants that require discussion and decision making prior to breast augmentation surgery. • Filler material • Implant shape • Surface texture • Access incisions for implants • Location above or below the muscle • Implant size

All breast implants have an outer shell made of a type of solid silicone but the filler material can be either sterile salt water or silicone gel. Silicone gel-filled breast implants are available only for women having breast reconstruction following mastectomy and in women having cosmetic breast augmentation that meets certain criteria. Breast implants can be round, oval, or tear drop-shaped and the outer shell can be smooth or have a rough texture. Implants that are not round are always textured so that the implant “sticks” to the surrounding tissue to minimize the chance of the implant turning upside-down or sideways. Round implants will look the same when rotated in any direction and therefore do not neces-

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sarily need to have a rough surface. In our practice, we use round, smooth saline implants for women having straightforward breast augmentation surgery, but there are specific occasions when we might choose different shaped and textured implants. Three incisions are most commonly used for breast implant placement during breast augmentation: in the armpit (transaxillary), along the areola (periareolar), and under the breast (inframammary). An incision in the hair bearing region of your armpit does not leave a scar on your breast but the resulting scar may be visible when you raise your arms. The surgeon’s visualization using the axillary approach is more limited and usually requires a lighted camera on a metal rod (endoscope) that is inserted through the incison during the surgery. A periareolar incision follows the curvature of the lower border of your areola, extending from approximately the four o’clock to eight o’clock position. The scar is usually minimal, but there is limited visualization by the surgeon. There may be a higher chance of altering your nipple sensation. An inframammary incision beneath your breast along the natural crease gives excellent visualization of the surgical area and the scar is hidden by the lower curvature of your breast. Putting implants in through an incision at the upper edge of your navel (transumbilical) must be performed with an endoscope and is seldom used. The location of the breast implant relative to the chest wall muscle is independent of the access incision we use. We can place the implant below the breast gland and above the pectoralis muscle (subglandular) or below both the breast gland and the muscle (submuscular) on the chest wall. Implants in the submuscular position are generally better camouflaged especially in women with small breasts and breast tissue is better visualized on mammograms when the implant lies behind the muscle. We may place implants on top of the muscle when you have a small amount of droopiness to your breast. We most commonly place breast implants in the submuscular

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position and use incisions along the lower edge of the areola or hidden along the lower breast crease. However, implant placement above the muscle and incisions in the axilla or at the top edge of the navel can be performed when you specifically request it. In all cases, we listen to what you want after we have gone over all the benefits and drawbacks of all of the different options for implant shape, texture, insertion sites, and location. The exact implant size is determined on the day of surgery once the implant has been filled with fluid, but we estimate the size of the implant you would like beforehand by taking measurements of your breasts and by having you put implant sizers in a surgical bra while looking in the mirror.

Breast Implants Past and Present The first documented report of breast augmentation surgery dates to the late 19th century, when fatty tissue was transplanted from one area of a woman’s body to repair damage caused by the loss of tissue due to removal of a non-cancerous breast tumor. By the early 1900s, breast enlargement was performed by injecting liquefied paraffin wax into the breast. The combination of paraffin and olive oil used to create an injectable liquid resulted in the formation of hard masses, so that technique was eventually abandoned. In the 1950s, liquid silicone was injected into women’s breasts in Japan to enlarge them, and this method soon found its way to the United States. Before silicone gel, implants used for breasts were hand carved from polyurethane blocks. The first silicone gel implants were developed in the 1960s and were smooth, teardrop-shaped bags with Dacron patches on the backs of them to fix the implant to the chest wall. All implants used today have a solid silicone shell that is either filled with salt water or silicone gel. Other fillers such as peanut oil, soybean oil, liquid silicone, and others have been tried and have failed. Concerns about the use of silicone gel-filled breast implants began to surface in the United States and Canada in the 1980s, and

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then spread to Europe in the 1990s. In 1992, spurred by concerns that silicone gel leaking into the body might harm the immune system, the FDA declared a moratorium on silicone gel use in the United States. Breast implants have been studied more intensely over the past two decades than any other medical device or material, and no link between breast implants and joint problems, connective-tissue disease (CTD) or breast cancer has been found. The chief advantage of silicone is that it feels very natural, more like a human breast. It has a fleshy consistency and “squeeze-ability” like real tissue. When silicone gel implants rupture the gel leaks into the surrounding pocket. Usually it is contained within the scar capsule that surrounds the implant. Sometimes however it can migrate out of the capsule and into the breast tissue causing small areas of scar tissue we call granulomas. The effects of a ruptured silicone implant are localized to the breast and are not known to travel around your body. When saline implants rupture the volume of the breast diminishes slowly over several days or even in the course of a few weeks. The body absorbs the saltwater fluid just like drinking a glass of water and is harmless. However, gel implant ruptures may be silent and no change in the appearance or feel of the breast is noticeable. It is for this reason that recommendations will be made for long-term follow-up in women with gel implants to undergo diagnostic testing such as MRI every five to ten years in order to assess the integrity of the gel implant. Women choosing silicone gel implants must be fully aware of this and weigh the benefits and risks. The newest model silicone gel implants are made of a thicker more cohesive gel material designed to minimize migration of the silicone that has been associated with conventional gels. The implants popular in the 1970s had thinner more liquid-like gel material that were more prone to rupture and migration than the products available today. In fact, a totally cohesive gel implant whereby no gel migration occurs is being developed and is under investigation even today. With this implant even if the outside shell

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breaks down the gel will not leak out over time because the molecules stick tightly together. It is firmer then conventional gel, but may strike the best balance between implant feel and safety.

“Although we are very satisfied with the results we can achieve with saline-filled implants, we are pleased that silicone gel breast implants may soon be available in the United States again so that women can have a choice.”

In July 2005, the FDA issued an “approval letter” with conditions to Mentor Corporation regarding its silicone breast implants. The approval letter stipulates a number of conditions that Mentor must satisfy in order to receive FDA approval to market and sell silicone breast implants in the United States.

How We Do It We usually perform breast augmentation under general anesthesia but it could be done under local anesthesia with intravenous sedation. It is usually too time consuming and impractical to inject local anesthetic over the entire chest wall. First, we make an incision, lift the breast tissue and/or the muscle to create a space or pocket beneath the breast. Then the implant is ready to be placed in the pocket. The most common approaches for insertion of implants include the lower part of the areola, beneath the curve of the breast, and through the armpit. Implants are also infrequently placed through incisions along the navel. The implants can be positioned beneath your breast gland and on top of the chest wall muscle or can be placed beneath the muscle depending on the quality of soft tissue that exists. Placement considerations include the anatomy of your breasts, whether you are interested in breast feeding, and your personal preference. Thin women with only a small amount of breast tissue get a better result when the implant is placed beneath the

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muscle to camouflage the edges of the implant and achieve a more natural look. We prefer under the muscle placement in the great majority of our patients.

What to Expect Afterward Your stitch lines will be covered with gauze and then you will wear a soft surgical bra for protection and support that has no underwire and opens in the front. After five to seven days, the gauze dressing will be removed and we recommend that you wear the surgical bra or an elastic type of sports bra continuously for several weeks. Initially your breasts may appear firm, swollen, and to be sitting high on your chest. As the swelling resolves and gravity comes into play, the implants will sink down slightly and assume a lower, more natural appearing position. You will be told to minimize arm movements and to bend from the knees only as needed. You may be able to resume work within a week or two after surgery, but aerobic activity involving running, jumping, or bouncing should be avoided for three to four weeks. We use absorbable stitches which should dissolve in two to four weeks.

Mary’s Breast Enhancement A former patient who had undergone a number of cosmetic enhancement procedures including breast augmentation brought her 17-year-old daughter to see us. Mary was a very attractive, athletic college-bound young woman, who was also very self-conscious about the size of her breasts. She wore a size 8 and a 34A bra, but she always had difficulty finding dresses and tops that fit her the way she wanted. With summer approaching, she wanted to show off her toned and tanned physique without looking “like a 13-year old boy.” We worked through the pros and cons, and Mary agreed to hold off for one more year. Between

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her first and second year at college, she underwent the procedure. “It is changed my life,” she says. “I wear different clothes, stand tall when I walk, and am confident in myself without being self conscious. It is one of the best decisions I ever made.”

What Are the Possible Risks and Adverse Consequences? Risks associated with breast augmentation can be divided into problems associated with the breast and problems associated with the implants. Infection is rare after breast augmentation and is treated immediately with antibiotics. In some cases, the implant needs to be removed and can then be replaced after the infection has been completely cleared. It is also possible for an implant to rupture due to a flaw in the outer shell. Implant rupture has not generally been associated with manual manipulation, mammograms, flying in an airplane, or scuba diving. Capsular contracture refers to the unlikely possibility that a thick layer of scar tissue forms around the implant causing shape distortion or discomfort. Your breasts can be uneven in terms of size, shape, or position of the implants and this can be adjusted with a small revisional procedure if necessary. Whenever the breast gland has been manipulated, it is possible, but not usual, to have problems with breast-feeding or to have changes in sensation of the nipple or breast skin. Numbness will continue to improve for six to nine months but in rare cases there may be some permanent decrease in sensation. Breast implants are not associated with the development of breast cancer and do not impair breast cancer detection. All breast tissue is never completely visualized using mammograms even without breast implants, which is why it is important to combine mammograms with physical exams, ultrasound studies, and MRI when indicated. There has also never been a definitive association with breast implants and autoimmune diseases, collagen vascular disorders, or joint problems.

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Rejuvenating Your Breasts (Breast Lift or Mastopexy) There are many changes that occur in your breasts following pregnancy and breast-feeding, after substantial weight loss, as a result of the hormonal effects of aging and due to the long-term effects of gravity. These changes affect the size and shape of your breasts and lead to sagging, loss of skin elasticity, and loss of firmness. A breast lift or mastopexy is equivalent to a surgical “Wonder Bra” so that without the support of a bra, the breasts have an uplifted appearance. Although the volume of the breast remains essentially the same, the breasts are raised, the nipples may be repositioned, and there is a tightening of the breast skin to give a more youthful appearance to the breast. Implants can be inserted simultaneously to increase size and firmness. A breast lift or mastopexy is a surgical procedure to raise and reshape breasts that have sagged as a result of pregnancy, breastfeeding, aging, weight changes, and the natural force of gravity. We can also reduce the size of the areola, the darker skin surrounding the nipple. A breast lift can sometimes be combined with the placement of an implant in some cases where volume needs to be enhanced or replaced. Several different techniques can be used to correct this condition, depending on the degree of sagging and breast tissue.

How We Do It First we remove excess skin from around the areola, and possibly also from the bottom of the breast, in order to shift the skin of the breast and tighten the skin envelope. Sometimes we insert additional volume such as an implant for added projection and smoothing of the skin which elevates the position of the nipple and areola to a more youthful position. Breast lift surgery can be performed under local anesthesia with intravenous sedation, or general anesthesia. The standard breast lift has four components: the areola is reduced, breast tis-

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sue is repositioned, the nipple and areola are elevated to a better position, and excess skin and breast tissue is removed so that a new skin envelope is formed. The most common procedure still involves an anchor-shaped incision following the natural contour of the breast. The incision outlines the area from which breast skin will be removed and defines the new location for the nipple. When the excess skin has been removed, the nipple and areola are moved to the higher position. The skin surrounding the areola is then brought down and together to reshape the breast. Stitches are usually located around the areola, in a vertical line extending downward from the nipple area, with or without a suture line along the lower crease of the breast, depending on the method used. In general, the more tissue that is removed, the more shaping is possible. In women with extensive sagging, the skin may be so stretched and thinned that a smaller incision will not allow us to remove sufficient tissue to lift the breast. In these cases, longer incisions may be required. The vertical mastopexy falls somewhere in-between the traditional and minimal scar technique, and is widely suitable for many types of breasts. We often favor this technique because most people like the idea of having less scarring.

What to Expect Afterwards After surgery, you will have minimal pain and bruising. You should wear your surgical bra after surgery around the clock, except when showering, for at least two to three weeks. You may begin to exercise approximately one month after surgery but you should wear a good supportive sports bra whenever you are running, bouncing, or jumping. There may be a slight initial relaxation of the “lift” effect in the first few weeks after surgery, and then your breasts will continue to gradually respond to the effects of gravity over the years. As with all surgery, the final appearance of the scars may take six months to one year to fade, soften, and flatten. It may be necessary years later to have an additional skin tuck to treat the continued effects of aging and gravity.

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What Are the Risks? Possible complications associated with a breast lift include mild asymmetries, scars, and the potential for loss of sensation in the nipple areolar complex. If you are considering subsequent pregnancies, it is generally recommended that you postpone breast lift surgery until after your last pregnancy to minimize the effects of pregnancy on the final outcome.

Reducing the Size of Your Breasts (Breast Reduction or Reduction Mammaplasty) Samantha’s Story “I’ve always been afraid of surgery, so the thought of a breast reduction was my last resort. But after I met with Dr. Rosen, I felt reassured that this surgery would better my life in the way that it would make my body proportionate. When the day came, I could not believe that I had spent six years trying to live with my body, and that after this two hour surgery, my body was going to be the way that I have wanted it to look since I was a little girl…. When I came out of surgery the first thing I did was look down at myself. That was the first time in many years that I had been able to see my stomach. Although I could barely move, I remember feeling at ease about my body for the first time. I would no longer have to wear my tank top over my bikini, and I would no longer spend time crying in the dressing room over the fact that I could not wear the same bathing suits, dresses, and types of shirts that everybody else was wearing. Looking back on surgery, I can safely say that it changed my life forever. Even though I underwent surgery only a couple of weeks ago, it is hard for me to remember how I felt in my body, I was always trying to cover up, and now I almost feel free since there is nothing to hide. On my first trip back to the mall after my surgery I went with my friend who needed a dress for her cousin’s wedding. I looked at the clothes in the windows of 116 BEAUTY IN BALANCE

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the stores that I had always wished I could buy that now I could buy. I found a dress that I’ve always loved but could never wear. Just to see how it would look, I tried it on. For the first time in many years a dress that I had tried on before fit perfectly. I was not small on top and large on bottom and I did not need expensive tailoring or an expensive bra, I could just buy it and go.” Samantha’s story is a very typical scenario for women with very large breasts. There are a number of physical and psychological complaints that bring women into our office for consultations about reducing the size of their breasts. Most commonly, women have neck, back, and shoulder pain as well as shoulder grooves from bra straps and skin irritation beneath the breasts. Disproportionately large breasts can also lead to embarrassment, self-consciousness, feelings of unattractiveness, unwillingness to exercise, and difficulty with clothing. When your breasts are smaller and lighter after breast reduction surgery, you will feel more comfortable exercising to lose weight and tone your muscles. Removing excess tissue from the breast usually leads to reduced neck and back pain and relief from rashes beneath the breast in addition to achieving a more shapely, lifted breast. Breast reduction represents a means to an end to the physical symptoms and discomfort you may have suffered with for years, and oftentimes decades. If you are considering breast reduction surgery, we recommend being as close to your ideal body weight for your height as possible. That way, we can make a more accurate estimate of the amount of breast tissue to be removed which will result in a breast size that is proportional to the rest of your body. Moderate or substantial weight loss following breast reduction surgery may ultimately lead to breasts that are smaller than you planned. Another reason for achieving a certain goal weight prior to breast reduction is related to insurance coverage. One of the criteria used by insurance companies when you go through the process of precertification for breast reduction surgery is a requirement that you are within 10 percent of your ideal body weight. Breast Reshaping

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How We Do It Although we usually perform the surgery under general anesthesia, breast reduction can also be performed under local anesthesia with intravenous sedation. Most often, the incisions for breast reduction are similar to those used for breast lift techniques. Breast reduction surgery is a trade-off between the extent of the scars and the extent of the reshaping and size reduction possible. One of the most common techniques we use for reducing breast size involves an anchor-shaped incision that circles the areola, extends downward, and follows the natural curve of the crease beneath the breast. Incisions outline the area of skin, breast tissue, and fat to be removed, and also outline the new higher position for your nipple. In most cases, we keep the nipples attached to their blood vessels and nerves. Excess glandular tissue, fat, and skin are removed, and the nipple and areola are moved into their new position. We then bring the skin from both sides of the breast down and around the areola to give new shape and contour to your breast. If your breasts are very large or pendulous, your areola may have to be completely removed and grafted, like a skin graft, into a higher position. Dissolving sutures are used to close the incisions, giving your breast its new contour. More recently, we have been using smaller incisions for breast reduction surgery in all but the largest or most droopy breasts. These incisions result in a scar in the shape of a lollipop instead of the shape of an anchor that is the result of the traditional type of breast reduction.

What to Expect Afterward After surgery, you will need to wear a support or compression bra for one to two weeks day and night to keep swelling to a minimum and allow the scars to heal without a pull-down effect of the suture line. You may have drains in each breast to collect fluid that will be removed in the office in one or two days. You may feel sore and stiff, until the swelling resolves over the first several weeks, but there is usually very little pain. In fact, breast augmentation surgery is often substantially more pain-

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ful than breast reduction due to manipulation of the underlying pectoralis major muscle. Breast reduction surgery is performed predominantly on the breast mound, which produces very little discomfort. Most people can return to vigorous activity within three weeks, and we recommend wearing a very supportive sports bra. It is quite common to lose weight after surgery, as women are frequently able to increase their athletic activity.

Jackie’s Chest Jackie was sent to us by her internist for a possible breast reduction. At the time, she was 39-years-old, 4’11’ tall and 132 pounds with a 38DD bra size. She had been suffering with severe neck and upper back pain for years that had only worsened with time. She completely abandoned any type of aerobic activity due to breast pain with jumping and bouncing movements. She had been sleeping at night wearing a bra ever since her late teens when she practically reached her full breast size. Jackie became very emotional and started crying when she described feeling self-conscious about her breasts all her life. She always felt that her breasts were the focus of attention, and she was never sure if men were interested in her or her breasts. After removing almost two pounds of breast tissue from each side, Jackie was beyond thrilled with her new 36C breasts. Not only did she have complete relief of her neck and back pain, but she also was able to exercise more comfortably and ended up losing the 15 pounds that she could never seem to drop. When we saw her in the office two months later, Jackie confided that she was gradually coming out of her shell and felt more comfortable about herself than she had in years.

What Are the Risks? Breast-feeding after breast reduction or lift surgery depends upon the technique used by the individual surgeon. Unless the breasts

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are extremely large requiring an extensive reduction, 50 percent of women can go on to breast-feed. It is rare but possible that the nipple and areola may lose their blood supply and the tissue may develop scabbing and have to be treated while it heals. Another potential complication of large breast reductions that is more common with free nipple graft methods, is the loss of pigment around the areola. This can be improved if necessary with medical tattooing. The procedure can also leave slightly mismatched breasts or unevenly positioned nipples that can be treated with a minor revisional procedure. Breast reduction scars can be lengthy, and they are permanent. They often remain lumpy and red for months, and then gradually fade to thin lines.

Areola and Nipple Reduction An enlarged areola, which is the pigmented area around the nipple, commonly develops after breast-feeding and is usually present in all large breasts, regardless of breast-feeding. When the size of your areola is disproportionately large for your breast, it gives your breast a more matronly or aging appearance. Some men who develop gynecomastia (enlarged breast tissue) will also have a large areola. Because this is a feminized feature, men sometimes want a reduction in the size of the areola. It is standard during breast reduction and breast lift surgery to make the areola smaller to better match the size of your new breast and also to give your breasts a more youthful appearance. Reducing the size of the areola as a separate procedure is more common in men. Nipple reduction, on the other hand, is more often performed as a separate procedure but can also be performed in combination with other breast surgery. Many women will develop large, projecting nipples that in some cases droop following breast-feeding. The nipple itself can be telescoped back into the breast and in this way appear more youthful and balanced for the breast.

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Correcting Nipple Inversion The milk ducts leading to your nipple from within the breast gland can sometimes become shortened for unknown reasons and result in the pulling down of the central portion of the nipple or even the entire nipple, giving it a “turned in” look. Nipple inversion is easy to correct at the same time that another breast procedure is performed but may also be performed under local anesthesia as a separate procedure. Correcting nipple inversion is a safe, simple, and effective procedure that is done as an outpatient surgery. First, we make an incision at the base of the nipple and completely release the tethered ducts that pull the nipple down. Sutures are then placed to maintain the turned-out, elevated nipple in its new position while it heals. After correction of nipple inversion, breast-feeding will be significantly affected and may even be impossible since the milk ducts are severed during the process.

Combining Procedures Breast Reshaping and Tummy Tuck Breast lifts, augmentations, and reductions are commonly performed along with abdominoplasty. This combination of rejuvenation of the breast and abdomen yields a dramatic improvement in the overall body contour, especially following changes associated with pregnancy and childbearing that affect both the breast and abdominal area. Keeping the surgery confined to the trunk area and sparing the head and extremities makes recovery easier.

Breast Reshaping and Liposuction Any procedure on the breast can be performed in conjunction with liposuction. Similar to performing breast surgery with tummy tuck, performing body contouring including breast and fat contouring of the inner and outer thighs, hips, and/or abdomen are an

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excellent way to achieve better balance between the upper and lower trunk. Classically, a person will undergo the liposuction of the inner and outer thighs and hips, and then have a breast reduction or lift. The decision on how many areas of liposuction can be performed safely at the time of breast surgery will be dependent on the volume of liposuction removed from the areas of concern. Guidelines from the American Society of Plastic Surgeons suggest that a five liter liposuction is the upper limit for volume to be removed at the time of a single liposuction procedure as an outpatient. The surgeon must predict and anticipate based on experience and judgment how many areas can be treated based on these numbers.

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CHAPTER

9

Non-Surgical Options for Cosmetic Enhancement

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There are a number of smaller procedures that are easily performed at the same time as facial and body rejuvenation surgery to complement your overall result.These procedures can also be performed in the office setting independently of a surgical procedure. Many of these procedures and treatments are used by people who are not “ready” for surgery yet who want to avoid a “surgical” procedure.

Botulinum Toxin Botulinum toxin was originally used to treat eye spasms and central nervous system disorders, and since the late 1980s, it has been used for cosmetic purposes as well as medical therapies. Botox® (Botulinum toxin A), a natural purified protein made from Clostridium botulinum bacteria,“sticks on” to nerve endings and prevents the release of the chemical transmitters that activate muscles. When injected in very low doses into specific areas of the face and neck, it inhibits the small muscles that cause frown lines, crow’s feet, and other wrinkles that result from making facial expressions. Botulinum toxin treatment weakens muscle activity thereby preventing the appearance of “dynamic” wrinkles that are caused by repeated facial expressions. The toxin acts on the junctions between nerves and muscles, preventing the release of a chemical messenger called acetylcholine from the nerve endings. Tiny amounts of the fluid are injected into a specific facial muscle so only the targeted impulse stops the muscle contractions that are the underlying cause of the unwanted lines. The lines gradually smooth out because of the prolonged relaxation and disuse, and the muscle blockade prevents new wrinkles from forming. Muscles needed for important functions like eating, kissing, smiling, and eye opening are not treated, and their continued function helps to maintain a natural look. Only muscles that are treated with botulinum toxin are affected and there should be no effect on skin sensation in the treated areas. Although botulinum toxin injections can have a dramatic effect on dynamic wrinkles, it has no overall effect on the texture of the skin. We use botulinum toxin most often for treating the creases

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between your eyebrows and across your forehead, but other areas of your face and neck can be treated. Improvements can be seen in a few days but you may not see the final result for up to two weeks. The effect generally lasts from four to six months with the lines gradually reverting to the pretreated appearance. Some studies indicate that after multiple treatments, results can last longer in between treatments. Every person responds differently, and different areas may have longer lasting results than other areas. Some people have a lasting partial effect or memory response, whereby the lines and creases never completely return to their appearance before any injections. First, a thorough assessment of facial wrinkles and creases is performed by examining your face at rest, and then having you perform a number of muscle movements including raising your eyebrows, furrowing your eyebrows, squinting your eyes, and wrinkling your nose.The location and depth of creases are noted and symmetry is assessed. Based on this evaluation, we decide which areas to treat and how much botulinum toxin to use in each area.

How Do We Do It? We perform the procedure in our office and it takes between 15 and 20 minutes. The skin may be treated 20 to 30 minutes ahead of time with a topical anesthetic. A thin, fine-gauge needle like that used in acupuncture is then used to inject the botulinum toxin through the skin and into the muscle of a specific part of the face. Crow’s feet are treated with three or more injections on the side of the face close to the outer eye area or orbital rim. Horizontal forehead creases are typically treated with 10 to 16 small injections, thereby weakening rather than paralyzing the forehead muscles. The muscles that create the vertical frown lines between your eyebrows are treated with four to six small injections.

Paige’s Frown Lines Paige was someone who would never have elective surgery. As a breast cancer survivor she had already been through

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a lot. Paige’s husband kept asking her if she was angry. She was not—in fact, she was quite relieved that her breast cancer was behind her, and she could now go on with her life. By the third time he mentioned that she looked mad, she picked up the phone and called our office. The expression her husband was noticing was nothing more than a deep crease between her eyebrows that sent the wrong signal. We treated her with some Botox® and her crease relaxed after a few days.. When she came back for her next treatment, about four months later, she told us that her husband noticed a change right away. She had not told him that it was the Botox® until he mentioned that she looked “softer” and more “relaxed.” Then, she gave away her secret. Botulinum Toxin can be used to improve but not completely get rid of the folds between the outer part of the nostrils and the corners of the lips, and the fine lines above the lips. Vertical muscle bands in the neck can also be softened with botulinum toxin. When a small amount of Botox® is injected into specific places around the eyebrows, a “chemical browlift” can be achieved, which can cause a change in the eyebrow shape (rounded or peaked) and can even create a mild lifting of the eyebrows. For deeper wrinkles, a combination of botulinum toxin and a filler such as your own fat or Restylane® is often recommended to achieve a maximum improvement. Type A (BOTOX COSMETIC®, Reloxin®, Puretox®)—Botulinum toxin type A is a purified neurotoxin complex that has been used since 1980 to treat ophthalmologic muscle disorders, such as lazy eye, eye ticks, and uncontrolled blinking. A salt water solution is added before use. BOTOX COSMETIC® received approval for cosmetic use from the FDA in the spring of 2002 for glabellar creases. Treating other areas of the face and neck with Botox® is considered off-label usage of the product. Botox® has also been FDA approved for injection into the axilla for treatment of excessive sweating. Reloxin® and Puretox® are undergoing clinical trials in the United States for FDA approval.

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Type B (MYOBLOC®)—Botulinum toxin type B is FDA approved only for neurological disorders causing cervical dystonias, and is not intended for cosmetic purposes.This form comes as a pre-made liquid that does not require addition of a solution to dilute it.

”The beauty of Botox® is that it is quick, safe, effective, predictable, and versatile. It is the most popular non-surgical cosmetic treatment used today.”

What to Expect Afterward Although there is some discomfort associated with the injections, the feeling is much like any other injection or an insect bite, and there is virtually no pain afterwards. You should keep your head upright for four to six hours and avoid massaging the treated area after the injections so that the botulinum toxin will remain in the desired location and will not migrate into other facial muscles. You can return to work and resume regular activities right after the treatment, but strenuous exercise and activity should be avoided for one to two days.

Are There Risks? Treatment with botulinum toxin can sometimes cause a brief headache and occasionally slight redness or a small bruise may occur at the injection site. You can decrease your chance of bruising if you avoid non-steroidal anti-inflammatory drugs and products containing aspirin for seven to ten days before the procedure. A potential adverse effect of botulinum toxin is a droopy eyelid, but this occurs in less than one half of one percent of people. Typically, the droop appears about five days after injection. It may start with a slight droopiness at the beginning, becoming noticeably droopy for a few days, and then gradually improving until it is gone. Certain risk factors can predispose you to this effect, such as having a low eyebrow position. A drooping eyelid or ptosis is tem-

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porary but can take up to six weeks to disappear. In some cases, you may be given prescription eye drops to speed-up resolution of the problem. Botulinum toxin is used in higher doses in deeper muscles of the neck, and it is rare but possible to have difficulty swallowing temporarily after having a treatment in the neck. Anyone who has a neuromuscular disorder such as myasthenia gravis or who has been on amino glycoside antibiotics may be advised not to have botulinum toxin injections. Women who are pregnant, nursing, or who are trying to become pregnant may be advised not to be treated.

Soft Tissue Fillers Soft tissue fillers are substances that are injected or implanted under the skin to plump up a hollow contour, soften wrinkles, and fill in furrows and some depressed scars on the face. Filling substances may include bovine collagen, hyaluronic acid gel, liquid silicone, fat removed from another part of your body, and many other variations, as well as polymer implants. Thinner substances work better for fine lines and superficial wrinkles and for thinskinned areas around your eyelids and lip lines. Generally, thicker substances are best for deeper creases and recontouring slightly larger areas such as cheek hollows. Restylane, Hylaform, Perlane, Captique, Sculptra, and Radiesse are some of the products available for filling creases and wrinkles not associated with facial animation. The products are injected after topical or regional anesthetic and gradually resorb over the course of four to six months and may last up to nine months. Compared to the collagen products of the past, the currently used dermal fillers do not require pretesting. Radiesse lasts for approximately 12 to 18 months. Sculptra may last two years, but at the current time, it is only FDA approved in the United States for treatment of facial fat atrophy in people who are HIV positive. It can be used “off-label” in other areas and has great promise for achieving a “lifting” effect in mild cases of loose skin. New soft tissue fillers continue to be under clinical investigation all the time.

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The duration of soft tissue fillers is very variable and depends on the formulation of the material, how deeply it is injected, and how much is used. Most fillers are only temporarily effective so that repeat treatments will be needed every three to six months on average but may last up to nine months. In some cases, laser skin resurfacing, microdermabrasion, or chemical peels which help to soften wrinkles by removing and smoothing the outer layers of the skin, may be more effective than adding volume to the face with soft tissue fillers. Each person needs to be evaluated individually, and the appropriate treatment is based on assessment of the skin tone; the location, depth and extent of the creases; and the degree of skin looseness. Treatments with soft tissue fillers can be performed in the office when done independently of other procedures. Topical anesthetic agents are often used for numbing the area but a dental block may be utilized for very sensitive areas like the lips and around the mouth. Fillers are also frequently done in combination with facial rejuvenation surgery in an operating room where topical or local anesthetics may not be used if you are already under general anesthesia. We keep a record of the amount of filler substance injected and the location of the injections at each visit to help us determine the exact amount of the product you need to give you the best correction. It is not uncommon to return to the office for “touchup” injections after your initial treatment, but even if a small dose adjustment is not needed, we like to see you in the office again to see the effect of the treatment.

“There is no filler substance that is right for every face, and most doctors like to use a wide variety of fillers that are suitable for different purposes.”

Types of Dermal Fillers Resorbable Fillers—Resorbable fillers are made from natural or

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synthetic materials that are broken down and resorbed by the body over time.They are temporary and will need to be repeated, typically in three to nine months. Of these, hyaluronic acid based fillers are the safest and most predictable, and the one that we use most often in our practice. Other commonly used resorbable fillers include human and bovine or cow collagen.The good news is that if you are not happy with the results, the material will eventually disappear. Non-resorbable Fillers—The non-resorbable class of fillers has synthetic components that do not get broken down by the body. They are considered permanent because the particles cannot be removed, or “semi-permanent” because the particles are suspended in a substance that gets absorbed in three to six months. They are considered permanent because some of the material cannot be removed after it has been injected. Examples of non-resorbable fillers include silicone and polyacrylamide gels. There are over 70 commercially available fillers reportedly on the market around the world, most of which will never enter into widespread use and will not enter the FDA approval process for various reasons including safety record and lack of funding.

Resorbable Filling Substances

Bovine Collagen Zyderm® and Zyplast® (Inamed Corp) are composed of highly purified bovine dermal collagen that has been used to correct facial imperfections since the 1980s. The bovine collagen is processed to create a product that is similar to human collagen. There are three forms: Zyderm 1®, Zyderm 2®, and Zyplast®. Four weeks prior to the procedure, a test dose is administered in the forearm to determine if you have a sensitivity to the implant material. Three percent of people tested may have sensitivities. Frequently a second test dose is administered. Collagen is most commonly used

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to fill out superficial wrinkles, skin depressions, and some scars. It has been largely replaced by newer substances including human collagen and hyaluronic acid gel.

Hyaluroinc Acid Gel Hyaluronic acid is a natural polysaccharide (sugar like substance) that is commonly found in the connective tissues of the body. The source of the material can be from animals (avian protein; i.e., roosters or poultry), or bacterial fermentation which is non-animal. Its normal function in the body is to bind water and to lubricate moving parts like joints. The most common areas for treatment are the nasolabial folds (creases from the nose to mouth), the nasomental creases (corners of the mouth), and around the lips, as well as cheek and chin contours. Since there is no anesthetic supplied in the syringe, a topical anesthetic or local block may be needed to maximize comfort. Aside from expected temporary redness/puffiness for the first day or two, there are few complications to report and we are seeing longevity of four to six months and even longer in some patients. As the substance naturally occurs in humans, allergic reactions are rare.

Restylane The FDA approval of Restylane marked the beginning of a wave of new bioengineered substances for the treatment of lines, depressions, and wrinkles. Our male patients are very satisfied with the results of Restylane, which lasts six months or longer in most cases. Because it is a gel, it offers a soft, natural-looking correction. Restylane, Perlane, and Restylane Touch are all the same material packaged in a different particle size. Perlane has a large particle size while the size of Restylane particles is small. We use the larger particles when we need to fill deep wrinkles and the smaller ones when we need to fill superficial ones. We have been surprisingly pleased with this family of products, and our patients love the variety and durability that they offer.

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Restylane is the only product presently approved by the FDA for use in the United States; however since Perlane and Restylane Touch are the exact same molecule, they will hopefully be approved soon. We use Restylane to treat nasolabial creases (smile lines) most commonly, but it can also be used for other deep creases around the mouth and between the eyebrows when Botox® is not effective. Perlane is great for restoring volume. It is used for deep creases including the nasolabial creases and for generalized facial sculpting.

Janice’s Wrinkle Relief Janice came in complaining about her crow’s feet and her nose to mouth lines. She was 44 and thought she really needed a facelift, but she actually had beautiful skin and very little sagging elsewhere. We used Botox for her crow’s feet and the creases between her eyebrows, and one syringe of Restylane for her nasolabial folds. Janice was very pleased with the results and she comes to the office every four to six months for periodic touch ups. One day she may have a facelift, but she is not ready yet.

Restylane Sub Q® The latest addition to the expanding Restylane® family of hyaluronic acid fillers is SubQ, a revolutionary new injectable treatment for facial sculpting. It can give you ”high” cheek bones and a more defined chin and jaw line. Restylane SubQ® is based on the same patented hyaluronic acid gel formula used in the other Restylane® products but it has much larger gel particles which are three times as thick as Perlane®. The gel safely biodegrades on its own. SubQ can also be used for restoring facial volume when your cheeks have become hollow from weight loss. The gel is injected deeply under the skin in one session after application of a topical anesthetic, and the newly enhanced contours are immediate.

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Hylaform® and Hylaform® Plus Hylaform® and Hylaform(E) Plus are hyaluronic acids that are similar to Restylane®. Hylaform® Plus has a larger particle size and is designed for deeper creases. A study comparing the duration of correction for Hylaform® Plus and Restylane® has been conducted, and the findings will be presented in the near future. For now, it is safe to say that most plastic surgeons tell patients to expect three or four months of correction from Hylaform®.

Captique® Captique® is basically the same as Hylaform® with the major difference that it is manufactured rather than harvested from rooster combs. This allows the product to be produced without any animal proteins that theoretically can cause allergic reactions. It is the same concentration and thickness as Hylaform®, and it is reasonable to assume it will have the same longevity.

Other Hyaluronic Acid Based Products Under Development Juvederm® has been used in Europe and is a major step forward for the hyaluronic acid fillers. It is a homogenous gel that does not contain gel particles. It is manufactured and is not derived from animals. Three versions are presently available, and they are well suited to a broad range of applications.The three varieties of Juvederm® (18, 24, and 30) vary in the concentration of hyaluronic acid contained. The variety of concentrations allows a broad range of uses for this filler ranging from filling crow’s feet with a less dense product to smoothing nasal furrows with a more dense variety. Juvederm® is currently undergoing clinical trials in the United States.

“You never want to be the first one on your block to try a new technique or procedure. Wait until it has been fully evaluated.”

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Poly-L-Lactic Acid Developed by a French dermatologist, Sculptra® is based on a substance called poly-L-lactic acid (PLA) which occurs naturally and has been used in suture material for years. PLA stimulates production of the body’s own collagen within the line or wrinkle, making the skin appear smoother and firmer. Sculptra® is reconstituted before it is injected and is most commonly used in the nasal labial folds, cheek hollows, and scars.The substance is non-allergenic and typically two to three treatment sessions are recommended for best results.

Human Tissue Fillers One of the fascinating categories of filling agents is derived from human tissue. Most of these products are obtained from cadaver tissue through tissue banks. Donor suitability is determined according to the standards of the American Association of Tissue Banks (MTB) and the FDA. Cadaver collagen must meet criteria established for extensive testing for human immunodeficiency virus antibody (anti-HIV 1-2), Hepatitis B surface antigen (HBsAG), Hepatitis B core antibody (HBcAB), Hepatitis C antibody (antiHCV), human T-lymphotropic virus type I antibody (anti-HTLV-1), and rapid plasma regain (RPR) for syphilis.

Cosmoderm®/Cosmoplast® CosmoDerm® and CosmoPlast® (Inamed Corp) contain human collagen that has been purified from a single fibroblast cell culture. This product does contain 0.3% lidocaine, so additional local anesthesia is usually not required. No skin test is required because this is fashioned from human tissues rather than an animal source. CosmoDerm® and CosmoPlast® are injected just below the surface of the skin to fill in superficial lines and wrinkles and to define the border of the lips.

Alloderm® / Cymetra™ AlloDerm® is human dermal tissue that has been decellularized to remove the risk of rejection or inflammation. It comes in strips

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in a freeze dried form to be implanted into lips, nasal defects, and around the eyelids. AlloDerm® is sometimes used as a soft-tissue replacement in facial reconstruction to build up cheeks, chins, hollows, and asymmetries. It can be rolled or layered so that it can be implanted under the skin to fill out depressions. Cymetra™ was introduced in 2000. It is micronized AlloDerm® tissue in an injectable form. It also needs to be reconstituted. More than one treatment may be required to achieve the level of correction envisioned. AlloDerm® may last up to two years; Cymetra™ may last two to four months.

“The key with soft tissue fillers is to select a safe product that has a long track record.”

Non-Resorbable Filling Substances Artefill® ArteFill® is a semi-permanent filler currently used in Europe, Canada, and Mexico. It is made up of 75 percent bovine collagen and 25 percent polymethyl-methacrylate microspheres (PMMA) which are carbon-based polymers. PMMA has been used in dental work, hip prostheses, and bone cement. The product is mixed with a local anesthetic, lidocaine, to numb the area to be injected. Over three months, the collagen fibers get absorbed, leaving the PMMA behind, which are too large to be broken down and remain permanently. It is tunneled under the skin, massaged and molded to fill the area to be treated. ArteFill® can be used for acne scars, nasolabial folds, and for filling depressions such as sunken cheeks. Possible complications include lumping, inflammation, granulomas, or localized hardening, rash, and the migration of the microspheres into other areas. Because of its permanence, ArteFill® is considered more risky than other biological fillers. At the time of printing, it is pending FDA approval.

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Radiesse™ Radiesse™ (BioForm) is composed of calcium hydroxyapatite, which has been used in the body for multiple applications including cheek and chin implants. Radiesse™ is injected into the face adding volume through microspheres that are suspended in polysaccharide carriers until encapsulation occurs. Calcium hydroxyapatite has been used for many years for other medical purposes in both injectable and solid implant forms, such as facial reconstruction. It is FDA approved only for vocal cord paralysis and urinary incontinence, however, off-label use is permitted in the United States Radiesse™ is a pure, synthetic calcium hydroxyl apatite composed of calcium and phosphate ions which occur naturally in the body so they are biocompatible. The particles are in a gel carrier made up of cellulose, glycerin, and purified water. The product manufacturer claims that Radiesse™ will remain soft and pliable as it permeates soft, fibrous tissue. As with any longterm filling agent, there is a possibility of a foreign body reaction which can cause lumps or granulomas, and migration.

Injectable Liquid Silicone Liquid silicone varies by degree of purity, and the form that is being used in the United States is sterile, purified, medical injectable grade silicone. The newest method of injection is referred to as the “micro droplet” technique, which has the advantage of causing fewer hard lumps than previous variations. Liquid silicone is only approved by the FDA for ophthalmic uses, so cosmetic uses are considered an off-label use of an approved product.

Recycling Your Own Body Fat Fat is perhaps the most widespread material used as a filling substance in facial rejuvenation.The fat that is injected into facial areas comes from your own body, so there is no chance of an allergic reaction or “rejection.” Fat can be used in higher volumes than most other injectable materials and can be used to create a fuller, more

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youthful appearance by reestablishing pleasing contours. Injections of fat into the deep layers of facial tissue can soften the angular, thin appearance that often accompanies aging. Fat is the first choice of material when injections of volumes greater than 10 cc are needed. The fat must be harvested from your own body, typically from the abdomen, thighs, or hips. After it is extracted, it is placed in a centrifuge to separate the fat from blood and other fluid. The fat is then packed into a syringe ready to be injected. Because fat molecules are somewhat larger than other injectable materials, it is usually injected more deeply and with a larger gauge needle. Volumes of up to 50–100 cc’s can be injected at one stage. Fat injections are particularly useful in the lips and perioral area, in cheek hollows, and around the eyes, as well as for some scars.

“Fat is one of the most commonly used fillers for plumping-up deep folds and restoring youthful contours.”

Fat injections have a very variable life span.The fat is slowly absorbed by the body, although the amount of absorption is variable, and hard to predict.Typically, more than half of the fat used in injectable treatments is absorbed within six months of the procedure, although it may last longer. Almost all people will permanently retain some of the injected fat.Two to three follow-up treatments are usually advised and can lead to a more permanent correction.

Lip Enhancement There are many options for improving the appearance of your lips to make them fuller and to reduce the associated fine lines and wrinkles. Injections or implants can enhance and improve your natural look. The upper and lower lips can be “outlined” by injecting a thin line of Restylane® or Hylaform® along the vermillion border and can also be made fuller with fat injections. Lip enhancement procedures are contraindicated in patients with certain diseases such as diabetes, lupus, and blood clotting problems

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and should also not be performed in people who have active cold sores or extensive scarring of the lips. Lip enhancement is performed using a topical anesthetic with or without a dental block. Many people say that they are afraid to have their lips enhanced because you see so many celebrities with “bee-stung” lips. Lip enhancement can be done in such a subtle way that no one will be able to tell that your lips have been injected at all. It can offer a pretty and feminizing effect, especially in lips that have lost definition with age.

What to Expect Afterward Recovery time will depend on your lifestyle, the type and extent of the treatment, and how much material is injected. Most injectable fillers have short recovery periods, and you can return to work the same day or the next day. If you are having superficial injections, your recovery can take a few hours. Most people experience some swelling and redness for the first 24 to 48 hours. When large amounts of any substance are injected into the face, swelling may last from several days to one week. Bruising is common, but can be covered with camouflage makeup as needed. Bruising can be minimized by avoiding the use of aspirin or aspirin containing product or non-steroidal antiinflammatory drugs such as Motrin, Advil, or ibuprofen for seven to ten days prior to the planned injections.

Are There Risks? There may be bruising and swelling following any dermal filler treatment. Itching and mild discomfort is not uncommon. You may develop asymmetries or irregularities that can usually be corrected with massage or additional injections. Some substances such as bovine collagen require pre-treatment testing for allergic reactions. Although less than three percent of people are allergic to bovine collagen, a reaction may cause itching, hives, redness, and prolonged swelling. With a few exceptions, most commercially avail-

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able filling substances have no anesthetic added, making injections somewhat uncomfortable. Many products and drugs are used in the cosmetic field even though they may not have FDA approval for a specific cosmetic indication. This does not necessarily constitute an illegal use of an approved substance. A physician may obtain access to an unapproved drug by participating in a clinical study as an investigator. In some cases,“off-label” use means that the drug or filler is approved for a use other than facial wrinkles. For example, botulinum toxin type A has FDA cosmetic approval only for the application of facial glabellar wrinkles, although it has been widely used for treatment of other facial lines and creases as well as for migraine headache relief.

Skin Resurfacing Polishing down wrinkles from the top down can be done with a variety of techniques that fall under the category of skin resurfacing. Each technique accomplishes the same goal of stripping off the top layers of skin. Each resurfacing technique has its own risks and benefits and each technique penetrates to a different skin depth (superficial, moderate, or deep). The deeper the resurfacing, the more dramatic the result, but the longer it takes to heal. People with superficial fine lines need more superficial treatments while people with deep lines require more aggressive peeling techniques and even laser therapies.

Chemical Peels A chemical peel, or chemexfoliation, involves the application of one or more exfoliating agents to the skin, causing the destruction of portions of the epidermis (outer skin layer) and/or dermis (deeper skin layer). The “wounding” of the skin layers leads to subsequent regeneration of new epidermal and dermal tissues. A particular peeling agent is chosen based on your skin type and the specific problems that need to be addressed.

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In our practice, we will select the best chemical or chemical mix for you after a thorough evaluation. In some cases, we may choose to use a combination of chemicals for your procedure to tailor the treatment specifically to your skin type and condition. A peel treatment begins with cleansing the skin and removing all traces of grease with rubbing alcohol or acetone. The face is then rinsed with water and blown-dry with a small fan. The solution is applied to the treated areas with a sponge, cotton pad, cotton swab, or light brush. We apply the peeling agent so that all areas of the skin to be treated are covered evenly. A grey-white film, referred to as “frost,” develops on the skin by the end of the application. The peeling solution is left in place for a few minutes and then thoroughly neutralized or removed with water. We often prescribe medications to prepare your skin prior to the peel treatment to decrease the chance of bacterial infection and pigmentation changes. The presence of active skin infections including rashes, acne, and cold sores is a contraindication to a chemical peel. Accutane® should be stopped for a period of 12-18 months before a treatment, depending on your doctor’s specifications. People undergoing a perioral chemical peel should receive prophylactic acyclovir to minimize post-treatment herpes simplex infection. You will be asked to limit your sun exposure for at least a month before chemical peeling and to refrain from shaving or waxing facial areas for several days or weeks. You should wear loose clothing that zips or buttons up the front and refrain from wearing makeup on the day of treatment. Darker skin poses special considerations due to increased risk of undesirable skin pigmentation changes.

Types of Peels Superficial Peels The most commonly performed chemical peels are superficial. These formulations consist of mild chemical solutions like glycolic

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acid, lactic acid, and salicylic acid, which lightly peel the skin and involve almost no recovery. Salicylic acid peels treat sun damaged, thicker skin, and can also unclog pores, smooth out underlying “bumps,” and improve acne. Superficial chemical peels usually take ten to 20 minutes and these types of peels are typically done in a series to maintain the results over time. The solution used is typically adjusted for each treatment session based on your skin’s response. Your face may be slightly red, and you can expect the redness to be followed by temporary flaking, dryness, and scaling until your skin adjusts to the treatments. For the best results, superficial peels should be combined with an at home skincare regimen. The technique of dermaplaning involves removal of a microthin layer of skin and is often used in conjunction with a glycolic acid peel to rejuvenate skin, improve fine lines, and even out pigmentary irregularities.

Medium Peels Jessner’s Solution,Trichloroacetic Acid (TCA), or other solutions are used to treat pigment problems, superficial blemishes, moderate sun damage, fine lines, and weathered skin.TCA peels are performed in a doctor’s office. Anesthesia is usually not necessary because the chemical solution itself actually numbs the skin.You may feel warmth or a burning sensation, which is followed by some stinging. We can control the depth to which the chemical penetrates. In some cases, previous skin preparation with Retin-A® or bleaching agents like Hydroquinone may be recommended to decrease the incidence of problems with skin discoloration after the peel.

Deep Peels Phenol and croton oil peels penetrate the deepest and are usually only a one-time procedure.They can produce more dramatic, long-term results for wrinkles, brown age-spots, and mild scarring. Because phenol peels result in permanently lighter skin, they are

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not recommended for darker skin tones, and it is necessary to use sunscreen at all times afterward. Phenol peels are usually performed in a surgicenter and require intravenous sedation and heart monitoring during the procedure.You may feel a warm or burning sensation that is followed by some stinging. Deep peels are generally reserved for fair, thin-skinned people with severe sun damage.

Dermabrasion Dermabrasion is a surgical process for resurfacing your skin by sanding or planning with a rapidly rotating abrasive tool. We can improve fine facial wrinkling, brown spots, acne scars, and a variety of traumatic scars when the epidermis and outer layers of the dermis are removed by this method. The procedure is usually performed under IV sedation and the most common area treated is the area around your mouth. People who are candidates for dermabrasion are usually also candidates for a deep chemical peel. Compared to a phenol peel, dermabrasion is a mechanical process, making it easier to control the depth of the resurfacing. Healing after dermabrasion may be faster and associated with less discomfort than a phenol peel. Similar to deep chemical peels, adverse consequences of dermabrasion include scarring and pigmentary changes.

Microdermabrasion Microdermabrasion is considered an alternative to a chemical peel. It entails treating the face with sterile micro-particles to rub off the very top skin layer, followed by removal of the sloughed skin cells. The technique exfoliates and gently resurfaces your skin, promoting the formation of new smoother skin. It is usually performed on the face and neck. Microdermabrasion can improve rough skin texture, some types of mild scarring, uneven pigmentation, and superficial brown spots. It is also useful for acne lesions, blackheads, and fine wrinkles. One of the advantages of microdermabrasion is that it

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can be safely used for all skin types. The results are similar to a light chemical peel with minimal discomfort, no need for anesthesia, and little or no downtime.

“Microdermabrasion is suitable for all skin types and can be effective in improving skin texture, tone, and luster, as well as acne and enlarged pores. Our patients have a rosy glow after each treatment.”

We perform microdermabrasion in the office and it is relatively simple. Through a wand-like hand piece, tiny aluminum oxide or salt crystals are delivered at high velocity onto the skin’s surface and immediately vacuumed away with the same instrument, taking the outermost layer of dead skin cells with it. The pressure can be varied to control the amount of penetration, or pass over an area several times to remove the most damaged skin. Each treatment will take about 30 minutes. A typical regimen consists of a series of four to eight treatments done at intervals of two to four weeks. Immediately after the procedure, you can put on makeup. Your skin will have a pink glow that will fade within a few hours. Multiple sessions of microdermabrasion can be part of a combined treatment plan that involves other resurfacing procedures such as peels and lasers.

What to Expect Afterward Superficial peels and microdermabrasion treatments require little or no downtime. After the procedure, your skin may be coated with a mild ointment. For dermabrasion and medium or deep peels, you may have up to ten days of crusting and peeling. You may be given an ointment to apply to your skin for seven to ten days following the peel to keep it supple and to prevent scabbing. Most people can resume their normal activities immediately after superficial treatments and within four to ten days following

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aggressive procedures, when the new skin has emerged. With all peels, it is important to avoid direct, prolonged sun exposure for several months to protect the newly formed layers of skin and minimize pigmentary changes. To this end, patients are advised to use liberal sunscreen with both UVA and UVB protection. Chlorinated pools should be avoided for one month.

Are There Risks? The possibility of adverse consequences following chemical peels includes infection, scarring, and temporary or permanent pigmentary changes. The skin color may become lighter or darker. Darker skin types are at a higher risk for darker pigmentation but may also suffer from a lightening of the skin color. Lighter skinned individuals are mostly at risk for developing an even lighter pigmentation in the treated areas. Phenol may pose a special risk for patients with a history of heart disease, and any peel carries the risk of cold sores in persons who have a history of recurring fever blisters or herpes simplex outbreaks.

Lasers and Light Sources A laser is a high-energy beam of light that can selectively direct its energy into the tissue. In many cases, it can provide the doctor with more control over the penetration of the skin than other resurfacing treatments, such as chemical peels and microdermabrasion. These beams can be targeted to a specific point and varied in intensity and in duration of emitted pulses. In addition to skin resurfacing, lasers can be used to treat numerous skin conditions including broken capillaries, acne scars, unwanted hair, tattoos, discolorations, and age spots. People with darker skin type can be treated, but there is a higher risk of pigmentation changes after laser treatment. Different types of lasers are suited to treating specific problems. Non-ablative devices penetrate through to the layers beneath to boost collagen production, which gives the skin a fresher, plumper, more youthful appearance.

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Ablative or Deep Lasers Another type of skin resurfacing uses laser light. It takes off the top layer of skin with thermal energy instead of chemical or mechanical means. Ablative laser resurfacing focuses laser energy on damaged surface layers of skin and vaporizes them.This allows a fresh layer to emerge and stimulates fibroblasts. Because of the laser beam’s precision, we can make several passes in one session over areas that require extra attention without harm to adjacent skin. The two most frequently used deeper lasers for skin resurfacing are Carbon Dioxide CO2 and Erbium:YAG. Brief high intensity emissions of light from the laser remove layers of damaged or wrinkled skin at precisely controlled levels of penetration. To begin, your face will be cleansed to remove oils from the skin. A beam of light is passed over the skin to vaporize the outer layers of damaged skin. The laser can be programmed for various levels of penetration. We may choose to penetrate more deeply in some areas that need more work. As the laser works, you may hear it zapping and smell smoke. Finally, an occlusive ointment or bandage will be applied to the treated area. Ablative resurfacing is normally performed under local anesthetic with intravenous sedation. The laser is passed over the area to be treated and literally evaporates the targeted areas of skin, leaving only a faint trace of smoke behind and revealing the lower layer of new, pink skin. By making more passes at the edges of the treated areas (feathering), we can avoid leaving a noticeable line of demarcation where the laser did not pass, such as at the jaw line and the area in front of the ears. Generally, the more numerous and deep the passes of the laser, the more extensive the treatment and the longer the recovery. People with lighter skin tend to remain pink for longer. Deep laser procedures involve seven to 14 days of postoperative care, but superficial treatments heal within days.

Carbon Dioxide The carbon dioxide laser was considered the workhorse of laser devices. The treatment can reach the deeper wrinkles because it

Non-Surgical Options for Cosmetic Enhancement

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heats the tissues more intensely. This is a more serious treatment with a longer recovery period that can range from one to three months. When energy is delivered into the skin over a certain temperature, superficial tissues are vaporized and ablated or destroyed. CO2 is still considered the workhorse of lasers because of its ability to cause up to 30 percent skin shrinkage and its dramatic results on deeper wrinkles. Typically, after treatment you will be required to apply an occlusive ointment for at least a week when the epidermis regenerates.

“Due to the risks of skin darkening and lightening, we only suggest deep laser resurfacing for very deep wrinkles in fair skinned people.”

Erbium:YAG This technology has gained wide acceptance as the second cousin to carbon dioxide, but without some of the side effects. The milder Erbium:YAG works well on fine lines and wrinkles, mild sun damage, and scars. These lasers target the skin itself and the wavelengths are absorbed by water. Since most of our cells are predominantly water, these wavelengths are absorbed by the first cells they touch. The heat effects of the laser are scattered so that thin layers of tissue can be removed with precision while minimizing damage to surrounding skin. The treatment is like getting a medium depth peel and works best for mild to moderate skin damage. If needed, you can repeat the treatment in the future.

Fractional Resurfacing The newest laser technology is called Fraxel® or fractional resurfacing. It will probably replace deep treatments except for the most severe wrinkles. This device removes old skin cells as it penetrates the skin. Fraxel offers a greater degree of precision than other lasers: it treats very small areas of the skin but leaves the

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surrounding tissue intact. This “fractional” treatment allows the skin to heal rapidly and it allows the body to create new, healthy tissue to replace old and damaged skin. Fraxel is an in-office treatment requiring topical anesthesia. Most patients experience a mild sunburn sensation for about an hour after the treatment. The skin remains pink for five to seven days following treatment. There is typically a minimal degree of swelling that lasts for two or three days. Epidermal regeneration is rapid, often beginning within 24 hours of the treatment. Following treatment, it is important to use sunblock and allow your skin to heal.

Non-Ablative Lasers This class of lasers does not produce a deep burn, and they give a much less invasive treatment that improves skin texture and tone by stimulating new collagen in the skin to smooth it out from underneath. These treatments do not destroy outer tissue as they work their way down to stimulate collagen growth in the dermis. Each device delivers controlled energy to the skin in slightly different ways, but the process is gradual and the softening of wrinkles occurs over time as the rejuvenated skin fibers reach the skin surface. Treatments are usually repeated every four to six weeks over a six month period to maximize new collagen formation. Since non-ablative lasers often have a very long wavelength, they are relatively safe for a variety of skin types. A topical anesthetic may be all that is necessary to numb the skin for more superficial procedures. Non-ablative lasers are ideal for maintenance after more aggressive resurfacing, or as part of a total maintenance program in combination with skincare and peels or microdermabrasion treatments. Most people will see an improvement in 30 days and may continue to see improvements for up to 90 days. The newly formed collagen will then age at the normal rate and you can repeat the procedure for maintenance as needed. These result in mild skin peeling and are great for people with mild wrinkling.

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Intense Pulsed Light Sources (IPL) These light sources work by creating a wound in the small blood vessels found in the dermis that cause collagen and blood vessels under the top layer to constrict. The light energy, delivered through the skin, removes facial redness, erases pigmented spots, reduces pore size, and minimizes fine lines. A series of five or six photo facial treatments are performed at three to four week intervals. There may be some minor discomfort similar to a rubber band snapping against the skin. You can return to work or resume your normal activities immediately after the procedure. After one or two treatments, your skin will have more even tone and smoother skin. If you have rosacea and facial flushing, you can expect to see a reduction in redness after each treatment. This treatment is good for fine lines particularly around the eyes and mouth, shallow acne scars, age spots, broken blood vessels, enlarged pores, and chronic facial redness. It can also be used to treat sun damaged areas on the neck, arms, chest, and hands. Again, this is specifically used on patients with early mild wrinkling (30s–50s) and it is not intended for moderate or deep wrinkles.

Radiofrequency Waves Devices utilizing radiofrequency waves are being evaluated for skin rejuvenation. Using radio frequency to tighten loose skin on the neck, face, and body areas works by delivering deep intense heat into the skin without injury to the epidermis. The system is comprised of a radio frequency (RF) generator, a controlled modular cooling system, and a hand-held treatment tip that couples both the cooling and the RF heating device to the treated area. Since this technology was introduced, the method has been changed to reduce the amount of discomfort and improve the results that can be achieved. Currently each treatment involves many passes at a low energy setting to produce an instant tightening effect. One treatment may be sufficient depending on the area, but in some cases, multiple treatments may be done for best results.

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Photo Dynamic Therapy Laser-assisted photodynamic therapy (PDT) is being used as an alternative to freezing with liquid nitrogen and topical chemotherapy for brown spots called “actinic keratoses.” The treatment works in two stages. First, a light-activated aminolevulinic acid is applied to the skin. About 14 hours later, a pulsed-dye laser light seeks out and selectively treats only the acid covered areas. PDT therapy may also be used for facial rejuvenation.

LED Technology Photomodulation refers to using low-energy light to accelerate or inhibit cell activity. Basically, during the treatment, you would sit in front of a panel of low level light emitting diodes (LED’s). Unlike laser technology that relies on high-powered coherent light to create heat energy, LED photomodulation triggers the body to convert light energy into cell energy without damaging the tissues with heat. IPL (intense pulsed light) is a variation of this theme. Both are gentle, require multiple treatments to see very subtle results, and require little or no downtime.

What to Expect Afterward If the skin has been treated with a deep depth laser (C02), it may be covered with either a thin film of antibiotic cream or a synthetic breathable skin to protect the newly surfaced tissue for the first five to ten days during the healing process, or treated in an open fashion (without any bandages). Redness and swelling and slight discomfort are to be expected. Regular icing can relieve some of the swelling for the first 48 hours, but if bandages are needed you must avoid getting the area wet. You may expect some redness, oozing, swelling, and discomfort. If a bandage was applied after the surgery, it may be changed in a few days and removed after one week, at which time an ointment is applied. Because the bandage must remain dry, you will not be able to shower normally until it is removed. If the treated area is not bandaged, you will

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wash your face several times daily and apply an ointment, such as petroleum jelly. Crusting will last for 10 days after surgery, and scabs should be left alone to heal. Picking at the scabs may cause permanent scarring. You may have to drink through a straw at first for treatments around the mouth area. The healing time depends on the depth to which the laser penetrated. It may take a week or more for the skin to reepithelize. The skin will turn pink, but it may take up to six months for the redness to completely fade, and up to one year for normal pigmentation to return. The redness gradually lightens to pink and then to a lighter, more natural color. Camouflage makeup can be applied after about seven to ten days to cover up redness. We will usually allow people to resume using AHA’s and retinoic acid in about three to four weeks after resurfacing. Absolutely NO sun exposure will be allowed for four to eight weeks, and broad spectrum sunscreen with UVA and UVB block should be worn at all times. Laser resurfacing can be used to reduce wrinkles, scars, discoloration, and imperfections in the treated area to some degree, but natural facial movements and expressions eventually cause some of the lines to reappear. Laser treatments may be repeated to maintain the desired results.

“No resurfacing procedure can stop the aging process nor are these a substitute for a facelift. Lines and wrinkles will eventually recur.”

Technology changes constantly, and new lasers and light sources continually come to market offering more effective and safer options. Often, a combination of devices may be used to effectively treat specific conditions and a variety of different treatments may effectively accomplish the same goals. It is nearly impossible for a consumer to keep up to date with new technologies as they are introduced, and to be able to evaluate which is appropriate for your particular skin type and concern. The best

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advice is to select a qualified laser surgeon you trust and let his or her recommendations guide you, rather than to be persuaded by individual technologies.

What Are the Risks? Any laser resurfacing treatment may lead to the development of infection, blisters, burns, scarring, temporary or permanent loss of sensation, and pigmentation changes, in addition to the risk of cold sores in patients who have a history of recurring fever blisters or herpes simplex. Acne breakouts are common after resurfacing, especially if you have a previous history of acne. Milia, which are very small superficial cysts may also appear on the treated skin, and contact dermatitis can develop due to the application of antibiotic ointments after treatments. Adhesions may occur when treated areas of skin may remain in contact with each other after the procedure and can heal together, forming a small fold in the skin. The risk of adhesion formation can be decreased by ensuring that problems areas, such as the lower eyelid, are taut when the dressing is applied after the procedure. Ectropion is a rare but serious complication of laser resurfacing around the eye area, which causes a pulling down of the lower lid making it appear everted. People with darker skin color are more prone to blotchiness and permanent skin darkening. Sometimes an inconspicuous spot test behind your ear is a good idea to determine if you are a good candidate for the procedure.

Permanent Cosmetics Permanent makeup (cosmetic tattooing) can be a solution for many changes in your face that occur with aging. Over time, your natural lip color fades and small vertical lines begin to appear all around the edges of your lips. Your lip contour also becomes flatter with less definition of the vermillion border as you get older, and eyebrows become thinner requiring regular application of eyebrow pencil.

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Permanent lip liner and lip color eliminate the “bleeding” of lipstick into the vertical lines around your lips and into the creases at the corners of your mouth. Permanent eyebrow color is a time saver and allows for a consistent appearance to your eyebrows that does not smudge or come off when you are exercising or swimming. When your eyes are no longer focusing as well and your hands are not as steady, permanent eyeliner is priceless.

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CHAPTER

10

The Waves of the Future “Plastic surgery is a constantly evolving specialty that is limited only by the surgeon’s imagination and skills.”

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How you feel about the way you look sends a signal to the outside world that you are confident, successful, and content in your own skin. Many people who come to see us view having cosmetic surgery as something to make them look as good as they feel. They are taking better care of themselves and view cosmetic surgery as a way to improve something about their appearance that they are unhappy about. This eternal pursuit for cosmetic procedures that offer less downtime has led to a whole new generation of minimally invasive devices and techniques. What they want most is a natural result, without the telltale signs of surgery.The results tend to be more subtle and do not elicit remarks like,“Oh my God, what have you done!”

Combining Procedures One of the biggest trends in aesthetic medicine is the advent of combination therapies. It is rare today that we see a person who is only interested in one procedure. Most of the people we see will have several chief concerns for which a combination of treatments may be recommended that produce a synergistic effect to maximize longevity and the outcome. The most common example is the combination of botulinum toxin with Restylane or other fillers. In this case, the botulinum toxin serves to relax the muscle and the filler smoothes the line. Botulinum toxin is often the first line of defense for dynamic wrinkles—wrinkles caused by facial muscle contractions. If the wrinkles are particularly deep, these may require treatment with a dermal filler to fill in the remaining imprint of the line after the botulinum toxin does its job. Another example is the combination of resurfacing agents and devices with botulinum toxin. The results of lasers and peels will last longer if there is less muscle movement in the facial areas.

“Our ultimate mission is to choose the right procedure for the right patient at the right time.”

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We customize the procedures and treatment plan for each patient, instead of simply performing the same treatment in the exact same way for everyone. People appreciate and deserve an individualized approach.

The Youth Window

“Maintenance plastic surgery allows you to stay one step ahead of the aging process.”

The trend is definitely leaning towards “maintenance” cosmetic enhancements. This philosophy involves making small changes and adjustments at younger ages than in the past, to avoid having procedures that will result in sudden drastic changes when you are older. The general rule is: the less severe the problem, the less dramatic the result following surgery. It is not uncommon for a woman in her 30s to consider having a conservative eyelidplasty if she has some excess skin or fat deposits that make her look tired By having surgery done before the results will be obvious to everyone, you are in fact maintaining your youthful appearance. If you wait to have a blepharoplasty when your upper lids are very droopy, the change will be more visible, and thus, harder to conceal from family and friends. So there are windows of opportunity as you age to make small subtle changes to stay one step ahead of the aging process. Most people usually start with smaller treatments and procedures such as injections with Botox® or soft tissue fillers and then progress to eyelid surgery, neck recontouring or a mini-facelift. Five to ten years later they may be “ready” for a full facelift. And with the advent of less invasive techniques such as the Contour Threadlift™, we are able to make subtle changes periodically to allow people to keep up with the aging process instead of waiting until everything has fallen.

The Waves of the Future

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Surgery with Less Scarring

“The proliferation of non-surgical minimally invasive procedures has revolutionized the field of aesthetic plastic surgery in recent years and will continue to in the future.”

Endoscopic surgery has been used in plastic surgery since the 1990s. We first started doing endoscopic browlifts at that time, and over the years, the technique has improved greatly. By incorporating new methods of fixation into our procedure, we are able to offer a longer lasting result that patients enjoy. The chief advantages of using the endoscope while lifting the brow and upper face area is the quick recovery and minimal incisions required that can be hidden in the hairline. Endoscopy is also used in breast enhancement surgery. A small incision is made in the armpit area where the endoscope is introduced to create the pocket where the implant is placed.The implant is inserted through the same opening and is then positioned. Even though there is a similar amount of tissue manipulation needed compared to other methods of breast augmentation, the endoscopic approach results in a scar that is not located on the breast.

Pump Up the Volume One of the new concepts in cosmetic surgery is total facial rejuvenation which includes volume enhancement or replacement, and not just skin excision. If you lift the skin of a face in which the soft tissues have been lost with age or illness, the end result may fall short. By adding volume, we can change the shape of the face and bring it back into a more youthful balance. Consider the face of a runner where there is often very little facial fat. A thin, gaunt face is not considered youthful. The support structures or deep layers where collagen and elastin live have broken down. The soft tissues have shifted. Usually with age, fat deposits descend and accumulate in the neck and jowls.

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For a long time, we did not have many options for replacing volume; there was bovine collagen and fat. Collagen did not last very well or long, and fat was often unpredictable. Today, there are many commercially available fillers on the market to choose from, and countless more variations under clinical investigation. Dermal fillers can improve and enhance a wide range of facial imperfections, from deep creases, to recontouring hollow cheeks and lips, to softening lines and wrinkles. We often combine fat transfer and fillers with facial surgery. This method works particularly nicely around the mouth area, which can sink with aging. We can enhance the lips and smooth out nasolabial folds as well as redraping excess skin in one stage. When additional volume treatments are needed, Restylane® or another soft tissue filler can be used to maintain the results for the long-term or until another surgery is indicated.

Lifting with Sutures In the past few years, there has been an increase in popularity of suture suspension techniques whereby the underlying support is performed with deep tissue sutures so that skin lifting and skin tension may be minimized. With less tension during surgery, there is a lesser chance for scars to become stretched and widened.

Beauty in Balance

“Beauty is harmony.”—Sir Francis Bacon

We are very fortunate to have so many choices available to help us achieve the goals of a naturally refreshed appearance, from fillers to lasers to surgery. The real growth in the field is being driven by scientific advancements and new technologies, as well as consumer demands for safer, less invasive procedures with shorter healing times. With these innovations, the results are instant in

The Waves of the Future

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most cases, and the scars are minimal, which is what most patients want today. Surgery is not a perfect science and there are no guarantees, but the more you know, the happier your experience and surgical outcome will be. Make sure you know what to expect after surgery so there are no surprises. Listen carefully to all risks and complications associated with the proposed surgery. Understand the timeline involved in the healing process. It is not the same as a day at the spa, and sometimes complications can happen. We can set back the clock, but we cannot stop it entirely, and wrinkles and sagging will return or worsen with aging. Most importantly, you should trust your surgeon and be confident that if a complication does arise, he or she will take care of it. The most exciting aspect of the field of aesthetic plastic surgery is that the future holds great promise for further advancements and improvements.

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CHAPTER

11

Frequently Asked Questions

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If I were considering cosmetic plastic surgery, what would be my first step? Anyone considering plastic surgery should visit the official website of the American Society of Plastic Surgeons (www.plasticsurgery. org) where you can click on “Learn about procedures” and then go to “make the right choice.” Here, you can find answers to whether plastic surgery is the right choice for you as well as find out what procedures are available, what questions to ask, and what to expect. What is the most important consideration when looking for a plastic surgeon? The most important credential to find out when looking for a plastic surgeon is whether the surgeon is certified by the American Board of Plastic Surgery, as this means that they have completed accredited surgical and plastic surgical residency programs as well as successfully completed the written and oral board examinations. The American Board of Plastic Surgery is the only board recognized by the American Board of Medical Specialties that certifies surgeons in plastic surgery of the face as well as the entire body. It goes without saying, that you should also have a comfortable rapport with the surgeon you choose. Does the United States government regulate who performs plastic surgery? The United States government does not regulate who performs plastic surgery. Any licensed physician can perform plastic surgery in an office setting in a given state, but unless a person has specific certification from one of the state specialty boards, it would not be possible to perform plastic surgery in a hospital setting or in most well regulated outpatient surgery centers. Is it appropriate to ask a surgeon where he or she was trained? Good training is an essential part of a plastic surgeon’s credentials. You have the right to ask where a surgeon completed medical school, residency, and plastic surgical training. If that information

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is not readily available, you can do your own research. The state medical society and the American Board of Plastic Surgery should be able to provide you with this information. What does an initial consultation cost? The cost of the initial consultation depends on the complexity of the problem and the time spent discussing the ways to achieve patient goals; this can vary from $125 to $250. Many surgeons would deduct the consultation fee from the cost of a cosmetic procedure if a person decides to proceed with surgery. Does plastic surgery mean that something plastic is used? The word plastic is derived from the Greek word plastikos which means changeable or moldable. We perform procedures which change the shape or form of a body part or area. Of course, there are times when implantable materials are used, but plastic is not one of them. What effect does skin type have on scars and healing? Skin type and race do play a major role in the final appearance of scars but do not impact the healing process per se. In general, people with fair, thin skin that burns easily tend to have the least visible scarring while people with darker, thicker skin that tans easily have an increased chance of developing thicker or darker scars. Of course, we have trained for many years in surgical techniques to make the best possible scar for a given person. There are certain skin resurfacing techniques including laser resurfacing of the face, microdermabrasion, and peels that are not recommended for darker skin types, however, healing from surgical procedures such as liposuction, tummy tucks, eyelid lifts, and breast reduction or enhancement is not usually impacted by skin type. Are scars after cosmetic surgery permanent? Scars formed by the body after an injury or surgery are merely the physical evidence that the body has healed a wound. A scar is part of the “trade-off” to achieve a better shape or contour on a part

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of the body. But even though the scars are permanent, we make every attempt possible to conceal them along natural skin creases, behind the hairline, at the junction of a natural skin color change, and in areas that are normally covered by clothing. Of course, scars related to breast surgery and body contouring procedures are always planned in areas that are not visible in a bathing suit. What is the best treatment for cellulite? Unfortunately, there are no surgical techniques for eliminating cellulite. We do not know of any topical creams, lotions, or ointments that are effective. Hopefully, some day there will be new technologies to finally address this problem. How long do facelifts, breast lifts and eyelid surgery last? Unfortunately, improvements in the contours of the eyelids, face, and breasts after skin tightening procedures are still subject to the continued effects of aging, gravity, and sun damage. But the improvements after rejuvenation surgery allow you to always remain 10 to 15 years “ahead” of your same-age peers who have not undergone cosmetic procedures and certainly “ahead” of what you would look like had it not been for the procedure. After fat is removed with liposuction, will it come back? In general, after maturity has been reached, the number of fat cells in the body will not increase. Removal of fat cells by liposuction or other techniques is permanent and these cells will not be replaced by other fat cells. However, existing fat cells may increase in size, and in rare cases of morbid obesity, fat cells may multiply. If you can keep your weight within a reasonable range after liposuction, you should be able to maintain your improved contours. What age is too young for cosmetic surgery? There are no specific age guidelines for cosmetic surgery and each person needs to be evaluated on an individual basis. The psychological as well as the physical maturity level of an individual should be taken into account when elective cosmetic procedures

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are considered, rather than using a pure age requirement as the deciding factor. The United States Food and Drug Administration has approved the use of saline filled breast implants for women at least 18-years-old and the American Society of Plastic Surgeons has adopted a similar policy with recommendations that adolescent candidates for purely cosmetic breast augmentation should be at least 18 years old. A similar physical maturity guideline applies to nasal reshaping surgery. When are you too old to consider cosmetic surgery? Advanced chronological age alone is hardly ever an absolute contraindication to cosmetic surgery. Healthy, active people can enjoy rejuvenation procedures well into their seventies, as long as they are medically cleared for surgery and their expectations are realistic. What is the difference between an FDA approved and offlabel drug? Off label refers to drugs and devices that are approved by the FDA for one use and used by doctors legally for another use. For instance, even though Botox® is only FDA approved for the treatment of creases between the eyebrows, it is also commonly used to smooth out forehead wrinkles. When Botox® is injected into the forehead area, it is considered off-label use of the product. Will I be able to breast-feed after breast enhancement surgery? There is usually no problem breast-feeding after having breast implant surgery, but of course, there are no guarantees since any time surgery is done on the breast including breast biopsies, breast lifts, and breast reductions, the milk ducts may be affected. There are also reasons unrelated to the breast surgery that may not make it possible for you to breast-feed following breast enhancement. How can I get rid of stretch marks on my abdomen? There are no good procedures or treatments for eliminating

Frequently Asked Questions

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stretch marks on any part of your body, but you can get rid of any stretch marks below the level of your navel when you have a tummy tuck since this is the area of skin and fat that is discarded during the surgery. How can I tell if liposuction or a tummy tuck is the best treatment for me? Generally, if you have had at least one full-term pregnancy or have had a large weight loss and you now have at least a moderate degree of loose or overhanging skin along your lower abdomen, you probably would get a better result from a tummy tuck. Liposuction alone will only remove the excess fat but will have no effect on the loose skin. Unfortunately, liposuction over the abdomen cannot be performed at the same time as a tummy tuck. If I have liposuction on my tummy first, can I still have a tummy tuck later? There are many people who have liposuction of their abdomen first and then have a tummy tuck six months or even six years later. Sometimes, we intentionally plan it that way, in order to decrease your overall abdominal girth before having a tummy tuck. And you can even have a tummy tuck first and then liposuction of your abdomen at a later date. The only thing that cannot be done is liposuction of the abdominal wall and a tummy tuck at the same time, as the circulation of the tissues may be compromised and have a negative effect on healing. When should I have a facelift? We would recommend a facelift when you are unhappy with your sagging face, neck, and jowls. There is no ideal age, and it varies from person to person. However, the trend is to do it earlier, before your loose skin and deepening creases become a point of contention for you. The average age today is in the early 50s, but many people are having modified facelift procedures done in their 40s.

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How do I know when I need my eyes done? If you have fatty, puffy eye bags, the answer is almost always surgical removal of excess fat and skin. We can treat the fine lines in the crow’s feet area and below the lower eyelids with Botox®, and lasers and chemical peels may reduce fine lines, improve pigmentary irregularities and can result in a small degree of skin tightening. But none of these things will improve puffiness or sagging skin. Will an eyelid lift give me that “surprised” look? The “surprised” look usually refers to the eyebrows being at a higher position, and eyelid lift surgery when performed alone has no effect on the position of the eyebrows. However, a browlift is sometimes performed with an eyelid lift when the person also has a low position of their eyebrows. Especially right after browlift surgery, the eyebrows may seem to be too high, but this slight over-correction takes into account some of the tissue “relaxation” that may occur soon after surgery. If a new mother is interested in having cosmetic plastic surgery to erase the battle scars of pregnancy and breast- feeding, what is the best timing for surgery? We usually advise women to have tummy tucks and breast lifts performed after child bearing has been completed as pregnancies and breast-feeding following correction of the “battle scars” may work against some of the tightening and lifting that has been achieved. Once a woman has decided against having more pregnancies, she should wait until she has returned to her normal weight and breast size before having surgery. How common is it to need a touch up after liposuction? In some cases, it may be necessary to remove more fat from an area after a liposuction procedure to even out imperfections or irregularities. We would usually wait at least six months after all the swelling has subsided and the tissues have settled before performing any revisions.

Frequently Asked Questions

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If I am having reconstructive dental work, is it best to wait to have a lower facelift? Depending on the extent of your dental treatment plan, it may be recommended that you wait until you are finished, especially if you are having several dental implants, bone graft, or other extensive procedures. The shape of your jaw may be altered slightly, and in these cases, we may prefer to operate when all dental work has been completed. What is the best method to add fullness to a thin, angular face? Fat transfer is commonly used to add volume to a slim, aging face. The fat would be extracted from the hips, tummy, or thighs and injected into facial areas as needed. Sculptra is also injected deeply in hollows and depressed regions of the face to add fullness. Another option is Restylane, which can be used to plump up creases and folds but is less useful when a large volume is needed. What are the most popular cosmetic procedures for men? According to statistics compiled by the American Society of Plastic Surgeons in 2004, men comprised almost 15 percent of people having cosmetic procedures or treatments which has steadily increased for the past four years. The top five most common cosmetic surgical procedures for men include nasal reshaping, eyelid surgery, breast reduction, liposuction, and hair transplantation. If I were a client who wanted to look like Julia Roberts, what would your advice be? We try to encourage people to consider what changes would be best for them based on their body type, skin type, and bone structure rather than to focus on a television or movie star. We are very straightforward in telling people what can and cannot be done. While we are able to make great improvements and changes, plastic surgery is not magic, and it is important for people to understand the limitations. Performing surgery on someone with unrealistic expectations should be avoided as it inevitably leads to patient dissatisfaction.

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What should I do if I am not happy with the results of my surgery? In many cases, initial imperfections and asymmetries are resolved over time without intervention. Just remember, swelling and scar tissue thickening will all resolve, but may take six months or more in some cases. And scars may continue to lighten and flatten for more than a year. But once you no longer see improvement and you are still dissatisfied, the best thing to do is to go back to your surgeon and discuss your concerns. There are cases when a touchup, revision, or secondary procedure may be required.

Frequently Asked Questions

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Glossary A Abdominoplasty—Plastic surgery of the abdomen in which excess fatty tissue and loose skin are surgically excised Ablation—Vaporization of the most superficial layers of skin Alar Base—The wing-like nasal structures where the nostrils meet the cheek Allograft—A graft from the same species as the recipient, as in human skin Alpha Hydroxy Acid—(AHA) A group of acids derived from foods such as fruit and milk, which can improve the texture of the skin by removing layers of dead cells and encouraging cell regeneration. There are many AHA’s but the most common forms are Lactic Acid, Glycolic Acid, Pyruvic Acid, Tartaric Acid, and Maleic Acid Anatomic Breast Implant—Teardrop-shaped implant as opposed to the round style designed to look more like a natural breast Anemia—A pathological deficiency in the oxygen-carrying component of the blood, measured in unit volume concentrations of hemoglobin, red blood cell volume, or red blood cell number. Antioxidant—A substance designed to prevent a chemical reaction with oxygen and minimize harmful free oxygen radicals; e.g. vitamins C, E, A, grape seed, green tea Areola—The pigmented skin around the nipple Arnica—A botanical derived from a mountain plant with antiseptic, astringent, antimicrobial and anti-inflammatory properties Autologous—Deriving from a person’s own natural body tissues

B Banana Roll—The ‘roll’ of fat situated directly beneath the buttock where it meets the back of the thigh Barbed Sutures—Unlike conventional sutures which are smooth, barbed sutures have tiny, teeth-like or barb-like cogs, and once inserted under the skin, they open in an umbrella like fashion to form a support structure that holds the tissues in place 168 BEAUTY IN BALANCE

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Beta Hydroxy Acid (Salicylic Acid)—A family of acids that enhance cell renewal, found naturally in willow bark Bleaching Agents—Substances which slow down or block the production of melanin to lighten age spots and fade areas of hyperpigmentation; i.e. Hydroquinone, Kojic Acid, Azelaic Acid. Blepharitis—Inflammation of the eyelids characterized by redness and swelling and dried crusts Blepharoplasty—Surgery to remove excess fat, muscle, and/or skin around the eyes. Incisions follow the natural contour lines of the upper and lower lids, or can be done through the lining of the lower eyelid, providing access only to excess fatty tissue Botulinum Toxin—A naturally occurring toxin that is purified, diluted, and then injected into facial muscles to temporarily relax them to soften and smooth expression lines on the forehead, between the eyebrows, in the crow’s feet area and along the neck Brachioplasty—An arm lift which involves making an incision from the armpit toward the elbow to remove excess skin and fat from the inner aspect of the upper arm resulting in a tighter, improved contour Buccal Fat Pads—Fat pads located in the cheek, also known as the fat pad of Bichet

C Cannulae—Long, thin hollow tubular instrument used to extract fat during liposuction Capillary—The smallest type of blood vessel in the body. Spider veins, for instance, are actually small capillaries commonly found on the face or legs Capsular Contracture—Scar tissue that forms around a breast implant and can become firm occasionally causing breast distortion Carbon Dioxide—Laser technology that can be used to resurface moderate to deep facial wrinkles, scars, and can also be used as a cutting tool Cauterize—To burn or sear abnormal tissue with a cautery or caustic instrument, such as a laser Glossary

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Cellulite—Deposits of fat, toxins and fluids trapped in pockets beneath the skin, more common in women Cheek lift—See mid-facelift Chemical Peel—A procedure in which a solution of varying strengths is applied to the entire face or to specific areas, such as around the mouth, to peel away the skin’s top layers. Common peeling agents are Alpha Hydroxy Acid, Beta Hydroxy Acid, Trichloracetic Acid (TCA), Jessner’s Solution, and Phenol Cohesive Gel—A thicker, more viscous type of silicone gel, used in breast implants. This variety decreases the potential for leakage Collagen—A primary component of human skin that gives it resiliency, suppleness and tone, and breaks down with age due to muscle movement and environmental damage Columella—The vertically oriented nasal structure dividing the nostrils at the base of the nose Commissure—The area where two anatomic parts meet, as in the corner of the eye or the lips, typically referring to a fold or crease Computer Imaging—The use of a computer to modify or enhance the digital image which allows a surgeon to demonstrate how a person may look after surgery Congenital Defect—Abnormality present at birth which formed in-utero Coronal—Of or pertaining to the top of the head or skull Corrugator—Muscle that is responsible for causing the glabellar or vertical lines that form between the eyebrows Cosmeceutical—A substance that falls between the classification of a drug and a cosmetic, i.e., non-prescription over-the-counter formulations that provide pharmaceutical benefits Craniofacial surgery—Surgery of the face and head Crust—Surface layer formed by the drying of a bodily secretion

D Deflation—A rupture or tear in the shell of a breast implant that causes the filler (saline, silicone gel, or other) to leak out and the implant to flatten

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Dermabrasion—Non-surgical resurfacing procedure in which a hand-held rotary wheel is used to remove the top layer of skin Dermal fillers—A category of substances that are either injected or implanted to shape and form overlying tissue Dermis—The layer of skin composed of collagen and elastin, lying beneath the epidermis (outer layer) and above the subcutaneous layers Diode—Contact laser technology that cuts and coagulates tissue Dry Eye—A condition of the eyelids which causes dryness, blurred vision and may give the eyes a “scratchy” or “gritty” feeling

E Ecchymosis—Patches of purplish red skin discoloration caused by the passage of blood from ruptured blood vessels into subcutaneous tissue, more commonly referred to as a bruise Ectropion—A condition of the lower eyelid in which the lid is pulled downward from loose eyelid skin, or deep scar formation, also called ‘lid retraction’ Eczema—A chronic skin condition that has superficial inflation in areas of the skin and scalp Elastin—A protein that is similar to collagen and the chief constituent of elastic fibers, also used as a surface protective agent in cosmetics to alleviate dry skin Endoscopic Surgery—An endoscope is a small rigid tube-like instrument equipped with fiberoptic lighting, which can be introduced into the body through a tiny incision so that it lights up the surgical area. The surgeon can see the area on a video monitor while performing an operation, as in endoscopic brow lifting, breast augmentation, facelifting and tummy tucks Electrocautery—To burn tissue with an electric current by use of a specially designed apparatus Electromyograph—An instrument used in the diagnosis of neuromuscular disorders that produces an audio or visual record of the electrical activity of a skeletal muscle by means of an electrode inserted into the muscle or placed on the skin

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Electromyography—The diagnosis of neuromuscular disorders with the use of an electromyograph Encapsulation—The growth of a membrane which acts to enclose material in a type of capsule Endoscopic—Pertaining to an endoscope, an instrument for visualizing the interior of a hollow organ Epidermis—The outermost layer of the skin Epinephrine—A white to brownish crystalline compound isolated from the adrenal glands of certain mammals or synthesized and used in medicine as a heart stimulant, vasoconstrictor, and bronchial relaxant Epithelialization—Regeneration of the epithelium or superficial layer of the skin, as occurs after laser resurfacing or long-term healing of an open wound Erbium: YAG—A type of ablative laser that produces energy in a wavelength that penetrates the skin, is readily absorbed by water (a major component of tissue cells), and scatters the heat effects of the laser light Erythema—Redness of the skin, as in post-laser or other resurfacing, etc. Exfoliant—A material that removes dead surface skin cells External Ultrasound—Utilizing ultrasonic energy applied externally to the skin to dissolve or liquefy fat deposits prior to liposuction Extrusion—The erosion of skin that causes an implant (chin, lip, breast, etc.) to become partially exposed

F Facelift—See rhytidectomy Fascia—The sheet of connective tissue that covers muscles and is sometimes used as a graft material Fat Embolus—Globules of fat that can infiltrate the bloodstream during surgery and can result in serious complication and death Fibrin sealant—A natural agent for the achievement of rapid hemostasis and tissue sealing in a variety of surgical applications, which is also referred to as Tissue Glue Fibroblast—A cell from which connective tissue develops

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Filler—A category of substances that are either injected or implanted to shape and form overlying tissue. Common fillers are hyaluronic acid, fat, and human donor collagen Follicle—A sheath that surrounds the root of the hair Forehead Lift—Also called a brow lift, which pulls up droopy brows and to a lesser degree, upper lids, and improves wrinkling and vertical and horizontal frown lines Free Radicals—A destructive form of oxygen generated by each cell in the body that destroys cellular membranes Frontalis—The muscle that enables the brows to move up and down, and contributes to the formation of horizontal wrinkles of the forehead

G General Anesthesia—Commonly referred to as ‘being asleep’, a total loss of consciousness is induced by an anesthetist or anesthesiologist. The patient does not feel anything, and a breathing tube is placed in the airway Genioplasty—To add projection to the chin, the bones are broken so that the chin area can be moved forward and secured in place. Glabella—The area between the eyebrows where deep vertical lines and creases often develop Graft—A piece of tissue that is totally removed from one part of the body and transferred to another area of the body, as in fat, cartilage, bone, skin, etc. Glycolic acid—an organic substance, found naturally in unripe grapes and in the leaves of the wild grape and produced artificially in many ways, as by the oxidation of glycol Gynecomastia—Male breast enlargement that can be treated by liposuction alone, through small incisions along the areola or in the crease beneath the breast or liposuction combined with direct excision of breast tissue

H Hematoma—A localized accumulation of blood beneath the skin caused by a blood vessel leak, that may require drainage or may resolve spontaneously if it is of small size

Glossary

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Hyaluronic Acid—An acid found naturally in the body and helps retain the skin’s natural moisture Hydroquinone—A bleaching agent that slows down or blocks the production of melanin to lighten age spots and to fade darkness and blotchiness Hyperpigmentation—Darkening of certain skin areas through overproduction of melanin Hypertrophic Scar—Thickened, raised, or red scar tissue Hypertrophy—Enlarged or thickened area Hypopigmentation—Reduction in the pigment cells in the skin resulting in skin lightening Hypoplasia—Incomplete or arrested development of an organ or a part

I Inframammary Crease—The skin crease or fold that lies beneath the breast Inframammary—Refers to the location below the mammary gland

J Jaw—Used to describe the maxillae and mandible and soft tissue surrounding the bony structure

K Keloid—Enlarged, permanent, and thickened scar formations that are more common in darker skin types and often run in families Kojic Acid—Natural skin-lightening agent derived from a Japanese mushroom

L Lactic Acid—A component of the skin’s natural moisturizing factor. Lagopthalmus—Upper eyelid retraction that results in difficulty closing the upper eyelids L-ascorbic Acid—The purest form of vitamin C, which when applied topically is an antioxidant, anti-irritant, anti-inflammatory

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Lateral Hooding—Excess fold of skin between the eyebrow and the outer portion of the upper eyelid which can interfere with peripheral vision Lidocaine—A local anesthetic (trade name Xylocaine) used topically on the skin and mucous membranes Liposuction—see Suction Assisted Lipoplasty Local Anesthesia—Medications (usually in the ‘caine’ family) that are injected into a surgical or treatment site to cause temporary localized numbness Lymphatic System—A network of structures, including ducts and nodes that carry lymph fluid from tissues to the bloodstream

M Malar Bags—The pouch of loose skin and fluid that sometimes develop below the lower eyelid area with aging Malar Fat Pad—A structure that sits in the second layer of the face below the cheekbone that is frequently positioned during facial rejuvenation procedures Malarplasty—Cheekbone reduction or augmentation Mammogram—An x-ray image of the breast produced by mammography Mandible—Jawbone Marionette Lines—The vertical creases that extend from the corners of the mouth towards the jowls Mastopexy—Breast lift procedure performed to re-shape the breast with or without nipple repositioning Melanin—The pigment that gives skin its color Melanoma—The deadliest form of skin cancer usually characterized by a black or dark brown pigmented lesion that can be light colored in rare cases Mentoplasty—Plastic surgery of the chin whereby its shape or size is altered Micro-dermabrasion—Also referred to as “derma-peeling’ or ‘micro-abrasion’ is a mechanical polishing of the face with sterile microparticles that abrade or rub off the very top skin layer, then vacuuming out the particles and the dead skin

Glossary

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Mid-Facelift—Also referred to as a “cheek lift,” a surgical procedure designed to lift sagging areas in the mid-face, including around the cheekbone areas below the eyes Midline—An imaginary vertical line that divides the face or body into two equal areas Mitral Valve Prolapse—Cardiopathy resulting from the mitral valve not regulating the flow of blood between the left atrium and left ventricle of the heart Mohs’ Surgery—A specialized technique of removing skin cancers from the ears, eyelids, nose and lips by serially excising a thin layer of tissue and performing immediate microscopic analysis until the lesion has been completely removed Monitored Anesthesia Care—Also called ‘local anesthesia with intravenous sedation’ and ‘twilight’, where medications are given intravenously to induce a state of sleepiness, supplemented with local anesthetic injections Musculature—The system or arrangement of muscles in a body or a body part

N Nasal Labial Folds—The deep creases on the face which extend from the outer part of the nostrils to beyond the corners of the mouth, commonly referred to as ‘smile lines’ Nasion—The depression at the root of the nose that indicates the junction where the forehead ends and the bridge of the nose begins Necrosis—Death of tissue cells Non Ablative Laser Resurfacing—A new class of lasers that does not produce a deep burn and provides a much less invasive treatment

O Orbicularis Oculi—A thin, flat muscle encircling the eye which function in the natural closing of the eyelid and in more forceful eyelid closure such as winking and squeezing the eyelids closed Orbit—The cavity in the skull where the eyeballs, eye muscles, nerves, and blood vessels rest

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Osteotomy—The operation of dividing a bone or of cutting a piece out of it Otoplasty—Reparative or plastic surgery of the auricle of the ear Outpatient Surgery—Ambulatory surgery in which you are discharged later the same day from the recovery room in a hospital, office surgical suite, or clinic

P Pectoralis Muscle—The muscle that is located beneath breast tissue and rests on top of the rib cage Petrolatum—An ingredient used in creams, to soften and soothe skin. It forms a film barrier to prevent moisture loss Periareolar—The area around the areola Periodontal disease—A disease that attacks the gum and bone around the teeth Phenol—Peeling formula applied to the skin to lighten pigment, soften wrinkles, and improve scars. This formulation is considered to be a deep and more invasive peel Phlebitis—Inflammation of a vein Photo aging—Damage to the skin due to cumulative exposure to the sun; i.e. wrinkles, age spots, fine lines Photosensitivity—Chemicals or topical ingredients that cause the skin to be reactive when exposed to sunlight such as inflammation, hyperpigmentation, and swelling Platysma—A thin sheet of muscle located just beneath the skin of the chin and neck which attaches to the mandible border and collar bone Platysmal Bands—The vertical edges of the platysma muscle of the neck located beneath the chin, that can become more prominent with age and are often sutured or tightened together in the midline during a face or neck lift Poly L Lactic Acid—Poly L Lactic Acid also known as PLLA, the main ingredient of Sculptra, is a powder that is mixed with water and then injected into the skin. PLLA is used in many medical products such as stitches and screws used to repair broken bones

Glossary

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Polysaccharide—Any of a class of carbohydrates, such as starch and cellulose, consisting of a number of monosaccharides joined by glycosidic bonds Procerus—Muscle that works with the corrugator muscles and contributes to the vertical frown lines between the eyebrows Psoriasis—An inflammatory skin disease characterized by recurring reddish patches covered with silvery scales Ptosis—A term for drooping as in eyelids, breasts, and brows

R Rectus Abdominus Muscles—Muscles located on either side of the navel which extend from the lower rib cage to the pelvic bone Retin-A (Tretinoin)—A topical medication derived from Vitamin A that is used to treat photoaging and acne Retinol—A gentler non-prescription strength alternative to Retinoic Acid. Retinol is an active form of Vitamin A that works deep under the surface of the skin to visibly reduce lines and wrinkles Rhytidectomy (Facelift)—Surgical procedure which rejuvenates the face by tightening the underlying musculature, removing excess fat deposits, and redraping sagging skin of the lower face and neck. Incisions are placed in the hairline and around the ears and/or under the chin Rosacea—A common skin condition of the face, nose, cheeks, forehead that results in redness, pimples, dilated blood vessels, and occasional pustules

S Saline—Salt water commonly used as a filler for breast implants and is also a common component of intravenous fluids Schirmer’s Test—A test that assesses tear production in the eyes and may help to predict people who are at increased risk for developing dry eye syndrome after eyelid surgery Scleral Show—Lower eyelid retraction, which causes the sclera (white part of the eyeball) to be visible below the pupil

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Sepsis—A reaction of the body to bacteria that circulate in the blood, characterized by chills and fever Septoplasty—An operation to modify or straighten the nasal septum in order to improve breathing Septum—The separating wall in the nose between the left and right nasal passages Seroma—A collection of clear fluid that may occur under the skin following surgery Silicone Gel Sheeting—Patches or strips of silicone that may be applied to the skin for extended time periods to help soften scar tissue Silicone—A synthetic substance used in a gel-like form in silicone breast implants, in a liquid injectable form for facial areas, and in other medical devices SMAS—The superficial musculoaponeurotic system (SMAS) is a layer of tissue that covers the deeper structures in the cheek area and touches the superficial muscle covering the lower face and neck called the platysma. The SMAS is often lifted and repositioned during the facelift procedure SPF (Sun Protection Factor)—A scale used to rate the level of protection sunscreens provide from UVB rays of the sun Spider Veins (Telangiectasias)—Tiny dilated blood vessels near the surface of the skin Steroids—Any of a large number of hormonal substances with similar basic chemical structure, produced mainly in the adrenal cortex and gonads Stratum Corneum—Surface layer of epidermis Striae—Commonly known as stretch marks, caused by thinning of the underlying skin layer (dermis) that appear first as red, raised lines, then darken and flatten gradually to form shiny whitened streaks Subglandular—Located under the gland, usually referring to the position of a breast implant Submental—Referring to the area below the chin Subpectoral—Also called submuscular, referring to the area below the pectoralis muscle where a breast implant may be placed

Glossary

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Subperiosteal—A term for a procedure that goes deep into multiple layers; a lift in which all tissues are separated from the underlying bone structure, thereby considered more invasive, as in brow, face, etc. Suction Assisted Lipectomy (Liposuction)—A procedure in which localized collections of fat are removed from the face and/ or body by using metal tubes connected to a vacuum which are inserted through small incisions Sunblock—A physical sunscreen or a barrier against the sun’s ultraviolet rays which is available in creams, lotions, ointments or sprays

T Tiplasty—Surgery to modify the nasal tip by placing sutures, trimming nasal cartilage and/or adding cartilage grafts Tissue Engineering—The science of production of human tissue ex vivo, (outside of the human body) as in growing cartilage in tissue culture Tissue Glue—An adhesive compound used instead of sutures or staples to approximate skin edges after surgical procedures or injuries Titanium Dioxide—A non-chemical, common agent used in sunscreen products that works by physically blocking the sun. It may be used alone or in combination with other agents TRAM Flap—Acronym for ‘transverse rectus abdominis myocutaneous’ flap, a breast reconstruction method whereby a full thickness section of abdominal fat, skin and muscle is moved to the chest wall to form a newly reconstructed breast following mastectomy Tragus—A small extension of the auricular cartilage of the ear, anterior to the external meatus Transaxillary—An incision placed in the armpit for access during surgery, as in breast augmentation Transumbilical—An approach whereby the incision is placed along the upper edge of in the umbilicus (belly button) through which breast implants may be inserted and then moved into position Tretinoin—A derivative of vitamin A

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Trichloroacetic Acid—A colorless liquid used topically as an astringent, antiseptic, and for moderate depth chemical peels Tumescent—A method of anesthesia where large dilute volumes of a mixture of local anesthetic, saline solution, and epinephrine (medication to constrict blood vessels to minimize bleeding) are injected to “plump up” the area to be operated on, commonly used in liposuction and body contouring procedures Twilight Anesthesia—See monitored anesthesia care T-Zone—The area of the face that consists of the forehead, nose, and the area around the mouth, including the chin

U Ultrasound—Application of a sound wave, a mechanical vibration of more than 16,000 cycles per second Umbilicus—Belly button or navel Undermining—Surgical separation of tissues from their underlying structures UVA—Long wavelengths emitted by the sun which take longer to produce a burn than UVB but penetrate deeper into the skin to cause sun damage UVB—Short wavelengths emitted by the sun, which are known to cause premature aging and skin cancer

V Varicose Veins—Enlarged, swollen and dilated veins just below the surface of the skin, commonly found in the legs and caused by the valves becoming filled with blood Vector—The direction of pull, as in facelifting, etc. Vermillion—The external pinkish-to-red area of the upper and lower lips. It extends from the junction of the lips with surrounding facial skin on the exterior to the labial mucosa within the mouth Vermillion Border—The periphery of the upper and lower lip vermillion associated with a distinct raised edge in youth that tends to flatten with aging

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W Wavelength—The distance between a given point on one wave cycle and the corresponding point on the next successive wave cycle, the light of the wavelength produces a pure color

Y YAG—Abbreviation for yttrium aluminum garnet, a crystal used in some types of lasers

Z Zinc Oxide—A cream applied to the skin that can act as both a moisture barrier and block for ultraviolet rays of the sun Z-plasty—A z-shaped incisional technique for scar revision that modifies the skin tension lines Zygomatic Arch—An arch formed by the temporal process of the zygomatic bone with the zygomatic process of the temporal bone. The tendon of the temporal muscle passes beneath it

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Resources www.psg1.com—The Plastic Surgery Group www.surgery.org—The American Society for Aesthetic Plastic Surger www.plasticsurgery.org—The American Society of Plastic Surgeions www.abplsurg.org—The American Board of Plastic Surgery www.abms.org—American Board of Medical Specialties www.acs.org—The American College of Surgeons

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Index A Abdominoplasty, 92–94, 96, 121, 168 Ablation, 168 Accutane®, 140 Acetylcholine, 124 Alar Base, 168 Alloderm®, 71, 134–35 Allograft, 168 Alpha Hydroxy Acid (AHA), 150, 168, 170 Aminolevulinic Acid, 149 Anatomic, 168, 170 Anemia, 168 Anti-Inflammatory, 39, 127, 168, 174 Anti-Oxidant, 168, 174 Areola, 9, 108–09, 111, 114–16, 118, 120, 168, 173, 177 Arm Lift, 36, 87, 98, 100–02, 169 Arnica, 168 Artefill®, 135 Augmentation Mammaplasty, 106 Autologous, 168

B Banana Roll, 168 Barbed Sutures, 55, 62, 168 Beta Hydroxy Acid (Salicylic Acid), 141, 169–70 Biological Fillers, 135 Blackheads, 142 Bleaching Agents, 169, 174 Blepharitis, 68, 169 Blepharoplasty, 61–66, 68, 155, 169

Body Dysmorphic Disorder (BDD), 16 Body Lift, 9, 36, 84, 98–100, 103 Body Mass Index (BMI), 97 Botox®, 36, 52, 81, 82, 124, 126–27, 132, 155, 163, 165 Botulinum Bacteria, 124 Botulinum Toxin, 10, 52, 56–7, 60, 65, 124–28, 139, 154, 169 Bovine Collagen, 128, 130, 135, 138, 157 Brachioplasty, 100, 102, 169 Breast Enhancement, 9, 35–6, 106–07, 112, 156, 163 Breast Implant, 9, 36, 107–11, 113, 163, 168–70, 178–80 Breast Lift, 25, 36, 82, 95, 98, 104, 106, 114, 116, 118, 120–21, 162, 165, 175 Breast Reduction, 34, 36, 41–2, 106, 117–19, 122, 161, 163, 166 Brow Lift, 59–63, 81, 171, 173 Buccal Fat Pads, 169 Buttocks Lift, 98–9

C Cannulae, 89, 90, 169 Capillary, 144, 169 Capsular Contracture, 42, 77, 113, 169 Captique, 128, 133 Carbon Dioxide (CO2) Laser, 145–46, 169 Cardiovascular Disease, 67

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Cellulite, 87, 98, 162, 170 Cervical Dystonias, 127 Cheek Augmentation, 75 Cheek Implants, 75 Cheek Lift, 54, 170, 176 Chemical Browlift, 126 Chemical Peel, 40, 129, 139–44, 165, 170, 181 Chin Implants, 75, 77, 136 Chin Reduction, 76 Clostridium, 124 Codeine, 43 Cohesive Gel, 110, 170 Collagen, 56, 113, 128, 130–31, 134–35, 138, 144, 147, 156–57, 170, 171, 173 Columella, 72, 170 Combining Procedures, 7, 9, 10, 24–5, 80, 103, 121, 154 Commissure, 170 Computer Imaging, 7, 30–2, 170 Congenital Defect, 170 Contact Dermatitis, 151 Contour Threads™, 55 Cornea, 68 Coronal, 60–1, 63 Coronal Brow Lift, 60 Corrugator, 170, 178 Cosmeceutical, 170 Cosmoderm®/Cosmoplast®, 134 Craniofacial Surgery, 170 Croton Oil Peel, 141 Crow’s Feet, 66, 124–25, 132–33, 165, 169 Crusting, 43, 143, 150, 169–70 Cymetra®, 134–35 Cysts, 151

D Deep Plane Lift, 53 Deflation, 107, 170 Dermabrasion, 142–43, 171 Dermal Filler, 128–29, 138, 154, 171 Dermaplaning, 141 Dermis, 139, 142, 147–48, 171, 179 Diabetes, 39, 67, 97–8, 137, 190 Diode, 149, 171 Dry Eye, 67–8, 171, 178 Dynamic Wrinkles, 124

E Earlobe Reduction, 78 Ecchymosis, 171 Ectropion, 68, 151, 171 Eczema, 171 Electrocautery, 39, 65, 171 Electromyography, 171–72 Encapsulation, 136, 172 Endoscopic, 60–2, 156, 171–2 Endoscopic Brow Lift, 60–2, 156, 171 Endoscopic Surgery, 156, 171 Endotine™, 55, 61 Epidermis, 139, 142, 146–48, 171–72, 179 Epinephrine, 88, 172, 181 Epithelialization, 150, 172, 187 Erbium:YAG, 145–46, 172 Erythema, 172 Excision, 101, 156, 173 Exfoliate, 139, 142 Extended SMAS Lift, 52 External Ultrasound (EUAL), 172 Extreme Makeover, 14, 21–3 Extrusion, 42, 77, 172

Index

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Eyelid Lift, 25, 35, 51–2, 54, 60–1, 63, 65–6, 81, 161, 165 Eyelid Rejuvenation, 9, 63–4

F Facelift, 17–18, 20, 25–6, 38, 35–6, 41–2, 50–8, 60, 69, 78, 81, 98, 132, 150, 155, 164, 166, 170, 172, 176, 178, 179, 181 Facial Implants, 74, 75, 77, 130, 157 Fascia, 172 Fat Atrophy, 128 Fat Embolus, 172 Fat Transfer, 76, 157, 166 Fibrin Sealant, 172 Fibroblast, 172 Filler, 10, 107, 128–30, 134, 173 Follicle, 173 Forehead Lift, 36, 59, 65, 173 Fractional Resurfacing, 146–47 Fraxel®, 146–47 Free Radicals, 173 Frontalis, 173

H Hematoma, 42, 59, 68, 173 Human Tissue Fillers, 134 Hyaluronic Acid, 128, 130–33, 173–74 Hyaluronic Acid Gel, 128, 131, 132 Hydroquinone, 141, 169, 174 Hylaform, 128, 133, 137 HylaformPlus, 133, 137 Hyperpigmentation, 169, 174, 177 Hypertrophic Scar, 174 Hypertrophy, 174 Hypopigmentation, 174 Hypertension, 67, 174 Hypoplasia, 174 Hypothyroidism, 67

I Inframammary Crease, 108, 174 Intense Pulsed Light (IPL), 148–49 Intraoral, 75

J G General Anesthesia, 8, 48, 60, 65, 74, 79, 88, 93, 98, 111, 114, 118, 129, 173 Genioplasty, 75, 173 Glabella, 126, 139, 170, 173 Glycolic Acid, 140–41, 168, 173 Graft, 71, 118, 120, 166, 168, 172, 173, 180 Graves’ Disease, 67 Gynecomastia, 120, 173

Jaw, 38, 50, 52, 54, 56, 74–76, 132, 145, 166, 174–75 Jaw Implants, 76 Jessner’s Solution, 141, 170

K Keloid, 174 Kojic Acid, 169, 174

L Lactic Acid, 141, 174 Lagopthalmus, 174

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L-Ascorbic Acid, 174 Lasers, 10, 143–47, 150, 154, 157, 165, 176 Laser Therapy, 56, 65, 139 Lateral Hooding, 175 LED, 149 Lidocaine, 92, 134, 135, 175 Light Sources, 10, 144, 148 Lip Enhancement, 10, 137–38 Lipoplasty, 175 Liposuction, 20, 24–6, 36, 41, 57, 75–6, 81–93, 95, 98, 100, 102–03, 121–22, 160–62, 164–66, 169, 172–73, 175, 180–81 Local Anesthesia, 8, 47–8, 56, 60, 65, 70, 74, 79, 91, 111, 114, 118, 121, 129, 134–35, 145, 175–76 Lower Blepharoplasty, 65 Lymphatic System, 102, 134, 175

M Malar Bags, 175 Malar Fat Pad, 175 Malarplasty, 75, 175 Malocclusion, 76 Mammogram, 106, 108, 113, 175 Mandible, 174–75, 177 Marionette Lines, 175 Mastopexy, 114–15, 175 Melanin, 169, 174–75 Medium Peels, 141 Melanoma, 175 Mentoplasty, 75, 175 Microdermabrasion, 40, 129, 142–44, 147, 161

Mid-Facelift, 54–5, 101, 176 Midline, 57, 176–77 Milia, 151 Mini-Facelift, 155 Mitral Valve Prolapse, 39, 176 Mohs’ Surgery, 176 Monitored Anesthesia Care, 47, 176, 181 Musculature, 176, 178 Myobloc®, 127

N Nasal Reshaping, 70–1, 81, 163, 166 Nasion, 176 Nasolabial Folds, 54, 131–32, 135, 157 Nasomental Creases, 131 Neck Contouring, 56–7 Neck Lift, 20, 56–8, 75, 177 Neck Suspension, 56, 58 Necrosis, 176 Nipple Inversion, 9, 121 Nipple Reduction, 9, 120 Non-Ablative Laser Resurfacing, 10, 144, 147 Non-Resorbable Fillers, 10, 130, 135 Non-Steroidal, 39, 127, 138

O Orbicularis Oculi, 176 Orbit, 125, 176 Orthodontics, 76 Osteotomy, 177 Otoplasty, 78–9, 177 Outpatient Surgery, 14, 18, 32–3, 44, 65, 74, 79, 88, 90, 93, 121–22, 160, 177

Index

Beauty in Balance FINAL 187

187

12/7/05 5:41:06 AM

P Pectoralis Muscle, 108, 119, 177, 179 Petrolatum, 177 Periareolar, 108, 177 Percocet, 43 Periodontal Disease, 177 Perlane, 128, 131, 132 Permanent Cosmetics, 10, 137, 151 Phenol, 141–42, 144, 170, 177 Phenol Peel, 141–42 Phlebitis, 102, 177 Photo Aging, 177 Photosensitivity, 177 Photodynamic Therapy (PDT), 149 Photomodulatio, 149 Pigment, 120, 140–42, 144, 148, 150–51, 165, 168, 169, 174, 175, 177 Platysma, 177, 179 Platysmal Bands, 177 Poly L Lactic Acid, 177 Polymethyl-Methacrylate Microspheres (PMMA), 135 Polysaccharide Power Assisted Lipoplasty (PAL), 131, 136, 178 Procerus, 178 Psoriasis, 178 Ptosis, 64, 127, 178 Puretox®, 126

R Radiesse™, 128, 136 Radiofrequency Waves, 148

Rectus Abdominus Muscle, 178 Reduction Mammaplasty, 116 Reepithelize, 150 Regional Anesthesia, 8, 48, 128 Reloxin®, 126 Resorbable Fillers, 10, 129–30, 135 Restylane®, 36, 126, 128, 131–33, 137, 154, 157, 166 Restylane Sub Q®, 132 Restylane Touch®, 131–32 Retin-A® (Tretinoin), 141, 178 Retinol, 178 Retrobulbar Hematoma, 68 Rhinoplasty, 69–73, 75, 81 Rhytidectomy, 51, 146, 172, 178 Rosacea, 148, 178

S Saline, 36, 74, 108, 110–11, 163, 170, 178, 181 Salicylic Acid, 141, 169 Schirmer’s Test, 178 Scleral Show, 178 Sculptra, 76, 128, 134, 166, 177 Sepsis, 179 Septoplasty, 71, 179 Septum, 69–71, 179 Seroma, 42, 91, 179 Silicone Gel, 36, 40, 107, 109–11, 170, 179 Silastic, 71 Silicone Implants, 76, 110, 136 SMAS Lift, 51–3, 179 Skin Resurfacing, 10, 52, 81, 129, 139, 144–45, 161 SPF (Sun Protection Factor), 179

188 BEAUTY IN BALANCE

Beauty in Balance FINAL 188

12/7/05 5:41:07 AM

Spider Veins (Telangiectasias), 179 Steroids, 179 Spot Test, 151 Steri-Strips, 99 Stratum Corneum, 179 Stretch Marks, 88, 92, 163–64, 179 Striae, 179 Subglandular, 108, 179 Submental, 179 Subpectoral, 179 Subperiosteal Lift, 53 Suction Assisted Lipectomy (Liposuction), 88, 175, 180 Sunblock, 147, 180 Superficial Peels, 140–41, 143, 147

Tumescent, 88, 91, 181 Tummy Tuck, 9, 20, 24, 28, 36, 44, 82, 84, 87, 92–4, 96, 98, 103–04, 121, 161, 164–65, 171 Twilight Anesthesia, 6, 45, 179 Tylenol, 41 T-Zone, 179

U Ultrasound, 113, 172, 181 Ultrasound Assisted Liposuction (UAL), 89 Umbilicus, 180 Undermining, 181 Upper Blepharoplasty, 66 UVA, 144, 150, 181 UVB, 144, 150, 179, 181

T

V

Tear Troughs, 66 Temporal Lift, 62 Thigh Lift, 84, 87, 98, 102–03 Threadlift™, 55–6, 62, 81, 155 Tiplasty, 180 Tissue Engineering, 180 Tisseal, 36 Tissue Glue, 7, 36, 172, 180 Titanium Dioxide, 180 Tram Flap, 180 Tragus, 180 Transaxillary, 108, 180 Transblepharoplasty Brow Lift, 61–2 Transconjunctival, 65–6 Transumbilical, 108, 180 Tretinoin, 178, 180 Trichloroacetic Acid (TCA), 141, 170, 181

Varicose Veins, 39, 181 VASER® Assisted Lipoplasty, 89 Vector, 181 Vermillion Border, 137, 151, 181 Vicodin ES, 43 Vitamin E, 39

W Wavelength, 146–47, 172, 181

Y YAG, 145, 146, 172, 182

Z Zinc Oxide, 182 Z-Plasty, 182 Zyderm®, 130 Zygomatic Arch, 182 Zyplast®, 130

Index

Beauty in Balance FINAL 189

189

12/7/05 5:41:07 AM

Notes

Beauty in Balance FINAL 190

12/7/05 5:41:08 AM

Notes

Beauty in Balance FINAL 191

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Notes

Beauty in Balance FINAL 192

12/7/05 5:41:08 AM

Before

After

This beautiful young woman has never liked the shape of her nose. She had nasal reshaping surgery in addition to insertion of a chin implant to give her better facial balance.

BIB Photo Gallery interior 1

12/7/05 6:08:02 AM

Before

After

At 58, this housewife was unhappy with the progressively worsening droopy neck bands, jowls and frown lines near her mouth. She had her neck lifted and fat added to smooth the jawline and soften the folds and now has a youthful, natural look.

BIB Photo Gallery interior 2

12/7/05 6:08:07 AM

Before

After

Before

After

To help combat the signs of facial aging, this active, single 52 year-old woman had a combined facelift and upper and lower eyelid lift. Restylane® was added into the folds around her mouth to complete her facial rejuvenation.

BIB Photo Gallery interior 3

12/7/05 6:08:13 AM

Before

After

Before

After

Excess, loose skin of the eyelids, face and neck annoyed this 58 year-old woman. She had a facelift with an upper and lower eyelid lift to give her a softer, more rested look.

BIB Photo Gallery interior 4

12/7/05 6:08:18 AM

Before

After

This 49 year-old self-employed woman was unhappy with the extra skin on her upper eyelids and the bags under her eyes. After an upper and lower eyelid lift, she has a younger, refreshed look, enhanced by Botox® to smooth out the area between her eyebrows.

BIB Photo Gallery interior 5

12/7/05 6:08:29 AM

Before

After

Before

After

For years, this 40 year-old woman had a hooded upper eyelid with no visibility of her upper eyelid crease. Removing upper eyelid skin unmasked her natural eyelid crease to reveal its underlying beauty.

BIB Photo Gallery interior 6

12/7/05 6:08:34 AM

Before

After

In this 63 year-old woman, a brow lift enhanced the rejuvenation effect of an upper and lower eyelid lift. This is a classic example of procedures that complement each other when done together.

BIB Photo Gallery interior 7

12/7/05 6:08:38 AM

This active 48 year old woman was not ready for face lifting, but received the freshening up she wanted with a contour thread lift to the brows and mid face. Lip enhancement with Restylane® and cheek filler with Sculptra® completed the rejuvenation.

Before

After

BIB Photo Gallery interior 8

12/7/05 6:08:44 AM

Before

After

This former beauty queen who is now 38 years-old, developed fatty deposits on her hips and thighs that did not improve with diet and exercise. She had liposuction to soften her curves.

BIB Photo Gallery interior 9

12/7/05 6:08:45 AM

This athletic 41 year-old developed loose, wrinkled skin on her abdomen after her pregnancies that did not change with diet or exercise. A tummy tuck gave her a flatter, tighter and smoother belly.

Before

After

BIB Photo Gallery interior 10

12/7/05 6:08:51 AM

This college junior was not happy with her small A-cup sized breasts. She had breast enhancement with saline implants to give her a spectacular C-cup breast. Before

After

BIB Photo Gallery interior 11

12/7/05 6:08:55 AM

After pregnancies and breast feeding, this 41 yearold mother of two developed “deflated” breasts. She had breast enhancement surgery with saline implants which increased her bra size from a large A-cup to a small C-cup to restore her pre-pregnancy fullness.

Before

After

BIB Photo Gallery interior 12

12/7/05 6:09:00 AM

Before

This college freshman had back and neck pain from large droopy breasts and wore 2 sport bras every day for support and to minimize her chest size. After removing breast tissue from both sides, she has gone from a D-cup to a small C-cup bra size and her breasts have an uplifted, more attractive shape.

After

BIB Photo Gallery interior 13

12/7/05 6:09:05 AM

This 49 year-old mother of two developed sagging breasts as a result of pregnancies, breast feeding and gravity. She had a breast lift and now her breasts have a more uplifted, youthful shape.

Before

After

BIB Photo Gallery interior 14

12/7/05 6:09:10 AM

Before

After

Botox injections were used in this 46 year-old woman to smooth out the frown lines between her eyebrows.

BIB Photo Gallery interior 15

12/7/05 6:09:15 AM

Before

After

Treatment of Smile Lines Courtesy of Medicis Aesthetics™

BIB Photo Gallery interior 16

12/7/05 6:09:18 AM