Patients frequently ask “what’s new in plastic surgery”. We are all looking for newer, faster, better. But be cautious. Unscrupulous physicians may try to sell you the “newest” which may not yet be proven or approved.

A prime example of this is the “stem cell face lift”. This has been touted as “a new technique using adult stem cells from the body’s own fat tissue that has been found to restore the plumpness, smoothness and skin tightness of a more youthful face.” Another example is the “stem cell breast augmentation” also known as “natural breast augmentation,” which “employs the latest technologic advances in fat harvesting, adult stem cell transfers and breast splinting technology to provide women the option of enlarging their breasts using their own fat.” These marketing claims are promoted as the latest techniques and we are bombarded daily with their promises in print ads, Internet ads and radio and TV ads. Although there is real hope within the Plastic Surgery community that stem cells may soon produce beneficial medical therapies, as of yet, such claims are not founded on the best science. The overall effectiveness of these so called “stem cell” treatments remains unproven.

The American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery have concluded that there is very little evidence of effectiveness of “stem cell therapies” used in aesthetic surgeries. The conclusion these societies have reached is that in time, good science and long term results will establish and confirm the truth about stem cell therapies, helping patients and plastic surgeons alike. Goods science will then trump clever but unsubstantiated marketing, for the benefit of all.

Several months ago it was announced by the media that the breast implants manufactured by Poly Implant Prostheses (PIP) were suspected to contain non-approved silicone gel that is believed to pose an increased risk of rupture. Since then I have received many calls from patients asking if they have this type of implant. To my patients, I have never used PIP implants in my practice. To any other women with breast implants in the United States there is little to fear. Although as many as 400,000 women in 65 countries in Europe and Latin America are estimated to have PIP implants, these implants were never approved for use in the United States. Therefore an American woman would have to have been implanted outside the United States in order to have received the implants that are now the subject of concern.
A lawyer for PIP told Agence France Presse that PIP knew it was not in compliance but claims the silicone used in the implants was non-toxic. He said it had not been proven that the implants were more likely to leak.
Approximately 80% of the PIP implants used were outside of France in the United Kingdom, Spain, Brazil, Argentina, Chile, Columbia and Venezuela. The implant was also marketed under the brand name “M” by a Dutch company in Germany.
The French Ministry of Health has recommended that the 30,000 French women with PIP implants have them removed. No other country has made any recommendations to date.

As we get older one of the most common problems for both men and women is sagging skin of the upper eyelids. This condition, known medically as blepharoptosis, creates a problem which is both cosmetic and functional. Fortunately the correction of this problem is relatively simple and many times inexpensive.

Blepharoptosis becomes a functional problem when the extra skin of the upper eyelid begins to hang into the visual field partially obstructing vision. Patients begin to notice that they don’t see things approaching from the side. This is called loss of peripheral vision and it can be measured with a visual field test performed by an ophthalmologist. Usually if a patient fails the visual field test indicating that they have lost peripheral vision due to hanging eyelid skin, the corrective surgery will be covered by their medical insurance.

If the redundant skin of the upper lid is not severe enough to obstruct vision then the problem is cosmetic. The extra skin creates lines and wrinkles giving the appearance of aging sometimes prematurely. Occasionally there is protruding fat creating a bulge usually in the corner of the eye near the nose. Removing this at the same time creates a flat smoothe eyelid and a younger appearance.

Patients worry about injury to the eyeball when having eyelid surgery. This would be extremely rare in the hands of a competent surgeon. Although the eyelid seems to be very thin it is actually comprised of multiple layers. Under the eyelid skin are several layers of muscle, cartilage and the inner lining against the eyeball called conjunctiva. When performing blepharoplasty of the upper eyelid a measured segment of skin is removed from the lid. The amount of skin to be removed is determined by pulling the skin outward until the eye starts to open. This tells the surgeon the maximum amount of skin that can be removed. The layer directly beneath the skin is the orbicularis muscle. If there is protruding fat it is located just beneath the muscle. To remove the fat an opening is made in the muscle and the fat is exposed exposed and removed. If the muscle itself is redundant a strip of muscle can be removed. When all of this is completed the skin is sutured closed. This usually results in a row of sutures which extends from the inner part of the lid near the nose to the outer part of the lid just past the corner of the eye. These sutures are usually removed four to five days after surgery.

Upper eyelid surgery is almost always an outpatient procedure. This surgery can easily be performed under local anesthesia. Some patients prefer to have some sedation like Valium. This is a personal preference. Either way patients undergoing blepharoplasty under local anesthesia may go home immediately after surgery. There are no bandages and patients may begin to shower and wash their face the next day. There is usually a minimal amount of pain or discomfort which is easily controlled with oral pain medication. Post operative limitations are minimal.

Because this procedure can be done in the office under local anesthesia the cost is significantly reduced. There is no charge for use of the operating room or anesthesiologist. In my office upper blepharoplasty can be done for $1000 to $1500 depending on different surgical factors.

I was surprised to learn recently that many newer plastic surgeons do not perform nasal surgery. When I asked why they said, it’s too hard to learn and too difficult to do. Since nasal surgery is one of my most common procedures, I may be one of an elite group of plastic surgeons who perform rhinoplasty surgery.
Rhinoplasty is the technical name for surgery of the nose. This surgery usually involves two components. The first is a functional component which addresses the patients ability to breath through the nose. The second is the aesthetic component which addresses the appearance of the patients nose.
The most common cause for nasal airway obstruction or difficulty breathing through the nose is over growth of internal structures called turbinates. We all have turbinates in our nose, three on each side. There is one up high, one in the middle and one low on each side. It is the low one which overgrows and gets in the way. Turbinates are boney out croppings from the side on the nasal wall which, like a radiator, provide more surface area in the nose so that when we breath in through the nose the air is warmed before heading for the lungs. If the lower turbinate gets too big it obstructs the flow of air and we have difficulty breathing through our nose. Surgery to correct this situation involves reducing the size of the turbinate so that it does not obstruct the passage of air through the nose.
The other cause of nasal airway obstruction is deviation of the nasal septum. If the septum moves to one side or the other it can obstruct the passage of air on that side. This is fixed simply by straightening the septum. Correction of functional problems such as nasal airway obstruction may be covered by medical insurance.

The aesthetic correction of the nose can be accomplished most of the time through the nostrils and therefore leaves no external scars.  Occasionally patients will have unusual or severe deformities which require an open rhinoplasty.  This procedure creates a scar across the columella which is the piece of skin between the nostrils.

The most common aesthetic deformity of the nose is the hump on the bridge of the nose. This is corrected by removing the hump. Ideally the best looking nose is either straight or slightly dipped on profile.   Once the hump is removed it leaves the back of the nose flat.  In order to correct this the nasal bones have to be tipped inward.  This also narrows the nose.  The cartilege in the nasal tip is reshaped in order to refine the tip.  Finally some of the cartilege at the end of the septum behind the columella is frequently removed to tip the nasal tip upward.  Care must be taken not to overdo this because too much upward tipping gives a pig snout look.

Dissolving sutures are placed inside the nose.  Some type of splint is placed on the outside and is usually worn for five days.  Some nasal surgeons put packing in the nose after surgery.  I do not believe this is necessary and almost never use nasal packing. It is very common to get bruising after this surgery, usually under the eyes. Bruising usually lasts five to seven days.

Reshaping of the nose is one of the most gratifying surgeries for patients. Nasal deformities can be very disturbing especially for women. Simple correction frequently improves ones appearance significantly.
 

I am frequently asked, “Will my surgery leave a scar?” and when I say yes, patients sometimes say that they thought that since I am a Plastic Surgeon, I could do surgery without leaving scars. If you read about or hear about having surgery with no scars, you are being deceived. It is impossible. They might mean tiny scars or very well hidden scars, but with today’s technology it is impossible to do scarless surgery. However, as improbable as it sounds, I believe that in the near future, we will be able to do surgery without leaving scars.  In order to illustrate, let me explain where scars come from.

When you were a developing embryo, your body had the ability to build any type of tissue; It could grow skin, muscle, nerve, fat, etc. from cells called stem cells. Unfortunately, once you are born that ability disappears, and your body is no longer capable of regenerating tissue. Therefore, if you injure any type of tissue and it needs to be replaced, your body can only produce a “patch” of tissue called scar tissue. If you get a cut in your skin, your body cannot grow new skin to repair the injury, so it makes a scar instead.  The same is true of other tissues such as muscle. If you have a heart attack and the heart muscle is damaged, your body repairs this with scar tissue, and your heart doesn’t function as well as it used to.

If you were to have surgery while you were in the womb (this has been done on animals) you would be born with no resulting scar because your body would regenerate new skin and would not need to make a scar tissue patch. Using information about tissue regeneration in embryos and extensive research on stem cells, it is very likely that we will soon unlock the secrets of tissue regeneration. If this occurs, we should be able to injure a tissue such as skin and cause it to regenerate.  This would mean that when we, as surgeons, use a scalpel on your skin to perform a face lift, tummy tuck, or any other surgery, there would be no resulting scar. This also has potential to eliminate things like stretch marks.

Of course, tissue regeneration would have many other benefits like replacing defective organs such as livers, kidneys and hearts. There is the possibility of growing new limbs. As a plastic surgeon I can foresee amazing advances in the treatment of burn scars, cleft lips, and the elimination of the need for face transplants, as well as the benefits to cosmetic surgery.  In the meantime Plastic surgeons will continue to create the most cosmetically pleasing scars possible.

Patients considering breast augmentation frequently have difficulty choosing between silicone and saline breast implants. The decision is not always easy, but if you know the basic difference between silicone breast augmentation and saline breast augmentation, it is easier to decide.

Approximately twenty years ago the FDA decided that not enough research had been done on the silicone implants. For this reason, the silicone implants were taken off the market while more research was done. After ten years of experimentation and study it was determined that silicone implants were safe, and they were returned to the market.  They are available now to any female over the age of twenty two. Now that silicone is available, patients must decide what type of implant they would like for their breast augmentation surgery.

Saline implants for breast augmentation come from the manufacturer sterile but not inflated. They come in a size range such as 350cc +25cc. This means the implant can be filled from 350 to 375cc. The saline solution is placed in the implant at the time of surgery. This can be done before or after the implant is inserted.
When a saline implant is used for breast augmentation, it is most often placed behind the pectoral muscle. Saline implants don’t feel like breast tissue, so it is necessary to bury them as deep as possible so that one cannot feel the implant. Therefore, the muscle provides an extra layer of covering for the implant.
If a saline implant gets a small hole in it, the saline will leak out and the implant will deflate. If this occurs it is not harmful, but the implant needs to be replaced. Implants are guaranteed for life, so if it deflates, the manufacturer will replace it free of charge.
Saline implants are less expensive than silicone implants.

Silicone implants come from the manufacturer sterile and filled to a certain size. Therefore the size cannot be adjusted at the time of surgery. The only way to adjust the size of a silicone implant is to pick a new implant.

If a silicone implant develops a small hole nothing will happen because the gel is cohesive and it will stay inside the shell and not leak out.
Silicone feels very much like breast tissue and therefore does not need to be hidden behind the pectoralis muscle. Silicone implants are more expensive than saline implants.
These are the basic differences between the two types of implants used for cosmetic breast augmentation. Many patients know immediately which type they would prefer. Others have trouble deciding. If you are in the second group take your time. Talk to your doctor, talk to your friends and get online and do your research. Eventually the answer will come.
Coming soon:Botox versus Dysport.

Dr. Corwin