Facelift, More Is Not Necessarily Better

Plastic surgeons have been doing facelift surgery for more than 70 years. The procedure began by removing a small strip of skin from in front of the ears thereby tightening the skin of the cheeks when the wound is closed. Patients and surgeons wanted more tightening and longer results, so the plastic surgeons began lifting the skin off the cheeks so that more skin could be advanced and removed. So the evolution began, lifting the skin off the cheeks and the neck, working on the underlying muscles, doing delicate dissection around the small nerves of the face and even dissecting down to bone to attempt to create the maximum lift. The latest thing now is fat grafting to fill in defects not corrected by the lift or even created by the lift. We have all seen on TV the results of this attempt to create perfection, Melanie Griffith, Bruce Jenner, Kim Novack and Joan Rivers to mention a few. In an attempt to create perfection we may have gone too far. The procedure now is very invasive and dangerous. Six or more hours of surgery is common requiring a general anesthetic. The recovery is not pleasant requiring bandages, drains, pain medication and limited mobility for weeks. Considerable swelling a bruising is the norm. The icing on the cake, of course, is the price. Because the procedure requires a general anesthetic and the use of an operating room for an entire day these must be added to the cost. Charges of $15,000 to $20,000 are not uncommon. For all of these reasons I realized It was time to re think this problem, so two years ago I decided to regroup.

In 2012 I began doing what I now call the Miracle Lift. It is a miracle because patients can hardly believe that they can get their desired result with a one to two hour procedure done easily with a local anesthetic and essentially no recovery time. I have done this procedure in an exam room, but I now use an operating room due to patient positioning. 50 percent of patients will take a Valium pill prior to the procedure while the other half choose to take nothing. A local anesthetic is injected into the surgical site in front of and behind the ear. This is minimally uncomfortable and very well tolerated. Once this is completed the procedure is completely painless. Because this surgery is minimally invasive there is almost no swelling or bruising. Patients are frequently out and about the day after surgery. The results are instantaneous and do not require healing time or waiting for swelling to subside. Stitches in front of and behind the ear are removed one week after surgery. There are no bandages and no drains. I do ask patients not to do heavy exercise for one week after surgery as a precaution. They may resume all medications including aspirin immediately after surgery.

I have done many of these procedures during the last two years and the patients are universally happy. The biggest negative when compared to a traditional facelift is that the results won’t last as long. With this procedure the results should last three to five years. If that is a concern the patient can simply have another procedure. They would have to repeat more than five times to match the cost of a traditional facelift.

The resulting appearance is actually better than the traditional face lift because you don’t get the facelift deformities (again refer to the tv). Patients who have a Miracle Lift end up looking great, not like some one who has had a face lift.

In summary, this procedure is less than one fifth the cost of a traditional face lift, has immediate results, takes about one to two hours to perform, requires no bandages or drains, requires no recovery time, has little to no swelling and bruising, has almost no chance of complications from surgery,and gives a better result than a traditional lift. I think it’s time to ditch the standard face lift and switch to the Miracle Lift.

Theodore R. Corwin, MD
Plastic and Reconstructive Surgery

Anti-Aging, Real Or Not?

Anti-aging seems to be the “hot” word today. We see it in almost every magazine and newspaper article which has anything to do with our appearance. So what is anti aging and what do we have to do to accomplish it?
Unfortunately with today’s scientific knowledge we are unable to stop or reverse the aging process. “Anyone who claims that they can stop or reverse the aging process is lying to you–even if they’re a doctor. It is not currently possible,” says S.Jay Olshansky, a demographer at the University of Chicago. Products sold such as “youth” hormone treatments, megavitamin cocktails, herbal elixirs, etc. have never been demonstrated to influence the processes of aging.

But just because you can’t slow or stop the aging process doesn’t mean you should stop taking care of yourself. In this regard you can accomplish two things. First you can minimize the aging process so that you do not age faster than your years. This is accomplished simply by healthy eating and exercise. Give your body all of the tools it needs to succeed.
Second, you can mask the aging process using cosmetics, topical skin treatments and the techniques of your plastic surgeon. These techniques can be simple things like Botox or dermal fillers or more extensive things such as cosmetic surgery.
The combination of healthy living and plastic surgery techniques will not slow your aging process, but it will look like it has.

Newer Isn’t Always Better

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.

The PIP Silicone Breast Implant Scare

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.

Blepharoplasty-Upper Eyelid Surgery

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.

Nose surgery

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.
 

Scars

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.

Botox versus Dysport

Botox has been around for many years. It is a chemical agent that can be injected into muscles to temporarily slow or impede their movement. For many years Botox was used by physicians to treat various uncommon conditions involving unwanted muscle spasms. About fifteen years ago it was discovered that Botox was effective in treating facial wrinkles by inhibiting the muscles that cause these wrinkles. The best example is the lines that occur between your eyebrows when you squeeze you eyebrows together. This action is caused by two small muscles, one on each side, called corrigator muscles. Putting Botox into these muscles causes them to stop working. Once the corrigator muscles stop working the lines between the brows disappear. One injection of Botox will last approximately three months. Other common areas for Botox use are the lines on the outer side of the eye that we call laugh lines, and the lines across the forehead.
About three years ago a Botox competitor called Dysport became available in this country. It has been available in Europe for years. Now that there are two products to choose from, patients frequently ask me about the difference between the two. There is not a great deal of difference between Botox and Dysport. Of course they are made by two different companies. They are essentially the same price. Dysport requires about three times as many units as Botox for the same effect, but the price per unit is three times less. They both last the same amount of time, approximately three months. Some users believe one lasts longer than the other, but there are equal proponents on both sides. Dysport may take effect a little quicker than Botox. Botox may have a more consistent effect than Dysport. In summary they are close to equal. Therefore my suggestion would be to try them both. If you have a better effect with one than the other then you can stick with that one. If they are equal in effect, take the one that’s cheapest. Just make sure that you know how many units you are getting and how much you are paying per unit. Find a good injector, one who knows his/her anatomy. Your best bet would be a board certified plastic surgeon.

Breast Augmentation, Silicone or Saline

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