Everything evolves. When cosmetic fillers were first used, we applied them to the problems of wrinkles – and they worked pretty well. Then we used them to enhance lips, and then to enhance cheekbones, and to smooth out jawlines…and the list of uses kept on growing.

This ever-increasing use of fillers has directly led to the concept of the “liquid facelift”, which is simply the use of a significant volume of injectable filler agents to add volume to the face. When done appropriately, and done well – the technique can look good, restoring the lost contours of youth, at least for a time, until the costly products are absorbed by the body. But like anything, it can be overdone. And quite expensive.

Hype alert: the liquid facelift technique is not really “just like a regular facelift”, despite the marketing hype of some websites. The two methods work totally differently. Let’s review some of the basic differences:

– In a surgical facelift, you remove excess neck and cheek skin. Not possible with the liquid facelift technique, which works by inflation.

– In a surgical facelift, you can tighten the neck muscles and re-suspend the SMAS layer (the fibro-fatty anatomic layer between the skin and the muscles). Not possible with the liquid technique.

– Traditional facelifts (with the exception of those that use fat grafting techniques) work by tightening tissue planes. This can sometimes cause a flattening effect on soft-tissue facial curvature.

– The liquid techniques work by inflation or “re-volumizing”, and can add fullness to areas that would otherwise be difficult to correct. Traditional facelifts can sometimes shift soft tissue fullness by re-distributing or lifting tissues, but they don’t add new volume.

– Surgical facelifts typically have an effect of 8 to 10 years, on average. Injectable products, even the newer, longer-lasting ones, last 1-2 years at most.

So, the two procedures are not directly comparable. Don’t be fooled – choose the right procedure for your particular needs. If you have a lot of lax skin, get a surgical facelift. If you have loss of facial volume issues with minimal skin laxity, then you might be a candidate for re-volumizing with fillers. Your plastic surgeon can advise you.

I’m also starting to see patients who have been over-treated with the facial fillers. It used to be just the lip area – but now it’s the entire face that is involved. Since there isn’t an official name for this, I’ll call it “puffy-face syndrome”. Features of “Puffy face syndrome” that I’ve seen include:
– generalized swollen or bloated look to the face, due to the over-injection of filler agents, which is out of keeping with the pre-procedure appearance;
– excessive fullness in some or all of the injected areas: brow, cheekbones, paranasal and perioral areas;
– obliteration of normal naso-labial creases.

Interestingly, many of the patients that I feel are over-injected seem to be somewhat addicted to their filler treatments. When I tell them “no, you really don’t need any more volume” – they react with shock and disbelief!

So, while I think that facial fillers are useful, they are but one option among many for the treatment of facial aging. Too much filler can lead to Puffy Face Syndrome! This is another example of how aesthetic judgement is important.

One variation of the usual abdominoplasty (tummy-tuck) is known variously as the “anchor”, the “vertical” or “Fleur-de-lys” abdominoplasty. This involves removing not only the lower abdominal skin and fat, but also adding a vertically-oriented segment shaped like an inverted “V” in the upper midline. When the surgery is completed, this leaves a T-shaped or “anchor” shaped incision, but it is a very effective tightening operation for those who need it.

It’s usually only performed for our patients that have lost a major amount of weight (>100 lbs), and who have obvious fullness or laxity in that upper midline zone of the abdomen. Standard abdominoplasty techniques don’t correct horizontal laxity of the upper abdomen very well, so this technique may be useful for patients with that particular issue.

Also, for patients that have had a previous traditional open-style gastric bypass operation, and who have a scar there already, the fleur-de-lys approach is a reasonable option, as we are not adding any new scars, and are merely using the pre-existing midline incision to take out a little more skin there.

As is commonly the case in excisional body lifting surgery, this operation is a trade-off: more scars, but better tightening.

Advantages of the fleur-de-lys approach:
– better tightening of upper abdominal zone when obvious laxity is present
– may permit excision of previous old-fashioned gall-bladder surgery scars
– gives horizontal tightening, unlike a standard abdominoplasty

– more scars, which are not as well hidden as a standard abdominoplasty
– has potential for wound healing problems at intersection of incisions
– umbilicus shaping is more complex, prone to post-operative shape changes

I came across an interesting survey in the latest issue of the Journal of the American College of Surgeons. A total of 895 board-certified surgeons were surveyed about their practice, their work hours and the levels of personal satisfaction about their practice, lifestyle and factors that might influence these perceptions.

Here are some of the findings:
– 80% were men, with an average age of 46.
– the average surgeon works 64 hours per week. Most would prefer to work less; about 50 hours per week.

Here’s the troubling news:
– 15% were dissatisfied with their careers.
– 33% said they did not have a good balance between work and their personal life.
– 40% would not recommend a career in surgery to their own children.
– 90% believed their lives and levels of career satisfaction could be significantly improved by diminishing litigation (medical malpractice / frivolous lawsuits)

Interestingly, these attitudes were consistent across different generations of surgeons. Generation X surgeons did not have different responses than “baby boomer” era surgeons.

As a surgeon, I fully understand and appreciate these issues. Surgery is a very demanding career choice. There’s a lot of responsibility, 24/7. It can be wonderful, however, when people appreciate the efforts you’ve made for them – a big smile or a simple “Thanks, Doc!” from an appreciative patient can make your day.

To keep up with the aging population, we’re going to need more surgeons. A surgeon shortage is already predicted, as currently working surgeons retire without replacements. These issues of career satisfaction, work hours, and litigation need to be addressed at a systemic level.

There are a few websites that claim to simulate the effects of plastic surgery on a photo that you can upload to the site. Others have adjustable 3-D renderings of models, where you can adjust their appearance by moving slider-type controls, to more closely mimic your own appearance.I’ve looked at a couple of these, and yes, they are fun to play with. You can check them for yourself: lookingyourbest.comreshapr.com, and liftmagic.comUnfortunately, they are quite limited with what they can do, and how realistically it corresponds to what surgeons can achieve in the operating room. I found the programs worked acceptably well when modelling the effect of wrinkle smoothing (“airbrushing”) lines and wrinkles. But I thought they fell short when modelling the much more complicated effects of rhinoplasty, blepharoplasty or facelift surgery. For example, the rhinoplasty simulator shows only a generic narrowing of the width of the nose on the front view, or reduction of a hump on the nose on the side view. There’s no way to simulate nasal tip surgery.

The breast augmentation program at lookinyourbest.com claims to show the effect of certain size and shapes of breast implants. While this site does give potential patients some education about the difference between high profile and moderate profile implants, I felt that the results pictured did not look like what the real result would be with an implant of the stated size or shape.

So, use these websites for fun – but they are not very representative of what your post-operative appearance will look like at all.

One of the most worrisome problems for surgeons is known as venous thromboembolism (VTE) – blood clots such as deep vein thrombosis and pulmonary embolism. These can occur after long operations, even in seemingly healthy people – and can be a life-threatening problem. In the past, we’ve used compression stockings, pneumatic sequential compression devices, or injectable blood thinners, like heparin and lovenox, to successfully reduce, but not completely eliminate, the risk of VTE’s. However, these therapies have been awkward to use, especially for outpatient surgery.

Now, the FDA is looking at approving a new medication that may be very helpful with this problem. Called Xarelto, it’s a once a day tablet. Technically speaking, it is classified as a direct Factor Xa inhibitor. According to the studies, it works as well or better than its injectable cousins (like lovenox) at preventing VTE. And unlike Coumadin, xarelto doesn’t require frequent blood tests to get the dose right. As an oral medication, it would be easy to patients to continue on this therapy at home, while they are recovering from surgery.

Barring side effects, Xarelto could be a real breakthrough for patient safety. In the field of Plastic Surgery, the obvious application would be for abdominoplasty (tummy tucks), where the risk of VTE is significant. The optimal dosing schedule for plastic surgery patients hasn’t yet been worked out.

The drug is approved in Europe. We’re hoping for FDA approval soon.

For those of you who are unfamiliar with the term, the Thread Lift was a much-hyped procedure in which a special type of barbed suture would be placed under the skin, to draw the loose facial tissue upward. The idea was to get a facelift-like lift, without actually doing a real facelift. It sounded so promising – just have a few of these magic threads inserted into your cheeks during your lunch break – and voila! – a younger looking you. A number of companies make and promote these barbed sutures, under a variety of trade names.

Well, as we’ve said before – when you do less, you get less.
Here’s some more evidence: in this month’s issue of Archives of Facial Plastic Surgery, a study looked at how well the thread lift procedure held up over a two year follow-up period. The answer: not good.

The authors evaluated the results of 33 patients who underwent a thread-lift procedure alone or in combination with other facial rejuvenation procedures to the brow, midface, jowl, and neck. Long-term aesthetic results were evaluated by 4 independent, blinded surgeons.

The thread lift group had a much smaller degree of improvement than the groups that were treated with standard procedures. Furthermore, any early improvement from the thread lift had vanished by the end of the two year study period.

The authors concluded that the short-term improvement of the threat lift was largely attributed to “post-procedural edema and inflammation” (swelling). After evaluating the thread lift extensively, they’ve decided to abandon it, stating “Given these findings, as well as the measurable risk of adverse events and patient discomfort, we cannot justify further use of this procedure for facial rejuvenation.”

Take home lesson: there is no substitute for a properly-performed facelift for facial rejuvenation. Don’t waste your time & money on thread lifts.

I noticed a new (to me) product at the 2009 ASAPS meeting: a saline-filled lip implant. I kid you not.

Known as VeraFIl, it has actually been FDA approved for about a year. Essentially, it is a tapered tubular implant with a silicone shell and a gore-tex outer coating. A tunnel is made in the substance of the lip under anesthesia, and the device is placed and filled – like some sort of miniature saline breast implant.

Theoretical advantages:
– permanent lip enhancement

Possible problems:
– encapsulation and firmness, with possible distortion of lip
– migration of implant (shifting)
– exposure of implant
– infection of implant
– difficulty of removal, with possible irreversible tissue changes / thinning of lip
– less shaping control than with injectable products
– deflation

We’ve tried lip implants before, with various companies that made Gore-tex tubes for lip augmentation. They felt, in my opinion, like “shoe leather” inside the lip, and thus were not realistically soft, like a lip should be. I didn’t use the product.

I have serious doubts that this generation of lip implants will be significantly different.

The company claims that their new design fixes many of the problems with previous types of lip implants. As you can probably tell, I remain unconvinced.

Time will tell.

One of the big topics of discussion at ASAPS this year was biofilms. Biofilms are a type of bacterial contamination that loves to form on solid, implanted devices like man-made heart valves, contact lenses, orthopedic implants, and yes…breast implants. There is a growing body of research that suggests that these biofilms are linked to the #1 unsolved problem of breast implants – capsular contracture.Implant-associated biofilms don’t cause fevers, redness or typical infection issues. They are difficult to detect without specialized testing. They are resistant to standard antibiotic treatment, and are virtually impossible to clean off from the implanted device. But when the sepcialized tests are done, there is a much higher incidence of these bacterial biofilms in women who have capsular contracture, compared to the tissue around soft, “normal” breast implants. Most commonly, the bacteria involved is Staph. epidermidis – the common bacteria that lives on our skin, and is also found inside the normal breast gland.So, what does this mean? Well, taking this concept to its logical conclusion would suggest:

1. At the time of the initial surgery, take steps to reduce the chance of implant contamination. This can be done through technical measures such as using an antibiotic irrigation (or betadine) to rinse the implant and the implant pocket. Consider using the infra-mammary incision (more direct) rather than the peri-areolar incision (more contact with breast tissue).

2. At the time of a capsulectomy operation, consider using a brand-new implant (no biofilm), rather than re-using the old implant. Perform total capsulectomy (removing all of the capsule) rather than capsulotomy (cutting the capsule, but leaving it in place.)

3. After surgery, treat the breast implant just like a artificial heart valve, and take antibiotics whenever you have a procedure that might cause bacteria in the bloodstream, like dental cleanings, endoscopy, or minor surgery.

4. Researchers are investigating anti-bacterial coatings for implants, and other longer-lasting antibacterial delivery systems. One promising method involves a compound called Ageliferin, which disperses biofilm, and re-sensitizes the bacteria to antibiotics.

So far, most of the research is lab stuff. There haven’t yet been large clinical studies giving us the answers that we need to make day-to-day decisions. But, it’s hopeful that we’re getting closer to finding an answer for the problem of capsular contracture.

At the recent ASAPS meeting, a number of breakthrough new technologies were presented, as potential alternatives / improvements on the standard liposuction technique. Bear in mind that most of these wonder gadgets are still in the developmental phase, and do not yet have FDA approval.

But some of the before & after photos looked pretty exciting! Definitely something to watch for over the next few years!

The techniques presented included:

Focused external ultrasound for fat reduction: “Liposonix”, “UltraShape”
Radio-frequency assisted liposuction: “BodyTite”
Water-assisted liposuction: “BodyJet” – which is FDA approved.

The BodyTite before and afters seemed to show some clinically significant skin shrinkage effects. Their built-in skin temperature monitoring system may offer a better degree of protection and higher effectiveness than competiting laser lipo machines. But the UltraShape and Liposonix machines have the advantage of being external, non-surgical treatments with minimal “downtime”, even though the results are more subtle than traditional liposuction surgery.

It’s too early to tell which horse will win this race….

Sounds like science fiction, right? – a wrinkle-fighter that works without needles…

One of the coolest products in development that I heard about at the ASAPS meeting belongs to a company called Revance therapeutics, based in Palo Alto, California. They seem to be the first ones to have cracked the problem of getting large molecules into the skin. Usually, large molecules can not be absorbed transdermally, so relatively few medications can be compounded in a gel or patch formula.

While there are countless applications for this drug-delivery technology, their first commercial application using this technology is with botulinum toxin (aka Botox), creating a gel that you put on the surface of the skin, in the area of the animation wrinkles, and presto! – you get the expected Botox-like relaxation effect – no needles involved.

It’s still in clinical testing, and is not yet FDA approved, but the presentation I saw of their phase I results for wrinkles in the lateral canthal (crow’s feet) area were impressive. The stuff works! Applying the gel in the armpit area also works to reduce excessive sweating, again without the multiple injections we currently use.

Besides working for Botox, the same technology could be applied to a number of other drugs. Imagine, for example, using this idea with insulin – diabetics wouldn’t need to use needles.

This could be a real game changer, folks.

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