Dr. Frank Ryan

The Truth About Message Boards and Plastic Surgery

2009-12-14T22:29:00.000-08:00

A few weeks ago, a friend of mine called me and asked me if I could refer him to a rhinoplasty surgeon in New York. His brother lives in New York and his brother wanted to have his surgery done in New York, as opposed to flying out to LA. I told him that I would ask a colleague of mine who he would recommend, since my colleague, also a board-certified plastic surgeon, had done his residency at NYU and continues to maintain close ties with colleagues in New York. I gave my friend the names of two surgeons in New York and, within minutes, I received a frantic call from my friend, “I looked up the two surgeons and the first one was rated only two stars! I can’t believe your colleague would give me the name of a surgeon with only two stars! There is no way I am sending my brother to him!” I just shook my head. A referral from a respected, board-certified surgeon is absolutely as good as it gets – to rely on a message board over a surgeon’s referral struck me as absolutely insane. But it got me thinking about the power that some of these plastic surgery web sites wield.

One thing that is probably fairly obvious to many people is that the doctors who pay more get the best placement on most sites. So, if a patient is in a hurry and just glances at a site and jots down the names of the first few doctors that are placed most prominently on the site, that patient is limiting herself to just those doctors that have simply paid for the best placement. In many cases, these are the doctors that need the business – they made a business decision that it was worth it to spend thousands of dollars to be placed prominently on the site because it will generate business and justify the cost.

Something that many people may not know is how the message boards and rating systems work. Presumably, most people go to the message boards to see what other patients have to say about a certain doctor. However, are those comments praising the doctor really from satisfied patients? Maybe not. I recently met the CEO of a web marketing company who described a type of marketing that his company does in which he and his team get paid by doctors to regularly log onto all the plastic surgery message boards and rave about those doctors. The CEO’s employees pose as patients and rave about what a wonderful surgeon so-and-so is and how they wouldn’t go anywhere else and how the doctor changed their lives, etc. The more the doctor pays, the more time the team will spend posting glowing reviews about the doctor. The CEO said, “If you visit some of these web sites, you will see names of doctors you never heard of with rave reviews and ten stars out of ten. You will also notice that some of the top doctors have fewer rave reviews, fewer stars and often more negative comments.”

I had always just assumed that many surgeons out there routinely had their nurses and secretaries post glowing reviews of them; in fact, I’m sure many surgeons personally post glowing reviews of themselves! However, I hadn’t realized that companies actually get paid to do that. Just after I heard about these tactics, a company called the “LifeStyle Lift” was fined for just that – employees were posing as patients raving about the merits of the LifeStyle Lift.

As with most things in life, caveat emptor applies to plastic surgery message boards and web sites as well.

The “Taco Bell” Facelift

2009-07-22T23:08:00.000-07:00

Whenever I see a surgical procedure that is patented, I cringe, expecting a marketing ploy devised by a slick doctor and an even slicker publicist. A case in point is a type of facelift that is getting a lot of press lately. The procedure shall remain nameless, but those of you who follow trends in plastic surgery know what I’m talking about – you’ve heard the television infomercials and advertisements (bad sign), seen the cute logo and the catchy name (another bad sign) and heard about the incredibly low fees (a really bad sign).

The way this procedure is presented to the general public has so many things wrong with it I don’t know where to start. First of all, it is difficult to determine from the information available to the public what the procedure is – is the “facial firming” that’s promised a surgical or non-surgical procedure? Who knows?

The “facial firming” procedure is described as a breakthrough that is so unique that it warrants its own patent. In truth, the procedure was described by a Belgian surgeon in the 1990’s. The American surgeon who “patented” it simply took the Belgian surgeon’s procedure, changed the name, hired a publicist and away he went.

It turns out that the procedure is actually a mini-facelift performed under local anesthesia, not unlike the first facelift performed over 100 years ago. The only difference between that early facelift performed in Berlin in 1901 and the new, patented lift is use of two permanent purse string sutures – of course, this technique was also borrowed from the Belgian surgeon.

Another aspect of this that is obvious to surgeons, but perhaps not to the general public, is that surgical procedures cannot be franchised, like a Taco Bell. Surgical skills are honed over years; one cannot just walk into a clinic and walk up to the counter and say, “I’d like a facelift and I’ll take whichever surgeon that’s not busy today”.

The following is an interesting article that applies to this subject:

Facelift firm placed bogus online reviews

By JENNIFER PELTZ (AP) – 2 days ago

NEW YORK (AP) — The online journal gave a chatty account of a problem-free face lift. "You will never regret it," the patient wrote.

But the seemingly satisfied customer actually was an employee of the firm behind the Lifestyle Lift, writing as part of a company campaign to plant plugs for the procedure online, state Attorney General Andrew Cuomo said in announcing a $300,000 settlement with the company Tuesday.

His office said the settlement appeared to be one of the first to address so-called astroturf marketing, or creating a bogus grassroots buzz about a product.

Troy, Mich.-based Lifestyle Lift Inc. said its informational material now accurately reflects actual patients' comments and is clearly labeled as coming from the company.
"We want to be acknowledged as a model of integrity and accuracy," company President Gordon Quick said in a statement.

Widely advertised through television infomercials as a relatively quick and inexpensive form of face lift, the Lifestyle Lift has been performed on more than 100,000 people since 2001, according to the company. It's affiliated with a network of doctors in New York and 21 other states.

The company has aggressively guarded its online reputation. In 2007, it sued an Arizona man who maintained a consumer-oriented Web site that included criticisms of Lifestyle Lift, saying the site's use of the procedure's name infringed on the company's trademark and amounted to false advertising. A federal judge in Michigan dismissed the case last year, saying the site was commentary protected by the First Amendment.

But Lifestyle Lift also came up with another new way to fight back: Having staffers post glowing reviews, comments and testimonials that appeared to come from clients.
"I need you to devote the day to doing more postings on the Web as a satisfied client," employees were told in one internal e-mail, according to the attorney general's office. Another internal message directed a worker to "put your wig and skirt on and tell them about the great experience you had."

The disguised workers did that and more, sometimes pushing to get message boards to remove critical posts and even setting up pro-Lifestyle Lift Web sites that masqueraded as independent views, Cuomo's office said. The postings dated back to early 2007, the attorney general's office said.

One such site featured a detailed "journal," stretching from a first consultation to two months after the procedure, and included photos and an exhortation to "GO FOR IT." Another supposed first-person account came complete with the names of the writer's children.

"This company's attempt to generate business by duping consumers was cynical, manipulative and illegal," Cuomo said in a release. He said the tactics violated consumer protection laws.
Lifestyle Lift said Tuesday the disputed endorsements were "representative of" real patients' comments but acknowledged they weren't rendered verbatim or labeled as coming from the company.

The company, which said it has since changed management, will pay the state $300,000 in penalties and costs. The settlement came as the attorney general's office investigated the company's practices, without any litigation in court.

The Federal Trade Commission is working on revising its nearly 30-year-old guidelines on the use of testimonials and endorsements to reflect the growth of online marketing. The review comes amid heightened attention to the role blogs and Internet comments can now play in a product's fortunes.

In the meantime, the American Advertising Federation, an industry group, has its own guidelines specifying that testimonials "shall be limited to those of competent witnesses who are reflecting a real and honest opinion or experience."

"We think the consumer has the right to know that an advertisement is an advertisement," spokesman Clark Rector said.

The Truth about Before and After Photos

2009-05-19T21:05:00.000-07:00

I am always amazed at how much credence people put in before and after photos. These days, it’s rare that a patient will ask me to see before and after photos; since I’ve been in practice 15 years, they don’t need to see photos before scheduling surgery. When a doctor is starting out in practice, however, before and after photos are almost essential to make a prospective patient feel confident in the doctor’s skills. The only problem: many doctors know how much weight patients place on these photos, so it is too tempting not to do some very misleading things.

The first example I saw of misuse of before and after photos was about 13 or 14 years ago when a young dentist starting out in Beverly Hills invited me to lunch at the Peninsula Hotel. He brought with him a beautifully bound book of before and after photos with his name embosses in gold on the cover. The photos showed impressive results of veneers and dental implants and other cosmetic dental procedures. The only problem: I had seen the exact same book with the exact same photos at my dentist’s office in Brentwood the week before. My dentist used the book to show examples of what modern dentistry could do, but he did not claim that the patients in the book were his. At the Peninsula Hotel, I just sat and nodded and commented on the beautiful work. Obviously, I had no interest in working with such a dishonest person.

Around the same time, a patient from Orange County came to see me about laser resurfacing. The CO2 laser was new at that time and few people had much experience with it. The patient told me that she had just seen a “laser expert” in Orange County who had such extensive experience with the CO2 already that the doctor already had lots of impressive before and after photos. I told the patient that I didn’t have before and after photos yet, since we had just started doing the CO2 laser a few months before. I told her that I could show her some stock photos that were provided by the manufacturer, Coherent Laser – at least she could see some stock photos demonstrating what the laser was capable of doing. I handed her the book and, after a few pages, she stopped and looked up at me and said, “Oh my God. These are the exact same photos that the other doctor said was her work!”

Over the years, I have seen many examples of misleading before and after photos. One patient brought in her before and after photos that her previous surgeon had taken at another office. The lighting in the before photos was poor, there was extensive shadowing and the background was a yellowish-green bilious color. The after photo on the other hand, was overexposed, and the background was a brilliant royal blue. After I pointed this out to the patient, she recalls that she found it curious at the time that the doctor had two completely different rooms for the before and after photos.

Of course, the ultimate tool in 2009 is Photoshop. I can usually spot the results of Photoshopping in before and after photos, but not always. Occasionally, a patient will bring in before and after photos from a newspaper ad or from a web site that shows an obese patient in the before photo and a toned and fit patient with a six-pack in the after photo. They say, “I want that, Dr. Ryan” as they point to the six-pack. I explain that I have done hundreds of liposuction cases over 20 years and that it’s simply impossible to achieve such results with liposuction.

Bottom line: I would be skeptical if I saw dozens and dozens of spectacular before and after photos on a web site or in a surgeon’s before and after book. Of course, there are many surgeons with lots of photos of their work and they show good quality and unretouched photos as an educational tool, not as a sales tool. However, it is getting more and more difficult to distinguish between the two.

Dr Ryan’s Personal Skin Care Regimen

2009-04-20T15:45:00.000-07:00

Almost every day, a patient asks me, “What do you do for your skin, Dr Ryan?” The truth is that for years, I did absolutely nothing for my skin. In fact, until I was around 37 or 38, I purposely tanned my face. I remember skiing at Aspen and trying to get as much sun as possible on my face; I would sit on the deck at Bonnie’s having lunch and rotate my body to follow the sun so my face got maximum exposure! My face was almost purplish, it was so sun-damaged.

As someone of Irish heritage, I am what’s classified as a Fitzpatrick skin type II, meaning that I have fair skin and blue eyes and that I burn easily in the sun. My skin issues pertain mainly to dilated (or “broken”) blood vessels and ruddiness. Therefore, I need a skin care regimen that is very gentle so that more blood vessels do not “break,” which would lead to even more ruddiness. On the other hand, many people with olive skin and brown eyes (Fitzpatrick skin types III and above) have issues with hyperpigmentation (i.e., brown spots or patches), not ruddiness and broken blood vessels. Therefore, these patients often need to focus on beaching creams such as hydroquinone or kojic acid. People with significant sun damage, fine lines and brown spots may need to focus more on products that contain ingredients that help to reverse sun damage; these ingredients include kinetin, retinol or acids. In people with sensitive skin, however, some of these ingredients may be irritating.

In the last five years, I have made great strides with my skin and here’s how I did it.

Gentle cleanser and moisturizer – Because of my sensitive skin, I require a very mild cleanser and moisturizer. However, I could never find one that met my exact specifications. So I decided to develop my own. Every morning and night, I use the Dr Frank Ryan cleanser and moisturizer. For people who prefer their skin care products to be paraben and sulfate-free, I also have a paraben and sulfate-free cleanser. The products are aloe-based, and contain ingredients like sage and arnica.

Broad-spectrum, high SPF sunblock – This is the most important thing for good skin. About five years ago, I began using a daily moisturizer with an SPF of 15. After a year or two of doing that, it occurred to me that I should probably use something stronger. So I tried many different sunscreens and concluded that the Skinceuticals SPF 45 was the best, in my opinion. It does not leave the skin white and provides excellent broad-spectrum coverage, since its main ingredient is zinc oxide, still the best sunblock out there in my book. This alone began to improve my skin dramatically. Other excellent sunblocks are made by Epicuren and Fenix. I am currently formulating my own sunblock for the Dr Frank Ryan line.

Skin Refining Gel – My secret weapon is the Dr Frank Ryan Skin Refining Gel. This product is very difficult to categorize, but in general, it serves to minimize or even eliminate the appearance of pores, fine lines and irregularities in skin texture or tone. It contains several topical vitamins, arnica and alpha-lipoic acid and is lightly tinted. Remarkably, many men are absolutely hooked on this product, because it improves their skin significantly, but is not considered “make-up”. When people comment on my skin, I always confess that I had a little help from my Skin Refining Gel.

There are many, many excellent products on the market that I don’t use only because they are not what my skin needs. Product lines like Kinerase and Epicuren are excellent and we carry both lines in my office. Individual products like Renova and Tri-Luma and Cellex-C are all excellent.

Bottom line: each person needs a skin care regimen specifically designed for his or her own skin type. A product like Renova, which would be beneficial for many people, would simply be too strong and irritating for my sensitive skin. On the other hand, a simple, gentle skin care regimen like I use would simply not be strong enough to help someone with severely sun-damaged, weather beaten skin.

Next up: the laser and light therapy devices that I have used – and to continue to use – to improve and maintain my skin.

The Mini-Facelift under Local Anesthesia

2009-04-06T19:28:00.001-07:00

For most of my fifteen years in practice, I performed the vast majority of my facelifts under general anesthesia with the patient asleep. About three or four years ago, a very determined young lady practically begged me to do her mini-facelift under local anesthesia, meaning that she would be awake. Because she had a high pain threshold and was stoic by nature, I agreed to do so. The procedure was a breeze and she raved about how easy the process was and how quickly she recovered. After that, I began to do more and more mini-facelifts -- and even more extensive facelifts -- under local anesthesia. I realized that in some cases, I could accomplish the majority of what I needed to accomplish without general anesthesia – the key was to choose the patients carefully and to educate the patient beforehand about what to expect.

When performing a facelift under general anesthesia, we routinely require the patient to obtain preoperative blood work and other tests, including an EKG and a chest X-ray. General anesthesia requires that an anesthesiologist be present, which adds to the expense. Furthermore, there is typically a bit more recovery involved after general anesthesia. Mini-facelifts under local anesthesia, however, usually don’t require the preoperative lab work and an anesthesiologist is not required to be present.

Local anesthesia typically also involves giving an oral medication like Valium; this type of anesthesia is known as “local with oral sedation”. The patient is given Valium approximately 20 minutes before beginning the procedure; that way, the patient is drowsy when he or she is taken into the operating room. Once in the operating room, local anesthesia (lidocaine) is injected into the face, not unlike at the dentist’s office. This is, perhaps, the most uncomfortable part of the entire procedure, more so than the surgery itself. The Valium, however, really takes the edge off this part and most patients say afterward, “The injections really didn’t hurt much at all!” After the local anesthetic has taken effect, the patient typically feels little or no discomfort for the rest of the surgery.

The mini-facelift takes a little over an hour and the patient is walking and talking immediately after the procedure. We typically wrap the face and neck in a light bandage that is removed the next morning when we see the patient in the office. After surgery, we send many of our patients to an after-care facility where they are watched by nurses. However, in some cases, the patient is able to go home if there is a family member or friend who can keep an eye on the patient overnight. Where the patient spends the first night after surgery depends on many variables, including the complexity and length of the surgery and the health and age of the patient. The stitches, located around the ear, are removed in seven to ten days; bruising and swelling is usually minimal. In fact, I am always amazed how quickly patients recover from these procedures. Most are back at work in a week.

In younger patients (30’s and 40’s), the mini-facelift may all they need. In patients in their 50’s and older, other procedures such as a browlift and upper and lower eyelid surgery may also be indicated. As the list of procedures increases, I lean more and more toward general anesthesia.

In older patients, a mini-facelift may still be appropriate. However, these patients need to be educated that a mini-facelift has limits in what it can do. If the neck is extremely saggy, for example, a mini-facelift is probably not the best procedure. Simply put, the mini-facelift can’t accomplish as much compared to what can be accomplished with a more extensive facelift.

In conclusion, the mini-facelift under local anesthesia is a quick and simple procedure that I am incorporating more and more in my practice. The results are excellent and the patients are happy – and that makes me happy.

LATISSE -- The Key to Fuller Eyelashes

2009-03-30T18:18:00.001-07:00

Allergan Corporation (the makers of BOTOX and Juvederm) recently released their prescription eyelash booster, LATISSE. When people ask me if it really works, my response is an emphatic YES!

LATISSE is an FDA-approved, once-daily treatment applied to the base of the upper lashes with a sterile, single-use-per-eye dosposable applicator. Most users see significant results in two to four months. If use of LATISSE is discontinued, the lashes simply return to how they were before the treatments were begun.

Latisse has an interesting history. The main ingredeint is based on a glaucoma drug, bimatoprost, and its effects on eyelash growth were discovered by accident.. Several years ago, people who were using LUMIGAN (the glaucoma drug containing bimatoprost) noted spontaneous eyelash growth. Based on those findings, Allergan began investigating the use of this drug for eyelash growth. This history is not dissimilar to that of BOTOX, which was initially used for muscle spasms. When people noticed that it also made wrinkles disappear, it was eventually approved for the elimination of wrinkles as well.

Since LATISSE is from a respected pharmaceutical company such as Allergan, it makes sense that there is solid scientific data to support its safety and effectiveness. In terms of effectiveness, studies have shown that there is, on average, a 25% increase in eyelash length, a 106% increase in eyelash thickness and an 18% increase in eyelash darkness. In terms of side effects, there was a 3.6% incidence of eye redness, a 3.6 %incidence of eye itchiness and a 2.9% incidence of skin hyperpigmentation. Less common side effects included eye irritation, dry eyes and redness of the eyelids. Hyperpigmentation refers to a slight darkening of the eyelid skin, which may or may not be reversible. There is also a possibility of increased brown pigmentation to the iris, the colored part of the eye.

In my experience with Latisse, I have seen only a handful of patients complain of mild irritation or redness or itchiness, but these symptoms were mild enough that none of these patients discontinued the product. In general, the feedback has been overwhelmingly positive.

Many people are familiar with competing over-the-counter products that promise to make the lashes fuller. Many of these competing products worked quite well -- and that's because they were knocking off Allergan's ingredient! However, because bimatoprost is patented and, more importantly, because it is a drug, these companies were skirting the law. They would try to get around these problems by very slightly changing one or two molecules on the drug, but it was only a matter of time until Allergan came on the scene with the real deal.

At this point, why would anyone use anything but the patented, prescription-only LATISSE from Allergan?

Although any physician can prescribe LATISSE, it can be obtained directly from many plastic surgeons and dermatologists, who dispense LATISSE in their offices. The suggested retail price is $120 and one container lasts for up to two months.

More detailed information can be found at www.LATISSE.com.

Footnote: Last Thursday Allergan officially launched LATISSE with an event on La Cienega Boulevard in LA. The room was filled with beauty editors from all the top magazines as well as celebrities like Jewel, Debra Messing, Debbie Mazur, Mandy Moore, Debbie Matenopolous and others. The thing I found interesting was that almost one half of the people I met that night who requested LATISSE prescriptions from me were men -- I have a feeling that the male market for LATISSE will be significant.

Non-Invasive Fat Removal

2009-03-23T17:03:00.000-07:00

Erchonia Medical has developed what is considered the Holy Grail of plastic surgery: a non-invasive, painless treatment that melts fat. The Zerona is a low level laser that emulsifies (i.e. liquefies) fat, allowing the body to excrete it naturally. Treatments are performed in thirty minute sessions, every other day for two weeks and are completely painless. After each treatment, we encourage our patients to increase their water intake, which helps to eliminate the emulsified fat. Our aesthetician performs lymphatic massages after each treatment which is also helpful in eliminating the fat. Some patients choose to wear a compression garment after the treatment, similar to what is worn after conventional liposuction.

So far, my office staff has seen some very exciting preliminary results. We have used the Zerona to treat the arms, abdomen, love handles, thighs and knees. We have also treated the jowls and under the chin. One staff member lost ½ inch off her arms and others have lost over an inch off their hips and thighs.

Just a week ago, I had an experience in surgery that convinced me that the Zerona has huge potential. I was performing liposuction on a male patient’s abdomen and love handles. During the procedure, I noticed immediately that the fat that was being removed was coming out very smoothly and was virtually bloodless. It appeared almost melted. Then it occurred to me that this particular patient was the first liposuction patient in my practice to have undergone a preoperative Zerona treatment. It appeared that the Zerona had indeed emulsified and liquefied the fat and that we were suctioning out what the Zerona had liquefied 72 hours earlier!

Currently, we are performing the Zerona on several subjects and accumulating more data.

Check back in a few weeks for an update.

Breast Implant Update

2009-01-05T16:52:00.000-08:00

Most people are aware of the difference between saline and silicone breast implants. Most people are also aware of the difference between round and teardrop breast implants. But what about the difference between moderate profile, moderate plus and high profile breast implants? These are terms that Mentor Corporation uses to describe their three different implant profiles. Moderate Profile refers to a less projecting, yet wider implant; High Profile refers to a more projecting, yet narrower, implant. Moderate Plus is somewhere in between these two, with a moderate amount of projection and a moderate width. Projection refers to the degree to which the implants protrude from the chest. The type of implant chosen is largely determined by each patient’s anatomy. The following two examples illustrate how these different implants can be used.

Case #1

Recently, a patient who had undergone breast augmentation came to me complaining that her breasts appeared too wide for her frame. She complained that the implants stuck out under her arms and that her breasts were too close together in the cleavage area. After examining the patient, it was immediately apparent that she was exactly right: her implants were simply too wide for her rib cage. In fact, the patient was very close to having synmastia, where the breast implants touch in the middle, often eliminating the cleavage completely. I explained to her that the combined diameter of the two implants was simply wider than the width of her chest. The solution: narrower implants. Not necessarily smaller (i.e., less volume), but narrower. Since she stated that she wanted to maintain a fair amount of projection, the perfect solution would be the narrower – yet more projecting – high profile implants. So I removed the moderate implants and replaced them with high profile implants, which fit her chest diameter better and maintained the projection.

Case #2

A few months ago, I saw a patient complaining of what she described as a “strange” shape to her breasts following breast augmentation. She couldn’t put her finger on what exactly made the breasts seem strange to her -- she just knew she didn’t like them. Exam revealed very narrow breasts that projected excessively from her chest. She had a very wide rib cage and a very protruding rib cage and it appeared to me, after examining her, that she had high profile implants in place. The combination of narrow, high profile implants in a patient with a wide, prominent rib cage resulted in a strange look indeed: very wide cleavage and breasts that looked like two oranges abruptly jutting off the chest. I explained that we needed to remove the high profile implants and replace them with moderate implants. The extra width and reduced projection would fit this patient’s anatomy perfectly. Sure enough, a simple switch to slightly larger moderate profile implants solved the problem.

The above examples represent cases where simply changing the profile of the implant solved the problem. There are many cases where more needs to be done to solve the problem, such as repairing synmastia or making the pocket smaller to accommodate a smaller implant diameter.
In conclusion, the three different implant profiles available today allow plastic surgeons to take into account variations in breast and chest wall anatomy to produce predictable and satisfactory breast augmentation results.

Jaw Augmentation

2007-06-08T13:13:00.000-07:00

A strong jawline (mandible) indicates strength and youth and is an attractive feature in both men and women. Some people are born with a strong jawline, but the definition is slowly lost over time as the aging process takes over. Other people were born with a relatively weak jawline that just tends to get weaker over time. The demarcation between the face an the neck is increasingly obscured as the skin loses its elasticity and as the jowls begin to form.

There are three main areas where the jaw may need augmenting:

1. The angle of the mandible, where the mandible angles sharply below the earlobe;
2. The body of the mandible, midway between the angle and the chin; and,
3. The area between the chin and the jowl, a depression known as the labiomandibular groove.

In the past, mandibular implants were really the only option out there for mandibular augmentation. These implants, usually made of solid silicone rubber, were placed through an incision in the mouth. The implants were often somewhat difficult to position properly and the implants tended to shift with mouth movements such as chewing in some people.

For the past several years, my procedure of choice for augmenting the mandible is fat grafting. Fat grafting is quick and easy and works quite well for this purpose. I usually tell my patients that they may need more than one fat grafting session, but many patients seem to get great results with just one session.

Another filler that I have used quite a bit is Radiesse. Since Radiesse can tend to lump if placed in areas of thin skin (like the nasojugal grooves of the lower eyelid), I use it exclusively in areas where there is a fair amount of soft tissue coverage, such as the mandible . It seems to last a year or more in these areas.

With the recent FDA approval of Arte-Fill, I have been using Arte-Fill more and more for mandibular augmentation. Last week, I placed a few syringes of Arte-Fill into a male patient’s mandibular angle and the results were dramatic. Instantly, he looked more masculine, more handsome and more youthful. Pretty powerful stuff!

The only anesthesia required for mandibular augmentation is numbing cream on the skin. The procedure takes ten minutes and the patients walk out with immediate results. Typically, patients note that that their jaws are slightly sore for a few days, especially when chewing.

The evolution from a surgical procedure (mandibular implants) to a more minor surgical procedure (fat grafting) to a non-surgical procedure mirrors the overall trend in cosmetic surgery: more and more is being done with fillers and other noninvasive methods.

Silicone Breast Implant Update

2007-03-15T13:16:00.000-07:00

Since the wide release of silicone breast implants by the FDA in November of 2006, I have not used a single saline implant. In fact, my surgery center is sending our supply of saline implants back to the manufacturer to make room for silicone implants. On the rare occasion in which we need saline implants, we will have them shipped special order from the implant manufacturer.

For the past fifteen years, 90% of the breast implants used in the United States were saline. During that same time period, over 90% of the breast implants placed in much of the rest of the world were silicone. Most plastic surgeons anticipate that in time, over 90% of the implants used in the U.S. will be silicone.

When patients ask me, “Dr. Ryan, which implants are better, saline or silicone?”, I respond that, like everything else in life, they each have their pros and cons, so I can’t say that one is “better” than the other. I tell my patients that before 1992 (when he FDA put restrictions on the use of silicone implants), over 90% of implants placed were silicone and that I anticipate that we will return to close 90% usage in this country.

When patients ask me, “But aren’t silicone implants dangerous?”, I respond “Of course they’re dangerous! We doctors love doing dangerous things to our patients all the time! And the malpractice lawyers love it even more!” I then explain to the patient, after we both finish laughing, that there is no way that I — or any other doctor — would ever do a procedure or use a device that we feel is dangerous. I then recite the many well-done, peer-reviewed scientific studies that refute that there is any link between silicone breast implants and cancer, autoimmune disorders or any number of other diseases that people have tried to link with silicone breast implants over the years.

In summary, it appears that silicone breast implants are here to stay and that the vast majority of surgeons and patients are welcoming their return.

The Ribbon Lift

2007-03-13T19:54:00.000-07:00

As I discussed in my April 4, 2006 post entitled "Jowls", the jowls can be a very stubborn problem. Since that last post, I have been doing a procedure called the Ribbon Lift. Unlike the so-called thread lifts, which many surgeons criticize as yielding disappointing results, the Ribbon Lift appears to be promising, since it is based on time-tested basic surgical principles. Furthermore, because the Ribbon Lift is based on sound surgical principles, the results seem to be long-lasting.

The Ribbon Lift involves placing a dissolvable device (the ribbon) under the skin of the face. An incision is made just below the sideburn and scissors are used to create a tunnel to the the jowls in the lower face. The ribbon, which measures about five inches long by less than a quarter inch wide, is a soft, flexible material with tiny points (like miniature spikes) at one end. It is made up of the same material that dissolvable stitches are made of. The ribbon is slid into the incision and the tiny points are pressed firmly into the jowl tissue. When the end of the ribbon is pulled up near the ear, the tiny spikes pull up on the jowl tissue as well. The jowls are thereby either eliminated -- or at least reduced significantly. A stitch holds the end of the ribbon in place and a series of stitches is used to close the sub-sideburn incision.

The procedure takes about a half hour and is performed with the patient wide awake, under local anesthesia. Some patients opt to take a Valium before the procedure, but this isn't necessary for most patients.

After the procedure, the patient is told to minimize activity for a few days. The ribbon dissolves after several months. For the first week or two, the ribbon can be felt if a finger is run along the cheek, although does not seem to bother the patients.

The Ribbon Lift appears to hold promise for the treatment of jowling and it has become a part of my armamentarium for the treatment of facial aging.

Please go to the "Videos" section of www.drfrankryan.com to a more thorough discussion of the Ribbon Lift.

Why Adrianne Curry Had Plastic Surgery :: Reprint from US Weekly

2007-01-05T19:55:00.000-08:00

[REPRINTED FROM US MAGAZINE (www.usmagazine.com), Issue 618, December 18th, 2006]
[By Shirley Halperin]

AMERICA's NEXT TOP MODEL
ADRIANNE CURRRY

WHY I HAD PLASTIC SURGERY
The My Fair Brady and ANTM star shares her diary of the painful -- and funny -- moments of her breast reconstruction and recovery.

THINK ALL MODELS HAVE PERFECT BODIES? Adrianne Curry, 24, a former AMERICA"S NEXT TOP MODEL champ, would beg to differ. Ever since she was in her early teens, the 5-foot-11 newlywed (in May, she married her SURREAL LIFE co-star Christopher Knight, 49, with whom she is currently filming the third season of VH1's MY FAIR BRADY) was hyperconscious of the fact that her breasts were noticeably different in size. After years of feeling badly about her chest, the reality-TV star contacted Beverly Hills plastic surgeon Frank Ryan to correct the imbalance with implants. Curry underwent the procedure on November 14 and shared her experience with US.

["It would be so embarassing when photographers would yell out, 'Your left boob is larger than the other'" Curry tells US.]

THE NIGHT BEFORE

I'm having surgery tomorrow at 7:30 a.m. I've always shown my boobs and acted confident with them, but I wasn't. My left breast is a full B or a small C-cup, and my right breast is a full A-cup. My friends jokingly call me One Hang Low. I used to stuff wads of toilet paper in my bra to fill out the smaller side [see "How She Did Her Asymmetry, below]. Being a model and having something so gravely different, it's like having a hug f--king birthmark on the side of your body and trying to hide it in every shoot. I'd get uncomfortable when Chris grabbed my boobs. One night, he was really drunk and said, "Don't worry, baby, it's like being with two different women." That was the last straw.

I've made it very clear to Dr. Ryan that I don't want to look like a cartoon character. I'm a very skinny girl, and I'd look ridiculous with big boobs.

SURGERY DAY

I was nervous. The anesthesiologist said, "Don't worry, because before we knock you out, we're going to shoot you up with happy venom." I have no recollection of what happened after. Chris told me that as they wheeled me into the operating room, he me the hand sign for "I love you," and I lifted my head halfway, gave him the finger, then passed out.

Dr. Ryan gave me a larger silicone implant on the right and a smaller implant on the left to make both breasts the same size -- a medium C-cup. I was really happy because the implants look and feel very natural. My surgery lasted three-and-a-half hours. The incisions were made through the nipples. He put in two stitches and glued the rest.

When I woke up and I couldn't open one of my eyes, the nurse tried to pry it open for me. I was so uncomfortable. I wanted to ditch everything and just run. When we got to the after-care facility, I was screaming in pain, and they shot me up with morphine. Later, I was perscribed Percocet and Valium, but think because I was addicted to cocaine and heroin as a teenager, they didn't really affect me. The doctor said I was on enough drugs to take out an elephant.

SIX DAYS LATER

Chris had been so helpful. He's pulled down my pants to help me pee and given me sponge baths. it's been very hard because I hate people doing things for me, and I was literally rendered helpless. I don't have any bruises, but my right side is swollen. It's amazing to look down and think, Oh, my God, I don't have deformed deformed boobs anymore.

16 DAYS POST-OP

My nerve endings are starting to heal and tingle, and I'm in even more pain now than I was right after the surgery. It feels better when I wear a compression strap -- which keeps pressure on the implants so they don't get rounded at the top and look fake. Realistically, it'll take a year before I'm 100 percent healed. I just threw out my chicken cutlets because I'm never shoving anything in my bra again.

HOW SHE DID HER ASSEMETRY

Before going under the knife, Curry spent years trying to make her breasts appear equal-sized.

PADDING. At red carpet events, she would wear two bras and stuff her right cup with a "chicken cutlet" gel pad -- or crumpled toilet paper. "I've had toilet paper fall out on the red carpet," she US. "Thank God no one noticed."

POSING. At photo shoots, she would twist her body to show off her bigger breast and throw her right arm in the air to distort the smaller breast. "If you look at my PLAYBOY shots, every single one is cheated," she says.

PUMPING. Curry headed to the gym thinking pectoral-muscle exercises would help balance out the unevenness: "It didn't work."

Sunscreens

2006-08-15T19:57:00.000-07:00

It is important to understand some basic principles behind sun exposure and ultraviolet radiation in order to understand what the various sunscreens on the market have to offer.

The sun's ultraviolet rays are measured over a spectrum of different wavelengths. Only some of the ultraviolet rays are harmful, namely those between 290 and 400 nanometers. Some of these rays are called UVB rays (290 to 320 nanometers) and some of these rays are called UVA rays (320 to 400 nanometers). The UVB rays are the rays responsible for a sunburn and they are partly responsible for skin cancers. The UVA rays don't cause a sunburn like the UVB rays, but the UVA rays penetrate deeper to damage the skin, leading to wrinkles, brown spots and other indicators of cellular damage. The UVA rays also cause skin cancers.

Many of my patients proudly say to me, "I wear an SPF 50 sunscreen." When I ask them what the ingredients are, 99% don't know. Unfortunately, SPF only refers to the UVB rays. 100% of the UVA rays could be going right through the sunscreen to damage the skin and cause skin cancers, even though one is wearing an SPF 50. Furthermore, the UVA rays penetrate glass and they are just as strong in the morning and afternoon as they are at noon. Luckily, most sunscreens today offer both UVA and UVB protection, but the amount of protection varies from sunscreen to sunscreen.

The best ingredients, in my opinion, are zinc oxide and titanium dioxide, since these substances block almost all of the harmful UV rays. Zinc oxide and titanium dioxide are known as sunblocks, not sunscreens, since they physically block the UV rays. Most other sunscreen ingredients react chemically with the UV rays, as opposed to physically blocking the rays. Therefore, these are called sunscreens.

A sunscreen that has been touted as one of the best for blocking UVA rays is avobenzone (Parsol 1789). However, it is not commonly known by the public that Parsol 1789 breaks down when it is struck by UV rays. Therefore, although Parsol 1789 is an excellent UVA sunscreen, it must be reapplied frequently throughout the day.

Something people always forget is the amount of reflective UV exposure that people get. Everyone realizes that water and snow reflect, but what about sand, concrete and grass?

Finally, many people think that wearing clothing is a fool-proof sunblock. However, anyone who went swimming as a child wearing a T-shirt to prevent sunburn knows that a wet T-shirt is about an SPF 1 or 2. The same applies to thin, gauzy material. Although these materials are cooler, a tightly woven fabric provides far more UV protection.

Juvederm

2006-08-03T19:58:00.000-07:00

The FDA recently approved the filler Juvederm (hyaluronic acid) for use in the United States. Juvederm, which has been available in Canada for several years, is similar to Restylane, which was FDA-approved in the U.S. a few years ago. Restylane is made by Medicis and Juvederm is now made by Allergan, the makers of Botox, after Allergan bought out Inamed Corporation earlier this year.

Juvederm is used for the correction of facial wrinkles and folds and there are three formulations of Juvederm available, Juvederm 24HV, Juvederm 30HV and Juvederm 30. Each formulation is designed to correct different types of facial folds and wrinkles. At this point in time, there is only one Restylane formulation that is FDA-approved. However, other Restylane formulations such as Perlane and Restylane Fine-Lines are expected to be approved by the FDA shortly.

The obvious question: which product is superior? At this point, Restylane certainly has the longest track record of the two and Restylane has become the soft tissue filler of choice in the U.S. However, there is some anecdotal evidence that Juvederm may result in slightly less swelling than Restylane, but this has yet to be demonstrated in controlled studies.

For now, Juvederm is another filler to add to our armamentarium and the choice of three different formulations is a definite plus, at least until Restylane adds their other two formulations to the marketplace.

Lip Lift

2006-07-21T19:58:00.000-07:00

Although significant attention has been directed toward lip augmentation, there is one situation in which lip augmentation alone may actually make the lips look worse.

In youth, the distance from the nose to the upper lip is generally fairly short, although the length varies significantly from person to person. With age, this distance increases. As the distance increases, the upper teeth are covered by the upper lip. Furthermore, the "pouty" aspect of the lips where the edges of the lips (the vermilion border) evert, diminishes with time, so that the lips appear flatter. Of course, the overall size of the lips also decreases.

Based on these observations, simply enlarging the lips by injecting a filler (e.g., fat, Restylane, Cosmoplast) addresses only one aspect -- the actual size -- of the aging lip. If a young patient already has a nice pout and has a short distance between the nose and the upper lip, simply increasing the size of the lips is all that is needed. However, if an older patient has a lost that pout and the distance between the nose and the upper lip is too long, just increasing the size of the lips may look strange. In fact, many of the odd-looking lips that one sees these days is the result of a doctor augmenting lips that really needed more than just a filler.

An ideal procedure for many of these patients is the lip lift. The lip lift involves a small incision placed where the nose meets the upper lip skin. The incision extends from one nostril to the other and is hidden quite well in the natural crease where the nostrils meet the face. The incision dips into each nostril, where it is easy to hide the incision. Because of the shadowing effect created by the nose, in the vast majority of cases the scar is virtually imperceptible.

I always perform the lip lift procedure in conjunction with a filler. The combination of a shorter upper lip, a poutier upper lip and fuller lips creates the youthful appearance that patients want. Because the lips are also lifted slightly, the upper teeth become more visible, also contributing to the youthful appearance.

When properly executed, the lip lift is an excellent procedure for many patients.

Mesotherapy Position Statement

2006-06-07T20:04:00.000-07:00

The American Society for Aesthetic Plastic Surgery (ASAPS) recently issued a "position paper" on the use of mesotherapy. A position paper by an organization such as the ASAPS presents the organization's official stance on a technique like mesotherapy or a device like a new laser. In this way, a plastic surgeon can better form an objective opinion on a new technique or device without listening to biased individuals like the inventor of the technique or the manufacturer of the device.

The ASAPS often forms ad hoc committees specifically to address new techniques like mesotherapy, where the public is inundated with non-scientific information from the media. Because of this media blitz, plastic surgeons are asked about mesotherapy by their patients. The Aesthetic Society Mesotherapy Committee scours the world literature for any and all information on mesotherapy. Is it safe? Is it effective? What exactly is it? Should plastic surgeons consider doing mesotherapy in their practices? How do they learn how do perform mesotherapy? These are all questions that organizations like the ASAPS want to answer through their ad hoc mesotherapy committee.

Here are the recommendations that the ASAPS made to its members, after an extensive investigation into the use of mesotherapy:

ASAPS does not endorse the injection of phosphatydal choline, deocycholate or any other drugs, vitamins, plant extracts, hormones, etc. into subcutaneous fat as practiced in mesotherapy/Lipodissolve treatments. At present, these therapies lack objective proof of safety and efficacy. They also lack FDA approval.
Members should therefore refrain from adopting these procedures until the results of the ASERF [a plastic surgery research organization] study are available to provide proof of safety and efficacy, or lack thereof. If and when patients ask about these treatments, the scientific reality that currently exists should be explained to them, along with the caution to wait until something definitive is known. Until then, patients should be warned about seeking treatments from people who may not be qualified to administer large numbers of injections that require very precise placement.

[Reprinted from the SPRING 2006 issue of Aesthetic Society News, Volume 10, Number 2.]

Jowls

2006-04-04T20:06:00.000-07:00

One of the signs of the aging face that people object to is jowling. The jowls are areas of fullness along the jawline that tend to increase with age. The straight, strong jawline of youth is gradually replaced by the soft, irregular jawline of the aging face. It is thought that jowls result from the combination of muscle, skin and fat that all begin to sag with age. An area known as the pre-jowl region is located directly in front of the jowl. It is thought that a ligament (the mandibular ligament) attaches the skin to the bone in this region, creating a depression in front of the jowl. Because the ligament doesn't stretch with age, as the howl increases in size with age, the pre-jowl depression becomes deeper and deeper, making the jowl look even bigger.

There are several ways to treat the jowls, both surgical and non-surgical. Surgical options include mainly facelifting and liposuction. During a facelift, the facial soft tissues are pulled upward and backward, thereby raising the jowls upward above the jawline so that they don't hang over the jawline. Adding a mid-face lift may improve things even further, since the mid-face lift pulls the facial soft tissues vertically, raising the jowls even higher above the jawline to hide them even more than with just a facelift alone. These procedures don't remove any jowl tissue, they simply reposition the jowls.

Another surgical option is a facial implant. These pre-jowl implants are similar to chin implants, but the part of the implant over the chin itself is paper thin. The implant then flares out to thicken in the pre-jowl area. The implant minimizes the jowl by filling out the depression that forms in front of the jowl, in the area of the mandibular ligament. With this implant, the jowl is not repositioned or removed, it is simply camouflaged.

Recently, another surgical option has been developed, although the jury is still out on this one. Various suture suspension techniques have been developed over the last few years in an attempt to minimize downtime. Names such as Featherlift and Threadlift have been bandied about in the media for the past few years. There is very little long-term data on these procedures at this time. At a recent plastic surgery conference in Palm Springs CA, the consensus among the surgeons in attendance was that it was too early to tell what role these suture suspension techniques would play. However, it was apparent that the techniques may be appropriate for younger individuals who want a minimal procedure that may last less that a year.

Liposuction, which actually removes some of the jowls, can be performed in conjunction with a facelift or it can be performed as a stand-alone procedure. Many surgeons feel that repositioning alone will not completely eliminate the jowls. These surgeons feel that the jowls need to be reduced in size somewhat in addition to being repositioned. However, liposuction needs to be performed carefully in this region with a very small cannula (1.5 to 1.8 mm diameter) because it is easy to cause irregularities and ridges if this area is liposuctioned too aggressively. Some surgeons use scissors to directly remove the jowls during a facelift, in an attempt to avoid irregularities from liposuction.

Non-surgical options include fillers, Thermage and mesotherapy. Of these, fillers have the longest track record. Any number of fillers can be used, including collagen, Cosmoplast, Restylane, Radiesse and fat. While none of these fillers is permanent, Radiesse and fat potentially last the longest. With the recent FDA approval of Radiesse, this is becoming more and more popular to treat jowling. With any of these fillers, the principle is the same: the filler is placed in the pre-jowl area in order to camouflage the jowl, similar to the pre-jowl implant.

Like the suture suspension techniques, the jury is still out on techniques such as Thermage and mesotherapy. Thermage uses a radiofrequency device to melt the fat and mesotherapy uses a "cocktail" of various ingredients injected into the jowl to melt the fat. The body then absorbs the fat and the skin then shrinks and tightens, theoretically.

Many surgeons, including myself, use a combination of techniques. During surgery, I will often perform a combination of a facelift, midface lift and jowl liposuction. After that, I will inject Radiesee into the pre-jowl area to fill the depression. In the months and years after surgery, I will inject Radiesse every year or so to maintain volume in the pre-jowl area. There may be a role for such things as mesotherapy or Thermage for maintenance, but I am waiting for more solid data before I proceed with these modalities.

Marionette Lines

2006-03-14T20:07:00.000-08:00

The lines that extend down from the corners of the mouth toward the chin are known as marionette lines. The marionette lines tend to deepen with age and they give the appearance that one is frowning. Some people have a strong tendency to have marionette lines, even at a young age, whereas some people never develop them. Surgical procedures like facelifts are notoriously ineffective in treating marionette lines.

The most commonly used method to treat marionette lines is to simply fill the lines with a substance known as a "filler". In the past, fillers such as fat, collagen and Cosmoplast were used. Today, fillers such as Restylane and Radiesse are more commonly used, since these fillers last much longer than most of the other fillers previously available. A five minute injection of Restylane can minimize -- or eliminate -- marionette lines. Repeat injections are performed at six to nine months. With Radiesse, repeat injections are necessary at twelve months. Microinjections of silicone, considered controversial by many physicians, is also sometimes done. Finally, permanent implants are sometimes used in this area as well. Implants made of Gor-Tex are sometimes done, but these implants can sometimes be visible or palpable.

I have found that Botox injections can be quite helpful in the treatment of marionette lines. Certain muscles, called the depressor muscles, can pull the corners of the mouth down and contribute to the downward slant to the corners of the mouth, which then leads right into the marionette lines. By injecting Botox into the depressor anguli oris muscle, the corners of the mouth go up slightly, and the n marionette lines are diminished. Typically, with this regimen, the patient will come into the office every three to four months for Botox injections and every six to twelve months for a filler, depending on the type of filler (Restylane v. Radiesse).

There are a few rarely-done surgical options that are designed to address the corners of the mouth directly. A corner lip lift involves cutting a small triangular piece of skin away from the corners of the mouth in an attempt to give an upturn to the corners. However, the scar can be objectionable and the corners can look unnatural. An ever rarer procedure involves cutting the depressor anguli oris muscle in order to deactivate it (like the Botox injections do). But most surgeons feel that the risks out weigh the benefits for this procedure.

Anastasia Oscar Spa

2006-03-03T20:07:00.000-08:00

Anastasia hosted her second annual Oscar Spa on Wednesday, March 1 and Thursday, March 2 at her home in Beverly Hills. Anastasia spa is arguably the most private and exclusive of the increasingly popular pre-Oscar spas, because it is held at her secluded home in the hills, unlike most of the spas which are held in public places like hotels. Because of this privacy and exclusivity, Anastasia attracted the likes of Oprah, Nicolette Sheridan, Eva Longoria, Kelly Preston, Debra Messing, Teri Hatcher the very first year she hosted the Oscar Spa. Of course, most of these people are Anastasia's regular clients as well and they were happy to support her new endeavor.

This year, Anastasia expanded the Spa, so that virtually every room in her house her house was devoted to a different service -- hair and makeup, pedicures and manicures and, of course, eyebrow sculpting by Anastasia. A new addition to the Spa this year was Twin Magic. Jimmy and Daniel performed eyelash extensions after Anastasia finished with the guests' eyebrows. Between treatments, guests lounged by the pool and were served lunch. Attendees this year included Lauren Sanchez, Catherine Bell, Amber Valetta, Garcelle Beauvais, Debra Messing, Molly Sims, Angela Bassett and Jessica Alba.

2005 Cosmetic Surgery Statistics

2006-03-02T20:08:00.000-08:00

The 2005 American Society for Aesthetic Plastic Surgery (ASAPS) Statistics on Cosmetic Surgery were released on March 2, 2006. The ASAPS consists only of surgeons certified by the American Board of Plastic surgery and these surgeons must have extensive cosmetic surgery experience and must meet certain ethical standards.

Here are some facts:

1. There were 11.5 million surgical and non-surgical procedures performed in the US last year.

2. Since 1997, there has been an increase of 444% in the total number of cosmetic procedures.

3. The top five surgical procedures were:
(a) Liposuction -- 455,489.
(b) Breast augmentation -- 364,610
(c) Blepharoplasty (cosmetic eyelid surgery) -- 231,467
(d) Rhinoplasty -- 200,924
(e) Abdominoplasty (tummy tuck) -- 169,314.

4. The top five non-surgical procedures were:
(a) Botox injections -- 3,294,782
(b) Laser hair removal -- 1,566,909
(c) Hyaluronic acid injections (Restylane) -- 1,194,222
(d) Microdermabrasion -- 1,023,931
(e) Chemical peels -- 556,172

5. Women accounted for 91.4% of the total

6. Eighty percent of patients were Caucasian, 9% Hispanic, 6% black and 4% Asian.

7. For breast augmentation, 83.4% of implants used were saline and 16.6% were silicone.

Endoscopic Browlift

2006-02-28T20:10:00.000-08:00

Forehead lifts (or browlifts) are an important part of overall facial rejuvenation. There are several types of browlifts, including coronal, anterior hairline, direct, suprabrow and endoscopic. With the exception of the Endoscopic Browlift, all of the other methods require fairly extensive incisions (coronal browlift and anterior hairline browlift) or incisions that are located in fairly visible locations direct browlift and suprabrow browlift). The coronal incision is located several inches back from the hairline, but the scar goes from ear-to-ear. The anterior hairline incision runs along the length of the anterior hairline, where the forehead meets the scalp. The direct browlift incision runs from one side of the forehead to the other. This technique is usually reserved for older patients with extremely deep forehead creases. In these cases, the scar will usually blend in with the other deep creases on the forehead. The suprabrow browlift involves incisions located directly over the eyebrows and is also often reserved for older patients with deep forehead creases. Because of the extent and visibility of the incisions with these more traditional browlifting methods, patient acceptance was quite low. This limited patient acceptance

In the mid-1990's, the Endoscopic Browlift was developed. The endoscopic browlift is a form of minimally-invasive surgery, where the incisions are quite small and, therefore, are relatively imperceptible when they healed. The endoscopic browlift became the preferred methods for many plastic surgeons, because patients were much more willing to accept five small incisions hidden in the hair, as opposed to the much larger and more visible incisions of the other methods.

The technique involves four or five small (less than an inch) incisions placed an inch or two behind the hairline. The forehead tissues are freed up from the bone, allowing the tissues to be moved upward. Various methods are used to keep the forehead tissues in place once they are lifted. Methods of "fixation" include titanium screws, absorbable screws and other methods. I have been using, for the past few years, a method of fixation known as the Endotine Method. The Endotine device is an absorbable, triangular device that has five tiny spikes (or "tines") on the top and a post on the bottom. The post is secured to the bone and the scalp is pulled up and placed firmly on the tines, thereby keeping the brow lifted. The Endotine devices dissolve in about six months, but by that time the tissues have healed into place and they stay where they are at that point, even thought the device has dissolved.

Minimally-invasive browlifting methods like the Endoscopic Browlift have led to much greater patient acceptance, and refinements like the Endotine Device has further improved the success rate with the Endoscopic Browlift. In the past, it was not uncommon to see a patient with a tight face, but with a brow that was droopy. This was because many patients simply did not want the large scar of the coronal browlift. Today, it is rare to see that "disconnect" between a youthful face and an aged brow.

Endotine Browpexy

2006-02-28T20:09:00.000-08:00

Although the endoscopic browlift was a tremendous advance in browlifting, there were still a group of patients who preferred not to have any scars on the scalp, since they had thinning hair or had no hair at all. In general, male patients with male pattern baldness are quite hesitant to have any scars at all on the scalp. Even the tiny endoscopic scars were too much for many men. For these patients, the Endotine Browpexy is the perfect procedure. The browpexy differs from the browlift in that in the browpexy, the eyebrows are raised only slightly and then fixed into place at this modestly higher location. With the browlift, the eyebrows are usually raised more than with the browpexy and fixed into place at this significantly higher location.

In 2005, the Endotine Browpexy was introduced and I have been very happy with the surgical results, especially in male patients, since no scars are needed in the scalp. The procedure is performed in conjunction with upper eyelid surgery (upper blepharoplasty), since nearly everyone that needs a brow procedure also needs an upper eyelid procedure). The browpexy is performed through the upper blepharoplasty incision. After the upper blepharoplasty is completed, the Endotine Device is fixed to the forehead bone just under the outer part of the eyebrow. The brow skin is lifted up and placed firmly on the small spikes ("tines") on the Endotine Device. The brow remains elevated at this position, even after the Endotine Device dissolves in a few months.

Although the Endotine Browpexy is commonly-used in both men and women, I have found it particularly useful in men. Most men do not want a dramatic browlift, and the browpexy, by definition, only provides a subtle lift. This, combined with the fact that men are hesitant to have scalp scars, makes the Endotine Browpexy an excellent procedure for male browlifting.

Eyelid Fat Transposition

2006-02-23T20:11:00.000-08:00

Puffy lower eyelids can be due to any number of anatomic factors. The eyelid is made up of several anatomic layers, including skin, muscle and fat. Any one of these structures can contribute to puffy lower lids and any or all of these structures may need to be addressed surgically in order to eliminate puffy lower eyelids. Of course, other factors such as allergies, lack of sleep, salt intake and alcohol intake can all contribute to puffy eyelids. These things cannot be addressed surgically.

For decades, the standard method of performing lower eyelid surgery (or lower blepharoplasty) involved making an incision in the skin just below the eyelashes. Excess fat, muscle and skin was removed and the incision was closed with stitches. The scar is almost invisible. With this method, however, it was not uncommon to see too much skin removed, resulting in the lower eyelids hanging like a hound dog's.

About twenty years ago, a method of lower eyelid surgery known as transconjunctival lower blepharoplasty became popular. The "transconj bleph" involved making an incision on the inside of the lower eyelid, eliminating the need for a skin incision. The transconj approach gave access to the fat only, however. The skin and muscle could not be addressed from this approach. To get around this limitaion, plastic surgeons began doing a "skin pinch" to get rid of any extra skin of the lower eyelid. Small forceps (resembling small tweezers) are used to "pinch" the skin, so that is stands up in the air. This extra skin is then cut off using scissors. The incision is then closed with stitches and, as with the standard blepharoplasty described above, the scar virtually disappears. Another advantage of the transconj approach: there was less scar tissue that formed during the healing process, since the muscle was not touched at all (only the skin and fat).

A potential disadvantage of the two procedures described above is the accidental removal of too much fat (or skin). If too much fat is removed, the lower eyelids begin to look hollow, which is not a youthful look. A youthful eye has just the right amount of fullness, somewhere between puffy and hollow.

In the last several years, a procedure known as lower Eyelid Fat Transposition has become very popular. As the name suggests, the lower lid eyelid fat is not removed, but it is transposed, meaning that it is shifted from one location to another. Many people that complain of dark circles actually have a problem known as a deep nasojugal groove. This groove extends from the corner of the eye near the nose and extends toward the cheek. Because a shadow tends to fall in this groove, it appears as a "dark circle." Instead of removing any fat, the fat is simply slid down (transposed) into the nosojugal groove and secured into place with stitches. This technique preserves the fullness of the youthful lid, but takes some of the fullness and simply puts it where it is needed.

I have been performing this procedure for the last several years and the results are excellent. There are still many situations where removing fat or muscle or skin are appropriate, of course. But in general, the trend is toward removing less and less fat from the lower eyelid.

Power-Assisted Lipectomy

2006-02-22T20:12:00.000-08:00

Power-assisted lipectomy (PAL) is a form of liposuction that makes the removal of fat easier and safer. For the first fifteen years since the advent of liposuction in the late 1970's, the technique required that the surgeon's arm move back and forth rapidly as he held the suction cannula, thereby using the movement of the suction cannula through the fat to break up the fat. Surgeon fatigue was a significant factor with this technique, especially when multiple areas of the body were suctioned. Furthermore, many surgeons developed "overuse" syndromes in their elbows and shoulders from all of this movement.

In the early to mid 1990's, a method of liposuction known as ultrasound-assisted lipectomy(UAL) came into vogue. The liposuction cannula was attached to a device that created ultrasonic energy. The ultrasonic energy was transmitted to the end of the cannula, where is dissolved the fat cells by essentially exploding them. The melted fat cells (not unlike melted butter) were then suctioned out very easily. Reports of surgeon fatigue and overuse syndromes among surgeons plummeted. This was because the ultrasonic energy replaced the need for a lot of arm and shoulder movement by the surgeon. In fact, surgeons were instructed to hold the liposuction cannula delicately and move it back very slowly and gently, like playing a violin. Slow movement of the cannula would allow more ultrasonic energy to reach the fat, melting the fat more easily. This method was especially useful in parts of the body where the fat was tougher and more fibrous. This included the upper abdomen, the back and the chest in men.

There were, however, a few downsides with UAL. Because the ultrasonic energy created heat at the end of the cannula, burns were possible. There were many reports of skin burns when UAL was introduced to the market, but proper training significantly decreased the incidence of burns. Also, because UAL melted the fat, there was a high rate of fluid collections called seromas. When a seroma develops after liposuction, it usually needs to be drained with a needle in the office. Several drainage sessions (called asperations) may be necessary, depending on the amount of fluid present.

Several years ago, a mthod of liposuction known as power-assistd lipectomy (PAL) was developed. With PAL, the suction cannula is attached to a power source that moves the cannula rapidly back-and-forth, not unlike a small jackhammer. This rapid back-and-forth (or reciprocating) motion helps break up the fat so the surgeon does not need to expend large amounts of energy by moving his arm back and forth as much. In fact, as with UAL, the surgeon purposely moves the cannula back and forth slowly (like holding the violin) in order to allow the reciprocating motion of the cannula to do the work for him. The reciprocating motion is also very good at breaking up tough areas of fat, just like UAL is.

In summery, PAL has many of the advantages of UAL but without many of the risks, such as skin burns. It is a true advance in the field of liposuction.

Non-Surgical Rhinoplasty

2006-02-17T20:12:00.000-08:00

Recently, I have been performing a new procedure I call the "Non-Surgical Rhinoplasty". Non-Surgical Rhinoplasty involves injecting Radiesse into the nose in order to reshape it. Radiesse, an FDA-approved filler, consists of calcium hydroxylapatite microspheres suspended in a gel carrier, made up of water, glycerin, and carboxymethylcellulose. Radiesse typically lasts for a year or more.

The past two days, I have performed this procedure on my patients while they were undergoing other procedures. On February 16, I performed a medial thigh lift, liposuction of the knees, a chemical peel of the face, and Radiesse injections to the smile lines on a 55 year old female. I also injected Radiesse into the patient's nasal tip, since a previous surgery had resulted in a very pinched tip. Literally before my eyes, the nasal tip became less pinched and looked much more natural. This is an example of using the Non-Surgical Rhinoplasty to correct a previous surgery.

Today, I performed facial rejuvenation surgery on a 57 year old female. The procedures consisted of a temporal lift, eyelid surgery, a facelift, cheeklift and chin implant. I also injected Radiesse into the patient's smile lines and into her marionette (or puppet) lines. Then I injected a small amount of Radiesse into the patient's nasal tip. With age, the tip loses its projection and begins to droop. The Radiesse instantly provided more tip projection and raised the drooping tip. The results were amazing.

It's just a matter of time until you begin hearing about the Non-Surgical Rhinoplasty in the media.

Face Transplant

2005-12-17T20:14:00.000-08:00

The recent partial face transplant performed in France reminded me of the time I was the medical advisor for the movie Face/Off in 1996. The director that initially signed on to direct the then-untitled film ,Italian director Marco Brambilla, came by my office to discuss the project. I just assumed that we were talking about a relatively low-budget production. We discussed how we would portray the procedure on film and Marco toured my office and operating room taking photographs of the facilities and equipment. As Marco left, I wished him good luck in Hollywood, thinking that he was new to the United States and that he must be excited about directing what I presumed was one of his first movies.

Two days later, I am reading an article in the entertainment section of the LA Times about Sly Stallone. As I am reading the article, there is reference to the director of Stallone's big budget film Demolition Man. The director was none other that Marco Brambilla. I began to think that this small sci-fi film about two people exchanging faces may not be so small after all. Marco must have thought it was strange that I wished him good luck in Hollywood!

A few months later, I get a call from John Woo, the new director of what was now called Face/Off. Marco was off the project. John said that they had signed Nic Cage and John Travolta to star and that they were ready to start shooting. "Will you be able to come over to the set at Paramount to advise us on how to portray the procedure of Nic and John trading faces?" I agreed to come to the set the following Saturday and I arranged for a Coherent carbon dioxide laser to be delivered to the set. The CO2 laser looked high tech and would fit the role perfectly. I was trying to decide how to portray the procedure on film. Should I go with a realistic portrayal of a face transplant or with an imaginary, sci-fi type procedure?

John Woo, the cast and I discussed the options and we decided that the best way would be a stylized, sci-fi approach based loosely on real surgery. We decided to use the CO2 laser in a realistic way to make the incisions for the face transplants, but we decided not to get into more of the specific anatomic maneuvers that would be used someday in a real face transplant. I explained to the cast and crew that we would some day in the future be performing face transplants just like we perform liver transplants and kidney transplants today. In real life, we would not only transplant the face, but we would also need to transplant the arteries, veins and nerves of the face. We would also need to prescribe medications that would prevent the recipient from rejecting the new face. Although we all agreed that this was a very an exciting concept, but we felt that keeping things simple would be preferable for the movie.

It seems like only yesterday that we stood on the Face/Off set at Paramount talking about how someday in the distant future, a real face transplant would be performed. Little did we know that only eight years later, an actual face transplant would be performed on a real patient in France.

The Tear Trough

2005-12-17T20:13:00.001-08:00

A rarely discussed area of the face is the tear trough (or nasojugal groove). The tear trough is the groove located where the lower eyelid meets the cheek. Some people have just a hint of a groove and others have an extremely deep groove. It is often hereditary and typically gets worse with age. People often complain of "dark circles" when referring to the tear trough deformity.

There are various treatment options for the tear trough. One option is fat grafting. Fat is taken from another part of the body (abdomen, inner thigh, knee), placed in a syringe and carefully injected into the tear trough. Because the lower eyelid skin is the thinnest skin on the body, there is a risk if the fat lumping and becoming visible. Some of the fat is absorbed by the body, although a certain amount remains as living, viable fat cells.

Another option is a silicone implant. This implant, made of solid silicone rubber, is not commonly used, but it is an option for some people. Again, because of the thinness of the skin in this region, the implant can be visible.

There are a few options that I prefer, some surgical and one non-surgical:

1. Non-surgical -- I have had tremendous success with Restylane injections to the tear trough. Surprisingly, these injections are virtually painless and require just a topical anesthetic cream. The Restylane is placed deep to the skin just above the orbital bone, to minimize the risk of visibility or lumps. The best results are seen in patients with relatively thick skin, since the risk of lumps is minimized in these patients. Older patients with thinner skin are best treated with a thinner soft tissue filler, such as Cosmoderm. Bruising is fairly common with this procedure, but it can be easily covered with makeup. A recent study showed that bruising occurred in 50% of patients and minor irrecularities occured in 20% of patients. The Restylane typically lasts more than six months in the tear trough.

2. Surgical -- There are two good surgical options for the tear trough:
(a) Fat transpostion. This is probably my favorite surgical option that addresses only the tear trough. In this procedure, fat that is already present in the lower eyelids (the lower eyelid 'bags") is slid down (or "transposed") into the tear trough. Because this fat is living fat (it is left attached to its blood supply), it does not slowly go away like injected fat (see above). The incision can be either inside the lower lid or on the skin just below the lashes.
(b) Cheek lift. This is another great option to soften the tear trough. In addition to softening the tear trough, it also results in a more youthful appearance to the face in general, since it involves lifting the cheek up to cover the tear trough. The cheeks fall with age, so the cheek lift simply puts the cheeks back to where they once were. There are various ways to do this. One involves an incision in the hairline near the temple. Another involves an incision in the lower eyelid.

Eyelash Extensions

2005-12-17T20:13:00.000-08:00

As a plastic surgeon, it is important to look globally at the face. For example, when examining a patient's nose, it is also important to examine his chin and neck to ascertain that the nose, the chin and the neck are in proportion. Likewise, when examining a patient's eyes, it is also important to examine the surrounding structures, especially the eyebrows and eyelashes.

Recently, eyelash extensions have become increasingly popular. Two twin brothers from Vietnam, Daniel and Jimmy (known professionally as Twin Magic), are on the cutting edge of this trend. My dear friend, Anastasia, told me about Twin Magic, so I invited them to come by the office to demonstrate the extensions. Daniel and Jimmy applied the extensions to the girls in my office, including Amanda, Carol, Cindy, Mona and Sue. Over the past several months, I have been increasingly impressed with how well the eyelash extensions complement my eyelid surgery. Eyelash extensions have become an integral part of the overall peri-orbital (peri-orbital refers to the area surrounding the eye) rejuvenation for my patients.

The initial application takes up to two hours, since each eyelash is applied individually. Touch-ups are required every few months, but the touch-up process is much quicker than the initial application. Twin Magic also gives the patient advice on conditioning the eyelashes and follows the patient carefully to determine when it is necessary to take a break from the eyelash extensions, which requires removing them temporarily every several months.

To see Twin Magic's work, simply open People Magazine or turn on Entertainment Tonight, since Naomi Campbell, Sofia Milos, Joss Stone, Lauren Sanchez and many others have been to the office to get Twin Magic's eyelash extensions.

Mesotherapy

2005-12-14T20:16:00.000-08:00

Mesotherapy involves injecting various medications and substances into the tissue beneath the skin. Although patients are constantly clamoring for procedures that are quick and painless with no downtime, there needs to be real, scientific data on these new procedures before most plastic surgoens will recommend them.

A comprehensive article in the April, 2005 issue of the definitive plastic surgery journal, Plastic and Reconstructive Surgery, found virtually no scientific data on mesotherapy.

Here's a little background on how some procedures become known by the public before there is solid data behind them:

Most plastic surgeons insist on seeing peer-reviewed scientific studies before recommending a treatment, but many physicians will offer a new procedure to drum up business. Many of these physicians really don't care if the procedure is effective or not. The media is always asking "what's new" when they call doctor's offices. They want the latest and greatest procedure. However, the media doesn't care if the procedure is effective or not, as long as they get a great story about this new breakthrough procedure. Frankly, if the new procedure is an absolute disaster and causes unforeseen complications, that's an even better story!

Scenario #1: A local reporter calls the doctor's ofice and asks "What's the newest, cutting edge thing you're doing?" The doctor answers "I'm doing this new procedure that was just brought to this country from Europe and I am the leading expert in this country and I am one of the only doctors currently doing it." The reporter says, "Really? I'll be right over." The television crew comes to the office, the doctor performs the procedure (on one of his nurses, perhaps) and the patient exclaims how simple and painless it was and how much she loves the results.

The segment airs on the local news, the beauty magazines all run articles on it and the doctor is on Oprah the following week. His office is swamped with calls requesting appointments with the leading expert with this new procedure and everyone is happy.

Scenario #2:

A reporter calls the doctor's office and asks "What's the newest cutting edge thing you're doing?" The doctor has been aware of Mesotherapy for some time, but because he prefers to wait for some solid scientific data about the safety and efficacy of Mesotherapy before offering it to his patients, he responds vaguely about various advances in the field of plastic surgery. The reporter becomes bored and thanks the doctor and hangs up, calling other doctor's offices looking for a better story.

There is no standard formula for mesotherapy.

Restylane

2005-12-14T20:15:00.000-08:00

In many practices, Restylane injections have replaced collagen injections as the soft tissue filler of choice. Restylane (hyaluronic acid) typically lasts six or more months, whereas collagen lasts three months. Restylane and collagen are typically used for the same purpose, namely soft tissue augmentation of the face. Some of the most popular areas for soft tissue augmentation with Restylane include the lips, nasolabial folds (smile lines), marionette lines and the nasojugal grooves (hollowing beneath the eyes). It can also be used for filling in irregularities the face after trauma or surgery. Restylane injections are much more painful than collagen injections, so many physicians administer nerve blocks, so that the entire peri-oral area (the area around the mouth) is numb for a few hours. This is the same thing dentists administer before they work on your teeth. Topical numbing cream is also usually used. Restylane is also more painful than collagen when the nerve block wears off. I have patients who told me their lips hurt for several days after Restylane injections. The lips are also swollen for a longer period of time with Restylane (three or four days v. one or two days with collagen). Allergic reactions are almost unheard of and the manufacturer doesn't recommend a skin test prior to treatment. A skin test is necessary prior to being treated with collagen because collagen comes from cowhide; therefore, there may be cross-reactivity because a protein from another species (cow) is being injected. Restylane is made of a substance called hyaluronic acid, a substance that is naturally found in humans.

In my practice, I use Restylane in 98% of my patients that request a soft tissue filler. A few patients still prefer collagen. If I don't use Restylane and the patient doesn't specifically request collagen, I tend to use a product called Comoplast, which genetically engineered from human skin. No skin test is necessary, since it from human skin, not cow.

Restylane is a bit too thick for fine lines, so I will often place Restylane in the deeper portion of the fold and place Cosmoderm (a thinner version of Cosmoplast) on top of the Restylane closer to the surface of the skin. This results in a better result that just Restylane or just Cosmoplast or Cosmoderm alone.

A thinner version of Restylane (Restylane Fine Line) is not yet approved in the US, nor is the thicker version called Perlane.