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.
Tuesday, February 28, 2006
Endotine Browpexy
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.
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.
Thursday, February 23, 2006
Eyelid Fat Transposition
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.
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.
Wednesday, February 22, 2006
Power-Assisted Lipectomy
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.
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.
Friday, February 17, 2006
Non-Surgical Rhinoplasty
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.
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.
Saturday, December 17, 2005
Face Transplant
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.
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
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.
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.
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