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.
Tuesday, March 14, 2006
Friday, March 3, 2006
Anastasia Oscar Spa
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.
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.
Thursday, March 2, 2006
2005 Cosmetic Surgery Statistics
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.
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.
Tuesday, February 28, 2006
Endoscopic Browlift
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.
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
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.
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