As much as we are all alike in being human, we all have particular and specific individual traits and reactions to the environment and particularly to medicines. In this way we are truly unique!

Drugs and medicines are formulated and tested, usually with great rigor, before being approved for use on humans in the USA by the Federal Drug Administration (FDA). All drugs and injectables are known to have some side effects and it is with the analysis of the risk – benefit that the FDA clears a drug  or injectable for the market’s use.

Facial skin dermal fillers

There are two commonly used facial skin fillers these days and both are based on the material known as Hyaluronic acid. Radiesse, a mixture of Hyaluronic acid and Hydroxyapatite crystals last about 1.5 years, and Juvederm, the other common facial filler, typically lasts about nine months. Some cosmetic plastic surgeons may still be using Restalyn, another hyaluronic acid, but its shorter period of effect has made it less popular. These medications have the ability of attracting water to themselves and as such plump up the skin wrinkles and lines that add to an aging face.

Common reactions of facial skin fillers

Although all drugs and facial fillers can have adverse reactions, their rate of occurrence is low. Common side effects to facial fillers include

• Bruising of the skin
• Swelling at injection site
• Lumpiness that is temporary

Rare complications of facial fillers

Some rare complications can occur either as a result of injection into an artery or following an idiosyncratic reaction to one of the materials in the injectables. It should be noted that even though Hyaluronic acid is a material found in our own bodies, the mixtures that are made to form an injectable product may contain other chemicals to which we may be allergic.

Here are photos of a patient with a rare allergic reaction to Radiesse. She was had Radiesse injected into the nasolabial folds and lip lines. Within an hour her lips and cheek swelled up. Treatment with ice, and anti-histamine drugs led to a decrease in swelling by the next morning.

complications of fillers- before

2 hours after injection of facial filler12 hours after reaction

As much as we would like all medical procedures and interventions to be risk free it is important to remember that a small but real risk always exists for any action we take and procedure we have performed. For that matter, the roof could fall on your head while you are sleeping; that is the way of the world.

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Your’e not the Expert in cosmetic surgery

In days gone by, your cosmetic plastic surgeon would have gone to college, medical school, five year surgery training and a two to three year plastic surgery training before being allowed to start a plastic surgery practice. After two years in practice they would take an oral examination given by senior plastic surgeons, and if they passed (30% did not), they would be able to call themselves a “Board certified plastic surgeon” .
Patients would seek their expertise in wound surgery, reconstruction and cosmetic surgeries. Options for treatment would be offered and the patient may even have been referred to a particular specialist in the field if the problem was too complex for the surgeon to handle. Patients would choose their plastic surgeon, have surgery and trust their surgeon to take care of them. After all they would have just trusted the surgeon to perform surgery on them with sharp instruments- and that takes a lot of trust.
It’s not like that anymore…

Cosmetic patients play at being surgeon

With the 1980s “empowerment  of the patient”movement surgery has changed significantly- and not always for the best. Before then, was the era of your being diagnosed with a fatal disease and doctors deciding not to tell you of your eminent demise for fear of upsetting you. They would tell your family instead. Obviously this was not such a good idea and change in the doctor- patient relationship was needed for a more equitable sharing of responsibilities and commitments.
The pendulum has now swung to the opposite pole. It’s the patients who now decide what they want done and dictate to the surgeon their treatment. If they don’t like what they hear, they ignore the surgeon’s years of training and experience and shop around to find the answer they want to hear or the one they read about in the internet .  There is no trusting of the cosmetic plastic surgeon.

Wrong choices by cosmetic patients

Case 1

Youngish woman has a tummy tuck and a few weeks later, after not wearing her binder, gets swollen and a small 1 inch wound opens in the lower abdomen. Common enough. She is instructed to clean and pack it, and given an appointment to come to have it re-sutured in 5 days. She didn’t like that plan. Made up a story about being on vacation, went to a wound clinic where she was fitted  with a “Woundvac” (the only thing a wound clinic can do- a suction apparatus to walk around with 24 hours a day- for 3 weeks) before the wound closes. She still has not been back to see the cosmetic plastic surgeon despite the fact that  plastic surgeons are THE WOUND SPECIALISTS!!!!
Case 2

Middle aged woman has tummy tuck but is slow to get up and around getting swollen in the belly area. Common enough. She is seen at clinic and reassured everything with the abdominoplasty is going fine and healing is progressing normally. She didn’t like to hear that so she spent the following evening in an emergency room to be seen by a doctor who has no idea what an abdominoplasty is, to be told that everything is fine!!!

Case 3
Another lady who is recovering 2 weeks after a tummy tuck  and is doing fine decides to go to the Emergency room  to be checked out- instead of coming to her appointment with her cosmetic plastic surgeon!!!!

Trust your cosmetic plastic surgeon

As a patient contemplating cosmetic surgery you should see several surgeons, get as much information about the surgery and choose your plastic surgeon based on his or her abilities and techniques, personal rapport, reputation and credentials and Board certification.
Then you will be paying lots of money to have your surgery performed and for included post-operative care given your surgeon’s experiences with many thousands of other patients.  Why you would not want to avail yourself of the expertise of this highly trained individual that you have engaged to provide surgical services to you, and whom you trusted very recently to cut you with a knife?
It makes no sense to me.!

Granted if the plastic surgeon is ignores your calls, cancels your appointments, has no system for coverage by other surgeons etc, you should seek surgical help elsewhere- But for goodness sake, trust your surgeon and know that they are doing the best for you- an emergency room doctor is not a substitute for your surgeon, and internet information is an even poorer choice. Cosmetic plastic surgeons really do care a lot more than you think.

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Face and Brow lifts too tight

Every week I have a patient sit in front of me during a face lift consultation and tell me that whatever I do during the surgery, she does not want to come out looking like Kenny Rogers, the American singer whose multiple bad face lifts and brow lifts have left him with a perpetual sardonic smile and surprised look.

Kenny Rogers face and brow lift too tight

The face lift patient obviously wants an improvement in their appearance and the opportunity to look better but not at the price of looking too “pulled” or having that “wind swept look”. Everyone rattles off the name of some poor has-been actor or actress who now looks atrocious after some “cosmetic surgeon to the stars” has tried too hard to give something they cannot- youth- by pulling on their skin.

I have written in the past about my philosophy of what a good cosmetic surgery should achieve. I believe that the whole art of cosmetic plastic surgery is to return the body to normal. Unfortunately for those of us destined to live on this planet, normal in terms of our brains refers to a goddess/god between 18-25 years!  Plastic surgery therefor tries to bring our cerebral image of normal to bear upon on jellied fat and skin. When your face starts to fall, we need to lift it back up to where it was in our youth- when we looked normal. An ageing body or face is not normal!

The loss of facial tone is often dramatic and sudden. The plastic surgery patient runs in terror to the cosmetic surgeon and says’ pull it as tight as you can”. Some plastic surgeons do just that; they pull the skin real hard and leave you with a forced, fake smile that is a tell-tale sign of a face lift. Unfortunately, so many women have had these bad face lifts that some think that is how you are supposed to look after a rhytidectomy and are unhappy if they don’t have that horrible look.

Some surgeons are skilled at judging the amount of pull on a face with the patient under general anesthesia and with no muscle tone. Most are not. The un-resisting muscles of the face and the attached skin get pulled too tight in those cases.

I prefer to perform my face lift surgery with the patient under sedation and local anesthesia to prevent the wind swept look. As I pull the skin and muscles back, the patient counters with their intrinsic muscle tone and prevents me from going too far. This technique has worked well for me over the years.

I love the look of wind in the hair but you do not want your face to look like you are in a wind tunnel. Try to have your board certified cosmetic plastic surgeon give you a natural look- that will look normal.

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Droopy Brows and lids fixed

The droop that occurs sometimes after Botox injections is the result of an imbalance between muscles of the forehead, eyelids and brow. If Botox that is injected into the Brow has an effect that is too strong or moves over too large of an area, the brow elevation will be stopped ( brow elevators are knocked out) and the unopposed action of brow depressors will come into play and make droopy brows! Likewise if botulinum toxin drifts down into the eyelid,  muscles that open eyelids may be affected and cause eyelid to droop.

What to do after a brow/ eyelid droop

The effect of the Botox will last about three to four months. That is a long time to go around looking droopy on one side, but there are some options exist to improve these situation.

1. Inject Botox into opposing muscle

If the droop is due to too much botox effect on a Frontalis muscle, injection of botulinism toxin into the outside part of brow depressor (Orbicularis Oculi) will weaken these opposing muscle and re-establish some balance by elevating their brow

2. Place eyedrops into eye.

Since droop of an eyebrow actually manifests itself more as an eyelid droop in most patients, placing a few drops of Apraclonidine 0.5%  will relax  Muller’s muscle and allow elevation of the eyelid and “correct” the droopy look.

3. Patience

In some patients,  droop may naturally dissipate after a few weeks to a point that it is no longer problematic.

In conclusion, droopy eyelids that occur after Botox injections are due to the imbalances that occur between different muscles groups. Your Board certified cosmetic plastic surgeon will get to know your particular anatomy and be able to titrate dosage of Botox that you need to strengths of your muscles. Even though you might get a droop the first time, you should get a good lift the next.

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Anatomy of Droopy eyelids after Botox

There is a 3% risk of getting a droop of the eyelids after Botox injection into the forehead area.
How can a simple procedure that is supposed to elevate the forehead, remove wrinkles from them and give you a “lift”, turn out to cause more problems than expected? Well, its all to do with our individual forehead anatomy.

Anatomy of the forehead

There are two types of muscles in the forehead area

Brow elevators

The main brow  and forehead elevator is the Frontalis muscle. The action of this muscle is to elevate the eyebrows. As it does so, it contracts and can cause skin folds of the forehead which are commonly known as “worry lines”. Its lowermost portion is about one finger-breadth above one’s eyebrows.

Brow depressors

There are three main depressors of an eyebrow area. These are muscles whose function is to bring down eyebrows.

• Procerus  ; muscles that cause  Bunny lines ; horizontal lines at the top of the nose

• Corrugator supercilli ; muscles in between eyebrows; responsible for two lines between brows – the one’s you get when you look angry-  “number 11s”

• Orbicularis Oculi muscles; muscles around eyes, both under and above  eyelids which are responsible in part for closing eyes such as when you squint. These are the ones that cause crows feet on either side of your eyes when you squint hard.(See below- part of this muscle also closes eyelids)

Anatomy of Eyelid muscles

There are two main types of Eyelid muscles

Eyelid Elevators

• Levator Oculi Superioris. This thin muscle lifts up the eyelid. Close your eyes. Now open them. You just used your Levators!

• Muller’s muscle ; the superior tarsal muscle also lifts the eyelid through our “sympathetic nervous system”- a system of nerves that is involuntary. This muscle elevates lids when you are startled. That open eye look of surprise  or fear is mainly due to elevation of eyelids by the action of this muscle.

Eyelid depressors

• The eyelid portion (Palpebral portion) of the orbicularis Oculi closes the lids gently as in when we go to sleep or blink.

Muscles always work in pairs with a depressor muscle being balanced by an elevator muscle. The fact that one group may be a little stronger and have more effect leads to the particular facial lines being more noticeable. If the muscles were in perfect balance there would be no lines!
The effect of Botox is to selectively stop the function of the muscle it is injected into. The balance of forces is thus affected and the opposing muscle’s action becomes more prominent as it is now unopposed. So for example you injected Botox into the Corrugator muscles between the eyebrows. Normally this muscle pulls the middle eyebrows in. After Botox it is knocked out so the opposing forehead elevator the Frontalis muscle pulls the forehead up!

Lots more on this topic on the next blog. Raise your brows and stay alert!

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The Wall Street Journal has an article on it, Google news mentions it and the whole of the cosmetic plastic surgery world has had its jaw opened about the latest statistic in plastic surgery- a 90% increase in chin enlargement surgery since last year.

Check out this article for instance;

http://todayhealth.today.msnbc.msn.com/_news/2012/04/16/11188357-for-cosmetic-surgery-chins-are-the-new-breasts-chinplants-on-the-rise?lite

In 2010, chin augmentation ranked 14th in terms of the number of plastic surgery procedures performed with about 10,166  mentoplasty surgeries being done that year.
In 2011, about 11171 chin augmentations were performed; the procedure ranked 15th in terms of the number of cosmetic procedures performed.  By comparison in 1997 it ranked 12th with 27,373 chin enlargements being performed!! A 59% decrease in comparison to 2011.

So what is the big deal? 1000 more people do the surgery in a nation of 300 million! It is still ranked lower in  than the number of thigh lifts done and is 30 times less frequent than breast enlargement surgery!

New causes for chin enlargement popularity

Part of it seems to be the need for the news media to grasp at anything remotely sexy within a cosmetic plastic surgery topic. The 18% decrease in breast reduction surgery is not as newsworthy apparently. I would have thought though that the 29% increase in brazilian buttock lifting by fat injections would have had a chorus of cheering fans but apparently the chins were out in front…literally it turns out.

The continued rise in popularity and use of internet chatting using cameras mounted on top of screens has apparently led to a realization that as a species we are becoming weak chinned. Those big wide jaws we still love on our actors and models hark back to a pre-historic age when we needed big teeth in big jaws to bite off and chew big pieces of animals. It seems that subconsciously we still find that a trait that is desirable. When looking at the miniature picture of ourselves on the corner of our chat screens (and who amongst you does not keep looking at that?), our faces appear larger at the top (big forehead)  and smaller at the bottom (small chin) based on the simple optic of the camera position. We also look like we have flabby jowls and loose necks since we are typically looking down towards our computer screens instead of up at eye level or above.

The news media went mad with this last week. Articles about “facelift surgery” for “facetime” and chin enlargement for a better on-line presence appeared everywhere.

Facts about chin enlargement surgery

Chin surgery is a great surgery for the few people who really do need it either because they really do have a small or weak chin or a large nose that in relation to the chin makes it appear small. The surgery is typically performed under local anesthesia in my office and one of several different type of implants can be placed under the skin of the chin. There is some pulling of the sagging skin of the neck with larger implants but not much. The average cost for the plastic surgeon’s part of the procedure was $2500.(Add implant fee of $300 and facility/ anesthesia fee and it gets closer to $3500).  Healing is initially a week or so and final swelling goes away in about 6-12 months.

Chin surgery for your on-line face?

My recommendation is to have chin augmentation surgery performed by your board certified cosmetic plastic surgeon for your real face- not your online face.
For your online digital representation I do have a few ideas;

1.  Sit a foot further back from your screen than you normally do- The camera optics will be kinder to your physiognomy.
2.  Lift your screen so the mid-screen area is at least level with your eyes.
3.  Place your camera to the side of your screen so it is looking at you on the same level and not from above.
4.  If none of the above work and you still have a weedy chin get plastic surgery to make you look like a movie star!

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Timing  Scar revisions

Whenever someone has a surgical incision or traumatic laceration, after the initial suturing, the urge to see a plastic surgeon for improvement of the scar is irresistable.

Initial care of a scar

After a traumatic injury or a cosmetic plastic surgery incision, the wound is usually closed with sutures or glue by a plastic surgeon or emergency room doctor. The care

of the wound in the initial few days is usually pretty standard. Patients typically apply

antibiotic ointment to the wound for a few days after keeping it dry for a couple of days.

After suture removal most plastic surgeons should recommend applying a sun block and silicone based cream to smooth out the scars and then you wait.

Scar Healing over time

The patients that come to the plastic surgeon’s office seeking improvement in a scar fall into two groups. Those that have had a scar for years and those that have had the scar for only a few days.

For patients with a new scar all the plastic surgeon can do is hold their hand. The new scar has to go through its normal and expected range of healing phases. Scar formation will reach a peak at 8 weeks after wound closure and the swelling may remain for several months more. Only after the scar has reached “maturation” is your plastic surgeon ready to intervene to improve the scar. Doing so earlier is not advisable unless the scar, as it heals, is pulling or puching other structures disadvantageously. Usually you must wait one year for the process of scar maturation.

Scar Healing in children

Waiting for a scar revision is always hardest when children are injured.

As parents we have a feebleness that engulfs our thoughts when it come to our children and an irrationality which often works against our childre’s best interest.

It is actually the most important group of patients in which to be the most patient with regards to a good scar result. Chidren’s scars typically take up to two years to mature and stop changing in color. They will however continue to change in shape and texture for as long as the body area grows; and if given enough food the child will grow and the scars will stretch and become thinner. Secondary, tertiary and even multiple scar revisions are often necessary on a childhood scar to achieve the best result.

Scar revision

Once the patient has waited for the scar maturation process to complete, which may last a year, the scar revision planning can occur. Surgeries may be minor or major, single step or needing multiple steps, and will inevitably result in another scar that will need… another year to mature. That is why there is a push to minimize scars during surgery and your board certified cosmetic plastic surgeon is the best person to place them in the most inconspicuous areas.

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Nude beaches problematic for plastic surgeon

As a cosmetic plastic surgeon I spend most of my day looking at and moving around the flesh of people in the nude. That is my job. I don’t think twice about lifting a breast up or squishing a tummy down. I wear my white coat and with my state sanctioned license to practice surgery and medicine, I go about my business.

When I leave the office, my brain changes and I go into normal human mode. That means that I am not looking at everyone and every thing through my cosmetic plastic surgeon eyes that can lead to life changes,  but  rather through those of a mere mortal.

Then I went to the beach at the French island of Guadalupe.

My first experience with a nude beach was when I was a teenager and went for holidays with my family to St. Tropez in France.  that was where Bridget Bardot  (Google her if you don’t know who I’m talking about) had gone to live and it was THE PLACE TO BE IN THE SUMMER in the 1970s.

I had seen enough  girly magazines at boarding school not to be shocked by the sites of voluminous jiggling flesh and firmer bouncing breasts. My 8 year old brother had not seen the magazines. He was walking along happily on the beach  until he came upon the nude beach and, as family lore goes, he let out a primal scream and ran away in horror, crying all the way back to the car.

Mono- kini  (going topless) has been common on the continental beaches for the past 40 years even though it goes in and out of style in certain degrees. Men are always topless on beaches (have you noticed that?). That level of female nudity has never caught on on our puritanical American shores.

Nevertheless, there I was looking at a whole range of naked bodies and …I was back at work! It lasted for a few days. Looking at every breast and following it down to the tummy or shooting up to the face and nose (Gallic noses have fame in plastic surgery circles). Every patient/person on the beach, was scrutinized as if in the privacy of my office consultation room and each was assigned a therapeutic and surgical plan. A breast augmentation here, a tummy tuck there. The possibilities were endless.

My frenzied brain settled down after a few days and a few rum laden treatments. I could then look on the world again through the eyes of a normal and nonchalant french holidaymaker.

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Broken nose

Our noses are one of the most prominent aspects of our faces, and for some of us one of the most protruberant. As such, when our faces hit other things around us, the nose frequently gets the brunt of the assault and does what it is designed to do which is to break as it absorbs the shock aimed at our face.

Anatomy of the nose

The nose is made up of two main parts. The bony nasal pyramid in the upper third, and the cartilagenous portion in the lower two thirds and middle.

When things break it is the hard parts that break; the bone and the central cartilage ,or septum. The nose will appear flattened or deviated. The septum may break to curve the nose and may even block the airway.

First aid for your broken nose

Usually there is some bleeding that occurs after a nasal fracture; at times it can be severe bleeding. Control of bleeding is paramount.

1. Pinch your nose and hold on for 5 minutes. If it’s still bleeding hold for another 5 minutes. If it’s still bleeding go to the nearest emergency room.

2. Place ice on your nose. This will decrease the amount of bleeding and also help with the resultant bruising that will occur.

3. Don’t blow your nose hard as you may restart bleeding.

4. Sleep with your head elevated for 48 hours to minimize swelling.

5. Plan to see a cosmetic plastic surgeon as soon as you can.

6. That means call today- You may need a surgery within a week and the sooner you start the process the better.

Surgery for your broken nose

After your nasal fracture you have about a 7-10 day window when you can have a nasal fracture corrected surgically. After that, the tissues become too swollen and the healing process that starts naturally (to heal your nose in a crocked position) will not allow for any surgery for up to six weeks. Your tissues will simply not hold sutures and bones will melt away if you try to have surgery. The results will be disastrous.

 The surgery itself is usually not particularly painful or time consuming. The nasal bones are straightened by directly pushing on them if early on, and by re-breaking them if later on. The septum may also need to be straightened (a septoplasty) or may need removal of the fractured segments (a submucous resection; SMR), if the airway is blocked and you cannot breath well from one nostril.

 A cast is usually placed over the nose at the end of the surgery and will stay in place for about a week. There may be some bruising under the eyes and swelling of the eyelids to the point of closing the lids! Some bleeding from the nose may occur but should be minor.

Healing after rhinoplasty

The nasal cast is removed after one week but the swelling will persist for months. It actually takes a whole year for all the swelling to dissipate and for your final nasal shape to become evident. massaging of  nasal skin will help this along as will placing tape on the skin at night time.

Your friends may tell you that your broken nose has added character to your face but as your cosmetic plastic surgeon I must advise you to find other ways to improve your character and to get your broken nose fixed pronto!

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Last week I was a guest at a rather fancy dinner in a fancy club with fancy guests in Washington DC. Illustrious diplomats and financiers, power brokers and members of the well healed establishment. I was there as I am a distant family member of the host- unfortunately I cannot lay claim to any of the other categories- yet!

I sat down to dinner at a table of ten whom I did not know. On my right was a man, who at first glance, I thought looked similar to me. Same complexion, salt and pepper beard, about the same age. He saw my name tag and asked me what type of doctor I was- cosmetic plastic surgeon. “and what do you do?” – “I’m a mentalist” (!!!!)

Gerard Senehi, I later found out, is a minor celebrity who entertains corporate and other publics by his feats of mind. He’s been on the “Ellen show”, Today show etc.

He made a piece of endive on the salad turn over…

I asked him what a mentalist really did and he made the endive flip!

That was the beginning. He made forks rotate on glasses, spoons bend, flower droop, cigarettes float, and also read minds. First, he did this for our table and then he got up and performed similar feats for the whole body of guests.

It was dinner that was being served, yet the large number of open mouths did not have food in them.

As one gets older we lose the ability to be amazed the way a child does. Our life experiences make us more wise as to the usual tricks and slights of hand of magician’s and street performers. We’ve seen those tricks before, been fooled before, and may have even seen the “behind the scenes TV show” that explained all to millions.

So, to be in a room of 60 people, mostly in their mid-70s, who in some way or other direct our lives and to see their open mouths reminded me of the look on the childrens’ face when Mr.Turley, the magician, performed at my daughter’s 5th birthday.

The ability to perform telekinesis (movement of objects using thought), and telepathy (reading minds) is one that we all apparently have. Gerard told me that its akin to the ability for playing music. We can all learn how to play an instrument and practice will make us better. Some of us though are gifted with that ability and it comes to them easier. They are just innately better at it than others, and if they practice, they become much better. In the same way mental abilities can be trained with practice but some of us will just be better at it than others.

A few years ago I bought a toy for a friend’s birthday after seeing a physical effect on my own mental powers. At the Swedish embassy in Washington, DC, there was an exhibit of all things technologically Swedish. One apparatus involved two contestants sitting on either end of a table with a metal ball in a trough. Each of us put a hat with electrodes attached to it and the table, and with the power of our thought (amplified brain theta waves) we were able to move the ball back and forth in a contest of brain power. The more you concentrated the more the ball moved.

The toy is based on a similar idea though now your brain controls a fan which whirls fast and floats a ping pong ball higher the more you concentrate. It is a great training tool but the novelty wears off soon. Here, you can buy it on Amazon

http://www.amazon.com/Mattel-P2639-Mindflex-Game/dp/B001UEUHCG/ref=sr_1_1?ie=UTF8&qid=1333413374&sr=8-1

The relevance of all of this to cosmetic plastic surgery is rather remote. However it did start me thinking about how if our brains can move objects outside our bodies, surley thay can move tissues within? Not that I want to wish away my livelihood but what if by mere thought – say ten minutes a day – we could lift our faces up, or make our tummy fat move away?

It has already been scientifically established that thinking happy thoughts makes your facial muscles form into a smile and unhappy thoughts will stimulate your frowning so would this not be the next logical step?

 As an exercise for this I think I will start to think about smiling more. So should you all.

Try it-you too can make things move, You too are a mentalist!

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