New Ideas on Facial Rejuvenation

Although the traditional "surgical" facelift is a cornerstone in the transformation of the aging face, an increasing interest and demand in "non-surgical" facelift treatments has become extraordinarily popular. The mechanism of facial aging is complicated and any plan for non-surgical correction must include several key factors. These factors are: 

1. the health, appearance, and quality of the skin, 
2. the tone and activity of the underlying facial muscles, and 
3. the volume of fat and facial soft tissues. To achieve the very best results attention must be given to each of these three areas.

Most everyone knows that a conventional "surgical" facelift involves removing loose and redundant skin of the face and neck, tightening of the underlying muscles, and often fat-injection into cheeks, lips, and facial folds to achieve the best and most long-lasting results. 

In recent times, however, there is a new paradigm of facial rejuvenation. It applies mostly to those patients in their late thirties and early forties who want the benefits of facial rejuvenation, but feel it is just a "bit early" for a conventional facelift. 

I will comment on each of the three factors below:

1. The facial skin. Youthful skin has a smooth texture with minimal pore visibility and a healthy "glow." It should also be of a uniform color without dark "age" spots. There are a number of things that patients can do to greatly improve their skin. I consider this an essential step in facial rejuvenation. We offer a comprehensive skin program ["SkinGlow"] which addresses the five key factors necessary for beautiful skin. These are: (a) glycolic acid, (b) Retin-A, (c) hydroquinone bleach, (d) moisturizer, and (e) a sunscreen. Glycolic acid is a mild exfoliant and helps eliminate dead cells on the surface of the skin. Retin-A, derived from vitamin A also act as an exfoliant to thin the outer layers of the skin but also helps thicken the deeper layers as well. Regular use can improve the appearance of the skin and minimize fine lines and wrinkles. Further, recent articles in the medical literature show Retin-A also has a protective effect against skin cancer. We recommend a bleaching cream primarily to "even out" the color of the skin, eliminating dark spots and blotchy areas. It is not intended, nor used, to lighten the color of the skin in general. A good moisturizer is important as it penetrates into the deeper layers of the skin and hydrates them. This causes the deeper tissues to "plump up" which helps improve fine lines and wrinkles. It is important to select the proper moisturizer as it is essential that the moisturizer actively penetrate the skin into the deeper tissues. Moisturizers that do not penetrate the skin simply remain on the surface and feel "greasy," or "oily." It is common knowledge that sun exposure is harmful to the health and appearance of the skin. Sun exposure accelerates aging, skin discoloration, and many forms of skin cancer. The use of a good sunscreen will protect your skin against the sun.
2. The tone and activity of the underlying facial muscles. We all use facial muscle for facial animation and expression. In some cases the muscle activity can be too much and this causes undesirable effects. The most common areas that this can occur are: (a) horizontal lines of the forehead, (b) the area in-between the eyebrows, (c) the "crow's feet" on the sides of the eyes, (d) around the mouth "smoker's lines," and (e) exaggerated dimpling of the central chin area [when holding the mouth in a closed position]. In order to control these problematic muscles, we use Botox [botulinum toxin], which temporarily causes the muscles to become very weak or even stop working. The effects of Botox usually last 3-6 months depending on the specific area treated, the amount of Botox used, the skill of the injector, and the patients unique metabolism. Targeted placement of Botox not only eliminates or improves the problem lines, it can also help elevate the brows and give a more rounded look to the eyes. Knowledge of the underlying muscle anatomy helps to place the Botox accurately, thus maximizing the result and minimizing complications. 
3. Facial volume. The youthful face is full. Proper soft tissue volume of the face is an important component to transforming "older" looking areas of the face into "younger" appearing areas of the face. The most common areas requiring additional volume are: (a) the area just above the eyebrows, (b) the cheeks, (c) the deep folds extending from the edge of the nose downward, (d) the lips, (e) the areas under the corners of the mouth and into the chin. There are many different materials that can be used to add volume to the face. Sometimes we choose to use the patient's own fat. In this case we harvest fat from the abdomen with liposuction and then re-inject the fat back into the face. Typically about 50% of the fat survives. Other options include commercially prepared products, the most useful of which is Juvederm-XC [Allergan Corporation]. Juvederm is made from hyaluronic acid which tends to absorb water once injected into the soft tissues thus "swelling up" and adding a soft fullness to the treated area. The effects of Juvederm-XC typically last about 8-10 months.

The Clarisonic Facial Cleansing Brush

We began our SkinGlow program of advanced skin care back in 1989 incorporating the use of both Retin-A and Glycolic Acid to beautify skin. That was really the "cutting edge" of skin care technology at the time. Over the years we have slowly added products to the SkinGlow regimen as we gained more experience and as new topical treatment options became available. In 2005 the Clarisonic Face Cleansing Brush was first introduced. This brush, created by the same company that invented the sonic toothbrush, uses high-speed oscillating technology [300 movements per second] to provide a thorough deep cleaning of the skin. While it was originally thought that the Clarisonic Brush would simply be good to cleanse the skin, we readily became aware of another, even more valuable benefit. After cleansing with the Clarisonic, the skin is noticeably more receptive via better absorption to all the SkinGlow products. Patients who had been happy on the SkinGlow program for years were suddenly finding that their skin started to look and feel even better after they began using the Clarisonic Brush. 

Studies have shown that the average American woman washes her face for an average of only 20 seconds once a day. This limited cleansing does not adequately remove all the sebum [oil material], environmental debris, and makeup accumulation and sets the stage for breakouts. It also leaves a filmy layer over the skin which interfere with the penetration of the topical SkinGlow products. Research has shown that the Clarisonic is six times more effective in removing makeup than traditional face cleansing and facilitates more than 60% additional absorption of Vitamin C through the skin. We believe that the use of the Clarisonic Brush twice daily will significantly improve the appearance, quality, and health of your skin. 

There are two different models of the Clarisonic Brush. There is a standard model, available in stores and online which has a 2-speed motor, and the MD model, available only from physician’s offices that offers a much more powerful motor with 3-speeds. The low and medium power settings are for the face, and the high power setting is for the body, shoulders, upper back, legs, arms, and scalp. There are also several different brush configurations available to meet your specific needs. For more information, including pricing, please call our office.

Breast Implant Scar Encapsulations. My Latest Thinking on the Subject.

Probably the most common complication of breast augmentation surgery is scar tissue that forms around the breast implants making them feel harder than desired. It is important to remember that the body is programmed to form a layer of scar tissue around any internal "foreign body" to isolate it from the rest of the body. This is not a rejection reaction but simply the body's normal and healthy response to any foreign material. A "capsular contracture" is then, an envelope of heavy scar tissue that forms around the implant [either saline or silicone] making it feel firm or hard. A capsule is important only if it occurs to such a degree that patients have symptoms [discomfort], asymmetry [one breast is soft and the other breast is hard], or distortion [breast has a rounded, spherical shape, or is pulled by the scar tissue out of alignment with the other breast]. In these instances, patients usually submit to additional surgery to remedy the problem.

It is very difficult to determine exactly what percentage of women will experience "capsular contracture," since perceptions of firmness of implanted women vary widely from patient to patient. Thus one patient may be delighted with the degree of firmness to her breasts whereas another woman may think it was "too firm."

It is important to know that most "capsular contracture" occur within the first year of surgery, but patients are never ever completely free from the risk of capsule formation and can unfortunately form problematic "capsular contracture" at any time following surgery.

Capsular contracture is never a health risk, but can be very bothersome [pain or discomfort], and can often trigger the need for additional unanticipated surgery to the augmented breast.

After 29 years of performing breast augmentation I am still intrigued and occasionally frustrated by capsular contracture. No one understands exactly why a breast will form a "capsule" or envelope of scar tissue around the implant. In my experience it is actually most common for the scar capsule to only form around one breast with the result that one breast is very soft and natural and the other breast is firm and quite "different." Oftentimes the patient will be led to think that the breast implant itself has hardened and they will come to the office thinking that the implant is defective. However, in reality the implant is almost always completely normal and it is the dense scar tissue that surrounds the implant that actually makes the implant feel firm or hard.

The widely quoted national statistics for breast implant scar encapsulation is around 15-20%. We are very proud of our statistics, which show an encapsulation rate of less than 4%.

There are certain circumstances that tend to increase the risk for capsular contracture. The list below is certainly not complete, but in my experience has proven to be true:

• subglandular placement of the implants "above the muscle"
• silicone implants are slightly more prone to capsule issues than saline implants.
• patients with very tight skin envelopes [not much room for the implant]
• patients who request and/or receive implants that seem to exceed the capacity of the overlying skin envelope [implants seem very tight at implantation]
• any infection following surgery [especially staphylococcus epidermidis in the ductal system]
• any collection of fluid within the breast pocket [blood or clear seroma fluid]
• a previous personal history of capsular contracture
• non-compliant patients who do not faithfully follow the post-operative instructions and exercises
• patients with a history of silent infections [frequent urinary tract infections, sinus infections, advanced gingivitis or teeth abscesses]
• patients who have had radiation therapy to the breasts [in association with treatment for breast cancer]

Our very successful approach to preventing capsular contracture is to:

• place the implants "under the muscle" or at least "partially under the muscle" whenever possible
• be very careful to balance the size of the implant with the patients existing and available soft tissue resources. In other words, one needs to balance the patients "wishes with her tissues." This is often a topic that takes up a large portion of the consultation. There must be room for the implant to "move around" inside or the implant will "stop moving" and a capsular contracture will occur.
• we wash the surgical pocket our with a considerable amount of saline solution before washing the pocket out with antibiotics.
• we use very high-dose antibiotics at surgery both through the patients veins into their blood stream, but also to irrigate the surgical pocket [three different kinds of antibiotics and a powerful germicide].
• we take extraordinary care to be sure that there is absolutely no bleeding present before closure and that the surgical field is completely dry.
• we completely re-prep the surgical area and change all the surgical gloves before opening and handling the new implant.
• we believe that the implant must move effortless within the surgical pocket, thus we advise patients not to wear a bra at all following surgery for a period of at least 2 months. Thereafter we allow patients to wear bras 'when they must," but to remove the bra as soon as "feasible and reasonable." This recommendation alone has diminished our office capsular contracture to less than 4% which is an excellent number.
• we do not have patients "massage" or otherwise manipulate their breasts. Instead we have them move the breast implants passively by lifting their arms over their heads and by bending forward and touching their fingers to the floor [allows the implants to fall forward and upward]. We have patients do these exercises 4 times on the day following surgery and double the frequency daily until they reach 32 times a day. Patients will continue this exercise for two months and then cut back to 8 times a day thereafter.
• we also recommend preventative antibiotics for dental care. This is controversial, but we feel the risk of a capsular contracture problem so outweigh the tiny risk of the one time dose of antibiotics that it is proper and reasonable to "overprotect" the patient in this way.
• If patients have very severe or recurrent capsule problems, then we also use a special graft material to line the pocket. This material is called “Strattice,” and has been shown to be 98% effective in preventing a re-occurrence of the problem. The only downside of Strattice is that it is very expensive.