2010 plastic surgery trends

Happy new year! 2010 promises to be an exciting new year, and hopefully an end to the global recession that affected every one so significantly in the past decade. In light of the continuing advances in the medical field, I have the following predictions in regards to trends in facial plastic and cosmetic surgery.

1. New products that rival Botox Cosmetic in treatment of facial wrinkles will become available. Botox Cosmetic has revolutionized office based facial rejuvenation, by allowing treatment of dynamic wrinkles of the brow and crow’s feet area. In 2009 Dysport was introduced as a competitor to Botox Cosmetic. In 2010 new products such as Pur Tox are likely to become available for use.  Research is also progressing in developing products that can be applied as a cream, and avoid injections. We may have to wait till 2012 before those products are available.

2. Increase in the number of plastic surgery procedures. As the economy recovers, we will see an uptick in the number of cosmetic procedures overall. The greatest increase will be in the minimally invasive treatments such as Botox Cosmetic and dermal filler injections, and skin laser treatments. But we will also see increases in surgical treatments such as face lifts, and rhinoplasties.

3. Fat injection will become more in vogue. Fat transfer from one part of the body into another area will gain more attraction. Facial fat injections for treatment of wrinkles and achieving a fuller and rounder face is well established. In 2010, we will see more fat transfer in other parts of the body such as the breast or the buttocks.

4. Face transplants will become more common. Thus far, there have been eight cases of face transplants in the world. The early success with this procedure will fuel further growth in this highly specialized surgery which is a last resort for patients with massive and catastrophic facial deformities. The biggest advances in face transplant will involve immunosuppressive therapy that will prevent transplant rejection.

In a recent article in the Annals of Facial Plastic Surgery, the authors analyzed the patient-derived computer generated images of twenty female patients who planned to undergo rhinoplasty. The morphed frontal and profile images were then analyzed. Analysis included evaluation of lenght to width, angles between to nose and forhead and nose and the lip, ratio of nostril width to eye width, and several other measurements. These objective measurements were then compared to standardized “ideal nose measurement”.

The “ideal nose measurements” have been popular with rhinoplasty surgeons in setting goals for rhinoplasty outcome. Some of these “ideal measurement” are based on classic Greek statutes and some are based on population averages. The study concluded that the nasal proportions prefered by patients corrolated closely with the standardized “ideal nose measurements”.

I strongly believe in the usefulness of pre operative computer imaging for rhinoplasty and use this technology routinely. However, I wonder about the conclusion of this study since 18 out of the 20 subjects were white and there was only one black and one South Asian patient. I think that our “ideal nose measurements” are based on white female subjects. Therefore, non Caucasian and male patients may not adequately fit the “ideal nose measurements”. Computer imaging gives the surgeons and opportunity to individualize each rhinoplasty procedure, to strive for best results based on each patients desires.

The news of death of the “King of Pop” Michael Jackson took the world by surprise. Micheal Jackson has left an undisputed legacy of greatness in the music and entertainment world. His most successful album “Thriller” has sold over 50 million copies, which far surpassed any other album in recording history. Michael Jackson’s musical success though, was marred by a number of personal problems that over shadowed his unparalleled achievements.

Michael Jackson also left an indelible imprint on the world of plastic surgery. His persistent foray into surgical treatments of the nose, left him with a grossly deformed and I presume dysfunctional nose. The numerous surgical treatments may have been secondary to an underlying psychological condition known as Body Dysmorphic Disorder (BDD), where a patient is overly preoccupied with a minor or imagined defect in his physical features. BDD is well known in the field of plastic surgery. Surgeons would do well to refer such patients to a psychologist or psychiatrist to help address the non physical source of the problem. Unfortunately for Mr. Jackson, repeated nasal operations resulted in near loss of his nose.

I believe that the legacy of Mr Jackson in plastic surgery will be a lesson to both patients and surgeons. For patients, the lesson will be the perils of repeated surgery and their potential ill effects. For surgeons, the lesson will be the importance of evaluating patients both physically and psychologically to determine if they are fit to undergo surgery. The second lesson for a surgeon has to be the courage to say no even to a pop icon such as Michael!

Recently I was reviewing some posts on a cosmetic surgery site called RealSelf.com. I was struck by the number of questions regarding “non-surgical nose jobs”. “Non-surgical rhinoplasty” is an office-based procedure, during which, a skin filler such as Restylane or Radiesse is injected into the nose. This procedure can be performed with topical anesthetic cream, and patients can return to their activities immediately.

The confusion about “non-surgical nose job” stems from the barrage of promotional news segments, and Internet postings which imply equal effectiveness when it comes to non-surgical rhinoplasty. Well, let’s set the record straight. “Non-surgical rhinoplasty” has a very limited place in improving nasal appearance. Specifically, injection of fillers (non-surgical nose job) can: smooth dorsal nasal humps, or dorsal nasal depressions which are congenital or secondary to previous nose surgery. Non-surgical rhinoplasty CAN’T: narrow the tip, narrow the nose, or make the nose smaller. Additionally, non-surgical rhinoplasty is not permanent.

Since the majority of patients in the United States desire rhinoplasty to make their noses smaller or narrower, that leaves a relatively small portion of patients who can be helped with “non-surgical rhinoplasty“. However, among qualified patients, “non-surgical rhinoplasty” may be a reasonable option to consider. Ultimately, a thorough discussion with a qualified surgeon with the help of computer imaging, will be the best method of evaluating whether “non-surgical rhinoplasty” is right for you.

Reconstructive rhinoplasty refers to restoring the normal shape and function of the nose following damage from: traumatic accident, autoimmune disorder, intra-nasal drug abuse, previous injudicious cosmetic surgery, cancer involvement, or congenital abnormality. Rhinoplasty can restore skin coverage; recreate normal contours, and re-establish nasal airflow.

Rhinplasty for traumatic nasal deformity:

Rhinoplasty for repair of nose fracture

Traumatic accidents are the commonest cause of nasal deformity. Typically the nasal bones are broken and displaced. Occasionally, the nasal cartilages are disrupted or displaced, and in the worst cases the nasal dorsum is collapsed. Rhinoplasty allows shaving of the displaced bony humps, and re-alignment of the nasal bones after they are cut. When cartilage is disrupted, stitching of the cartilage for re-suspension, or use of cartilage grafts to camouflage depressions allows re-establishment of normal nasal contour. When the dorsum is collapsed, grafts of rib cartilage, ear cartilage, or cranial bone can be used to restore continuity to the dorsum. Although synthetic implants are also available for augmenting the nasal dorsum, cartilage or bone graft from the patient’s own body poses fewer risks of infection or rejection.

Rhinoplasty for collapsed nose due to septum perforation:

Rhinoplasty for nasal collapse due to autoimmune problem

Autoimmune problems such as Wegener’s Granulomatosis, Sarcoidosis, Churg-Strauss Syndrome, and Relapsing Polychondritis can lead to creation of a hole in the nasal septum, and loss of support in the dorsum leading to a saddle nose deformity. Intra nasal use of drugs such as cocaine, or extreme abuse of nasal decongestant sprays can similarly cause septum perforation and nasal dorsum collapse. Dorsum reconstruction is accomplished through the use of rib cartilage or bone grafts.

Rhinoplasty to correct nasal obstruction following injudicious cosmetic surgery:

rhinoplasty to restore breathing after over-aggressive prior rhinoplasty

Rhinoplasty to restore breathing after injudicious cosmetic surgery Reconstructive rhinoplasty after injudicious cosmetic surgery allows the restoration of normal breathing. When nasal cartilages are over-aggressively trimmed during rhinoplasty, the nose can appear pinched and nasal potency compromised. Patients complain of nasal blockage that is worsened by attempts at deep inspiration. Internal cartilage grafts to support the nasal tip (batton grafts) or widen the middle vault of the nose (spreader grafts) can be quite effective in restoring normal breathing. These grafting techniques will increase the size of the nasal tip and widen the dorsum.

Rhinoplasty for repair of skin cancer defects on the nose:

Rhinoplasty for cancer reconstruction

Rhinoplasty for skin cancer reconstructionExcision of skin cancers from the nose can lead to loss of internal support as well as external skin coverage. Skin cancer excision in the nose is commonly accomplished via the Mohs’ technique. Once the cancer is removed, reconstructive rhinoplasty aims to provide skin coverage utilizing techniques such as skin graft, local skin flaps, or pedicle flaps. If cancer resection leads to loss of tissue in the area of the nasal tip, cartilage grafts are utilized to maintain support and prevent long-term distortion, by the force of scar contracture.

Rhinoplasty for Rhinophyma:

Rhinoplasty for repair of rhinophyma

Rhinophyma is the late stage manifestation of a skin condition known as Rosacea, where the skin is infected with acne roseacea. The skin in the area of the nasal tip becomes red, thickened, and enlarged as exemplified by W C Fields. Although known acne treatments such as antibiotics and Acutane can halt the progression of this disease, thickening of the skin and obscuring of the nasal tip landmarks can only be remedied by surgical correction. Currently, laser excision of thickened abnormal skin represents the best option in rhinoplasty for Rhinophyma. The CO2 laser and the Erbium YAG laser are the most effective types of laser for this disorder.

Rhinoplasty for congenital nasal abonormalities:

Rhinoplasty for cleft lip deformity of the nose

Cleft lip anomalies and vascular malformations are relatively common causes of congenital nasal deformities. In vascular malformations, the disease process can cause distortions of the skin and underlying structure of the nose. In cleft palate abnormalities, the size, position, and orientation of the nasal tip cartilages may be distorted. Rhinoplasty for reconstruction of vascular malformations can involve laser treatment of the skin and possible surgical excision. When the underlying cartilage structure is disturbed, cartilage grafts and stitching of the native nasal cartilages can help improve nasal appearance. In cleft lip patients, reconstructive rhinoplasty allows re-orientation of the nasal tip cartilages. Additional refinements with cartilage grafts to the tip are also frequently employed.

The Academy Awards cerimony is a celebration of achievements in acting and movie making. For millions of people, the Academy Awards is a chance to catch a glimpse of elegance and glamour which personifies Hollywood. The red carpet event is a time to see the “beautiful people” in designer clothes, with professionally applied hair and makeup. The red carpet, teaming with glamorous and beautiful people, can cast a harsh shadow on the few celebrities who have suffered “bad plastic surgery“.

This year at the Academy Awards, Mickey Rourke, the nominee for the Best Actor category, will be the poster child for poor face lift surgery outcome. Mickey Rourke became a recognized celebrity in the 1980’s for his roles in 9 1/2 Weeks, and the Pope of Greenwich Village.  His handsome looks helped him gain “sex symbol” status in the 1980’s. It was thus shocking to see Mr. Rourke some twenty years older, looking transformed and deformed after what looks like poorly done and over done plastic surgery.

Looking at recent photographs, I assume Mr. Rourke has had face lift surgery, chin implantation, lower lip augmentation, blepharoplasty, rhinoplasty, Botox injections, and dermal filler injections. Unfortunately, the facelift operation has caused his sideburns to disapear, and the chin implant and the lower lip implants are too large and unatural in their appearance. I am a firm believer that plastic surgery should achieve beauty that is natural. This may force us, as plastic surgeons, to avoid performing certain operations despite patient requests. We are doctors and patient educators, and not just technicians. We must alert patients to the consequences of cosmetic surgical procedures, and help them find treatments that will make them look natural. In plastic surgery, the enemy of good is “looking fake”!

When I mention celebrity rhinoplasty, most people conjure images of Michael Jackson with his grossly deformed nose. Rhinoplasty, though, has been under taken by plenty of other celebrities with usually good outcomes. I rank Halle Berry and Ashley Simpson as those who have had good nose job surgery. In both cases, the nose is not overly small and it appears natural.

In the case of Lil Kim, though, the rhinoplasty is more reminisent of Micheal Jackson’s nose. In an effort to make the nose small and narrow, the plastic surgeon has gone too far. Lil Kim’s nose is too narrow and pinched. It appears unnatural and out of place on her nose. I would not be surprised if she chooses to undergo revision rhinoplasty to undo some of these problems.

Rhinoplasty surgery, as all cosmetic surgery, has gone through an evolution. Currently, the goal in plastic surgery is achiving a natural and seemless result that fits the patient both in in terms of age and  ethnicity. This has always been my guide in performing plastic or reconstructive facial surgery. I discuss my aesthetic goals with my patients during a consultation and use computer imaging to demonstrate my vision. The following case represents just this idea in one of my patients. The three photos (from left to right) show the pre operative picture, computer generated image during consultation, and the final post operative results of rhinoplasty. Note that the computer generated image in the middle is very close to the final result on the right.

The New York Magazine recently published a cover page article titled About Face. The catch phrase in the article is: “Out with the gaunt and tight, in with the plump and juicy. There’s a new face in town—and it’s a baby’s”.

Celebrities like Demi Moore, Michelle Pfeiffer, Elizabeth Hurley, and Naomi Campbell were shown as examples of beautiful faces where subtle and minimal cosmetic work enhanced an already attractive face.

On the other hand, pictures of Faye Dunaway, Meg Ryan, Cher, and Melanie Griffith were featured as examples of bad plastic surgery. Where too much was done resulting in unnatural results.

I like the article since I agree with its main premise that a young face is plump and heart shaped, and that any intervention designed in rejuvenating the face should be aimed at restoring those qualities. Thus, facelifts should not be “tight”, fat in the lower eyelids should not be removed aggressively, and fat grafting should be considered in most cases. The article also reflected my thoughts on rhinoplasty. In that a strong profile is much preferable to a washed out nose.

Just as an example, here is a patient who was looking for a younger look. A combination of upper eyelid surgery and fat transfer gave her a totally natural rejuvenated look.

Here is an example of a natural rhinoplasty, where the dorsum was not exessively lowered and the patient retains her ethnic features, albeit in an enhanced form.

I come across this question frequently. Patients want to know the best time of the year to undergo facelift, rhinoplasty, or other cosmetic procedures. The answer is “It depends”. The most important factor about timing of surgery is patient’s preferences, such as the ability to have time off from work, etc. Having said that, there are some advantages to having surgery in a particular time of the year.

In general, following a facelift operation, patients experience mild bruising in the lower face and upper neck. In the cooler months of the year, it’s easier to wear high neck sweaters and scarves which can hide the bruising. When it comes to rhinoplasty (nose job) though, things are a bit different. Dry air can be more irritating for patients who are recovering from rhinoplasty. Therefore, warmer months of the year with less dryness are prefered. No matter when the surgery is performed, I ask patients to refrain from significant sun exposure, especially during the first six post operative months.

That is the title of an article in the Wall Street Journal today. It appears that with the continued drop of the value of the dollar against the Euro and the British pound, plastic surgery in the US is increasingly affordable to Europeans. East coast destinations such as NY and Miami are particularly noted to be the destination cities for Europeans seeking cosmetic surgery. Dr. Faod Nahai, president of International Society of Aesthetic Plastic Surgery is quoted as saying “The US has always been a center for plastic surgery, not because of price, but because of high quality. Europeans are realizing that for the price of a surgeon in their own country they can afford an internationally recognized specialist in the U.S.” As the president of the NY Facial Plastic Surgery Society, I hear a similar remarks from our society members. There are increasing numbers of European patients coming to New York for procedures such as facelift, bleparoplasty, and nasal reshaping.

In the past, we have heard about U.S. citizens traveling abroad to South America or Mexico to have cosmetic surgery. Although I am sure there are many competent surgeons in those locations, the practice of travelling to those locations leaves worry and wonder about the quality of care. I welcome the trend of Europeans coming to the U.S. for plastic surgery, not just because I am a plastic surgeon, but also because I feel that provision of surgical care in the U.S. is safe and high quality. I don’t ascribe to doctors advertising, but the article in the Journal mentions that some U.S. plastic surgeons are now advertising in Europe to attract patients. This is certainly a sign of globalization of plastic surgery!