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.

As the summer comes to an end and fall season starts, I thought it would be an opportunity to discuss and review options of facial rejuvenation, and in particular face lift surgery updates.

Historically, face lift is known as an operation to rejuvenate the lower face and upper neck. Forehead or brow lifting, and blepharoplasty are procedures that allow rejuvenation of the upper face and the eyelids. There are several variations to the face lift, each with its own advantages and disadvantages.

1. SMAS face lift: This is the commonest form of the operation. In this type of surgery the skin and the underlying facsia (fibrous layer on top of facial muscles) is tightened.  This form of face lift surgery gives excellent results in the jowl and neck region.

2. Short scar face lift/ mini face lift: In this variation of the surgery, the incisions do not extend behind the ear or into the hair line. The surgery is more limited in its effects. It does not allow tightening of the neck skin, and is more suited to patients with isolated jowl formation.

3. Deep plane face lift: This is a variation of SMAS surgery, where the dissection of the fascia layer (fibrous tissue on top of facial muscles) is more extensive.  Extending the scope of dissection leads to better rejuvenation results near the mouth. However, the recovery and bruising can be more extensive.

4. Liquid face lift or non-surgical face lift: This is not an operation, but rather a way of rejuvenating the face with a combination of injectible fillers and Botox. Such techniques are limited in their rejuvenating effects and therefore most appropriate for younger patients without significant aging.  Volume augmentation of the face via fat grafting is often performed as an adjunct to various forms of face lifting.

I am often asked this question from patients who seek facial rejuvenation.  I can make some broad generalizations based on the “average patient”, to say that facelift surgery can be considered in the mid 50’s, but once a patient reaches his or her 70’s the operation is not very effective. However, I need to emphasize that facial aging is not a strict chronological phenomenon. There are many factors that affect facial aging and can hasten or slow the process. These factors include:

1. Genetics: The quality of skin, fat, muscle, and bone in each of us is dependent on our genetic heritage. For example, Asian patients tend to show facial aging less, showing jowl formation in their 60’s vs Western Europeans who exhibit jowl formation in their 50’s. Also, patients with well developed/prominent cheek bones and jaw bones appear to age less quickly. Evaluating the parents and their pattern of facial aging is the most effective method of predicting facial aging in any patient.

2. Sun Exposure: Adverse effects of sun exposure on facial skin are well documented, and include wrinkle formation, thinning of skin, and uneven pigmentation.

3. Smoking: Chronic smoking results in formation of facial wrinkles. In one recent study of patients 40 to 60 years old, smoking was estimated to equate 1.4 years of aging.

4. Weight: A recent scientific article, comparing identical twins, concluded that in women over 40, being slightly over weight, imparted a younger appearance to the face.

6. Hormone Replacement in Women: Estrogen replacement therapy delays facial aging in post menopausal women.

So, in answering the title question individually, I like to have a consultation with a patient in order to garner the information listed above. The consultation also allows clinical examination of the face to look for sagging, wrinkle formation, loss of volume (fat or bone), and skin quality. In many instances, it becomes evident that simple office procedures such as Botox or filler injections are sufficient in rejuvenating the face. In other patients though, facelift surgery is clearly the most efficient and even the most cost effective method of facial rejuvenation.

In the last two decades, there has been significant progress in facial cosmoceuticals and cosmetic lasers. We can now recommend specific treatments for maintaining and improving facial features and complexion for various age categories:

In your40’s:

Use Vitamin A creams (retinoids) such as Retin A Micro or Renova to boost collagen production and skin turn over. This will help give your skin uniform in color and radiant. Begin treatments as every other night application and increase to every night, to avoid irritation and excess dryness.

Exfoliate regularly. You can use Alfa Hydroxy Acid (AHA) creams two or three times a week to boost the effects of retinoids. Alternatively, you can consider micro dermabrasion once a month.

Consider Hydroquinone. Hydroquinone is a bleaching agent which when used over time can help minimize dark skin patches and uneven skin tone. The prescription strength has a 4% concentration, but OTC preparations are available with %2 concentration. It’s important to avoid sun exposure as much as possible.

In your 50’s:

Hydrate. With onset of menopause, female hormones diminish and skin can become increasingly dry. Avoid harsh cleansers or soap, and use effective skin moisturisers. You may consider Try L’Oréal Paris Age-Perfect Pro-Calcium Restorative Hydrating Cream ($20; drugstores) and the Body Shop Wise Woman Regenerating Night Cream ($34; thebodyshop.com).

Continue using retinoids, and consider switch to Renova or Atralin; both are moisturizing. Also, use a nightly eye cream to plump lines.

In your 60’s and beyond:

In this age group the skin begins to sag, and deep folds or jowls can form, dryness of skin becomes a more significant issue. Use only creamy cleansers such as Albolene ($12; drugstores) and Avène Gentle Cleanser ($20; drugstores). Use seriously intense moisturizers. Look for formulas with a high concentration of oils, such as petrolatum.  You should also adjust your retinoids and mix it with a moisturiser as you apply it to your face.

Turning to the pros:

In each age category, there are treatment options that are only available as physician administered procedures. These include laser treatments, IPL treatments, or LED treatments to: even skin tone, increase skin thickness, and remove fine wrinkles. Botox or Dysport injections to: eliminate frown lines, and crows feet from the face. Filler injections such as Restylane, Juvaderm, or Radiesse to: smooth folds or depressions such as nasolabial fold or the jowls. Some fillers can be injected into the lips to make them fuller and plumper. Surgical treatments such as blepharoplasty to eliminate sagging eyelids, and face lift surgery to rejuvenate the face by removing exc            z               fess skin in the face and neck.

On the home page of our website, I state: “Although we are ardent supporters of innovation in medical devices and technology, we prefer to offer treatments that have proven clinically helpful rather than those that attract headlines without proven benefit”. A recent article in the Archives of Facial Plastic Surgery speaks to that philosophy. The authors evaluated the long-term results of a technique known as thread lifting. Thread lifting was espoused as a minimally invasive alternative to face lifting. The procedure could be performed under local anesthesia. A long needle with an attached barbed suture is passed under the skin in the cheek and pulled up towards the temple. As the suture is pulled, the cheek skin is pulled back to get rid of skin redundancy. Typically multiple such sutures are placed on either side of the face. This procedure garnered significant media attention when it was first introduced about 5 years ago. Many surgeons embraced the technique in an attempt to be perceived as trend setters in plastic surgery.

The Archives article concludes that: “thread-lift provides only limited short-term improvement that may be largely attributed to post-procedural edema and inflammation. Our results objectively demonstrate the poor long-term sustainability of the thread-lift procedure. Given these findings, as well as the measurable risk of adverse events and patient discomforts, we cannot justify use of this procedure for facial rejuvenation“. The Food and Drug Administration has rescinded approval for use of this device, although similar products are still available, and the procedure is widely advertised.

I believe the thread-lift phenomenon is symptomatic of a media driven environment in which cosmetic surgery has been evolving for the last decade. Patients and physicians are increasingly in search of the newest device or technique. Unfortunately, science has been playing catch-up with the hype and occasionally, long-term clinical evidence conflicts original claims of device manufacturers. It’s precisely in this envirornment that physicians and surgeons must act as patient advocates and resist the temptation of embracing sexy new techniques without credible clinical evidence.

In a recent medical conference entitled “About Face 2009″, one of the panel members, Dr. Burgess,  gave a presentation regarding aging in the ethnic population. I found her observations astute and would like to share them with you.

Signs of aging in the ethnic population are similar to Caucasian patients and include: loss of volume, skin laxity, wrinkles. Additionally, ethnic patients frequently experience uneven complexion and skin tags. Dr Burgess had the following recommendations for best results in the ethnic patients:

Sun screen and vitamin D3 supplements: Ethnic patients are at risk for sun damage to their skin, just as Caucasian patients. Therefore, a sunscreen with UVA and UVB protection is important. In addition, many patients have low vitamin D levels in their bodies. This is specially true for people living in the northeast with cold and long winters. Vitamin D3 supplements will restore vitamin D levels in the body.

Anti aging topical medications: Retinol (Retin A) and its equivalents, as well as glycolic acids or salicylic acid topical agents help rejuvenate skin.

Treatment of pigment irregularities: Several options are available such as microdermabrasion, chemical exfoliation, or Q-switched Nd:Yag laser treatments.

Volume loss in the face and wrinkles around the eyes and in the forehead can be effectively treated with a combination of dermal filler injections and Botox injections. More involved procedures such as blepharoplasty, face lift surgery, brow lift, and neck lift are options for patients with more notable aging of the face. In the ethnic population there is an increased incidence of keloid (unsightly) scar formation. It is important that the surgeon attain a detailed clinical history in regards to past scarring and family history of keloids, in order to minimize the risk of poor scarring after surgery.

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”!

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!

I found the recent article in US News and World Report entitled “How plastic surgery can boost your career” interesting. In the article Judy Jernudd, an executive coach, notes that good-looking people have a universal appeal that attracts everyone. Although not suggesting that everyone go out to have cosmetic surgery, Ms. Jernudd suggests that executives can improve their prospects by judicious use of cosmetic surgery.

Throughout my career I have treated numerous patients who were interested in cosmetic procedures as a way of getting a leg up in their careers. Patients want to appear healthier and more vibrant. They want to project strength and stability. Interestingly, in my practice, career motivation is sited more commonly as a reason for cosmetic surgery in males rather than females. Rhinoplasty (nose jobs) , chin augmentation , and injectible fillers are usually requested by men, while rejuvenation procedures such as blepharoplasty (eyelid lift) , facelift , and filler injections are requested by women.

Cosmetic surgery should not be considered lightly. I always take time to discuss the ramification of any procedure with my patients. This discussion includes consideration of risks and potential complications. However, when performed in appropriately chosen candidates, cosmetic surgical treatments are safe and very effective in achieving the patient goals.