Over injected cheeks

I was watching the annual Barbara Walters special and I was struck by the appearance of her cheeks. I thought it would be appropriate to discuss the down side of over done facial plastic procedures.

When it comes to plastic surgery, the overwhelming number of patients and surgeons look for results that are aesthetic as well as natural. Unfortunately, some times patients feel that “more is better”, and that attitude can lead to unnatural results.

You can see from this recent picture of Ms. Walters, she has had filler injections into her cheeks. I think a significantly less volume of the filler should have been injected so that her cheeks would not look over blown. This point should have been made by her plastic surgeon or cosmetic dermatologist who performed the injections. When it comes to cosmetic procedures, more is not always better!

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!

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”!

The NY Post recently published an article “ Is Joe Hidin’ Facial Work?”. I was interested in reading the article because while watching the vice presidential debate, I was struck by the odd shape of Senator’s lower eyelids and brow. The NY Post published the following two photos from 2005 and 2008.

The photo at the bottom is from 2008. One can clearly see that the forehead is smoother and the brow is positioned lower. the forehead and brow shape is caused by excess Botox injection into the forehead. The midbrow appears awkwardly low and devoid of facial expression. The lower eyelids appear narrowed and pulled up. Botox can not casue such in the lower eyelids. It is more likely that Senator Biden had a Thread lift or possibly a lower blepharoplasty.

In either case, in my opinion, the cosmetic work has been sub-uptimal. It has resulted in an unnatural appearance to the face. A natural appearing result, is the most important goal in plastic surgery. As plastic surgeons we must avoid the over reduced nose, the over pulled face, and the over Botoxed forehead. Fortunately, the Botox effect should reverse after about four months. I hope that Senator Biden will refrain from repeating the same procedure!

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.

I recently came across an interesting posting about Olympic athlete and tennis star Lindsey Davenportdiscussing her experience with the dermal filler (Juvederm). She had very positive comments in regards to the procedure and how it has helped her look younger and well rested. She received her injections four months before her Olympic appearance. The area of treatment was the fold between the nose and the corner of the mouth (nasolabial fold). Although the posting made it obvious that she was acting as a spokes person for Juvederm, it has been my own experience that patients have very favorable comments about their experience with dermal fillers, such as Juvederm or Restylane.

Dermal fillers are easily injected during a consultation visit in the office. The area to be treated can be made numb with a cream or a small Novocaine injection. Patients can apply makeup immediately and return to work right away. Whereas surgery for total rejuvenation may be necessary for older patients with significant loose tissues, filler injections and Botox work wonderfully for younger patients. I’ll be rooting for Lindsey in Beijing!

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.

Celebrity watchers are always looking for clues as to who may have had plastic surgery. Of course in someone like Michael Jackson or Pamela Anderson the evidence is hard to miss. Other times, it’s more difficult to figure out if a celebrity has had plastic surgery. Cosmetic treatments like Botox and Restylane injections are more subtle and harder to discern.

The recent pictures of Madonna seems to indicate she had some work done on her face. Although her body is extremely this, her cheeks and lips appear quite full. It is likely that she has had injection of fillers such as Restylane, Juvederm, or Radiesse into her cheeks. Alternatively, she may have had fat injection into her cheeks and filler injection into the lips. From this picture I would say the cheeks were overdone.

One wonders how a plastic surgeon would choose to overdo a cosmetic procedure in a high profile patient such as Madonna. This is probably due to a surgeons unwillingness to “just say no!”. There is a point when too much of a good thing can look un-natural.

The goal in plastic surgery should be a beautiful and natural result. That principle has guided me in my own practice, as demonstrated in my surgical results in the photo gallery.