Facial fillers like Juvederm and Restylane are quite popular in wrinkle filling, facial volumizing, and lip enhancement in addressing facial aging . Amongst the various products currently available for injection, the trend has been to add anesthetic to the filler agents so that injections would be less painful during administration. Juvederm, Juvederm Ultra, Restylane, and Perlane are all available in formulations with added lidocaine (numbing agent).

The latest trend in improving the patient experience with facial fillers, however, is the needle itself. In new class of blunt needles (cannulas) are now available for injection. These cannulas do not have a sharp tip and therefore nearly eliminate the occasional bruising that is seen with conventional needles. Patients report less discomfort with cannulas, especially during lip injections.

In another front, there are ongoing clinical studies to develope Botox-like agents that could be applied to the skin rather than injected into the skin. This trend in develpement of less invasive, more comfortable treatment modlaities of facial rejuvenation is welcomed by patients and treating physicians.

In today’s Wall Street Journal, there is an article detailing the increased incidence of cosmetic surgery and non-surgical cosmetic treatments in men. Cosmetic surgery continues to be far more common in women. However, recent statistics from the American Society of Plastic Surgery reveal a higher growth rate of plastic surgery procedures in men as compared to women, discounting the breast procedures.

The increase of plastic surgery in men can be due to higher societal acceptance of cosmetic procedures and  patients interest in maintaining a healthier appearance in a competitive work environment.

From the standpoint of the surgeon, cosmetic surgery in men requires adjustment of techniques in procedures such as facelift surgery or rhinoplasty. The aesthetic norms for men and women are different, and surgery must be planned in a way that maximizes the desired outcome based on the sex of the patient. Otherwise, appropriate counceling about the nature of recovery, the risks, and the potential complications is similar for male and female patients.

Fortunately, the pictures of this patient with recurrent earlobe keloid is not typical of most patients with keloids. This patient represents an extreme example of keloid formation. Non the less, even small keloids are problematic for patients. They are visually disturbing, sometimes itchy, and sometimes deforming.

Keloid scars are defined as large and deforming scars that go beyond the boundaries of the original skin incision or injury. Keloids are significantly more common in African American patients and those with higher levels of skin pigmentation. There is a genetic pre-disposition to keloid formation, and those with history of keloid in the family are at higher risk for developing keloids.

When keloids are small, steroid injections can cause them to shrink. However, most keloid scars are too large to respond to steroid injections alone. Surgical excision is the commonest treatment option. In nearly all cases, I recommend post excision injections of steriods. In cases of recurrent keloids, post excision radiation therapy may also be offered.

The most important risk in treating keloids is the possibility of recurrence, and keloid prevention by avoiding unnecessary skin incisions is paramount. Indivisuals with a strong family history of keloids and those who have had keloid scars in the past should probably avoid body piercing, tattoos, or cosmetic surgery.

Non invasive facial rejuvenation has evolved significantly in the last decade. Forehead wrinkles, frown lines, and crow’s feet can be erased with Botox injections. The nasolabial folds can be softened with injections of facial fillers. Cheek bones can be made higher with filler injections, and tear trough depressions can be restored to a more youthful appearance. Laser treatments can revitalize the color and texture of skin. Soon, we will be able to treat another facet of facial aging with a non-surgical modality. KYTHERA Biopharmaceuticals, a Los Angeles-area based biotechnology company,  is starting the Phase 3 trial of a nonsurgical, injectable adipolytic agent  for the reduction of submental (underneath the neck) fat. If approved, submental fullness can be treated without the need for liposuction. Such treatment would be ideal for younger patients with little skin redundancy who are not facelift candidates.

Non invasive submental fat reduction represents yet another option to those patients who desire subtle facial rejuvenation with minimal to no down time. Although non invasive facial rejuvenation will not replace traditional surgical therapy for facial aging, it expands the treatment options for patients. I look forward to FDA approval for this novel technique.

An advisory panel to the FDA has recommended approval of Restylane injections for volume augmentation of the lips. The FDA still has to make the final decision for approval, however, the agency usually follows advisory panel recommendations.

Restylane is a form of hyaluronic acid similar to Juvederm. This form of filler material has shown excellent safety record. Restylane was approved by the FDA in 2003 for smoothing the deep wrinkles in the nasolabial fold. Both Restylane and Juvederm have long been used for lip augmentation as an off label use of the drug. The FDA approval will allow the drug company and physicians to advertise and promote such use. 

It remains the responsibility of the plastic surgeon though, to use good judgment in augmenting lips. Although well done lip augmentation is simply natural and rarely noticed, over done lips are very distracting and diminish rather than enhance a patient’s facial beauty.

Economist at the University of Texan in Austin recently published a paper after analyzing data from 5 large surveys conducted between 1971 and 2009 in the USA, Canada, Germany, and Britain. They found that beautiful people are generally happier than the plain Jane or the ugly Joe. They estimate that the economic benefit from beauty is at least half of the extra happiness.

Other studies have previously concluded that beauty helps the budget in several ways. Better-looking people earn more money, and marry those with better looks and higher income. Psychologists suggest that the study make sense, since better looking individuals are afforded more opportunities both at work and socially.

Should the findings make you think twice about having plastic surgery? The study author says no! In 2002 he conducted a study that looked at the effect of buying better clothes, hair and cosmetics. There was no impact from such alterations. The study author suggests that “Your beauty is determined to a tremendous extent by the shape of your face, by its symmetry and how everything hangs together.” Although such statement is mostly true, I believe that isolated procedures such as correction of a large and unflattering nose with rhinoplasty, or augmentation of flat and unattractive lips with Restylane injection will in fact enhance facial beauty appreciably. Therefore, that expensive nose job may end up being a good investment in your future income and happiness!!!

Allure magazine in its 20th anniversary March edition published a beauty census. 1,000 men and women were shown pictures of models with defferent ethnicities and features and were asked to rank the models . “We anticipated that the whole beauty ideal has changed, but the results are really different from the results 20 years ago,” the author says. “It’s not blue-eyed blond anymore, it’s a woman of mixed race, dark hair, darker skin, she’s more voluptuous with a bigger butt and a flat stomach — not that easy to do, thank you very much.”

“Models ARE younger, thinner and prettier than the everywoman because they’re models. But what’s interesting is the underlying social commentary that while the value people place on being beautiful has increased … there is a wider range”, the article notes. “There is an interest in the natural look, of improving on one’s own assets instead of mimicking what models do.”

This article’s conclusions parallel my impressions from discussing cosmetic treatments and aesthetic surgery with patients. Patients want to improve their features while preserving their identity and ethnicity. They desire natural results from cosmetic treatments; be they Botox and Restylane injections or facelift and rhinoplasty operations.

Nasal obstruction can be due to a myriad of various causes. The commonest causes include deviated septum, allergies, or polyps. Nasal trauma can also cause obstruction due to displacement  of bone or cartilage. Often times, cosmetic nasal surgery causes weakening or excess narrowing of the nose with resultant nasal blockage.

The pictures above represent an unusual cause of nasal obstruction, due to innate weakness of the cartilages in the lower third of the nose. This area is also known as the nasal valve region, as it is the narrowest part of the nose. Weakness of cartilages in the nasal valve area leads to dynamic collapse, especially during exercise or deep inhalation (See the top right hand picture).

Surgical correction of nasal blockage, due to nasal valve collapse, involves placement of a cartilage graft as a brace to strengthen and stiffen the nasal valve area. This technique is equally useful in patients who have developed nasal obstruction due to cartilage removal during rhinoplasty.

Fortunately, refinements in surgical technique allow us to restore the nasal valve competence without adversely affecting the cosmetic appearance of the nose. The bottom photo demonstrates the same patient during restful breathing and forceful inspiration. Note that the overall appearance of the nose is unchanged, although the nasal valve has gained the necessary strength to prevent collapse (Bottom right photo).

I’m happy to announce that I’ve recieved the Patient’s Choice Award for 2010.

“Your patients have selected you for the Patients’ Choice Award for 2010. You are a member of an elite group. More than 100,000 patient reviews and ratings are gathered each month, and this top rating has only been awarded to you and a select few of the nation’s most beloved doctors. Congratulations.

Your patients have taken the time to compliment you in areas such as: your bedside manner, the amount of time you spend with them, the courtesy of your staff, appropriate follow-up, and their overall opinion of you as a physician. Quite simply, you are one of the best!”

African American rhinoplasty

The art of rhinoplasty has evolved tremendously in the last four decades. The improved results in rhinoplasty stem from better understanding of the structural anatomy of the nose, and the long-term effects of surgical maneuvers on the aesthetics and function of the nose. Another important driver in evolution of rhinoplasty has been the patients’ pursuit of  natural results while maintaining their own ethnicity.

Rhinoplasty in African American patients is an excellent example of why each rhinoplasty needs to be individualized and custom tailored. The African American nose is generally wider and lower across the top with a wide tip and flaring nostrils. The skin tends to be thicker and the cartilages are softer and less resilient.

Whereas cartilage shaving and bone trimming are commonly used maneuvers in Caucasian rhinoplasty, cartilage grafts and nostril trimming are often utilzed in African American rhinoplaties. It is particularly important for the surgeon to discuss the goals and limitations of the procedure. Computer imaging is quite useful in aiding those discussions. Above all, African American patients who desire rhinoplasty don’t wish to have Caucasian noses. They wish to have more aesthetic African American noses.