A special edition of the journal, Clinical Risk, published by the Royal Society of Medicine, looks at how the combination of an under-regulated market, “professional greed”, increased marketing and overwhelming media hype have created a “perfect storm” that threatens patients and practitioners alike. The journal’s editor argues that cosmetic surgery patients in the UK are at more risk than ever before.

This raises a similar question here in the US. The marketing efforts, media hype, and patient expectations are at an all time high here in the US. Cosmetic surgery shows such as “Dr. 90210″ and “extreme makeover” can over simplify surgical procedures and minimize surgical risks. In this environment, some surgeons may be reticent to discuss surgical risks in depth due to fear of loosing a prospective patient. Additionally, there is no legal qualification for any medical doctor to perform a medical procedure. Hence, many medical doctors without specialty training are dabbling in non-surgical cosmetic treatments such as Botox or filler injections.

Critics in England are requesting putting limits on the ability of doctors to advertise, as in France. In the US there have been calls for government veting of cosmetic doctors qualifications. The New York legislature has already taken some steps to make cosmetic surgery safer by requiring certification of private operating rooms in doctors offices. In this environment, active involvement of patients in assessing the qualifications of their doctors is specially important. Ask about board certification of your cosmetic doctor, inquire about their training and their specialization. In the words of Cy Syms the, recently dececed founder of Syms clothing store, “an educated consumer is our best customer”.

The current healthcare legislation in the US senate has a provision for a new 5% tax on all cosmetic procedures. The tax, which would be paid by the customer but collected by doctors, would be levied on any cosmetic surgery that is not necessary to address deformities arising from congenital abnormalities, personal injuries resulting from an accident or trauma, or disfiguring diseases, a definition taken directly from current tax code covering deductible medical expenses. I agree with most plastic surgeons in considering this new tax out dated and discriminatory.

The old perception that all patients who undergo cosmetic surgery are wealthy is clearly not true. According to the internal surveys by the American society of Plastic Surgeons, 60% of patients undergoing cosmetic procedures earn less that $90,000 per year. “A lot of people think of this as a tax on rich Republican housewives; rich, nonworking Republican housewives,” said Dr. Phil Haeck, the group’s president-elect. “And that’s not the case.”

The tax is also discriminatory towards women, who make up the vast majority of cosmetic surgery patients. Terry O’Neill, the president of the The National Organization for Women, said middle-age women, who make up a bulk of her group’s financiers, would be particularly susceptible to the tax, especially now. Many who have lost jobs might be considering surgery, she said, because they are looking to impress potential employers.

Furthermore, the like between elective and necessary surgery is often blurry. Patients who have had trauma to their nose may request rhinoplasty. It could be argued that rhinoplasty in this case, would be reconstructive rather than cosmetic. It’s note worthy to mention that a cosmetic surgery tax has already been in place in the state of NJ for the last three years. NJ, however, has collected very little money due to relative small volume of cosmetic surgery, and difficulty in auditing and collecting such tax. Our senators and legislators would be wise to look at other sources of income, such as reduction of fraud and waste in the medical system.

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.

I recently participated as a presenter at the Annual National Meeting for Otolaryngologists and Head and Neck Surgeons in San Diego, as a panel member in a seminar. The seminar, which was attended by over three hundred physicians, was entitled “Office-Based Facial Plastic Procedures for the Otolaryngologist”. Amongst the topics, we discussed were: dermal filler agents, Botox, lasers and light based devices, and chemical peels. The presentations were extremely well received, and we have been asked to present the course again during the next Annual Meeting in Boston.

Participation in educational opportunities such as this is a highly rewarding aspect of my profession.  Facial plastic surgery, is a rapidly evolving field of medicine. Continued research and education is imperative to our progress and success as specialists.

Alexandria, VA – Maurice M. Khosh, MD, of New York, NY, received the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) Honor Award at the opening ceremony of the 2009 AAO-HNSF Annual Meeting & OTO EXPO, in San, Diego, CA, October 4 – 7, 2009.

The Academy presents Honor Awards to medical professionals in recognition of outstanding service through the presentation of instructional courses, scientific papers, or participation on a continuing education committee or faculty.

Dr. Khosh is currently at Columbia University.

Featuring more than 165 scientific research sessions, 200 posters, and over 300 instruction course hours for attendees, the AAO-HNSF Annual Meeting & OTO EXPO is the largest gathering of otolaryngologists in the world.

About the AAO-HNS:

The American Academy of Otolaryngology – Head and Neck Surgery (http://www.entnet.org), one of the oldest medical associations in the nation, represents more than 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The organization’s vision: “Empowering otolaryngologist-head and neck surgeons to deliver the best patient care.”

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Official Press Release

A recent article in the Journal of Plastic and Reconstructive Surgery gives scientific credence to the observation of plastic surgeons, that patients who undergo fat grafting to the face show improvement of skin color and texture. Fat grafting is a well known surgical technique for restoration of lost volume to the face. and an alternative to filler injections such as Restylane, Radiesse, or Sculptra. Fat grafting can be performed as an isolated procedure or in combination with other facial procedures such as face lift or blepharoplasty.

It has been my observation  that several months following fat grafting, patients demonstrate improved skin quality in the grafted area. In this journal article, researchers from France injected human fat into the backs of nude mice and later evaluated the quality of the overlying skin. For comparison, adjacent skin was injected with nothing, injected with a growth medium, or treated with subcutaneous tunneling. The results showed thickening of the dermis, increased levels of collagen, and thickening of the extracellular matrix. These microscopic findings are consistent with younger and healthier skin.

Fat grafting will not replace other facial fillers due to higher initial cost, higher technical difficulty, and more prolonged recovery. However, more permanent results from fat grafting and expected improvement of the skin may convince some patients that fat grafting is preferable to filler injections in the face.

A recent research article in the Journal of Plastic and Reconstructive Surgery provides scientific proof that migraine headaches can be significantly improved by surgical techniques that are similar to those involved in rejuvenating the forehead and brow. In the study, patients with migraine headache who responded to Botox injections, were divided into two groups. One group had surgery to decompress the sensory nerves in the forehead, temple, or back of scalp by removing some of the surrounding muscles. The second group had a sham operation where skin incisions and dissection was performed, but no muscle was removed. The two groups were then followed for over a year and frequency and severity of headaches was compared. Statistical analysis of the results showed a significant benefit from the surgery.

The study results validate the claims of headache resolution in some patients undergoing forehead rejuvenation. The surgical steps involved in treating forehead and temple area migraines were very similar to typical forehead lift surgery. Surgery for treatment of headaches in the back of scalp, however, does not have a cosmetic counter part.

This study is an interesting reminder that the scientific discovery can be circuitous and haphazard. In this case, reports of headache improvement in cosmetic patients lead investigators to a surgical remedy for migraines. Botox injections, on the other hand, were initially performed for spasm of the eyelids, but the side effect of fewer wrinkles around the eyes lead to an entire new modality for facial rejuvenation.

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.

1.   Blepharoplasty is one of the most commonly sought after facial rejuvenation procedures. Over 100,000 procedures per year in the US.
2.   Blepharoplasty does not affect the appearance of dark circles below the eyes, sagging brows, or wrinkles in the outer corner of the eyes (crow’s feet)
3.   A browlift, in certain patients, can be more effective than blepharoplasty for rejuvenating the upper eyelids.
4.   In certain patients, lower eyelid rejuvenation may be better accomplished through mid-face augmentation rather than lower blepharoplasty.
5.   An eye examination is recommended prior to blepharoplasty, so that conditions such as dry eye syndrome or visual deficits can be ruled out before surgery.

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.