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“Reducing the Incidence of Ear Deformity in Facelift”, Daniel Man, MD~

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“Reducing the Incidence of Ear Deformity in Facelift”
Daniel Man, MD

Background: The telltale signs associated with facelift procedures, including tightening of the lower face (lateral sweep), visible scars, a distorted hairline, and the “pixie ear” deformity are grounds for concern among both patients and aesthetic surgeons. It is the author’s belief that facelift results can be improved with correct positioning of the ears, so that these signs are reduced or eliminated altogether.

Objective: The purpose of this paper is to study the causes of ear deformity and describe the advantages of the author’s technique for the prevention of ear deformities in facelift surgeries.

Methods: Between January 2005 and November 2007, the author performed facelifts on 106 patients using a technique that included autologous fat injections to improve facial volume, hidden incisions in and around the ear, and absorbable bidirectional barbed sutures. Patient charts and photographs were reviewed retrospectively. Pre- and postoperative angles were measured with respect to the ear and face and were documented to determine the degree of improvement or deformity.

Results: Significant improvement of the specified angles was noted in 70% of cases following facelift surgery; in these cases, the ear position was elevated. No change in ear position occurred in 10% of cases. Some distortion and lowering of the ear was seen in the remaining cases.

Conclusions: Recognition of the effects of aging on the ear and the mechanisms leading to ear deformity associated with facelift procedures can aid in achieving improved aesthetic results. The advantages of the author’s technique include shorter incisions, a diminished need to remove redundant skin, ear elevation, and a smoother repair with improved contour. Further investigation of long-term results is necessary. (Aesthetic Surg J 2009;29:264–271.)

Figure 1. The “pixie ear” deformity. A, Preoperative view of a 55-year-old patient. B, Postoperative view one year after facelift.

Patients are often aware of and concerned about an unnatural appearance resulting from face – lift surgery. The most obvious characteristic of this “artificial” result is an unnatural tightening of the lower face, often called a “Joker’s line” or “lateral sweep.”1 The hairline can frequently become distorted, revealing obvious facelift scars, and there can also be visible scars both in front of and in back of the ears. In addition, elongation of the tragus and earlobe may occur. This particular deformity is referred to as a “pixie ear” deformity (Figure 1). The author presents a method for avoiding ear deformities by which he believes such deformities can be reduced or completely eliminated. The classical facelift, S-lift, short scar, and minimal access cranial suspension (MACS) lift techniques usually involve repairing loose tissue through an incision around part of the ear and into the hairline, elevating and tightening the superficial muscular aponeurotic system (SMAS) and repairing the neck. Regardless of whether the facelift is achieved with the use of a SMAS elevation or imbrication, it may still result in ear deformity because the force of elevation of the SMAS or plication may cause the ear to be distorted. The added effect of the traction lines caused by the various vector repair procedures (Figure 2) can result in the afore – mentioned artificial-looking tightening of the lower face. This “pulled” look is undesirable to both patients and surgeons. There have been many attempts to correct these deformities, but the distortion of the earlobe tragus (and drooping of the ear related to changes in its longitudinal axis) are often con sidered inevitable.

Figure 2. Forces distorting the ear.

The effect of the traction involved in vector repair may distort the lower face and ears by emphasizing and elongating facial shadows (V. Lambros, MD, personal phone communication). Some of the vectors, as shown in Figure 2, increase deformity, especially if the patient has thin or sun-damaged skin. The unnatural look often becomes exaggerated if the patient has horizontal, static sleep lines or deep wrinkles. The angle of these lines changes and thereby exacerbates the unnatural, “pulled” look of the operated face. Changes in the shape, length, or angulation of the ear cause this deformity to become even more obvious. Any attempt to tighten the SMAS to the surrounding periauricular fascia with vertically- or horizontally- oriented vectors causes further distortion of the ear. This deformity of the ear can be seen before placement of the last suture in the classical facelift technique, while the patient is still supine on the operating table and before gravity worsens the deformity. The author’s impression is that, at the completion of surgery, the superior aspect of the ear already drifts 0.5 cm to 1 cm below the horizontal level of the eyebrow. This situation worsens with time as the impact of gravity further affects the ear; the soft tissue of the ear is very delicate and may become elongated on its own. Heavy earrings can also stretch the earlobe. In addition, the skin envelope is larger and more skin has to be discarded in a sunken face with lowered ears. The use of longer incisions to remove the excess skin results in visible scars and distorted hairlines. In summary, distortion of the face resulting from classical facelift techniques is seen in the form of a flattened midface, changes in the shape and angles of the ears, and the presence of visible scars. The author recognized that in facelift procedures, reduced skin removal was associated with a shorter scar around the ear. In the author’s method, the flaps are elevated; repair of the neck and SMAS is performed accord with autologous fat and the entire ear is elevated relative to its preoperative position. A face with more volume and ears that are positioned higher requires less skin removal, allowing the use of shorter incisions hidden mostly inside the ear, with no distortion of the hair lines. Many thin patients will benefit from a combination of increased volume and various vector tractions. In patients who present with excess facial skin, a modified technique can be adapted, such as the use of a V–Y advancement flap in the back of the ear. Another option is removal of the hairless skin at the top of the ear.

Figure 3. Incisions in the interior part of the ear.

Figure 4. Incisions in the posterior part of the ear.

TECHNIQUE
Between January 2005 and November 2007, the author performed facelifts on 106 patients. At the beginning of each procedure, the patient’s own fat was harvested, and 20 mL to 30 mL of fat was injected into various compartments, such as the malar area, nasolabial fold, marionette lines, and lips. This replenished the facial volume that had been lost during aging and created an improved three-dimensional appearance of the face. Hidden incisions were made using a 360° (round block) technique both inside and around the back crease of the ears (Figures 3 and 4).
The connection between the anterior and posterior incision lines was accomplished with a 90° incision over the top of the helix at the junction of the ear and the face, where there is hair-free skin. The skin flaps were elevated all the way down to the midline of the neck, leaving a bridge of soft tissue (ie. a bulge of super- and subplatysmal fat).

Figure 5. U-shaped sutures were used to elevate the ear. The red line illustrates hidden ear round block incisions. Inset: close-up view of Ushaped bidirectional absorbable barbed suture.

Ear Elevation With the Shaped Stitch
In cases of preexisting pixie ear deformity, the pulleddown lobe was released from its fibrosed ligament with scissors or cautery. A 2–0 Quill suture (Angiotech Pharmaceuticals; Vancouver, British Columbia, Canada) was placed at the base of the tragus, which became the new inferior otobasion. Each of the Keith needles (Angiotech Pharmaceuticals) with 2–0 Quill sutures was allowed to run all the way up to the temple—one in front of and one behind the ear (Figure 5). By controlling and distributing the tension in the periauricular area, the entire ear complex was advanced towards the temple in a 360° island round block technique. The typical descent and migration of the ear—forward and downward—was reduced significantly. The anterior border of the ear canal was secured at a higher position without distortion.

Neck Repair: Submental Approach
Dissection was performed through a 4-cm submental incision to the base of the neck. Using a long forceps and cautery, the fibrofatty tissue was removed, leaving the two edges of the platysma exposed. Removal of the axis super- and subplatysmal fat was performed with the use of the direct excisional method. Careful attention was paid to maintain hemostasis.
Using a U-shaped 2–0 bidirectional absorbable barbed suture, the edges of the platysma were approximated in the midline from the chin down to the base of the neck, then back up toward the midline. By returning a needle back from the base of the neck toward the midline, a purse-string effect was obtained without bunching the skin and without any need to tie a knot.
The Quill polydioxanone (PDO) self-retaining system suture allows for an increase in both speed and reliability, therefore providing good strength to the repair. These sutures are fabricated with specific barb geometry parameters, creating a superior wound-holding ability when compared with conventional sutures. Each suture contains a spiral array of barbs that are divided into two equal but opposing segments.2 The barb wound closure device eliminates the need to tie a knot and enables use of running (as opposed to interrupted) sutures. Increased control of the tension within the wound as the suture is advanced is possible without creating any bulk. In addition, two 2–0 sutures were placed on each side of the neck at the midline. The increased length of these sutures allowed them to run from the cricoid cartilage at a 90° angle to the midline along the jaw line, providing better support to the submandibular ptotic tissues. The suture was inched along the platysma up to the mastoid fascia and the postauricular area, and as high as the temporal fascia. The needle was allowed to exit above the ear, outside of the occipital hair, where it was pulled under tension and cut short under the skin and sunken so that it does not protrude.

Correction of the Aging Face
The facial flaps that were elevated at the beginning of the procedure were inspected and hemostasis was obtained with care. The jowls were trimmed. A long, U-shaped, double 4–0 Quill suture was fixed to the deep temporal fascia at the starting point, 0.5 cm above the zygomatic arch and 0.5 cm in front of the helical rim cartilage of the exposed ear. Care was taken to avoid injury to the superficial temporal vessels and nerves. One needle was directed toward the tragus, parallel to the anterior border of the ear vertically. Firm bites 1 cm to 2 cm apart were used to elevate the loose SMAS tissue. The bidirectional barb sutures controlled and distributed the tension of this loose tissue.

Figure 6. Insert of the flap.

The repair continued down to the region of the mandibular angle. At this point, the first needle was turned vertically upward to the superior portion of the preauricular area, facilitating a purse-string effect and elevating sagging tissue. This needle was brought back to the starting point diagonally, toward the trimmed jowls, gathering the SMAS. Careful attention was paid to taking bites in the superficial fascia to eliminate any danger of injury to the facial vessel and nerves. The needle was then redirected diagonally back to the starting point in a zigzag fashion. Note that, at this time, both the vertical oblique and horizontal laxity of the facial tissue has been corrected. Some tissue protrusion appeared to be present between the suture materials. The second needle was then directed from the original starting point, thereby correcting the tissue profusion and turning a “hill and valley” into a smooth plain. The full length of the suture was used, bringing the second needle back to its starting point. At this point, all the loose tissue had been gathered, flattened, and repaired, creating a full midface and malar mount. In the end, the two needles were brought to the starting point, and then the suture was cut and knotted together. Finally, an additional 4–0 Monocryl suture (Ethicon, Somerville, NJ) was placed at the starting point; this suture was used to further even out any irregularities left behind by the Quill sutures.

Figure 7. Degrees of ear position improvement.

Skin Reposition and Resection
Unlike the classical facelift repair, the vector of the midface repair in this procedure was mostly vertical and only partially horizontal. It did not compromise or lower the ear. This was possible because the ear had been secured with the U-shaped bidirectional barbed suture, up into the temporalis fascia. The skin flap was subjected to moderate vertical tension and any skin excess was determined and addressed (Figure 6).

Measurements
Through the retrospective examination of preoperative patient photographs, midface vectors and angles were calculated by measuring the angles created by the intersection vertical vectors with lines drawn from the base of the nose (X) to the integral incision (I) and the subaurale (S) (Figure 7). These angles (as they appeared in postoperative photographs) were recalculated at three months for all patients by an independent reviewer to determine the degree of improvement.

Figure 8. A, Preoperative view of a 75-year-old woman. B, Postoperative view nine months after facelift.

RESULTS
A total of 106 patients were treated using this technique between January 2005 and November 2007. The success rate in preventing ear deformities and achieving a natural look was significant. In 70% of patients, the angles between points I, S, and X increased by an average of 9.0°. The entire ear was elevated, creating a better appearance (Figures 8 to 10). In 10% of patients, the ear remained at the original site. In 20% of patients, the angles between points I, S, and X were reduced by 3°. In these cases, the ear was lowered, creating a pulled, deformed look. Using the 360° round block inside-ear incision technique resulted in a more natural-looking facelift. Eighty percent of patients surveyed at one year by a patient educator during follow-up visits were pleased with the overall results.
No hematoma or infection occurred in this series. Twelve patients complained of transitory discomfort in their ears caused by initial swelling, which subsided in two to three weeks. Two patients needed revision of the suspension suture repair; these were in the first group of patients, in whom the repair was performed with 4–0 nylon sutures that were damaged or became loose. The author no longer uses these sutures. Healing proceeded in all patients without major sequelae. Most patients returned to normal activities in 10 to 14 days.

Figure 9. A, Preoperative view of a 53-year-old woman. B, Postoperative view 16 months after facelift.

Figure 10. A, Preoperative view of a 61-year-old woman. B, Postoperative view 24 months after facelift.

DISCUSSION
In the author’s opinion, most facelift techniques leave the top of the helix lower than the horizontal level of the eyebrow, while the bottom of the ear extends to the bottom of the mandible. Before surgery, there is no sign of such a deformity; it develops as the operation progresses. Several different authors have discussed the anatomy, morphology, and repair of the external ear.2-4 Connell 5 recommended resetting the earlobe so that the “angle of the dangle” is rotated 12° to 15° posterior to the long axis of the ear. Stuzin 6 recommended converting a lobule without a dangle to one with a dangle by rotating the “O” point upward to round off the front of the lobe, thereby creating a slightly higher inferior otobasion. This is accomplished by removing a small, triangular portion of the earlobe skin. A similar technique was also suggested by Lindgren and Carlin.7 Clevens and Baker 8 define a pixie earlobe as an attached earlobe that appears to be stretched and elongated caudally. It is an iatrogenic earlobe deformity in which there is increased tension at the earlobe skin flap junction or incorrect placement of the base of the earlobe, and it is commonly seen after a facelift. 4,6-15

Although various approaches, discussions, and solutions have appeared in the literature, a complete explanation of the cause of this deformity is still lacking. In the author’s opinion, the ear deformity is brought about by the repair of the SMAS, the neck, and the distortion of the hairline. The author first discussed ear deformity in 1996,9 noting that the ear’s original position can change as a result of various facelift techniques that impose a high degree of tension on the soft tissue of the ear. Even without this tension, the ear drifts caudally as the patient ages. At first, the author connected the ear’s island round block sutures with a buried 4–0 nylon suture. This suture was connected to the island sutures at the 12 o’clock position using a long needle, with interrupted incisions in the scalp over the calvarial bone. These island sutures were placed under tension, either elevating the ears or preventing them from drifting downward. Because the entire ear was elevated, a lesser amount of facial skin flap had to be removed and there was no change in the hairline or the shape of the ear. Furthermore, the hidden incisions prevented any pull on the earlobe and the helix. The logic behind this was that the occipital bone is the only stable structure in the head that will not “give,” so deformity of the ear and face would be prevented. This technique was time-consuming and required the use of suture knots that could be palpated and exposed. With the advent of the bidirectional Quill barbed suture, the repair could be accomplished without knots. This suture allows progressive control (and even tension) on the tissue. It is not necessary to pass these sutures over the entire calvarium; instead, they are threaded to the temporalis fascia, pulled through, and cut off. This technique significantly shortened the amount of time needed for the operation.
The results presented in this manuscript are preliminary; a long-term (three-year) follow-up is still under way and a complete analysis of the data has not yet been undertaken. Thus far, we have not encountered any deterioration of the repair other than that caused by the normal aging process. Further data, including an assessment of the long-term results using the Quill sutures, are still needed.

CONCLUSIONS
An explanation of the mechanism leading to ear deformity associated with facelift procedures is presented. A facelift technique is described that uses autologous fat to improve facial volume, hidden incisions made almost totally within the ear with a 360° round block technique, and absorbable bidirectional barbed sutures. The described technique allows less skin to be removed, while the remaining skin flaps heal remarkably. It also results in shorter and more concealable scars, and achievement of a smoother repair, improved contour, and a more natural look. Further long-term assessment of the results is necessary.

ACKNOWLEDGMENT
The author would like to thank Vinod Podichetty, MD, MS, for his assistance with research and manuscript preparation.

DISCLOSURES
The author has no disclosures with respect to the contents of this article.

REFERENCES
1. Hamra ST. Frequent facelift sequelae: Hollow eyes and the lateral sweep: cause and repair. Plast Reconstr Surg 1998;102:1658–1666.
2. Rubin LR, Bromberg BE, Walden RH, et al. An anatomic approach to the obtrusive ear. Plast Reconstr Surg Transplant Bull 1962;29:360–370.
3. Tolleth H. Artistic anatomy, dimensions, and proportions of the external ear. Clin Plast Surg 1978;5:337–345.
4. Tolleth H. A hierarchy of values in the design and construction of the ear. Clin Plast Surg 1990;17:193–207.
5. Mowlavi A, Meldrum DG, Wilhelmi BJ. Earlobe morphology delineated by two components: The attached cephalic segment and the free caudal segment. Plast Reconstr Surg 2004;113:1075–1076.
6. Connell BF. Neck contour deformities. The art, engineering, anatomic diagnosis, architectural planning, and aesthetics of surgical corrections. Clin Plast Surg 1987;14:683–692.
7. Stuzin J. Discussion of Azaria R, Adler N, Silfen R, Regev D, Hauben DJ. Morphometry of the adult human earlobe: A study of 547 subjects and clinical application. Plast Reconstr Surg 2003;111:2403–2404.
8. Lindgren VV, Carlin GA. Preventing a pulled-down or deformed earlobe in rhytidectomies. Plast Reconstr Surg 1973;51:598–600.
9. Clevens RA, Baker SR. Plastic and reconstructive surgery of the earlobe. Facial Plast Surg 1995;11:301–309.
10. Hoefflin SM. Simple repair of a pixie earlobe. Plast Reconstr Surg 2001;107:1623–1624.
11. Man D. Dealing with a distorted ear in a facelift. Plast Reconstr Surg 1996;97:1080–1081.
12. Mcgregor MW, Greenberg RL. Rhytidectomy. In: Goldwyn RM, ed. The unfavorable results in plastic surgery: Avoidance and treatment. Boston: Little Brown, 1972:343–349.
13. Mckinney P, Giese S, Placik O. Management of the ear in rhytidectomy. Plast Reconstr Surg 1993;92:858–866.
14. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. Effect of facelift on earlobe ptosis and pseudoptosis. Plast Reconstr Surg 2004;111:988–991.
15. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. Incidence of earlobe ptosis and pseudoptosis in patients seeking facial rejuvenation surgery and effects of aging. Plast Reconstr Surg 2004;113:712–717.
16. Mowlavi A, Meldrum DG, Wilhelmi BJ. The “pixie” ear deformity following facelift surgery revisited. Plast Reconstr Surg 2005;115:1165–1171.
17. Du Bois JJ. A technique for subcutaneous knot inversion following running subcuticular closures. Mil Med 1992;157:255.

Accepted for publication February 16, 2009.
Reprint requests: Daniel Man, MD, 851 Meadows Rd., Ste. 222, Boca Raton,
FL 33486. E-mail: podichettyv@rppmed.com.
Copyright © 2009 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$36.00
doi:10.1016/j.asj.2009.02.018

“Use of Fibrin Sealant for Face Lifts”, Daniel Man, M.D. and Harvey Plosker, M.D.

A Prospective, Randomized, Double-Blind Trial of the Use of Fibrin Sealant for Face Lifts

Plastic and Reconstructive Surgery: Volume 108(7) December 2001 pp 2106-2107

by David W. Oliver, M.B., Ch.B., F.R.C.S., Stuart A. Hamilton, M.B., F.R.C.S.(Ed.), Andrea A. Figle, M.D., Simon H. Wood, M.B., B.S., F.R.C.S.(Plast.) B. George H. Lamberty, M.A., M.B., B.Chir., F.R.C.S.(Plast.)

Man, Daniel M.D.; Plosker, Harvey M.D.

The field of plastic surgery has witnessed an explosive growth in the use of tissue sealants and adhesives over the past several years. The pace of this has increased with the introduction of products and modalities allowing for the easy use of these substances even in office-based surgical facilities. With this increased demand, there has been a concomitant increase in both research and development of new products in this field. The search, however, continues for the ideal preparation, which would be safe, with no risk of disease transmission, effective, easy to prepare and use, and of reasonable cost.

Oliver and colleagues present their findings with the use of a commercially prepared fibrin sealant (Beriplast P) in face lifts. Although there have been published reports of the use of fibrin sealants in plastic surgery, this is the first that was performed as a prospective randomized study. The authors discuss the background and mechanism of action of fibrin sealants in surgery, and describe their method for the preparation and application of the fibrin sealant. The technique they describe meets many of the above-mentioned criteria. It is simple to use, convenient in that it is an off-the-shelf product, and relatively safe. Their findings show this product to be effective in reducing postoperative drainage in face lift surgery.

The discussion raises some issues regarding the use of material derived from blood products in elective cosmetic procedures. The authors mention a theoretical risk of disease transmission. However, there are some serious issues regarding the use of material derived from human blood donors. The risk of disease transmission, although remote, is not zero but real. There have been at least two case reports of disease transmission with the use of fibrin glue, one involving the transmission of parvovirus B19 infection with the same preparation used in this study (Beriplast) 1 and one involving the transmission of human immunodeficiency virus following the use of a cryoprecipitate-based form of fibrin glue. 2 Commercial fibrin glue systems use random donor homologous cryoprecipitate. Although the risk of disease transmission by these preparations is minimized by screening plasma donors, testing for certain viral infections, and heat treatment, these all serve to reduce but not eliminate the risk of disease transmission. Some viruses, including both the parvovirus B19 and the hepatitis A virus, have been shown to be particularly difficult to inactivate by the heat treatment processes used. 3 As new infectious diseases continue to emerge, there is also the possibility that such infectious agents may be transmitted by these products.

The mention of safety concerns with regard to the bovine source of the aprotinin used in the fibrin sealant used in this study in light of recent concerns with bovine spongiform encephalopathy is eye-opening. Very little attention, if any, has been paid in the United States to the bovine source of thrombin available, and thrombin is widely used in plastic surgical procedures, both on its own and as a component of fibrin sealants and platelet gels. The forthcoming introduction of recombinant human thrombin will help minimize this risk where thrombin is used.

The authors also discuss various strategies for the perioperative preparation of fibrin sealants and platelet gels, as well as the relative merits of these different preparations. The differences between a fibrin glue clot and an autologous platelet gel clot merits some discussion. A fibrin glue clot is composed of tightly cross-linked fibrin strands forming a dense matrix structure, which provides a scaffold into which fibroblasts can migrate. 4 The matrix, however, is bioactively passive in that it does not possess a mechanism to actively recruit undifferentiated cells into the scaffold. Although this does not affect the fibrin clot\’s hemostatic properties, it does affect its tissue regeneration properties. Additionally, the dense fibrin matrix architecture may actually inhibit healing 5 and make it difficult for new capillaries to penetrate newly formed tissue. A platelet gel clot consists of a far less dense fibrin matrix that is conducive to the ingrowth of new capillaries, plus a concentration of platelets that bind to each other and to the fibrin strands. It is the presence of the platelets that makes this a bioactive matrix. The platelets in the matrix, in addition to contributing to overall clot strength, play an important role in tissue healing. As the platelets become activated, they release a multiplicity of growth factors into the matrix, which actively attract undifferentiated cells into the matrix and trigger cell division in both fibroblasts and other undifferentiated cells. 6 To achieve a bioactive matrix with a platelet gel clot, it is important that the process used in obtaining the platelet concentrate yields viable platelets. Of the many methods for preparing autologous platelet gel, only the SmartPReP system (Harvest Technologies, Plymouth, Mass.) has published data documenting the platelet viability. 7

The authors are to be commended for describing and evaluating an effective and simple method of preparing fibrin sealant. Their use of patients as their own controls (i.e., using fibrin sealant on one side and using the contralateral side as the control) is to be commended. The occurrence of a hematoma in one patient requiring a return to the operating room on the side treated with fibrin glue emphasizes the fact that these substances are not a replacement for meticulous hemostasis and surgical technique, but rather surgical adjuncts.

The use of both fibrin sealants and platelet gels in plastic surgery should continue to grow, with the introduction of new, more effective, more convenient and, it is hoped, safer products and devices for their preparation. The use of autologous products (such as those prepared with the SmartPReP system) where possible is preferable because it eliminates the risk of disease transmission.

References
1. Morita, Y., Nishii, O., Kido, M., and Tsutsumi, O. Parovirus infection after laparoscopic hysterectomy using fibrin glue hemostasis. Obstet. Gynecol. 95: 1026, 2000.
2. Wilson, S. M., Pell, P., and Donegan, E. A. HIV-1 transmission following the use of cryoprecipitated fibrinogen as gel/adhesive. Transfusion 31 (Suppl. 8S): 51S, 1991.
3. Tisseel Fibrin Sealant (package insert). Deerfield, Ill.: Baxter Healthcare Corporation, 1998.
4. Donaldson, D. J., and Mahan, J. T. Fibrinogen and fibronectin as substrates for epidermal cell migration during wound closure. J. Cell Sci. 62: 117, 1983.
5. Byrne, D. J., Hardy, J., Wood, R. A. B., et al. Effect of fibrin glues on the mechanical properties of healing wounds. Br. J. Surg. 78: 841, 1991.
6. Herndon, D. N., Nguyen, T. T., and Gilpin, D. A. Growth factors: Local and systemic. Arch. Surg. 128: 1227, 1993.
7. Kevy, S., Jacobson, M., Blasetti, L., and Fagnant, A. Preparation of growth factor enriched autologous platelet gel. Presented at the 27th Annual Meeting of the Society for Biomaterials, St. Paul, Minn., April 24-29, 2001.
2001 Lippincott Williams & Wilkins, Inc

“Intraoperative Tissue Expansion in Rhytidectomy Revisited”, Daniel Man, M.D.

G Jackie Yee, M.D., Boris Volshteyn, M.D., and Charles L. Puckett, M.D.

Plastic and Reconstructive Surgery: Volume 111(1) January 2003 pp 439-440

Man, Daniel M.D.

Received for publication March 11, 2002.

Since its introduction over a decade ago, the validity of tissue expansion during rhytidectomy has continued to be a focus of some controversy. 1 Despite this relatively long history, there has been no formal study of the improvement achieved with this technique. Yee et al. present an interesting attempt to objectively evaluate the cosmetic improvement obtained with the use of tissue expansion. The authors are to be commended for their effort in objectively evaluating the utility of intraoperative tissue expansion. Nevertheless, a number of points merit further discussion and clarification.

An important factor affecting this study is that it was retrospective. There is no discussion whatsoever as to how the decision was made as to which patients had intraoperative tissue expansion and which patients did not. This raises the question of selection bias; i.e., were the patients who underwent intraoperative tissue expansion the more difficult cases? In addition, the treatment group and the control group were compared only with regard to gender, age, and additional ancillary surgical procedures. Absent were important factors such as skin thickness, sun damage, deep wrinkles, and smoking history. For this study to have any validity, at a minimum the patients would have to have been randomized as to who would have intraoperative tissue expansion and who would not. An even better method would be to perform tissue expansion on one side and use the contralateral side as the control. However, this is an unacceptable option in reality because of ethical and legal considerations.

From a technical point of view, the Man face-lift expander was specifically designed to be inflated with air, 1 whereas the authors in their study use saline. In my experience, using air as opposed to saline allows for the rapid circumferential relaxation of the elevated skin, whereas saline inflation often causes the expander to drift away from the midline of the face-lift dissection and yield expansion in the wrong direction (i.e., laterally instead of medially).

After expansion, some caution must be exercised with regard to the amount of tension applied to the skin closure because of concerns regarding the blood supply to skin that has already been placed under tension. The authors mention that, in the group of patients who had undergone tissue expansion, they used minimal tension during skin closure. In this context, the phrase minimal tension is in fact a technically variable term that can be ambiguously interpreted. With the use of intraoperative tissue expansion in rhytidectomy, an optimal amount of tension must be used. There is a learning curve in understanding this optimal amount of tension necessary to achieve a good, long-lasting result. The use of less than optimal tension will lead to disappointing long-term results. This is illustrated by the fact that the authors mentioned that they were somewhat surprised by the findings of their study after 6 months, in that they thought that the expanded group had a better appearance in the early postoperative period.

Intraoperative tissue expansion is not appropriate in every face lift; rather, it is another tool in our surgical repertoire that can be of great utility in some circumstances and skin types but actually counterproductive in others. Patients with excessive loose skin, heavy jowls, excessive wrinkling lateral to the corners of the mouth, and sun damage are particularly good candidates for intraoperative tissue expansion. Conversely, in patients with thin or scarred skin, this technique should be avoided. 2 By using this technique, I have been able to perform a number of procedures that otherwise could not have been undertaken. The advantages of intraoperative tissue expansion can be well illustrated by the case of a young female patient who had undergone two previous face lifts. These previous procedures resulted in scars that had migrated medially and were far in front of the ears, causing significant cosmetic deformity. She had been repeatedly denied additional surgery by her original surgeons. By incorporating intraoperative tissue expansion, thus taking advantage of the viscoelastic properties of the skin, I was able to develop enough additional flap surface area to perform her surgery and return the scar to an acceptable aesthetic location within the ears, without creating a pulled look (Fig. 1). This result could not have been achieved without the use of intraoperative tissue expansion. The utility of this technique in specific situations can be further illustrated by reviewing the authors’ photographs. The patient shown in the authors’ Figure 1 who did not have tissue expansion is an excellent candidate for the use of tissue expansion in that she suffers from sun damage, deep wrinkles, heavy jowls, and deep lines lateral to the corners of the mouth. Had intraoperative tissue expansion been used, greater improvement in skin draping could have been achieved and her overall result would most likely have been significantly better.

Fig. 1. (Left) Scar deformity and shortage of skin following two face lifts. (Right) One year after rhytidectomy with intraoperative tissue expansion. Note that the scar has been relocated to its proper position within the ear.

Finally, the lack of any demonstrated benefit to intraoperative tissue expansion in this study is overshadowed by the overall lackluster results. It is disappointing that among 50 patients undergoing face lift, methodology notwithstanding, the mean rating of improvement on a scale of 1 to 10 was approximately 5 (5.27 versus 5.07). Most of our patients expect, and consistently receive, results that are well above average from our professional services. Many would wonder whether having an improvement of only this magnitude would justify having cosmetic surgery at all.

References
1. Man, D. Stretching and tissue expansion for rhytidectomy: An improved approach. Plast. Reconstr. Surg. 84: 561, 1989.
2. Man, D. Stretching and tissue expansion for face lift: Five year experience. In U. T. Hinderer (Ed.), Plastic Surgery, 1992, Vol. 1. Amsterdam: Elsevier Science Publishers, 1992.
2003 American Society of Plastic Surgeons

The Cross-Incision for Lipoplasty

MINIMIZING LIPOPLASTY SCARS

Plastic and Reconstructive Surgery: Volume 116(3) 1 September 2005 pp 930-931

Man, Daniel M.D.

Suction cannulae and most other lipoplasty instruments are round. When a round instrument is passed back and forth through a traditional linear incision, the tension in the skin causes an elevation in the contact pressure between the skin and the instrument. This pressure is highest at the incision midpoints and is accompanied by tearing stresses at both ends of the incision. During the course of an operation, the incision edges are abraded and the incision ends are either torn or permanently stretched. This trauma to the skin is often seen postoperatively as increased redness in the early postoperative period and brown pigmentation that is frequently visible and long-lasting (Fig. 1).

Fig. 1. Typical postoperative incisions.

Much like the lid of a soft drink, which typically has a cross-shaped perforation through which a straw can easily be inserted, the cross-incision combines two incisions, with the second incision perpendicular to the first (Fig. 2). This pattern decreases the contact pressures for round instruments by providing a much more uniform stress pattern in the skin and by allowing the skin to stretch in two directions. As a result of using this incision, we have found a significant reduction in trauma to the skin edges, resulting in a better-healing scar that is both less visible and smoother.

Fig. 2. The cross-incision.

The edges of the skin can be further protected by using a Vaser skin port (Sound Surgical Technologies LLC, Louisville, Colo.) (Fig. 3). The skin port provides a percutaneous channel that completely eliminates instrument contact with the incision edges. Although the cross-incision may be used with or without a skin port, we have found that using the skin port further reduces trauma to the incision edges, resulting in further minimization of the scar (Fig. 4).

Fig. 3. The Vaser skin port.

Fig. 4. Suturing the skin port into place.

The cross-incision is made using a no. 11 blade, with the first incision measuring 3 to 4 mm in length. The second incision is then made perpendicular to the first at the midpoint. It is important that the blade penetrate deep enough to cut the tissues below the skin. The opening and tissues below the skin are gently stretched with a hemostat to provide easy entry for the suction cannula or the skin port. If a skin port is being used, we place the selected skin port in the incision using the skin port and plug. The tip of the plug opens the incision and tissues below the skin to make insertion easy. The plug can also be used to seal the skin port to prevent leakage of infused tumescent fluids or emulsion. The skin port is sutured to the skin on the edges of the disc. The Vaser skin port is reusable and can be cleaned and sterilized using autoclave sterilization.

The cross-incision may be closed with either a subcutaneous or an external circular stitch, or both. The subcutaneous approach is preferred and uses a circular closure with a 5-0 Monocryl suture, sewn tip by tip in a circular pattern so that the tied suture closes the wound. The skin edges are further secured with Dermabond and half-inch SteriStrips in a criss-cross pattern.

The Vaser skin ports were designed by William W. Cimino, Ph.D., of Sound Surgical Technologies LLC. I have no financial interest in Sound Surgical Technologies.

Daniel Man, M.D.

851 Meadows Road, Suite 222, Boca Raton, Fla. 33486-2348, info@drman.com

A Double-Blind Study

The Influence of Permanent Magnetic Field Therapy on Wound Healing in Suction Lipectomy Patients

Plastic & Reconstructive Surgery: Volume 104(7) December 1999 pp 2261-2266
Man, Daniel M.D.; Man, Boris M.D.; Plosker, Harvey M.D.

Boca Raton, Fla. 851 Meadows Rd., Suite 222; Boca Raton, Fla. 33486

From the Aesthetic Plastic Surgery and Laser Center. Received for publication April 8, 1999; revised June 11, 1999.

Article Outline

• Abstract
• Patients and Methods
• Patient Selection
• Surgical Procedure
• Study Design
• Statistical Analysis
• Results
• Discussion
• Conclusions
• Acknowledgment
• REFERENCES

Figures/Tables

• Fig. 1
• Table I
• Fig. 2
• Fig. 3
• Fig. 4
• Fig. 5
• Fig. 6

Abstract (top)

The authors present their experience with the healing influence of permanent magnets on postoperative wounds. The responses of 20 patients who underwent suction lipectomy and postoperative negative magnetic field therapy were studied in a double-blind fashion. Magnets in the form of patches (10 patients) or sham magnet patches (10 patients) were placed over the operative region in each of the patients. Pain, edema, and discoloration (ecchymosis) were evaluated at 1, 2, 3, 4, 7, and 14 days postoperatively. Our results show that the treatment group had significant reductions in pain on postoperative days 1 through 7, in edema on days 1 through 4, and in discoloration on days 1 through 3 when compared with the control group. These results demonstrated that commercially available magnets have a positive influence on the postoperative healing process in suction lipectomy patients.

Modalities potentially capable of improving wound healing carry great interest in plastic surgery. Despite the effort devoted to investigating the effects of different physical modalities on wound healing, few significant advances in the use of any of these new modalities have occurred.

The processes involved in cell and tissue repair and regeneration represent one of the most fundamental properties of complex organisms. Any physical or chemical process capable of improving wound healing merits thorough investigation. In comparison with the advancement and acceptance of magnetic instruments in many other scientific fields, the use of magnetic field energy in the practice of medicine remains extremely limited, despite the fact that magnets for medical treatment are readily available commercially. Both static and time-varying magnetic fields have been successfully applied to treat a variety of musculoskeletal problems. For example, after its description over 25 years ago, the use of electromagnetic fields to help trigger the healing of fracture nonunions1-3 has become an accepted clinical practice worldwide.

Currently, a great deal of activity and interest in studying the effects of magnetic fields on biological organisms exists. On the one hand, grave concerns have been voiced about the potential negative health effects of electromagnetic fields.4,5 On the other hand, many claims are made regarding the use of permanent magnets to treat various types of painful conditions.5-8

Although well-controlled studies have been performed on the stimulation of bone growth by electrical and magnetic fields, the effects of magnetic fields on soft tissues remain unclear; they represent the next frontier in electromagnetic biology and medicine. It has been demonstrated in animal experimental wound models that these modalities can promote healing and increase wound tensile strength.9-12 Electrical and magnetic fields have been associated with a number of demonstrable effects advantageous to wound healing, including increased collagen deposition, enhanced fibroblast migration, increased migration of macrophages and leukocytes leading to decreased bacterial counts, decreased sympathetic vasoconstriction, increased cellular oxygen delivery, and increased wound epithelialization.9-12

Evidence exists that magnetic field therapy can be effective in improving some of the most important factors in wound management, namely, the optimization of the supply of nutrients and oxygen to the treated area. This is of major importance in the case of surgical skin flaps. It is well known that skin flaps exhibit progressive ischemia, with potential tissue necrosis, toward their distal end. An accumulation of neurotransmitters follows the transection of sympathetic nerves during flap elevation, with the resultant vasoconstriction inducing a temporary capillary occlusion within the flap. This sequence of events further involves ischemia followed by reperfusion in the transition zone between adequately perfused proximal tissue and inadequately perfused distal areas. It has been shown in animal studies that the treatment of skin flaps with electric current or magnetic fields may prevent severe ischemia, thus avoiding ischemia/reperfusion injury. However, there are no reports on the use of magnetic fields for the treatment of postsurgical skin flaps in humans.

Any factor that is capable of improving the healing process, especially in the absence of significant side effects, would be of particular interest in plastic surgery. Herein, we present our experience with such a technique: the use of permanent magnetic field therapy in plastic surgical patients.

Patients and Methods (top)

The protocol for this double-blind, randomized study was approved by the Essex Institutional Review Board, Inc. Written informed consent was obtained from 20 patients scheduled to undergo suction lipectomy of various body regions. Patients were randomly assigned to either the treatment group or the control group.

Patient Selection (top)

Enrollment was limited to patients of either sex between the ages of 18 and 75 who were scheduled to undergo suction lipectomy and who had major medical problems. Exclusion criteria included the following:

• Patients unable to give informed consent
• Patients with electronic cardiac pacemakers
• Patients with open wounds
• Patients with infection
• Major medical problems
• Patients with metallic implants at the treatment site
• Skeletal immaturity

Surgical Procedure (top)

The same surgeon performed all suction lipectomies. The areas suctioned included the abdomen, saddlebags, love handles, and thighs, with a variety of areas being suctioned in different patients. A tumescent technique was used in all cases; a 2:1 ratio of tumescent solution was used to aspirate. Ultrasound-assisted suction lipectomy was performed in all patients, and internal ultrasound was employed.

Study Design (top)

The treatment group received magnetic field treatment postoperatively with magnetic devices in the form of patches (Tectonic, Magnetherapy, Inc., North Palm Beach, Florida), which varied in size from 5 ? 15 to 20 ? 30 cm, and in shape (including both square and rectangular). The patches contained ceramic magnets oriented unidirectionally within them, with a total magnetic field strength of from 150 to 400 gauss, depending on the size of the magnetic patch used. The control group had sham patches placed. These sham patches were identical to the magnetic patches in all respects, including having the same ceramic material inside, but they possessed no magnetic activity. All patches were fixed with compressive dressings, with the negative pole of the magnet placed against the skin. The patches were placed on the skin overlying the areas that had been suctioned, with various sizes and shapes of magnets used so as to best fit the area being treated. The patches were applied immediately postoperatively, and they were left in place for a total of 14 days, with the treated areas inspected on postoperative days 1, 2, 3, 4, 7, and 14.

All postoperative assessments were made by the same blinded observer. The patients, surgeon, and observer were all blinded as to which patients had the real or sham magnetic devices.

Discolorations (ecchymoses) within the limits of the area covered by the magnetic patches and the area outside were compared and documented by the same observer on a scale of 0 to 10, with 0 representing a completely normal skin color, with no discoloration at all, and 10 representing severe ecchymosis covering the entire area, with a dark blue/violet color and no normal skin color showing through. Edema was also assessed by the same blinded observer on a scale of 0 to 10, with 0 representing no edema when compared with neighboring regions that had not undergone any surgery, and 10 representing marked swelling, with a shiny skin surface due to stretching of the overlying skin.

Pain was assessed by means of a visual analog pain scale throughout the study period. While in the facility, this was recorded by our blinded observer. Once the patients were discharged, this was accomplished by having the patients keep a log of their pain scores on a daily basis.

Statistical Analysis (top)

All data were subjected to statistical analysis, and the results are presented as means and standard deviations. On the basis of the nature of the data and its distribution, nonparametric statistical tests were used in analyzing the data. Discoloration, edema, and pain scores were compared between groups at each time interval using the Wilcoxon rank sum test and the Kruskal-Wallis test. p < 0.05 was considered statistically significant.

Results (top)

Patient demographics were similar between the two study groups with regard to age, sex, volume of tumescent solution used, and volume aspirated.

In the treatment group, a statistically significant decrease (p < 0.05) in discoloration occurred when compared with the control group on postoperative days 1, 2, and 3. The magnitude of the reduction in discoloration was also clinically significant, ranging from 43 percent on postoperative day 1 to 28 percent on postoperative day 3. By postoperative days 4, 7, and 14, there was no longer any significant difference in discoloration between the two groups (Fig. 1; Table I).

Fig. 1. Postoperative discoloration after suction lipectomy in patients treated with magnet patches versus placebo patches. Values are means and standard deviations.

Table I. Postoperative Edema, Discoloration, and Pain after Suction Lipectomy in Patients Treated with Magnet Patches or Placebo Patches

With regard to edema, a statistically significant decrease (p &.05) in edema occurred in the treatment group when compared with the control group on postoperative days 1, 2, 3, and 4. The reductions in edema on days 1 through 4 were clinically significant as well, varying from 40 to 53 percent when compared with the control group. By postoperative days 7 and 14, although there continued to be some decrease in edema, it was no longer statistically significant (Fig. 2; Table I).

Fig. 2. Postoperative edema after suction lipectomy in patients treated with magnet patches versus placebo patches. Values are means and standard deviations.

When compared with the control group, pain was significantly decreased (p < 0.05) in the treatment group on postoperative days 1, 2, 3, 4, and 7. By postoperative day 14, although the pain scores continued to be lower in the treatment group, the difference was not statistically significant (Fig. 3; Table I). The patients in the treatment group felt noticeably better, demonstrating a 37 to 65 percent decrease in pain when compared with the control group, leading to a decreased consumption of analgesic medications.

Fig. 3. Postoperative pain (as measured by visual analog scale scores) after suction lipectomy in patients treated with magnet patches versus placebo patches. Values are means and standard deviations.

There was no difference in the incidence of adverse events between the treatment group and the control group throughout the study period. No side effects were observed in either group.

Figures 4 through 6 illustrate patients after suction lipectomy and demonstrate the virtually complete disappearance of ecchymoses 48 hours after the application of the magnet patch, except beyond the border of the magnet patch where discoloration was still visible.

Fig. 4. (Left) Abdomen 48 hours after suction lipectomy, with magnet patch in place. Note ecchymosis and discoloration of the abdomen. (Right) Abdomen 48 hours after surgery and the application of the magnet patch, with discoloration markedly diminished in the area covered by the magnetic patch.

Fig. 5. (Left) Ecchymosis and discoloration 24 hours after suction lipectomy and treatment with the magnetic patch. (Right) Operative site 72 hours postoperatively. Note the virtually complete disappearance of discoloration, other than that beyond the borders of the magnetic patch, at both intervals.

Fig. 6. (Left) Thigh 72 hours after suction lipectomy, with magnet patch in place. Note the marked ecchymosis and discoloration. (Right) Thigh 72 hours after suction lipectomy with magnet patch removed, showing markedly diminished ecchymosis and discoloration within the area covered by the magnetic patch.

Discussion (top)

Much of the theoretical basis for the postoperative use of magnetic stimulation is based on the work of Becker,5 who theorized the existence of an electromagnetic system in the body that controlled tissue healing. When the electrical balance of the body is disturbed by an injury, an injury current is generated, with the resulting shift in the body\’s current triggering a set of biological repair systems. As healing progresses, this current of injury decreases until it reaches zero, at which time the healing process is complete.8 This is the basis of the manner in which externally applied magnetic fields are thought to stimulate biological homeostatic feedback mechanisms and trigger the events that result in tissue repair.

The healing process is accompanied by many dynamic processes and events, the most obvious and troublesome of which include pain, swelling, erythema, and diminished function. The beneficial effects of magnetic fields that may be of particular benefit to surgical patients include a reduction of edema, an increase in cellular oxygen delivery, an anti-inflammatory effect, and an analgesic effect.9-12 One possible mechanism by which magnetic fields may exert these effects is by enhancing blood flow to the site of injury, thereby increasing oxygen delivery and speeding the overall healing process.13,14

In our group of study patients, magnetic field therapy was quite remarkable in both the prevention and treatment of these signs and symptoms and also in the alleviation of pain itself. The magnitude of the reduction in postoperative pain was quite significant, allowing for a decrease in the need for analgesic medication. In procedures in which significant ecchymoses or hematomas occur, one would normally expect manifestations such as these to take at least 2 to 3 weeks to resolve, whereas with the use of magnetic field therapy, they resolved in 48 to 72 hours, as is well demonstrated by the photographs (Figs. 4 through 6).

Although the application of any padding has the potential to reduce edema and ecchymosis, we think that our control group, who used identical, nonmagnetized pads, demonstrated that this factor alone did not account for the improvement. This is evidenced by the significantly greater reduction in edema and ecchymosis found in the treatment group.

Conclusions (top)

In this first attempt to use postoperative magnetic field therapy in plastic surgical patients, a beneficial effect was clearly exerted; it markedly ameliorated many of the undesirable factors associated with the healing process, with no side effects observed. In view of this apparent efficacy and the freedom from adverse effects, this modality certainly appears promising, and it merits further investigation.

Daniel Man, M.D.

851 Meadows Rd., Suite 222; Boca Raton, Fla. 33486; info@drman.com

Acknowledgment (top)

We thank Edsel Baker, M.S., of the Statistics Department at the University of Florida for the statistical analysis.

REFERENCES (top)

1. Friedenberg, Z. B., Harlow, M. C., and Brighton, C. T. Healing of nonunion of the medical malleolus by means of direct current: A case report. J. Trauma 11: 883, 1971.
2. Bassett, A. C. Fundamental and practical aspects of therapeutic uses of pulsed electromagnetic fields (PEMFs). Crit. Rev. Biomed. Eng. 17: 451, 1989.
3. Sharrard, W. J. W. A double-blind trial of pulsed electromagnetic fields for delayed union of tibial fractures. J. Bone Joint Surg. Br. 72: 347, 1990.
4. Wilson, R. Risk assessment of EMF on health. IEEE Eng. Med. Biol. 15: 77, 1996.
5. Becker, R. O. Cross Currents, The Perils of Electropollution, The Promise of Electromedicine. New York: G. P. Putnam’s Sons, 1990.
6. Altman, L. K. Study on using magnets to treat pain surprises skeptics. New York Times, December 9, 1997.
7. Horstman, J. Explorations: Magnets. Arthritis Today 12: 48, 1998.
8. Vallbona, C., Hazelwood, C. F., and Jurida, G. Response of pain to static magnetic fields in postpolio patients: A double-blind pilot study. Arch. Phys. Med. Rehabil. 78: 1200, 1997.
9. Foulds, I. S., and Barker, A. T. Human skin battery potentials and their role in wound healing. Br. J. Dermatol. 109: 515, 1983.
10. Jaffe, L. F., and Vanable, J. W., Jr. Electric fields and wound healing. Clin. Dermatol. 2: 34, 1984.
11. Weiss, D. S., Kirsner, R., and Eaglstein, W. H. Electrical stimulation and wound healing. Arch. Dermatol. 126: 222, 1990.
12. Markov, M. S. Electric current and electromagnetic field effects on soft tissue: Implication for wound healing. Wounds 7: 94, 1995.
13. Lednev, V. V. Possible mechanisms for the influence of weak magnetic fields on biological systems. Bioelectromagnetics 12: 71, 1991.
14. Mayrovitz, H., and Larsen, P. B. Effects of pulsed electromagnetic fields on skin microvascular blood perfusion. Wounds 4: 197, 1992.

1999 American Society of Plastic Surgeons

Look Better, Feel Better:

Anti-Aging Breakthrough Techniques

Everyone wants to be at his or her best. Men and women all over the country strive to get rid of fine lines, wrinkles, crows feet. Basically, a battle has been waged over the past few years to restore the vitality and effortless beauty of youthfulness. Since the beginning of the 21st century, cosmetic techniques and practices have gained momentum in terms of popularity, and more importantly, acceptance.

Although, cosmetic surgical techniques and procedures are constantly being improved with safer procedures that are less traumatic and more effective, we are in a highly charged environment these days with fast paced lifestyles. It can seem as if there is never enough time to do those little nagging tasks of importance, much less take a few weeks out for a surgical recovery.

More individuals are turning to less invasive procedures such as “Lunchtime Procedures” so that they can erase those pesky frown lines in an hour then dash to their appointment, event, function, etc. These days with the dawn of the non-invasive fillers such as the ever-popular Botox, Collagen, Fat Injections, and the recent recommendation of Restylane approval to the FDA’s advisory panel, men and women alike are looking great in no time flat. These lunchtime procedures or quick fixes are rapidly becoming the norm. It would not be surprising to see these injectables becoming as routine as your manicure, pedicure, and your trip to the hair salon.

YOUR EASY REFERENCE TO QUICK FIXES:

Botox

PROS:
-FDA approved.
-Great for smoothing wrinkles on forehead, (glabellar region)
-A quick fix.
- I personally love Botox!

CONS:
-3-6 months lasting ability depending on the individual
-In rare cases could cause bruising or side effect of a droopy eyelid

Collagen

PROS:
-FDA Approved.
-Great for lips and nasal labial folds
-Fills wrinkles, scars and lines on face and around lips
-Immediate results
-Lasts up to six months depending on the individual

CONS:
-Could be Costly
-Not permanent
-Patient has to be skin tested for possible allergic reaction

Fat Injections

PROS:
-Taken from your own fat, which is great
-No allergic reaction
-Results are variable, but can be permanent

CONS:
-Body absorbs own fat
-Patient should retain approx. 25-30% depending on the individual
-Could be costly

Restylane / Perlane

PROS:
-I personally love restylane/perlane. It is MY personal choice.
-Recent recommendation of Restylane approval to the FDA’s advisory panel.
-Great soft tissue filler that adds volume.
-Rarely ever an allergic reaction.
-Can last up to one year.

CONS:
-Can be costly
-Not permanent

Injectable Silicone

CONS:
-Not approved for cosmetic use in the United States
-In 1991 the FDA banned its use for wrinkles and facial defects
-Injectable silicone tends to harden, migrate, inflammation and skin necrosis
-In my personal opinion, DO NOT USE

Confidentially speaking, I believe injectables are a great quick fix because there is no downtime. If you would like to find a Board Certified plastic surgeon to fit your specific needs, please call Helen Elliott Enterprises, Inc., toll-free at (888) 433-9091 or (310) 285-8505.
It would be our pleasure to assist you. We believe that the more informed you are the more positive your experience will be.

Cosmetic Surgery Offers a Second Chance

We only get one chance at a first impression, and the person who projects the best self-image makes the best impression. In today’s competitive society, people recognize the importance of self-improvement, whether it is for social or professional reasons. Exercise, skin care and nutrition are important but can only do so much. Real structural change requires more. In a sense, cosmetic surgery offers a second chance – the opportunity to defy both the calendar and genetics. Here I have compiled some of the most successful techniques used to achieve this goal.

Rejuvenation Techniques

Facelift (rhytidectomy)
Over the past few years, the term facelift has become a topic of increased interest and discussion. The cumulative effects of time, gravity and heredity show on any face. The facelift operation itself, also known as rhytidectomy, is performed to correct double chins and sagging jowls. The modern-day, long-lasting facelift operation, involves the permanent removal of undesirable accumulations of fat. As well, sagging muscles and connective tissue are repositioned and re-supported.

Because excess fat is now removed in the operation, patients no longer need to lose weight before surgery. In fact, for people who previously had chubby cheeks or a fat neck, one of the benefits of facelift surgery is an apparent loss of weight following surgery. The overall effect is a younger, fresher and more vibrant (yet natural) appearance.

Often lumped under the term facelift are a group of operations designed to rejuvenate faces that show signs of aging. These include blepharoplasty (eyelid surgery), brow and forehead lift, mid-face lift, and skin resurfacing, among others.

48 year old woman before and after
facelift, browlift, and chin augmentation

Blepharoplasty
Americans stress eye contact and believe that they can judge a person?s character by what they see in their eyes. While people talk most about facelifts, the most popular age reversing operation among my patients these days involves the eyelids. Heavy, ?hooded? (drooping) upper eyelids and baggy lower eyelids make people look tired, old, and certainly past their prime. The surgical correction known as blepharoplasty can remove the fatty pouches that cause these unfortunate problems. When present, skin that has become stretched over the years can also be removed. Upper eyelid drooping, which sometimes partially obscures vision, is corrected by removal of excess skin, muscle and fat. Incisions follow natural contour lines in the upper eyelids, and in the lower lid can be made on the inside, so there is no scar at all. In some cases, circles under the eyes can be filled in and the lids tightened.

Brow and Forehead Lift
A pleasing eyebrow shape and arch is associated with youth and beauty. On the other hand, an unfavorable eyebrow shape and angle can make a person look tired, worried or angry. The brow and forehead lift, in addition to lifting the eyebrows back to where they belong, smoothes out a deeply furrowed and pinched forehead. I prefer the high-tech endoscopic method, which is a big improvement to older more invasive surgery, because it requires only very small incisions within the hair. A tiny video-connected scope is then passed under the skin; the tissues are released, repositioned, and secured into position. With this advanced procedure I no longer make the old fashioned long incision across the top of the head and never remove scalp or hair. The benefits are brighter, more open eyes, a fresher, and more pleasant and alert demeanor.

Mid-Face Lift
The mid-face is the area immediately below the eyes, next to the nose and above the lips. It is left behind by the facelift discussed above, which benefits the jowls, under the chin, and the neck. The mid-face lift corrects sagging in this important area in the center of the face, helps circles under the eyes, and enhances cheekbone definition. I perform the mid-face lift with the only incisions in the scalp and inside the mouth under the lip. In other words, it can be done with no facial scars. The mid-face lift can be done alone or in combination with any of the other facial rejuvenation procedures.

Botox
Botox is used for the treatment of frown lines, forehead furrows, “crow?s feet”, and lines and wrinkles of the lower face. Botox has proven to be a very popular nonsurgical cosmetic treatment. The type of lines and wrinkles that respond to Botox injections are those caused by muscles?specifically those muscles that contract during facial expressions such as frowning or squinting. It works by relaxing the muscles that cause the lines so wrinkles smooth out. There is no downtime, and patients can immediately resume normal activities.

Skin Resurfacing
Skin resurfacing uses either a laser or special chemicals to smooth the skin, reduce wrinkling, and even out the complexion. I personally use the newer Erbium: YAG laser, which has proven to be a kinder and gentler alternative, with much faster recovery than the CO2 laser.

Some people prefer to correct one thing at a time — what one of my patients once called “weeding the garden.” Others want a more dramatic improvement; they have as much done as necessary and feasible at once so as to achieve maximum benefits. It is an individual choice, and one of the reasons a thorough consultation with a well-qualified, experienced, sympathetic plastic surgeon is so important. I have found that video imaging assists in creating plans for facial surgery that meet each individual’s specific needs and desires.

Breakthroughs in anesthesia methods and monitoring devices have made it possible for all of these operations to be performed on an outpatient basis. This is a positive step because patients feel more comfortable and heal faster in this environment. In addition, outpatient procedures reduce expenses overall.

Techniques for the Body

Body Contouring Surgery
In the months leading up to the summer, I see an influx of women seeking to re-contour their figures. They are usually trying to plan ahead, getting their ?problem areas? taken care of well in advance of spring and summer’s more revealing clothing styles.

According to statistics kept by the prestigious American Society of Plastic Surgeons, Liposculpture, more commonly known as liposuction, has become the most frequently performed cosmetic surgery procedure. I choose to perform the tumescent form of liposculpture, which can be done on an outpatient basis.

In liposculpture, a combination of saline (saltwater) and local anesthetic is first flooded into the areas to be contoured. Working through tiny incisions just large enough to fit the thin liposculpture vacuum tube, fat cells and some fluid are then gently swept away by suctioning back and forth under the skin. Liposculpture is truly a matter of sculpting the human form; it effectively removes unwanted fat from areas that are often resistant to diet and exercise. These can include the neck, upper arms, chest, sides, abdomen, thighs, hips, knees and ankles.

Other procedures for figure improvement include abdominoplasty (tummy tuck), breast lift, breast reduction, and–last but not least–cosmetic breast surgery. Saline implants, which have now replaced silicone gel implants, are used both to enlarge and to enhance shape. Following surgery, many of my patients are particularly happy that the tops of their bathing suits fit as well as the bottoms.

Any of the procedures described in this article can potentially help to improve physical appearance and enhance self-image. But no matter what procedure you choose, be sure to do your homework and choose a qualified, experienced plastic surgeon.

The Art of Cosmetic Plastic Surgery Recovery

Advice To Prepare For Post-Op Success

When you have cosmetic surgery, you are tricking Mother Nature and she is not going to be happy about it. If you are not properly prepared, you can hurt yourself! After working with post-op patients for over twenty years I thought I knew exactly what to expect from the post-op experience. I was wrong.

My husband had to go to the store 6 times in 36 hours to buy things I wasn’t told I needed, and those waiting hours were painstaking! Be careful…it could happen to you!

You need to know your post-operative and recovery instructions. These will include suggestions to eat lightly, starting with liquids for two days and moving onto soft solids. When the surgical procedures involve your face, you need to be reminded to keep your head elevated to control swelling. To sleep on your back ,elevated by three pillows, for at least a week. I hated that part! Most of my clients complain that sleeping on their back elevated is a great strain. Most patients do not understand that they won’t be able to strain themselves in any way, including motions requiring bending, lifting or exercise of any kind.

I consider it my job to make sure they get it. I am always surprised how many patients write to me to ask if they should take their pain medications regularly as well as the antibiotics prescribed.

The amount of information that was never told to me was astonishing in retrospect. Without really chastising any surgeon’s criteria for preparing their own patients for post-op, most don’t tell you all you really need to know, because they are afraid to overwhelm their patients. My advice? Tell them everything…no surprises please!

Here’s some great tips for plastic surgery recovery. Gather these items well in advance so you are completely prepared:

-Lots of pillows, including one at the base of their spine and one under their knees. I also needed a pillow under my buttocks for extra softness. My tush ached after only one day of immobility. (Who would have thought my natural padding wouldn’t be enough!)

-Mouthwash to rinse their mouth. It will be days until a toothbrush can fit into their mouth after a facelift. All efforts toward normalcy concerning hygiene are imperative to your patient’s overall sense of well-being.

-Safe skin-care products to wash their face with for the first time. Make sure that all of their skin care is hypo-allergenic and specifically formulated for sensitive and dry skin. The cleanser must have a moisturizing component too.

-Gentle, effective creams to use on the incisions and laser surgery sites, if needed. This will include a triple antibiotic cream, a cream to massage the into scars, a moisturizer for their lips with vitamin E, an emollient body lotion, and possibly petroleum jelly. If they need the petroleum jelly, tell them to look for one in a tube versus a jar. It is so much easier to use.

-A stool softener or mild laxative since the pain medications are usually binding. What can also be binding is the inactivity. Having a tough time performing even the most rudimentary body functions is a bore!

-An over-the-counter aid for sleeping. I recommend Melatonin to all my clients. I’ve been taking it for years to help me sleep through my husband’s snoring! In the morning I wake up quickly and without any grogginess. Remind your patients that rest and sleep are imperative to their healing process. If they have trouble falling asleep under normal conditions like I do, postoperative sleep will probably not come easy, even with the pain medication. Ask them.

-Homeopathic remedies used for healing the surgical wounds, reducing the bruising and detoxification from the anesthesia. Many or your patients may not be aware of the growing respect alternative healing products have in today’s modern medical practice. As you know, homeopathy is a natural pharmaceutical science that uses extremely small, nontoxic doses of substances from the plant, mineral, animal and chemical kingdoms. Homeopathic remedies are curative because they aid the body’s overall defenses rather than simply treating the symptoms. These remedies stimulate the person’s immune system thereby strengthening the individual’s ability to heal. Join the ranks of progressive surgeons by recommending such remedies as part of your healing philosophy.

-Soft foods and water-including protein shakes, fruit to be pureed, applesauce, oatmeal, yogurt, etc.

-Plenty of juice. Tell them to be careful with highly acidic juices like orange and grapefruit juice that could sour their stomach. The last thing you want is having your patients throw up immediately after surgery.

-Flexible straws. The straws will need to have flexible ends so they can drink liquids easily in a reclining position.

-A hand-held showerhead in their tub or shower enclosure plus a plastic chair to sit on. This is a must! There will be no other way to safely bathe or have their hair washed for the first time without these two essential items.

-Mild hair products to wash their hair for the first time including a leave-in hair conditioner. They will also require tools to unsnarl their hair-a pick and a vented hair brush work very well. Recommend brand new items since they will be used over newly sutured areas.

-A telephone with a speaker near their bed. Holding a phone to their ears will be impossible immediately after a facelift. Being able to communicate on their own, without help, will be such a gift. Especially when they need to speak to you. It also helps those patients who have older parents that don’t live close enough to come and see how they are on their own. Keeping the family stress free greatly helps your patients to concentrate on themselves.

-Lubricating eye drops. From surveying my clients, I found that most had dry eyes from the anesthesia whether or not they had procedures involving their eyes. The drops feel great and make it easier for them to blink and focus.

-All of your prescription drugs in the house before you need them. I loved being told to remember to take the pain medication, as if I could forget!

-Two large bags of frozen peas and six large self-sealing plastic storage bags to make cold packs. Suggest that they make at least six cold packs since they could use as many as three at a time and will need to replace them after 20 minutes.

-Lots of patience and a sense of humor! These may be the most vital requirements of all. Guide your patients to rely on their family and friends to help them out. My clients tell me that hugs help immensely, as long as they are administered gently!

The majority of these requirements seems pretty straightforward, yet you would be amazed by how many things are overlooked or never even considered when planning your cosmetic plastic surgery recovery needs. Most people are consumed with the more obvious issues such as covering for their absences at work and at home. This coverage is vital so you can take the time off to have surgery and recover from it. Don’t allow yourself to diminish your focus on all the items you will need for a successful recovery. Being prepared is what it’s all about.