California Cosmetic Surgery Blog

The Skinny About Liposuction

2009-11-02T22:07:24-08:00

Ever since the onset of tumescent liposuction, there have been a number of modifications of the procedure, attempting to produce better results or to speed up the procedure. These approaches include mechanically assisted liposuction, ultrasonic assisted liposuction and, most recently, laser assisted liposuction.

We have had experience with mechanically assisted liposuction, and have been unimpressed. Although it makes the procedure easier on the physicians, it does not make the procedure any quicker. Ultrasonic assisted liposuction has never become very popular, due to the relatively high incidence of reported complications. This approach uses ultrasound vibrations to break up the fat cells. Then this is followed by traditional liposuction to withdraw the fluid. one of the associated complications has been the formation of seromas, accumulations of fluid that have a tendency to recur.

Laser assisted liposuction has been the newest and most popular entry in this field. This has become an advertising catchphrase, probably because people believe there is something magic about lasers. The first and most popular of these devices has been the SmartLipo Laser. The claim was that, although the procedure was slower and took longer, it's advantage was that it produced additional skin tightening, above that usually seen in traditional liposuction. The manufacturer has never sponsored any studies to test this, and independent studies, reported at this meeting, showed no evidence of a skin tightening effect. This lack of evident benefit, accompanied by the risk of burns, should give one pause before undergoing this procedure.

There are those who believe that other laser wavelengths may be more effective, but even they admit that the vast majority of time they do traditional liposuction. They use the laser less than 10 % of the time, and then only for special circumstances.

When one considers risks versus benefits, it does not seem that laser assisted liposuction is a very good deal for the patient.

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

Cryolipolysis: Fat Removal Without Surgery?

2009-10-11T21:59:10-07:00

As cosmetic surgery has become more more sophisticated, there has been a movement toward less invasive procedures. Many of the initial attempts were marginally effective, but with time the effectiveness and specificity of these procedures has improved. Fat removal has so far not been affected by this trend. The supposed, but still unproven, advances of laser assisted liposuction still required surgery. The use of mesotherapy, which involved the injections of solutions of varying composition, proved to be problematical for treating fatty areas of significant volume, and had problems that resulted in a number of lawsuits and the bankruptcy of a chain of facilities that were formed to capitalize on the treatment. Now, an article in the most recent "Dermatologic Surgery" journal reports on the use of external cooling to reduce fat.

It has been observed that fat cells appear to be more sensitive to cold than the cells of the skin. However, as seen in frostbite and other conditions, it is certainly quite possible to seriously injure the skin through cold exposure. The authors of the study used pigs whose skin was cooled using a rectangular probe, which at times was moved in a massaging motion. The treatment sessions were 15 to 60 minutes each, and there were one to several sessions per area. The cooling device monitored the skin temperature and continuously adjusted the amount of cooling to keep the skin temperature at a safe level. After the treatment the skin felt cold but it was not hard or frozen. The skin appeared pink for about thirty minutes after the chilling was stopped, but otherwise appeared normal.

About 60 days later there were noticeable indentations where the cold had been applied. Examination of the tissue showed inflammation and reduction in the thickness of superficial fat.

It's obviously a long way from preliminary studies on pigs to the final development of a device that can safely be used on humans. Nevertheless, these initial results show promise for less invasive fat reduction . Cryolipolysis is not the only non-invasive method for fat removal that is being studied. There are also studies underway using focused sound waves to achieve a similar result.

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

Sculptra Article: New York Times

2009-09-23T00:31:23-07:00

There will be an article about Sculptra published in the New York Times on Thursday September 24. I have been interviewed for the article and, unless I'm edited out, you can read my thoughts about the topic.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

The First Advanced MACS-Lift Workshop

2009-09-15T21:03:22-07:00

A week ago I attended this workshop in Ghent Belgium. It was given by two plastic surgeons, Patrick L. Tonnard and Alexis M. Verpale who developed the MACS-Lift and have published two books about it. The workshop was divided into two parts. The first was a didactic session discussing the fine points of the procedure. The second was a live surgical demonstration showing details of the extended MACS-Lift procedure, as well as ancillary procedures (blepharoplasty, temporal brow lift and fat injections) that can be performed to give additional improvement.

The MACS-Lift, or short scar face-lift, is the latest in a series of procedures that have been developed to overcome some of the shortcomings of the traditional face-lift, as well as creating a procedure that involves less surgery, less risk of problems and less recovery time.
Because the tightening pull of the MACS-Lift is almost 100% vertical, it produces a very natural appearance, as contrasted with the angled pull of the traditional face-lift, which frequently produces a "wind tunnel" appearance. Since the MACS-Lift uses the same method for tightening the deeper tissue as does the traditional face-lift, its durability is as great. Finally, because the MACS-Lift involves less tissue undermining and a shorter incision line than the standard face-lift, recovery time is less, as is the risk of complications.
The multiple advantages of the MACS-Lift make it, in my opinion, the procedure of choice for the vast majority of people desiring improvement of the loose skin on the lower one third of the face and neck. The one exception to this rule are the people who have thick skin and a very full neck, who may be better off with a traditional face-lift.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

Finally a Use for Sculptra?

2009-08-30T23:40:05-07:00

Sculptra has been one of the products that we have used and discarded. The advantage of Sculptra is that it is the longest lasting of the fillers, frequently lasting 2 years or more. The disadvantages of Sculptra have been many: it requires a series of injections and was slow to produce visible improvement; it can be expensive and it has a propensity to develop nodules, sometimes starting more than a year after the material was injected. Because there were other fillers that were less expensive, relatively long acting and produced immediate improvement without the same propensity for nodule formation, there seemed little reason to use Sculptra. Now there is a report from Brazil that describes new uses for Sculptra that allow it to treat problems that previously had no good solution.

In the August Journal of Dermtologic Surgery there is a report of the use of a dilute solution of Sculptra to produce minimally invasive rejuvenation of the neck and chest. The problem of lines and wrinkles on the neck have only been treatable by surgery, or other tissue tightening techniques such as Thermage. The fine wrinkles on the chest have been treated, not very successfully in our hands, with botulinum toxin and various laser therapies. We have not used Thermage on these areas, but have seen improvement in similar fine wrinkling on the arms. The injection of Sculptra into these areas produces new growth of collagen and an improvement that is visible in 10 to 30 days, versus the 30-60 days necessary to show improvement in the face. A smaller amount of Sculptra is needed for the 1-2 treatments (chest) or 1-4 treatments (neck), so the costs are more reasonable. Although there are other fillers that stimulate collagen growth, none currently available seems appropriate for use in these areas.
In the study a total of 36 paients were injected and of those 33 said they liked the results and would do the procedure again. Two did not like the results and one did not like the accompanying bruising. Only one patient, who did not follow instructions to massage the area, had nodules, the only complication. The results were still present 18 months after treatment. The photographs accompanying the article show impressive improvement.

Gerald N Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

The Ten Minute Nose Job

2009-08-16T12:47:47-07:00

People who were born with lumpy or bumpy noses had, until recently, only one choice if they wanted to correct things. That was nose surgery, or rhinoplasty, a procedure that costs thousands of dollars and is said to be one of the most technique sensitive of the cosmetic procedures. Side effects, including excessive bleeding, loosening of the cartelage, irregularity and scarring occur in up to 18% of patients. Now, through the use of fillers, very nice results can frequently and easily be obtained through the use of fillers. Improvement of the shape of the nose through fillers is much less expensive than surgery, and has no downtime, when compared to the 6 week downtime of surgery. This filler can help people who are unhappy about the shape of their nose, but not those who are unhappy about the size.

The Brittish newspaper "Mail Online", in an article about this procedure, features Chloe Laughlin, a 24 year old beauty therapist from Surbiton. She said "I used to have a nose where, in profile, you could see this big bump. It upset me so much I was considering having surgery to straighten it."

Chloe Loughlin is thrilled with the shape of her new nose

Rather than having surgery, Chloe chose to have her nose deformity corrected through the use of filler.

Two injections straightened out my nose and changed its overall shape,' says Chloe.

'They used an anesthetic cream but that was it. The results were instant and there was such an obvious improvement. I walked out really liking my nose. I was amazed.

'It's amazing how something as small as your nose shape can change the way you feel,' she continues.

'With my old nose, I'd look in the mirror and feel slightly awkward. Now, I'm pleased with my reflection and that has affected the way I am about myself in general. It is a subtle, emotional change and I'm happier and more self-confident.'

Chloe before Chloe after

As you can see, a short, relatively minor procedure has made a relatively significant difference in her appearance. For this procedure we use Restylane, Juvederm and Radiesse.

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

Botox vs. Dysport

2009-08-01T11:15:10-07:00

Now that Dysport has been on the US market for a bit more than a month, it's possible to make some preliminary comparisons. In general the products are very similar. We have used Dysport in a number of patients who previously had Botox. No one has had any complaints. In many patients the onset of effect is more rapid with Dysport, usually within a few days. The pre-marketing studies show that Dysport has the same potential side effects as Botox (mostly headache, lid droop and brow droop), and they occur with about the same frequency. In about 1/3 of Dysport patients, the effect seems to last longer than Botox, often by a month or two. That appears to have been seen in Europe too, where the average Botox patient comes in three times a year while the Dysport patient comes in twice yearly. Dysport has been available in Europe since 1991.

It's important for physicians to be aware that the units of Botox and Dysport are not equivalent. One unit of Botox equals 2.5-3 units of Dysport. Unfortunately Medicis priced Dysport very close to the price of Botox, so there is no cost savings to the patient in using Dysport. Nevertheless, the presence of Dysport on the market will almost certainly put a stop to the annual price increases that were routine with Botox.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

Lifestyle Lift Fakes Reviews

2009-07-26T13:16:26-07:00

Lifestyle Lift agreed to pay $300,000 in costs and penalties to the State of New York for having its employees post fictitious reviews of its services. The company had ordered employees to pretend they were satisfied customers and write glowing reviews of its face-lift procedure. Lifestyle Lift also created its own site of what appeared to be independent face-lift reviews, concealing the fact that this site was controlled by the company.
"It's an incredible violation of consumer trust and it's a pernicious element of the Web that some companies have embraced this idea, under the guise of reputation management," said Thomas Seery, founder of RealSelf.com, a site on which he said Lifestyle Lift had posted misleading reviews.
Andrew M. Cuomo, New York's attorney general, said in a statement that Lifestyle Lift's "attempt to generate business by duping consumers was cynical, manipulative and illegal."

The problem with Lifestyle Lift is that its very structure violates the common sense rules about choosing a cosmetic surgeon. Lifestyle Lift has tried, and succeeded, in selling face-lifts like auto dealers sell cars. Their premise is that a face-lift is the same, no matter who performs it, just like a Chevrolet is the same, no matter which dealer sells it.
This, of course, is patent nonsense. The surgeon does make a big difference in the results of a procedure, and with cosmetic procedure chains, it is almost impossible to learn the reputation of the surgeon who will perform the procedure. It is very possible that the doctor who performed procedures at a particular location one year will nor be the same one who is working there this year. As always, it's buyer beware.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi

The Truth About Sunscreens, Continued

2009-07-19T17:00:16-07:00

In the previous post I made the point that the best sunscreen is one that protects against both ultraviolet A and ultraviolet B rays. Even this may not be the whole story. It may be that other parts of the electromagnetic spectrum, including blue light and infrared light may also be involved in skin aging. It is clear that the sunscreens we have been using so far have not given as good protection as that afforded by clothing. The take home message is that sunscreens are an adjunct to the protection afforded by clothing and shade. They should not be regarded as a substitute.

While the degree of sunscreen Ultraviolet B protection can be judged by looking at the SPF number on the sunscreen label, there currently is no good way for you to evaluate its ultraviolet A protection. Legally, sunscreen manufacturers can label their product as providing ultraviolet A protection, even if the protection is minimal. Today it is difficult to find a sunscreen that does not claim ultraviolet A protection.
It is best to look at the ingredients in the sunscreen to get some idea of the protection they afford. Physical blockers, such as zinc oxide and titanium dioxide, provide broad spectrum protection. Zinc oxide is felt to be the better of the two. The protection may vary with the percentage of these compounds in the sunscreen. There also have been two new chemicals developed to add ultraviolet A protection to sunscreens. The first of these is Meroxyl, developed by L'Oreal and used in Ombrelle and Anthelios sunscreens. Meroxyl is stable on exposure to sunlight, and it absorbs a broader range of ultraviolet A light than many other sunscreens. Another of these newer products is Helioplex. This is a stabilized complex of two older sunscreens, oxybenzone and avobenzone, making them more resistant to breakdown by ultraviolet light. Helioplex is found in the high SPF Neutrogena sunscreens.
Currently the evidence suggests that sunscreens with zinc oxide, Meroxyl or Helioplex will give you the best sun protection.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

The Truth About Sunscreens

2009-07-12T18:29:41-07:00

Sunscreens first came into use in the 1940s and the concept of the sun protection factor (SPF) was developed in the 1960s. The purpose of these agents is to protect against ultraviolet light. Ultraviolet light has been divided into three bands: ultraviolet C, which never reaches the surface of the earth, ultraviolet B which extends from 290-320 nanometers, is the primary cause of sunburn and does not penetrate window glass and ultraviolet A 320-400 nanometers, which does penetrate window glass and is adjacent to the visible light spectrum.

At the time of development of the SPF rating system and the development of the first of the modern sunscreens, it was believed that ultraviolet B was the bad actor and a good sunscreen had only to provide good Ultraviolet B protection. This was the initial focus of sunscreen development.
One of the significant advances in dermatologic therapy was the use of ultraviolet A therapy to treat a variety of skin conditions, including psoriasis. As a result of these treatments, it became clear that considerable damage to the skin was occurring. There was more wrinkling and increased freckling and brown skin discoloration. The skin surface became more rough and mottled. It was also clear that too much ultraviolet A can cause a burn which is different from an ultraviolet B burn in that it begins about 24 hours after exposure.
Patients treated with Ultraviolet A therapy showed an increased incidence of squamous cell carcinoma and an eventual increased incidence of melanoma.
As a result of these findings it has become clear that it's important to choose a sunscreen that has both good ultraviolet A and ultraviolet B protection. How to do this will be covered in the next post.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA