Many women and men, even when they are in their forties or fifties, prefer not to look as old as they are. Botox parties, however, are helping these folks deal with these problems both medically and socially. Although these gatherings are as common as any party, spas and clothing boutiques are the venues of choice for these events. Making friends, and having a ball is the general idea behind these parties. The fun part begins when they go to a room where a certified doctor is waiting to perform BOTOX injections.

Putting a BOTOX Party Together

Ideal places to hold such gatherings include a doctor’s home, a patient’s home, or even a spa. That way, everyone will be less stressed throughout the experience, helping them enjoy the party better. Several doctor practices around the country sponsor BOTOX parties in their own surgical facilities.

The highlight of the party is when individuals sit down with the doctor, who will then explain the pros of using Botox, followed by the administration of Botox injections.

BOTOX Party Dont’s

The Botox injections may be compromised by alcohol, so women and men alike should refrain from drinking alcohol because this. Unnecessary pain due to too much drinking that may have weakened a person’s immune system can be one of the side effects of Botox.

The Good Thing About BOTOX Parties

The nice thing about Botox parties is that it’s an event where people meet up with the sole purpose of having fun and encouraging each other to look good. The fact is that this is a party – folks will have fun whether they get a Botox injection, or are just there to mingle. The combination of light drinks, soft music, and food, will help the guests loosen up.

When everything is set for giving out the injections, a specialist will call people over one by one. This is, as was mentioned, the highlight of the party, and since a specialist is involved, there is no danger in the procedure.

Botox parties are great because, among other purposes, they save a lot of money and effort for everybody involved. There will also be some people who’d prefer to have a doctor make a house call for the sake of privacy.

Botox parties usually feature Botox products that are sold at a discounted price so that the participants may easily buy them. There are sure to be other freebies and discounts to be given by the physician during the night as well.

Why is a Gluten Free Diet Good?

Many people love to eat gluten-rich protein in their diet, but there are those whose bodies cannot absorb it. For this reason they have to eat a gluten free diet. Rye, barley, and wheat are among the foods that contains gluten. Nevertheless, there are individuals whose small intestines were affected by gluten because their bodies cannot stomach it, so they got sick with celiac disease.

A gluten free diet is a must for those with this ailment, so this will likewise prevent any complication or symptom. Gluten causes inflammation in the small intestines of people with celiac disease.

It is very important that people suffering from celiac disease should not consume foodstuff that contains gluten, so they have to read all of the ingredients thoroughly. One should refrain from consuming cereals that consist of wheat, wheat bran, oats, porridge, corn flour, wheaten, couscous, and wheaten.

Furthermore, breakfast fares should not consist of the following: corn, oats, barley or meals that contain rice even sugar in icing and baking powder. A gluten free diet to work on people various types of pasta should not be part of the diet as well.

Meat is good and nice to eat, but ideally it should be gluten free and other meaty goods that have breadcrumbs, sausages, thick soups, and meals that are placed in the freezer should not be consumed and be evaded as well. Desserts that are composed of delicious fruit-pie pilling, several ice cream products and even some drinks derived from soya are nice to eat because they taste good, but if they are filled with gluten, people have no other recourse but to abstain from eating these treats.

A typical ailment like celiac disease persists these days, so a gluten free diet is the only way to battle it. Unluckily, there are some people who had the misfortune of not being able to absorb gluten in their diet, so they have no choice but to eat gluten free foods.

Although celiac disease affects many people, they just have to follow the diet to alleviate themselves of the discomforts associated with it. A nutritional therapy like a gluten free diet would be a permanent regimen in a person’s life because doctors will recommend to anyone that this diet would eliminate loose bowel movement, constipation, stomach pain, and fatigue to name a few.

Living with Celiac Disease

Celiac disease is incurable, but a gluten free diet would help manage a person’s gluten levels. On the onset, one may have so difficulty and be tempted to not consume these foods that are gluten free. Still, the facts about the disease are something that the Celiac Society can provide support to a number of people, so they will be informed and able to control themselves.

For his or her cholesterol levels to be lessened significantly, a gluten free diet would effectively make that person feel renewed and energized. Various foodstuff and soy sauce made of malt are acceptable because there is an absence of gluten.

What is NuBrilliance?

The possibility of doing microdermabrasion in the comfort of your own home is made a reality with NuBrilliance. Dermabrasion is a controlled exfoliation of the upper layers of skin through a surgical procedure. Removal of fine wrinkles, acne scars and the smoothing of the skin are just some of the aims of the procedure. Another process for exfoliating skin without involving any surgical procedure is called microdermabrasion, though it only removes the outer epidermal layer.

What is NuBrilliance

The possibility of performing microdermabrasion on yourself at home is what Nubrilliance brings you. In the skin care industry, it sets itself as the first and only one of its kind. The device utilizes diamonds which are crystal-free and gives a dual-action therapy for suctioning and exfoliating. After the skin has been exfoliated, it finishes the job via suctioning the exfoliated skin, thanks to the efficient design.

What makes it work?

The combination of the suction as well as the use of crystal-free diamond exfoliation is the force behind its dual-action therapy. Because it can exfoliate and offer suction, it is a complete microdermabrasion treatment. The entire thing is like a diamond peel exfoliation you gave yourself.

What happens is the epidermis, or the outermost layer of your skin is removed through the use of very light abrasion. Healthy cells can grow again through this abrasion. Elastin and collagen is stimulated because of the suction that increases blood flow.

There’s one thing you should always remember upon purchase, and that’s to always start at the lowest setting. Also make sure to remember that the coarse tip is for your body, as the skin of the face is much thinner than any other part of the body. Remember not to overdo it, and only increase the level of dermabrasion if your skin can tolerate it.

What Can NuBrilliance Do

Dermabrasion of the entire body, not just microdermabrasion on the face, is possible through NuBrilliance. You can keep your skin perpetually healthy and lessen the need for pricey trips to the dermatologist by using the device.

The guiding design principle that is used in Nubrilliance is based on the microdermabrasion devices that are used in hospitals. Your safety is ensured because potentially harmful crystals and any abrasive elements aren’t present in it. The areas of the nose and the mouth are also parts you can use it on.

If the positive aspects are not so convincing, feel free to look at all the Nubrilliance reviews that are readily available on the Internet.

Through the use of real diamonds that are hypoallergenic and much safer to use there is no need to cover your nose or eyes when using the Nubrilliance microdermabrasion. It includes usage for the entire body and not just the face, a complete dermabrasion package. The fact of it is, it is meant for your home convenience.

Using Nubrilliance doesn’t have to be complex: simply press the diamond tip lightly against your face . By using this innovative new tool, you can avoid those frequent trips to the dermatologist, and save yourself some money while investing on your skin’s health.

Body contouring after massive weight loss is fast becoming one of the most talked about areas of cosmetic surgery. This segment of Inside Cosmetic Surgery speaks to American Academy of Cosmetic Surgery Trustee, Dr. Robert Shumway on the hot topic, Post Bariatric Body Contouring.

Dr. Shumway also touches on the importance of doctor education and patients doing their homework in finding the right surgeon to perform their cosmetic procedure.

Listen to the interview, or read through the transcript below.

Sharon Odom (SO): Hi everybody, this is Sharon Odom from Cosmetic Surgery Today and welcome to Inside Cosmetic Surgery, our continuing series of interviews with top doctors from across the nation. Our topic today is post-bariatric body contouring, and to lead the discussion, we are honored to have Dr. Robert Shumway, a board certified cosmetic surgeon from beautiful La Jolla, California. Hi Dr. Shumway, welcome.

Dr. Robert Shumway (DRS): Well, thank you. Thanks for having me.

SO: Well, thank you for joining us to discuss post-bariatric body contouring, and why don’t we start with the definition. What is that exactly?

DRS: Post-bariatric contouring is one of the most important things that people can have done after they’ve had weight loss procedure such as the gastric band or the Roux-en-Y gastric bypass procedure or other Nissen fundoplication procedures that help patients lose weight, but they have a lot of cosmetic issues thereafter. So post-bariatric body contouring is how we shape people cosmetically to help them look better after weight loss.

SO: Because after weight loss, there is a lot extra skin from where their body was big before and then shrunk, right?

DRS: Extra skin, extra fascia, and also areas that don’t look right from stretched or torn tissues that needed to be repaired.

SO: If there is loose skin on the face as well, does the patient go to another cosmetic surgeon to have that type of procedure performed?

DRS: So they do need to have different procedures for different parts of the body, which are oftentimes broken up into different days or different surgical days. Yet, some physicians will specialize on the face, and some will specialize maybe in liposuction.

Other cosmetic surgeons have been trained to do both of those areas and it can be addressed. For facelifts, we might use fatty tissues to actually go back in to fill it an area that’s been deflated or we may need to use some suspension techniques in order to lift the face so it looks more aesthetic and pretty.

SO: So I guess it depends upon the doctor that they choose to do the surgery because if the doctor only specializes in, say, the lower part of the body and they needed some upper body work done like in the face, then they have to go to somewhere else, right?

DRS: Right. Oftentimes, general surgeons or gynecological surgeons who have had additional training and additional credentialing make very good body contouring physicians. Head and neck surgeons or facial plastic surgeons or ocular plastic surgeons or oral and maxillary facial surgeons who have additional training for facial cosmetic work might delve in there.

Those who have been trained ubiquitously across the board and feel comfortable with all those different procedures might do things like facelifts, tummy tucks, liposuction or breast lifts, etc., arm and extremity lifts. So it depends on the practice and the volume of the physician’s work.

SO: Who is the ideal candidate for post bariatric body contouring?

DRS: It’s somebody who is stable from weight loss. In other words, they are not still trying to lose weight and that they are in good shape nutritionally and they don’t have a lot of other risk factors such as smoking or diabetes or having problems with the super high cholesterol and they are having trouble with their high blood pressure, or things like that. So those all need to be addressed and controlled first before we move forward with body contouring.

SO: Does it make a difference in your approach if the patient lost weight quickly versus over longer period of time?

DRS: The standard approach is losing a few pounds a month rather than going on crash diets. It’s better to have somebody who has lost weight over a period of time. When they have a body mass index that’s well over 30, they really need to be stable between 25 and 30 before body contouring procedures in the range of around six months of stable weight with weight loss that didn’t come off all at once and they don’t expect any huge changes in the ensuing future.

SO: It’s better if they lost the weight over a long period of time. So if someone comes to you and they lost weight quickly, you would tell them to wait for six months.

DRS: Yes, and we would see them back probably every month to see where they are. Have a consultation with them and make sure that their weight really is what it says. That way we can check their weight and we can get laboratories to see how their protein levels are, et cetera.

SO: With post-bariatric patients, do they need to be thought of differently in terms of the body contouring versus a person of normal weight?

DRS: Somebody that comes in like, for example, today who is very normal in weight, has had a baby and wants to be shaped, say, around the midline might be an excellent candidate for lipoabdominoplasty. Where a person who has had extensive weight loss who may have a panniculus or an area that hangs over might need more like a belt lipectomy where the incision is longer, the recovery maybe more difficult.

The condition of the patient maybe somewhat suboptimal because they still have other issues such as excessive fatty tissues that are probably going to stay there for the rest of their lives, yet they probably really won’t lose that weight.

So I always look at bariatric patients from a more of a workup standpoint. They need to be thoroughly worked up before you would actually do surgery on anyone who has had bariatrics. I need to know what their iron count is to make sure that they’re not anemic, that they don’t infections at other places, that they don’t have other complicating issues such as diabetes. Oftentimes they should have several other physicians with consults from internal medicine doctors or even cardiologists to clear them for cosmetic procedures.

SO: What are the unique challenges and possible complications of this type of post bariatric body contouring for the patient?

DRS: Usually, bariatric patients need help not only with the torso, but the extremities as well, and oftentimes in the neck and/or the face. As you lose weight, you become more gaunt in your appearance in the face and also the submental or the area beneath the chin takes on a different appearance. So this extra tissue has to be redraped and refilled so that it looks natural, but it looks not surgerized on after the procedure has been done.

For the torso, brachioplasty or arm tucks and tummy tucks, breast tucks or breast lifts and/or reductions can be performed along with thigh procedures. In other words, when the thigh becomes lax because the fat has left the area, it may need more of an actual lifting procedure rather than true liposuction.

So once the torso has been addressed, then you have to consider the skin itself.

SO: Okay, so something struck me right away when you say when the fat has left the area. There is something about that just made me laugh because that’s something that a lot of people would really like, if the fat would leave the area.

DRS: Yeah, that was the whole idea with the bariatric surgery. To begin with, it was to make fat leave the area. Fat is a great filler. As a matter of fact, we would like to shift the fat into other places, so if we are able to find some fatty deposits, we can reanimate other portions of, say, the face or even the gluteal, the buttocks lift concepts need to be addressed. So fillers are good. The fat is wonderful. It just needs to be appropriately positioned and deflation with the saggy skin and the saggy fascia needs to be repaired.

SO: How many procedures can you perform in one surgery? Because if a person has multiple areas to be addressed, I’m sure that you can do more than one procedure, right?

DRS: Yes. The safe rule of thumb is four hours per cosmetic procedure or procedures is plenty. So I am in a joint commission certified facility, so I’d like to follow that particular rule and I think the American Academy of Cosmetic Surgery would feel strongly with the guidelines of liposuction that we put together twice this past decade.

So in other words, there is a certain amount of fat that be removed when fat does need to be removed, which is generally around five liters in an ambulatory setting, and the amount or length of time is always a consideration. I personally like to use local procedures such as tumescent along with some conscious sedation so that I never use general anesthesia which is a greater risk to the patient and likely the surgery itself.

SO: So you don’t do anything that requires general anesthesia.

DRS: That’s correct. Even tummy tucks, breast lifts and facelifts and all done under conscious sedation and local infiltration techniques.

SO: Wow. So if someone needs something done and it goes beyond four hours, then they need to schedule another surgery?

DRS: Well, that’s all determined beforehand. The surgeon would know how long it would take that person to have, let’s say, a belt lipectomy or a body lift or torso lift, so that could be done in one setting and allowed to heal.

So they can come back later for their thigh tucks and their arm tucks and perhaps in the future maybe another time they can address the face. So it should be just like you eat a sandwich, you wouldn’t chew it all up in one bite. You take bites out of it until it’s consumed and then there is no problem with digesting it.

SO: Okay. Is there a preferred sequence? Do you do one area, the neck area, like you have a map?

DRS: Yes, I listen to the patient’s needs and wants first. They may have a real concern with their tummy area, so that would be a good place to start. Other folks have excessive skin tissue that’s very prominent in the lower face and neck area and that’s what people see more, so they might try to have a facial procedure done first.

SO: Now, what about insurance? I know that it will sometimes cover bariatric surgery. But what about the post-bariatric body contouring that’s needed afterwards?

DRS: Insurance for bariatric procedures and weight loss is very helpful, and I think that’s very appropriate because it affects the patient’s health. The mental health and the overall quality of life that’s improved with cosmetic surgery haven’t really found its way into the insurance industry yet.

SO: What about the recovery time for this post-bariatric body contouring? What is the downtime? How long does it take to recover with postop care, that sort of thing?

DRS: I always give people a one-month window when they are doing body procedures. The face and neck area tend to heal the quickest because it has such a wonderful blood supply where the torso is going to lag behind that. So a one-month period of time is usually a standard for doing tummy tucks, et cetera. Those who are doing extremity tucks might even require a little bit longer, maybe up to six weeks to eight weeks for full healing.

SO: As far as choosing a cosmetic surgeon, what should a patient look for when they think about doing this post-bariatric body contouring? What should they look for when trying to choose a surgeon?

DRS: I think it’s easy to look at your hand. There are five fingers there and so I would put my hand up and I go through this with the patients.

Number one, they need to go to an office and that physician has been certified by the American Board of Cosmetic Surgery because it’s the only board that is totally dedicated to the specialty of cosmetic surgery. So that’s the first hurdle.

Now there are other doctors who may not be board certified, so if they don’t have their boards in cosmetic surgery, they would need to have their boards in a specialty that would help serve that area, such as somebody who’s going to do facelifts or rhinoplasties, or let’s say, eyelid lifts, then they would need to be a facial plastic surgeon.

So they have to look at the background of the physician. There are board certifications and number three is how many of these procedures do they do in a year. Is this something that’s done once a year? Or is this something that’s done twice a year or once a month, or this is a weekly procedure that physician has done many times.

The other is has the physician been involved in teaching other doctors.

And then the other aspect is they want to be able to see befores and afters from that particular physician’s work, so that they can comfortably understand visually of what is realistic and what’s not realistic.

SO: Do patients ever come back to you to get follow-up surgery, or the result is fairly permanent?

DRS: Well, the results are totally permanent with every [post bariatric body contouring] procedure that’s done because you are actually removing tissue, reconstructing it, and putting them into place. You can always do further procedures, one, because of patient aging, or two, just because they are looking for another type of look or further refinement, and then also sometimes, patients will tend to gain or lose weight and that might also affect their overall results.

SO: Yes, that’s what I want to ask. What if the patient gains some weight, would that undo the results of the surgery?

DRS: It would depend on what percentage. So let’s say a person weighed 200 pounds and their ideal weight was 120. Let’s say they got down to 120 and they had a number of cosmetic body contouring procedures done after having, let’s say, bariatric surgery. Their bariatric gastric bands, let’s say, was removed and now they are back up to 150. So they are really 30 pounds above where they should be. That would represent about a 20% weight gain.

So different things would need to be done for different weight gain. Sometimes it’s diet and exercise for six months following up with the physician’s office is the appropriate therapy to give rather than doing a procedure.

So in other words, surgery really is the last resort that we use. It’s done because there really is no other good option. The option is played when the patient is tuned up and is that an appropriate body mass index or BMI, so that they get the best results, have the less chance of complication and also are more likely to come back to that physician because they trust them, they trust the doctor and the practice and they know that they’ll get good care for whatever kinds of things that they really need from a cosmetic standpoint.

SO: What if someone gained some weight and then they lose that same amount of weight? So let’s say they gained 30-35 pounds after they had the surgery and then they slapped themselves and said, “I went through too much trouble. Let me get this weight off.” Would they look exactly the same as they did after the surgery was done?

DRS: They generally will because as long as not too much time has gone by and they haven’t stayed at that more of a modern obesity for too long of a time. There will be some metabolic changes internally for sure, but once they get back to further exercise and dieting, in other words, controlling intake and caloric usage is really the whole key there.

The appearance of somebody going back from weight gain to weight loss, the weight gain to weight loss, that’s actually not a very good thing to go through, not only physically, emotionally and cosmetically, but it should be a little bit of a red flag to the cosmetic surgeon saying that this person has a tough time maintaining stability, in other words, homeostasis.

That what’s really key. Once you get a person fixed up to where they are looking nice, you really want to encourage them to stay in that category of life.

SO: Do you have any patient stories you would like to share, and no names, of course, but just the story itself?

DRS: Yeah, I have a number of patients who have been well into their almost 300-pound range on which I said, “Well, we need to first do the bulking of these areas.” So once we debulk them with liposuction, oftentimes they are so happy with the results, they are done, they are finished, they are happy and they don’t need anymore surgeries.

I had a patient from England several years back. She is a TV personality there and we did quite a bit of torso and body liposculpting and she looked marvelous. She had one of the super 8 figures that looked just stupendous.

And she called me about two years later and said, “I’d like to come back over for some more liposuction.” And I had done two sessions with her previously, and I said, “That sounds fine. Why are you coming back over? Didn’t we get enough fat out with the first couple of times?” She said, “Oh no, that’s not the problem. But it’s that I gained 50 pounds.” And so in that situation, she was from across the ocean so we had to work with weight control there and then later on, I just helped her with some contouring and little tucking procedures.

So you have to look at the skin as an envelope that expands and contracts and sometimes it needed to be tucked if the expansion has been beyond its resiliency to contract back again.

SO: Well, I know that this is a busy time for you, so why don’t we tell people how they can find out more about you. What’s your website?

DRS: Okay, it’s www.shumwaycosmeticsurgery.com.

And I am a current trustee of the American Board of Cosmetic Surgery or the ABCS. I am a trustee of the American Academy of Cosmetic Surgery, the AACS. Past President of the California Academy of Cosmetic Surgery, the CACS. And the past President of the American Society of Cosmetic Breast Surgery, or the ASCBS.

So the important thing is to continue your training and to encourage physicians to become good at what they do, specialize specifically in cosmetic surgery procedures, and always be truthful in their advertising and in the things that they can and cannot do.

In order to find us, we are on the Scripps Memorial Hospital Campus, and that’s the main hospital there in Northern San Diego or in other words, La Jolla

SO: Thank you very much, Dr. Robert Shumway, from La Jolla, California. It’s been a real pleasure and we will speak to you soon. Thank you so much.

DRS: Well, thanks so much, Sharon. It’s been a pleasure.

Unlike many cosmetic procedures, otoplasty, or cosmetic surgery for the ears, can be performed on patients as young as 5 years old. While often performed to reduce the appearance of protruding ears, otoplasty is more than just ear pinning.

In this edition of Inside Cosmetic Surgery, we speak to Dr. Carey Nease, a facial plastic surgery specialist, about this delicate procedure.

Listen to the full interview or read through the transcript below!

Sharon Odom (SO): Hi everybody, this is Sharon Odom from Cosmetic Surgery Today and welcome to another episode of our continuing series Inside Cosmetic Surgery. Our special guest today is Dr. Carey Nease, a triple board certified cosmetic and facial plastic surgeon with offices in Chattanooga, Tennessee and Calhoun, Georgia. Hi Dr. Nease, welcome.

Dr. Carey Nease (DCN): Hi Sharon, how are you?

SO: I’m great. Thank you. Well, today’s discussion is otoplasty? Which is what exactly?

DCN: Well, it’s a cosmetic procedure for the ears.

And that often includes making the ears smaller or what most people call an ear pinning or pinning them back if they are too prominent, and sometimes it’s a reconstruction of the ear if there is a trauma or some sort of congenital deformity.

SO: So when children have ears that kids make fun of, this is the procedure they have?

DCN: That’s correct.

SO: Are ear pinning and otoplasty interchangeable?

DCN: It is, but that kind of simplifies it a little bit too much. I mean, an ear pinning seems like a procedure maybe you are worried that ears are prominent and you are just reducing their prominence or the projection from the side of the head. In many cases, it’s much more complicated than that. If it’s that’s simple, then it is a fairly simple and straightforward procedure, but it’s still a surgery and not just a few stitches.

An otoplasty really is a bigger term that can refer to just purely a cosmetic setback or pinning procedure. It can be a reduction in the size of the ear or the change in the shape and then probably more commonly if there are some sort of congenital or developmental deformity and it could be recreated in the certain folds the appearance of the ear as well as potentially some reconstruction if the ear doesn’t develop as normal.

SO: So it’s not just ear pinning, it’s surgery on the ear.

DCN: Correct, on the other part of the ear, not the ear canal or anything with the inside. So it’s still an aesthetic procedure, but it could be considered a reconstructive-type procedure as well, just depending on what the problem is.

SO: How long does the procedure take?

DCN: Well, if it’s simply just a setback for a prominent ear, then it may only take about 20-30 minutes per side, so about an hour. But if you are talking about doing a procedure where you are having to recreate the folds, like what’s called antihelical rim or something more invasive where you may need to do cartilage graft or something like sometime you would actually take cartilage from the rib to recreate it or even have to do like a skin graft, then you could be talking about three to four hours. So it could be a very short procedure or a very long procedure, depending on what the goal is and what we are trying to accomplish.

SO: I imagine that if it’s removing cartilage from different places then that will require a general anesthesia?

DCN: It does. Yeah, absolutely. If you are doing any kind of reconstructive work or borrowing cartilage from somewhere else to help reconstruct or skin graft, then absolutely general anesthesia is required. If it’s simply an ear pinning or just a setback-type procedure for a prominent ear, then that can be done with local anesthesia and/or with a little IV sedation, depending on the patient.

One good question is whether it’s something we do for children or adults or both. So when I do it an otoplasty on a child, which is commonly about five or six year old before they start kindergarten, then we do them under general anesthesia because they are not going to tolerate the numbing process that it takes for the procedure.

For kids that age, it’s not really reasonable to expect. So for children, we almost always do general anesthesia. For adults though, it’s fairly commonly done with local with light sedation, even just sometimes oral sedation like Valium, and they tolerate it very well.

SO: What percentage of your patients are adults versus children?

DCN: It’s about 50/50 actually. In certain centers, if you are in maybe in a university setting, probably you are more likely [performing the surgery on] children. I’m in private practice and I’m kind of away from the university setting and so I actually do more adults than children at this state. I probably do about 75% adult and about 25% children, just based on the nature of my practice.

SO: So these are adults that made it through childhood with ears that they were unhappy with and then when they got to adulthood…

DCN: Correct. It’s prominent to maybe, say, the 20- to 30-year-olds. So it’s rarely on someone over age 40, but definitely there are quite a few adults who made it through childhood or they’ve had issues with their confidence in this sort of things and they’ve gotten to be an adult and maybe got a job and then can afford to actually, you know, and will get the nerve up sometimes where they are embarrassed by it. They come in and actually have something done.

SO: Now, you mentioned the word “setback,” what is that exactly?

DCN: Well, if the ear is protruding from the side of the head, if you look at someone straight on, if you are seeing too much of the ear and it looks more prominent, then it’s just a matter or rotating the other part, the helical rim, back towards the side of the head so that it basically narrows the angle between the mastoid bone behind the ear and the ear itself. You are basically rotating the ear back towards or closer to the side of the head, so that’s called a setback procedure.

SO: And ear pinning is…

DCN: The same thing. Ear pinning is kind of like the more common term for otoplasty where you are simply just setting the ear back closer to the side of the head.

SO: And what sort of downtime are patients looking at after otoplasty?

DCN: Well, honestly, it’s just a few days. It’s pretty quick. The recovery is very, very quick. You get very little swelling, very little pain, and very little bruising, so the thing is on the first 24 hours, if easily you get all wrapped up with a special headband. It’s kind of a compression bandage and then for a couple of weeks after they have to wear kind of like a tennis a headband to hold the ears back and usually a very light gauze dressing.

So it’s really more just having to have that dressing on is what you would consider downtime. Otherwise, if it weren’t for that, it could be back to the normal routine activities within just a few days, but because of the dressing, I would say that the downtime is about a week.

When they have a funny dressing or headband on, they are kind of embarrassed by that and usually they kind of stay home or maybe around a little and do some errands. But they might not even go to work or not go to school for about a week.

SO: Do the kids get otoplasty mostly during the summer?

DCN: Yes, yes. It’s like summer or Christmas breaks, spring break or things like that, and again, it’s ideal for kids if we are going to do it before they even start school. The kind of a textbook answer is that we try to do it before they start kindergarten if possible, and that age is important because we want the ear to be fairly close to its adult size.

And that’s the age when it’s getting fairly closest when the kids are about five to six years old, so it’s kind of why that’s the perfect time to do an otoplasty on a child if necessary.

SO: So that means that the ears are pretty much the adult size at age six. Really? They don’t grow that much more from there?

DCN: Yeah, not much more. It’s pretty close to that by that age.

SO: Interesting. So what are the risks?

DCN: Well, I mean, the risks of any surgery are, of course, you have bleeding and infection, those sorts of things. But when you are talking about otoplasty specifically, an infection would be a risk that would be a concern because we are suturing a cartilage back to the lining of the bone, and so if a cartilage gets infected, that can be a problem. We’ve been using antibiotics before and the week after the surgery to minimize that, but an infection would be something definitely to discuss.

And the other risk is that you don’t get a great cosmetic outcome. It’s pretty rare, and because you have two ears, the risk of having asymmetry afterwards, meaning maybe one works really well and you got a great result and the other side is not quite as good and so you are also going to compare one to the other. The risk of needing to do a revision on one side or the other is there. It’s probably in the 10% range or so, which for aesthetic surgery that’s fairly normal.

But besides that, besides the infection, bleeding is very rare, and anytime you are under general anesthesia, a risk of having a reaction to the anesthesia, but with young, healthy people, especially kids, that’s really rare, too. The biggest risk is infection or needing a revision because the cosmetic outcome isn’t as good as you would like.

SO: How do you make sure? I guess that’s part of your experience, right?

DCN: That’s right. It’s big actually. It is. There is a lot of artistry to it because everything that we do as cosmetic surgeons, a lot of artistic ability comes into play and there are measurements you can do to make sure of this. If you are doing it, say, just the ear, any ear setback procedure with the outer part of the ear that you would call the helical rim at certain point has the same distance from the back of the scalp behind the ear. You should get some measurements and just do a general appraisal of your result at the end of the procedure. So that’s the nature of cosmetic surgery.

SO: Given that this is a popular procedure for children, would it fall under reconstructive surgery?

DCN: It depends. If the ears are too big or prominent or protruding from the side of the head too much, that really is an aesthetic procedure. That doesn’t need to be done. You are not going to go to your insurance company or health insurance company, and in those cases, you are not going to get them to pay for it.

Now, if the difference is what if a child is born with one ear that’s normal and one ear that’s only partially developed, and yes, that is a reconstructive problem. Now, it still would be considered cosmetic, but you could certainly argue that this would be a necessary indicated procedure for the child, not necessarily for improvement in hearing, but just to get from abnormal to normal, not just unappealing aesthetically to appealing.

So in children with a deformed ear or a poorly developed ear, then certainly that would be considered a reconstructive and probably medically indicated.

SO: And that goes back to the definition of plastic surgery versus cosmetic surgery, correct?

DCN: It does. Sure, I mean, plastic surgery is more common. I’m a facial plastic and reconstructive surgeon as well as a cosmetic surgeon, so there is definitely a difference between the two, of course.

They are different, no question, and it’s interchangeable in a lot of people’s minds because they just don’t understand the difference, but it’s easy. Most people just say plastic surgery and they think of everything.

They actually more commonly think of the cosmetic procedure than the reconstruction, and the reality is that whether it’s facial plastic surgery or general plastic surgery, a lot of our training is more in the dealing with trauma and reconstruction after cancer and those sort of things, and the cosmetic part is not as prominent in most plastic surgeon’s training.

That usually comes with more training after your residency or fellowship. It comes with experience and then there are cosmetic surgery fellowships that’s out there, which I’m actually a director of a cosmetic surgery fellowship program here in Chattanooga and there are about 25 around the country that are available.

SO: Didn’t you do some fellowship or training with the AACS? Could you talk about it a little bit?

DCN: Yeah, sure. Yeah, I’m a fellow with the American Academy of Cosmetic Surgery, and also I’ve completed, after I did my head and neck surgery and facial plastic surgery training, I did a cosmetic surgery fellowship with Jim English in Little Rock, Arkansas. I spent an entire year devoted just to cosmetic surgery and that’s five years ago.

I actually just started my own program through the American Academy of Cosmetic Surgery. So I have a fellowship training program that is a postgraduate program, so you have to complete a surgery residency first and be board certified in one of the ABMS Surgical Boards, and then you can qualify to come and work with me for a year and learn cosmetic surgery and then you are qualified to sit for the boards in cosmetic surgery through the American Board of Cosmetic Surgery, which I’m a Diplomat of and I’m actually a board examiner as well.

SO: So it sounds like training is probably the most important factor in doing this type of surgery. How would you advise someone to find and go to the right doctor to do this kind of procedure?

DCN: Training is really important. Kind of having just what I would say is God-given talent for having some artistic ability as well as having great surgical training and then what’s your area of interest.

For me, I’m interested in both face and body surgery. But I would say my area of greatest expertise would be in facial rejuvenations or facelifts, rhinoplasty and otoplasty and brow lifts and things like that because that’s probably what I have done the most, even though I’ve done plenty of breast surgery and tummy tucks and things like that. My main interest is in the face.

That’s how you can kind of gauge of what surgeon is maybe right for you is find out what they really love to do, what’s most interesting to them. They maybe qualified to do everything, head to toe, based on their training and education, experience over time but if you would really say you want to have a face lift or rhinoplasty or even an otoplasty, you can interview a doctor and say, “Well, how many do you do? What’s your favorite procedure to do, and why?”

Because the thing that you would like the most is likely what you are going to be best at.

SO: Now, do you have any patient stories you can share with us?

DCN: Yeah, with otoplasty, I actually had an otoplasty patient just about two weeks ago that is about 25-year-old gentleman who had been thinking about doing it. Honestly, he wanted to do it when he was about eight or nine years old, but he never had the resources. His parents didn’t have the finances because this is not cheap, and unfortunately for him, it was purely a cosmetic procedure.

He had very similar ears, but they were just really prominent, and the one thing that bothered him was that he has early male pattern baldness, so he couldn’t even grow his hair out to cover it. He felt like because of he had a significant amount of baldness that he shaved his head and that made his ears look even more prominent.

So when he graduated high school, he got a job. He has been working, saving money for almost six years to come and have it done. We were able to do it for him just two weeks ago and he came back the next day and we took off the dressing and looked.

He was just thrilled. It’s something he has been longing for for years and years and his self-confidence, you can see just immediately when he left the room that day, the next day in the office was dramatically better. So it’s really exciting to be able to do that for someone and just give them the confidence just to face the day, and every morning he get to look at the mirror, he has been happier with their results. It translates into all aspects of his life.

So that’s exciting to have. That’s really rewarding.

SO: What would you like to tell our listeners about your practice? I know that you’ve pioneered a procedure that maybe we can talk about another time. The laser facelift, right?

DCN: Yeah. We have two. It’s a new procedure that we developed over the last couple of years. One is a laser facelift. It’s a minimally invasive facial rejuvenation where we use two lasers. One is the subdermal laser for the neck and jaw line. The other one is a resurfacing CO2 or fractional CO2 laser.

That combination is really powerful to the right patient population, which are women in their like late 30s to late 40s. They don’t need a facelift. They don’t need the big procedure with scar and lots of downtime, but want to look maybe five years younger and it’s been really, really successful. There are a couple of other surgeons around the country who are doing the similar thing now, so it’s kind of catching on. I think it will become pretty popular as a rejuvenation procedure here in the next couple of years.

The other one is a type of breast lift with augmentation combination procedure. I can’t talk about too much of that here. We are just in a research phase with that, but we are thinking on making that available to the public and to other surgeons to learn it here in the next couple of months.

SO: Oh, that’s sounds like a scoop. Well, I’ll be definitely following up with you on that one.

DCN: Yeah, it’s very interesting. I’ll be able to talk about it after January.

SO: Okay. What’s your website address?

DCN: Well, our website is SouthernSurgicalArts.com. It’s Dr. Deal and myself, and we are in Chattanooga, Tennessee and another office in Calhoun, Georgia. It’s about an hour apart in North Georgia and Southeast Tennessee, and I’ve been here for five years and Dr. Deal has been with me for one year.

We’ve got a very busy practice, have our own surgery center, AAAC-accredited. We’ve got the fellowship program where we are training one surgeon a year right now and actually next year we’ve been approved to train two surgeons a year through our Academy of Cosmetic Surgery Fellowship Program, so we are excited about that, and I’m welcome to answering any questions that anyone might have and the website is extremely valuable as far as information with lots of before and after pictures that list all the procedures we offer, and of course, bio information about Dr. Deal and myself.

That’s definitely if you are interested in learning about me or Dr. Deal or our practice, the website would pretty much find anything you want.

SO: Thank you, Dr. Nease. It’s been a pleasure. Thank you for your time and we will speak to you soon.

DCN: All right, Sharon. Thank you.

In this edition of Inside Cosmetic Surgery, we speak with American Academy of Cosmetic Surgery member, Dr. Bruce Chisholm. He specializes in above the neck procedures, and gives us great info on facial implants of the cheek, chin, and jaw areas.

Dr. Chisholm also speaks on the trend of moving away from the tightening and pulling of facelifts, toward re-volumizing particular areas of the face through facial implants and injectable fillers.

Give the interview a listen, or read through the transcript.

Sharon Odom (SO): Hi everybody, this is Sharon Odom from Cosmetic Surgery Today and welcome to another episode of our continuing series Inside Cosmetic Surgery. Our special guest today is Dr. Bruce Chisholm, also known as the Facelift Specialist, who is quadruple board-certified, and he has offices in Rancho Mirage, California. Hi Dr. Chisholm, how are you?

Dr. Bruce Chisholm (DBC): Hi, how are you?

SO: I’m great. I just couldn’t help, but say quadruple board certified because I have never seen so many boards on one doctor’s website.  Thanks for joining us to discuss facial implants, and that is of the jaw, cheek and chin, correct?

DBC: That’s right.

SO: First of all, what are facial implants made of?

DBC: The facial implants that I use, a hundred percent are made of silicone, solid silicone material, called silastic. It’s a molded silicone made by silicone manufacturers into the shape and size for support in the region you are trying the treat, whether it’s the chin or the midface or any other area.

SO: So they are all made of silicone. There are no other options?

DBC: There are other options. There is Gore-Tex, which is also used. It’s probably the second most common material and then there are some of the older materials like Medpor and such and there is also polymethylmethacrylate. You can actually custom make an implant, but for the most part, it’s solid silicone.

SO: What keeps them in place? How do you secure it to the face?

DBC: There are actually three options. You can make an exact pocket, whether it’s in the chin or the midface, and you don’t have to fixate in all circumstances, particularly with the newer implant with a broader base. If it’s a smaller implant, then you will want to secure the implant either with several resorbable sutures or with small micro screws into the malar buttress region.

SO: And that’s in all areas, the chin, the cheeks, the jaw?

DBC: That’s correct. Yeah, the cheek would be the malar buttress region. With the chin, you could use a small screw. Generally, the chin implant does not require a screw. Occasionally, the midface implants do, and the angle implants almost always.

SO: Now, I was trying to visualize before I got on the call the cheek and the jaw. What is the difference? Where do they separate?

DBC: Well, with the cheek, we are generally talking about the upper part or the mid-part of the face, the upper jaw. The most common area to augment in a cheek is actually what we call the midface region area right below the eyeball itself and that is the area that’s lost most frequently almost on everybody as they get older.

The actual cheek area, the malar region, which is just outside of the eye socket, outside the lower canthus, that area doesn’t loses as much volume. If you put an implant, such as a cheek implant in that area, it tends to change in appearance versus restoring your appearance if you placed an implant toward the nasal region and in the midface region. So most of the time, we are doing midface implants.

The jaw line itself would either be the chin, which would the actual chin area, put in through a small incision out of the chin. The angle area is back by the angle of the jaw just below and in front of the ear and that’s the augmented lateral projection that sometimes lent to the jaw itself.

SO: Are the implants permanent? Are touchups or maintenance required?

DBC: The implants are permanent. They are there forever. They will last forever and ever.

SO: So it’s nice to hear that something is really permanent.

DBC: It’s the most significant benefit. The benefit of the implant is that we age, we all lose volume, projection and support, and these [facial implants] replace it permanently.

SO: I’ve seen on women, especially the area right around the eye with a sort of, I don’t know, it’s felt like a little hollow area. Is this something that addresses that or is that some other procedure?

DBC: Well, this is a procedure that addresses that hollow region. It does not correct it completely, but it improves it dramatically and is the single most effective thing in the long term that’s particularly permanent treatments. In that particular area, as people get older, even if you augment that area with an implant, you often find yourself having to do a little bit of injectable fillers as the hyaluronic acid, the Juvéderm, and things like that to augment it maybe once a year to keep the area looking really good. But the implant itself will take care most of the problem, but generally not all of it.

SO: That sort of answers my next question, which is what are the benefits of facial implants over other methods like injectable fillers.

DBC: Well, the implants are permanent. That’s the big thing. You can do just about everything with fillers than you can do with facial implants. But it’s going to resorb and go away, and people do that, but after several times or several years, they get a little bit tired of it. As we get older, we lose more and more volume, more and more support, so you are having to do more and more fillers.

It’s nice to have something permanent done that provides a very natural cosmetic aesthetic restoration of volume and support in the cheek area, the chin area, the angle area. Then even if you need a little bit of filler as time goes on, it will be a lot less and in between fillers you will maintain most of the projections and support that would not have been there if you are just doing fillers alone.

So there is an excellent way to reestablish a baseline, and sometimes correct it completely and then if you need a little bit later on with fillers, you can always augment [facial implants] with that.

SO: So it sounds like you used them in combination?

DBC: Yes, in combination. I think most of the time most people are happy with just the implants, but with the one exception being around the eyes. The medial tear trough region is very difficult to augment with implants correctly because the skin is so thin. So that area is one area we do touch up maybe once a year with a little bit of filler.

SO: I’ve heard that facial implants are a sort of unsung hero in facelift. Can you talk a little bit about that?

DBC: They are. The facelift procedure has changed so much. Years ago, maybe 10 or 15 or 20 years ago we thought of it as a tightening, pulling procedure, and it just isn’t that anymore. It’s considered more of restoration of tension, restoration of volume, and restoration of support, and so much volume and support is lost.

It cannot be replaced with a facial surgical procedure that’s pulling and repositioning the native tissues. The facial implants have come along and provided that 50% that was missing and that’s the support and volume that is just naturally lost in the chin, and mostly the midface, it’s the number one area. Second would the chin and third would the angle of the jaw.

SO: As far as chin implants, how do people usually choose those? I mean, what type of person would want a chin implant?

DBC: Well, there are two different types of reasons we use chin implants. One is the person who is born with a small chin, or microgenia, and an excellent way to give them a balanced facial appearance is just to put in a small anatomic chin implant. It’s an excellent way to do it because it’s permanent; it’s simple; it’s easy. It doesn’t really require cutting the bone or anything like that.

The second is the aging chin. Some individuals, or actually a significant number of individuals, like with the rest of the face lose support, lose projection, and lose volume. A very small anatomic chin implant placed in there can restore their natural appearance without giving them the appearance of a bigger chin.

Those are the two most common reasons. Sometimes it’s in combination where some people are older and have a small chin and lose volume. But for the most part, it’s someone who is born with a small chin or just the natural aging chin process we restore with a chin implant.

SO: Can you feel the implants?

DBC: Can you feel the implant? No, the midface implant, the chin implant, and the angle implant, you can’t, but we can feel them. As surgeons, we can feel the edges of them and such, but the patient can’t feel them as long as you keep them under the more supportive muscular regions.

SO: That means if someone has an implant and they try to touch it and rub it, they can’t feel it with their hands?

DBC: Most people can’t feel it, no. Cheek implants are a bit different. It’s what we call the malar or cheek implant. That is not very well covered. I personally don’t do a lot of cheek implants. You can feel those because the coverage is very thin, but the midface implants, the medial cheek implants, chin and angles, you generally cannot feel them. Patients aren’t aware and are unable to feel them.

SO: They can’t even feel them inside of their face, and not with their hands, or they just aren’t aware of them like a hair in the eye or anything like that.

DBC: They are not aware.

SO: What board certifications should patients look for in a facial implant surgeon? I imagine that a surgeon should be specialized in this kind of surgery?

DBC: They should. Board certifications are very important and that’s something you should ask your surgeon each time. Then look for hospital privileges and experience and then results. All of them are very, very important. I wouldn’t skip any one.

The thing about facial implants is it’s a bit of a niche area and lots of, or a fair number of, people don’t do it and a fair number of people do do it. So when you are thinking about facial implants, you do want to check the person’s training, the board certification, hospital affiliation, and then you will really find out if this is a procedure they are doing a lot.

SO: Who would be a good candidate for facial implants?

DBC: It’s anybody who has a congenital atrophy or missing volume such as a small chin, cheeks or such. But in today’s practice, what we mostly see is the person getting into their 40s, 50s, 60s, and above who are just naturally losing the volume and support in their midface.

Well, the midface is number one, and then some in their chin, and then some people lose not quite as much, but in some groups of individuals, more so in the jaw area. So what we really see is a lot of people, the vast majority of people as they age normally could benefit from a midface implant. A smaller percentage would benefit from the chin implants, just from the natural aging process to restore real balance and support so it’s natural looking.

SO: Is it considered reconstructive surgery?

DBC: In those circumstances, no. It would be considered cosmetic, but we do do it for reconstructive surgery. People who’ve had cancer, tumor removals, gunshot trauma, and/or there are people who’ve had cancer who have ended up paralyze one side of the other or for any other reason, they tend to get atrophied in the area and the implants can provided a very nice balance back to the face.

SO: So do you get many people seeking reconstructive surgery or most of them cosmetic?

DBC: Most cosmetic, but we have a fair amount seeking reconstructive.

SO: What are the potential risks and side effects?

DBC: The implants are really a tried and true procedure at this time. Infection is almost unheard of. It’s as close to zero as you can get. For most people, it’s a little bit of an altered sensation that resolves over a few weeks, then there is the occasional person that might feel that they want more or less, that’s a very small amount, and then you’d have to look for movement of the implants, which again with a new anatomic implant is very rare. So the problems with the implants are very, very, very minimal.

SO: What about anesthesia? Are they under local or general?

DBC: They are very simple to place once you gain the experience and you can place them with local anesthetic, a little bit of light sedation or general. I, most of the time, use a very light sedation with a little bit of augmentation of local anesthetic.

Some people do it. We have a fair number of particularly busy, the professionals, that don’t have a lot of time and they will do them on a Friday. We do it under local anesthetic. It’s a very brief and quick procedure and they can go home and resume most of the normal activities the next day.

SO: Does their face look different? Does it look bruised? Like what’s the downtime?

DBC: The downtime physically, if it’s just a facial implant you are doing, is you would limit it to a day or two. The visual downtime is different. There is swelling. There is going to be a bit of swelling, more swelling than bruising, but definitely swelling, and they may experience a small amount of bruising that’s going to take a week or so to go away. So it’s more of a visual downtime than it is a physical downtime.

And that is a very individual subjective thing. Some people don’t mind it with people knowing, and some people don’t want anybody to know.

So that really depends on the patient.

SO: Right. Can you share a patient success story with us? No names, of course, but just an idea.

DBC: Okay. One of the things I really enjoy with the implants that we didn’t have in the past or what we weren’t using as much as today or using fillers that disappeared, was the person who has a very imbalanced face. Maybe a large nose or a bump, a deficient midface and a small chin. They are pretty, they are confident, they like the way they look, but there is just a significant balance that’s missing.

When you combine a midface implant that’s very, very aesthetic, very small, very natural with a small chin implant and then just a very, very conservative reduction of the nose, it’s just amazing the balance that returns to the face from a very, very simple procedure. From a cosmetic standpoint, that’s one of the most rewarding.

From a reconstructive standpoint, the reconstruction of the jaw is much more complicated issue. I’m going to talk more about maybe the midface, particularly with people who have had previous cancer surgery with tissue removal or people who were paralyzed on one side of their face, whether it’s a neurological problem or cancer surgery, there is a very significant imbalance that occur that’s difficult to return them to normal and do normal function.

What you can do is give them an initial appearance of balance that nothing else will do that for them, and the midface implants have been very successful in restoring people who has had a stroke, weakness in the neuromuscular complex from whatever reason and giving them just more. They are happy with their appearance and it just puts a little a bit of joy in their life.

SO: It’s interesting what you said about balance, because I remember reading somewhere that beautiful people, if you study their face, that that is the number one thing, that they are symmetrical.

DBC: It is. I’ve been doing facelifts now for over 20 years. The first part of my facelift experience was technical and getting results, and the second half was the other stuff, which is balance and support and volume restoration. It is the key to a really long lasting balanced pretty facelift, and that’s where implants come in.

SO: Would you like to tell our listeners about your practice in sunny Southern California?

DBC: Well, the vast majority of my practice is cosmetic multi-facelift. It’s what I enjoy the most. One of the fun things about facelifts today are the implants that I use in just about every patient. I know a lot of people think implants change your look, not aesthetic looking, but it’s actually the opposite.

It gives them a very balanced, very natural look as long as all you replace is what they have lost. In the American Academy of Cosmetic Surgery (AACS) meetings, there has been a real push to talk about the natural restoration of balance and support, and I could not agree more with them.

SO: And you specialize in above the neck surgeries, correct?

DBC: Yeah, and most of my practice is facelift.

SO: What is your website?

DBC: My website is bchisholmmd.com

SO: Great. Thank you very much. I really appreciate your time.

DBC: Thank you for you time.

Here’s an Inside Cosmetic Surgery first: a video! Take a look at this webinar interview we’ve done with Dr. Gary Hitzig, a board certified hair restoration specialist with Prasad Cosmetic Surgery.

Some of the results are so incredible, that you have to see it to believe it!

Dr. Hitzig walks us through the his hair restoration process, which includes the use of extracellular matrix technology (Acell) and platelet rich plasma (PRP), to promote cell duplication instead of scarring.

Learn more about Dr. Gary Hitzig via his website, www.nyhairloss.com.

Is there anything more sensitive on the human face than our eyes? In this installment of Inside Cosmetic Surgery, we speak with Dr. Nancy Swartz, an ophthalmic plastic surgeon in Philadelphia, about the advantages of seeking a specialist for your cosmetic eye surgery, or blepharoplasty.

Not all cosmetic eye procedures are invasive. Dr. Swartz also talks about the evolution from surgically invasive procedures to now being able to treat many conditions with dermal fillers like Botox or Restylane.

Listen to the full interview, or read through the transcript below!

Sharon Odom (SO): Hi everybody, this is Sharon Odom from Cosmetic Surgery Today and welcome to another episode of our continuing series Inside Cosmetic Surgery. Our special guest today is Dr. Nancy Swartz. Hi Dr. Swartz, how are you?

Dr. Nancy Swartz (DNS): Hi Sharon, how are you?

SO: I’m great. Well, Dr. Swartz is an ophthalmic plastic surgeon with offices in the Philadelphia area and she’s in practice with her husband, Dr. Marc Cohen, and today we are going to be discussing cosmetic eyelid surgery. And there is another name for that, Dr. Swartz, and what is it?

DNS: Yes, the actual technical name for cosmetic eyelid surgery is blepharoplasty.

SO: That’s it, yes. So today we are going to discussing that, and so the first thing we need to find out is when should someone come to see you instead of an ophthalmologist.

DNS: Well, I’m an ophthalmic plastic surgeon, and ophthalmic plastic surgery is a subspecialty of ophthalmology. There are a lot of specialties that perform blepharoplasty well, but the advantage of seeing an ophthalmologist that specializes in plastic surgery is that we are specifically trained to take care of your eyes. Ophthalmic plastic surgeons are ophthalmologist first and then specialize in plastic surgery.

SO: How did you get into plastic surgery? You started out doing ophthalmology-type cases and then you moved into plastic surgery?

DNS: Yes, that’s correct. Ophthalmology has a lot of different specialties. Actually, I did fellowships in two of them, ophthalmic plastic surgery and neuro-ophthalmology. My practice is limited to ophthalmic plastic surgery though.

SO: Okay, so you deal specifically with the eyes. This is your specialty.

DNS: Yes, ophthalmic plastic surgery has really expanded over time and many people now call it oculo-facial surgery and we do only face surgery, but don’t limit it only to eyes anymore.

SO: What percentage of patients actually are seeking a solution to improve their functionality instead of just improving the aesthetics?

DNS: Well, when your eyelids are droopy enough that they cover part of your pupils, the black pupil in your eye, they make it difficult for you to see things that are above you and sometimes to the side as well, and people whose vision is blocked by their eyelids often complain of a tired or a heavy feeling because they lift their eyebrows to see better all day long and the muscles get tired.

I would estimate that maybe 20% of my patients that I see for blepharoplasty are considering surgery for improving those symptoms, but most of the patients who do this for symptomatic relief and also appreciate the improvement in their appearance.

SO: Now, that brings up a question, if it’s something that they need in order to see better, is it sometimes covered by insurance?

DNS: That’s correct and there are tests that insurance companies ask us to do for our patients and provide information so that they can assess whether or not it’s blocking their vision.

SO: To prove that [insurance] should pay for it. Do you combine procedures sometimes like an upper eyelid lift with a lower lift all at the same time?

DNS: We combine procedures all the time. People often have their upper and lower eyelids done at the same time and we often combine blepharoplasty with injectable treatments like Botox and fillers.

SO: Because eyes are such a sensitive area, what sort of precautions do you take to make sure they aren’t damaged during the procedures?

DNS: Well, safe eyelid surgery really starts when you first visit your doctor. A good examination is important to evaluate the health of your eyes. Conditions like dry eye syndrome and eye allergies tend to get worse temporarily after surgery, so they need to be controlled first.

During surgery, a protective contact lens is placed in the eye to protect them and I use a laser when I do blepharoplasty surgery. So I use a special contact lens that’s designed specifically to protect the eyes from the lasers. After surgery, we use eye drops and ointments to keep the eyes moist and protected.

SO: When someone comes to you, what are they usually coming for? The initial visit is usually to just talk about the eyelids. What’s the typical first visit?

DNS: So yes, people often see changes as they age in their eyes before other places. When we look at people, we look directly at their eyes for a good part of the time, so it’s a place that we see and we pay attention to. Women put makeup on their eyes because it is such a focus of our appearance and so a lot of people come to me because they notice that their eyes don’t look the same as they used to. Sometimes, they are more hollow, or sometimes, the skin is loose, and so those are typical things that people come to me for.

SO: What about that little hollow area right under the eye?

DNS: Yes, that’s a common problem that people have. They get hollow under their eyes and sometimes when they are hollow, when they lose volume and get hollow, they start to see bags right above the hollow.

And those are all very common problems that people have that we address sometimes with surgery and sometimes with other injectable fillers.

SO: That area under the eye can be filled with fillers, or does it require invasive surgery?

DNS: It depends on the person. If the person really has too much fat or very loose skin or their lids have stretched, those people need surgery, but most people really don’t need surgery now. Most people have changes in their eyes because they’ve lost volume and those people do really well with fillers.

SO: You know it’s funny. So you lose volume in some place, right? So there is a little dent under the eyes, and then you have fat in other areas, right?

DNS: Right. Most of the time, the fat that you see, the bags under the eyes and other places have always been there, but you didn’t see them because you had fat under your skin that kind of gave you a more full look and kind of hid what was underneath.

And when you lose that fat, you start seeing what’s underneath it.

SO: What are the trends? Are there certain eye shapes that patients are requesting more than others?

DNS: Well, the trend right now is really to look natural and to look like yourself. People don’t want to look like somebody else. A lot of my patients come in and they ask me about celebrities that they have seen that have had surgery and are now hard to recognize and they want to make sure that doesn’t happen to them.

They want to look refreshed and they want to look natural. They don’t want to look like they had surgery. They just want to look like themselves.

SO: Just a fresher, rested version of themselves. Are all the procedures invasive?

DNS: Not all the procedures are invasive. Blepharoplasty is a surgical technique and all surgery is considered invasive and all eyelid rejuvenation is not invasive. The neuromodulators like Botox, Dysport and Xeomin are, in office, we consider them minimally invasive procedures. We use them to soften wrinkles, to shape the brows and sometimes to open the eyes.

Fillers like Restylane and Juvéderm, we use those for wrinkles as well. But what most people don’t realize is that they can be used to rejuvenate the facial contours so they can fix the hollowness and hide the bags and make people look like they did when they were younger.

SO: Do you use fat transfer as well.

DNS: I don’t use fat transfer. Fat transfer can be a very valuable tool in some parts of the face. I don’t think it does well under the eyes. It’s a technique that some of the fat tends to lift more than others and lower eyelids are a place that if it goes away in an irregular pattern, you will see that, so lower eyelids do much better with fillers than they do with fat. With other parts of the face, you can do very well with fat.

SO: Do you usually do a combination of surgery and fillers or it just depends on the patient?

DNS: It really does depend on the patient. It used to be when I started practice that when people came in for eyelid rejuvenation, really the only thing we had to offer was surgery.

We have so many options now. It depends on your anatomy and your lifestyle and what you are looking for.

SO: All of the options are just wonderful.

DNS: It’s a lot of fun and it’s going to keep getting better.

SO: So what are the potential risks or side effects?

DNS: Well, anytime you do surgery around the eyes, you have risk to your eyes, to your eyelids, to your vision. Fortunately, eyelid surgery is really very safe and problems like that are very rare. One of the problems that is a serious complication of eyelid surgery is having difficulty closing your eyes after surgery, and that happens when too much skin is removed and it is completely preventable just by avoiding aggressive skin removal.

SO: They actually are not able to close their eyes?

DNS: That can happen if too much skin is taken out. You need to have enough skin to go from your eyebrow down to your eyelashes with your eyes closed, and if too much is taken out, it’s difficult to close your eyes.

SO: And I would imagine that’s a function of choosing the correct surgeon?

DNS: Yes. Absolutely.

SO: And that brings me to the next question, which is, what should patients be looking for when choosing a cosmetic surgeon for blepharoplasty?

DNS: So, with any cosmetic surgery, and eyelid surgery is no different, you want to surgeon who has experience doing that type of surgery. So your surgeon should have a lot of experience doing eyelids if that’s what you are going to have done.

Your surgeon should ask you about problems that you have with your eyes. They should ask you about your general health, your medications. They should evaluate your eyelids and your eyes before the surgery. You want to make sure you know exactly what the surgeon is planning to do and results they think they will achieve with the surgery.

You want to ask where the surgery is going to be done and what type of anesthesia you are going to get. You want to make sure that the operating room is accredited. If you are having anesthesia, and most eyelid surgery, there is anesthesia involved. You want to make sure that an anesthesiologist or nurse anesthetist will be with you the entire time you are having surgery.

SO: Is that general anesthesia?

DNS: Usually, it is not general anesthesia. Usually, it’s just sedation. But certainly that is something that different surgeons do differently and different patients want different things. So it’s a conversation you want to have with your surgeon.

SO: How soon can patients see results and then how long does the results last?

DNS: So usually, cosmetic eyelid surgery doesn’t need to be repeated. There are exceptions to this, but it tends to be something that you do once. That doesn’t mean that you don’t do other eyelid rejuvenation techniques over time, you see, if they want to do fillers or the neuromodulators like Botox, but the surgery tends to be one event in your life.

Eyelids are very delicate and they bruise and swell easily and the less bruising and swelling you get, the sooner it’s going to away so the sooner you are going to look good.

SO: So how long afterwards are they bruised? Immediately after surgery, how do they look?

DNS: Well, with the laser, most people have either no bruising and swelling or just a very small amount, but you can get some over the next few days, and you have a little bit of control over this so if you limit your activity, if you keep your head elevated and you use cold compresses for those first few days, you will see much less bruising and swelling.

A lot of patients look good in a week or two, but you certainly can’t guarantee that. I tell my patients that they should have at least a month or two before they have a big event, so that they have plenty of time to heal.

SO: The results aren’t obvious right after since there needs to be some healing first.

DNS: It completely depends on whether or not you have bruising and swelling. If you have none, you look good right away. If you have a lot, you have to wait for that to go away before you really see the results.

SO: Okay. Now, what if someone wears his contacts, can they wear them afterwards or not?

DNS: You need to wait until your eyelids heal before you can wear your contacts, and that’s usually about ten days to two weeks.

SO: So if there is someone like me who can’t function without contacts, I just need to stay in bed or just make that they wear a pair of glasses.

DNS: Or wear a pair of glasses. One of the reasons we wait with soft contact lenses is because soft contact lenses absorb your tears and make your eyes a little drier and you want your eyelids to heal well before that.

But with the harder lenses, that isn’t a problem. You would get back into yours a little faster.

SO: That’s good to know. Do you have any patient success stories you would like to share, not names, of course, but just examples of successful patients you’ve done? I know they are all a success, but just specific example.

DNS: Oh my, I’m having a hard time thinking of one person. I take my surgery very seriously as I know all surgeons do and I take it very personally, and I am very attached to my patients. And all of them are important to me to be a success and to be happy with their results.

SO: Well, is there anything we should know about blepharoplasty?

DNS: No, I think you’ve covered that very nicely.

SO: Would you like to tell our listeners about your practice and your website?

DNS: Sure. I practice ophthalmic plastic surgery. I have an office in Southern New Jersey and in the Main Line area of Philadelphia and I also see patients at Thomas Jefferson University Hospital. I’m in practice with my husband who is my partner at home and at work, Dr. Marc Cohen, and our website is www.cosmetic-eyes.com.

SO: Well, thank you, Dr. Swartz. It’s been a pleasure and we appreciate your time.

DNS: Thank you so very much.

Inside Cosmetic Surgery speaks with Dr. Marc Cohen about the often overlooked area of the face between the upper eyelids and the hairline: the forehead.

Check out this interview as Dr. Cohen explains how the introduction of hyaluronic acid fillers caused a gradual transition from traditional brow lifts to less invasive forehead rejuvenation.

Sharon Odom (SO): Hi everybody, this is Sharon Odom from Cosmetic Surgery Today and welcome to another episode of our continuing series Inside Cosmetic Surgery. Our special guest today is Dr. Marc Cohen, an ophthalmic plastic surgeon with a private practice in the Philadelphia area. Hi Dr. Cohen, how are you?

Dr. Marc Cohen (DMC): Fine, thanks. How are you, Sharon?

SO: I’m great. Thank you. Well, today’s topic is forehead rejuvenation. And let’s just start out by asking what is forehead rejuvenation exactly.

DMC: Well, forehead rejuvenation is anything that would be included in things to make your forehead and eyebrows look younger and more attractive, and that really includes somewhat the eyelids also because the eyebrows and the eyelids are now considered to be one cosmetic unit.

So it’s really the area from your upper eyelid up to your hairline. And taking care of wrinkles and eyebrow position and having the fullness and the natural curves that we would like to see in a young attractive forehead.

SO: What about the dermal fillers that are on the market? I mean, how do they play into the forehead rejuvenation?

DMC: Well, we’ve learned over time that faces tend to deflate rather than just fall. We used to think of things two dimensionally that foreheads and the rest of our faces fell downward. But now we could think of them as sinking inward. Fillers add volume, so we can re-inflate the eyebrows and parts of the forehead to make them look like they did when they were younger.

SO: So the fillers play a very important role in the rejuvenation process. Is that all there is to it, just the fillers?

DMC: Well, we treat foreheads with fillers. We also treat with neuromodulators, which are things like Botox Cosmetic, Dysport and Xeomin, and those help to reposition the eyebrows and shape the eyebrows and then we do things to treat the skin of the forehead like we do in other places of the face with things like skin resurfacing with these various lasers or with topical creams to make the skin look younger and more attractive.

SO: Now, what about fat transfer, how does that play into this?

DMC: Well, fat transfer is really another type of a filler. It adds volume and it’s very popular among some surgeon and less popular among other surgeons. Fat transfer has the benefits of being possibly more permanent, which is an advantage. Some of the disadvantages are it’s much more of a surgical procedure. There is more bruising afterwards and more downtime. It’s done generally in an operating room as opposed to fillers, the other types of fillers I’m talking about, which are done in an office setting.

Also fat does not always last permanently and sometimes when it does not last, it resorbs, it dissolves in an uneven way at times. And if that happens, it can leave you with some irregularities which are always easy to repair, but there are many surgeons who believe much in fat transfer and certainly some of them get very good results.

SO: What is the difference between forehead rejuvenation and the traditional brow lift?

DMC: So a brow lift is really an upper facelift. It involves taking the forehead and mostly the eyebrows and raising them to a higher position, and that’s a form of rejuvenation. Also, it’s a surgical rejuvenation that lifts the brows.

The approach we tend to take now is to feel that generally eyebrows do not fall a lot. In many patients, they don’t fall at all as they get older. They just sort of look like they have fallen because they have deflated. There is less full fat beneath the brows and because of that, because the curves of your youth are not there, it gives the illusion that the brows are lower than they actually are.

So we often add volume underneath the brows in order to return those natural curves rather than doing a surgical lift, which just makes the brows higher and often puts the brows in an unnaturally high position.

SO: When did you shift to more forehead rejuvenation versus the traditional brow lift?

DMC: Well, it was sort of a gradual transition. Forehead lifts became very popular in the 80’s and in the 90’s. And in the 90’s, Botox Cosmetic came along, so we started doing some rejuvenation with Botox and lifting of the brows somewhat with that. Then in the mid-2000s, around 2004, hyaluronic fillers became available and that was sort of an ideal weight and volume to the forehead. So it was sort of a gradual transition.

SO: And I imagine it’s better because it’s less invasive.

DMC: Well, it’s definitely less invasive. People that have rejuvenation with hyaluronic acid fillers tend to have it done as a lunchtime procedure and they may have a little bit of swelling, and it’s always possible they could have bruise, but basically they are back to work either that day or the next day after they have it done.

SO: Is that the general trend to move towards fillers versus the traditional lift?

DMC: Well, there certainly are some surgeons who still do a lot of forehead lifts, but there is a trend in general to minimally invasive treatments like fillers. Last year, about 85% of all cosmetic treatments done were minimally invasive rather than surgical procedures.

SO: I can see why. It’s so much better for the patient, I would think. But how often do patients come in and say that they want a forehead lift and you talk them into fillers instead?

DMC: Well, basically, I don’t think cosmetic surgeons should really talk their patients into having a procedure that they don’t want to have. So when someone comes in to see us, we evaluate them and listen to their concerns and then we educate them as to the available options.

As I mentioned before, most people don’t realize this, but a young and attractive woman would, let’s say, tends to have very full and relatively low eyebrows. In youth, there is a small, smooth curve that goes in the eyebrow then all the way down to the eyelid crease. Brows can look lower as they deflate so people sometimes think their brows have dropped even though they haven’t.

So I’ll often ask patients to bring in old photographs and we compare them to their recent pictures. Most people’s eyebrows are not significantly lower than they were years ago, they are just flatter, and when people realize that, the often like the idea of brow filling rather than brow lifting.

SO: Once you’ve presented the less invasive option, do they usually choose to do that instead?

DMC: They often choose to do that. Often it starts with the idea of, “Well, let’s give that a try because it’s less invasive and it doesn’t tend to be permanent.” And so we will give that a try and then they feel they have the option to later have a surgical treatment if they want to, but usually it doesn’t even come to that.

SO: How often do they come back and say, “You know, this is great, but I want the lift?”

DMC: It’s pretty rare in our practice, I would say. I would say most people feel they get a nice, natural rejuvenation with things like fillers and modulators and then they do not tend to have surgery.

SO: What are the potential risk and side effects of forehead rejuvenation?

DMC: Well, basically, anytime there is anything with injections, there is always a chance of bruising and swelling and that can occur with any treatment. That’s a very minor side effect. It’s almost hard to call that a side effect, but it certainly can happen.

You can get lumps and bumps with hyaluronic acid fillers or with any type of filler. Fortunately, if you are using fillers, particularly hyaluronic acid fillers, they are very easy to correct.  There are some more serious side effects, which are extremely rare, with things like scarring and infection and even the possibility of visual loss when having treatments that close to the eye.

SO: Could you name some of those fillers that you were talking about? Is that Juvéderm and Restylane?

DMC: The fillers that we prefer are the hyaluronic acid fillers, and of those, the ones that we use are the Juvéderm family of fillers and the Restylane family of fillers.

SO: What are the limitations of using fillers versus the traditional brow lift?

DMC: Well, basically, they are not permanent. Of course, brow lifts are not really permanent either, but they last a lot longer than fillers do. So patients who get fillers tend to come in for repeat treatments.

However, with hyaluronic acid fillers, they tend to last longer than most people think. In the forehead area, it’s not unusual for fillers to last a year or even longer and that’s from the initial treatment, and on repeat treatments, they last even longer.

There are some patients who are sort of born with very, very low eyebrows. That’s just sort of their look and if they don’t like that and they want their brows to look physically higher and that’s really what their problem is, then a forehead lift is better for them than fillers.

SO: With forehead rejuvenation, would you say that it affects a certain age group or a particular gender?

DMC: Well, it’s certainly both men and women who have brow rejuvenation, but like almost all cosmetic procedures, it’s much more common in women than in men and like most cosmetic procedures, the most popular age groups are in the sort of 40 to 65 year age group.

SO: Yes, I noticed that. Most of the surgeries tend to be focused towards women, but more and more men are getting cosmetic surgeries these days, correct?

DMC: Yeah, there is no question. There are plenty of men who have cosmetic surgery. They feel they would like it for career advancement or for social reasons. Certainly, it’s not unusual, for men to have cosmetic surgery. But in terms of the overall statistics, it’s certainly more common in women than men.

SO: Do you have any cases where someone comes in for the forehead rejuvenation and then they will say, “You know, now, my lower face needs some work.” Does that ever happen?

DMC: It is quite common, not because having one thing done makes it look more necessary to have other parts of your face done, but it’s rather sort of getting your toe in the water. You’ve tried it and you found it to be a pleasant experience. You like the fact that you look better and you didn’t find it to be difficult to do.

So people are then interested in exploring other avenues of looking better just like they did with their forehead. It works in both directions, of course. Some people come in with lower face questions and then later on have brow rejuvenation or the other way around.

SO: You specialize in forehead rejuvenation or do you specialize in the face?

DMC: Well, I specialize in both and really anything to do with the face. I’m a board certified in cosmetic surgery as well as in ophthalmology.

SO: So I would imagine that anything involving the eyes that someone would have to be specialized, right, because you have to be very careful around the eyes, correct?

DMC: Well, I mean, there are certainly are very good cosmetic surgeons of different specialties that do eyelid surgery, but we focus on that particularly because of our background in ophthalmology, yes.

SO: Do you have any patient stories you would like to share, no names, of course, but just examples of success stories?

DMC: Boy, I’m not sure I can think of a specific story. I mean, I think that there are many patients that have forehead rejuvenation and they often have their surgery and are delighted with the results. The most successful ones, people who look at them don’t realize that anything specific was done. They just feel as if they look like they’ve had a vacation or they’ve changed their hairdo or new type of glasses.

They are people that were the most excited about in terms of results because we’d like people to look like nothing was done, but just to look better.

SO: Well, is there anything else you would like to tell our listeners about forehead rejuvenation? Perhaps tell us about your practice, your website?

DMC: Well, we are in practice in the Philadelphia area in the suburbs of New Jersey and the Main Line in Philadelphia. Our website is www.cosmetic-eyes.com and you can read more about us there if you would like.

SO: And you are in practice with your wife, correct?

DMC: I’m practicing with my wife, Dr. Nancy Swartz. The two of us both are active plastic surgeons, and we have a mom and pop practice.

SO: Excellent, and you are also a member of the AACS (American Academy of Cosmetic Surgery)?

DMC: Absolutely! I’m a proud member of the AACS. We think it’s a wonderful organization. It promotes people from many different specialties, all of whom are interested in cosmetic surgery, and we all learn from each other and it’s a wonderful avenue for the advancement of cosmetic surgery.

SO: Thank you. This has been great, and I really appreciate your time and we will talk to you soon.

DMC: Thank you.

Restylane, one of the most popular hyaluronic acid dermal fillers for medium to deep facial lines, is now FDA approved for use in lip augmentation procedures.

Restylane had previous FDA approval for its use to improve the look of facial folds. The FDA can approve a company’s “New Drug Application,” and can work with the manufacturer to write up the indications (usage/directions), but the FDA cannot regulate how the drug is prescribed.

Many cosmetic surgeons have been using Restylane off-label for a while. Off-label does not mean illegal. It simply means that a product is used for something other than what it was intended. Doctors and cosmetic surgeons have the right to use a product for something other than what it was FDA approved for. However, the manufacturer cannot promote the use of their drug for any reason other than what it currently has FDA approval for.

Restylane’s parent company, Medicis Pharmaceutical Corporation, is happy to have the FDA’s stamp of approval for lip augmentation. Medicis CEO and Chairman, Jonah Shacknai, stated that Restylane is, “the first and only hyaluronic acid dermal filler approved in the United States for lip augmentation.”