Chin Augmentation

In Hollywood, where most of the talent trades on their facial attractiveness, it has been common for both men and women to enhance their profiles with chin enhancement.  Especially in men a strong jawline and profile are a must for matinee idol handsomeness.   In an industry where attractiveness is the primary currency, chin surgery has always been common; more common than anybody suspected.  So it is not a surprise that the American Society of Plastic Surgeons statistics show that chin augmentation with chin implants has risen 71% making it the fastest growing plastic surgical procedure.  Slightly more men than women are undergoing the procedure which is not a surprise due to the large cachet placed on a strong chin and jawline in men.

Implants for chin augmentation have been around for 30 years or more so the science behind the procedure is fairly well worked out.  Commonly, an incision is placed in the mouth below the front teeth on the bottom (a skin incision below the chin is also feasible).  A pocket is then created over the boney part of the chin or mentum.  This pocket is carefully placed below the tooth roots and away from the nerves that supply sensation to the lower lip.  Small improvements of 4-5 mm are easily achieved with a variety of silastic (silicone) implants with various shapes and sizes.  Most experienced surgeons would agree that a chin augmentation of 10mm or more is more difficult to obtain with an implant.  These large augmentations are associated with a small chin (microgenia) as well as a poorly defined, obtuse, neck contour.  Simply placing an implant gives minimal improvement to the neck.  Large implants are more likely to cause boney erosion of the chin due to their size and the tension required to advance the tight soft tissues.  For this reason, large chin advancements of a centimeter or more are frequently achieved with a different operation known as a genioplasty.  A genioplasty is performed again through an oral incision, but rather than placing a silastic implant, the chin bone is cut in a horizontal direction below the tooth roots so that the small chin may be advanced and fixed in position with titanium plates and screws.  If the small amount of titanium hardware becomes a problem it may be removed after healing of the bone at about 6 months post-operatively.  The intrinsic beauty of the genioplasty is that the neck muscles are left attached to the boney chin and as the chin is moved forward to effect the augmentation, the neck muscles are also tightened improving the once obtuse neck line.  In the rare instance of a chin implant infection, removing the implant and performing a genioplasty can salvage the result as the small amount of titanium used for fixation almost never causes an infection.

The most common complications of chin implant surgery are the rare infection, rare boney erosion involving tooth roots, and more commonly prolonged lip numbness (rarely permanent) with the most frequent complication being inadequate chin projection as well as over-projection of the chin giving a profile in women that it too strong and sometimes masculine.  Occasionally, a chin implant that is not properly healed can shift causing the chin to be asymmetric.  Even years after fully healing, a trauma to the chin implant can cause a secondary hematoma and inflammation necessitating implant removal.  On a very rare occasion a lower jaw (mandibular) tooth abscess can secondarily infect a chin implant, but not a genioplasty.

Over the years, many creative surgeons have tried to create chin implants with mesh material such as mersilene or prolene mesh.  The primary problem with porous materials is that they can get chronically infected causing prolonged oral drainage.  Also, these porous implants become incorporated into the chin soft tissues and thus are impossible to revise (bigger or smaller) and can be very difficult to remove.  The good news is that these so called “chin cripples” can be salvaged by a well performed genioplasty.

Chin augmentation is one of those procedures that lends itself to facial imaging.  Using the already well known proportions, the exact profile can be agreed upon pre-operatively so that no misunderstandings develop post-operatively.

All in all, chin augmentation is one of the easiest and most satisfying operations performed by plastic surgeons.  Naturally, when studying the profile, the nasal profile comes under scrutiny and in many cases rhinoplasty and chin augmentation are done simultaneously to overhaul the entire profile all at once.  Again, facial imaging can predict the profile that is desired.  One warning is in order:  Many times dental malformations (malocclusions) can mask themselves as a weak profile.  A good dental evaluation to rule out malocclusions and dental caries, especially in the lower jar, is indicated pre-operatively.  Beware the dentist/orthodontist with today’s fancy facial imaging software.  Not everyone with minor malocclusions needs $5,000 of orthodontics on a fully formed jaw.  These orthodontists many times feel the need to recommend both nasal and chin surgery acting like they and their referrals are a necessity.  This is the tail wagging the dog.  It should be very easy to identify fully trained Plastic Surgeons to perform both chin augmentation as well as the rhinoplasty in a single operation.

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Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD) is a psychological disorder in which the affected person is excessively concerned about and pre-occupied with perceived defects of their face and/or body features.  The obsession with body image can be all consuming to the point where occupational and/or social functioning is impaired.  The disorder is frequently associated with anxiety disorders, social withdrawal and clinical depression.  In fact, many people suffering with BDD also have a depression diagnosis as well as obsessive compulsive disorder, social phobia, and chronic social anxiety.  BDD sufferers have a more than double rate of completed suicide and a suicide ideation rate of 80%.  Men and women are affected equally.  There is no specific cause for BDD, but is thought to be a combination of psychological, emotional, biological, and environmental factors.

Many patients with BDD are able to hide their diagnosis from plastic surgeons by down-playing the crisis within and may appear just another vain patient which all Plastic Surgeons are used to seeing.    In my experience, many of these people actually have small, but visible problems that may be described as much worse than the actual problem.  These patients usually have consulted with other Plastic Surgeons and have learned not to be too dramatic regarding the perceived defect so as to get the surgery desired.  It is only after surgery that the full extent of the problem is revealed.  Basically, these patients, if operated on, cannot be satisfied with the result even if photographic documentation shows improvement.  One way to identify these people pre-operatively is that they frequently do not see the problem in photographs, but will readily show you in the mirror or on their face.  Since these people generally spend at least an hour per day studying their visage, they can in detail describe the nature of the problem even though it may be “within normal limits.”

Many of these people describe in detail and quite convincingly how their defect has kept them from employment and socialization.  They reveal chronic low self-esteem and exhibit paranoid ideation thinking that everyone notices the problem and is secretly mocking.  They frequently will have a litany of “friends” that reinforce the severity of the problem.  If left untreated, the symptoms persist or even worsen over time.  The diagnosis is usually obvious, but can be documented with any of a number of BDD questionnaires available on-line.  Even with the chronic and unremitting nature of the disorder, it is treatable with cognitive behavior therapy and medications such as Prozac®.  It is uniformly true that Plastic Surgery to address the perceived deformity is never a good idea and in many cases can cause harm to the patient (psychologically).

The most common complaints have to do with the nose, face, and skin issues.  It is well known that the nose and facial features are psychologically charged ones even for those without BDD.  A poor self-image leads to a chronic loss of self-esteem and destroys any quality of life for those sufferers.  Referring these individuals for psychiatric evaluation is necessary, but seldom happens unless there is family support for the intervention.  I have also noticed a higher than usual incidence of anorexia and/or bulimia in these patients.

Realistically, as a plastic surgeon one should never be caught off guard by the BDD patient as these people have a very difficult time hiding their diagnosis even if they know they will be turned down for surgery.

Joggers and Runners: Beware

In our current healthy and image conscious environment many people choose to maintain fitness by running, jogging, or high impact aerobics.  While these exercises are great for cardiovascular fitness they are extremely bad for facial aging.  First and foremost facial aging is primarily a result of loss of skin elastic tissue due to sun damage, environmental factors and smoking.  Pounding the pavement has an adverse effect on facial aging in the face of poor skin elasticity.  Compression garments can be worn to hold firm abdominal, thigh, and buttock tissues as protection against the effects of running on these tissues.  No such garment can protect the face from the deleterious effects of extreme exercise.  Runners are usually thinner than others of the same age.  It is a well-known fact that while healthy, thin faces age quicker than faces with some fat content.  The opposite is true for necks – little fat in the neck is good whereas a fat neck is difficult to contour.  Many people who exercise heavily do not maintain adequate hydration.  Drinking large amounts of water help keeps skin hydrated and less likely to manifest dryness, fine wrinkles, and laxity of aging.  There are plenty of aerobic exercises and machines that provide a serious workout without the up and down pounding that can exacerbate the facial aging process.

Rhinoplasty – Minimal Surgery with Major Results

There is a certain subset of patients who, by genetics or trauma, will require a true septo-rhinoplasty to correct breathing problems and to straighten an injured nasal pyramid.  There is a much larger group of patients who have relatively minor cosmetic nasal problems, usually confined to the tip or the bridge of the nose.  It is a well-known that the tip of the nose tends to lose its support as we age causing the nose to tilt over the upper lip and gives the impression of a longer nose.  Minor nasal tip cartilage problems can create the impression of a “boxy” tip or even a “pointy” nose.  Minor bridge problems can be addressed with small operations.

The use of filler in the nose has only recently become popular.  There are a few situations where fillers may improve the nose without surgery.  Small discrepancies of the nasal bones usually due to trauma and certain small tip and bridge asymmetries may be improved with the judicious use of fillers.  To this point in time the “perfect filler” is still your own fat.  Harvested and processed fat is long-lasting and usually does not require secondary procedures.

The nasal refining procedures do not require general anesthesia and are not covered by insurance.  These procedures are for refining the nose and as such do not change to overall ethnicity of your nose.  Think of your same nose yet more refined, elegant, and at a greatly reduced price.  For some people a major nasal reconstruction may be necessary due to trauma, for those who want a completely new nose, or those with significant nasal breathing problems.

 

Dr. Paul Howard

View rhinoplasty before and after photos on Dr. Paul Howard web site.

Luscious Lips

Beautiful, full, pouty lips are considered youthful. One of the natural consequences of facial aging is the loss of normal lip volume causing a deflated appearance with wrinkling.  There are many misconceptions regarding attractive lips that seem to have found their way into the social consciousness due to plastic surgery results that seem to have gone awry.  Merely increasing the size or the amount of vermillion show (red portion of the lips) does not make lips youthful or attractive.  In fact, exaggerated lips seem to invoke the opposite response much like the overdone rhinoplasty, facelift, or breast augmentation.  It should be clear that exaggerated plastic surgery is a choice, not a necessity.  Plastic surgery has progressed do the point where overdone is not mandatory and we Plastic Surgeons should question not what we can do but what we should do.   Because a patient asks for bad plastic surgery doesn’t mean we are obliged to do it.   Our role should be to educate those who ask for things we know are unattractive and if no common ground can be negotiated, no surgery should be performed.

There are details commonly associated with youthful lips that are easy to achieve as long as you know what you are trying to achieve.  Full lips are youthful, grossly inflated lips are not attractive and reek of bad Plastic Surgery.  Full lips require replacing the lost lip fullness with natural material such as fat.  There are numerous off-the-shelf graft materials that seem easy to use, but as foreign materials they present a multitude of problems that make the result less than perfect.  Autologous fat taken from the abdomen or hips, when properly processed, provides the best graft material for lip augmentation.  Increasing lip volume causes some increased vermillion show (red portion of lips) seen from the front as well as increased “pout” as seen from the side.  The increased volume must be apportioned so that they appear fuller and pouty.  Other aspects of the beautiful lip include definition of the white roll, fully visible philtral columns, and important for a natural look, a lower lip that is slightly fuller than the upper lip.  These nuances are not obtained by luck, but rather because of detailed surgical planning using the correct filler material.  The results should be apparent immediately and should last a lifetime.  Continued aging may lead to the need for touch-up grafting after several years even though the transferred fat, once healed, is permanent even though the lips are a highly mobile area of the face.  Any perceived problems with graft “take” are generally due to poor harvesting of the fat and inadequate processing of the harvested fat.  One should expect to have the fullness lost since the teenage years. It can be helpful for your Plastic Surgeon to see high school photos for reference.

Dr. Howard has been a world leader in fat grafting for over 25 years.  Patients travel from all over the world for his fat grafting mastery to rejuvenate their appearance, or fat grafting for reconstructive procedures due to injury or birth defects.  To learn more about fat grafting for  lip enhancement, facial rejuvenation, or cosmetic hand rejuvenation please visit:

Read more about Dr. Paul Howard’s lip augmentation.

 

Lip Augmentation Before Picture

Lip augmentation before photo

Lip Augmentation After Picture

Lip Augmentation after picture

Laser, Light Savers, and other Fanciful Ideas

There are literally hundreds of companies developing, manufacturing, and selling laser systems to treat a wide variety of ailments. Some of these laser platforms actually work, but for the most part they never live-up to the expectations created by their marketing campaigns. There are many companies that sell the exact same technology as others but offer new “bells and whistles” as well as more attractive packaging. Doctors have a bewildering number of choices with conflicting claims of “remarkable” results. Complicating the marketplace even further is that the companies market their laser and other “do-dads” directly to the patient hoping that patient inquiries to their doctors will drive the marketplace rather than scientific studies which determine the efficacy of a specific laser treatment.

Concomitant with the latest marketing schemes a lexicon has evolved to describe the wondrous things these lasers can do. Certain words reappear frequently such as: powerful, pain-free, immediate visible results with superior comfort, fast treatment times, and the ubiquitous product that produces superior results and a great ROI (return of investment).

Besides shooting down enemy missiles (ICBM) and providing the “red dot” for laser guided weapon systems, today’s lasers are useful but not required to treat the following: tattoos, vascular skin lesions, superficial facial wrinkles, acne scarring, and for skin rejuvenation in its most generic form. It is human nature to want to look younger with no surgery, no down-time, and no pain. Unfortunately, this is rarely if ever possible. The best plan is to consult first with a physician you trust that has knowledge about Plastic Surgery and skin rejuvenation. Hopefully he or she can help you make sense of the aesthetic industry and give you useable information regarding your particular wishes. Many times a laser may not be necessary at all when much simpler explanation and recommendation will suffice. Sometimes common sense will lead you to the right answer. It is always true that a claim that is too good to be true frequently is.

There are a number of newer technologies now available that are not lasers but make fanciful claims. Intense Pulse Light (IPL), cold therapy (Zerona®), mesotherapy, and radio frequency (RF) tissue healing are out there with little to no data proving their efficacy. A very thoughtful Plastic Surgeon once said, “I’d rather not be the first to jump on the new technology band wagon, nor do I want to be the last.”

Dr. Paul Howard is Board Certified by the American Board of Plastic Surgery. To learn more about Dr. Howard and his Plastic Surgery practice in Birmingham, Alabama please go to his web site:

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Smoking and Plastic Surgery

Patients who smoke are a problem for plastic surgeons for multiple reasons.  It is a well-documented fact that smokers are much more likely to have wound complications especially with procedures that require undermining the skin such as face lifts and tummy tucks.  Smoking also affects the healing of all incisions whether undermining or not, and I think smoking is one of the causative factors for capsular contracture of breast implants (hardening of the breast implants).  Even those incisions that appear to heal initially are more likely to open after the sutures are removed and usually produce poor scars both in quality and appearance.  In scars that technically heal without “complication,” the period of time it takes for effective healing of incisions is longer than for non-smokers.  Once incisions have failed to heal, primarily the problems escalate.  In addition to poor quality scars, these incisions act as though they have an inadequate blood supply similar to scar healing after radiation therapy.  Open incisions are prone to bacterial infection and require a great deal of time and effort for local wound care.

Inhaled cigarette smoke also causes damage to living tissue causing bronchitis, wheezing, and eventually emphysema.  Intrinsic lung damage complicates the administration of general endotracheal anesthesia and blood oxygenation.  These pulmonary problems with smoking are not exclusive to plastic surgery patients, but nonetheless should be counted in our complication list for smokers.

There are several things that plastic surgeons can recommend to the smoker to mitigate some of the problems caused by smoking thereby reducing but not eliminating complications.  The most important thing a smoker can do is stop smoking.  There is data that suggests stopping smoking for two weeks before surgeries decreases smoking related complications.  A good pre-operative evaluation may uncover some pulmonary related problems such as congestion associated with bronchitis or bronchospasm.  Early recognition and treatment of those problems may reduce the pulmonary related complications.  Personally, I believe that staying away from general anesthesia if possible decreases smoking related risks.  Full monitoring with local anesthesia plus sedation decreases complications for smoking and stabilizes swings in blood pressure for both non-hypertensive and patients with hypertension.

Only those patients who refuse pre-operative instructions and cannot or will not stop smoking should not be accepted as a candidate for elective cosmetic surgery.  It is not clear if the wound problems are secondary to nicotine alone or a combination of nicotine and other toxic substances associated with cigarette smoke.  The data is unclear if using nicotine containing products to stop smoking causes the same level of wound problems associated with smoking.  Chantix® is a good alternative to stop smoking without using replacement nicotine (Nicorette®, etc.)

Patients should be careful to create a healthy non-stressful environment.  Recovery in a smoke-free environment is extremely important as second-hand smoke has been shown to be as harmful as first-hand smoke to wound healing.

PaulHowardMD.com

Men & Plastic Surgery

Men pay for approximately 80% of the cosmetic surgery performed while becoming a patient only 20% of the time.  It is hard to know if this is indicative of the social taboo regarding men and cosmetic surgery or is it a result of the idea that men are much less stoic than women and are basically averse to the minimal discomfort involved.  Regardless of the cause, men are more frequently having plastic surgery and generally have the same reasons for having cosmetic improvement as our women patients:  improved self esteem, being competitive with younger people in the work place, and to appear more youthful and attractive to the opposite sex.

Men age somewhat differently than women and require surgeries that are tailored for their specific facial aging issues.  For instance, men are more likely to complain about their necks while women focus on the midface/cheek area.  Both men and women have upper and lower blepharoplasty but men rarely want the browlift procedure so as to not look like “Kenny Rogers.”   Kenny Rogers is a well known celebrity, singer, actor and country music star who was the unfortunate victim of an overdone browlift – forehead too tight, too smooth, too high, thus totally changing his appearance for the worse.  In addition to eyelid and neck rejuvenation men are likely to inquire about liposuction of the waist and abdomen area. Men desire a nice tight, jaw line and neck with a youthful profile, a sculpted waist and bright, open, uncluttered, youthful eyes.  Post-operatively, men tend to go back to work too quickly, tend to bruise worse than women, and are less likely to follow post-operative instructions.  Men and women both require a full dose of positive reinforcement throughout the healing process.  Early and often post-operative photos to document healing and cosmetic improvement are helpful during the early stages of healing where bruising and some swelling is to be anticipated.  Men are less likely to keep all of their post-operative appointments and tend to be more secretive regarding their surgery than women.  Men are uniformly less patient while healing but more appreciative of the good results and more youthful appearance over time.  Men are less likely to have researched the procedures they want and tend to be referred mostly by other patients and thus are less affected by marketing schemes than women.  Terminology is also important to men who shy away from the term “facelift” but respond well to being offered a “necklift.”  Even with their idiosyncrasies, men are generally some of our most appreciative patients.

Dr. Paul Howard

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A Primer on Liposuction

The development of liposuction about 30 years ago was driven by our patients who asked for a method to reduce body fat without the scars associated with the usual tummy tuck procedures.  Our primary focus is the safe removal of isolated pockets of fat to improve body contours.  While the goal (fat removal) has always been the same, the methods of anesthesia for liposuction have changed through the years making the procedure more “patient friendly,” yet achieving the same contour results.  Most of the technological advances are intended to make the fat removal easier and, even more importantly, an attempt is being made to tighten loose skin and improve the appearance of cellulite utilizing the latest surgical laser technology. Most plastic surgeons believe that the skin tightening effects have not been as impressive as the manufacturers claim.  Each manufacturer slightly alters the laser platform so their product can be claimed as “unique” while there is no discoverable clinical difference in the final result.  Laser assisted liposuction is marketed under any number of trademarked names including Smartlipo, Vaser, Slim Lipo, Cool Touch, etc.  The marketing department of the manufacturer uses the trade names to market these laser liposuction platforms directly to the patients.  The laser can be purchased by ANY practitioner, even those with no laser or surgical training.  Regardless of the laser manufacturer, the practitioner is told that the patient referrals will be generated through their web marketing and the practitioner is allowed to use the trademarked name (Smartlipo) in their practice marketing efforts.

This marketing strategy is similar in design to the pharmaceutical companies who advertise their drugs directly to the public and offer the names of certain physicians who prescribe their products.  All of these marketing schemes are evidently legal, but in the laser liposuction example, the machines are sold to any doctor with the money, training is offered but not required, marketing and patients are guaranteed without checking the doctor’s credentials.  The red elephant in the room is that laser liposuction is inherently more dangerous than standard tumescent liposuction techniques and in many instances is performed by non-plastic surgeons who are damaging their patients because of a lack of basic education and the need to market the trademarked product that they own rather than choosing the proper technique for each individual patient.

Many of these doctors ask you to ignore their training and credentials and emphasize their marketing skills.  In the final analysis, patient education is not advanced with unclear or even false advertising and many people have suffered as a result.

The MidFace Lift

Facial aging is complicated by genetics, environment, sun damage, smoking, and drinking.   There is not a single procedure that works for everyone, therefore it is important that individualized evaluation leads to an operation which is specific for that person.  The uniqueness of all faces as well as the patient’s desires may lead to a slightly different surgical approach for each individual.  Another way to say this is that the one-size-fits-all facelift has become antiquated.  To facilitate individualized care we prefer to look at each part of the face separately leading to a unique surgical treatment plan.

We divide the face into its component parts; forehead, eyes, midface, and neck with primary emphasis on the midface.  Midface aging is characterized by sagging of the facial soft tissues causing a deepening of the nasolabial folds, dark circles beneath the eyes, and the development of marionette lines from the corner of the mouth to the jaw line.  The jaw line becomes less defined as the sagging facial soft tissues drop below the mandible causing jaw line “bubble.”  In addition to the sagging soft tissues aging always involves a loss of volume and a loss skin elasticity.  It is the surgeon’s charge to address individual manifestations of aging for each component part of the face.  Elevating the soft tissues must be done and requires a specific vector or direction of elevation which may be unique for each face.  This maneuver defines the jaw line, improves the deep nasolabial folds, addresses the marionette lines, and elevates the lower eyelid skin.  This procedure is always required and must be performed accurately with minimal incisions.  Elevation of the cheek tissues is so important that it must be done under direct vision with the results being technique dependent.  The incisions are much less obvious than the old facelift scars.  While elevating the cheek and malar tissues some augmentation of the malar prominence (cheek bones) is achieved.  The need for additional volume can be affected by adding autogolous fat to the procedure.  As a rule of thumb, we rarely, if ever, remove fat from the midface but frequently add fat back to replace the soft tissues we lose over time.

The next issue to be addressed is the blending of the cheek elevation with the lower eyelids.  These procedures are typically done together; that is lower blepharoplasty and mid-face lift.  The elegance and effectiveness of the mid-face lift sets up the rejuvenation of the remaining parts of the face.

Read more about Dr. Paul Howard’s Howard Lift Facelifts