What You Need to Know About Stem Cells

plastic surgery dr paul howardResearchers and even medical students have known about stem cells for decades. They are the multi-potential cells in embryos that can become any cell in the body; brain, muscle, heart, etc. Years later an adult version of the stem cell was identified, not quite as basic as the embryonic stem cells, but able to become many other types of cells.

Once identified, we could grow them outside the body and stimulate them to become more advanced cells such as those composing cartilage, muscle, bone and even heart tissue.

More recently it was discovered that the bodies’ main repository of adult stem cells is in our fat (adipose) tissue. These adult stem cells can also be harvested from the bone marrow in much smaller quantities and with significantly greater pain.

This discovery was great for plastic surgeons as we are the primary surgeons who harvest fat for cosmetic reasons by suction-assisted lipectomy (liposuction). With this technique, liters of fat can be harvested at one time to be processed to release the adult adipose-derived stem cells from the fat.

There are methods that currently exist to multiply the number of stem cells from thousands to hundreds of millions, but this must be done in a laboratory and is controlled by the FDA.

These stem cells once multiplied and stimulated in the lab can become a medical treatment by replacing injured or worn out cells in the heart, joints and maybe even other organs such as the liver and kidney.

For the present, we can use a person’s own stem cells (not Aunt Thelma’s) to replace soft tissues if injured using your very own fat cells which already are charged with stem cells. Fat grafting to the face as part of a facial rejuvenation procedure has been around a decade or so in my practice. The addition of extra stem cells to the facial fat grafting we do with facelifts gives a remarkable improvement in skin tone and texture due to the rejuvenating qualities of stem cells.

The limit to stem cells is that they only work for you because you and your stem cells have the same DNA. Therefore, one can harvest and freeze your fat with your stem cells for future use but no one can “borrow” your stem cells.

Another limitation to stem cell medicine is that you cannot rub stem cells on your skin like sun block. The stem cells only work inside your body where they can interact with other cells. It naturally follows that if you cannot use Aunt Thelma’s stem cells, stem cells from other DNA sources like plants and trees have no effect on humans but are probably great for other plants and trees.

Just the words “stem cells” have become a cultural phenomenon. I’ve read recently where stem cells can reconstruct a breast and even make a small breast larger. Of course, none of that is true but fat grafting, with or without stem cells, is commonly used to reconstruct soft tissue defects of the face, breast and buttocks. The stem cells are there just to improve the amount of fat that survives with grafting and provide no volume on their own.

Advertisers who use the words “stem cells” to describe their latest, greatest fountain of youth product are taking advantage of the hyperbole of public perception which is totally different from the public facts regarding stem cells.

Aging & Fat Grafting for Facial Wrinkles

fat-grafting-for-wrinkles-and-lips

It was about ten years ago that I first met Dr. Sidney Coleman. He had just published a text called Structural Fat Grafting and was showing his results which were superior to others I had seen. I had been studying fat grafting since 1991 when I did my first case. I immediately saw the genius behind his methods backed up by beautiful photographic documentation; I purchased his book, had him sign it, bought all of the recommended equipment and was on my way.

It was about this time that it became obvious that adipose tissue was special in ways we had never figured. Our own fat turns out to be the bodies’ primary depository of mesenchymal stem cells, rather than from bone marrow, explaining adipose tissue’s ability to rejuvenate our faces when injected into the face.

After a number of years and hundreds of cases I began to notice a pattern in our results. It became clear that our older (>60 years old) patients seemed to have much less than the 80-90% graft survival that we had become accustomed to. Others had noticed the same phenomenon (PRS 2014 August; 134(z), 227-232) but placed the cut-off at 45 years of age.

Empirically we studied the gross appearance of the suctioned and centrifuged fat noticing there tended to be a demarcation within the fat layer itself. Approximately 30-50% of the fat looked somehow different, less “cellular or robust” if you will. The location of the donor fat areas also seemed to appear different with the entire specimen seeming more cellular. Donor locations have been studied and our observations confirm that flank and upper buttock fat seem more vital than abdominal or thigh fat. For younger patients the opposite seems true.

We also believe, as do others, that stem cells from older individuals seem to lose some of their “potency” in regards to being multi-potential mesenchymal cells. The rejuvenating ability of adipose derived stem cells may age and become less potent over the lifetime of the organism. This observation has practical implications as many people are choosing to donate their adipose stem cells for possible future use as a treatment for certain diseases and possibly even cancer. It makes sense to donate one’s stem cells as early- as young- as possible to have maximum effectiveness. The cryopreservation of adipose tissue is now a growing industry requiring only standard liposuction techniques to obtain the fat which is cryopreserved indefinitely for a small yearly storage fee and a one time set-up fee by the storage facility (not including in-office surgical removal).

The Hidden Risks of Homeopathic and Herbal Supplements on Plastic Surgery by Dr. Paul Howard

The use of complimentary or alternative medicines such as those found in herbal or homeopathic preparations has increased from 20% of our patient population to more than 60% of our patients.  The fascination of herbals, teas, and homeopathic products exists because people believe these medicines to be “natural” and therefore perceived to be “safe.”  Only recently have these products been scrutinized carefully by the medical community to determine how safe they actually are.  In preparing for plastic surgery, safety issues are being addressed due to the fact that there are an increasing number of reports describing bleeding

www.paulhowardmd.com Dr Paul Howard Board Certified Plastic Surgeon Birmingham Alabama

complications due to herbal remedies.  We now know the chemistry of most herbals so we can now identify the substances within each herbal preparation that are likely to cause bleeding problems.  To date, the only documented sequelae of herbals that effects plastic surgery is the increased risk of peri-operative and post-operative bleeding which usually manifests as more swelling and bruising than one would normally see.  In more severe cases, these homeopathic medications may even cause significant bleeding and hematomas.

A partial list of common herbal supplements that are known to cause bleeding problems is provided:

Chinese Agrimony

Chinese Peony

Feverfew

Fritillaria Bulbs

Dan Shen

Devil’s Claw

Garlic

Geum Japonicum

Ginger

Ginkgo

Ginseng

Licorice

Oil of Wintergreen

Poncitrin

Red Chili Pepper

Saw Palmetto

Other dietary supplements known to effect healing or cause bleeding:

Chondroitin & Glucosamine

Fish Oil

Vitamin E

As a general rule of thumb, any herbal supplement which is known to cause or have any pharmaceutical activity should be discontinued 2 weeks prior to a general anesthetic or outpatient surgery under local or sedation.  Since many herbal or homeopathic formulations contain numerous plant extracts, it is best to stop all homeopathic remedies including herbal teas a full 2 weeks before surgery.  Patients may renew taking their supplements once uncomplicated healing has progressed for at least one week post-operatively.  It is probably in the patient’s best interest to assume all homeopathic supplements have the potential to effect healing and should be discontinued 2 weeks prior to surgery.

Dr. Paul S. Howard, Board Certified Plastic Surgeon Birmingham, Alabama

Preparing for Plastic Surgery by Dr. Paul S. Howard

On the Training of Horses, Linebackers, Pilots and Plastic Surgeons by Dr. Paul Howard

The critical reader may come to the opinion quickly that I am only a Plastic Surgeon and probably know little about training horses or football players.  While this is essentially true, I don’t believe it disqualifies me to comment on other fields of endeavor that require many of the same complex skills that are inherit to the plastic surgeon.

The training of surgeons is unlike any other field of endeavor.  One can read massive amounts of material, study diligently for four years of medical school, memorize the indications for an operation, actually study the pertinent anatomy and how to perform an operation and yet know virtually nothing without taking the final exam by incising the patient’s skin and performing an actual procedure where the stakes are as high as they can be.  This discipline is entirely different than any other medical specialty as the requisite study of disease is not the endpoint of training, it is the ante that allows one in the real game which is the application of knowledge to perform a mechanical skill (surgery) which is basically unnatural and requires skills that are not genetic but entirely learned.  Since surgery is learned behavior, there is no way to be graded except by the subjective appraisal of a competent surgeon.  As time evolves and the surgeon becomes independently proficient, the grading of results requires continuous, honest self-assessment of one’s results.  The built-in weakness of the surgical training paradigm is the quality of the “on-the-job” training.  This is the primary reason why surgical, and more specifically, Plastic Surgical training, can lead to widely diffuse results in the quality of the surgeon.  These facts became self-evident to me and led me to seek the most talented and well known surgeons of my era of medicine.  Since we learn surgery by watching and imitating others, it makes perfect sense to seek the best to emulate.  This quest is how I came to know John Kirklin, M.D, Ralph Millard, M.D, and Paul Tessier, M.D.  For those who are unfamiliar with the names, these are the best of the best in surgery.

Let me begin by admitting that I am a hero worshiper.  It happens that I have a small but unique set of personal heroes that I have accumulated over a lifetime.  These men have excelled in their respective fields which happen to include the thoroughbred racing business, the aircraft industry, the National Football League, and the field of plastic surgery.

Those who only know horse racing by watching the Kentucky Derby the first Saturday in May every year are not privy to the complexities of thoroughbred breeding, training, and racing.  You may notice the atmosphere in Louisville, KY at Churchill Downs includes beautiful hats and the unfettered consumption of Kentucky bourbon in the form of the ever present Mint Julep.  This pageantry belies the complexity of horse genetics and gene pools as well as the training of these extremely fragile animals.  Additionally, they are trained to race beginning as a two year old animal.  The three year olds that race the Derby are still adolescent animals and behave in many ways the same as our teenaged children.  Yet, the results of their early races can lead to a multi-million dollar horse, both as a racer and later as an addition to the thoroughbred gene pool.

Dr. Ruel Cowles is a veterinary physician/surgeon whose practice and life is dedicated to the healthcare of these majestic animals.  One of my mentors, John Kirklin, MD, was an established horseman and was convinced that race horses were essentially untrained whereas gaited, dressage, and jumpers were the only horses truly trained.  Dr. Kirklin also opined that a good jumper must be at least 10 years of age.  Racing 3 year-olds in packs of 10-20 over a mile long course against the best 3 year-olds in the world would probably be a daunting task for a 10 year-old thoroughbred.   It’s like training a 15 year-old to pitch in the major leagues – you can never be sure exactly what you will get.

Dr. Cowles embodies the best of clinical veterinary medicine as well as the intellect to excel as a horse breeder.  Dr. Ruel Cowles is one of my heroes.

I have more than a passing interest in the sport of American Football.  I was, as many of my colleagues were, a high school football player.  I managed to keep my NFL dreams alive through my first year of college where the physical and mental rigors of the game caused me to turn in my shoulder pads to pursue academics full-time.  As such I developed an almost unhealthy respect for those players who made it to the NFL.  I particularly liked linebackers as that was my chosen position.  The day I met Kevin Greene, at the time playing for the LA Rams, I realized who I would have become if I had the fortitude to continue playing.  Kevin was a walk-on at Auburn University in the early 1980’s under Coach Pat Dye.  He showed early on his pass rushing prowess, but only a few NFL scouts agreed and was chosen by LA in the sixth round of the draft. From his first training camp, Kevin’s coaches and teammates understood that going easy on the veterans was not part of his game.  All Pro offensive tackle Jackie Slater found out Kevin was a “maniac” on every play, pre-season or not.  Kevin was soon inserted in the line-up for the Rams and there he stayed.  After leaving the Rams for Pittsburgh, he truly found his identity, grew his hair to his shoulders, married a beautiful Alabama girl, and became a favorite in Pittsburgh because of his aggressive and relentless style of play.  He was known for sacking the quarterback but in fact was a complete linebacker in the 3-4 scheme.  I cannot remember a single time that a running-back or receiver managed to even fall forward after he got his hands on them.  I was privileged to be Kevin’s friend through the entirety of his 16 year NFL career including multiple Pro Bowls and defensive linebacker awards.  His intensity and dedication to his craft were unparalleled.   Ten years after his retirement from the NFL, he still holds the career sack total among linebackers.  Today, Kevin is imparting his knowledge to younger players as the outside linebacker coach for the Green Bay Packers.  Kevin is also one of my heroes.

I’ve known but a few fighter pilots and one submariner personally.  There are a few common traits these people have that separate them from the rest of us.  First, they all have very acute and agile minds that can assimilate knowledge quickly and apply it so that they are constantly evaluating their performance and improving by self-evaluating and reflection.  These traits are similar to those needed for plastic surgeons with the added immediacy of going Mach II or being thousands of feet under water.

As a first-year resident under Dr. Ralph Millard, I became acquainted with Dr. Gregory Lovaas senior resident under Millard.  Greg was like a xenon light in a room full of candles.  He shown brightly and was a wonderful teacher to me.  Knowing Greg as I did it was not easy to imagine the government putting him in a single seat F-104 fighter with nuclear weapons.  As I learned more about Greg, I realized he was the perfect personality for such a dangerous, in-your-face profession.  Greg, as most intelligent people do, had a wondrous sense of humor that may or may not have served him well over the years. My most vivid memory of Greg is the fighter pilot/Plastic Surgeon maniac.  He taught me the fighter pilot credo – “sometimes wrong, never in doubt.”  Greg Lovaas is one of my heroes.

A young boy and his twin brother grew up fatherless during the Great Depression in rural Griffin, Georgia.  Times were tough for everyone and the twins did the best they could for themselves and their family.  As they became teenagers, sports helped fill their days.  It was an accident playing baseball that knocked out the two front teeth on one of the boys causing a speech impediment and a lasting impression as he did not have enough money to receive the necessary dental care.  The twins with no prospects on the horizon lied about their age and enlisted in the Army and the Navy.  The story goes that the twins couldn’t understand why the new recruits were homesick and even cried at night while the twins were elevated from their Hell to three square meals a day and they weren’t worked very hard.  The addition of free dental care made WWII a life altering experience, all for the good.

New pair of shoes, one suit, two new teeth and training in electronics were enough to start a new life several years after the war with a new wife and further training in repair of the new-fangled American commodity – the television set.  The younger of the twins was desperately trying to live the American Dream.  Fixing the notoriously unreliable TVs and their vacuum tubes was a decent job.  Utilizing his military training and hands-on electronics experience, twin got a job with Lockheed Aircraft in Marietta, Georgia where he taught electronics to the new hires needed to build the C-130 “Hercules” and the new super airliner – the L-1011.  The younger twin learned he had a knack for teaching and especially training people to do a job.  He eventually parlayed this experience into industrial training programs for four Southern states eventually having a training facility posthumously named after him in Montgomery, Alabama.  Twin number two, and one of my heroes, was George L. Howard, my father.

The training of plastic surgeon is a long grueling process due to massive amounts of material to learn, but more importantly the aptitude, mental acuity, and complex decision making necessary.  Most students of plastic surgery realize that the training is so long (± 6 years) because the depth of knowledge necessary is vast and by necessity practicing plastic surgery requires a malleable mind to attack each challenge with freshness, intensity, and thoughtfulness. These attributes are not something one can read about, but can only be obtained by acquiring the knowledge from others who already have it.  This is why it is so important to ask the credentials of a plastic surgeon so one can surmise the quality of his/her education in plastic surgery.  In plastic surgery, it makes perfect sense that truly the best plastic surgeons are the best teachers.  My final heroes are two of my plastic surgery mentors that encompass the best that our field has ever created.  D. Ralph Millard, Jr., M.D., and Paul Tessier, M.D. are also my heroes.

Recent history has taught us the penalty to be paid by the consumer of plastic surgery who is swayed by the exquisite marketing of doctors who believe for financial reasons that the least amount of education in the intricacies of plastic surgery is somehow better than the full training program that has been in place for 30 years.  There is no other example of attenuated training in any of the surgical specialties.  Neurosurgeons are required to train in all aspects of neurosurgery and even take a year of basic neurology training even though few neurosurgeons practice all of the aspects of the specialty.  This is mainly because for the last 100 years it is clearly shown that almost all specialists benefit from a wide and diverse basis of knowledge leading to calmness under pressure and the ability to elicit a laser-focus required of the expert.  This is true for training many kinds of endeavors and one will never find a short-cut to the training of the best race horses, NFL linebackers nor in the making of aircraft or the training of plastic surgeons.  Hippocrates said it best in his aphorism “Life is short, and the art is long; opportunity fleeting; experience perilous, and decision difficult.”  The first time I heard this warning was from the great cardiac surgeon John Kirklin, M.D. in his famous surgical “blue-book” to help train young cardiovascular surgeons.

To learn more about Dr. Paul Howard, please visit his web sites:

PaulHowardMDcom

TheHowardLift.com

Fibroblasts vs. Stem Cells by Dr. Paul Howard

The TV news media is reporting the latest “break-through” in cosmetic medicine science.  Evidently for a mere $4,000 one can take a punch biopsy of a patient’s skin, send it to a lab where fibroblasts are isolated, cultured and expanded.  This results in millions of fibroblasts which are then re-injected into the face to rejuvenate the tissues as fibroblasts are known to synthesize the protein collagen which is lost in the aging face.  This clearly is a break-through in cell biology albeit an expensive one and not a popular alternative since it doesn’t last longer than 6 months.

A different technology has been available for several years and achieves pretty much the same thing at a fraction of the cost, and it lasts forever.  Adipose derived stem cells are isolated from liposuction aspirate and then re-introduced into the areas requiring rejuvenation.  The stem cells are more basic precursor cells to fibroblasts thus are thought to transform into fibroblasts as well as other cell types that increase vascularity and provide many of the trophic growth factors that help rejuvenate skin.  Depending on their environment, stem cells can be encouraged to form cartilage, even re-create osteoblasts that form bones.  Therefore, stem cells have been used for a wide variety of clinical problems including skin rejuvenation, joint cartilage re-growth and healing, wound healing and even re-growth of cardiac muscle tissue.

All of these new technologies whether or not they are “FDA approved” need to be evaluated through the prism of overall scientific advances.  It seems that the imprimatur of the FDA allows the science to be exploited for marketing gain by the few.  Regardless, FDA involvement with these new scientific advances has not been well defined and tends to allow for marketing adulteration of the product  in question often misleading the consumer regarding other available options

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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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‘s 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:

PaulHowardMD.com