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.
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
Read more about top plastic surgeon Dr. Paul Howard.
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.
There are a number of techniques to smooth the forehead and elevate the brow. Practitioners always tout the technique they use as being the “best” but more likely the procedure some view as “the best” is primarily the operation they are more comfortable with. Surgeon’s comfort should not triumph patient results for browlift or any procedure where the results of the two procedures are different.
The antiquated browlift requires an incision in the forehead skin – the so-called “direct browlift.” In an attempt to hide the scar and elevate the brow without the hairline, surgeons flocked to the pre-hairline incision and many claim the very long incision is easy to camouflage and causes no problems. Common sense belies these claims and most surgeons have abandoned this procedure due to the scarring involved.
The last 10 years has seen the development of endoscopic techniques which minimize the scars by placing the two short incisions behind the hairline while allowing access to the three glabella muscles and the forehead muscles from beneath the skin. Elevating the brow must be accompanied by some sort of fixation to hold the forehead skin and brow in the raised position for at least 2 weeks. The brow elevation may relapse to its pre-operative position without fixation while the muscle surgery used to decrease glabellar rhytids (wrinkles) and sometimes forehead wrinkles is not fixation dependent. These rhytids are improved by effectively weakening the forehead and glabellar muscles that cause wrinkles.
Over the last 8 years or so we have developed a unique and quite elegant way to fix the brow and forehead in the raised position with bio-absorbable screws that dissolve after the golden 2 week period of required fixation. The polymer chosen must be strong enough to withstand screw placement in bone, must maintain its bio-mechanical properties for at least 2 weeks and must eventually be cleared from the body. The material chosen is a co-polymer of polylactic acid.
The “Modern Browlift” is a well researched procedure with at least 8 years of documented results, short incisions, no hair loss, no prolonged numbness in the scalp and minimal to no elevation of the hairline.
Read more about brow lift and view brow lift before and after photos.
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Botox and Restylane have become the mantra for those seeking facial rejuvenation without the inconvenience of having a “surgical procedure.” While these off-the-shelf products are enticing, they are expensive, temporary, and can be painful to inject, especially in the lips. For more Plastic Surgeons, these artificial fillers (Restylane, Juvederm, Strattice) are appropriate only for temporary improvements where there are time constraints and the need to be in public within a couple of days. Searching for the perfect facial filler had been elusive until recently. The emergence of fat from your own body (autogenous) has paralleled the refinements in fat harvesting and injection techniques that have elevated the “take” of fat injections to the 80-90% range. Coupled with improvements in local anesthesia and anesthetic agents make the overall experience with the new fat injection techniques less painful and more likely to give a permanent, elegant improvement in facial contours and rhytids (wrinkles). Many non-surgical practitioners complain of the donor site for obtaining the fat. While we must respect the donor site, offering the patient an improvement in body contour by harvesting fat for injection offers the patient the benefits of a liposuction (method of harvesting fat) procedure and cosmetic improvement of the donor site as well as the areas of the face injected with fat.
What does the future hold for facial fillers? Ongoing research using stem cell and growth factor technology may lead to even further improvements in fat injection techniques while artificial filler research tries to make their artificial substances last longer and the cost with longer lasting substances is naturally higher and will continue to increase over time.
Fat injection techniques have proven to be a vast improvement over foreign-body injections for facial rejuvenation. Fat is permanent, soft, cannot be rejected by the body, natural, and requires only small (3-4mm) stab wounds for injection. The patient can request which body area is preferred as a liposuction donor site obtaining body contour improvement at no additional charge. The well informed patient will usually choose the elegance of fat injection over the expediency of foreign material injected in the face.
As an extension of fat technology, we have begun fat injections in the back of hands for hand rejuvenation. The injected fat decreases the appearance of prominent veins, knuckles, and tendons that become more pronounced as we age. No one should let their hand reveal their age when we have the procedures to reduce the signs of the aging hand.
Read more about top fat grafting surgeon Dr. Paul Howard and view fat injection before and after photos.
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 facelift. 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