Archive for June, 2011

Facelift, fat injection combination provides optimal results

Monday, June 6th, 2011

almost a century, plastic surgeons have believed that lifting and tightening could fix all of the problems associated with the aging face. That turned out to be a tall tale, according to San Francisco plastic surgeon Timothy Marten, M.D.

“Now we know that we cannot lift our way out of all of the problems seen on the aging face,” says Dr. Marten, who was one of the first plastic surgeons to champion the use of facial fat injections in facelift patients more than 15 years ago. “Experience has shown that patients with significant facial atrophy and age-related hollowing from facial fat loss will generally achieve suboptimal improvement from surgical lifts alone.”

Surgeons now recognize that the face ages in three ways: The surface of the skin ages, facial features sag and skin becomes loose, and the face undergoes a process of atrophy, and shrinks and becomes hollow.

A 75-year-old patient before (left) and one year and seven months after facelift and fat injections. A total of 90 cc of fat was injected. (Photos credit: Timothy Marten, M.D.)

“Traditional facelifts just treated the laxity and looseness; they didn’t address atrophy,” Dr. Marten says. “Fat grafting is really our first good tool to address that shrinkage.”

Dr. Marten says that while a surgeon can insert a cheek implant or use nonautologous fillers to restore cheek volume and make the face look fuller, these will typically not create the soft, natural, feminine, healthy appearance that fat does.

Ultimately, Dr. Marten says, neither facelifts nor fat injections alone produce results that are as satisfactory as those attained with a combination of the two.

TURNING BACK TIME Despite the fact that facial fat injections still have critics whose primary objection to the technique is its purported inconsistent “take,” Dr. Marten says there is an expanding body of evidence that the technique produces a predicable and sustained improvement that has resulted in the procedure becoming increasingly attractive to surgeons as well as patients.

“It has caught fire. Just a few years ago, surgeons didn’t believe in this, and now it has a major following,” Dr. Marten says. “A decade ago, if I told a patient who wanted a facelift that she needed some fat in her face, she didn’t really understand that. She would say, ‘Doctor, I’m already too fat. I don’t want to look fatter.’ Gradually, patients began to learn about atrophy as a part of the aging process. They read about it in magazines, and they experienced the improvement they could get with artificial injectable fillers.”

Before patients understood and accepted the use of fat injections as a means of obtaining a more youthful appearance, Dr. Marten says he would perform the facelift first and evaluate the patient later to determine whether they could benefit from and agree to a follow-up treatment with fat injections. Once patients came to understand the treatment and its benefits, however, Dr. Marten began receiving requests to have the facelift and fat injections done together to minimize downtime.

“When patients started letting me do that, I was stunned at how much better the facelifts were,” Dr. Marten says. This, he says, may be due in part to a not-yet-clearly defined “stem-cell effect” that results in fat injections actually inducing improvement in facial tissue quality. “Now people seek me out because I do both procedures at once,” he says.

Research competition, market needs before purchasing aesthetic technologies

Monday, June 6th, 2011

Walnut Creek, Calif. — Before investing in aesthetic devices, physicians need to do their homework and carefully weigh the pros and cons of each device and attend lectures focused on various aesthetic devices and technologies. This approach may help them ultimately choose an aesthetic device that is right for them and their patients.

Dr. Lee

“Many physicians may find it very difficult to keep up with the fast-paced aesthetic market in terms of the new and evolving technologies available. Many different companies offer very similar devices with various catchy names,” says Min-Wei Christine Lee, M.D., M.P.H., dermatologic surgeon and director, East Bay Laser & Skin Care Center, Walnut Creek, Calif. “However, oftentimes these devices can achieve similar aesthetic outcomes, adding frustration to the would-be investor in terms of which device to choose.”

Many of the competing aesthetic companies often come out with similar products that may not even be new in terms of the technology used — only their version of other longer-standing devices and technologies is what’s novel. Currently, there are more than 20 companies that manufacture fractional resurfacing lasers, but according to Dr. Lee, not all of these devices perform in the same ways or produce the same level of results.

It can be hard for doctors to know what new devices can really do and ascertain whether a device is actually new simply by reading company literature.

“The problem is that there is no consumer report for laser industry for doctors,” Dr. Lee says. “Therefore, I and physicians like myself will evaluate these devices and try to sift through the hype and marketing pitches to see what these devices can actually do and achieve what they claim.”

Aesthetics defined

According to Dr. Lee, the different categories of aesthetics must first be defined, and here, it is important that physicians know which category a given device falls under and the clinical endpoints one can achieve.

UltraShape (UltraShape), for example, is a body-contouring device and one of the only modalities that actually melts fat. This is different from endermology devices such as the Vela-Smooth and VelaShape (Syneron), which do not melt fat but are used for cellulite and skin tightening.

For more in-depth information on aesthetic devices, physicians should not only ask their colleagues for appropriate guidance, but also attend meetings and lectures dedicated to offering more insight on the different capabilities of aesthetic devices. According to Dr. Lee, simply conferring with individual companies may not always be the best approach, as each company seeks to promote its device in the best light.

When shopping for an aesthetic device, Dr. Lee says it is imperative that each company comes into the office to give a demonstration of a particular device. This way, the physician can compare the specifics of each device first-hand and see what each can achieve in their aesthetic patients.

It’s also important that the physician perform an extensive literature search and read the white papers published on a device of interest. Researching each individual company is also very important when considering an investment in an expensive aesthetic device.

“There can be a big difference between newer companies and longer-established companies in terms of the service one may receive should the device fail or require maintenance sometime after its purchase. Also, physicians should investigate whether a company was bought out from another, as this may be a cause for confusion in terms of the responsibility of servicing a device in the future,” Dr. Lee says.

Buyer beware

Physicians need to research and understand market needs in their area of practice, know who the competition is and determine whether other physicians in their area are offering similar treatments using similar devices.

Dr. Lee says many physicians will often invest in an aesthetic device without doing enough research and then wonder when the device does not return the expected and even promised investment. On average, physicians should spend at least six months researching different companies and devices before arriving at their device of choice.

“An aesthetic device can be an extremely expensive office investment. Therefore, it behooves doctors to take the appropriate precautions and find transparency among the different devices available, so that the decisions made are solid,” Dr. Lee says.

Lasers, shaving tips address pseudofolliculitis barbae

Monday, June 6th, 2011

Minneapolis — Charles E. Crutchfield III, M.D., has had a lifelong battle with pseudofolliculitis barbae.

“When I became a dermatologist, it’s one of the things I focused on,” he says.

Razor bumps tend to haunt men — especially those who shave their beards daily — in the neck area.

Dr. Crutchfield, who practices in Eagan, Minn., and is clinical associate professor of dermatology, University of Minnesota Medical School, says athletes who shave or wax their chests also seek treatment for the unsightly bumps and pustules that result from hair removal. Pseudofolliculitis barbae can occur anywhere hair is temporarily removed, whether by shaving, plucking, waxing or chemical depilatory.


There are two causes of pseudofolliculitis barbae, according to Dr. Crutchfield: transfollicular penetration and extrafollicular penetration.

“Either curly hair or hair that is oriented to an oblique angle has a higher propensity to form razor bumps,” he says. “If you have curly hair under the skin’s surface, it grows straight into the sidewall. That’s a process called transfollicular penetration.

“You can also have hair that’s really curly, grows out of the hair follicle and, then, curls and pokes back in (extrafollicular). The problem is that hair is made up of the protein keratin, which is one of the most inflammatory substances to the skin. You can get pustules and secondary infections, and it’s very painful.”

Treating the problem

A male patient suffering from pseudofolliculitis barbae on the chest (top), occurring after shaving, and a male patient suffering from the condition on the face and chin area. (PHOTOS: CHARLES E. CRUTCHFIELD III, M.D.)

One of the most important aspects of treatment, according to Dr. Crutchfield, is education.

“I think once you have the patient educated and onboard with the program, compliance is very high and results are much better,” he says.

Treatment should focus on getting rid of the offending agent, hair. And the best tool to that end is the laser, Dr. Crutchfield says.

“The laser works because you remove the offending and causative agent and everything clears. The real trick, though, is you have to differentiate between the melanin, or melanosomes, in skin and the melanosomes in hair,” he says. “If you don’t, it’s very easy to burn the skin while trying to get rid of the hair.”

Dermatologist can avoid burning the skin by spreading out the laser’s pulse duration. This is especially important when using laser hair removal on patients who have darker skin types.

“The laser is a good treatment for pseudofolliculitis barbae, but for dermatologists who are not familiar or skilled with lasers for treating skin of color, it’s a real danger zone. You could have terrible burns and scars,” Dr. Crutchfield says.

Even experienced dermatologists should always start with an inconspicuous test site, behind the ear, for example. Dr. Crutchfield’s treatment regimen for pseudofolliculitis barbae generally includes using the laser once a month for four to six months; then, two to three times annually, to maintain a hair-free state.

“A lot of guys worry that they’ll never be able to grow a beard. I point out that they don’t grow a beard on the neck (where razor bumps often occur) and, even if you use the laser on their faces, if we stop treatment, hair will grow back within a year,” he says.

Surgeons compare traditional with less invasive facelifting techniques

Monday, June 6th, 2011

Today, there are varying facelifting procedures and techniques used, all of which have evolved since their dawn in aesthetic surgery more than a century ago. These can range from more invasive traditional facelifting techniques to less invasive short-scar techniques, and though there is no consensus as to which technique is the best approach, the keys to a successful procedure remain careful patient selection, as well as techniques that work for a particular surgeon.

Dr. Niamtu

“There are many different lifting techniques used to improve lower face and neck aging. I believe that the best facelift technique is the one that works well in the hands of the specific surgeon, provides good results with low complications, and, most importantly, happy patients,” says Joe Niamtu III, D.M.D., a board-certified oral and maxillofacial surgeon with a private practice limited to cosmetic facial surgery in Richmond, Va.

Aesthetic surgeons remain at odds as to which facelifting technique is best and which can achieve superior aesthetic outcomes. Though specific techniques may vary, a more invasive traditional facelift procedure will typically involve pre- and postauricular incisions, platysmaplasty and SMAS treatment.

THE SHORT-SCAR FACELIFT Minimally invasive, so-called “short-scar,” techniques may consist of only a preauricular incision that terminates at the mastoid region with no posterior auricular and scalp incision. These lifts are also usually performed without midline platysmaplasty and frequently utilize variations of purse-string sutures. Here, an accurate assessment of the degree of lifting needed in an individual patient may ultimately direct the surgeon in choosing the appropriate technique.

“I personally do not favor minimally invasive facelifts,” Dr. Niamtu says. “It is not that I never do a short-scar facelift, but my parameters are only for young individuals with minimal aging, meaning those patients with early jowling and almost minimal neck laxity. However, even younger patients may require a larger, more comprehensive lift.”

During short-scar facelift surgery, Dr. Niamtu says he may even switch to a traditional lift and perform a conventional pre- and postauricular procedure.

“I have changed to the larger lift in mid-surgery numerous times and have been glad I did, as even patients that did not exhibit significant neck laxity actually had impressive skin excess as evidenced when the posterior auricular incision was completed,” Dr. Niamtu says.

The face of each individual patient may age in a different way. The spectrum of an aging face can range from a mere sagging of the tissues to more deflation where the fat and sub-tissues melt away.

CUSTOMIZING COUNTS While a short-scar facelift is in essence less invasive, proponents of this technique often choose this approach because they believe it can better address the individual aspects of the aging face.

Radiofrequency for noninvasive body contouring turns up the heat for results

Monday, June 6th, 2011

Yokneam Illit, Israel — Among the various aesthetic device technologies used to treat skin laxity, cellulite and achieve circumference reduction, radiofrequency (RF) appears to be one of the most efficacious energy sources currently available.

The VelaShape II (Syneron) uses high-powered bipolar RF technology that can achieve these cosmetic goals. Here, a higher energy output appears to be the key to better treatment outcomes.

The VelaShape II device combines four different technologies including RF, IR (infrared), vacuum and mechanical tissue manipulation using massage rollers. According to Ruthie Amir, M.D., the combination of these technologies is unique to aesthetic devices, and their combination along with the higher RF output result in neocollagenesis and an increase in circulation and lymphatic drainage in the targeted area, she says.

A 43-year-old patient before (left) and after five treatments with VelaShape II. (Photos: Ruthie Amir, M.D.)

“The technology actually reduces the volume of adipose tissue through more efficient heating, but also allows you to stretch the fibrous septae and increase the connective tissue, resulting in a skin tightening. The body contouring itself is actually the result of both cellulite and skin laxity improvement because while you are effecting a dermal remodeling, you are also reducing the volume of adipose cells,” Dr. Amir says.

As all other aesthetic device manufacturers, Syneron and its technologies have undergone changes. Operating at 25 watts, the original VelaSmooth is approved by the Food and Drug Administration (FDA) for the improvement of cellulite. Operating at 50 watts, the VelaShape is FDA-approved for circumference reduction (such as around the thighs) but is used off-label for the abdomen, submental area and arms.

However, further raising the RF energy output in the VelaShape II to 65 watts appears to be the most effective approach in achieving the best aesthetic outcomes such as for fat and circumference reduction, Dr. Amir says.

“Since the reduction in adipose tissue volume is temperature dependent, and because the bipolar RF power seems to be the major contributor for tissue heating, we found that increasing the RF power up to 65 watts can significantly enhance treatment efficiency,” says Dr. Amir, who is director of clinical research, Syneron Medical, Yokneam Illit, Israel.