We’ve had doubts for a long time about the effectiveness of thread-lifts for revitalizing the face. For those who don’t know, this procedure involves a bunch of barbed sutures or threads that are placed under the skin under local anesthesia to lift sagging brows, cheeks, and necks.

That just doesn’t make sense to us. You can’t expect a thread to do what a real lift should without pulling through the tissues over time. More involved lifts work because the sagging tissues are widely lifted away from underlying tissues and allowed to reheal in a new desirable position. Thread-lifts aren’t even anywhere near the same ballpark. The threads can’t support the weight of the tissues and when they break and fragment, a whole host of problems can arise.

It’s one thing for guys who don’t like the idea and who’ve never used them to trash these threads. But, when docs who embraced the technique start raining on the parade, that’s a reason to take notice. In the latest issue of Archives of Facial Plastic Surgery, a report on thread-lifts by an experienced surgeon indicated that a whopping 30 out of 75 patients treated experienced a complication. In 14 patients, the thread was extruding, meaning it was popping out of the skin! They all required procedures to repair or remove the thread. Three patients needed threads removed for visible puckering or dimpling of the skin. Another 17 patients on top of that were unhappy with the result and had to undergo repeated or alternate procedures to achieve the change they were hoping for. Even in the patients who didn’t have a problem, the surgeon wasn’t impressed with the longevity of the results and has stopped offering the procedure.

Sounds like he’s not the only one. Recently, at least 1 manufacturer has removed their thread product from the North American Market. Are we finally hearing the death knell of this overhyped procedure? We think so. It’s about time plastic surgeons got back to procedures that work, even if their names aren’t on them…  

With the growing trend toward more permanent results, we are surprised that more than 6 months after receiving FDA approval, Glabella Furrow Relaxation(GFX), or “No-Tox”, has received little hype.

The minimally invasive procedure uses radiofrequency thermal energy to “shock” the nerves that allow you to frown (and only those nerves, avoiding the all-over frozen look that many women are scared of when considering Botox). The results appear to last at least 2 years, and essentially replace those painful Botox shots between the eyes.  Of course that doesn’t mean no more Botox because the procedure is only for the frown lines and does not replace Botox in other areas, such as around the eyes.

GFX sounds like an ideal alternative for those who get Botox routinely or those too scared of being injected with a toxin. There are, however, two drawbacks:

1. Only two doctors in the entire United States are performing the procedure right now, and…

2. For the $2000-3000 price tag, you may be able to just get a brow lift.

Happy Fourth of July!!!

We don’t write that often about larger political issues as they relate to Medicine. In honor of American Independence Day, we thought we’d say something positive about America. I want to thank Dr. Rob Oliver for bringing my attention to an article from the Investor’s Business Daily about the awful state of Canada’s health care system. Canada’s socialized health care is often compared to its counterpart in the US, usually by someone who would like to see the same sort of system here. Take the movie Sicko, for example, which held up Canada’s system as the shining beacon for us all to look towards for inspiration.

The article quoted one of the father’s of the Canadian system talking about its ruinous state and advocating for some privatization. The article mistakenly referred to Claude Castonguay as the architect of Canada’s socialized medicare when, in fact, this distinction belongs to Tommy Douglas who, while Premier of Saskatchewan in the early 1960’s, instituted a number of government interventions into the corporate and medical world. These changes have influenced the self-perception of Canadians until this day, and many do still see Canada as a kinder, gentler nation for it. To give you an idea of how much Canadians have thought of these events, they recently voted Tommy Douglas as ”The Greatest Canadian” of all time in a nationally-televised contest.

Having lived and worked in both systems, I’ve had a unique opportunity to see both in action. The US system’s treatment of the underinsured is without a doubt less than ideal, with most having poor access to preventive care and using the ER as a walk-in clinic. I was amazed though, when I was training in New York, that even patients with Medicaid could walk-in same-day and see a specialist without a referral. That kind of thing doesn’t EVER happen in Canada. Wait lists to see a specialist can range from weeks to months. If you don’t have a family doctor to refer you, you might be out of luck because they’re hard to find these days. And access to highly specialized testing, treatments and surgery is far slower than it is here.

In Canada, the system is far more equal for all…not completely, mind you. A whole underground network has evolved where favors and influence can move someone up the list, known as ‘jumping the queue’. The costs are contained (somewhat) by rationing services. My most memorable run-in with the Canadian system was when a surgery I had scheduled was cancelled by the hospital because I ran later than expected with my previous case which, in turn, had been bumped by a slash wound neck trauma that I had been dealing with the night before.

It devastated me to have to come out to the patient waiting room at 3 in the afternoon to break it to this poor woman that I was sorry she had been left starving all day, and that she would have to wait weeks longer for a necessary surgery that had taken 4 months to schedule in the first place, even though I was more than willing to proceed. My hands were tied. She swallowed the bitter pill quietly. What choice did she have? And that was the breaking point for me. I’m not sure any American would put up with that, or even knows that this goes on.

That type of event symbolizes for me the differences between Canada and the US. Canada is like the friend who says “Sorry you’re hurt, hope you feel better”….kind, but passive. The US is more likely to say “What are we gonna do about it?”….headstrong, but taking action. If you ask Americans, theirs is the greatest country in the world. Canadians?? Same thing. Neither one has a perfect answer to Medicare in the modern age.

If you ask me, I don’t trust pencil pushers on either side of the fence, government or private. Private medicine has its problems, but don’t count on politicians to ride in and save the day with universal healthcare! Anything that’s completely free loses its value, gets taken for granted, and ultimately gets thrown away like a wet rag, as I saw in Canada. I found it interesting that the number of patients we saw in New York for the sniffles and other frivolous visits went down by 60% when a small $2 co-pay was instituted. So, if every doctor and patient takes personal responsibility for how we use the system, we could save a lot of money and a lot of wasted air-time, and still take care of those who need it.

Rant over. Just one opinion of a cross-border doctor. Easy for me to say, I do elective surgery most of the time…

We are constantly on the lookout for interesting stories about Beauty as it relates to Plastic Surgery. There are many beauty sites out there that specialize in repackaging information without adding much to it. So, when we find a site that doesn’t trot out that same old format, we like to make mention of it. One blog that breaks the mold is Cosmetic Makeovers. Meg Wilson provides the perfect combo of fun and thoughtful commentary on everything from cosmetics and fashion news to the latest surgical procedures. Meg’s terrific blog has our seal of approval.

There was an interesting article in the New York Times yesterday by Natasha Singer about the effect of the economic slump on Plastic Surgery. After all, you would think, with a “luxury item” like plastic surgery, how can it not be tied to the economic cycle?

And, sure enough, when Ms. Singer called around to all of the “top Plastic Surgeons” in major cities (if being on TV makes you one of the top plastic surgeons), the wait list to see the surgeon or to book a surgery date was shorter than it has been for a long time. This was the main thrust of the article.

Worse yet, according to the Times, are the recent 2007 statistics which supposedly show that actual facial surgical procedure numbers are down everywhere in favor of non-surgical procedures like Botox or dermal fillers because, so the argument goes, people just can’t afford surgery.

Funny thing is these stats are compiled by the American Society of Plastic Surgeons, which represents only General Plastic Surgeons in the US. So their numbers show a 64% increase in breast augmentation and a whopping 137% increase in tummy tucks since 2000, yet there were double digit declines for facial plastic procedures being done by general plastic surgeons.

HOW DO WE EXPLAIN THAT?

Well, that is the most interesting thing about the article. You just have to read carefully because they only briefly touched on it.

The fact is that people aren’t having body surgery in record numbers and simply avoiding facial surgery. Not at all. Facial plastic procedures are keeping pace, only it’s not the General Plastic Surgeons who are doing them any more. Facial plastic procedures, including nose jobs (rhinoplasty), facelifts, forehead lifts, and eyelid tightening (blepharoplasty) procedures are simply being done by Facial Plastic Surgeons, not general plastic surgeons.

You need only look at other statistics compiled by the American Academy of Facial Plastic Surgery, our professional organization, to see the other side of the story. According to them, the average number of eyelid lifts performed per surgeon was up 11% over 2 years earlier while forehead lifts were up 29%. To top it off, Facial Plastic Surgeons, on average, each did 79% more facelifts in 2007 over 2005. That’s more than increases in Botox and Fillers combined.

So, facial plastic surgery isn’t going the way of the Dodo. Just the opposite, gains in these procedures are outstripping many of the more publicized non-surgical procedures. Why?? Because they work. And people are coming around to that realization, and they’re also figuring out that super- specialists in the face (facial plastic surgeons) are the ones they trust to work on their faces.

As we surf the web to find all the hype that surrounds Plastic Surgery, we occasionally come across some very thoughtful and insightful editorial commentary. One of the sources we look to as inspiration are the musings of Dr Robert Oliver, who is a Plastic Surgeon in Birmingham, Alabama. Dr Oliver focuses his writings on breast augmentation and reconstruction, but talks on a variety of topics from liposuction to legislation regarding medicine, and really helps in debunking some of the gimmicks surrounding plastics.

Plastic Surgery 101 has our Seal of Approval

Dark circles under the eyes have always been understood to be largely a function of pigment, and as a result there really has never been a good treatment for the problem.

There is the occasional patient who we find who has allergies which result in blood pooling under the area, or the even more rare patient who has noted the problem since starting birth control pills; but for the vast majority of patients presenting with this problem there has always been few treatment options. So we were surprised to see the NY Times tackle the subject in a recent article.

As we read the article we were first somewhat surprised at the sheer magnitude of the numbers quoted as being bothered by this phenomenon, but also the money involved in addressing the issue. The NY Times quotes a Clinique company survey of 13,000 Clinique users in 2006, of whom roughly 53%  cited under-eye circles and puffiness as their No. 1 beauty concern. Almost as fascinating was the fact that sales of “anti-aging” skin care treatments have nearly doubled over 6 years to a whopping $1.08 billion dollars in 2006. Sephora alone is noted to now sell more than 50 products designed to specifically treat under-eye circles.

While all of this was interesting because the article itself goes on to note that, “The problem is that few, if any, of the creams on the market are formulated for people with excess pigmentation or dilated veins,” we were more bothered by the fact that the article then goes on to tout how a number of physicians and patients have gone on to  use restylane or juvederm off label under the eyes for treatment.

What is disconcerting is that though they do note the off label nature of this treatment, we think that they under state the number of problems encountered by patients who have undergone this treatment. In our own experience we have had a number of patients who presented after being treated elsewhere who noted that the circles actually appeared either darker after injections of restylane/ juvederm or who noted a blue tint under the skin from the injected material.

There have been others who had lumpy/ bumpy appearances after the injections. But perhaps the most disconcerting problems are left for those patients who then had injection of products meant to break down the filler in trying to resolve these problems. These patients have presented with significant thinning of the overlying skin and a resulting crepe appearance which usually can only be treated with a lower eyelid blepharoplasty to remove the now excess skin.

Unfortunately the number of people who read this will be far less than those who read the NY Times article and go running to whichever doctor they can find who is promoting this off label treatment.

As a final note to the article we wanted to note that one doctor quoted regarding all the products available for treatment of under eye circles said, “If there are that many of them available, that usually means they’re not terribly successful.”

PS COME BACK SOON WHEN WE GO ON TO DISCUSS WHAT GOOD OPTIONS ARE AVAILABLE

Plastic surgery journals are filled with pseudoscience, “How I do it”, and “Me too” articles, so when the odd actual attempt at science comes around, we like to give it a little attention. Such is the case with a recent article in this month’s volume of Plastic and Reconstructive Surgery about the anatomy of the fat pads in the cheek area. “Medical News Today” has summed up the key points of the article here.

In the study, researchers better described the complex anatomy of this area by injecting dye into cadaveric cheeks. They were able to identify a discrete deep fat compartment that is associated with aging of the midface, as it loses volume with age. Restoring the volume in this area can reverse these signs of aging.

This photo of Angelina Jolie highlights the appearance of a youthful cheek. This area should be the widest point of the face. You can see how the cheek has a smooth dome-like shape with a fullness in the center, gradually smoothing out towards the eyes and the lips.

This is a useful finding because the cheek area has always been the hardest area to improve with traditional face lift procedures. That’s why we’ve had the opinion for some time that some sort of volume is often needed as part of any procedure that deals with the cheek area. So, we’ve incorporated micro fat transfer as part of our Hybrid Lift™ for many of our patients who are face lift candidates. This can give the entire face a smooth, cohesive youthful look without the usual stigmata of a traditional face lift such as pulled skin, visible scars, and sagging cheeks that don’t fit with the windswept jawline.

We all age, but how the aging process takes its toll on us physically depends upon a host of factors ranging from our genes to our sun exposure, eating and smoking habits. There was a fascinating recent slideshow titled “Classic Beauties: How They Aged” which showed how some of Hollywood’s most iconic beauties looked as young women and how they looked in later life.

As you scroll through the images, you notice some of the classic signs of aging- the wrinkled skin, jowling neck, bags under the eyes, falling brows. For some of these women aging seemed to have taken a smooth natural road, but for others the process was more harsh making some of the women unrecognizable.

The point is simple: we all age and how we choose to deal with that process is our own. For some aging without doing anything seems natural and “as it should be,” for others they want to do the things that keep them looking as young on the outside as they feel inside- yes its cliched but we all know its true.

Luckily for those who want to look younger, there is an ever wider array of safe alternatives ranging from minimally invasive injectibles and fillers to more dramatic lasers and surgical options. So you decide…