Facial Plastic Surgery Blog

This is a nice summary of rhinoplasty, written by a reporter who attended one of my lectures…

http://www.shlnews.org/?p=101

Recently, the New York Times published an article that focuses primarily on revision rhinoplasty surgery (http://www.nytimes.com/2009/10/29/fashion/29Skin.html). I am glad that this was published, as it highlights a few issues regarding facial plastic surgery, and rhinoplasty in particular. Revision rhinoplasty is a significant portion of my practice in San Francisco, so I thought I put a few pertinent issues down in the blog.

First, surgery of any kind is not without risk. Even something that may seem straightforward may not turn out exactly as planned. The reasons for this are not always obvious. For example, it may seem a simple issue to remove a ‘bump on the nose’. However, for every action we perform in rhinoplasty, there are often non-obvious consequences that require remedy. In this case, if we remove the so-called ‘dorsal hump’ without any other changes to the nasal structure, we could end up with an awkward-looking nose (open roof deformity). To prevent this, we often must ‘break the bones’ of the nose to ‘close’ this open roof. These maneuvers themselves can have consequences on nasal shape and breathing…..and so the list goes on.

Now, the above example was relatively simple one…in more complicated maneuvers (hump reduction + tip changes), the variables increase. One can imagine that this is why we often call rhinoplasty one of the most difficult procedures in facial plastic surgery, and one that requires experience.

In the case of revision rhinoplasty, the complexity level increases exponentially, as we are operating on a nose that has been operated on before. Thus, every aspect of the surgery is more difficult: the initial opening of the nose is more difficult (scar tissue), developing a plan is more difficult (because we often don’t know with certainty what we will find ‘under the hood’, so to speak) and execution requires more skill (we may have to retrieve ‘grafts’ from other parts of the body, such as the ear or rib). Most importantly, once again, is experience, as this increases the likelihood that the surgeon has seen similar situations before and knows how to deal with the unexpected.

Recovery from revision rhinoplasty in the short-term is usually not much different that primary rhinoplasty. However, I find that the minute swelling that occurs in rhinoplasty takes a bit longer to resolve in revision cases—at least 1 year.

For more information on rhinoplasty, visit www.sfrhinoplasty.com

Sam P. Most, M.D., F.A.C.S.
www.drmost.com

What is a facelift?

As a facial plastic surgeon, I commonly find myself explaining to my patients the details of a facelift. The term has always been a bit misleading, as it typically refers to a procedure that does nothing for the eyes or forehead (which are also part of the face, last time I checked). However, I find myself thinking about this more and more, as this term is now being used for a number of procedures.

The medical definition ‘rhytidectomy’, the common medical term for facelift (which, by the way, means ‘wrinkle excision’), is a surgical procedure that tightens the lower face and neck. There are multiple variations of the rhytidectomy.

For example, the “minilift” is a term that may be used to describe any type of facelift that is meant to suit the more active lifestyle. Lifts that are thus labeled are sometimes modified by the surgeon ever so slightly and renamed as if proprietary. More often than not, they are insignificant modifications to a procedure that has been around for a while. In any case, these types of lifts typically offer slightly less downtime but a lesser result in the long term (that is, more than 1 year). Rigorous studies regarding the effectiveness of various types of mini-facelifts are lacking. Thus, one must rely on anecdotal evidence, which is often inadequate.

What about “MACS” lifts?

The MACS lifts originated in Europe, and is an acronym for ‘Minimal Access Cranial Suspension”. In this technique, a type of mini-lift is performed. The addition is the use of sutures from above the ear to the tissues of the mid-face, jawline and jowl areas. Thus, this is really variation of the minilift. A number of surgeons have used sutures in various ways, in combination with a min-lift, to good effect. As I mentioned above, however, it is important to understand that the longevity of these types of lifts is probably less than the more traditional lifts.

What is a “Deep Plane Facelift”?

The so-called ‘deep plane’ facelift is also a term that, in the strictest sense, refers to a specific type of lift. However, in the facial plastic surgeons’ parlance, it may refer to a more substantial repositioning of facial tissues that ostensibly gives a more long-lasting and natural result. This is the facelift that is typically most often used by experienced facial plastic surgeons (such as myself). Non-facial plastic surgeons (such as dermatologists or ophthalmologists) who have started to do facial cosmetic surgery do not typically have training to do this procedure and thus stick to the so-called mini-lifts (though they may call them ‘facelifts’).

What about non-invasive facial rejuvenation?

Facial rejuvenation is undergoing a revolution. While initially we as surgeons thought the revolution would be from the knife to totally non-invasive procedures, things don’t appear to be panning out quite that way. Rather, we seem to be arriving at the conclusion that in order to rejuvenate the face, an individualized approach that may combine both non-invasive and surgical techniques is the most appropriate.

For more information regarding facelifts, visit http://www.drmost.com/faclft.html

Is there a new, quicker-acting alternative to Botox®?
A study on a new type of botulinum toxin type A for treating facial wrinkles was published in the March/April 2009 issue of Archives of Facial Plastic Surgery.  The article, titled “Long-term safety and efficacy of a new botulinum toxin type A in treating glabellar lines”, details the results of a Phase 3 study (for explanation of FDA study phases, see here) of patients who received a new type of botulinum toxin type A, called Reloxin.  The primary goal of the study is the evaluate the long-term safety of repeated administrations of Reloxin in treating the frown lines between the eyebrows (glabellar lines).  Secondly, the study sought to determine how well Reloxin works (effectiveness and duration).
The study was a multi-center trial, involving 21 separate sites across the United States.  Twelve hundred patients were enrolled, and each patient received at least 1 treatment with 50 units of Reloxin.   Four more treatment cycles followed, and in each cycle some patients were dropped from the study (for a variety of reasons).  In the end, 177 patients received five full treatments of the glabella with Reloxin.
Adverse events are recorded in this type of study, and range from the somewhat innocuous or expected to the more serious.  In this study, the most common events were ‘injection site events’ which occurred in 18% of patients.  According to the authors, these were generally considered ‘mild to moderate’ events.  The second most common events were headaches, and these occurred in about 15% of subjects.  Finally adverse events around the eye were reported in 9% of subjects, and typically resolved within 3 weeks.  The exact types of events were not defined, though the authors did point out that ‘ptosis’ (drooping of the eyelid or brow or both) occurred in about 1.3% of subjects, which is comparable to Botox®.
The effect of Reloxin was seen typically around 3 days after injection, and as soon as 1 day in some subjects.  Contrast this with Botox®, in which the effect is typically observed at around 5-7 days (though it may start earlier).  Duration of effect was typically around 90 days, which is comparable to Botox®.   No reduction of effect was noticed in subjects who underwent repeated treatment.  In other words, there was no development of reduced response over time (or resistance to Reloxin).
What does this mean for you?   It may mean that a new type of injectable botulinum toxin type A is around the corner.  Reloxin showed similar duration of effect as Botox®, and seemed to show its effects more quickly.   Complications of treatment were similar to its long-used cousin.  Of note, Reloxin has been in use in Europe for 15 years (where it is called Dysport).  Bringing this drug to the United States will mean more options for patients who would like to treat wrinkles in the upper face.
It should be noted that the study was funded by Medicis, the company that manufactures and plans to market Reloxin in the United States.  Furthermore, one of the study’s lead authors disclosed that he owns stock in, has been a consultant for, and has received research support from Medicis.
For more information on Advances in Facial Plastic Surgery, be sure to visit www.drmost.com or www.sfrhinoplasty.com.

In my rhinoplasty practice in the San Francisco/Palo Alto/Bay Area, I have found several questions that are commonly asked.  Here are a few of them.  I may update this regularly.  If you have a question that you’d like to ask that is not addressed here, please email info@drmost.com.  Or, for more information you can visit www.drmost.com and www.sfrhinoplasty.com.

Rhinoplasty FAQs

Will a septoplasty change the shape of my nose?
Septoplasty is typically done without changes to the shape of the nose.  Certainly, it is not the goal of the procedure.  In cases where the caudal (bottom) of the septum, near the nostrils, is deviated, correction may result in a difference in appearance.
Note that many patients will elect to have a rhinoplasty (to change the shape of the nose) at the SAME TIME as the septoplasty.  Commonly, Dr. Most sees patients in his office for revision surgery who say they had a ‘septoplasty’ many years earlier.  In most cases, a rhinoplasty was also performed.

What is the recovery from rhinoplasty like?
Most patients feel the need to take a few days (up to a week) off from work.  Typically, the nose is taped for 6-8 days, and this alone often is reason enough to ‘lay low’ for a few days.  Usually, the pain is quite well tolerated, and patients are provided with pain medicine to ensure their comfort.  We recommend patients follow this schedule:
First week: No strenuous activity
Second week: May begin light aerobic exercise
Third week: May begin lifting weights
Sixth week: May resume full activity

I heard that it takes a year to recover from rhinoplasty—is that true?
Actually, no.  However, it can take a full year for the result of rhinoplasty to be ‘finalized’.  That is, while most of the swelling, etc. will be gone within weeks, the final tiny amount of swelling within the skin, and changes due to the healing process, can take a year.  This is common knowledge amongst those familiar with rhinoplasty, and is probably where the above statement originated.
What is “Ethnic rhinoplasty”?
This term is used to describe rhinoplasty in the non-Caucasian nose, and is perhaps not a good term.  Many of the aesthetic ‘norms’ used to describe the ‘ideal’ nose were based upon the Caucasian nose (particularly the female Caucasian nose).  Thus, these ‘ideals’, if applied to everyone, would result in disharmonious results.  In other words, the nose would not fit the face.  Dr. Most realizes this and is one of the first to promote ethno-centric rhinoplasty.   In other words, there are no ‘cookie-cutter’ rhinoplasties.  Each patient is evaluated individually and surgical goals are made together, with the patient, to achieve a natural result.  The result is a natural rhinoplasty, with a form that is in harmony with the other facial features.

Are there special considerations for Asian rhinoplasty?
Yes (see above).  Dr. Most’s philosophy is to evaluate each patient individually.  In Asian rhinoplasty, there are typically a few commonalities in anatomy that must be looked for and recognized if present.  For example, the request is often made to ‘raise the bridge’ of the nose.  Some surgeons perform the same surgery for all Asian rhinoplasty surgeries. However, not all noses are the same.  Furthermore, not all patients with the same nose will want the same look from surgery.  Therefore, it is imperative to have surgeon with both experience and the patience to listen to your concerns/desires before proceeding with Asian rhinoplasty.

The Facial Rejuvenation Revolution
Sam P. Most, M.D., F.A.C.S.
www.drmost.com
In the past few years we have seen a significant evolution in thinking about facial rejuvenation.  In this space I hope to shed some light on this, and what this means when you visit the doctor’s office.  In the past, facial aging has been thought of as primarily a battle lost to the effects of gravity.  We understand now, however, that the process of aging is a complex one, and involves more than simply sagging of the skin on the face.  Recent research has shown that the changes that occur are, to use an oft-used phrase, ‘more than skin deep’.
For example, we know that what we see in an aging face is partly due to changes in the skin at the microscopic level—changes in pigment cell and collagen fiber organization, as well as loss of elasticity (the ability of the skin to stretch and “bounce back”).  While in the past it was thought that fat should be removed from the face (especially in areas such as the upper and lower eyelids), we realize that one of the stigmata of facial aging is loss of facial fullness, partially due to fat loss or redistribution .  Finally, we are just starting to understand the interaction of the facial fat and muscle with the cartilage and bony skeleton, and what makes a young face look the way it does.  All of these have changed the way we (as facial plastic surgeons) approach our patients.

What can I do?

What can YOU do to reduce the effects of father time?  First, take care of yourself.  Eat a healthy, balanced diet.  Don’t smoke. Cleanse, moisturize and protect your skin.  Avoid the sun .  Even if you do all of the above, there are some things you will not be able to control.  You can’t go back in time and tell your twenty-something self to be more careful with your skin.  You cannot stop the biology of aging (despite what you may read on the internet).  No anti-aging cosmeceutical yet exists that can penetrate your skin and change the process of aging .  Even if you do all of the above, the time may come when you search for ways to rejuvenate your face.
“It’s not your mother’s facelift anymore”
As I alluded to above, the old way of thinking about facial rejuvenation was ‘tighter is better’.  Given what I discussed above, I’m sure you can appreciate that our approach to facial rejuvenation has likewise changed.  While in the past the primary approach for facial rejuvenation was surgery (a ‘facelift’); we now have many non-invasive techniques that can be used to restore a youthful appearance to the face.
Non-invasive facial tightening
Chemical peel, dermabrasion, and laser peels are tried-and-true methods for removing skin wrinkles.  You have probably heard of these procedures, or you may know someone who has undergone one of these.  While these techniques have been around for a while, most all of the new research has centered on improvement of the laser.  Specifically, the goal has been to reduce the ‘downtime’ associated with it maintaining its benefits.  The latest technology involves treating only a fraction of the skin with the laser, thereby stimulating rejuvenation with less downtime (this is called a ‘fractionated laser’; some brands include Pixel and Fraxel).
You may have also heard of techniques that promise ‘nonsurgical facelifts’.  One of the first such techniques was Thermage®, but many similar techniques have come along.  The premise of these technologies is to transfer energy (often in the form of heat) to the deep tissues of the face, thereby ‘tightening’ the tissues that have ‘loosened’ over time.  The results on this have been mixed.  Some studies have shown that about 1 in 3 patients will have a noticeable effect.  Unfortunately, we cannot tell who those patients will be.
Injectables
There are 2 main types of injectables.  Muscle ‘freezers’ and facial fillers.  Botulinum toxin type A (most commonly Botox®) is the most commonly used ‘muscle freezer’ and is one of the most common facial rejuvenation procedures in my practice in the San Francisco Bay Area (as it is nationwide).  It works by temporarily blocking the muscle from getting a nerve signal.  Since muscle movement causes some types of wrinkles, it is only effective in treating so-called ‘dynamic’ wrinkles.  Note that Botox® is FDA approved for use in the glabella (the area between the eyebrows), but is commonly used ‘off-label’ in other areas of the face.  It takes about a week to show its effects, and lasts typically 3-4 months.
The other main category of injectables are the fillers.  Classically, collagen was used to ‘plump’ the face, especially the lips.  Given what we now know about loss of volume throughout the face, our use of fillers has expanded to include virtually all areas of the face.  Our repertoire of materials has also expanded far beyond collagen.  The hyaluronic acid (a naturally occurring substance) derivatives include Restylane®, Perlane®, and Juvederm®, to name a few.  Radiesse® is derived from a calcium base.  Other, more permanent fillers, include Artecoll®.  The ultimate injectable is your own tissue, namely, your own fat.  In this procedure, called fat transfer, we move small droplets of fat from an undesirable place to areas of the face that need more volume.
What about surgery?
The non-invasive procedures can only do so much.  When you and your surgeon feel the time is right, surgery may the best choice to give a natural, more long-lasting result.  As you can see, there are a number of options available prior to taking the plunge into a surgical procedure.  Surgery of the face to reverse aging includes brow rejuvenation (endoscopic browlift), eyelid lifts (blepharoplasty), and lower face/neck lifts (rhytidectomy).  These procedures can be done alone or in combination.  Each of these has undergone its own evolution, the discussion of which is beyond the scope of this summary.  Suffice to say that the trend is towards more conservative and natural-looking results.
OK, I want to take that first step…

Do your research.  Find someone who has experience and limits their practice to the face.  Importantly, this person should be familiar with the full range of facial treatments (surgical and nonsurgical).  Finally, it is important to find someone you trust will give you an honest assessment.  The goal of facial rejuvenation in 2009 is just that—rejuvenation.  This implies a natural restoration of facial youthfulness.  Our goal as facial plastic surgeons is to achieve this as safely and effectively as we can, with as minimally invasive a procedure as possible.

Does Botox® go to the brain?

This is a question that has been bounced around quite a bit since the paper published by an Antonucci, et al. in the April 2, 2008 issue of Journal of Neuroscience.

Having published in this journal myself, I know that it is very highly regarded in scientific circles.  So I wanted to read this article myself.

Before going any further, it is worth pointing out that Botox® is a term that should be reserved for botulinum toxin type A (there are multiple types) that has been purified and is approved for use in humans, and is produced by the company Allergan. The material used in the study noted above is indeed botulinum toxin type A, but it is a research grade (ie, not for human use) product whose composition may differ (based on purification methods and units of activity per weight of product). So, Botox® itself was never tested in this study.

Having said that, the botulinum toxin type A (hereafter referred to as BoNT/A, for brevity) used in the study is the same basic molecule, so we can make some assumptions regarding the mechanisms.  Its just that using a differently purified product in another species can complicate matters.

BoNT/A works by blocking the signal from the end of the nerve that causes the associated muscle to contract.  The signal is the neurotransmitter acetylcholine (ACh) and BoNT/A blocks its release from the end of the nerve (the nerve terminal) by altering a molecule that is necessary for the machinery that is involved in releasing ACh. That molecule is SNAP-25.

Each BoNT/A can alter many SNAP-25s.  Because so very little BoNT/A is around after injection, and thus is very hard to detect, the researchers in the study measured the amount of altered SNAP-25 present instead.

Before we go further, you must realize that cells in the brain (neurons) are wired to each other by sending long projections to other parts of the brain or out to muscles in the body.  These projections are called axons.  For example, the neurons that cause your face to move are located in the brain, and send out axons to the muscles of your forehead, etc.  There, the nerve terminals that activate the muscles release ACh to cause the muscles to contract.  That’s why Botox® is injected into the muscles it finds its way to the nerve terminals and deactivates them. (Funny thing…my honors thesis at the University of Michigan as an undergraduate was a study of ACh in rat neurons.)

Here’s where it gets interesting.  The axons have transport mechanisms that allow molecules to move back and forth between the nerve terminal and the cell body, in the brain.  The researchers in this study propose that BoNT/A is transported along the axons back to the brain.

As I mentioned above, there is no good way to measure BoNT/A, as the amounts used are so minute. So, the researchers measured SNAP-25 that had been altered by BoNT/A.  They injected BoNT/A directly into the brain (something we do not do routinely!) and measured altered SNAP-25.  They found altered SNAP-25 in other regions of the brain regions that were connected by axons to the areas injected.  In addition, they injected the whiskers of the rats, and found altered SNAP-25 in the neurons (in the brain) involved in whisker movement.  If you are following this, you realize that this does not prove that BoNT/A is actually moved along the axon to the brain, but that SNAP-25 is.  This is a big issue, because it is not surprising at all the the degraded SNAP-25 would be moved along the axon.

To address this, the authors devised an indirect way to examine if it is actually BoNT/A or just altered SNAP-25 that is transported along the axons.  This was done with the direct brain injections, not with the facial muscle injections.  Without getting into the details, I thought this experiment (which was a small portion of the study) was the weakest and found the results less than convincing.

What does this all mean?

First, we should remember that these studies were done in animals, and any time you try to compare animals studies to human studies you can get into trouble.  Second, the composition and concentrations used may differ from that Botox®.  Third, the primary molecule measured was NOT BoNT/A, it was the molecule it alters and this is a big difference.  Fourth, no direct evidence of active BoNT/A in the brain was shown. Fifth, only a small part of the study was done in a system similar to the muscle injections performed in humans, and the results there were not that surprising.

Finally, it is worthwhile to remember that millions of cosmetic injections of Botox® have been performed over the last decade(s) and (to my knowledge) no adverse events related to effects on the brain have been reported.

With any drug, it is always useful to have more studies to examine its mechanism of action. Hopefully, future studies will clarify some of the questions raised by this article.

www.drmost.com

Dr. Most has published his most recent research on the effectiveness of over-the-counter anti-wrinkle creams.

Visit:

http://archfaci.ama-assn.org/cgi/content/abstract/9/5/340

Facial Plastic Surgery Videos

To learn more about Facial Plastic Surgery techniques, from the minimally invasive technologies (such as Fraxel, Pixel, and Thermage) to the latest twists to more traditional surgical techniques, look for online lectures on these topics.

We have posted several videos on topics such as these online, and these can be found on YouTube or at http://www.drmost.com/video_main.html

Furthermore, you can view Dr. Most’s most recent lecture on the Research Channel.
To check on airtimes, or to watch this video online now, click here.

Seminars in Facial Plastic Surgery (Fraxel, Pixel, Thermage, Facelift and Botox discussed!)

Dr. Most will be hosting his next Seminar on the latest Advances in Facial Plastic Surgery on Wednesday evening November 19th, at 801 Welch Road, Stanford, CA.

Topics to be discussed:
-Lasers peels and types (CO2, Pixel, etc)
-Chemical peels and types
-Botox®
-Restylane® and other hyaluronic acid-based fillers
-Radiesse®
-Facelifts, minilifts
-Eyelid Surgery

-Plus more!

Refreshments will be provided.

Please RSVP to info@drmost.com or call 650 736 FACE (3223) to reserve a seat!

Our seminars have been very popular and informative in the past, we hope you join us!
For directions or maps, please visit www.drmost.com