By Franklin D. Richards, MD Bethesda, MD
Breast augmentation is a surgical procedure to enhance the size and shape of a woman's breast for a number of reasons. Most often a woman seeks breast augmentation to enhance the body contour, who, for personal reasons, feels her breast size is too small or to correct a reduction in breast volume after pregnancy. Some desire to improve an imbalance in breast size. By inserting an implant behind each breast, surgeons are able to increase a woman's bustline by one or more bra cup sizes.
Breast augmentation can enhance your appearance and your self-confidence. Before you decide to have surgery, think carefully about your expectations and discuss them with your surgeon. If you're physically healthy and realistic in your expectations, you may be a good candidate.
Possible Complications
A breast implant is a silastic shell filled with a saltwater solution known as saline. Breast augmentation is relatively straightforward. But, as with any operation, there are risks associated with surgery and specific complications associated with this procedure.
The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. If this occurs it can make the breast feel firm or even hard. Capsular contracture can be treated by removal or scoring of the scar tissue.
Complications with this procedure are possible, but fortunately, unusual. They include bleeding, infection, nipple numbness and implant leaking. Sporadically, breast implants may break or leak. Rupture can occur as a result of injury or even from normal compression and movement of your breast and implant, causing the shell to leak. If a saline implant breaks, the implant will deflate in a few hours and the salt water will be harmlessly absorbed by the body. However, the ruptured or leaking implant must be replaced. This involves opening the original incision and inserting a new implant.
While there is no evidence that breast implants cause breast cancer, they may change the way mammography is done to detect cancer. When you request a routine mammogram, be sure to notify the center that you have breast implants. Often this will mean that additional oblique mammographic views are performed. Ultrasound examinations may be of benefit in some women with implants to detect breast lumps or to evaluate the implant.
While the majority of women do not experience the above complications, you should discuss each of them with your physician to make sure you understand the risks and consequences of breast augmentation.
The Surgical Procedure
Breast augmentation is most commonly performed in an outpatient facility using general anesthesia, so you'll sleep through the entire operation. Some surgeons may use local anesthesia, combined with a sedative to make you drowsy, so you'll be relaxed but awake, and may feel some discomfort.
The method of inserting and positioning your implant will depend on your anatomy and your surgeon's recommendation. The incision can be made either in the crease where the breast meets the chest, around the areola or in the armpit. Usually the incision around the areola is less conspicuous, however, the incision under the breast is frequently hidden by the breast itself. The armpit incision often heals well, but it may be noticeable with a raised arm, and it is difficult to create an accurately placed pocket with this incision.
The implant may be placed in a pocket under the pectoralis muscle or directly on top of it. Generally, saline implants are placed behind the muscle as there is often better breast form, less chance of capsular contracture (hardening) and it helps to prevent any waviness‚ of the implant from being noticed. If you have any significant breast droopiness (ptosis), the implant pocket may need to be placed on top of the muscle. This allows the implant to fill out the breast skin and results in a better correction of the droopy breast.
Shape of the Implant
Several considerations are made in choosing a breast implant. There are round implants and also tapered sometimes called contoured or anatomical implants. Generally, for a very thin individual, a tapered implant will result in a more natural, less rounded appearance to the upper portion of the breast. However, if the implant is placed behind the muscle, the appearance is very similar.
Additionally, implants may have a smooth or textured surface. The textured implant was developed to help reduce the incidence of capsular contracture (hardening). Again, if the implant is placed behind the muscle, there does not appear to be significant differences between the implant surfaces.
You’ll want to discuss the pros and cons of these alternatives with your doctor before surgery to make sure you fully understand the implications of the procedure. The surgery usually takes one to two hours to complete. There is often a wrapped gauze dressing around the breasts for one or two days.
After the Surgery
You should be able to return to work within a few days, depending on the level of activity required for your job. Follow your surgeon's advice on when to begin exercises and normal activities. Your breasts will probably be sensitive to exercise and direct stimulation for two to three weeks.
Your scars will be firm and pink for at least six weeks. Then they may remain the same size for several months, or even appear widened. After several months, the scars will begin to fade, although they will never disappear completely.
It's Your Own Decision
For may women, the result of breast augmentation can be satisfying, even exhilarating, as they learn to appreciate their fuller appearance. Your decision to have breast augmentation is a highly personal one that not everyone will understand. The important thing is how you feel about it.
Tuesday, January 6, 2009
Lasers: New Technology for Skin Conditions & Tattoo Removal
We’ve all heard about the many uses of lasers in medicine. Lasers are used in surgery to destroy cancerous and precancerous tissue, to remove tissues such as tonsils with much less pain and swelling than with conventional surgery, and to remove tumors which contain many blood vessels that otherwise might be difficult or dangerous to remove.
Earlier lasers such as the C02 and Argon Lasers were also used to treat certain skin conditions such as birthmarks, tattoos, and warts. These earlier lasers had the disadvantage of leaving more scars after the treatment of certain skin lesions especially if the tissue to be removed extended deeper into the skin, as in many tattoos. The patients generally preferred the scar to the tattoo; however, since the scar had less social stigma than the tattoo. As a plastic surgeon in the military, I had abundant experience removing tattoos with these early lasers, but I was not satisfied with the scars that resulted.
Fortunately technology came to the rescue. A second generation of lasers was developed for treatment of these superficial skin lesions. Depending on the color and depth of the skin lesion, we are now able to select from a number of lasers that differ in the wavelength of light that the laser produces. When the laser light hits the brown or red skin discoloration or tattoo pigment, it is selectively absorbed. The rapid absorption of the light energy causes the tattoo ink or the pigmented cells in the skin brown spot to destruct or burst apart. The body’s natural filtering system then removes the debris. Because the surrounding normal tissue does not absorb the laser energy, the treated area is less likely to scar.
Superficial skin spots such as brown age spots, "liver spots", and freckles are usually removed with one to two treatments. Common areas that develop brown spots are the sun exposed areas of the face and back of the hands. Occasionally after laser treatments, some brown birthmarks may return after several months to a year. Elevated brown spots such as moles or lesions that may be cancerous should not be treated with the laser, but should be removed surgically so that they may be sent to a pathologist for a definitive diagnosis, as further treatment may be needed.
Red skin spots and superficial blood vessels especially on the face may be treated with the laser, which is selectively absorbed by the red blood cell hemoglobin. The overlying skin is usually left undamaged, but the superficial vessels and/or spots are destroyed. Small spider veins of the legs may be treated with the laser but generally respond better to other treatment methods, such as injection of sclerosing solutions.
Tattoo Removal
The most exciting use of the new lasers are in the treatment of tattoos. Decorative tattoos have been in vogue for at least 5,000 years and a multitude of tattoo removal techniques have been used throughout history including sanding of the skin, chemical treatment of the skin, and laser removal of the skin containing the tattoo. All treatments lead to the same problem; a scar similar to a burn scar, since most tattoos extend deeper into the skin. With the advent of this new generation of lasers that selectively send energy only into the tattoo pigment, we have seen a marked decrease in the scarring. Tattoos are either professional, where a large amount of pigment is placed using a tattoo machine, or non-professional where a small amount of pigment is placed usually using a needle. Non-professional tattoos require fewer laser treatments than professional tattoos as they have less pigment to be destroyed. On the average, non-professional tattoos required three to four treatments and professional tattoos require six to eight treatments. Usually the treatments are spaced at one to two month intervals to allow the body’s filtering mechanisms to clear out the tattoo pigment debris. Not all colors respond equally well with all lasers, but fortunately several different types of lasers are available so that most pigments will respond to one of the available lasers.
Laser treatment is usually performed in the office, requires no anesthesia, and takes only ten to twenty minutes. The impact of the laser light hitting the skin produces a sensation similar to the snap of a thin rubber band. After treatment the area will feel similar to a mild sunburn.
For treatment of brown spots the area remains reddened for two to four weeks then gradually returns to its normal coloring and texture. For red skin spots, the area typically bruises, but does not leave an open wound. For tattoos which are deeper, there may be pinpoint bleeding and an antibacterial ointment and dressing is applied to the area. A small amount of lighter discoloration and texture change is evident, which gradually improves over time. Permanent scarring is rare.
Laser treatments are usually less expensive than conventional surgery. Costs range from $300 - $600 per treatment session and are usually dependent on the amount of time the laser is in use and on the type of laser used. Insurance usually does not cover the cost of laser surgery for tattoo removal, but may cover the removal of other skin lesions depending on the particular policy.
So the next time you have to cover up those brown discolorations with make-up or conceal that tattoo that you got in your twenties, think about taking advantage of this latest development of laser technology to create healthier and more attractive skin.
Earlier lasers such as the C02 and Argon Lasers were also used to treat certain skin conditions such as birthmarks, tattoos, and warts. These earlier lasers had the disadvantage of leaving more scars after the treatment of certain skin lesions especially if the tissue to be removed extended deeper into the skin, as in many tattoos. The patients generally preferred the scar to the tattoo; however, since the scar had less social stigma than the tattoo. As a plastic surgeon in the military, I had abundant experience removing tattoos with these early lasers, but I was not satisfied with the scars that resulted.
Fortunately technology came to the rescue. A second generation of lasers was developed for treatment of these superficial skin lesions. Depending on the color and depth of the skin lesion, we are now able to select from a number of lasers that differ in the wavelength of light that the laser produces. When the laser light hits the brown or red skin discoloration or tattoo pigment, it is selectively absorbed. The rapid absorption of the light energy causes the tattoo ink or the pigmented cells in the skin brown spot to destruct or burst apart. The body’s natural filtering system then removes the debris. Because the surrounding normal tissue does not absorb the laser energy, the treated area is less likely to scar.
Superficial skin spots such as brown age spots, "liver spots", and freckles are usually removed with one to two treatments. Common areas that develop brown spots are the sun exposed areas of the face and back of the hands. Occasionally after laser treatments, some brown birthmarks may return after several months to a year. Elevated brown spots such as moles or lesions that may be cancerous should not be treated with the laser, but should be removed surgically so that they may be sent to a pathologist for a definitive diagnosis, as further treatment may be needed.
Red skin spots and superficial blood vessels especially on the face may be treated with the laser, which is selectively absorbed by the red blood cell hemoglobin. The overlying skin is usually left undamaged, but the superficial vessels and/or spots are destroyed. Small spider veins of the legs may be treated with the laser but generally respond better to other treatment methods, such as injection of sclerosing solutions.
Tattoo Removal
The most exciting use of the new lasers are in the treatment of tattoos. Decorative tattoos have been in vogue for at least 5,000 years and a multitude of tattoo removal techniques have been used throughout history including sanding of the skin, chemical treatment of the skin, and laser removal of the skin containing the tattoo. All treatments lead to the same problem; a scar similar to a burn scar, since most tattoos extend deeper into the skin. With the advent of this new generation of lasers that selectively send energy only into the tattoo pigment, we have seen a marked decrease in the scarring. Tattoos are either professional, where a large amount of pigment is placed using a tattoo machine, or non-professional where a small amount of pigment is placed usually using a needle. Non-professional tattoos require fewer laser treatments than professional tattoos as they have less pigment to be destroyed. On the average, non-professional tattoos required three to four treatments and professional tattoos require six to eight treatments. Usually the treatments are spaced at one to two month intervals to allow the body’s filtering mechanisms to clear out the tattoo pigment debris. Not all colors respond equally well with all lasers, but fortunately several different types of lasers are available so that most pigments will respond to one of the available lasers.
Laser treatment is usually performed in the office, requires no anesthesia, and takes only ten to twenty minutes. The impact of the laser light hitting the skin produces a sensation similar to the snap of a thin rubber band. After treatment the area will feel similar to a mild sunburn.
For treatment of brown spots the area remains reddened for two to four weeks then gradually returns to its normal coloring and texture. For red skin spots, the area typically bruises, but does not leave an open wound. For tattoos which are deeper, there may be pinpoint bleeding and an antibacterial ointment and dressing is applied to the area. A small amount of lighter discoloration and texture change is evident, which gradually improves over time. Permanent scarring is rare.
Laser treatments are usually less expensive than conventional surgery. Costs range from $300 - $600 per treatment session and are usually dependent on the amount of time the laser is in use and on the type of laser used. Insurance usually does not cover the cost of laser surgery for tattoo removal, but may cover the removal of other skin lesions depending on the particular policy.
So the next time you have to cover up those brown discolorations with make-up or conceal that tattoo that you got in your twenties, think about taking advantage of this latest development of laser technology to create healthier and more attractive skin.
Laser Resurfacing for the Treatment of Facial Imperfections
Did you ever look in the mirror only to see your facial imperfections, such as wrinkles, dark spots, blemishes and acne scars staring back at you?
We now have a new laser technology that removes the outermost layer of the facial skin very selectively. When the new skin grows back, in five to fourteen days, this skin is smoother and less likely to have such prominent surface irregularities.
The areas that are most effectively treated with this technology are wrinkles, pigment irregularities and acne scars. Other blemishes such as raised moles, broken vessels and large pores are better treated with surgery, other laser technology or skin care programs utilizing Retin A and glycolic acid. Usually a skin care evaluation by the plastic surgeon can effectively identify which techniques are best to correct the problem areas that are of most concern to you.
If laser resurfacing is recommended then often Retin A is applied to the facial skin each evening after removal of makeup, if worn, for several weeks prior to treatment.
Areas of the face to be treated are identified. Choices include the entire face, the cheeks, the area around the mouth and the area around the eyes. Treating large areas often requires anesthesia to sedate the patient. Local areas may be done without anesthesia in select patients.
After treatment, a tape dressing is applied and remains in place for three to seven days. Discomfort is minimal as long as this tape remains in place. Healing is usually complete in five to fourteen days although the skin must be protected from ultraviolet rays for several months after surgery. At first the new skin is more delicate and often reddish in color for two weeks to two months after treatment. Occasionally, this reddish tint may last up to six months usually with more extensive treatment in certain patients with skin types susceptible to this redness.
Laser resurfacing is safest in patients with fair skin and is more likely to have prolonged redness in patients with deep wrinkles. Creams can be used to decrease the redness and makeup can be used to camouflage the redness. Patients with olive or pigmented skin have a risk of discoloration of the skin that is resurfacing the face.
After the new skin heals and has time to mature, the surface is smoother and often has less pigment variations.
With the use of an effective skin care program to help maintain this improved skin surface and of course sun blocks to help prevent further sun damage to the skin, you can now face the mirror with a more vibrant and youthful appearance.
We now have a new laser technology that removes the outermost layer of the facial skin very selectively. When the new skin grows back, in five to fourteen days, this skin is smoother and less likely to have such prominent surface irregularities.
The areas that are most effectively treated with this technology are wrinkles, pigment irregularities and acne scars. Other blemishes such as raised moles, broken vessels and large pores are better treated with surgery, other laser technology or skin care programs utilizing Retin A and glycolic acid. Usually a skin care evaluation by the plastic surgeon can effectively identify which techniques are best to correct the problem areas that are of most concern to you.
If laser resurfacing is recommended then often Retin A is applied to the facial skin each evening after removal of makeup, if worn, for several weeks prior to treatment.
Areas of the face to be treated are identified. Choices include the entire face, the cheeks, the area around the mouth and the area around the eyes. Treating large areas often requires anesthesia to sedate the patient. Local areas may be done without anesthesia in select patients.
After treatment, a tape dressing is applied and remains in place for three to seven days. Discomfort is minimal as long as this tape remains in place. Healing is usually complete in five to fourteen days although the skin must be protected from ultraviolet rays for several months after surgery. At first the new skin is more delicate and often reddish in color for two weeks to two months after treatment. Occasionally, this reddish tint may last up to six months usually with more extensive treatment in certain patients with skin types susceptible to this redness.
Laser resurfacing is safest in patients with fair skin and is more likely to have prolonged redness in patients with deep wrinkles. Creams can be used to decrease the redness and makeup can be used to camouflage the redness. Patients with olive or pigmented skin have a risk of discoloration of the skin that is resurfacing the face.
After the new skin heals and has time to mature, the surface is smoother and often has less pigment variations.
With the use of an effective skin care program to help maintain this improved skin surface and of course sun blocks to help prevent further sun damage to the skin, you can now face the mirror with a more vibrant and youthful appearance.
Avoiding End Hits In Ultrasound-Assisted Lipoplasty
A potential disadvantage of ultrasound-assisted lipoplasty is tissue burns. These may occur when the tip of the probe hits the undersurface of the skin. These "end hits" occur when the tip of the probe is vertically oriented to the skin surface, and they are more likely to happen when the surgeon is trying to go around the sides of the patient from centrally located access incisions.
To help avoid hitting the skin’s undersurface around the lateral aspect of an area being treated, a lateral meridian is drawn before surgery with the patient standing. The surgeon should not cross this lateral meridian when working in an anterior direction from the central access incisions with the patient in a prone position or when working in a posterior direction with the patient in a supine position. The prone position displaces this lateral line posteriorly, whereas the supine position displaces it anteriorly because the operating room table pushes up against the patient’s body.
The surgeon’s non-dominant hand assists by rolling tissue toward the probe so that its tip does not approach the skin in a vertical orientation. Early in my experience, I would sometimes push the probe too far around a contour. The surface orientation provided by the lateral line has helped prevent that problem so the tip of the probe is not perpendicular to the skin.
I limit access incisions to well-concealed sites. One or two incisions at the superior border of the escutcheon or umbilicus for the anterior abdomen and lateral flanks, and one at each of the lower lateral borders of the escutcheon for the inner and outer thighs have been adequate when the patient is in the supine position. Incisions on either side of the spine and in each buttock crease have sufficed to treat flanks and thighs with the patient in the prone position.
To help avoid hitting the skin’s undersurface around the lateral aspect of an area being treated, a lateral meridian is drawn before surgery with the patient standing. The surgeon should not cross this lateral meridian when working in an anterior direction from the central access incisions with the patient in a prone position or when working in a posterior direction with the patient in a supine position. The prone position displaces this lateral line posteriorly, whereas the supine position displaces it anteriorly because the operating room table pushes up against the patient’s body.
The surgeon’s non-dominant hand assists by rolling tissue toward the probe so that its tip does not approach the skin in a vertical orientation. Early in my experience, I would sometimes push the probe too far around a contour. The surface orientation provided by the lateral line has helped prevent that problem so the tip of the probe is not perpendicular to the skin.
I limit access incisions to well-concealed sites. One or two incisions at the superior border of the escutcheon or umbilicus for the anterior abdomen and lateral flanks, and one at each of the lower lateral borders of the escutcheon for the inner and outer thighs have been adequate when the patient is in the supine position. Incisions on either side of the spine and in each buttock crease have sufficed to treat flanks and thighs with the patient in the prone position.
Facelift: Prevention and Treatment of Facial Aging
Facial aging is due to a combination of factors. In a previous article we discussed photoaging or aging due to sun exposure which is fortunately a largely preventable cause of aging. In this article we will explore some other factors that contribute to aging. Some of these factors are less preventable, but fortunately are able to often be corrected once established.
Gravity
One prominent cause of aging is due to the effect of gravity. As you study the difference in facial features between the extremes of age, you see a drooping of certain areas of the face and neck frequently. Such areas include the jowls or lower cheeks, the neck or "turkey wad", the chin, the nose, the eyebrows and forehead, and the upper and lower eyelids.
Plastic surgery has various techniques designed to rejuvenate the face once gravity has caused these areas to droop and thus form the folds and deeper wrinkles associated with aging. No other form of facial rejuvenation such as chemical peel is effective in treating these drooped areas once formed.
Plastic surgery techniques include facelift which typically elevates the cheeks, jowls, and neck. Facelifts remove excess skin from the lower face and neck through incisions around the hairline and ear area and underneath the chin. Typically deeper layers including the muscles are tightened to help prevent recurrent drooping of facial tissue. Facelifts are rarely necessary before age 40 and are usually performed in men and women when they have sufficient laxity of tissue to justify the small but real risk of surgery.
Sometimes a chemical peel can achieve some tightening of tissue and thus delay the time when facial laxity would only be corrected with a facelift. The neck, however, cannot be treated with a deep chemical peel due to potential complications, so this area is best treated with a facelift. On occasion, usually in men who do not object to a visible neck scar, excess neck skin can be removed directly. This scar is much more prominent and visible than the usual facelift scars. Facelifts usually last from 5 to 10 years although some patients with poor skin elasticity notice a recurrence of facial drooping sooner. Usually the second facelift is longer lasting.
Other areas which are susceptible to gravity include the chin and nose. Elevation of the chin directly or elevation using a prosthetic implant produces a more youthful appearance. Many different techniques are available and the particular technique best suited to your bone structure and appearance is best discussed with a plastic surgeon. Incisions are placed inside the mouth or under the chin. Elevation of the nose including the nasal tip can usually be accomplished through incisions hidden inside the nose.
One early sign of facial aging is around the eyes and brow area. Perhaps this is due to the thinner tissues of the eyelids and their constant motion compared to other areas of the face. Most people show their first signs of facial aging around the mid 30's when the eyebrows begin to droop. You can see for yourself if your eyebrows are drooped by elevating the outer half of the eyebrows while looking in the mirror. Do you see the small fold of excess skin of your upper eyelid become less prominent?
Drooping of the brow has several effects including a shift in position of the eyebrow, especially the outer half, drooping of the tissue of the eyelids due to pressure of the brows on the thinner skin of the upper eyelids, and horizontal forehead wrinkles due to constant elevation of the forehead muscles in order to relieve this pressure from the drooped brows. Vertical forehead wrinkles are usually due to overactivity of certain muscles and will be discussed later under expression lines.
The treatment for drooped brows is a forehead lift. This is usually performed by making an incision across the top of the scalp and lifting the tissues of the brow and forehead. The overactive muscles can be removed and the elevation of the forehead and brow helps eliminate the horizontal forehead wrinkles after a browlift. Often crows feet are softened or eliminated. There is less upper eyelid skin to remove after elevation of the brow and in some patients a browlift is all that is required to correct aging around the eyes.
For drooping of the upper eyelids not corrected with a browlift, or in patients who prefer less surgery, an eyelid lift or blepharoplasty is possible. Excess skin and fat is removed from the upper eyelid and the incision is mostly hidden in a natural crease. Some insurance policies will cover the costs of an upper eyelid blepharoplasty or a browlift if visual field tests by an ophthalmologist or optometrist are abnormal. If you have a moderate to severe amount of hooding of the brow and upper eyelid skin that may be obstructing your vision off to the side, you may consider having this test performed.
For drooping of the skin and treatment of the fatty bulges that develop in the lower eyelid area, a lower eyelid lift or blepharoplasty may be helpful. This procedure removes excess skin, muscle, and fat from the lower eyelid. The incision is usually made just under the lash line and usually heals with minimal scarring. Sometimes the incision can be made through the conjunctiva, or pink tissue on the inside of the eyelid, if there is only fat to remove.
Depending on your particular facial structure, gravity is more likely to take its toll in one area before another. Although one cannot neutralize gravity, various methods exist to counteract its effects.
Expression Lines
The next category of facial aging involves expression lines. These lines form due to facial muscle activity such as squinting and smiling and are mostly prominent around the eyes and mouth.
Preventive measures include wearing sunglasses to avoid squinting and never smiling or laughing. Only so much prevention is possible, however, and I would not recommend limiting your facial expression, unless that expression is that of frowning. Treatment for facial expression lines depends on the position and depth of the line. Lines that are less deep may be treated with a chemical peel. Medium deep lines are treated with placement of fat, dermis, or filler materials such as collagen and fibrel under the crease. Some of these materials last longer than others. Deeper lines are usually treated with surgery such as facelifts, and eyelid and brow lifts.
Inherited Facial Features
Inherited facial features can contribute to premature aging. Lack of adequate bony support in the area of the upper cheeks can cause premature drooping of the lower eyelids. This can be corrected with malar or cheek implants at the time of the lower eyelid lift so the condition will be less likely to recur. Upper eyelids are more likely to droop with inadequate bony support of the brow.
Fatty deposits in the cheeks and under the chin can contribute to a plumper, older appearing face. These can be corrected using facial liposuction and/or the removal of the cheek fat pad through an incision made inside the mouth. A thinner more youthful appearance results from sculpturing the unwanted fat from the face. If the skin is still elastic, it will redrape without needing more extensive plastic surgery procedures which remove excess skin.
Balance of facial features such as the chin and nose creates a youthful appearance. In some people, plastic surgery procedures are done to create fuller lips or reduce lips that are too full in order to restore balance to the face.
Stress
The last cause of facial aging I would like to discuss is stress. Researchers studying aging have discovered that aging often occurs in spurts. You may have noted this in yourself or your friends when you see signs of accelerated aging after particularly stressful times. If you don't believe me, look at pictures of our former presidents before and after their 4 to 8 year terms.
One field of research that I feel is largely unexplored is that of the effect of stress reduction techniques on aging. The ability to reduce stress through daily practices such as exercise, yoga, and meditation can produce remarkable delays in facial aging and may even reverse some already established signs of facial aging. Of course a healthy diet including use of distilled or filtered water is also advisable, for the skin acts as a secondary organ for the elimination of unwanted material from the body. Dermatologists have long been able to study the effect of various diseases and malnutrition by the appearance and quality of the skin.
So what can you do to maintain your youthful skin and face? Avoid sun exposure, use a sunblock of S.P.F. 15 or higher, wear sunglasses to avoid squinting, eat a healthy diet consisting of fresh vital foods with elimination of excess fat and sugar, drink filtered or distilled water, and exercise regularly. I would also advise you to investigate some form of meditation where you quiet the mind perhaps while listening to soft music or perhaps while walking in nature, to allow the daily stresses to dissolve. Take time also to listen to your inner guidance for solutions to your stressful situations. And above all, celebrate and enjoy life, for in the enjoyment of the simple pleasures, we are renewed and rejuvenated in our body and soul.
Gravity
One prominent cause of aging is due to the effect of gravity. As you study the difference in facial features between the extremes of age, you see a drooping of certain areas of the face and neck frequently. Such areas include the jowls or lower cheeks, the neck or "turkey wad", the chin, the nose, the eyebrows and forehead, and the upper and lower eyelids.
Plastic surgery has various techniques designed to rejuvenate the face once gravity has caused these areas to droop and thus form the folds and deeper wrinkles associated with aging. No other form of facial rejuvenation such as chemical peel is effective in treating these drooped areas once formed.
Plastic surgery techniques include facelift which typically elevates the cheeks, jowls, and neck. Facelifts remove excess skin from the lower face and neck through incisions around the hairline and ear area and underneath the chin. Typically deeper layers including the muscles are tightened to help prevent recurrent drooping of facial tissue. Facelifts are rarely necessary before age 40 and are usually performed in men and women when they have sufficient laxity of tissue to justify the small but real risk of surgery.
Sometimes a chemical peel can achieve some tightening of tissue and thus delay the time when facial laxity would only be corrected with a facelift. The neck, however, cannot be treated with a deep chemical peel due to potential complications, so this area is best treated with a facelift. On occasion, usually in men who do not object to a visible neck scar, excess neck skin can be removed directly. This scar is much more prominent and visible than the usual facelift scars. Facelifts usually last from 5 to 10 years although some patients with poor skin elasticity notice a recurrence of facial drooping sooner. Usually the second facelift is longer lasting.
Other areas which are susceptible to gravity include the chin and nose. Elevation of the chin directly or elevation using a prosthetic implant produces a more youthful appearance. Many different techniques are available and the particular technique best suited to your bone structure and appearance is best discussed with a plastic surgeon. Incisions are placed inside the mouth or under the chin. Elevation of the nose including the nasal tip can usually be accomplished through incisions hidden inside the nose.
One early sign of facial aging is around the eyes and brow area. Perhaps this is due to the thinner tissues of the eyelids and their constant motion compared to other areas of the face. Most people show their first signs of facial aging around the mid 30's when the eyebrows begin to droop. You can see for yourself if your eyebrows are drooped by elevating the outer half of the eyebrows while looking in the mirror. Do you see the small fold of excess skin of your upper eyelid become less prominent?
Drooping of the brow has several effects including a shift in position of the eyebrow, especially the outer half, drooping of the tissue of the eyelids due to pressure of the brows on the thinner skin of the upper eyelids, and horizontal forehead wrinkles due to constant elevation of the forehead muscles in order to relieve this pressure from the drooped brows. Vertical forehead wrinkles are usually due to overactivity of certain muscles and will be discussed later under expression lines.
The treatment for drooped brows is a forehead lift. This is usually performed by making an incision across the top of the scalp and lifting the tissues of the brow and forehead. The overactive muscles can be removed and the elevation of the forehead and brow helps eliminate the horizontal forehead wrinkles after a browlift. Often crows feet are softened or eliminated. There is less upper eyelid skin to remove after elevation of the brow and in some patients a browlift is all that is required to correct aging around the eyes.
For drooping of the upper eyelids not corrected with a browlift, or in patients who prefer less surgery, an eyelid lift or blepharoplasty is possible. Excess skin and fat is removed from the upper eyelid and the incision is mostly hidden in a natural crease. Some insurance policies will cover the costs of an upper eyelid blepharoplasty or a browlift if visual field tests by an ophthalmologist or optometrist are abnormal. If you have a moderate to severe amount of hooding of the brow and upper eyelid skin that may be obstructing your vision off to the side, you may consider having this test performed.
For drooping of the skin and treatment of the fatty bulges that develop in the lower eyelid area, a lower eyelid lift or blepharoplasty may be helpful. This procedure removes excess skin, muscle, and fat from the lower eyelid. The incision is usually made just under the lash line and usually heals with minimal scarring. Sometimes the incision can be made through the conjunctiva, or pink tissue on the inside of the eyelid, if there is only fat to remove.
Depending on your particular facial structure, gravity is more likely to take its toll in one area before another. Although one cannot neutralize gravity, various methods exist to counteract its effects.
Expression Lines
The next category of facial aging involves expression lines. These lines form due to facial muscle activity such as squinting and smiling and are mostly prominent around the eyes and mouth.
Preventive measures include wearing sunglasses to avoid squinting and never smiling or laughing. Only so much prevention is possible, however, and I would not recommend limiting your facial expression, unless that expression is that of frowning. Treatment for facial expression lines depends on the position and depth of the line. Lines that are less deep may be treated with a chemical peel. Medium deep lines are treated with placement of fat, dermis, or filler materials such as collagen and fibrel under the crease. Some of these materials last longer than others. Deeper lines are usually treated with surgery such as facelifts, and eyelid and brow lifts.
Inherited Facial Features
Inherited facial features can contribute to premature aging. Lack of adequate bony support in the area of the upper cheeks can cause premature drooping of the lower eyelids. This can be corrected with malar or cheek implants at the time of the lower eyelid lift so the condition will be less likely to recur. Upper eyelids are more likely to droop with inadequate bony support of the brow.
Fatty deposits in the cheeks and under the chin can contribute to a plumper, older appearing face. These can be corrected using facial liposuction and/or the removal of the cheek fat pad through an incision made inside the mouth. A thinner more youthful appearance results from sculpturing the unwanted fat from the face. If the skin is still elastic, it will redrape without needing more extensive plastic surgery procedures which remove excess skin.
Balance of facial features such as the chin and nose creates a youthful appearance. In some people, plastic surgery procedures are done to create fuller lips or reduce lips that are too full in order to restore balance to the face.
Stress
The last cause of facial aging I would like to discuss is stress. Researchers studying aging have discovered that aging often occurs in spurts. You may have noted this in yourself or your friends when you see signs of accelerated aging after particularly stressful times. If you don't believe me, look at pictures of our former presidents before and after their 4 to 8 year terms.
One field of research that I feel is largely unexplored is that of the effect of stress reduction techniques on aging. The ability to reduce stress through daily practices such as exercise, yoga, and meditation can produce remarkable delays in facial aging and may even reverse some already established signs of facial aging. Of course a healthy diet including use of distilled or filtered water is also advisable, for the skin acts as a secondary organ for the elimination of unwanted material from the body. Dermatologists have long been able to study the effect of various diseases and malnutrition by the appearance and quality of the skin.
So what can you do to maintain your youthful skin and face? Avoid sun exposure, use a sunblock of S.P.F. 15 or higher, wear sunglasses to avoid squinting, eat a healthy diet consisting of fresh vital foods with elimination of excess fat and sugar, drink filtered or distilled water, and exercise regularly. I would also advise you to investigate some form of meditation where you quiet the mind perhaps while listening to soft music or perhaps while walking in nature, to allow the daily stresses to dissolve. Take time also to listen to your inner guidance for solutions to your stressful situations. And above all, celebrate and enjoy life, for in the enjoyment of the simple pleasures, we are renewed and rejuvenated in our body and soul.
Prevention and Treatment of Sun-Damaged Skin
What causes facial aging? What can we do to prevent facial aging, and once established how can the damage from facial aging be corrected?
Facial aging is a result of a combination of factors, many of which are avoided with some awareness and preventive measures. A largely preventable cause of facial aging is called photoaging, or damage from sun exposure. Even if you are not a sun worshipper, cumulative exposure to sun over a lifetime can take it's toll. The once pink and fresh quality of the skin turns more yellow and sallow appearing, just as fabric on your furniture that is constantly sun exposed turns pale and yellow.
To avoid this chronic exposure of sun, we recommend a makeup with a sunscreen or sunblock built into the base. This provides yearlong protection. For those occasions that call for extra protection, use a sunblock with a 15 or higher rating applied prior to the makeup on all sun exposed surfaces. Photoaging appears as the yellow, sallow change in the skin, but may also result in multiple fine wrinkles, blotchy pigmentation spots, and a dried out or leathery appearance to the skin.
Prevention of course is the best course, but if you find yourself with sun damaged skin, there are several treatments available. In addition to a vigorous prevention program to avoid any further damage, we recommend a treatment program with Retin-A, often using a glycolic acid cleanser to loosen surface skin cell connections, so that the Retin-A is more effective. Retin-A or tretonin is a medication that helps to return the epidermal skin cells (or those cells on the skin surface) to normal after they are sun damaged. There is some evidence that Retin-A may help prevent skin cancer due to this effect. Currently Retin-A is only approved for the treatment of acne, but dermatologists and plastic surgeons have noted some improvement in the fine wrinkles and other signs of photoaging probably as a result of the changes of the epidermal cells at the skin surface.
Retin-A is used at night after your makeup is removed. A low concentration (0.025% to 0.01 %) is usually prescribed followed by a gradual increase in strength up to 0.1% in order to see full benefits from the treatment. As Retin-A can be irritating to the skin with redness and dryness, a moisturizing program usually twice daily is necessary. Retin-A makes the skin very susceptible to sun damage, therefore a sunscreen program must be started at the same time. Retin-A's effects take several weeks to months, but clinical benefits include improvement in blotchy pigmentation, smoother texture, decreased pore size, softening, or even resolution of fine wrinkles. We believe new fresher skin may also be less prone to superficial skin cancers.
Another program that helps with photoaging is glycolic acid. Glycolic acid is a weak acid found naturally in sugarcane, that acts as a super moisturizer to help reduce the dryness caused by sun exposure, helps to remove superficial pigmentation or brown spots, helps to even out the epidermal or skin surface, and helps to reduce pore size. It does not appear to have the benefit of Retin-A in repairing damage that may cause skin cancer. Glycolic acid is placed in various products supplied for daily use on the face. The most effective program consists of daily treatment with a general glycolic acid facial cleanser for two to three weeks prior to a glycolic acid peel at a higher strength. The glycolic acid peels are performed by trained personnel usually in plastic surgery or dermatology offices. A series of peels given at one to two week intervals is recommended for optimal results.
The advantage of glycolic acid peels, compared to other facial peels, is that after neutralization, the surface changes consist usually only of some mild to moderate redness. Makeup can usually be applied after the peel and no special precautions are needed. For this reason, we are able to use this peel on women of color with virtually no risk of pigmentation irregularities, often seen with deeper peels. Not all brown spots and pigmentation problems respond to glycolic acid peels, however. This is why your dermatologist and/or plastic surgeon evaluates your skin prior to recommending a particular skin program.
For more severe photoaging with leathery skin and deeper wrinkles, a deeper chemical peel is needed. The depth of the skin damage determines the depth of the chemical peel needed to correct the damage. A chemical peel of medium depth usually involves T.C.A. or trichloracetic acid which is a stronger acid than glycolic acid. This acid is applied to the facial skin alone or in combination with other agents, in order to create a deeper degree of peel.
After a T.C.A. peel there is usually a more noticeable degree of redness and superficial blistering and peeling of the skin surface similar to a severe sunburn. After five to ten days, the epidermal or surface layer regenerates as a smoother and more even skin surface with less blotchy pigmentation. It is critical not to expose this delicate new skin to the sun. Inadvertent sun exposure can lead to complications of blotchy pigmentation, irregularities, and the need for additional chemical peels to correct these problems. A moisturizer program is also advised after a peel and many dermatologists and plastic surgeons pretreat peel patients with Retin-A for two to six weeks to help reduce potential unevenness of the peel due to thickened, dried epidermal skin cells.
For those patients with severe sun damage, a phenol chemical peel may be advisable. This peel has several ingredients of which the main one is phenol which produces a deeper peel that is used to treat deeper wrinkles. The disadvantage of this peel is the length of recovery (usually seven to fourteen days) during which wound care to the face is needed, and the persistent redness of the skin for many months after the peel. As sun exposure is very detrimental to the newly formed skin, this peel is usually performed in the fall or winter so some healing has taken place prior to the sun intensive seasons. Neither T.C.A. or phenol peels would be performed on patients who are taking Accutane for acne.
As there are many factors to consider in choosing a peel including skin type, depth of wrinkles, skin pigmentation, pre-existing skin conditions such as acne, skin sensitivity, pore size, and lifestyle as well as many types and subtypes of peels available, evaluation by a plastic surgeon or dermatologist is advisable.
If facial aging is more severe, a plastic surgeon also has a variety of surgical procedures to correct other aspects of facial aging such as those due to gravity, expression lines, and localized fat deposits in the cheeks or under the skin.
Facial aging is a result of a combination of factors, many of which are avoided with some awareness and preventive measures. A largely preventable cause of facial aging is called photoaging, or damage from sun exposure. Even if you are not a sun worshipper, cumulative exposure to sun over a lifetime can take it's toll. The once pink and fresh quality of the skin turns more yellow and sallow appearing, just as fabric on your furniture that is constantly sun exposed turns pale and yellow.
To avoid this chronic exposure of sun, we recommend a makeup with a sunscreen or sunblock built into the base. This provides yearlong protection. For those occasions that call for extra protection, use a sunblock with a 15 or higher rating applied prior to the makeup on all sun exposed surfaces. Photoaging appears as the yellow, sallow change in the skin, but may also result in multiple fine wrinkles, blotchy pigmentation spots, and a dried out or leathery appearance to the skin.
Prevention of course is the best course, but if you find yourself with sun damaged skin, there are several treatments available. In addition to a vigorous prevention program to avoid any further damage, we recommend a treatment program with Retin-A, often using a glycolic acid cleanser to loosen surface skin cell connections, so that the Retin-A is more effective. Retin-A or tretonin is a medication that helps to return the epidermal skin cells (or those cells on the skin surface) to normal after they are sun damaged. There is some evidence that Retin-A may help prevent skin cancer due to this effect. Currently Retin-A is only approved for the treatment of acne, but dermatologists and plastic surgeons have noted some improvement in the fine wrinkles and other signs of photoaging probably as a result of the changes of the epidermal cells at the skin surface.
Retin-A is used at night after your makeup is removed. A low concentration (0.025% to 0.01 %) is usually prescribed followed by a gradual increase in strength up to 0.1% in order to see full benefits from the treatment. As Retin-A can be irritating to the skin with redness and dryness, a moisturizing program usually twice daily is necessary. Retin-A makes the skin very susceptible to sun damage, therefore a sunscreen program must be started at the same time. Retin-A's effects take several weeks to months, but clinical benefits include improvement in blotchy pigmentation, smoother texture, decreased pore size, softening, or even resolution of fine wrinkles. We believe new fresher skin may also be less prone to superficial skin cancers.
Another program that helps with photoaging is glycolic acid. Glycolic acid is a weak acid found naturally in sugarcane, that acts as a super moisturizer to help reduce the dryness caused by sun exposure, helps to remove superficial pigmentation or brown spots, helps to even out the epidermal or skin surface, and helps to reduce pore size. It does not appear to have the benefit of Retin-A in repairing damage that may cause skin cancer. Glycolic acid is placed in various products supplied for daily use on the face. The most effective program consists of daily treatment with a general glycolic acid facial cleanser for two to three weeks prior to a glycolic acid peel at a higher strength. The glycolic acid peels are performed by trained personnel usually in plastic surgery or dermatology offices. A series of peels given at one to two week intervals is recommended for optimal results.
The advantage of glycolic acid peels, compared to other facial peels, is that after neutralization, the surface changes consist usually only of some mild to moderate redness. Makeup can usually be applied after the peel and no special precautions are needed. For this reason, we are able to use this peel on women of color with virtually no risk of pigmentation irregularities, often seen with deeper peels. Not all brown spots and pigmentation problems respond to glycolic acid peels, however. This is why your dermatologist and/or plastic surgeon evaluates your skin prior to recommending a particular skin program.
For more severe photoaging with leathery skin and deeper wrinkles, a deeper chemical peel is needed. The depth of the skin damage determines the depth of the chemical peel needed to correct the damage. A chemical peel of medium depth usually involves T.C.A. or trichloracetic acid which is a stronger acid than glycolic acid. This acid is applied to the facial skin alone or in combination with other agents, in order to create a deeper degree of peel.
After a T.C.A. peel there is usually a more noticeable degree of redness and superficial blistering and peeling of the skin surface similar to a severe sunburn. After five to ten days, the epidermal or surface layer regenerates as a smoother and more even skin surface with less blotchy pigmentation. It is critical not to expose this delicate new skin to the sun. Inadvertent sun exposure can lead to complications of blotchy pigmentation, irregularities, and the need for additional chemical peels to correct these problems. A moisturizer program is also advised after a peel and many dermatologists and plastic surgeons pretreat peel patients with Retin-A for two to six weeks to help reduce potential unevenness of the peel due to thickened, dried epidermal skin cells.
For those patients with severe sun damage, a phenol chemical peel may be advisable. This peel has several ingredients of which the main one is phenol which produces a deeper peel that is used to treat deeper wrinkles. The disadvantage of this peel is the length of recovery (usually seven to fourteen days) during which wound care to the face is needed, and the persistent redness of the skin for many months after the peel. As sun exposure is very detrimental to the newly formed skin, this peel is usually performed in the fall or winter so some healing has taken place prior to the sun intensive seasons. Neither T.C.A. or phenol peels would be performed on patients who are taking Accutane for acne.
As there are many factors to consider in choosing a peel including skin type, depth of wrinkles, skin pigmentation, pre-existing skin conditions such as acne, skin sensitivity, pore size, and lifestyle as well as many types and subtypes of peels available, evaluation by a plastic surgeon or dermatologist is advisable.
If facial aging is more severe, a plastic surgeon also has a variety of surgical procedures to correct other aspects of facial aging such as those due to gravity, expression lines, and localized fat deposits in the cheeks or under the skin.
Laser Breast Reduction
Dr. Grant Stevens, Medical Director of Plastic Surgery Associates, has performed hundreds of breast reduction operations for women who share many similar experiences. He has observed a dramatic increase in the number of patients seeking breast reduction surgery. Although the procedure is not new, traditional reduction mammoplasty has had its drawbacks, including loss of nipple sensation, inability to breast feed, prolonged surgical time, blood loss that sometimes requires transfusion, and poor cosmetic results. Dr. Stevens has helped to refine the surgical techniques in order to minimize these concerns using laser. Women have breast reduction surgery for many reasons. Many complain of pain and soreness of the back, shoulders and neck, while others experience pain and indentations from bra straps. Women who are active in athletics often experience soreness from the constant weight shifting during their activities.
The psychological aspects of very large breasts are also compelling. Women understandably feel self-conscious when their breasts are the focal point of attention. Many women experience difficulty finding fashionable clothing. Some are forced to split sizes and may avoid wearing bathing suits and other clothing altogether. Overall, these experiences may have serious negative effects on a woman's self-esteem.
Dr. Stevens assures women considering laser breast reduction that sensation to the nipple is rarely lost and, in fact, often times increases once the heavy breast tissue is removed. In addition, since the nipples are not detached during laser breast reduction surgery, the overwhelming majority of patients are able to breast feed their children.
Laser breast reduction surgery is performed under general anesthesia. The incisions are made horizontally and vertically, adhering to the natural contours and folds of the breast. The laser is then used to preserve the pedicle of breast tissue that supports the nipple. The entire breast is lifted along with the nipple that remains attached to the breast at all times. Excess tissue, fat and skin are removed from the sides of the breast. Once the breast is repositioned properly and the excess tissue removed, the incisions are closed with dissolving sutures placed beneath the skin. With this technique, there are no cross-hatches or stitch marks visible and no need for sutures to be removed. Most women experience minimal post surgical discomfort and generally a quick recovery period. Women frequently return to work in one week and resume full activities in 2-3 weeks.
Dr. Stevens not only reduces the size but also aesthetically sculpts the breast when performing the laser breast reduction. He is actually able to "sculpt" and lift the breast for optimum aesthetic appearance and balance within the overall structure of the patient's body contours. This "liposculpting" is done over the chest and armpit area. This cosmetic sculpting not only improves the appearance of the final breast reduction, but also minimizes the size of the incisions. While reduction mammoplasty is still performed primarily for medically indicated situations, more women are electing to have this surgery for cosmetic purposes.
Laser breast reduction, along with liposculpting of the breast, has resulted in decreased surgical time, minimized scarring, decreased blood loss, preservation of nipple sensation and a natural lifting of the breasts. With the addition of the laser and breast liposculpture, breast reduction surgery achieves the goals of relieving the pain and suffering while beautifying the natural form and contour of the breast.
The psychological aspects of very large breasts are also compelling. Women understandably feel self-conscious when their breasts are the focal point of attention. Many women experience difficulty finding fashionable clothing. Some are forced to split sizes and may avoid wearing bathing suits and other clothing altogether. Overall, these experiences may have serious negative effects on a woman's self-esteem.
Dr. Stevens assures women considering laser breast reduction that sensation to the nipple is rarely lost and, in fact, often times increases once the heavy breast tissue is removed. In addition, since the nipples are not detached during laser breast reduction surgery, the overwhelming majority of patients are able to breast feed their children.
Laser breast reduction surgery is performed under general anesthesia. The incisions are made horizontally and vertically, adhering to the natural contours and folds of the breast. The laser is then used to preserve the pedicle of breast tissue that supports the nipple. The entire breast is lifted along with the nipple that remains attached to the breast at all times. Excess tissue, fat and skin are removed from the sides of the breast. Once the breast is repositioned properly and the excess tissue removed, the incisions are closed with dissolving sutures placed beneath the skin. With this technique, there are no cross-hatches or stitch marks visible and no need for sutures to be removed. Most women experience minimal post surgical discomfort and generally a quick recovery period. Women frequently return to work in one week and resume full activities in 2-3 weeks.
Dr. Stevens not only reduces the size but also aesthetically sculpts the breast when performing the laser breast reduction. He is actually able to "sculpt" and lift the breast for optimum aesthetic appearance and balance within the overall structure of the patient's body contours. This "liposculpting" is done over the chest and armpit area. This cosmetic sculpting not only improves the appearance of the final breast reduction, but also minimizes the size of the incisions. While reduction mammoplasty is still performed primarily for medically indicated situations, more women are electing to have this surgery for cosmetic purposes.
Laser breast reduction, along with liposculpting of the breast, has resulted in decreased surgical time, minimized scarring, decreased blood loss, preservation of nipple sensation and a natural lifting of the breasts. With the addition of the laser and breast liposculpture, breast reduction surgery achieves the goals of relieving the pain and suffering while beautifying the natural form and contour of the breast.
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