THE FACELIFT

Welcome to the 21st Century

Facial aging is a complex process related to changes in several tissues and structures in the face and neck. For over a century, it has been well known that skin relaxes and becomes redundant in people as we age. The first attempts to rejuvenate the face, in earlier days, were to remove the redundant skin excess. As a result, limited improvement was obtained by eliminating some of the signs of aging, which mainly manifested in the lower face and the neck. This kind of limited skin excision was able to raise, somewhat, the eyebrows; moderately tighten the face; and many times improve the neck in a substantial fashion. During all those years, including the decade of the 60s, facial rejuvenation was then restricted to what was called skin facelift; that is, making incisions in front of the ear, sometimes inside the scalp and around the ear onto the neck, separating the skin from the muscle and then pulling the skin up in order to remove any excess. The benefits of this procedure were limited, mainly in the central portion of the face, where the aging process is related to other causes, which we will soon describe, and also need to be corrected in order to rejuvenate the face. The other two components of facial aging, besides the increased skin laxity secondary to loss of collagen and elastic fibers, are (1) reabsorption of fat, not only subcutaneous fat (the fat under the skin) but also the deep fat deposits that give shape to the face, and (2) involution, i.e. decrease in size of the facial bones. Depending on a person’s genetics, some of these processes are more noticeable than others. Usually, early aging of the face starts with reabsorption of fat from around the eyes and on the cheeks, creating what is called a “tear-trough,” drooping of the malar fat pad and sinking of the mid-face. Facial lines secondary to thinning of the skin, absorption of the fat and hyperactivity of the muscles on the forehead, or the upper third of the face, can be noticeable in some people sooner, although in other people later, in life. Finally, aging of the lower third of the face, meaning everything located below the upper lip, including the jawline and the neck, usually is secondary somewhat to fat atrophy and bone resorption, but mainly laxity of the skin. As you can imagine, because aging is secondary to different processes, different treatments need to be utilized in order to rejuvenate the face. Wrinkles in the upper third of the face (i.e., the forehead), can be easily treated with Botulinum toxin (Botox, Dysport, etc). These treatments are very effective; however, not all patients are interested in them because they need to be repeated 2-3 times a year and they are somewhat expensive. Surgery on the forehead is mainly aimed at raising the eyebrows, but can do little for the wrinkling of the forehead and between the eyes, which occur secondary to years of repetitive facial expressions, like frowning. Both treatments are indicated according to the patient’s needs. Regarding the eyelids, the skin excess on the upper eyelid is usually manifested by a skin fold that can drape over the eyelashes on the upper lid, and bags protruding below the lower lids, where there may be a component of excess skin as well. These problems can be addressed with a blepharoplasty that consists of removal of excess skin and fat from both upper and lower eyelids. The mid-face is the area in which surgery has gained the most ground in recent decades, because it has been observed that most of the aging of the mid-face is secondary to fat resorption from the deep and superficial compartments, and not because of relaxing of the skin. This area is now treated with fat grafting in order to replenish subcutaneous fat and correct the deformities that occur secondary to fat atrophy. Furthermore, discovery of the presence of stem cells in the adipose tissue itself has refined this procedure. It can now be performed in more consistent and effective ways by adding, to the fat, stem cells contained in the stromal-vascular fraction, which is the structure of the fat tissue that can be isolated, with proper techniques, from the patient’s own fat. So, combining the patient’s own fat with his/her own stem cells makes these procedures more effective at correcting the problems and provide long-lasting results. With the fat grafting combined with stem cells in the mid-face, we can correct the tear-trough deformity, which is the visible contour of the inferior border of the orbit, as well as raise the cheeks and correct the depressions in the mid-face, all of these symptoms that lead to what is called “skeletonization” of the face, and which are changes that are very easy to observe as people age and reach older stages in their lives.

The lower face is treated with more conventional procedures, i.e., removal of skin, removal of fat from the neck and tightening of the muscles of the area. However, it is important to remark that a conventional facelift, which just treats the skin and muscles, will not provide, in many patients, noticeable or satisfactory facial rejuvenation if all the problems created from the fat atrophy are not addressed. The lips also get smaller over time, and can be enlarged with different fillers, and the lines that appear around the mouth and around the eyes, as well as sometimes on the cheeks are treated with new laser resurfacing. Of course, all of these procedures can be performed at one time or in different stages, according to the patient’s needs and desires. Usually, for a full facial rejuvenation, the recovery time would be between 7-10 days, if no laser rejuvenation is performed; if the patient needs a more intensive treatment of the skin with the laser, recovery time may be 3-4 weeks. Rejuvenation of the face with fat grafting could have a 7-day recuperation. A smaller facelift, such as when only the neck is addressed, could also allow the patient to return to work in a week. Finally, ancillary procedures to address significant bone resorption are the placements of implants, not only in the chin but also in the cheeks, although these are not the most common procedures performed these days.

We are presenting in this blog a case that was performed approximately a year ago, in which the benefits of the above-mentioned surgery can be clearly observed. The surgery on the eyes, the neck and the face combined with a brow lift and fat grafting of the mid-face, has remarkably rejuvenated this patient’s face, making her really more confident and happy. In this practice, we specialize in fat grafting combined with stem cells, which provide better, long-lasting results. We are excited and enthusiastic about this procedure, which appears to be one of the most helpful and innovative techniques in the last 2 years in the evolution and improvement of plastic surgery.

LIPOSUCTION UPDATE

Removal of fat from different areas of the body by inserting a cannula through small incisions in the skin was first formally described in the early 1980s by French surgeons. They demonstrated that fat could be extracted from under the skin, helping to improve the contour of the body, without the need for performing large incisions and removing portions of skin along with the fat. Before the era of liposuction, contouring of the body in the different areas was only achieved by making large incisions and removing the overlying skin along with the underlying fat, resulting in large scars and many times severe deformity. This new technique, then called liposuction, allowed for removal of only the fat, thereby creating a latticework of vessels and fibrous tissue that kept the skin attached to the deep fascia, allowing the skin to retract and re-contour to the new given shape of the area. When originally described, the surgery was performed with cannulas that were up to a half-inch in diameter. Because of this large width of the cannulas, they could not be used close to the skin surface, so liposuction could only be performed in the deep fat compartments to avoid creating wavy, irregular skin surface contours. Years later, surgeons realized that fat could be extracted with thinner cannulas, and the use of thinner instruments allows us now to perform more superficial liposuction procedures, now referred to as liposculpture. Liposculpture was then performed, as we do these days, closer to the skin, in the superficial fat compartments, but of course always with care not to take too much fat from under the skin, which could lead to indentations and severe deformities that are impossible to correct once they are unfortunately created.

Another big advance in liposculpture/liposuction technique was the introduction of tumescent anesthesia. Tumescent anesthesia is the infiltration of large amounts of fluid under the skin, in the fat, which is done before performing the liposuction. This solution contains substances that largely decrease the bleeding and also provide a local anesthetic effect that allows the procedure to be performed under local anesthesia. There is no doubt that this “wet” liposuction is the way to go, whether you want to perform the procedure under local anesthesia or under general anesthesia. In the case of general anesthesia, the benefit of the tumescent technique is not only decreased bleeding during the procedure, but also patient comfort when the patient wakes up and recovers from the general anesthesia. It is my experience that when performing several areas of liposuction at the same time on one patient, it is better to use either a “twilight” or general anesthetic so as to be able to perform a complete and intense surgery without having to stop it because of patient discomfort.

Having described the basic principles and technique for liposuction/liposculpture, what follows is a discussion of the newer equipment that has allowed us to improve our results. The first requirement for liposuction is the machine that generates ultrasonic waves. Ultrasonic liposuction is performed with equipment that generates a specific frequency of ultrasonic waves that has the particular ability to melt fat. The use of this equipment also decreases the bleeding and allows the surgeon to work closer to the skin, heating the undersurface of the dermis, not only removing more fat but also allowing better sculpture of the different treated areas. Some of the fat that is not even removed when we complete the procedure with the traditional liposuction will be reabsorbed by the body over time because it has already been liquefacted and the fat cells “damaged” by the ultrasonic waves.

Laser liposuction, often called “Smart Lipo,” utilizes a specific wavelength of laser that is delivered to the tissues with a fiberoptic cannula before liposculpture is performed. The goals are the same as ultrasonic liposuction; i.e., to melt the fat, warm up the skin and stimulate skin retraction and better contouring. Like anything else, each of the above-mentioned techniques has specific indications depending on the area of the body that is being treated. Ultrasonic liposuction is excellent for large areas, like the abdomen and back, while laser liposuction is optimal for smaller areas with thinner skin and less fat. A good example of the benefits of laser liposuction can be seen in the following pictures, where a patient’s neck was treated using this technique.

The ideal candidate for liposculpture is someone with localized fat; someone who is not extremely obese and has not lost massive amounts of weight, allowing the skin to retract when the excess fat is removed with the liposculpture. So basically we can say that liposculpture is ideal for patients who have localized adiposity, who cannot lose these adipose deposits with diet or exercise. Stretching the indications, some moderately obese patients can be helped with liposuction, and even some diseases that are related to weight and excess fat, like diabetes, have been proven to improve with liposuction.

Other equipment we use in our practice is Power Liposuction. This equipment allows the cannula to vibrate at the time that we are performing the liposculpture, allowing for gentle removal of the fat, making the procedure less traumatic for the patient and easier for the surgeon, who in this way can work longer on the patient and remove virtually all the fat that needs to be removed. As an easy-to-understand analogy, it would be like the difference between using a manual screwdriver versus using a power screwdriver. Everybody knows how much easier and less fatiguing it is to perform tasks with power instruments versus manual instruments. As mentioned, vibration of the cannula also induces melting of the fat and allows a more intense and complete liposculpture.

In our surgery center, there is no limit of how much fat can be removed, since the regulations for ambulatory surgical centers are different from the regulations for in-office surgery. Of course, we take into consideration the safety of the patient and the fat is removed according to the patient’s needs, but patient safety is our priority.

Depending on the treated areas, the recovery period could be from 4 days, if just the torso is treated, up to 7 days if liposculpture of the lower extremities or the arms is involved. Most of the procedures are ambulatory, meaning that the patient can go home the day of the surgery. However, for special conditions or larger liposuction treatment, we have available a suite in the same building complex for the patient to stay overnight with a nurse, and then be discharged home the next morning. after liposuction, because of the tumescent anesthesia infiltration, it is common for the small incisions performed in the skin to continue leaking some reddish fluid, which is a mix of tumescent solution with fairly small amounts of blood, so sometimes patients who don’t have enough assistance at home, or who those might who have anxiety about this, feel more secure if they stay with somebody with experience in the postoperative care of liposuction patients, someone who can assure their wellbeing, take care of the dressings and help them more easily manage any postoperative discomfort they might have.

finally, liposuction needs to be understood as a safe procedure but it needs to be performed properly and carefully by a well-trained and experienced practitioner, and also deserves to be respected for what it is, which is surgery, in order to prevent and avoid any complications.

LASER HAIR REMOVAL WITH THE CANDELA ND:YAG

In our innovative use of the ND:YAG laser for hair removal, we have had notable results in patients with dark or pigmented skin which is prevalent in South Florida. Most of the lasers currently available are difficult to use in darker skinned patients without burning the skin. The ND:YAG laser, manufactured by Candela, has a special cryogen spray to cool the skin and prevent possible skin burns in these darker skinned patients.

The laser light is absorbed by melanin that is associated with the hair. In the melanin, the laser energy travels down the hair shaft into the hair bulb where the blood supply is localized. When the laser energy is absorbed it is converted into heat energy. This raises the temperature of the bulb and causes the blood vessels that supply nutrients to the bulb to be cauterized. As a result, the hair follicle dies and hair growth is stunted. This is a selective process – it does not damage the epidermis or the surrounding tissues which are protected by the cooling cryogen spray.

Hair grows in a cyclic, nonsynchronized fashion. Therefore, at any given time, each hair is at a different stage of the growth process and is subject to varying degrees of response with the laser. Usually patients require up to 5 treatments to achieve the desired effect.

Here are pictures of the axilla in which we treated 3 round spots in a dark skinned patient. It is clear that the treated areas had no hair growth after 3 weeks while the surrounding areas showed normal hair growth.

LOWER EYELID “BAGS” AND MALAR “FESTOONS”

Lower eyelid “bags” and malar “festoons” are very unsettling signs of mid-face aging that occur in some people.  As we all know, one of the first areas affected by the aging process is the mid-face.  This area comprises the middle third of the face and includes the area whose upper limit is delineated by an imaginary horizontal line drawn at the level of the glabella (between the eyebrows), and whose lower limit is delineated by another imaginary horizontal line drawn below the tip of the nose.  In this mid-facial area, we find the eyes, the nose and the cheeks.  This area of the face ages soonest, and causes deformities that are the most difficult to correct.

In a young face, there is no step-off at the curvature of the cheek where it joins the lower eyelid.  Youthful, healthy fullness in this area is attributable to the presence of fat under the orbicularis oculi muscle (the muscle that surrounds the eye), and the fat that is inherent in the cheek itself.  During the aging process, this fat is resorbed by the body and disappears.  Although the reason for this is unknown, it happens to everyone at some point.  The timing is different for different people, presumably based at least partially on one’s genetic tendencies.  As a result of these changes, one of the first signs of mid-face aging is the appearance of a fold that divides the lower eyelid from the cheeks, referred to by plastic surgeons as the “tear trough.”  This “valley” visually separates the lower eyelid from the cheek.  Depending on the patient, it may be accompanied by protrusion of the lower eyelid fat pad, creating what people describe as lower eyelid bags.  However, in other people, there is residual fat accumulation on top of the cheekbone, bordered by a depression created in the tear-trough area and in the center of the cheek.  Having this condition, a sulcus is also formed in front of the malar bone/cheek eminence, causing a festoon.  This condition makes the residual fat accumulation on top of the cheek bone even more noticeable.  Many people consult physicians because they think they have bags under their lower eyelids.  Unfortunately, many times they are misdiagnosed, and end up undergoing a lower eyelid blepharoplasty that does little, if anything, to solve the problem of the festoon.  In these cases, what the patients need, in addition to a special technique to release and re-shape the lower eyelid, is removal of the residual fat on top of the malar bone eminence with filling of the tear-trough indentation, in order to create a smooth surface and for the indentation to disappear. In Figure 1, arrows highlight the malar festoons, the tear troughs and the lower eyelid fat bags.

In order to correct these deformities, we need to remove the fat from the malar festoons, fill the tear troughs, secure and tighten the lower eyelids and remove some redundant skin from the lower eyelid as well.  This delicate surgery is performed with a very tiny micro-cannula used to suction the unwanted fat from the malar festoon; the fat is then injected into the tear troughs, where it is needed.  A lower blepharoplasty with a transconjunctival approach is performed in addition, in order to remove the lower eyelid bags and release the muscles and fibers that put traction on the lower lid and pull it down.  The lateral aspect of the lower eyelid, which is tethered to the orbital bone via the canthal tendon, needs to be tightened with a procedure called a canthoplasty, during which the canthal tendon is secured to the periosteum of the lateral orbital rim. Finally, the redundant skin of the lower eyelid can be safely removed to further tighten the area and to correct any possible festoon that is secondary to excess skin and loose orbicularis oculi muscle.

In the case presented in this blog, you see the “before” photos of a patient who then underwent the above-described combined procedure, and the “after” photos that show her results 2 months postoperatively. Recovery from this surgery is similar to the recuperation from a lower blepharoplasty.  The patient needs to apply ice over the course of the first 3-4 days.  Once the stitches are removed, the patient can resume regular activities.

Again, a malar festoon is not corrected with traditional lower eyelid surgery.  This is a more complex condition that requires several surgical maneuvers in order to completely correct it, and to return a youthful appearance to the mid-face.

ENLARGEMENT OF THE BREASTS IN MALES (GYNECOMASTIA)

Gynecomastia is not an uncommon disorder.  It can present in young
males as they go through puberty and the hormone levels in the blood
rise.  The disorder can also be found in older male patients who have
been exposed to extrinsic hormones, like testosterone or estrogen.  In
either case, enlargement of the male breasts occurs, causing them to
resemble female breasts.  This can be further exacerbated by fat
accumulation on the chest, which will worsen the aesthetic situation.
Cases that are not related to hormonal issues s are usually called
idiopathic, which means there is no medical explanation for the
development of the disorder.  However, it is important that a young
patient have a consultation with his pediatrician in order to rule out
any hormonal imbalance he might have.  Once it has been ascertained
that the patient has no endocrine issues, we can proceed with surgical
treatment.

In a young patient who simply develops enlargement of the breasts
without any component of fat surrounding or infiltrating the breasts,
the indicated treatment consists of making a small incision around the
areola and subsequent removal of the gland; the procedure is
technically called a subcutaneous mastectomy.  The removed tissue is
routinely submitted for examination by a pathologist.  At the end of
the surgery, the incision will be closed with resorbable sutures, and
a compression vest will be used for approximately 1-2 weeks until the
swelling in the area subsides, the stitches are absorbed and the wound
has healed, allowing the patient to return to his normal activities.

In other cases, when a fatty component is added to true gynecomastia,
the treatment is different.  This could be the case in a young patient
who is overweight, but is usually seen in older patients.  Breast
tissue has a large component of fat, which can be up to 50% of the
total volume, and also is spread across the entire pectoral (chest)
area.  A combined procedure must be done in order to avoid deformities
of the chest that usually are created when the procedure is not
properly done, and result in severe indentation deformities under the
areolae.  Ultrasonic-assisted lipectomy should be done first to remove
some of the breast tissue and the fat in the area, followed by removal
of the residual breast gland that we then locate under the areola,
which is entered through a small incision performed in that area.  The
procedure starts with infiltration of tumescent solution, the same as
used for liposculpture.  Two small incisions, one on each side
(laterally and medially) of the subpectoral fold (i.e. where the
pectoralis muscle ends), are made, and through those incisions
ultrasonic liposuction is performed, removing as much breast tissue
and fat as possible in order to create a smooth and flattened chest
area.  The residual ?lump? of dense, fibrous breast tissue will then
be surgically removed through a peri-areolar incision.  This part of
the surgery is facilitated by the dissection that was already
performed with the ultrasonic cannula, and allows the surgeon to
smoothly remove the remaining portions of breast tissue, creating a
smooth, regular surface at the end of the surgery.  This combined
approach leads to excellent results and high patient satisfaction.  In
cases in which ultrasonic liposuction is performed, a drain is left in
place to allow for faster healing.  A compression vest is also
utilized.  The drain is usually removed 2-3 days postoperatively.  The
compression vest should be maintained in place for approximately 3
weeks.  Nevertheless, the patient will be ready to go back to school
or work approximately 2-3 days after the surgery is performed.

Finally, there are cases in which, secondary to extreme obesity, the
skin in the area becomes completely stretched, so that in addition to
removing the fat and the breast tissue, the excess skin needs to be
addressed.  These cases are more complex and require different
incisions in order to remove the excess skin.  The most important goal
in this disorder is to achieve a smooth surface at the end of the
procedure, remove the breast tissue and avoid complications that are
nearly impossible to treat once they occur.

If you need further information, do not hesitate to contact our practice!

BREAST REDUCTION WITH IMPLANTS

When the healing of scars cooperate, the results are so nice.

Source: http://www.carlosspera.com/blog/?p=126

MIAMI MOMMY MAKEOVER: BEFORE & AFTER PHOTOS, COST AND SPECIALS

After pregnancy and delivery, a woman finds herself with remarkable changes in her body.  These changes include enlargement of the breasts secondary to hormonal surges and relaxation of the abdominal wall secondary to the stretching of that area from the pregnancy itself.  These changes are distressing to many women, who still remember the bodies they had before they became moms!  Many women come to our office seeking to regain their pre-pregnancy silhouettes.  The most obvious changes occur in the breasts, which become larger and may sag; the tummy, which may develop stretch marks and/or a hanging abdominal “apron” (panniculus); and expansion of the waistline secondary to stretching of the abdominal musculature.

When performed in a safe environment like our exclusive ambulatory surgical center, correction of these problems can be done with just one surgery.  This way, a patient undergoes just one recovery period, and usually by two weeks later she can resume her regular activities, including driving and taking care of her child.

The idea of a “safe environment” means several things.  First of all, we have a state-of-the-art operating room with all the equipment that you would find in a hospital operating room, since, like hospitals, we are regulated by the Department of Health.  Second of all, prior to performing surgery, we perform all the usual and necessary preoperative tests, and, if necessary, seek consultation with the patient’s primary physician in order to authorize and clear the patient for the surgery.  Once we are sure that the surgery can be safely performed, we do so, and we dedicate the entire day to the patient.

Surgery usually begins with a breast lift to achieve the pre-pregnancy contour, but may also include breast reduction and/or insertion of implants to achieve more perkiness or better size.  We balance the amount of tissue that is removed during any reduction with the volume that is added by the implant in order to achieve the final breast size and shape that a patient desires; this is usually a B- or C-cup.  We prefer to use saline-filled implants, which we consider safer.  However, if for some reason a patient prefers to go with silicone gel implants, we will do that.

Once we are finished with the breast reconstruction, we focus on the abdomen.  Sometimes we need to do liposculpture of the abdomen, and may also do liposculpture of the back, combining these procedures with the removal of any excess skin from the abdomen; this is the procedure that people know as a “tummy-tuck.”  Again, this can be safely performed if the patient’s blood counts are monitored before and during surgery, and if you have a properly trained and efficient surgical team that can complete the surgery in a reasonable amount of time.  We also tighten the central abdominal (rectus) muscles to correct the separation of those muscles that occurs during pregnancy; this surgical maneuver helps reduce waist size as well.  In addition to that, removal of fat from the flanks and removal of skin from the lower abdomen trims and enhances the waistline as well.  In our facility, the procedure takes around 6 hours, which is significantly faster than what the Board of Medicine considers to be the standard of care, in terms of time, for these types of combined procedures outside a hospital setting.  A patient usually recovers from the anesthesia within 1-2 hours and can then be discharged home.  However, for comfort and convenience, we also offer the option of transfer to a VIP suite physically connected to our facility, in which the patient can recover the night following surgery.  There, a nurse can provide all the postoperative care and monitoring needed, and keep the patient comfortable.  The nurse has the ability to stay in contact with the physician, who can be rapidly available to evaluate the patient immediately after surgery.

Pictures posted below show “before-and-after” examples of a patient who developed enlarged, sagging breasts, excess fat on the abdomen and back and a large abdominal apron after her pregnancy.  Pictures taken one month later show the quick recovery and the dramatic changes the patient achieved in that short time.