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Category Archives: facial rejuvenation

DERMAPLANING BLOG

By Rebecca Ludwig

Dermaplaning is a client favorite as well as a personal favorite of mine for many reasons.  I call it an instant gratification service, and recommend it before any special event.  The main intention for dermaplaning is to allow better penetration of products, masks, treatments, or peels.  For this reason I perform dermaplaning as part of a full facial treatment.  The technique of dermaplaning involves using a surgical scalpel to ablate the surface layers of dead skin cells and vellus hair. All of the accumulated dry dead flaky skin cells are removed, improving the texture of the skin.  The vellus hair is the peach fuzz that many of us experience in certain areas or all over our faces.  By removing this fuzz the skin looks dramatically brighter.  Dermaplaning is a great option for many clients who are unable to use other methods of hair removal, such as waxing or depilatory creams, due to contraindications from topical cosmeceutical products, such as tretinoin, retinoic acid, retinal, etc. Dermplaning can be performed prior to facial peeling to improve the outcome of the facial peel.  Moisturizes, antioxidants, and humectants are easily absorbed post dermaplaning, leaving the skin feeling baby soft. Treatments are typically repeated every four weeks.  Step it Up with The Lucas Center, give us a call at 865.218.6210 today.

Fat grafting versus filler agents: which is best for facial volume restoration?

tammyinjecting

For many years, facial rejuvenation was limited to skin resurfacing with lasers and peels, and various surgical soft tissue repositioning procedures. However, our options have expanded with the understanding of muscle relaxation via neurotoxins such as Botox, and the evolution of our knowledge of how fat atrophy in the face leads to stereotypical architectural changes with aging. Plastic surgeons can now add volume to refresh the face. In order to achieve a youthful but natural appearance for my patients, I use a combination of muscle balancing, skin resurfacing and tightening as well as volume restoration. Ultimately, when the battle of gravity versus skin plays out over time, surgical repositioning is required.

Let’s examine the question of how best to restore volume in the face.

One option for facial volume restoration is off-the-shelf materials such as hyaluronic acid, in various structural manifestations, as a direct filler. Another option is a polymer of lactic acid (Sculptra), which acts as an inflammatory material inducing collagen synthesis to create a guided tissue volume additive over time. Both are easily administered in the office without any donor site pain or bruising. While these procedures are easy and safe, it takes experienced hands, eyes and judgement to achieve the best outcomes. Results can be expected to last up to two years.

Fat grafting is another source of filler material to restore volume to the face. Fat is easily harvested from the abdomen or the thighs to use in the face. The technique is a gentle form of liposuctioning which then requires a minimal amount of processing followed by reinjection into the desired locations. In the office setting under local anesthesia, patients may not enjoy some of the pressure sensations required to obtain the fat. In an effort not to injure the fat and to prevent fat from being injected into vessels, blunt cannulas are utilized to place the cells into the tissues. This technique causes some degree of pressure sensation as oppposed to a sharp small needle, which can inject off-the-shelf fillers. The advantage of fat is that it is cheaper to obtain than manufactured materials. In most cases, there is a relatively unlimited supply. Furthermore, peripheral stem cells may direct cellular differentiation leading to improved tissue quality.

Fat versus fillers

Fat is certainly more technically demanding and unforgiving. For injections around the eyes to smooth the eyelid cheek junction, I prefer hyaluronic acid. When injected smoothly with appropriate application, no lumps or bumps should occur. In the lips, when I am working to recreate vertical ridges of the phyltral columns of the upper lip and “Cupid’s bow” points as well as a nice rolled margin of the lip, I prefer hyaluronic acid, because it is the consistency of caulking material and can provide shape. Fat is soft, and does not exert force on the skin in the same way as fillers. However, recent research from the University of Texas Southwestern Medical Center demonstrates excellent results of restoring large volume loss of the upper lip beyond the vermillion by placing fat cells in a broad area making the loose skin less apparent.

With regard to the common area of deflation of the sub-malar fat pad in a non-surgical case, I prefer the highly crosslinked stiff material of Voluma which does an excellent job of re-supporting the facial structures to a more youthful position. If I am already performing a surgical case of a face or neck lift, I always add volume to the face prior to elevating the tissue; this is when I choose fat, because of the ease of harvest and injection under anesthesia. Some thin women may show very demarcated loss of volume in the temple area giving the face a skeletonized appearance around the eyes and making the brows seem to sag. This is an excellent indication for Sculptra. If the volume loss exceeds several vials worth of Voluma in the sub-malar fat pad per side, I also prefer to use Sculptra.

Fat grafting is an evolving technique in plastic surgery. Every industry conference has a significant discussion about the techniques and the science behind the results with just about every region of the body applicable to its uses, including face, breast, hand, buttock and other contour deformities. For the early stages of facial rejuvenation, which can occur in the third decade of life and beyond, much of the volume restoration is performed with off-the-shelf filler agents in an office setting due to ease and convenience.

It’s a case-by-case decision.

So when do you use fat versus fillers? It depends. It’s a case-by-case decision to determine the best protocol for each patient. I take a customized approach from the consult to the procedure, based on my unique skill set and my years of experience and training. My goal is to provide the absolute optimal results for each of my patients and to cultivate a lifetime relationship.

Why are Plastic Surgeons uniquely qualified to perform facial analysis and rejuvenation

Board certified plastic surgeons have a very diverse training experience because we do not own a particular body part such as an Orthopedic or an ENT surgeon and we must be prepared to reconstruct or rejuvenate all parts of the body when the demand arises. Those who felt the calling to become plastic surgeons out of medical school realized their gifts and talents that could be offered to patients pertain to their unique skills of three dimensional thinking and artistic perspective to be able to see the problem and formulate a solution no matter how complicated the deformity exists.

I am troubled by the notion that patients think that facial filler agents, neurotoxins, LASERS, non-invasive contouring machines and other technologies or even surgery will work the exact same way no matter who is providing the services. I feel that Madison Avenue and corporate greed is mostly to blame because all aesthetic companies want to sell the product and place it in as many provider hands as possible to deliver their product to the masses. Many products can provide safe, and reproducible results in the right hands but in the untrained provider can result in injuries, poor outcomes and unhappy patients. None of these products are dirt cheap so why go to a clinician who is unable to critically analyze the face or body because of the lack of years of extended training. Remember if you can’t see the problem correctly then you can’t formulate a proper solution. My analogy for this situation is you can give a novice and a true artist the exact same canvas, paint and palate and ask each to create their masterpiece I hazard to guess there will be a distinct difference in outcome and quality. Why risk your face and body or your wallet to chance go to a true trained professional in aesthetic procedures. All providers are not created equal. Plastic surgeon have a unique training and perspective which I can assure you results in better outcomes.

As an example of why I feel uniquely qualified to analyze faces and what can be provided to achieve your aesthetic goals look to my experience as a craniofacial plastic surgeon who spent years mastering the art and science of the rehabilitation of the child with cleft lip and palate. It requires great understanding of the biology of the facial structures of bone, teeth, muscle, skin, fat, and cartilage and how growth and wound healing affects theses structure over time. Typically the child undergoes a lip and initial nose repair at three months of age with or without pre-surgical orthopedic repositioning of the bony segments. Followed by cleft palate repair at age six months to reposition the muscles that move the palate and close the hole between the nose and mouth. The third surgery to repair the cleft of the bone which house the teeth utilizing bone from the hip is performed somewhere around five to six years of age. After a period of six months then the cleft nasal repair is performed to balance the nasal tip with cartilage taken from the back of an ear. Additional surgeries may be required to improve speech function or revise the lip scar. We work closely with ENT’s, speech therapist, orthodontist and pediatric dentist to achieve excellent results.

These principles have been engrained in me and I can apply this knowledge to improving your aging face both non-surgically as well as surgical repositioning of aging soft tissues, changing the shape of your nose, lips and other structures. Please see below pictures of representative cases of cleft lip and palate surgery I have performed over the years. If you have any questions and if you would like a consultation we me and my staff please contact me via our website.

Age three months prior to first surgery
Cleft 1

Age Eight after four surgeries
Cleft 2

Age three months
Cleft 3

Age Eight after three surgeries
Cleft 4

Age three months
Cleft 5

Four months after presurgical repositioning of upper jaw and bilateral lip repair
Cleft 6

Turn back the clock with facial volume restoration

mother

As we age, the volume in our faces diminishes over time. However, in the right hands you can age gracefully and look as good as you feel for a long time, which is the goal I have for all my patients. Volume restoration of the face, as a part of an overall comprehensive facial rejuvenation algorithm, combined with skin resurfacing and tissue repositioning, can yield beautiful results.

The aging process causes fat volume reduction in the face. The fat in our faces is organized into discrete packages and, predictably, the fat found just below our cheekbone is one package which reduces in volume first. The combination of gravity and volume loss in cheek fat results in our faces changing shape. Our cheeks appear to decrease, and our skin drops. Cheek folds become more pronounced, creating the inevitable downward-turning at the corners of the mouth and contributing to the jowling effect in the lower jaw line.

Another area that can experience volume loss is the lateral forehead in the temple region, which results in the brows re-draping downward, causing a hooding effect and obscuring the upper eyelids. Still another indication important to women is the loss of volume of the lips and the relative loss of the three-dimensional appearance of the upper lip with increased vertical lines emanating from the red border.
The tear trough region around the lower eyelid can lose volume, regardless of your age, particularly if the eyelid fat pads are prominent with a relatively soft mid face projection.

All the above areas can be treated nicely with filler agents. The advantages of out-of-the-box filler agents is they can be used quite nicely with topical anesthetic agents in the office. There’s relatively little to no bruising and no downtime. Many filler agents contain hyaluronic acid, which is a naturally occurring agent in our skin that acts like glue to hold components of our dermis together. Denser material with lots of cross-linking can have a better effect of lifting tissue. Because of its dense properties, Voluma can last up to two years and is routinely placed in the area where the cheek fat packet decreases. This filler is used to lift the cheek back to a normal position, thus improving the cheek fold and the corners of the mouth.

Lips can be enhanced to normal volumes (not the duck lips that I see coming from various spas) to create a natural red lip border with the adjacent skin helping to eliminate the vertical lines. I also enhance the vertical pillars that span between the base of the nose and the cupids bow high points, which returns a three-dimensional appearance to the upper lip. I mostly utilize Juvederm for this area.

The tear trough deformity can be handled nicely with Restalyn or Juvederm to blend the eyelid cheek junction and smooth the appearance of the lower eyelid.

Volume restoration of the temples to return the brow to a more normal position can be best handled using a step-wise approach with Sculptra, which is an injectable form of a polymer of lactic acid. When introduced to the tissue, the lactic acid induces an inflammatory response leading to the formation of new collagen. The advantage of this material is that it can restore large areas of volume loss, which would be difficult with traditional filler agents. It also slowly builds up collagen and restores volume over a six-week period making your transformation less obvious to your friends and family.

Without question, the concept of volume restoration of the face as a part of an overall comprehensive facial rejuvenation algorithm has led to superior results compared to plans that did not include volume replacement. As with Botox, the overall value of the injection material is greatly dependent on who is administering the filler agent.

Poor technique can result in poor outcomes. I liken filler agents to sculpting materials for the face. You can put clay in front of a true artist who can transform this simple material into a work of art. An untrained eye with no sense of perspective or artistic skill will create very little value out of the raw materials. The same goes for these injectable products in the Wild Wild West of aesthetic services here in American and abroad.

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