Strategies to maintain a youthful face throughout your life
Age is certainly just a number. What is more important is your physiologic age which is a culmination of genetics, diet, exercise, sun exposure protection, smoking status, and how well a person manages any chronic diseases. But in general terms I find it useful to stratify algorithms for best practices for maintaining a youthful face into decades of life.
In the late teens and twenties the single best strategy for long term health and appearance of the skin of the face is appropriate sun block protection. Excessive unprotected sun exposure and tanning beds may yield what appears at a brief moment in time as a healthy glow to the skin will ultimately result in loose inelastic skin with greater degrees of wrinkling along with unfavorable splotchy pigmented appearances. The sun makes everyone happy and feel good but our skin must be protected with hourly reapplication of sun screen while in direct sunlight and every morning a layer of sunscreen applied as part of a normal routine for face care. Peels, Laser’s, micro-needling, and home skin care can improve and repair some of the damages but prevention is the best course to look your best over time. Another aspect of care during the twenties is preventative treatment of severe acne formation of the skin. Anyone who has been left with multiple ice pick scars from cystic acne would do anything to improve the surface of the skin. Once again Lasers and micro-needling can improve the appearance but cannot eliminate all the scaring. Routine facials, extractions of pores, topical application of metronidazole or doxycycline, toners, retinols and, fruit acid applications are all useful tools to combat skin pores from clogging, become infected, and resulting in severe inflammation with resultant scaring of the dermis.
While still being youthful the physiology of the skin can change somewhat particularly dependent on genetics, the degree of skin pigmentation protection, sun exposure, and hormonal changes related to pregnancies. If someone is an avid tanner the repercussions of a couple of decades of excess UVA and UVB radiation from sun can already be seen in the skin’s appearance. Also unfortunately women who have been pregnant may experience hyperpigmentation of the skin about the face. As skin elasticity is reduced the animation of muscles directly under the skin around the eyes, forehead, and mouth may begin to create wrinkles during this decade and rapidly progress throughout the rest of the life of the individual. An important tool to alter the progression is the use of neuromodulators such as Dysport and Botox. These chemicals, derived from the botulinum toxin, block nerve transmission to the muscle thus reducing their tone leading to ellimination of wrinkles of the skin overlying the muscle. This treatment can help not only the immediate appearance of the facial lines but can also act as a preventative measure to avoid deep folds in the face if administered routinely from the thirties on. Also depending on an individual’s anatomy or issues of chronic sinus disease of the ethmoid sinuses some people may begin to have the appearance of bulging lower eyelid fat pads with an increased eyelid cheek junction demarcation which may lead to a fatigued demeanor of the eyes. Many times this can be reduced in appearance with the injection of a hyaluronic acid filler agents ( Restylane and Juvaderm) blending the eyelid and cheek junction similar to photo-shopping the bags out of a portrait. Even in the thirties this can make a nice refreshing improvement in the eyes and face with no down time except some minor bruising that can be easily covered up with makeup.
This is the decade where programed fat atrophy begins to occur leading to aging facial appearances. The fat in our face is in discrete packets under our skin and when certain fat pads begin to shrink in volume particularly the cheek fat pad (sub-malar fat pad), and the temporal fossa fat pad (in the temples) the cheek projection begins to diminish leading to a landslide affect that pivots along the nasolabial fold enhancing this structure and flattening the upper cheek, and causing the corners of the mouth to descend. In the temple region with reduction of volume the lateral brow begins to fall into the upper eyelid space. Fortunately plastic surgeons can reverse these changes with adding volume back into these spaces with either hyaluronic acid filler agents or induction therapy with Sculptra which stimulates the body to produce collagen to replace the missing fat. These non-surgical techniques have made big strides in warding off the early signs of aging. Also during the forties neuromodulators such as Botox and Dysport can play even more important roles in balancing muscle activity to provide subtle lift to the brows, minimize crow’s feet around the eyes, and reduction of muscle tone of the upper lip to avoid animation vertical lines during smiling. Lips are certainly a focal point of the middle third of the face and can experience signs of aging with the loss of a three dimensional appearance of the upper lip, down-turning of the corners of the mouth, and reduced skin tone leading to vertical lines. Hyaluronic acid filler agents can be utilized to subtly define the vermillion-cutaneous border of the lips, recreate the vertical columns that extend from under the nose to the each high point of the cupids bow of the upper lip as well efface deeper vertical lines that extend vertically from the vermillion. Improvement in the tone of the upper lip skin can be developed with micro-needling (Please see previous blog for this technique). Unwanted pigmentation blotches can be reduced by home treatments with retinols, topical vitamin C, and niacinamide combined with serial skin peels to provide more even tones.
The Fifties and beyond
All treatments listed in the forties can certainly be continued into the later decades to promote longevity of youth. However gravity and tissue thinning and loss of elasticity is ongoing and never ceasing, leading many to pursue surgical options to correct hanging brows, loose upper and lower eyelid skin, and restore normal jaw line appearances. See blogs on surgical rejuvenation of the face.
Skin Strategies was last modified: March 21st, 2017 by admin
Just as no two faces are identical no two women’s breast and torso’s are the same either. At The Lucas Center, Plastic Surgery I do not use a cookie cutter approach to breast enhancement. I employ many algorithms to determine the best treatment plans for my patients. I am not just focused on just the breast mounds nor am I content to just place the same round implant in everyone. I analyze your breast bone (sternum), the shape and slope of the rib cage, any spine asymmetry such as scoliosis, the amount of soft tissue in the arm pits just lateral to the breast tissue, and the breast fold to collar bone length before even evaluating the breast themselves. I then measure the actual width and height of the breasts, how much thickness exists in the upper poles, the overall shape and position of the nipple areolar complexes with respect to the breast mound, how much stretch the tissues exhibit, and the volume and distribution of the volume and any skin excess. Many patients are surprised how analytical and detailed my exam is for the consultation compared to many surgeons who just eyeball the breast and decide on an implant after placing many different sizers in the OR. Normally I go to the operating room with a plan and have pre-determined the shape and size and texture of the implant prior to surgery. I avoid sizers when at all possible because the more implants are pushed through the incision the greater the likelihood of creating biofilm in the pocket (a leading cause of capsular contracture.) I also utilize a three dimensional imaging system which helps patients see themselves from a new prospective and have the ability to evaluate truly what a given implant looks like on their specific body. Much more exact than asking a patient to fill a desired cup size bra with different size implants.
My operative plan not only includes which implant to employ but the position within the breast (partially under the muscle, under just the gland or under the layer of tissue which wraps around the pectoralis muscle.) Each of these pockets have advantages and disadvantages and is not a one size fits all approach for me I use them all depending on circumstances. The shape and type of implant very much is determined by all the above mentioned measurements which involve the breast and the surrounding chest wall each type of implant has their benefits and downsides. I also determine well before hand any need for a breast lift in conjunction with implant placement.
Other adjunct procedures I often employ which can maximize the aesthetic outcomes of breast surgery beyond determining the implant size and shape or additional skin and breast lifting procedures may include the process of fat grafting. The addition of lipo-filling the breast and chest wall is analogous to photo-shopping this area of the body to uniquely sculpt your tissues such as the decollate area to enhance cleavage of in the upper pole of the breast to give the appearance of a higher positioned breast on the chest wall or even to correct contour asymmetries. This tissue refinement is invaluable to enhance the overall result for a women which cannot be achieved with an implant alone. Another fine detail which can separate an excellent result from a normal good outcome is to evaluate the arm pit / bra skin roll of tissue as it intersects with the lateral breast silhouette. Excess tissue can generally be removed or reshaped with power assisted liposuction techniques which includes removal of excess fatty tissue and equilibrate the fat volume from areas of excess to deficient regions giving an artistic aesthetic lateral profile to the breast which many surgeons ignore all together but when viewed with a discerning eye certainly creates a whole different level of excellence weather viewed with or without clothing.
My goal for my patients who seek either primary breast enhancement or “Mommy make-over” breast rejuvenation is to provide customized excellence for their outcomes. No two people are alike therefore with a thorough three dimensional examination of all associated tissues of the chest and breast we can devise a unique surgical plan incorporating all means necessary to maximize the aesthetic outcomes. I view myself as an artisan not a mass production factory for my breast services.
Three dimensional breast rejuvenation, my personalized approach for the breast enhancement patient. was last modified: February 8th, 2017 by admin
Current treatment for enlarged male breasts (gynecomastia)
Gynecomastia (“man boobs”) is a condition in which the fibro-glandular structures centered under the nipple areolar complex on men may result in a wide range of enlargement deformities. Many males find that it occurs around puberty and will persist despite maintaining ideal body weight and good exercise habits. Certainly the enlargement can be made worse with excessive weight gain. Men may also experience new onset of this condition any time during their life time. Medications may potentiate gynecomastia such as exogenous testosterone replacement due to the fact that testosterone can be converted in fat to estrogen particularly if the testosterone levels are in excess of normal values. Some have argued using an estrogen blocking agent at the same time as giving testosterone if men developed increased in breast size. With legalization of recreational marijuana in many parts of this country there will undoubtedly be an increase the incidence of gynecomastia due to marijuana’s potentiating effect on male breast size. Older gentlemen may also experience increase in breast size as natural hormonal changes occur resulting in an increased estrogen/testosterone ratio leading to this deformity. In my practice I commonly see a full spectrum of ages ranging from young teenage boys who are embarrassed to go shirtless or wear tight fitting shirts to twenty somethings who participate in cross-fit and body building but still see an enlargement of their breasts that detracts from their well- earned physique, and finally men who had been overweight and have lost weight either from bariatric surgery or lifestyle changes and desire to eliminate a large amount of excess skin on the breast and chest region to regain a healthy masculine appearance.
Treatment options for gynecomastia
As with any deformity that has a wide spectrum of presentations the treatment varies as well. For the male who has excellent skin quality with minimal or no stretch marks and a normal nipple position with respect to the chest wall and has enlargement of the breasts, these are excellent cases for suction assisted lipectomy with an additional energy source such as an oscillating motor (PAL – Power Assisted Liposuction) or ultrasonic energy. The reason regular liposuction has limitations is that the male breast has lots of fibrous tissue encasing fat and glandular elements which help to tether the overlying skin to the chest wall to keep the tissue from excessive movement. Regular cannulas utilized in liposuction cannot break up and penetrate this tissue to extract the fat and glandular elements effectively nor can it release the fibrous tissue to allow for re-draping of the skin for a smooth contour postoperatively. Either ultrasonic energy or the oscillating motor in conjunction with liposuction provides the ability to breakup this tissue to both extract tissue and provide smooth contours. However, I have found that even after aggressive liposuctioning of the area, at least twenty five percent of patients require me to make a peri-areolar incision to perform direct resection of the residual fibro-glandular tissue under the areola to provide an ideal appearance. My experience with men who have enlarged areola (nipple) diameters is that with skin retraction after liposuction, the size generally contracts eliminating the need to surgically reduce the areola diameter such as a mastopexy (breast left) technique thus avoiding risk of scaring.
I have seen a number of teenage boys who are overweight and have loose skin, breast tissue herniating into the areola with the nipple-areola complex hanging down creating a matronly appearing female breast. This deformity requires not only liposuction but at least a peri-areolar mastopexy technique to reposition the nipple complex and reduce the areolar diameter to achieve a more masculine appearance.
Gynecomastia is a fairly common condition and many men find that it detracts from their appearance and leads to self-confidence issues. Fortunately surgical treatment can be very easy and effective to achieve wonderful, very natural results. Please consult a board certified plastic surgeon to discuss gynecomastia repair – there is no need to cope with this disfigurement.
Current treatment for enlarged male breasts was last modified: January 16th, 2017 by admin
Individual Options: Post bariatric massive weight loss and body deformities
The epidemic of obesity in this country is contributing to millions of Americans developing diabetes, hypertension, heart disease, and worsening the outcomes of degenerative joint disease. Ultimately a true commitment to life style changes will lead to healthier outcomes. Some morbidly obese individuals need invasive bariatric surgery to aide in this endeavor and the results can be spectacular. Results including long lasting weight loss of sometimes two hundred pounds or more. Many times the unfortunate end result is individuals being held prisoner by their deflated, left-over skin that hangs from the breasts, arms, abdomen, flanks, and/or medial and lateral thighs. There is well documented literature which supports body contouring after weight loss in motivating patients to maintain their new life styles.
What are the options for body contouring after massive weight loss?
For the lower torso
Many patients initially fixate on the fact they have a large pannus of the abdomen (layman’s terms: apron or flap of tissue over the abdomen) and think all they need is to remove this isolated deformity. This is emphasized by bariatric surgeons who only feel comfortable offering panniculectomies (tissue/skin removal) for lower torso deformities because they do not possess the skills or have the aesthetic eye of a fully trained plastic surgeon. In fact many women and men complain that the lower pelvic tissue also hangs and has thinned and fallen away from the pubic bone leading to aesthetic deformities of the external genital region such as the mons pubis (layman’s terms: the area over the pubic bone) and vulvar region (layman’s terms: the area around the entrance to the vagina). Panniculectomies do not address this condition. Secondly the abdominal rectus muscles (the “Abs”) which act as an internal corset for the abdominal contents, holding them in check, often times become separated resulting in not a hernia but a large abdominal bulge. Women who have had children often will have a greater deformity than men. This also is never addressed during a panniculectomy. Another thing to consider: massive weight gain is not two dimensional therefore weight loss skin changes are also a three dimensional deformity. In addition to the abdomen and pelvic region, lower torso problems include excessive skin and fat hanging on the flanks, very proximal lateral excess thigh tissue, as well as the buttock becomes flat and shapeless making clothing difficult to wear. My recommendation for this constellation of deformities is the circumferential lower body lift. This is a single stage operation which includes a full lipo-abdominoplasty (removal of excess skin of the abdomen, correction of the underlying muscle deformity), pelvic rejuvenation (suspending and reshaping the mons pubis or the tissue surrounding the penile shaft), Flank tissue recontouring, lateral thigh resuspension, and lastly buttock reshaping and elevation with transposing excess tissue from the flanks to the buttock region. Yes this is a significant operation around six and a half hours but it is outpatient and our results are excellent and have never had to readmit anyone after surgery. This truly is a transformational operation freeing patients of their unwanted excess skin and all associated deformities and a very distinct difference from just a panniculectomy.
For patients who have already undergone a lower body lift and still have excess tissue in the upper abdomen that is loose a reverse abdominoplasty can be an ideal method to remove this excess and can be used to provide added vascularized tissue to add volume to the breast if an implant is not selected as part of a mastopexy.
Upper torso options
Just as there are many body shapes there are many variations to massive weight loss body changes. Both women and men experience deflation and hanging tissue from the upper arms and upper back region. The only way to correct this is through an aggressive skin reduction technique that commonly starts at the elbow and extends in a posterior medial line angle of the upper arm to the armpit and then continues on the posterior axillary line angle and follows the back as far down as required to remove the excess. In some women we can stop near the bra line. But our goal is to avoid hanging skin over the bra. Both men and women also have unsightly shapes to the chest and breast region. Women lose significant breast volume and have skin excess which leads to very flat deflated hanging breasts. In post-bariatric patients we try to avoid implants if we can because the residual soft tissue is generally not mechanically strong and holding implants in the correct position on a chest wall is quite difficult. I would prefer to perform breast lift with significant skin reduction and adding volume with either fat grafting or reverse abdominoplasties to obtain acceptable shapes. Sometimes I am forced to use implants but it increases the need for revision surgeries to get ideal results. Men often need gynecomastia (breast tissue removal) repair utilizing a significant skin reduction technique similar to a mastectomy and blending the scar into a chest fold. The standard gynecomastia techniques with PAL (power assisted lipectomy) with or without a periareolar (around the areola) mastopexy are not an option.
Once again there are many variations among patients and this region. I have seen men who have lost almost two hundred pounds and have near normal inner thighs. I have also seen women who are near ideal weight and have never lost any significant weight and have excess skin in this region. I will say I often see women who have cascading hanging skin of the inner thigh and upper knee area that prevent these people from feeling comfortable in shorts or skirts. Just as in the upper arms we aggressively liposuction the inner tissue and determine the skin excess and then remove this tissue blending it into the posterior and medial upper thigh and curving the incision into the groin crease. We purposely avoid anchoring the tissue superiorly to the ischium (curved bone forming the base of each half of the pelvis) to avoid deformities of the labia on women. Just as on the arm there is a scar but the vast improvement in contour out-weights the negative results of a scar.
Post-bariatric weight loss can be an amazing journey for patients allowing them to reclaim their health and happiness. Body recontouring is a necessary step to realize the freedom from the prison of excess skin left behind by the weight loss. Understanding that everyone unique, please come to the Lucas Center, Plastic Surgery to hear about our customized approach to restoring your confidence in yourself after weight loss.
What are the options for Post bariatric massive weight loss on body deformities was last modified: January 16th, 2017 by admin
Necklines for both men and women can be a focal point of self-consciousness. However, the etiology of an unattractive neckline can be diverse, so treatment options must be tailored to the underlying cause. There is no one solution for everybody. Careful three-dimensional analysis of the soft tissue and underlying bony structure of the midface, lower jaw and neck are imperative to choosing the correct modality to improve your neckline.
Some common underlying causes of poor aesthetic necklines:
Small lower jaw – If you have a deep underbite despite orthodontics and a short chin, this leads to less bone support of the soft tissues of the jawline and submental region. People with this type of lower jaw may have a very obtuse chin-neck angle leading to redundant skin. An ideal treatment for this situation is bony chin advancement (genioplasty).
If your chin is horizontally too short, then an augmentation with a chin implant is an excellent choice. I prefer the Medpore implant, which is carvable, and screw fixated and becomes an extension of the bone.
Both genioplasty and chin implants can easily incorporate the technique of liposuction as a means of sculpting the soft tissues of the neckline by removing unwanted fat. Liposuction induces collagen production and facilities skin shrinkage and redistribution yielding a pleasing result. This combination therapy can produce a wonderful outcome that makes you look more facially balanced. However, if your skin is too loose and hanging, a more formal neck lift may be preferable to liposuction.
Mid face descent of soft tissues – Aging can affect facial fat compartments leading to decreased volume, which results in the midface falling over time. This sagging increases nasolabial folds and causes lower facial soft tissue to drape over the jawline. A crisper jawline can be restored by replacing missing soft tissue volume in the fat compartments of the midface with filler agents like Voluma and Sculptra or via fat grafting. Subtle volume enhancements can create a nice effect on the jawline without looking like you’ve undergone a surgical procedure.
Gravitational changes to the soft tissue of the neck – Gravity affects all of us. The skin and muscles of the anterior neck begin to pull away over time. The appearance of the platysma muscle medial bellies becomes apparent leading to unsightly banding. In the early stages of gravity-induced changes, treatments such as chemical peels, micro-needling and radio frequency can yield improvements and delay the inevitable soft-tissue sagging.
Ultimately the best treatment option is a face/neck lift. A well performed facelift by an experienced board-certified plastic surgeon will yield excellent results with longevity of up to ten years depending on how well you age forward and take care of your skin, avoiding further sun damage.
Obesity: People with elevated body mass indices will accumulate increased fat throughout the body. The neck is no exception. Very mild amounts of fat excess with firm, good quality skin may realize improved contours with Kithera (an injectable product that dissolves fat in the neck). However, in my experience, few patients I evaluate are ideal candidates for this treatment. The injection results in inflammation, which can cause collagen production and skin remodeling, but most people need bigger guns to fight the battle. The price of several rounds of injections is as much as a true liposuction with less effective results.
If you have significant fat in the submental region and reasonable skin quality, liposuction can be a great treatment option to uncover a more normal neckline without a lot of expense or downtime. However, a face/neck lift with a corset platysmaplasty is the tried and true corrective option that works very predictably.
If you’re obese and undergo bariatric surgery or make lifestyle changes to produce massive weight loss, you’ll likely develop excess deflated skin that hangs off your face and neck creating an aesthetic deformity. Modifications of standard face and neck lifts must be incorporated to achieve a pleasing result.
The takeaway is that if you’re unhappy with your jaw and neckline, you can improve your appearance and boost your self-confidence by seeking out proper consultation with an experienced plastic surgeon. During the consult, a detailed facial analysis should be performed. Treatment options can be formulated to yield the best results by addressing your unique issues as presented during the interview. No need to hide your neck behind scarves and turtlenecks any longer.
Consider custom solutions for a sagging neckline was last modified: December 9th, 2016 by admin
The buttock area has reached new levels of interest thanks to the influx of the Latin culture from South America and pop culture’s fixation on the shapely, self-absorbed Kardashians. Surgeons on the cutting edge of buttock enhancement choose to use fat grafting instead of buttock implants to avoid some very difficult complications.
Thanks in part due to Dr. Simeon Wall’s concept of tissue equilibration in body sculpting, tissue can be removed from areas of excess and transposed to areas of deficiency. For example, we can take excess areas like the muffin top and the lateral thigh and place that fat into the under-projected gluteal areas creating the idealized shape of the buttock both in terms of the outer framing and the projection.
The breast is another area where fat is very important. Most of the breast volume under the skin is composed of fat with small islands of glandular material dispersed throughout. With aging, volume in the breast is lost by glandular atrophy and some fat loss. Previously breast rejuvenation or enhancement was only thought of with augmentation via implants, with or without tissue repositioning such as a mastopexy. Today fat grafting is critical to achieving superior results. Research suggests that over 60% of breast augmentation procedures could be improved with the addition of fat grafting performed simultaneously.
Furthermore, fat that is harvested contains peripheral stem cells. The presence of stem cells in harvested fat has implications for rejuvenation medicine and the potential growth of tissue such as bone, skin, solid organs and bone marrow cells. Unfortunately, the art of marketing has outpaced science, and many clinicians are calling fat grafting to the face a “stem cell face lift.” This is a misleading statement. Much energy has been directed toward the understanding of the stem cell, but it’s not ready for prime time yet.
Plastic surgeons employ biologic tissue as our medium to create beautiful forms of living art. Fat is a wonderful way to sculpt the human body. It is truly like airbrushing imperfections in three dimensions.
Regardless of the Kardashians over-developed assets, fat grafting is worth the hype. Call 865.218.6210 today or go online to thelucascenter.com to schedule your consultation. I look forward to discussing with you the myriad of options for face, breast and buttock enhancement via fat grafting.
The bottom line on fat grafting was last modified: December 9th, 2016 by admin
A Comprehensive Three-Dimensional Rejuvenation Center