BREAST AUGMENTATION

According to Dr. Edward Pechter, M.D., F.A.C.S., "The longer implants remain in the body, the more likely it is that they will wear out and break." He adds, "if this occurs with a saline implant, it's obvious — the breast gets a 'flat tire.' Silicone implant rupture can be harder to detect, which is why the FDA recommends an MRI examination at three years after implantation and every two years thereafter." Due to the relatively high cost of MRI imaging, Dr. Pechter notes that it's unlikely that most women will follow through on this advice.

Finally, Dr. Pechter advises that some surgeons suggest that patients with breast implants take antibiotics immediately before and after dental procedures. He explains "No matter how conscientious a person's brushing, flossing, and rinsing habits, bacteria can escape into the bloodstream through tiny cuts in the gums, the result being potential contamination of breast implants. Ask your surgeon for his or her advice."

LIPOSUCTION

According to Steve Laverson, M.D., F.A.C.S., long-term post-operative satisfaction with liposuction is directly linked to the patient's body weight in the months and years after the procedure: "Liposuction is an adjunct to healthy diet and regular exercise, not a replacement for these habits. Regular athletic activity and disciplined diet can go a long way toward giving you the body you want, as well as supporting your cardiovascular and musculoskeletal health."

INJECTABLES/FILLERS

According to Dr. Joe Niamtu, D.M.D., "Botox has the rule of three. It begins working at about three days; it reaches its full effect in about three weeks; and lasts about three months." He adds that many myths and fallacies surround Botox and the need for repeated treatments. His analogy "...you don't have to continue treatments. Nothing bad will happen. It's like being on a diet. If you quit dieting, your fat will return. If you quit using Botox, your muscle activity, and hence, your wrinkles will return. A positive reason to continue usage of Botox, is that the less your muscles wrinkle your skin, the less deep the wrinkles will be." He adds: "I believe the long-term use of Botox in contemporary society is viewed in the same way as coloring one's hair: It's 'youth maintenance.'" While there have been no long-term problems with Botox, throughout its thirty years of use, Dr. Niamtu adds, "As we age, we become less sensitive to Botox and its effects do not last as long. Women over 65, and men in general, may need more Botox and can expect it not to last as in younger patients."

Fillers, such as collagen, Juvéderm, and others are temporary in nature, states Dr. Niamtu, lasting anywhere from three months to many years.

According to the doctor, the advantage of a filler "going away" is not necessarily a bad thing. He explains "...as styles and values change, for example, a patient may want their lips different than they are now. Longer lasting fillers, like silicone oil and ArteFill may last many years, but usually still require a touch-up every several years." Lastly, he warns: "The buyer must beware when it comes to permanent fillers, as you need a competent injector — because it is not reversible."

Dr. Niamtu again points out: "The beauty of temporary fillers is that they go away. One potential problem with permanent fillers is that, as a person ages, the skin will droop; and if a patient has a lot of permanent filler in the skin, it may look unnatural. In rare cases, surgical procedures may be necessary to remove the permanent filler."

RHINOPLASTY

Dr. Michael S. Kluska, D.O., F.A.A.C.S., F.A.C.O.S., board-certified plastic and reconstructive surgeon, tells ITK, "Because rhinoplasty changes the structures in the nose, it is a permanent procedure and will last a very long time." And he adds that, "while there are no maintenance issues per se, beyond the initial six-week healing period, scar tissue formation sometimes requires a second, or revision, surgery. As such, scar tissue would take about a year to form and finalize completely." Therefore, he cautions, "A patient undergoing rhinoplasty should never have another surgery before the one-year mark. This can lead to thickened, heavy scar that could result in permanent disfigurement."

As a final caution, Dr. Kluska explains, "The most common reason for a second surgery is due to unrealistic patient expectations. Many times patients expect something different than what they get. A clear line of communication between patient and surgeon is essential for positive outcomes."

Dr. Jasin

QUELL THE SWELL One of the key advantages to the intraoral injection approach over transcutaneous injections is the reduction of bruising and swelling, Michael Jasin, M.D., F.A.C.S., tells Cosmetic Surgery Times . This, he says, not only allows patients to go about their activities immediately, but helps avoid the challenges that swelling presents when trying to inject just the right amount of filler for the desired aesthetic results. "With the intraoral approach, you don't get that kind of tissue reaction and swelling that you get from a transcutaneous injection because there aren't as many needle sticks," explains Dr. Jasin, Medical Director of the Jasin Facial Rejuvenation Institute in Tampa, Fla. "Less swelling means you get less distortion at the treatment site, allowing you to better monitor your degree of correction and get a more precise idea while injecting of how close you are to your endpoint."

Since there is no needle trauma just below the skin, bruising is also kept to a minimum. "The injections are all below the muscle and fat, so anything that relates to that doesn't tend to show through," he explains. Dr. Jasin said he uses the intraoral approach on most of his mid-face correction work, and adds that the only time his filler patients do have bruising or swelling is if some transcutaneous injections are provided to supplement the intraoral injection.

The deeper placement of filler provided by intraoral injection gives an overall evenness of volumization and a more natural feel, with areas such as the cheek and tear trough gaining a smoother transition, Dr. Jasin adds. "All of the tissue planes are elevated simultaneously, providing a smoother correction to places like the tear trough and cheek, instead of having the bulk of the volumization placed superficially." The intraoral approach takes an advanced level of skill and anatomic knowledge, however, and it's not for everyone. Even skilled injectors need to use extra caution to avoid injecting directly around the temporal nerve and the mental nerve, Dr. Jasin notes.

RISK AVERSE Many injectors have avoided the intraoral approach due to concern about the higher risk for infection presented by going through the mouth. Few cases have been reported, but there has nevertheless been enough anecdotal evidence to turn some away. "I've abandoned the intraoral method because, theoretically, there's a risk for infection, and although I haven't seen it, I've heard about it," cautions Steven H. Dayan, M.D., a clinical assistant professor at the University of Illinois and a facial plastic surgeon.

Dr. Farris

But when it comes to understanding precisely how HRT affects the skin, the jury is still out. Logically, hormone therapy may be more capable of preventing skin aging in the first place than in repairing damage once it has occurred, but two new studies offer intriguing insights regarding approaches that may or may not work.

A downhill slope

The study, said to be the largest randomized controlled trial studying the effects of HRT on the skin, randomized 485 subjects into one of three arms: a placebo group of 165 subjects; a group receiving 1 mg continuous combined norethindrone acetate and 5 microg ethinyl estradiol (162 subjects); and a group receiving 1 mg norethindrone acetate and 10 microg ethinyl estradiol (158 subjects).

Investigator global assessments looking at skin texture, dryness laxity, sagging and wrinkle depth after 48 weeks found no statistically significant differences between the groups receiving hormones and those receiving placebo.

One big difference between this study and earlier research showing skin improvement with hormone therapy was a lower dosage of estrogen, which was used to better reflect the levels that doctors are currently using, says Tania Phillips, M.D., the lead author on the study and clinical professor of dermatology at the Boston University School of Medicine.

"A lot of previous studies looking at estrogen and the skin have used far higher doses of estrogen, but there are now concerns about those higher levels and we wanted to use the standard doses that are commonly used in clinical practice nowadays."

In addition, since the subject selection didn't specify that participants be any particular number of years past menopause, the majority of women enrolled in the study wound up being as far as five to seven years past menopause.

"Marginally significant" improvements were reported in a small subgroup analysis of women who were less than 24 months postmenopausal, however, and Dr. Phillips suggests that further studies focusing on that group may show better results.

Earlier administration of hormone replacement therapy may be safer anyway, she notes.

"One of the big criticisms with the Women's Health Initiative trial was that the hormone replacement was given to older women who were many years postmenopausal and had other risk factors. Recent data suggests that if given for a relatively short period for menopausal symptoms, they're probably safe. Whether this will have beneficial effects on the skin, needs to be examined further." For the time being, however, there is not enough data to support the use of low-dose systemic estrogens for the treatment of skin aging.

As more teenagers express interest in undergoing cosmetic surgery, researchers are asking critical questions about their motives, issues and whether young people are even equipped to make informed decisions regarding what are often permanent changes to their appearance.

Dr. Abraham

These adolescents and young adults are interested in changing their bodies at a point in their development during which their beliefs and attitudes are often most nascent and confused, observes David B. Sarwer, Ph.D., associate professor of psychology in psychiatry and surgery at the University of Pennsylvania School of Medicine. Dr. Sarwer, who has long studied teens' body image, says it's usually teens and young adults who report the greatest body image dissatisfaction. "What we're doing is taking a very turbulent time in terms of their body image development and permanently changing their bodies. There is some concern that some young adults may not be prepared for that," he says.

ADVISE & CONSENT The final recommendation of Dr. Abraham's study has to do with informed consent. She notes that studies have shown that the human brain does not complete development before 25 years of age. "That is why the concept of informed consent is particularly important when talking about young people," Dr. Abraham says. "We highly recommend that a true informed consent include a real discussion about risks and benefits and also about body image concerns and their expectations of surgery."

This discussion, in Dr. Sarwer's view, should not be limited to patients, but should also include parents. Particularly in the case of adolescents, cosmetic surgeons have to question whether the potential patient's interest in cosmetic surgery is truly coming from the adolescent or from some direct or indirect pressure from parents or peers.

TEEN MOTIVES Dr. Sarwer explains that two factors seem to predict especially young women's interest in future cosmetic surgery procedures: their degree of body image dissatisfaction, and their amount of exposure to mass media—including that from reality-based cosmetic surgery programs. According to Dr. Sarwer, the mass media exposure element calls into question the accuracy of the information these women may be getting. "When we think about some of the shows of the last several years...most plastic surgeons would agree those are pretty unrealistic depictions; yet, many of their patients may be viewing these shows and thinking that they are good and accurate representations," he says. "These shows could set up false and misleading expectations about what a given woman's experience will be."

In Dr. Sarwer's view, one of the key considerations with teens and young adults is not so much their chronological age as their developmental age, or maturity, in grasping how they will feel about their changed appearances decades down the road.

The "typical" patient undergoing a liposuction procedure is female with unwanted fat deposits in the trochanteric region whose goal is to improve body contour. According to one expert, the indications for liposuction treatments are growing, particularly in the pediatric population.

NOT SO DIFFERENT

"Basically, what changes in this younger patient population is the etiology of the adipose disharmony, where the fat is in an abnormal location or in an abnormal configuration. Some of these atypical indications for liposuction include post-traumatic lipoma, post-traumatic asymmetry, lipodystrophy regardless of the etiology, adiposis dolorosa or Dercum syndrome and Klinefelter syndrome," Dr. Berenguer says.

PEDIATRIC PROBLEM SOLVER

Pix1. And Pix2. 14-year-old girl with juvenile Dercum experiencing painful, abnormal trochanteric fat deposits (before) and 6 months after regular liposuction, which resulted in pain elimination and normal contour.

Pix2.

"Liposuction should be used only if there is an MRI verification that the involution is complete. This way there is no danger that the cannulas employed in the liposuction technique will pierce and rupture any remaining blood vessels in the target area," Dr. Berenguer says.

Dr. Berenguer has also successfully treated the abnormal fat distribution seen in children after traumatic etiologies such as post-traumatic lipoma that can occur after accidents. The technique can also be used after the surgical separation of twins where each patient often can have very visible contour deformities at the site of separation. Here, Dr. Berenguer employs liposuction as well as lipo-filling to improve and harmonize the contour at the site of separation.