Dr. Connell

This 37-year-old patient had a diagnosis of large anterior bellies of the digastric muscles and subplatysmal fat. Only a 2.5-cm long submental incision behind the crease was required. The patient also had a small chin implant. No skin was excised. (ALL PHOTOS CREDIT: BRUCE CONNELL, M.D.)

A frequent Aesthetic surgery procedure for young patients is contour correction of neck deformities. No skin removal was required because changing the deep structures from convex to concave uses the excessive skin. This 24-year-old patient had transection of the platysmal muscles at the level of the cricoid and removal of subplatysmal fat.

Dr. Connell recalls one 19-year-old woman who said that if she had a better looking neck, she could make $50,000 more a year modeling. "To correct the problem, we made an incision behind the ear and a small one upfront because the platysmal muscle was too short, which happens a lot in younger people," he explains.

UPPER THIRD Dr. Connell says that it is also common to come across the under-40 patient who looks angry or sad because of pulled brow muscles. Patients complaining of these problems often feel, he says, that the expressions impede their abilities to land jobs or even dates.

If, when the patient holds a neutral expression, that patient's medial brows are not level with the eyebrow sides closest to the ears, they will have unintended expressions of either sadness or anger (depending on the slant of the brow), he observes.

"That can be very simply corrected by elevating the part of the brow that is hanging down, without performing any surgery on the middle or lower thirds of the face," Dr. Connell says.

SIMPLE GOOD PRACTICE Surgeons evaluating the under-40 patient should use the same practice parameters as they would for the older patient, according to Dr. Connell.

"If anything, you want to make sure that what you do is going to be an improvement, and the person will be happy with the results," he says. Operating to correct a specific problem can be done late or early in life, he concludes.

REFERENCE

Lewis CM. Should face-lifts be performed before the age of 40? Aesthetic Plast Surg.1985;9:47-49.

WASHINGTON — The results of a recent study has prompted the FDA to issue its second warning in two years about the potential dangers of using topical anesthetics for pain relief from medical tests and conditions. The most recent warning also begs the question of whether the first advisory was as effective as it might have been in getting across its message regarding the use of topical anesthetics containing drugs such as lidocaine, tetracaine, benzocaine and prilocaine.

In its latest advisory, issued in January, the FDA responded to the results of a study, reported in Radiology, which looked at women taking acetaminophen and ibuprofen orally as opposed to using lidocaine gel, a topical anesthetic, to decrease discomfort during mammography. The study results favored the use of lidocaine gel — which was spread over the chest area and covered with plastic wrap for a total absorption time of about 45 minutes — over oral acetaminophen or ibuprofen, reporting that there was significantly less discomfort with the lidocaine gel. The study reported no serious or life-threatening side effects with the gel.

In its second advisory, however, the FDA states that "given the life-threatening side effects associated with the use of topical anesthetics during laser hair removal, FDA is concerned that similar side effects could occur when topical anesthetics are used during mammography. Further, the study [reported in Radiology] was small and it is possible that a larger study might show different findings."

"FDA remains concerned about the potential for topical anesthetics to cause serious and life-threatening adverse effects when applied to a large area of skin or when the area of application is covered," reads the most recent advisory.

Cosmetic Surgery Times asked three physicians for their response to the FDA advisory. All three report that adverse effects can be minimized greatly when such products — whether over-the-counter or prescription — are used under direct professional supervision.

"This is a wise advisory," says Geoffrey R. Keyes, M.D., director of the Keyes Surgery Center in Los Angeles and President-elect of the California Society of Plastic Surgeons. "It is a reminder to physicians that always, when applying such products, the proper dosage in every situation must be understood, and it is an important cautionary reminder to consumers who might be using these products without proper professional supervision. This is especially critical when products such as lidocaine are used around open wounds — the topicals can get into the entire system rapidly and cause serious damage."

Boston dermatologist Ranella Hirsch, M.D., echoes Dr. Keyes' insistence on proper professional supervision.

"It is true that when a large area of skin is covered with topical anesthesia, or it is applied to open or denuded areas of skin, the risk for increased systemic absorption rises substantially," says Dr. Hirsch, who also serves as president of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "As in the case [of the two women], this risk is greatly magnified by the use of occlusive barriers. At our center, topical anesthetic is used only for limited anatomic areas, and the application is performed by staff to reduce such risks. Topical anesthetics are marvelous tools that facilitate the safe and comfortable performance of many medical procedures — however, direct supervision of their use and application by the treating physician must be a requirement."

Though in agreement with the FDA's intent in issuing the second advisory, David J. Goldberg, M.D., says stronger steps need to be taken to prevent the kind of tragedy that befell the two women two years ago.

"Although the warning is reasonable, it unfortunately is not directed at the group that is responsible for the two deaths," says Dr. Goldberg, director of Skin Laser & Surgery Specialists of New York/New Jersey and clinical professor of dermatology at New York's Mount Sinai School of Medicine. "Those deaths occurred because of non-physician-supervised use of non-FDA approved, potent topical anesthetics over very large body areas. In both situations the patients were not aware of the dangers involved because there was no physician involved in the application of the anesthetics.

"In a physician-supervised setting, such a catastrophe is highly unlikely to occur," he adds. "It is for this reason that the American Academy of Dermatology, American Society for Dermatologic Surgery and American Society for Laser Medicine and Surgery all have guidelines that stipulate that laser treatment should occur under direct on-site physician supervision. Similar guidelines for the on-site physician supervision of mammography and the associated use of topical anesthetics should also apply."

As for its guidelines in the use of topical anesthetics, the FDA advocates that consumers consult a health-care professional when considering using such drugs in conjunction with a mammogram. The agency also included the following consumer "Don'ts" in its most recent advisory:

• Don't make heavy application of topical anesthetic products over large areas of skin
• Don't use formulations that are stronger or more concentrated than necessary
• Don't apply these products to irritated or broken skin
• Don't wrap the treated skin with plastic wrap or other dressings
• Don't apply heat from a heating pad to skin treated with these products

Surgeons who perform liposuction ideally have extensive training and routines that guide them through procedures, but in following established guidelines for liposuction, doctors can have an important added layer of protection — and an organized method of procedures — that could be critical if and when physicians find themselves in the spot of having to defend themselves, according to Ronald A. Fragen, M.D.

Organizations such as the American Academy of Cosmetic Surgery (AACS), the American Society for Dermatologic Surgery (ASDS) and the American Society of Plastic Surgeons (ASPS) have established liposuction guidelines that cover everything from recommended training and procedural issues to documentation and patient communication guidelines. (See Liposuction Guidelines at the end of this article.)

Dr. Fragen, who helped craft the AACS guidelines, says the guidelines' key benefits are not just in giving doctors a checklist of points to remember, but in making sure patients are also well-informed of what they are agreeing to and what lies ahead.

"The beauty of the guidelines is that regardless of the liposuction modality that you use, you will have better informed patients and you can know that you have looked at more of the things you should be looking at."

TECHNIQUE TRAINING

The AACS recommends adequate training and experience in the field, either through residency training, cosmetic surgery fellowship training, CME accredited post-graduate didactic and live surgical programs, one-on-one observational training and another means to acquire proper training of surgical techniques.

For some surgeons, that may involve playing a game of catch-up, Dr. Fragen says.

"A lot of surgeons may not have necessarily learned liposuction in their training, so they may need more instruction on proper techniques."

The guidelines address proper settings that are appropriate for performing liposuction, which can include outpatient clinic-based surgical facilities, free-standing surgical facilities or hospital settings, and the essential need for a sterile technique, no matter where the procedure is performed.

Another important issue is criteria for monitoring and documentation in all procedures. "It's extremely important to document what the patient's skin and physical condition are like prior to the procedure," Dr. Fragen says. "If the patient has a hernia, for instance, you need to be aware of that."

"If you want to be safe, you simply must document these things," he added. "Doctors often forget to do that documentation and it really can get them in trouble later."

A PATIENT PARTNERSHIP

A key issue that has been emphasized in recent revisions of AACS guidelines is the importance of patient communication, which simply cannot be overestimated, Dr. Fragen says.

"Patients often have unrealistic expectations about liposuction," he says. "A woman in her 50s, for instance, may have liposuction and expect the body she had when she was 20, or there may be a little dent or small complication that can easily be fixed, but they don't understand that and think it never should have happened because they were not forewarned."

And while a patient in his or her 20s may be able to expect their skin to contract after the procedure, older and heavier patients, or patients who have had pregnancies need to know that results may not be quite that perfect.

"If patients have had several pregnancies and their skin is not really elastic, they need to know that they can expect more irregularity when they have liposuction," Dr. Fragen says.

Heavier patients need to know that there will likely be multiple sessions and that skin removal may be necessary at some point, and, importantly, they need to be instructed to make efforts to lose weight.

"A key point in the guidelines is that patients are told that this is not a weight-loss procedure," Dr. Fragen says. "I tell them they have to be a partner with me in this and be responsible for the weight loss themselves, and I will instruct them to come back in several months so we can re-evaluate them."

The joys of motherhood are many, and many women include in that category the satisfaction of breastfeeding their infants. It's too bad that breastfeeding — which has so many proven benefits — takes such an aesthetic toll on the mothers' breasts. Or does it? Some recent research seems to put that concept pretty firmly in the "old wives' tales" camp with results that disprove the theory that breastfeeding has negative aesthetic consequences.

Brian Rinker, M.D., F.A.C.S., associate professor of plastic surgery, University of Kentucky, Lexington, wanted definitive answers.

"Many patients would blame adverse changes in breast shape or size to breastfeeding. This prompted me to wonder whether or not there was a link between breastfeeding and changes in breast appearance after pregnancy," Dr. Rinker tells Cosmetic Surgery Times .

THEORY MEETS DATA Dr. Rinker notes that several international health organizations have conducted surveys which illustrate that women's concerns about changes to the physical appearance of the breasts is a chief reason why women worldwide elect not to breastfeed. "It may be even higher," he speculates, "because, as the investigators point out, many women may be reluctant to admit that that is the true reason. This notion is extremely pervasive and crosses cultural and socioeconomic boundaries." And although he says that pediatricians and groups that promote breastfeeding are very adamant that breastfeeding does not change the appearance of the breasts, surveys have shown that mothers felt their breasts changed after pregnancy — and not favorably.

In Dr. Rinker's study, researchers took a detailed medical history, including history of pregnancies and breastfeeding, from the patients via telephone. They then analyzed standardized pictures of the patients to correlate degree of breast ptosis with factors in the patients' histories. Their conclusion was that, based on the data, breastfeeding had no correlation to subsequent breast ptosis. What was positively influential, rather, were the number of pregnancies (the more pregnancies, the greater likelihood of ptosis), higher age, higher body mass index, larger pre-pregnancy bra size and smoking.

"I think most women are surprised to hear that breastfeeding isn't related to subsequent ptosis," says Dr. Rinker. "Some don't believe it! And that's fine. I'm not trying to change anyone's mind, just make sure they have all the data to make the most informed decision they can."

Edward Pechter, M.D., F.A.C.S., a Valencia, Calif., plastic surgeon and assistant clinical professor of plastic surgery at University of California, Los Angeles, believes that this study is an important first step in educating women — and physicians — about the relationship between breastfeeding and breast aesthetics.

"It's not uncommon for women seeking mastopexy with or without augmentation to state, 'I breastfed my children and they sucked the life out of my breasts.' So there's clearly a perception among women that breast feeding adversely affects breast shape and volume," Dr. Pechter says. "The benefits of breastfeeding probably outweigh any considerations about its effect on ptosis," he notes, "But if it can be proven that breastfeeding doesn't cause ptosis, it will give reassurance to those women for whom concerns about sagging keep them from breastfeeding."

Dr. Pechter also believes that tangentially, if smoking can be proven to be a cause of breast ptosis, this may give smokers an additional reason to kick their nicotine habits.

The American Society of Liposuction Surgery was born from the American Academy of Cosmetic Surgery and the society started giving the first courses in liposuction surgery in 1983, according to Dr. Fragen.

The guidelines have evolved since then to address the many issues that have emerged as more practitioners started performing the procedures, such as when in-office procedures are and are not appropriate.

The number of liposuction procedures dropped 6 percent between 2005 and 2006, from 323,605 in 2005 to 302,789 in 2006; however, liposuction was still the third most-popular cosmetic procedure in 2006, behind breast augmentation and breast reshaping, according to the American Society of Plastic Surgeons.

ASPS Guidelines: http://www.plasticsurgery.org/medical_professionals/health_policy/Liposuction.cfm/

ASDS Liposuction Guidelines: http://www.asds.net/GuidelinesOfCareForLiposuction1.aspx

As the population ages, logically so does a large share of the potential patient base of the cosmetic surgeon. The Census Bureau states that the U.S. population aged 65 and over is expected to double in size within the next two decades. By 2030, almost one out of every five Americans will be 65 years or older, and the age group 85 and older is now the fastest growing segment of the U.S. population.

Dr. Becker

(BEFORE and AFTER) 60-year-old patient before and 4 months following SMAS facelift and transconjunctival blepharoplasty. (PHOTO CREDIT: FERDINAND BECKER, M.D.)

HEALTHY GROWTH What is a factor is not a patient's age, Dr. Becker contends, but rather "the patient's health. We've turned down people in their 50s or younger who drink or smoke too much." In Dr. Becker's practice, most of his older patients are seeking facelifts — and while the younger generation may be more computer-savvy, the older patients have still done their research, he finds. "The elderly people I see are generally fairly knowledgeable" about what procedures are available.

And if the patient is healthy with no contraindications, Dr. Becker says there's no reason to deny that patient a procedure he or she seeks. What has been his oldest patient? "I did a facelift on a lady who was just three or four months shy of 90. She did fine. She played golf about three days a week, too." Dr. Becker has a healthy view of the aging population, and its implications on cosmetic surgery practices. "I call it a growth industry."

REFERENCES

http://www.bio-medicine.org/medicine-news/Elderly-Become-Conscious-About-Their-Looks-10711-1/

http://www.census.gov/population/www/socdemo/age/age_2006.html

Becker FF, Castellano RD. Safety of face-lifts in the older patient. Arch Facial Plast Surg. 2004;6:311-314.

EARLY CONCERNS

"One must really listen to these patients, as most do not want to make as significant changes as younger patients. Less is indeed more in the mature rhinoplasty patient. Often, the rhinoplasty is done in conjunction with other operative procedures, so it is indeed a subtle change that is needed or implied by the patient," says Rod Rohrich, M.D., F.A.C.S., professor and chairman of the Department of Plastic Surgery at UT Southwestern Medical Center.

And communicating early in the process, for example, during the pre-operative interview, about other issues including concurrent medical problems, medications they may be taking and their goals and expectations for the surgery is also important.

"I usually find these [older] patients to be very grateful with very reasonable expectations that are usually centered around just breathing better. In general, this patient population has a better idea of what can and cannot be accomplished with surgery alone, and they are less concerned about some cosmetic issues that might bother the younger patient population. But, every patient must be treated individually, of course," says Marcus W. Moody, M.D., director of the Division of Rhinology and assistant professor in the Department of Otolaryngology/Head and Neck Surgery at the University of Arkansas for Medical Sciences.

According to Dr. Moody, "If a patient presents primarily for breathing issues, avoid any drastic and unnecessary cosmetic changes unless specifically having addressed these with the patient beforehand. Often, the surgeon may have an aesthetic ideal in mind that is compatible with the goal of breathing better, but the older patient may be very disappointed to have the appearance of the nose changed beyond minimal adjustments," he explains.

In their paper, Dr. Moody and colleague also point out that the pre-operative exam should also include a comprehensive head and neck evaluation because older patients can have undiagnosed abnormalities that need to be identified pre-operatively.²

SURGICAL TECHNIQUE

Many older patients have functional disorders that have worsened with age, and surgery requires special care as these patients' tissues are more delicate than younger patients' and potential donor sites are fewer, according to experts.^1-3

Additionally, the authors note, anatomic changes in skin, cartilage, underlying bony framework and nasal airways require special consideration to achieve optimal outcomes.² "The effects of age on the skin, ligaments, and cartilage of the nose conspire with the relentless pull of gravity to create a ptotic tip and collapsing nasal sidewalls."²

Therefore, when performing rhinoplasty, "a firm structure is always important, but in the older patient it is doubly important. Cartilage is weakened or thinned. Connective tissue is lax. The surgeon must anticipate the need for grafting materials and reconstruction of the support of the nose in every case. Weakening of existing structure is to be discouraged," Dr. Moody says.

And according to Dr. Rohrich, "there are certain common goals in performing rhinoplasty in the older nose: perform tip derotation with tip refinement; increase tip projection and relative columellar lengthening; decrease the overall nasal length; correct the dorsal hump; address and support the internal nasal valves; and correct septal deviation and inferior turbinate hypertrophy, if present."¹

Teresa McNulty

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It makes sense that one must understand the mechanisms of facial aging in order to recreate the appearance of youth through cosmetic interventions. For at least a decade, aesthetic practitioners have been aware of volume restoration as an important aspect of facial rejuvenation. However, it is only recently that we have begun to understand how facial fat is stored in multiple discrete compartments (Figure 1), a fact which supports the clinical observation that the face ages differently in its various regions and not as a confluent mass. This knowledge is the key to our ability to achieve optimal results with facial fillers, such as fat, and to appropriately analyze patients for total facial rejuvenation.

FILLING FAT COMPARTMENTS

Our anatomic research has identified multiple distinct subcutaneous compartments of forehead and temporal, orbital, cheek, nasolabial and jowl fat. With an understanding of the position of the various facial fat compartments, one can inject in a precise manner to reconstruct the shapes and contours of youth. Injections beneath the skin between compartments have the effect of softening the transition between regions. These superficial injections decrease wrinkling and can significantly reduce the signs of aging. Deep injection into the fat compartments is essential; the deeper the fat is injected, the longer it will remain.