In today’s world of internet and TV shows, plastic surgery is a frequent topic of great interest to the public. While I have seen very few of such shows, I do hear of them from time to time as patients ask me specific questions on procedures that they have been presented on them. Today one of my patients asked me about a show on Dr. Oz that appeared last week. She stated it was about the ‘three plastic surgery procedures you should not have’. These included buttock implants, silicone lip augmentation and facial threadlifts.

One of the two established ways to increase buttock size is either the placement of an implant or by fat injections. The popularity of buttock augmentation today is primarily due to the use of fat injections. Known as a Brazilian Butt Lift, it offers the simultaneous benefit of unwanted fat reduction elsewhere since donor fat is needed. But before fat injections, buttock implants were the only option. The use of such implants is actually very successful and it offers permanent volume retention. But it was never widely popular because the recovery is significant due to the submuscular placement of the implant. On the Dr. Oz show it was stated that you shouldn’t have this procedure because you can not sit for weeks after surgery. This is not true. The buttock implant is actually not placed on where you sit, the lower buttocks or ischium. It actually sits higher in the upper half of the buttocks region so you never actually sit on the implants.

Lip augmentation has become both possible and very popular due to injectable fillers. Largely done through the use of hyaluronic acid-based fillers, the increase in lip size is both immediate and very visible. Its only downside is that the results are not permanent and lasts only as long as the material’s properties permit. (between four and eight months) Silicone oil is a permanent injectable soft tissue filler but it is not FDA-approved. It also has a long history of known soft tissue problems that date back from the late 1960s. It is true that the material today (Silikon 1000) is a medical-grade material which is FDA-approved for eye fluid replacement. Some injectors use it employing a micro-droplet technique that purportedly eliminates the soft tissue problems of the past. I would have no doubt that a better material and injection technique is much more likely to be successful. But when the successful use of any permanent implantable material is highly technique-dependent, a significant rate of complications will ensue. Stay with the more temporary injectable fillers which have a proven track record of safety.

Threadlifts were very popular in the mid-1990s as a minimally invasive facial rejuvenation procedure for lifting of the brow, cheeks and neck. It has faded in use because it was realized that it could only produce a limited lifting effect and the results were not long-lasting. More traditional soft tissue excision and lifting procedures (e.g., Lifestyle lift, Quicklift etc) are more effective and offer a much better value. As one ages, it is possible that the subcutaneous linear location of these threads could become obvious due to fat atrophy and tissue thinning. Apparently the show stated that the removal of these implanted threads, if needed, was very difficult. I have removed numerous of these threads over the years and have not found their removal difficult or a particular problem. The reason to avoid threadlifts is because they do not work well. Because these facial threads are no longer manufactured, avoiding this procedure is no longer a concern.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Minimally invasive cosmetic surgery techniques continue to have great appeal. Most everyone would like to look better without a major effort like some form of surgery. Or, at the least, they would like the surgery to be ‘minimal’.

Sagging  brows, or brow ptosis, is one sign of facial aging that makes one look tired and increases the amount of extra skin that appears in the upper eyelids. Brow lifting is a common cosmetic procedure for its treatment which can be very effective. Minimal browlifting techniques today are largely about using an endoscopic technique rather than removing skin or scalp tissue. This is a procedure that involves an epicranial shift or the repositioning of forehead and scalp tissue backward after being loosened. The tissues are loosed off of the bone through the aid of an endoscope. As the forehead shifts backward (and the hairline moves back as well), the brows are carried with it and end up in an uplifted position.

While an endoscopic browlift appears minimal from an incision standpoint, the extent of surgery under the skin is the same as a more traditional open browlift operation. A true minimally-invasive browlift is better illustrated in the once popular and now defunct procedure known as a threadlift. Using plastic sutures that had barbs along their length (machined cuts that allowed pieces of the plastic suture to stick out, they were thread in with a needle from the scalp down into the brow area. Once tightened and tied, the brows were lifted to some degree. This approach uses a skin shifting concept without separating it from the bone. While the procedure had a lot of appeal because it didn’t require real surgery, it is no longer performed because its results were at best minimal and not sustained.

In the spirit of minimally invasive browlifting, I recently saw a modification of the threadlift brow concept. Using small stab incisions in the scalp and the tail of the brow, small permanent sutures are threaded in to create a horizontal mattress suture pattern when tied. This can be done in three areas at the outer, middle, and inner aspects of the brow. In looking at patient results, it appeared to be effective for the tail of the brow but not impressive in the other brow areas. This is most likely because the tail of the brow is more moveable and less fixed to the underlying bone than the rest of the brow.

While this form of brow threadlifting looks appealing and certainly qualifies as minimally-invasive (could be done in the office under local anesthesia), it is still a skin only lift which does not change the whole thickness of the forehead tissues. For this reason, such a procedure is doomed to have results that will not last.

Effective browlifting requires that the entire forehead tissue unit must be mobilized and repositioned for significant brow elevation and sustained results. It is anatomically incorrect to think that any form of ‘tunneled’ skin tightening is an adequate replacement. However, when combined with other procedures such as Botox and skin resurfacing in a patient with only a minimal brow problem, this type of ‘minimal browlift’ may be useful and desireable for select patients.        

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis

The appeal of using specialized sutures to resuspend sagging facial tissues in a minimally-invasive operation is enormous. Doing a little facial tightening or tuck-up as an office procedure with little downtime has its obvious advantages. As a result, numerous types of barbed sutures have become available over the past five years and many such procedures have been done over this time period. Much marketing and claims have been put forth about the benefits of barbed sutures in the face and neck but real convincing long-term data remains lacking.

In a recent article in Dermatologic Surgery, Kaminer and colleagues report on their limited experience with barbed sutures for facial lifting. With patients that had an average age of 58 years and whom were followed for 6 to 16 months, six to eight threads per side were placed. Patients judged their own cosmetic results on a scale of 1 to 10. In an effort to provide some objectivity, the amount of cosmetic improvement was also rated by a panel of independent physicians on a scale of 1 to 10 looking at seven of the patients. Patients rated themselves with an average score of 6.6. Independent ratings had an average score of 4.6. The final results were obtained at the 4th postoperative month. Optimal results were judged to last for up to 3 months thereafter.

What do these results tell us? While this study was very small (only 12 patients), there is some critical information in it that does translate to what is already ‘known’ about barbed suture facial lifting. First and foremost, it is really not a procedure for an ‘older’ patient. The results of this clinical study had mediocre clinical results because of the age of the patients. Better results would have been obtained in younger patients in the 40s range. Suture suspension face lifting, in my opinion, is more suited to those patients with minimal facial sagging problems. Preferably those who want to do something but are not ready for an operation of any consequence. In essence, it may be a procedure that helps bridge the time until the patient’s problem worsens and they are ready for a more invasive procedure that provides much more significant changes. Ideally, it will help the patient delay that time a little longer.

Secondly, one can see that the long-term results from suture suspension is not great. Getting a year’s result or so is probably the most one can expect. Again, in a younger patient, the result will likely last somewhat longer. The simple concept is that lifting and cutting (more invasive) is always going to get a better result than lifting and bunching. (minimally invasive) The more scar that is created underneath the skin, the more the result will stay. Or to put it another way, cutting skin out is always going to last longer than simply bunching it up elsewhere.

Lastly, patients almost always see cosmetic results better (or worse) than an objective analysis may show. The emotional element of a patient assessing a cosmetic result is huge. One can never underestimate how a small change can make some patients feel better. And, after all, the patient is the final judge and jury of their own outcomes in cosmetic surgery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis