Posted on March 27th, 2013
Question: A mini lift sounds sooo much more appealing to me. less expensive…less invasive…can get rid of my sagging skin and jowls. why would I opt to get full facelift surgery?
Dr A’s Answer:
Mini Facelift is a very limited facelift. For the most part it is tightening of the skin only and perhaps some minimal lifting of the deep tissues. Many people think that sounds great. They pull on their skin and their face looks great, right? The thing is skin isn’t the problem nor the solution. Skin is following the shape of the deeper tissues. The deeper tissues are not sagging because of the skin, the skin is sagging because of the deep tissues. Skin does not have the strength to hold the shape of your face long term. It works great for a few minutes while you pull on it with your fingers, even for a few weeks after surgery. But fixing your face with a mini facelift is like fixing a bad foundation in your house be redoing the siding.
The best solution is not to tighten your face at all, but to reposition it. The deep tissues need to be unattached and reattached higher. . . where they used to be. The skin then follows the new shape, and yes, some skin is removed, but this is like fixing the siding after the foundation is fixed.
If you are 45, a mini lift may be for you. But for the vast majority of patients who show up in their 50′s, don’t waste your money on a mini-lift.
Posted on February 11th, 2013
These are the procedures I would like done:
Nose and chin .. Liposuction under chin and bump removed on nose
Dr. A’s Answer:
Malignant Hyperthermia and Elective Surgery
There are certain drugs that cause MH, specifically inhalational anesthetics (the sleeping gasses), and depolorizing muscle relaxants. Some gasses are much less likely than others to trigger it, but if you have the MH gene, you should just avoid all of them. It is very possible to do the surgery you want avoiding all triggering agents. In fact I do all of my surgery avoiding these trigger agents. IV anesthesia with a combination of drugs including propofol, ketamine, versed, and fentanyl is my standard technique. You should avoid being intubated (breathing tube in the lungs) and connected to a machine since any traces of gas in the machine from other users might still be present. If you are connected to a machine, it needs to be a specially set aside machine that is only used on MH patients and has never had any triggering agents loaded into it. Using the drug combination I mentioned renders patients completely asleep for the surgery, but they continue to breath under their own power without a tube. Also consider doing the procedure with just oral pills to relax you and local anesthesia. The neck can certainly be done this way, the nose requires a person with a little bit more courage.
Posted on February 4th, 2013
Q: I was recently told that injecting botox will relax eyebrows enough to flatten the high arches and bring them down to a more rested position. as if to lower them. how many would it take to do so? is it more or less than the amount it takes to bring up an arch?
Dr A’s Answer:
This can only be determined by an exam since forehead muscles can differ a lot from person to person. In a male with a strong forehead, it could take a lot more Botox than 4 to 12 units. It may also be that no amount of Botox lowers your brows to the level you desire. To some extent, there will be trial and error adjustments. Based on years of experience, I would expect needing a minimum of 20 units to get noticalbe lowering in a typical male and perhaps more than 30. You can always start with a smaller amount of Botox and add more every few days until the desired result is achieved. To this end, I would suggest using Dysport since the results are usually seen in 24 hours whereas Botox is often 3 or 4 days.
Posted on January 15th, 2013
Question: I am 27 and have always suffered from puffy eyes since highschool. Makeup helps but does not heal! I went for a consultation and it was about 8 minutes so I did not feel comfortable enough to do it the cost was about $2800. He suggested a transconjunc… I just want to know what direction I should be going in. Please help I would like to get this done asap.
Dr A’s Answer: You Have Tear Troughs
Your problem is not puffy eyes, it is the groove under the “puffiness”. This situation should be addressed by filling the groove and taking some of the fat that is producing the puffiness and allowing it to blend down into your cheek. You certainly do not need skin removed from your lower eyelids. You are only in your 20′s and you do not have extra stretched-out skin. Furthermore, removal of skin can put you at risk of a pulled or outward turned lower eyelid. There is no benefit for you in skin removal and there is risk, plus you will have a scar.Your problem has nothing to do with aged or stretched tissues. It is because of how your genetics shaped your face. The lower eyelid fat is protruding out in front of the bone of your cheek. A tear-trough implant will bring the bone further forward to match the location of the fat and at the same time the fat should be smoothed into the cheek. This is a very long lasting way to address the problem and is reversible in the unlikely event you change your mind.
Simply removing the fat is another option, but as you age your eyes will look hollow, especially as you get into your 50′s.
Also fat transfer is an option. This is where fat is liposuctioned from elsewhere on your body and injected into the groove. I am not a proponent of this procedure because of very inconsistent results (the fat may not survive the transfer).
As a temporary solution, Restylane can be injected into the groove.
Posted on January 9th, 2013
Q: I am in my mid twenties and considering having a skin pinch done under my eyes to correct slightly loose skin and wrinkling. I have heard however that surgically tightened skin loses some of its elasticity and which causes the skin to loosen again with time, more quickly than if nothing had been done. This would mean having to redo the operation every few years to maintain the results, and ending up with a “pulled” look. Is this true or false?
A: Skin looses elasticity with time, sun exposure, over distention (massive weight gain/pregnancy), and other environmental factors. A skin pinch won’t change elasticity. However, one skin pinch will probably fail to make you look any better. As a 20 something year old, any kind of skin removal surgery from the lower eyelids is most likely going to be a zero gain. Furthermore, however unlikely, you risk a complication that would make you look worse. I suggest you avoid skin removal surgery from your lower eyelids.
Instead, protect what you have with good skin care habits, don’t smoke, and stay out of the sun.
Posted on January 2nd, 2013
Q: I am considering rhinoplasty but saw a couple reviews of people that had it done saying it went terrible and the doctor that did it put a fake picture of them up! That freaks me out as I search for the right surgeon for me. I think the before and after pictures are really important and that’s one of the key things I look for in a surgeon. HELP I’m freaking out now.
Answer from Dr A.:
How to Spot Forged Photos
There are 2 types of photos that mis-represent reality. The first type may or may not be by accident and can generally be determined by examining the photo. The second type is pre-meditated deception and not necessarily something that you can figure out looking only at the photos.
1) Poor photographic technique is a very common way to have photos mis-represent reality. Generally this involves using very different techniques when taking the before and after and may not be pre-meditated.
- Differences in make-up are very common and to some extent expected. Significant differences should make you consider the photo comparison useless. Major differences in make-up may or may not be a pre-meditated action, but should at the very least be considered sloppy on the part of the physician and reflect poorly on him if he has chosen to show the photo.
- Lighting is a very common error. I see this constantly, even in medical journals. The before and after MUST be taken with the same lighting. Look at the eyes, you should see a reflection of the light source (flash). It should be nearly identical in the before and after. If the eye is not in the photo, look at the shadows and any “flares” reflecting off the skin, they should be nearly identical. If the photo is so cropped down that you can not see eyes or other structures that throw shadows, consider the photo useless. Wrinkles, scars, and cellulite will look totally different with different lighting.
- Patient position is another issue. The slightest change in position can alter things such as loose skin, wrinkles, and cellulite. Be wary of any photo that is so cropped down that you can’t tell if the position is identical in before and after.
2) The above items may be pre-meditated, but often are just the result of being sloppy. They reflect poorly on the physician but don’t amount to fraud unless done on purpose (at least in my opinion). There are other tricks that can only be pre-meditated. This involves using “morphing” software. It will be difficult to spot this type of modification just looking at the photo since it was done on purpose and if the person has any skill with the their photo program, virtually impossible to tell. Only the overall reputation of the physician can help you to spot this. The only acceptable manipulation of a photo is to crop it and make minor adjustments in such things as brightness, contrast, and color balance in order to have the before and after photos become photographically balanced. Doing this properly improves the accuracy of the before and after comparison.
Posted on November 19th, 2012
Dysport and Botox, Seem to Be About the Same
I have been using Botox for 13 years and Dysport for about 3 years. Clinically, they both make the muscle stop moving when used in appropriate doses. I do see Dysport taking affect quicker, about one day. I have not perceived any difference in longevity, about 3 to 5 months. Dysport is slightly less expensive.
You need to realize that a Botox “unit” and a Dysport “unit” are two different things. Think of metric versus English measurements. Each system has their own way of determining what a unit is. The same effect can be achieved with somewhere around 2.5 to 3 units of Dysport compared to 1 unit of Botox. Dysport units are about 1/3 the price of Botox units so the price isn’t that much different.
Both products are made of a protein called botulinum toxin type A. There are some differences but that discussion is a bit complicated for this format. They both function in the same way be disabling the nerve that signals muscles to move. Your body recovers from both by building new nerve tips
Posted on October 29th, 2012
I read the paragraph below on an Oprah.com article, and was wondering if this muscle is commonly or ever frozen by botox injections? “When someone smiles out of genuine delight, a facial muscle called the orbicularis oculi involuntarily contracts, crinkling the skin around the eyes. Most of us are incapable of deliberately moving this muscle, which means that when a person fakes a smile, her orbicularis oculi likely won’t budge.”
Dr A: I have not looked at Oprah’s explanation, but it is not true that the orbicularis muscle is inactive during a fake smile. It is very easy to voluntarily activate that muscle and a fake smile would most certainly include the orbicularis. In fact, it would require a great deal of concentration to fake a smile and not use the orbicularis muscle to any appreciable degree. It is true that a faked smile is different than a real smile, but it has to do with the fine details of the activation and includes all of your smile muscles, not just the orbicularis.
Botox could be used to fully disable the orbicularis muscle. But this is never done. You only treat the portion in the Crow’s foot area. If you were to disable the entire muscle, you would not be able to close your eyes except by passive “spring” of the tissues and gravity. This is seen in people after nerve injuries or strokes and it can be very dangerous to the health of your eye.
Posted on October 24th, 2012
A: Restylane is used to fill what is called the “tear-trough”. This is the groove in the lower eyelid below the bulging fat (“bag”). The darkness you see in that area is often the result of the shadow that is cast by overhead lighting. Filling that area so that the groove is gone will correct that shadow. However, many people also have pigment in that skin (melanin) or a purple hue as a result of the quality of the skin, allergies, or other issues. This will not be fixed with a filler. In fact, filler in some people can make that worse, especially if it is placed too superficial. Looking at your photos, your bags and tear-trough are advanced. You really should consider surgery. Restylane is limited in the amount of filling that it can successfully accomplish without creating other problems. Usually 1/2 cc per side is about the max and that will not be enough for your tear-troughs.
Posted on September 17th, 2012
Q: I had a chin implant 4 weeks ago with another surgeon and my lower lip is still numb. Also, I can’t speak, eat, or smile as I did before, and the smile is really unattractive. When will I gain feeling back in my lower lip? There is also a dimple that appears in my chin as I speak. Is that temporary as well?
A: Chin Implant Recovery
There are two approaches to doing a chin implant, through the mouth and under the chin. Each has its advantages.
Most younger people choose through the mouth because their skin under the chin is so nice and perfect that they don’t want an incision. If you already have a scar (common childhood injury), a crease, or are having other surgery on the neck that requires that incision, you should have the chin implant placed that way.
I am going to assume your implant was placed through the mouth. With the incision through the mouth, a few of the very small nerve branches to the central lower lip are cut and some mild numbness in the very middle can occur. This is temporary. If there is total numbness and goes all the way to the edge of the lip, you should contact your surgeon as it is possible the main branch was injured. When the incision is inside the mouth, it also causes some swelling and disruption of the muscle in the lower lip. This results in the lip being a little higher when you smile and some challenges to forming words. These are temporary but take a few months to go away.
Putting the incision under the chin usually causes none of the numbness and lip mobility issues. It is a much quicker return to normal. You do, however, have a small scar that is slightly visible when viewed from below.
In short, if you want an essentially invisible placement of the implant and are willing to deal with a few months of quirks, go through the mouth. Otherwise go underneath