Cutting Edge

The Real Deal in Cosmetic Surgery Advancements

By Marilyn Moss, M.D.

Ben Franklin astutely said, “All would live long, but none would be old.”

This inherent desire in people for youthfulness has fueled the field of cosmetic surgery, which has continued to grow at a dizzying rate. According to statistics released by The American Society for Aesthetic Plastic Surgery (ASAPS), consumers spent $12.2 billion on plastic surgery in 2006 to pay for 11.5 million procedures. Although the number of women who undergo plastic surgery far outweighs the number of men, there has been a steady rise in the number of men who seek cosmetic procedures.

Non-surgical
Non-surgical procedures have proliferated in the cosmetic surgery field, making aesthetic surgery even more appealing. According to Dr. Foad Nahai, president of ASAPS, “What’s really new in the field is the tremendous growth in non-surgical treatments.”

Non-surgical cosmetic therapies are safe and fast, requiring very little downtime for the patient. The procedures can be done in an outpatient setting, commonly in the doctor’s office. Recovery time is much shorter, allowing patients to resume normal activities almost immediately, in many cases.

Fillers
Over the last few months, the FDA has approved several new non-surgical treatments for the face to add to the armament against aging. These newly sanctioned therapies involve the use of “fillers” for facial wrinkles. The injected substances add volume to reduce wrinkles and lines.

Most fillers are composed of a substance found in the body, such as hyaluronic acid, which reduces the risk of allergic reactions. In the past, collagen derived from animals was often used as the filler, and the incidence of allergic reactions was 3 to 4 percent. Nahai said, “These products are not permanent, but they are safe and free of side effects.”

Laser
Another relatively new procedure to reduce wrinkles or other signs of aging involves tightening the collagen underlying the skin. Tightening the sub-surface collagen gives the overlying skin a tighter, younger look. The treatment spares the overlying skin surface. Skin tightening procedures can be used on the face, the neck, the eyelid, the abdomen and the thighs.

The results of skin tightening, however, are less pronounced than surgical interventions, such as face lifts. “The changes are not that dramatic. But this is a promising technique that needs to be refined,” Nahai corroborated.

Surgical

Breast Augmentation
Breast augmentation surgery is the most popular cosmetic surgery among women. There are some new initiatives in use, as well as some on the horizon. To begin with, the FDA recently re-approved, again, the use of silicone breast implants, after withdrawing its approval because of health concerns.

Silicone is reportedly more “natural” appearing, but the implant can rupture without the patient noticing, allowing the silicone to seep out into the breast tissue. Medical texts have suggested that exposure to silicone may be associated with connective tissue diseases. Although that remains controversial, it is undisputed that the ruptured silicone can lead to hardening.

Saline implants have a safe health profile, and ruptures can be easily detected. These implants, however, are more prone to wrinkling or rippling at the edges. Dr. George Bitar, medical director of Bitar Cosmetic Surgery Institute in Virginia and a visiting lecturer at the plastic surgery department at the University of Virginia, said, “I like saline. And I insert the implant from the armpit and place it below the breast muscle to keep the implant separate from the breast tissue.”

According to Bitar, this method offers several advantages: no nipple nerve damage, no scarring of the breast tissue to confuse mammograms and little interference with breast-feeding.

At the cutting edge of breast augmentation is the promise of stem cells. Researchers are evaluating the use of stem cells derived from fat to increase the size of the breast. Dr. Adam Katz, an assistant professor in plastic surgery at the University of Virginia, explained that for years, fat transplants have been used in the cosmetic field, although not with breast surgery. Fat taken out by liposuction has been injected elsewhere to add volume. According to Katz, “This kind of transplant may have some beneficial effects for surrounding tissues.”

Those studying fat grafting feel that the stem cells within the adipose tissue are responsible for such additional benefits, along with the increased volume. Katz said, “There is emerging evidence that suggests the stem cells enhance vasculature [arrangement of blood vessels] and also affect the overlying skin.”

Blepharoplasty
Patients who seek eyelid surgery present different causes for their complaints. Some have loose skin, while others have a droopy brow. And others have experienced skin changes that make the eyelid surface look like crepe paper. Treatment for the individuals, therefore, must be tailored to their specific needs. According to Dr. Victoria Suh, a board-certified plastic surgeon at Victoria Plastic Surgery and Laser Skin Care Center in Fairfax, laser therapy may work well for crepe paper skin, but “sometimes you just have to do surgery.”
Brow and eye lifts can be done endoscopically, giving the surgeon visual access to the tissues. The fiber-optic scope is inserted through small incisions, rather than a large incision like that used in traditional lift procedures. Suh often uses a small, biodegradable device called an endotine. The endotine hooks the sagging skin from below the surface, lifting it up. The other end of the endotine is then anchored to the bone. Over time, the healing process causes the skin to adhere to this new position, and the device dissolves within seven to eight months. The anchored skin gives the face a younger, rejuvenated look. Suh said the endotine is an improvement over the use of threads, which do not dissolve. “The threads have not been all that successful,” Suh said.

Hair Transplantation
Cosmetic surgery offers micro-hair transplant surgery to treat baldness in individuals.

The micro transplant is a significant improvement over transplants offered 10 years ago. Hair follicles are harvested in mini-strips from the back of the neck. Individual hair follicles are prepared as follicular units for transplant, unlike the older method that transplanted multiple hair follicles together.

Dr. James Vogel, an associate professor in plastic surgery at the Johns Hopkins Hospital and a private practitioner with an office in Owings Mills, Md., said the new individual method produces a very natural appearance. Vogel commented that the procedure is much more demanding for the physician because of the size and number of the transplants. “This is very labor-intensive,” Vogel said.

He added that the effort was worth it, however, saying, “There should never be any physical evidence of a transplant.”

Liposuction
Although many modifications to the basic procedure have been introduced, none seem to have significantly improved on the old-fashioned method. According to Bitar, “These new devices are just a new twist on regular liposuction.”

Bitar, who has been performing plastic surgery for more than 13 years, remarked that the new approaches, such as liposuction with ultrasound or laser, had some advantages but also some downsides. The new procedures can often be done under local anesthesia, reduce blood loss and tighten skin. These benefits, however, are offset by a loss in precision, which might result in poorer outcomes.

Even the newest intervention, which involves injecting a fat dissolver under the skin, does not overly impress Bitar. He explained that the procedure causes fat cells to burst, and then the body absorbs and excretes the debris; no suctioning is required. The physician, however, cannot control which fat cells get targeted. Bitar said, “This can lead to lumps and bumps or require multiple treatments.”

Rhinoplasty
The most significant change to cosmetic nose surgery has been the use of an open technique instead of the former closed technique. Dr. George Weston, a partner with the Austin-Weston Center for Cosmetic Surgery in Reston, explained that the nose is opened at the junction with the upper lip. This allows the surgeon to open up the nasal area and view the structures. “It’s a huge advance,” Weston said.

Before any surgery occurs, Weston has the patient view a computer simulation of the result. This gives the patient a glimpse of an approximation of what to expect. “Every nose is different. You want to give the patient what they want, but you want to balance that with what is possible,” Weston said.

No matter what cosmetic procedure is done, Bitar cautioned patients to do their homework: Research both the procedure and the physician. To Bitar, the outcome depends largely on the provider. “It boils down to the operator. The procedure is only as good as the operator.”

Bitar advised consulting a board-certified plastic surgeon, saying, “These doctors are fully trained and have a lot of experience.”

Additionally, the best outcomes result when patient anticipations are well-matched with realistic expectations. Dr. Gary Price, a plastic surgeon affiliated with Yale University, stressed the need for communication about the different options and their expected results. He said, “Counseling the patient is very important. The patient needs to have realistic expectations.”

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Saline vs. Silicone
By Carissa Sutherland

Because of safety concerns, the Food and Drug Administration restricted the use of silicone breast implants 15 years ago, making saline implants the only option for American women. Then after years of research, in November 2006, the FDA lifted the ban to the cheer of plastic surgeons and patients nationwide. 
One has to wonder: If saline proved so safe and effective, and thousands of women continued to receive implants, why was the ban lifted? If silicone is the better type of implant, have thousands more women raced to their nearest surgeon now that the FDA changed its mind? Three Northern Virginia board-certified plastic surgeons—Drs. Anne Nickodem, Christopher Hess and David E. Berman—weigh in on which is better: saline or silicone.

Size Matters
Many surgeons and patients widely accept that silicone implants look and feel more natural than saline implants since silicone has texture similar to breast tissue.

Well, not necessarily, according to Nickodem. “It’s really based on the patient and how much tissue she has already. Saline can equally feel like a breast in a patient with more tissue. The more fat she has to start with, the more likely saline will feel just as natural.”

Hess echoed Nickodem’s remarks. “I recommend the silicone if women have smaller breasts to begin with. There is a point that saline and silicone will feel similar if the patient has a decent amount of tissue to start with.”

However, according to Berman, there is no question—silicone is better. He said, “It’s not even controversial; one feels like jelly, and one feels like water.”

Safety First
When it comes to safety, it would seem nothing rivals saline implants. Since water composes every human body, salt water causes no harm. But recent advances in the production of silicone implants make them safer than ever before.

“All implants get encapsulated naturally by the body, even pacemakers. Therefore, I could go in and easily remove ruptured silicone,” Hess said. Unlike their ancestors, newer silicone implants resemble Jell-O, are easier to remove and aren’t sticky or runny.

Cost Comparison
Aside from safety alone, patient concerns also lie in the differences in cost and post-op scarring when making the choice between silicone or saline implants. For example, silicone may cost twice as much as saline but won’t deflate if it has a leak. Hess said, “I offer both, but there is the cost factor. Silicone does cost more. But, when saline ruptures, it’s like a tire going flat.”

Leave a Mark
Berman added, “Silicone implants come pre-filled, so you have to make a bigger incision on the lower part of the breast and can’t hide the scar as well.” Alternatively, saline implants require a smaller incision and are filled once placed inside the body. Therefore, saline implants offer the least amount of scarring on the breast.

In the debate over silicone versus saline, weigh the costs, consider the starting breast size and ponder the issue of scarring. All the doctors agreed that each patient’s personal situation varies but that both options prove safe.

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Five After Five
Cosmetic Surgery Patients Share Their Reports Five Years Later
By Carissa Sutherland

Plastic surgery practices won’t be closing shop anytime soon.

The American Society of Plastic Surgeons (ASPS) reports that nearly 2.5 million people in this region of the country received surgical cosmetic procedures in 2006. In other words, 25 percent of all plastic surgeries throughout the nation happened on the East Coast last year between Delaware and Florida. The West Coast’s plastic surgery popularity may take the cake, but the numbers don’t lie—our area of the country holds a close second. And, perhaps even more shocking, that number has more than doubled from just a million patients in 2002.

Of those million people who went under the knife five years ago, five of them from our area share their stories.

Vanessa Marulli Baltimore, Md.
“I was always insecure about the size of my chest,” Vanessa Marulli, 25, remembered. She wasn’t alone; 42,000 other women in the region opted for breast implants in 2002 as well.

Marulli’s surgeon, Dr. Adam N. Summers of Glen Burnie, Md., required two consultations. “At the first consultation we talked about the incisions, risks and complications, the long-term effects and the eventual need for implant replacements,” Marulli said. At the next consultation, swept up in excitement, she scheduled her surgery date.

But after the procedure, Marulli wasn’t out of the woods. Her left breast healed properly while her right breast stayed hard and high. Marulli had developed scar tissue under the implant. Three months after her original surgery, she had another surgery to remove the scar tissue. Though she was numb from local anesthesia, Marulli could feel the tugging, scraping and pulling. “It was very uncomfortable and at times painful, but in the end it was worth it because my breast healed correctly, and now it looks and feels great,” she said.

For others considering breast implants, Marulli advised, “Think about every complication possible and ask yourself if it’s worth the risk.”

Vicky Decker Sterling
The number of people receiving Botox nationwide quadrupled since 2002. Like millions of other women, Vicky Decker, 44, seized the opportunity to look younger. She hated maintaining her body with exercise while her face revealed her age.

After researching online and talking to friends, Decker chose to treat her brow furrow and horizontal forehead lines. She felt pleased with her results, which took only a day to kick in. “There’s a joke about Botox—that you become expressionless. I still make facial expressions, but they don’t involve my forehead. And that’s just fine with me!”

The effects of Botox eventually fade, requiring ongoing injections. Though many people swear by Botox, Dr. Christopher Hess, a board-certified plastic surgeon in Northern Virginia, warned against using Botox as a substitute for face or brow lifts. He said, “Injectables do good for a lot people, but they’re no replacement.” Future face lift or not, Decker intends to continue her quick Botox injections. “I look younger and I feel better,” she concluded.

Dylan Scholinksi Washington, D.C.
Since Dylan Scholinski’s childhood, he felt uncomfortable in his own body. Scholinski, 40, was born a female and endured years of agony for having masculine traits. At 18, he decided to begin living as a man. However, his breasts made this transformation difficult.  “Every time I looked at my body in the mirror, nothing fit or made sense,” he remembered. After years of hunching his back and wearing several layers of clothes, Scholinski chose to undergo chest reconstruction surgery.

Scholinski picked his surgeon, Dr. Michael L. Brownstein, based on reputation. “Dr. Brownstein is one of the best in the country,” he said. “He’d done this type of surgery many times and understood what I wanted.” Within an hour of flying from Washington, D.C. to San Francisco, Calif., where Brownstein is based, , Scholinski completed his initial consultation and had the procedure the next day. During the two weeks he spent healing in San Francisco, Brownstein addressed all of Scholinski’s concerns. His lengthy healing process prevented Scholinski from raising his arms over his head for over a month.

Looking back, Scholinski wished he’d dedicated himself to fitness before surgery to expedite his healing. In addition to exercise, he recommended “having a support system in place for physical and emotional recovery.”

Five years later, Scholinski remains pleased with the results of his surgery. “When I hug people, all of a sudden I can feel myself touching another person without all the layers covering up my body. That’s nice,” he said.

Jill Russell Alexandria
“I had heavy bat wings, like most of the women on my mother’s side of the family, and it was difficult to find clothes to fit over them,” said Jill Russell*. Both men and women have difficulty defeating upper-arm fat. Since diet and exercise sometimes aren’t enough, some people opt for an upper arm lift, called brachioplasty.

Russell and only about 1,000 other people in this area chose to have brachioplasty in 2002. Fed up with how she looked and felt, Russell, 50, surveyed several area doctors and chose Dr. Dean Kane. Kane’s high ratings in Baltimore Magazine as well as the size of his practice sealed the deal.

At her initial consultation, Russell and Kane discussed options for the best possible results. Russell already knew the traditional way to have the procedure, along the underside of the upper arm. However, Kane suggested a different way, through the armpit. “By coincidence, his wife had the same surgery and showed me her results,” Russell said. She was immediately pleased with what she saw and scheduled her surgery.

Though Russell remains pleased with Kane’s work, looking back, she might have done things differently. “Everyone should consider both the traditional and the armpit procedure. I might have had the traditional, even with the long suture, because the results are more even,” she said.

Elizabeth Gunthert Washington, D.C.
“I hated it when I smiled because one of my eyes would completely close,” Elizabeth Gunthert remembered. Gunthert, 25, suffered from a weakened eyelid muscle, and it not only affected her looks and self-confidence, but also her sight. “My eye drooped so much at the point of the surgery that it was affecting my vision.”

Gunthert’s eye especially drooped when she was tired. “My eyelid would become very heavy and uncomfortable,” she said. A specialist identified her issue immediately. Luckily, since Gunthert’s drooping eyelid affected her sight, her insurance company covered the costs of her procedure.

After the surgery, her sight immediately improved. “My eye no longer bothered me when I got tired, and I noticed a difference in pictures immediately.”

Now, five years later, she reflects upon the extended follow-up required for her particular situation. “For medical reasons, I couldn’t have waited any longer.  In a few years, I will probably have to do it again.”

Hess recommended visiting a few surgeons before selecting one. And, he noted, ensure the surgeon is a board-certified plastic surgeon. Dr. David E. Berman, a board-certified plastic surgeon in Northern Virginia, also noted that the best candidates for any type of plastic surgery maintain emotional stability, good health and realistic expectations. Dr. Anne M. Nickodem, another board-certified Northern Virginian surgeon, agreed. “It’s still a body image change, even if you’ve wanted it for years. What I do will make you feel more confident, and then you’ll feel stronger overall.”

(October 2007)

Tags: Beauty, Cosmetic surgery, Health & Beauty, Plastic Surgery, Top Plastic Surgeon