Cutting Edge
 
The Real Deal in Cosmetic Surgery Advancements

By Marilyn Moss, M.D.

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.”

(October 2007)