Tear Trough Filler Trend Continues

As 2012 draws to a close we continue to observe that "Tear Trough" filler injection continues to emerge as the new go to procedure for facial enhancement:

http://www.nytimes.com/2012/12/13/fashion/tear-trough-fillers-may-help-under-eye-shadows.html?_r=0

These procedures remain complication prone and require an advanced appreciation of the underlying anatomy and technique if unhappy results are to be avoided.

My wonderfully talented colleague Dr Naomi McCullum from Paddington Sydney http://www.drnaomi.com.au/HOME.html  and I will co-present a paper on this tricky subject at the Cosmetex 2013 conference in Melbourne.

http://www.cosmetex.org/melbourne2013/pdf/Cosmetex_2013_Program.pdf
http://www.cosmetex.org/melbourne2013/

Blood Sweat and Tear Troughs' What Is It, Where Is It and How Should We Actually Be Injecting It? Dr. Ronald Feiner, Cosmetica Medical Aesthetic Clinic, Sydney Australia   Dr Naomi McCullum, Dr. Naomi Clinic, Paddington, Sydney Australia

The Anatomy of The Tear Trough-Why This is a Difficult Treatment Challenge

There are numerous instances of unhappy patients after tear trough filler injections. There seems to be a sound anatomical explanation for this. Injection of a filler deep to the muscle (as is the popular recommendation) is veritably impossible as the "overlying" muscle is firmly attached to the underlying bone in this target area (see below). In other words there is no tissue plane to accommodate the injected filler "deep to the muscle".  "Non Esiste" as the Italians may say. This does not mean that improvement by injection is impossible but it does confirm why so many tear trough injections result in complications and misery. Essentially the intended injection placement has nowhere to go other than into the muscle itself or "out the side" so to speak. The injected product ends up in the muscle, over the muscle into the subcutaeous fat plane, into the inferior orbital fat or inferior to the muscle in a fat pad know as SOOF. This will be a source of debate and conjecture among cosmetic injectors for some time to come. However anatomy is a fact rather than theory. I recently attended Australasian Society of Aesthetic Plastic Surgery-An Anatomical Basis for Non-surgical Rejuvenation seminar at Macquarie University ( www.facebook.com/asaps.org.au )  where facial human anatomy dissections were performed. I was keen to examine the controversial anatomy of the tear trough and lid-cheek junction. Essentially the following extract from a 2009 scientific paper is consistent with what I saw demonstrated in the anatomy dissections:  

"In the suborbicularis plane, the tear trough and the lid/cheek junction differ. Along the tear trough, the palpebral portion of the orbicularis oculi muscle is rigidly attached to the bone, with no dissectible anatomical plane deep to the muscle. It was not technically possible to dissect above the periosteum and below the muscular attachment. Along the lid/cheek junction, however, the orbicularis muscle has a ligamentous attachment to the bone by means of the orbicularis retaining

ligament. Unlike the tear trough region, there is a plane deep to the muscle into which material can
be injected or surgical dissection performed."

The tear trough and lid/cheek junction: anatomy and implications for surgical correction
Haddock NT, Saadeh PB, Boutros S, Thorne CH Plast Reconstr Surg. 2009 Apr;123(4):1332http://www.ncbi.nlm.nih.gov/pubmed/19337101

Another Study Supports Liposuction Safety Under Local Anaesthesia Compared To General Anaesthesia

Combination Cosmetic Surgeries, General Anesthesia Drive AEs
Laura Newman, MA
February 9, 2012 — The use of general anesthesia, the performance of liposuction under general anesthesia, and a combination of surgical procedures significantly increase the risk for adverse events (AEs) in office-based surgery, according to reviews of statewide mandatory AE reporting in Florida and Alabama. More than two thirds of deaths and three quarters of hospital transfers were associated with cosmetic surgery performed under general anesthesia, according to an article published in the February issue of Dermatologic Surgery.

The study, derived from 10-year data from Florida and 6-year data from in Alabama, "confirms trends that have been previously identified in earlier analyses of this data," write the authors, led by John Starling III, MD, from the Skin Cancer Center, Cincinnati, and the Department of Dermatology, University of Cincinnati, Ohio.

In a companion commentary, C. William Hanke, MD, from the Laser and Skin Surgery Center of Indiana, Indianapolis, presses for 3 patient safety practices: "(1) Keep the patient awake!... 2) Think twice before supporting a patient's desire for liposuction that is to be done in conjunction with abdominoplasty under general anesthesia.... 3) "[B]e advocates for prospective, mandatory, verifiable adverse event reporting...[that] should include data from physician offices, ambulatory surgical centers, and hospitals to define and quantify problems that can be largely prevented and eliminated."

The authors and editorialist are especially critical of liposuction performed under general anesthesia. The study revealed that although liposuction is perhaps one of the most common cosmetic surgical procedures, no deaths occurred in the setting of local anesthesia. "Liposuction under general anesthesia accounted for 32% of cosmetic procedure-related deaths and 22% of all cosmetic procedure-related complications," the researchers write.

The researchers analyzed mandatory physician AE reports in ambulatory surgery submitted to their respective states, encompassing 10-year data in Florida and 6-year data in Alabama. A total of 309 AEs were reported during an office-based surgery during the 10-year period in Florida, including 46 deaths and 263 reportable complications or transfers to hospital. Cosmetic surgeries performed under general anesthesia accounted for the vast majority of deaths in Florida, with liposuction and abdominoplasty the most frequent procedures.

Six years' worth of data from Alabama revealed 52 AEs, including 49 complications or hospital transfers and 3 deaths. General anesthesia was implicated in 89% of reported incidents; 42% were cosmetic surgeries. Pulmonary complications, including pulmonary emboli and pulmonary edema, were implicated in many deaths in both states.

Plastic surgeons were linked to nearly 45% of all reported complications in Florida and 42.3% in Alabama, write the researchers. Office accreditation, physician board certification, and hospital privileges all revealed no clear pattern.

One limitation acknowledged by the authors is that case logs of procedures performed under general and intravenous sedation are required in Florida, but are not public domain, and so were unavailable for analysis. In addition, investigators were not able to obtain data on the total number of liposuction procedures performed in either state. The lack of those data prevented them from calculating the overall fatality rate.

The authors and the editorialist have disclosed no relevant financial relationships.

Dermatol Surg. 2012;38:171-179. Article abstract, Commentary extract

Medscape Medical News © 2012 WebMD,

Is There a Non Surgical Face Lift That Works?

Every now and again one encounters a facial plastic surgeon who has a keen appreciation of the limitations and pitfalls of formal surgical face lifting. We see patients who have had face lift surgery with disappointing and unnatural outcomes. For the non or minimally invasive surgeon it can prove difficult or sometimes impossible to subsequently perform our facial procedures where the anatomy is distorted and the underlying tissues scarred and inelastic. The underlying tissues can be almost as unrelenting as concrete.

Dr Philip Young a US facial plastic surgeon's response to the question:

"Is there a non surgical face lift that works?" www.realself.com/question/there-non-surgical-face-lift-works  is very interesting and shows great insight for a surgeon who actually does selectively perform face lifts.

    "There are different options to rejuvenating a person's face. You don't necessarily have to undergo a major facelift with long incisions to make yourself look better. A great option is facial fat transfer. When people age, they lose volume in the face and this contributes to the facial skin drooping and the wrinkles to form. It has been the practice of surgeons to cut away skin that appears to be excessive to what it used to be. This approach is not always the best way to make a person look younger. Sometimes the extra skin is the result of the face losing volume and the skin sags and droops due to this process. It is analogous to a grape losing volume when it turns into a raisin.
Traditionally, surgeons have practiced reductive procedures, meaning they reduced what is left. This can make a person look better but oftentimes the person doesn't necessarily look younger. A person will look like a more shapely raisin instead of a younger and healthy looking grape.
Fat injections can restore this volume and help you look younger in a natural way and it can be done with no incisions. Most all of the time, all that is needed are very tiny puncture holes for the special instruments used to restore volume into the face. Other ways to bring youth to your face without surgery include a resurfacing procedure to remove wrinkles, fillers to fill in volume in a piecemeal way over time, etc."

Philip Young, MD

Bellevue Facial Plastic Surgeon

www.drphilipyoung.com

Her Majesty The Queen-Could We Have Retarded The Aging Process?

With minimally invasive and non-invasive techniques it seems certain that the advanced changes of ageing in our lovely queen  (as seen  in the following inventive You Tube link) may have been retarded or minimised.
http://www.youtube.com/watch?v=E8nJhG1xE5o&feature=em-share_video_user

The Queen over time demonstrates the ageing phenomenon of tissue involution at all facial levels with bone loss, muscle loss, fat loss, sub-cutaneous tissue loss/laxity and skin thinning.

Naturally in the era of the Queen's more youthful years only radical face lift surgery was available to her. Today we  would have had the opportunity to maintain her skin and volumise her soft tissue contraction with various fillers. Her lips would be injected with fillers to maintain their warmth.

Thin lips are unfortunately often associated with a mean appearance. Yet, in youth, the queen displayed fulsome lips that imparted the appearance and impression of a welcoming warmth.

As is the case with many females, it can be seen that the Queen displayed in her the late 40's (corresponding to an approaching menopause and diminished circulating hormones) a time of accelerated involutional changes. Intervention at this stage is very important and modern women have become very much aware of this.

Expert advice and treatment with minimally invasive procedures can maintain the youthful allure and warmth that underpins attractiveness. Our experience is that patients are generally ecstatic with the outcomes of minimally invasive interventions. Our intention is rejuvenate with naturally beautiful outcomes while avoiding an "operated on" appearance.

Excellent results depend more on the surgeon than the equipment

In cosmetic procedures, pleasing outcomes are achieved by the talented surgeon/proceduralist and not necessarily by the brand of equipment or product used. An excellent piano can enhance a great pianist's performance. However a mediocre pianist cannot generate a great performance even on the best of pianos. Technology and pharmaceutical filler companies  may well claim that their particular laser or filler generates exceptional cosmetic results. The truth is that excellent outcomes are in the hands of the proceduralist. It follows that a talented proceduralist will utilise quality equipment and products to optimise creative efforts.
Patients understandably can fall prey to commercial hype about injectables, fillers and equipment.
However a syringe or two of the same filler can be used creatively for facial enhancement or injudiciously to the detriment of a face. It depends so much more on the ability and quality of the proceduralist rather than the claimed merits of the injectable product or equipment used.
It has become apparent that successful cosmetic outcomes are being achieved consistently by experienced "boutique" based proceduralists, where every patient is assessed and treated as an individual challenge. This is the artist's studio rather than the factory floor sweatshop.
In my experience this standard is rarely seen in the outcomes of the cosmetic supermarket like clinics where time/profit work ratio standards rule.
Some cosmetic proceduralists  have achieved truly artisan levels of creativity in their minimally invasive work and deserve due recognition for their excellence. More about this in a future post.

Medical Aesthetics Incorporated

With the growth of corporate medical cosmetic clinics expanding dramatically here in Australia, one reads with surprise that in California USA (that epicentre of cosmetic surgery) regulations on who can own and run a medical clinic are quite tough.

For example regarding the "Corporate Practice of Medicine" :

The following types of medical practice ownership and operating structures also are prohibited:

• Non-physicians owning or operating a business that offers patient evaluation, diagnosis, care and/or treatment.
• Physician(s) operating a medical practice as a limited liability company, a limited liability partnership, or a general corporation.
• Management service organizations arranging for, advertising, or providing medical services rather than only providing administrative staff and services for a physician's medical practice (non-physician exercising controls over a physician's medical practice, even where physicians own and operate the business).
• A physician acting as "medical director" when the physician does not own the practice. For example, a business offering spa treatments that include medical procedures such as Botox injections, laser hair removal, and medical microdermabrasion, that contracts with or hires a physician as its "medical director."

from:
http://www.mbc.ca.gov/licensee/corporate_practice.html


Apparently here in Australia non-medical entrepreneur owned cosmetic surgery chains are enjoying great financial success.

Discerning patients should always reflect upon the issues of ethical care and management in treatment delivery in any potential clinical experience and  perhaps take a keen interest in who owns and operates a medical clinic before committing to a medical cosmetic procedure.

Cosmetex Cairns 2012 Conference

It is almost 2 weeks since our annual conference "Cosmetex"in Cairns.
http://www.professionalbeauty.com.au/2012/05/04/article/Cosmetex-2012-Kicks-Off/POBKUHOCNQ.html
 http://www.professionalbeauty.com.au/2012/05/08/article/Impressive-Attendance-at-Cosmetex-2012/SPOZSNKYFX.html

It was great to experience the warmth of topical Queensland and the camaraderie of our colleagues.

At last I have found time to report on the conference for this blog. The Australasian College of Cosmetic Surgery and its associate organisation the Cosmetic Physicians Society of Australasia are to be congratulated for another huge and successful cosmetic medicine and surgery event that is without parallel in Australia. The inexorable drift towards minimally invasive therapies over traditional surgery continues with externally delivered, non-invasive fat reduction ultrasonic and freezing treatments emerging as alternatives to internal cannula liposculpture techniques.
However equipment remains very expensive and outcomes still rather modest at this stage.

A new potentially long acting soft tissue filler from Holland was launched http://www.youtube.com/watch?v=6bRsYaK46GY&feature=related that is claimed lasts up to 4 years in the most durable its formulations. This is a significant advance and may now set the pace for filler innovation and development. We look forward to see how this integrates into injection filler strategies.

Otherwise the conference seemed to reflect that experienced Australian cosmetic practitioners remain  at the top of their game and equal in knowledge, ability and skills to colleagues anywhere in the world.

This bodes well for our patients who can access the best and appropriate therapies right here in Australia without compromising quality of care as can be the case in overseas vacation treatments.

The Failed Aesthetic Of Tear Trough Injection Treatment

Injection of commercial fillers into tear troughs has been one of the most unfortunate trends in recent cosmetic medical practice. The treatment often delivers an incomplete or failed aesthetic result and is frequently associated with long term swelling , lumpiness, bruising and a bluish skin discolouration known as Tyndall effect.
http://chemwiki.ucdavis.edu/Physical_Chemistry/Physical_Properties_of_Matter/Solutions/John_Tyndall

This filler treatment fails on the basis of a misappreciation of the ageing anatomy in this facial region that has been educationally promulgated by most of the filler companies via their medical advisers. This has resulted in an entire battalion of misguided injectors (including myself initially) out there causing grief to patients with poor aesthetic outcomes.
http://www.realself.com/review/australia-juvederm-juverderm-eye-bags-tear  http://www.realself.com/review/Restylane-Vey-Unhappy
http://www.realself.com/question/restylane-deep-tissue-bruising-tear-trough
http://www.plasticsurgerypractice.com/issues/articles/2009-09_03.asp

The anatomy of tear trough (nasojugal groove) ageing need to be understood. It is is a normal anatomical depression that runs from the inner aspect of the eye (near the nose) diagonally outwards down the cheek. The tear trough deepens with ageing due to the cheek (malar) fat pad below reducing in volume and also sagging downwards (ptosis). Another fat pad located under the circular muscles around the eye (oribularis oculi) called SOOF also reduces and sags with ageing.  

Essentially the popular rationale that promotes treating the tear trough by injecting fillers under the orbicularis muscle may somewhat augment the diminished the targeted SOOF fat pad. However such an approach is usually aesthetically insufficient as it is the whole cheek (malar) complex that requires  augmentation by much more volumising  and durable fillers. The outcome in the hands of skilled injectors results in a projected and somewhat elevated the cheek that is in aesthetic harmony with the eye (orbital) complex above it.

Cosmetex Meeting Cairns 2012

The annual scientific meeting of the Australasian College of Cosmetic Surgery (ACCS) and Cosmetic Physicians Society of Australasia (CPSA) will take place in May at the convention centre Cairns Queensland. http://www.cosmetex.org/cairns2012/program.php
This meeting is always a very informative event with many invited international speakers and also our own Australian contingent. Interestingly invasive surgical procedures remain a small component of the programing reflecting the preeminence of non-invasive treatments in aesthetic medical practice.
With 2 lecture session and 3 workshop sessions all running concurrently, the meeting can be quite challenging for the attendant. There are always some great technical tips to be gained from such meetings although generally it becomes apparent that one or two speakers emerge as standout educators.
However historically some speakers can incline to spruik or overly promote methods with outcomes that appear to fall well short of the hype. One is left to sort the wheat from the chaff in these presentations.
Hopefully after this meeting I will be in a position to report on some interesting developments. 

Filler Fever

I had the pleasure of attending 2 cosmetic medicine presentations this week featuring excellent practitioners reviewing and demonstrating filler and muscle relaxation techniques for facial rejuvenation. It remains apparent that much can be achieved with injectables to naturally improve faces naturally.
Choice of fillers can be determined by several factors, the most important being matching appropriate filler to the facial region targeted. Equally important is a keen appreciation of beauty principles that allow practitioners to inject in an aesthetically pleasing dynamic that can also prove cost effective.

My talented and charming Paddington cosmetic practitioner colleague, Dr. Naomi McCullum has written informatively on the highlights of one of these meetings. I am linking to her always compelling blog on the subject as follows:
www.drnaomi.com.au/blog/
Thank you Dr. Naomi!!

"Jowl Trowel" Treatment of Adjacent Tissues to Correct Jowls

One of the most challenging problems in aesthetic surgery has been how to treat the development of lower face jowls. There has been no successful localised surgery invented to directly address this issue. Face lifting attempts to pull the jowl outwards towards the lower ear but this does result in a rather stretched and anatomically incorrect appearance.




It should be appreciated that in the lower third of the face there is a volumetric loss of bone, muscle, fat and skin. This creates the so called  pre-jowl sulcus which may by subtraction represent the impression of a neighbouring and detested jowl as seen in this ageing rock icon.



However are we seeing true jowls or just deficient tissues adjacent to the jowl? Certainly it is logical to re-volumise this area with biological fillers-what I have termed "jowl trowelling".




Below is a commercial photo of successful treatment with a filler of the pre-jowl sulcus-jowl gone!

Generous Warm Lips

 

The lower third of the face is defined as the area immediately below the nose to the base of the chin.

In this region treating the lips in a manner that restores youthful definition and volume is the key target that can provide standout results.

The loss of volume and contour with lip ageing can impart an impression of unintended meanness or anger.
However restoration of lip volume and contour can reverse this tendency to convey a sense of warmth and generosity.

The reality is that we all tend to form an impression of people at least initially on their appearance and feminine attractiveness is founded on curvaceous form.

Last week I was watching the immortal movie classic "Casablanca" on TV and was once again moved by the captivating beauty of the female lead Ingrid Bergman.

Her beauty was characterised by an elegant screen persona complemented by her arresting femininity. Bergman was able to portray both strength and vulnerability into her character .

She had a striking face with a beautiful lip contour that added to the impression of a natural personal warmth. Her lips were well proportioned, curvaceous and balanced--- an aesthetic we try to emulate in clinical practice.

http://www.liveinternet.ru/users/4223781/post173721321/

A Revolution in Aesthetic Design. Beauty may well be "in the eye of the Beholder" but does the "Beholder" understand why?

"Beauty is in the eye of the Beholder" but does the "Beholder" understand why?

It is argued that beauty is an entirely personal or emotional interpretation.

Indeed all of us inherently recognise facial beauty.

However is is not generally appreciated that this recognition is founded on laws of nature related to mathematical dimensions and ratios known as "PHI".

There are certain characteristics in nature that are universally acknowledged to be aesthetically beautiful. This includes the face and is applicable across all ethnic boundaries. In fact such boundaries simply do not exist in this concept of beauty.

"Phi" is the basis for the "Golden Ratio" and in facial aesthetics it is truly an intriguing concept.   
 http://www.goldennumber.net/neophite.htm

Managing facial aesthetics in a way comply with these mathematical laws of nature enables contemporary cosmetic practitioners to beautify the face in a manner that is far more effective than simply filling wrinkles or stretching a face surgically with face-lifting. http://www.youtube.com/watch?v=oL0wpOXX5-k

The "PHI" concept is a wonderful tool that  illustrates to patients how treatments (while individualised and adjusted) can conform to this universal beautification principle.

Safe Liposculpture-Respecting Body Physiology

We have been safely performing liposculpture under tumescent local anaesthetic in our clinic procedure rooms for 10 years now without any significant complications. In my opinion the key to safe liposculpture (apart from good general technique principles) is to limit the number of tissue regions (and the amount of fat to be removed) in any one session. One should not test the limits of a patient's safe physiologic function with excessive liposculpting treatment and avoid combining liposculpture with other operations in the one session.

As is the case in many other cosmetic procedures, pleasing and safe outcomes are founded on the avoidance of overly agressive surgery.

An Australian colleagues gives an excellent summary on Liposculpture on his website and I link to it here: http://www.facialartistry.com.au/liposuction-tumescent_liposuction.html

2012!

Cosmetic practitioners are inclined to contemplate what surprises may be in the offering for 2012. In this exciting field treatment options can change rather swiftly but demand careful scrutiny.

Botulinum toxin treatments are likely to remain very popular. The injections are so tiny and in experienced hands the treatment session so quick.  Mainly used in the upper face what is not always appreciated is that while wrinkles are diminished an attractive  open-eyed appearance is achieved. This is the real magic of these injections.

Lasers treatments and alike are likely to further evolve although evidence of outcomes must be carefully evaluated for efficacy as sometimes outcomes fall well short of long term expectations.

Fillers for aesthetic facial volumisation and injectable aesthetic nasal corrections are set to replace the simplistic concept of just filling wrinkles. Although many casual injectors try their hand at these techniques, there will continue to be a widening gap between occasional injectors  and those practitioners who really understand aesthetic principles. Cheaply priced injection offers (eg. coupon entrepreneurs)  can equate with very disappointing aesthetic experiences.

Liposuction practice will continue to differentiate into those who remain classical "lipo-sculptors" or expedient thermal or chemical "lipo-meltors" (fat melting techniques-laser, ultrasound, chemical lipo-dissolving). Traditional "Lipo-sculpting" using variably sized and configured cannula is an art form that cannot be replaced by melting fat just as Michelangelo could not have sculpted his masterpieces with a blowtorch.

Plastic surgeons in Australia do not generally perform cosmetic injection treatments, often seconding these procedures to compliant medical or nursing injectors with variable experience. This trend is set to continue into the future unless more plastic surgeons accept the value and artistry of minimally invasive procedures. A recent very interesting review article about this topic "A Viable Future" http://www.plasticsurgerypractice.com/issues/articles/2011-10_01.asp
by Sarah Russel expanded on this topic when she interviewed US plastic surgeon W. Grant Stevens, MD, FACS, on the role of aesthetic education in a changing field. The following extract is very enlightening on this issue:-

Is he saying plastic surgeons will become insignificant if they don't embrace formal cosmetic plastic surgery training, nonsurgical body sculpting, and facial rejuvenation? "These patients want these nonsurgical procedures, and if they don't get them from plastic surgeons, they're going to get them from their other providers. Once they do, they will then be educated by those providers and they'll go to those providers for plastic surgery. Within a decade, they won't be going to plastic surgeons for facelifts, but to ophthalmologists or dermatologists, because they embraced those services wholeheartedly."