V>W=F (Volume creation more than wrinkle treatment =Femininity)

Attended 2 presentations in Sydney in the last week on injectables

Excellent presenters Dr. Danny Vleggar (Switzerland) http://www.youtube.com/watch?v=ldezLZKQlaM & Dr Glenn Murray (Perth) http://www.youtube.com/watch?v=0z6xA1GCM0A while demonstrating different injectable products both focused on Volumisation in preference to Wrinkle treatments in modern aesthetic facial rejuvenation.
This trend to volumise rather than to "chase" wrinkles is completely correct in my opinion and is certainly  reflected in the wonderful outcomes achieved by informed cosmetic aesthetic practitioners.
In this regard the disappointing outcomes we frequently witness with formal radical face lift outcomes are founded on the erroneous objective of stretching the face (achieving wrinkle reduction) rather than creating aesthetic contours. We frequently see patients who have spent near $20,000 on face lifting with unnatural and rather "de-contoured" faces who require their faces aesthetically "re-contoured" with appropriate fillers. They leave the clinic generally delighted with their feminising outcomes. A few have stated I had the wrong procedure having a face lift?? We try to be diplomatic!
http://www.youtube.com/watch?v=p3hYzRIOJrs
http://www.youtube.com/watch?feature=endscreen&v=yfPO147wxYs&NR=1
http://www.youtube.com/watch?v=g1D666k0nvA

Tweaking Facial Rejuvenation with Muscle Relaxant Injections

Traditionally teaching encouraged cosmetic injectors to over-treat faces with muscle relaxants,  often resulting in cases of stunned and rather expressionless features. Add to that droopy brows, droopy cheeks, asymmetrical smiles diminishing character. Generally the effects are to be endured for some 3-4 months. The following celebrity examples attest to this unfortunate trend.
http://pinterest.com/barbiegurl29/botox-gone-bad-celebs-with-out-make-up/

For some years now many Australian injectors have appreciated that less is more and that subtle treatments should prevail. Judicious tweaking with these injections can enhance other the outcomes of other facial enhancement procedures.  So we are effectively value adding with such injections.

Will expand on this interesting topic in a future blog.

Weird Therapies and Procedures

Fringe if not bizarre cosmetic procedures abound, with questionable professional ethics only matched by gullibility of some patients.

Women considering genital enhancement surgery should first consult the following paper just published online: http://whv.org.au/static/files/assets/ca7e9b2f/Women-and-genital-cosmetic-surgery-issues-paper.pdf
 A short excerpt from this article follows:   Women and Genital Cosmetic Surgery. Women’s Health Issues Paper No. 9, February 2013 Page 1 © Women’s Health Victoria

9.1 Reduced sensation
It is ‘not yet understood exactly how labia minora engorgement during sexual arousal may be involved in sexual pleasure and how labia removal might affect this’4. However, there is evidence to suggest that female genital cosmetic surgery involves removal of tissue that may contribute to sensory sexual arousal28, 66, and is likely to interfere with innervation and sensation in the genital area10, 34, 66, 67. The outcomes of genital surgeries suggest decreased enjoyment of being caressed, impaired arousal and lubrication, and an inability to reach orgasm12, 36.

There is a particular risk of providing female genital cosmetic surgery to younger women who may not fully understand the implications for their future sexual lives
68. Genital surgery during adolescence risks damaging sensitive genital tissue and may require reoperation68 if puberty is incomplete. The risk associated with operating too early in a woman’s development is highlighted in the case of a ten-year-old pre-pubescent girl who underwent one procedure on her left labia minora and, nine months later, had the same operation on her right labia minora. The surgeons themselves reflected that ‘in retrospect we feel that she could have had both operations after puberty’32.

There is no information to demonstrate how female genital cosmetic surgeries will impact on childbirth



http://www.iol.co.za/lifestyle/love-sex/sex/the-disturbing-rise-of-the-g-spot-jab-1.1464150
http://www.dailymail.co.uk/femail/article-2245450/Cosmetic-fillers-destroy-looks-The-truth-botox.html

Non-invasive Body Contouring alternatives to Liposculpture

While patients and cosmetic doctors enthusiastically embrace non-invasive technologies as alternatives to liposculpture, a recent review article seems to suggest that, to date, outcomes from these technologies are either only fair to modest or simply disappointing.  Focused ultrasound and cryolysis seem to hold the most promise thus far but patient expectations should be realistic before committing to rather expensive treatments that may come to little or no improvement. In my view Tumescent Liposculpture remains the gold standard in the quest for a reliable and durable outcome. Additionally there would appear to be very little if any difference in costs. http://www.plasticsurgerypulsenews.com/13/article_dtl.php? QnCategoryID=130&QnArticleID=262 In Summary:

ULTRASOUND CAVITATION aims to induce fatty tissue disruption. However, the frequencies associated with cavitation are difficult to focus with precision. There are several ultrasonic cavitation devices on the market, but there appears to be little evidence that they produce a true cavitation effect resulting in cell lysis with lasting effects. RADIOFREQUENCY The permanence of RF as a body-contouring treatment has not been well proven and newer technology platforms have taken the spotlight. CRYOLIPOLYSIS Treatments are generally well tolerated but are limited to areas that can be lifted into the suction head of the device. Each application takes about 1 hour, and an average of 25% reduction in thickness of the adipose layer has been reported. Each area is treated once, though re-treatment is possible after a period of months if desired. FOCUSED ULTRASOUND Though this may be associated with greater discomfort during these procedures, focusing may be more precise than it is with frequencies used for cavitation however the effects are mostly modest. LASER There is skepticism as to the clinical mechanism of action and long-term results. No histological studies of tissue treated in vivo have been presented despite the marketing claims of efficacy.

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,