by David Newman, MD | Oct 2, 2019 | Blog
Fillers are a class of injectable medication designed to soften and sometimes flatten folds, depressions and wrinkles of the skin. They are produced predominantly by US companies and are sold as syringes containing one cc. of clear gel product that is sterile and ready for immediate use. In the US, patients are only treated with fillers by physicians and nurses. These materials were first used to treat facial wrinkles and skin folds around the mouth but their use has expanded to include augmenting the bony surfaces of the face such as the cheekbone, chin and jaw line. Recently, fillers have found use in nonsurgical rhinoplasty (nose job) and treating surface changes after rhinoplasty surgery. Fillers are also currently used to fill areas of muscle loss due to the aging process and other causes. The most common area for this muscle loss treatment is in the temple areas on the side of the face.
The filler substances currently in use are composed of a chemical called hyaluronic acid, also known as “HA”. The HA that is used for cosmetic purposes is completely man-made but hyaluronic acid is a significant component of human skin. HA is found in all layers of the skin but especially under the uppermost layer of skin called epidermis. Within skin, hyaluronic acid is important in skin support and is a key component of skin healing. Hyaluronic acid is a small chemical but can be synthesized into a polymer of many of the same units. Longer polymers can last longer under the skin and therefore fewer treatments are required. The chemical polymers can also be modified to change their consistency and feel as well as other properties.
There are currently about twenty fillers on the market and the most common fillers for wrinkles and skin folds are the juvederm line of products and the perlane/restylane group of products. The most often currently used product for enhancing bony prominences is Voluma. The FDA currently approves all facial fillers and the approval not only clears these products for use but for use in specific areas of the face. Physicians and “nurse injectors” are instructed by the FDA to use these specific for specific areas but injectors often also use product in areas not mentioned by the FDA. These areas are referred to as “off label” locations. Off-label use can be safe and effective but should be discussed with the treating physician.
Fillers are commonly confused with Botox treatment. The rule is that fillers fill and Botox paralyzes muscles to lessen wrinkles. Botox is most commonly used for wrinkles that occur between the eyebrows, over the forehead and within the Crow’s foot area outside the eyes near the temple. There are some parts of the face where both Botox and fillers can be of use. For example, the corrugator muscle folds the skin between the eyebrows. When patients are younger, muscle overactivity leads only to folding in this area and Botox is a great fix. But with the aging process, permanent wrinkles can be seen even when the patient is not flexing these muscles. It is at this point where fillers can be used effectively to soften and flatten wrinkles and folds.
Facial filler side effects most commonly encountered include irregularities that can occur under the skin, pain bruising, itching and rash. The types of dermal fillers used can all have these side effects and some of the side effects are related to the experience of the injector.
by David Newman, MD | Oct 2, 2019 | Blog
How much does rhinoplasty cost?
Rhinoplasty (nose jobs) vary in cost depending upon the surgeon, the type of surgery that is being performed and the location of the procedure. Rhinoplasties are one of the most gratifying surgeries performed by plastic surgeons today because of the prominent place the nose has on the face. It’s one of the first things others see when they look at us. We also associate something of our personality and ascribe some personality traits to our nose and so, when the nose becomes obvious we feel it is “too much’ and wish to diminish the effects of the shape to match more the shape of the average nose.
Most patients seek consultation for nasal surgery because they feel their nose is simply too large for their face. Women may especially have smaller faces and sometimes their nose grows to resemble the shape and size of one of their relatives. There may be other aspects of the nose that bothers patients and it is also often the case that the nose simply does not “go” with the rest of the face. For example, some patients have a long and angular nose that seems to droop and point downward, especially when they smile. They may see that this shape simply doesn’t match other features of their face that may be more round. Rhinoplasty surgery goals include not only reshaping the nose to gain improvement but also viewing the nose artistically to see how the nose relates to the face. In this fashion, changes can be made that appear most natural because the nose then becomes part of the face and blends in better.
Closed Rhinoplasty
Most procedures to reduce the size of the nose and make other changes are done as closed rhinoplasty. All incisions are made inside the nose and the structure of the nose is altered (bone and cartillage) through these inside incisions. Closed rhinoplasty is often the least expensive option when considering what type of rhinoplasty is best but sometimes open rhinoplasty is necessary to get patients to their goals.
Open Rhinoplasty
There are some shape issues for which open rhinoplasty is a better choice. These shape problems invariably involve the nasal tip, whether it be deficient (doesn’t stick out far enough), or is irregular or asymmetrical. In these situations, the incisions located inside the nose are extended across the columella (the part of the nose at the bottom between the nostrils) and the skin of the lower part of the nose is lifted so that the surgeon can see the tip directly to make changes in the cartilage of the tip.
There are other situations where open rhinoplasty is the preferred choice and also, there are surgeons who do all of their rhinoplasties open. Open rhinoplasty takes, on average two to three times longer depending on what needs to be done and so are significantly more costly.
Breathing Problems
Some patient who wish to gain cosmetic improvement with rhinoplasty may also have difficulty breathing through their nose. They may have a deviated septum which blocks air flow through one or both sides of the nose or they may have other cause of blockage that can be addressed at surgery. In these cases, rhinoplasty can be combined with airway surgery. Medical insurance never pays for cosmetic rhinoplasty but it does pay for airway surgery and the rhinoplasty surgeon can apply to a patient’s insurance carrier to see if they will cover such surgery. Some surgeons will discount the cost of the airway surgery when it is performed with rhinoplasty because when airway surgery is performed in a patient that is a good candidate for it, the patient can have very significant functional improvement in their breathing. It is very important to remember that cosmetic rhinoplasty generally doesn’t affect a patient’s breathing when it is performed by itself. That is because inspired air flows downward after entering the nostrils. So removal of the bump on the nose doesn’t decrease air flow.
by David Newman, MD | Oct 2, 2019 | Blog, Featured
Advances in fillers have led to their safe and effective enhancement of lip shape and size. Lip injections not only contain the filler material but also lidocaine, the local anesthetic used by dentists to numb tissue and so the procedure is more comfortable than ever. Most patients feel that both the upper and the lower lip are small and so have both the upper and lower lip enhanced. There are also many patients who feel one lip requires enlargement as compared to the other and only have that one lip enlarged. Lip injections can also be done to reduce the wrinkles that pop up around the edge of the lips.
Lip injections before and after
Before patients have lip injections they may notice that their lips are small or perhaps the pink part of the lip seems to roll in. Patients may also note that the lips don’t have the curvy shape they wish to make them look their best. Others may feel that they simply “have no lips” and wish to have more definition. After lip enhancement with fillers, patients note not only improvement in the size of their lips but also improvement in shape and that their lips are more well defined.
Lip enhancement is an outpatient procedure and patients can have it done on their lunch break, though there is some swelling that takes about 48 hours to come down. So the day after lip injections patients experience generally moderate swelling but usually no pain. The final size and ultimate shape of the lips are achieved usually by 7 to 10 days and generally last about one year for most of the fillers.
What not to do after lip injections
Patients may resume normal activities after lip fillers but should not exercise or do anything strenuous for the next 8 hours. The site is treated as one would normally with cleansers as needed. Aquaphore ointment can also be applied to keep the lips moist.
Lip injections near me
When friends and relatives of patients have the chance to observe lip injections near them they see that the results are natural and not strange looking like they see on TV or in the movies. The enhancement leaves the lips looking more youthful, fuller and in better proportion.
Cost of juvederm lip injections
Costs vary by practitioner. Prices are generally close to each other and patients should be wary if the price is very low.
Side effects of lip fillers
The most common side effects of lip fillers are swelling, bruising and itching. Less commonly, bumpiness of the site may occur.
Do lip fillers hurt?
The lip filler material itself has a numbing agent in it and so when the lips are injected there is mild to moderate pain, depending on the patient. When patients are sensitive to pain or discomfort, a dental block can be performed and this is often done by a physician. One the dental block has been done the lips are completely numb and the lip injections are better tolerated.
Natural lip fillers
The filler material used by all of the common products is composed of hyaluronic acid synthesized as a polymer. It is completely man made. Hyaluronic acid is a chemical that is found in between the cells of our skin tissue. It provides support and has healing properties, and so though it is man made, one can consider it natural because the same material is naturally occurring.
by David Newman, MD | Sep 26, 2019 | Blog, breast-surgery, Featured
Among the most exciting changes in plastic surgery have been the development and widespread use of different types of implants used in breast augmentation. These additions have helped plastic surgeons achieve excellent cosmetic results in nearly all patients. Today, there are more implant choices available than ever and so more to talk about with your plastic surgeon!
A recent survey of plastic surgeons in the US and in Europe has revealed that saline, or salt water filled breast implants are the implant most commonly used in the United States and in Europe, silicone gel breast implants are more commonly used for cosmetic breast surgery. The commonest shape of implant used both in the US and Europe is the round implant by an overwhelming majority and few surgeons still use breast shaped, or “anatomical” implants. Anatomical implants were more frequently used in the past as they were thought to provide a better shape for patients but over time, these implants have been associated with more complications than the simple round breast implant. Anatomical breast implants had also been textured on their surface to keep them in proper position and this textured surface has been implicate in the very rare BIAL, or breast implant associated lymphoma. To date, there has never been a case of BIAL associated with a smooth surfaced breast implant.
Breast Implant Shapes
Along the way in the development of different shapes of breast implants, manufacturers have varied the width and projection of implants to solve issues some patients have in terms of the width of their chest. The ideal shaped breasts create a space in the center of the chest where the breasts come together near the midline. They don’t need to touch but there should be some relation to each other. The ideal breast shape also includes fullness on the side where the breast comes to fall at the edge of the chest but no further. Additionally, the ideal breast shape includes fullness of the upper portion of the breast because this is the part of the breast that is exposed. Breasts should also have good projection, where the breasts stick out from the chest. Both projection and fullness of the upper pole create a sense of youth and vitality.
For round shaped implants, manufacturers have varied the width and the projection of the implants. For example, there are wider implants with less projection and on the other end of the spectrum, narrower implants with more projection. Some patients with wider chests can have a better and more natural breast shape with a wider breast implant that has less projection. And some patients with a narrower chest night also have a better shape with a narrower breast implant that has more projection.
Most patients are best served with an implant that’s in the middle of these extremes. These are round shaped implants with good projection that also have enough width so that the extend towards the middle and the sides of the chest. That way patients have the best of both worlds.
It’s What’s Inside
Implants are constructed as a shell of solid silicone rubber on the outside and the shell is filled with either saline (salt water) or silicone gel. The shell is similar, in concept to a balloon in terms of its flexibility but the shell is very strong and can withstand very high pressures and not deflate. But it is what is inside that can affect how the implant feels and appears. In patients with smaller breasts that have less tissue covering the implant, there is a higher chance to be able to feel the implant or to feel or see waves. This is termed “rippling” and is more common with saline filled breast implants. Silicone gel filled implants have a lower chance for this rippling effect.
Recent Developments
The basic silicone gel breast implant that is still in use today was one of the first implants to be placed on the market 65 years ago. There are three breast implant manufacturers that produce FDA approved gel implants in the US today. They use different names for their products but the implants are basically the same product. The last two years have seen the release of silicone gel breast implants that have a denser gel fill and each company also has their own names for these more dense gel products. The manufacturers state that these thicker gel filled implants have more fullness in the upper part of the breast and that there is a lower chance for rippling than with the basic gel fill. Both of these claims still await independent scientific proof.
The choice of implants is best discussed thoroughly with a plastic surgeon that can listen to a patient’s needs, both in terms of shape and size and is open to discuss the pluses and minuses of each type of implant.
by David Newman, MD | Sep 26, 2019 | Blog, breast-surgery
Breast Augmentation is one of the most gratifying cosmetic procedures offered by plastic surgeons today, and in fact, studies show a 95% satisfaction rate with this surgery which is one the highest rates among all procedures. A large number of patients have breast augmentation when they are in their younger years where they are just joining the work force, are in school or otherwise find it difficult to fund surgery. It may still make sense to have this surgery both because of the high satisfaction rate and because the beneficial effects of the surgery are so long lasting. Breast implants provide for a permanent size that never changes during a patient’s life time. Implants also affect shape, and make the breast appear natural and youthful, even when patients are in their older years. Breast implants also allow for greater ease in the wearing of different styles of clothing. In a way, breast augmentation surgery might be considered a worthwhile investment.
Breast implant surgery is generally performed under anesthesia and so support personnel are required to provide the safest and most pleasant experience. Staffing for surgery involves not only the physician performing the procedure but also an anesthesiologist and nursing staff, as well as other operating room personnel. The surgery must also be performed in an accredited surgery center and all materials and procedures must comply with the best standards and practices. Despite the high cost for providing this high level of medical care, competition has made breast augmentation surgery affordable for almost every patient. One factor has put an upward pressure on the cost of breast augmentation surgery.
Breast Implant Cost
In the 1980’s, there were two types of implants available: saline and silicone filled breast implants. The cost of the implants was so low that they represented approximately 4% of the total cost of the surgery and so breast augmentation prices remained low. More recently, breast implant manufacturers have brought different types of breast implants to the market and at higher prices. Most significantly, “gummy bear implants” were introduced and these breast implants have a thicker silicone gel fill than previous gel breast implants. When gummy bear implants are used, they drive implant cost to account for 30% of the total cost of surgery.
Higher Cost But are they Better?
The breast implant manufacturers state in their sales literature that gummy bear implants support the upper part of the breast more than saline implants and more than their other silicone gel breast implants. They also state that it is more difficult to “feel” the implant and that therefore the results of breast augmentation surgery are more natural with the gummy bear implants. These claims have not been confirmed yet by independent scientific study.
As mentioned above, breast implants are quite durable when one considers that they move with the patient’s movements and appear totally natural and part of the patient’s natural anatomy for many years. Patients, in consultation are encouraged to feel the different types of implants, to “try on” the implants in a specially designed bra and also to look at breast implants before and after photos.
One issue that might affect a patient’s shape with gummy implants is that, with time, and as normal breast tissue is lost, the more solid shape of these implants may become more noticeable. Gummy bear implants are relatively new and although they are FDA approved, it may take some years of actual patient experience to determine what the long term effects are on the shape of the breast as compared with the current saline and silicone gel alternatives.
Fat Transfer Breast Augmentation
Recent innovations in the field of liposuction and fat transfer have made the use of fat an alternative to enlarge the breast. Benefits of the use of fat are that no foreign object (i.e. a breast implant) is required. The greatest negatives regarding the use of fat to enlarge the breast are the degree to which the breast can be enlarged, which is a fraction of one cup size and that multiple treatments may be required. The average increase in cup size when patients opt for breast implants to enlarge the breast is between one to two cup sizes. Additionally, with time the fat that has been transferred may be lost, whereas breast implant volume never changes, with the exception of the occurrence of a deflation which is uncommon. Thus, for now fat transfer breast augmentation is probably not the best option for patients seeking breast augmentation but technological advancement may change that.
Breast Lift with Implants
Some patients may develop loosening of their breasts, especially after childbirth and with breast feeding and this can cause the breast to droop. The other issue with drooping is that, at the same time, there is a loss of tissue in the upper part of the breast and so the breast can appear less full.
Patients who develop drooping of their breast and also note loss of fullness in the upper part of the breast usually require a breast augmentation with a breast lift. Since this surgery takes at least twice as long to perform, the cost is more. There may be alternatives and so it is important to discuss these with your plastic surgeon.
by David Newman, MD | Aug 14, 2018 | Blog
TIPS FOR MAINTAINING YOUR COSMETIC SURGERY RESULTS
You have worked hard to achieve excellent cosmetic results through plastic surgery. You have invested in surgery of the body (tummy tuck, liposuction, and breast surgery) or facial treatment including facelifts, brow lift or laser treatment for wrinkles. This work requires both surgeries as well as an emotional investment. Patients want to make the results of their surgery last as long as possible. The following tips will help you get the most from your efforts. Ensure your cosmetic surgery results will be long-lasting to give you the best return for your investment.
Eat Healthy food
Cosmetic surgery procedures that focus on the body may have a subtle but significant influence on your appetite and metabolism. Surgeries like tummy tuck and liposuction affect patients physically, in terms of how the body itself feels to the patient and also how one might feel when looking at oneself in the mirror. This change in appetite may affect how much you want to eat, and so it’s important to “listen to your body” and monitor the situation! During early recovery and even over the long term, it’s good to get into the habit of eating healthy foods. Stick to whole grains, lean protein, lots of vegetables and fruits and drink a moderate amount of water to keep hydrated. Drink to take up space in your tummy so you won’t feel like you need to eat between meals. We are made up mostly of water. Our cells are packed with it, and the cells are bathing in water. Water also flows through the body, facilitating our metabolism.
Regular Exercise
When we exercise regularly, we engage our metabolism and help our weight remain constant. The constant burning of calories ensures that even when we have occasional dietary indiscretions, our body will continue to burn these extra calories. Exercise will smooth out weight fluctuations that can wreak havoc on our skin. Exercise is especially important with a patient who has had tummy tucks and liposuction. Both cardio and weight training can burn calories and maintain your beautiful physique. Weight training can help sculpt and strengthen the bodies support structures and keep you looking and feeling healthy. Keep your workout schedule constant and perhaps three times per week and work the whole body evenly for best results.
Good Skin Care
For the best skincare products, it’s most important to consult a skincare specialist. Skincare products, including hydrating creams and gels and special makeup can prolong the effects of facial plastic surgery. Great skincare products not only treat the skin but also protect our skin from the harmful rays of the sun. Skin protection should be a part of everyone’s daily regimen, and this should not only include skincare solutions but also the general covering of the skin with hats, scarves, and sunglasses but also clothing in areas where there is a strong sun.
Quit Smoking and Drinking
It’s commonly known that smoking and cosmetic surgery don’t go together. Nicotine inhibits healthy skin healing, and there is even carbon monoxide in cigarette smoke. However, inhaled substances can have a significant effect on the skin if used over the long term. So make the surgery period a new start on your life and carry the abstinence from smoking forwards into your new future to protect the long term health and look of your beautiful and youthful skin. Also, keep consumption of alcohol to a mild or at least less than a moderate degree. Alcoholic drinks lead to slow dehydration and can rob all of our tissues of its necessary water and nutrients, including the skin and support structures like healthy muscles and bones.
Follow these few important rules, and you will be on your way to not only a healthier you but in preserving what you have gained from your cosmetic surgery treatment.
