“I am a surgical R.N. and I have seen the procedure on TV, ” The Doctors”. A plastic surgeon is one of the hosts. He practices in L.A. A series of tiny incisions are made under the chin (maybe eight) from ear to ear. An “I guide” (a lighted cannula type device) is weaved in and out of the incisions with a suture shoestring resemblence. It goes under the chin and is pulled tight, just like tying your shoes. Very good results for a less invasive procedure that takes minutes to perform with an experienced surgeon. Less costly and recovery is fast. Everyone wins! Just check on the website “doctorstv.com”, it was on Wednesdays show I think. Wish someone would bring this here! Keep me informed please. I have also seen this on another show, but I didn’t catch the name. I just remember hearing it is fairly new and clever. I will volunteer to be a learning patient if you need. Thanks!”

“Surgical R.N.”(Actual Name Withheld for Privacy)

My reply:

Dear “Surgical R.N.”,

Many thanks for the follow-up note.

I found and reviewed the video of the procedure you mentioned here: http://www.thedoctorstv.com/main/procedure_list/1344.

The Doctors TV link gave me enough information to further research the procedure on the Internet.

There is nothing published about this technique in our respected refereed medical journals, nor has there been a presentation at one of our scientific meetings.
The IGuide technique is a variation on the Thread Lift which was a bit of a hype 5-7 years ago and has fallen out of view, if not into disrepute because it turned out to have too many unsatisfactory results and did not hold up well for most patients.
One problem is that the cost of the special sutures is so high that the procedures cost as much as more conventional techniques.
I also have some questions as to the validity of the technique conceptually, knowing what we know about essential plastic surgical technical principles. For example, experience has shown us that without some actual surgical re-draping of the tissues, suture suspension alone (like the Thread Lift and the similar appearing IGuide) fails to hold up over time (6-12 months).

There have also been problems with skin pleating: if you pull the loose or redundant skin up with a thread and don’t remove/cut-out the excess, where does the extra skin go? I have seen numerous patients who have tried the thread lift and ended up with wrinkles and pleats of the neck and cheek skin.

As a surgical nurse, you have probably seen various surgical techniques come and go, and can appreciate the importance of good medical reports including long-term outcomes that instruct us regarding validity of the procedures, satisfactory results and complication rates.

As a Plastic Surgeon, I would not do a procedure on a patient that I wouldn’t do on my own wife: Besides my doubting the conceptual validity of this technique, in my assessment, the IGuide face- and neck lift and techniques do not yet have the track record to merit one volunteering to be a guinea pig.

“Caveat Emptor!” (Let the buyer beware!)

Having said that, I do not know of anyone in Denver who is trying or offering the IGuide technique, but I am certain someone will be, in the near future, and it will be prominently advertised in our media, offering “more for less.” As I mentioned in my previous e-mail, cosmetic surgery is subject to a lot of marketing hype; The IGuide is a perfect fit for that sort of thing, with a catchy name and a promise of fewer incisions, less invasiveness (Are 8 stab incisions along the jawline better than the 1-inch incision in the crease under the chin of a conventional neck lift?) and as good results.

Thanks again for your inquiry and follow-up note.
Paul C. Zwiebel, M.D., D.M.D.

Although I anticipate the answer, speaking with them through an interpreter, I ask what they want me to do for their child. Rather than reply verbally through the interpreter, the answer is almost always made by pointing to the obvious cleft of the lip, or by opening the child’s mouth to point to the gaping opening of the roof of the mouth, a cleft palate.

It is so easy to feel a bond with the patients. Even though we do not speak the same language, the instinctual parental sense of attraction and desire to protect and nurture is irresistible. This seems common among my fellow American teammates who continually comment “how cute” the children are and the nurses are quick to want to hold the babies and play with them. These seem unusual, even extraordinary and unexpected reactions to a child with such an obvious facial deformity.

Later, I notice those same feelings manifest in how the crew is playful and caring for the baby as we bring the baby into the operating room and prepare to begin the surgery. My mind shifts to focus on the steps of preparation, administration of anesthesia and the technicalities of the reconstructive procedure. With cleft lip surgery, the challenge is in the planning. I wear magnifying lenses as I measure and mark with needle and ink the relevant anatomic points that are crucial to the precision of the ensuing incisions and surgical rearrangements of the repair. It is a unique sort of puzzle: finding the hidden pieces and moving them to complete the aesthetic solution.

An hour passes without my notice, my consciousness engulfed in the conceptual and technical challenge before me. Finally, we place the last stitch and pull back the drapes.

Then, I see the cute little baby, again.

Only now, without deformity the cute baby can be seen by every one.

Pingliang is almost exactly in the middle of the map of China, right.

I had a chance to visit Kongtong Mountain, which is a short taxi ride from our accommodations in Pinliang. It is interesting to note that traffic regulations are quite different here. It appears that the lines in the road are merely “suggestions.” Cars do not hesitate to drive on the “wrong side” of the road, if it is convenient for the driver. This adds interest and excitement to the trip, like watching a national tournament of vehicular “chicken.”

The landscape is terraced for agriculture, and sandstone rock faces are perforated with thousands of man-made caves, used for centuries as dwellings, now mostly for storage – typically of grain and other agri-products grown here. The Chinese consider the area “desolate and dry,” but it feels humid to a Coloradoan. Things do grow here, but it is hardly lush, as the sandstone and conglomerate soil is not very fertile. This accounts for this being a poor province, since agriculture is the main industry here.

The road curves to the left and we are abruptly in a more verdant landscape bordering a remarkably green lake above which is the steeply rising 2200 meter Kongtong Mountain. The immediate impulse is to get to the top of this natural tower that dominates the Gansu plateau.

The sharply ascending cable car ride over the lake is accompanied by rapidly clicking camera shutters. I join in taking pictures, knowing these photos fail to capture the beauty and feelings I am experiencing today, but I hope the photographs can serve to remind me even a little about how it feels to be in this place.

Even before the cable car arrives at its station, we see many temples perched on the mountain’s tiers of rocky projections. I have a moment of recognition that I am actually in one of those exotic places I have seen in ancient works of Chinese art; I feel I recognize the dragon- and gargoyle-adorned, pointy-roofed temples at the edges of thousand-foot precipices from some movie or travelogue. Only now, I am actually here, they are real, and not just an exotic image or artist’s creative machination.

After a bit of walking over the rocky landscape among great centuries-old temples, I have broken away from the group distracted by the fortune-tellers, souvenir booths and beer garden of the Tourist Center. The thousand stairs that very steeply rise to the next peek beckon and intimidate, but the view through the trees to the temple looming above is irresistible. The irregular stone steps are very tall and dotted with pilgrims pausing to rest and scan the panorama. Intermittently, a small path directs me to ancient Tao alters like “Temple of the Clouds,” each on its own particular perch, with its unique view.

My senses are further filled by incense, intermittent prayer gongs, and the chanting of robed monks.

High up in “Heaven City,” I happen to meet up with one of our crew; Barry is a bright Anesthesiologist from Beijing. He is cheerful and physically very fit. He is surprised to see me at this remote altitude, smiles and asks, “Should we go to the top?” By now, “the top” seems illusory, unreachable, like a mirage; as soon as I think I have gotten there, I see another temple through the trees above. Of course and without hesitation, I answer, “Yes!”

Some stairs are cut into the mountain with a temple carved around them. The views, altitude, and climbing steep narrow rocky paths on precipices with drops measured in hundreds of meters can all be described as “breath-taking.” One of the most thrilling is the narrow cable-suspended, “Bridge to Heaven,” the only tenuously thin attachment traversing to an isolated, needle like tall spire rising many hundreds of meters from the valley and crowned with its own small temple.

Barry and I reach the very top of Kongtong. The top temple is heralded by an archway before which Barry immediately poses, instructing me to photograph him being certain to clearly include the three Chinese characters painted on the arch which frames the temple behind. I comply. Barry takes the camera to ascertain adequacy of my photo-documentation. Sure that we are standing at an ancient and sacred spot, paramount in significance to the lore and history of Taoism, I ask Barry what the sacred calligraphy means. He points to the words and interprets for me: “This is the top.”

Communication is always a challenge in remote parts of the world with different languages, dialects and cultures. I particularly remember a time in Ziwane, Kenya. We accessed a remote village using 4-wheel drive trucks traversing dried river beds and wash-outs, over 45 minutes from the nearest road of any form. The clinic was set-up in a 2-room structure with a dirt floor. Each of the blankets we spread on the floor was a separate “treatment area.”

My patient was an elderly man, age unknown: below his head dress, his deeply lined and sun-weathered face featured a scraggly beard dyed a deep red color more typically seen streaking the hair of attention grabbing adolescents at an urban mall. I had a translator who spoke Kiswahili, the language dominant in Kenya; my translator brought another translator who spoke a local dialect different enough from Kiswahili. When I asked a question, my English-Kiswahili translator translated to her translator who spoke to the patient; however, translator#2’s dialect was different enough from that of the local tribe, that my patients very young daughter translated one more time for my patient.

You can picture the scene: I sat patiently as many words passed in sequence in our small circle. The time it took for the response to make its way back to me was longer than the delay in sending messages up to a satellite in outer space and back, again. Though the distance traveled by our Kenyan question and answer was infinitely shorter than words bouncing off a telecommunications satellite, the reply I received from my series of translators was much more garbled and totally irrelevant to my initial question.

Somehow, here in Pingliang, China, it is not because of esoteric dialects. Here it seems more “administrative.” One of our greatest obstacles has become having our patients ready for surgery. Unfortunately, some of the local caregivers independently overrule our preoperative orders, resulting in surgery cancellations for the day, and leaving us with gaps in our schedule. Some of the babies have been postponed three times! Imagine the frustration of the parents/family who cannot understand why “the doctors inexplicably keep changing things!”

Each day, we try different things to assure best direct communication and coordination, but still so much is “getting lost in translation.”

Yet, thoughts about communication problems vanish when I complete a cleft lip repair that reveals just how cute these babies are.

The smiles on the parents’ faces are wordless expressions that require no form of translation.

As is typical for these surgical trips, the schedule doesn’t go as planned. Most of the scheduled cases for the morning are delayed for a variety of reasons.  Adapting to the conditions and the unexpected is critical and never-ending: even as I write this, I overhear one of the nurses, “The boy for the next case has a cold.”

The hospital here in Pingliang is much nicer than expected: the nicest medical facility in which I have worked on any mission trip.

China is certainly exotic and the realization that I am half-way around the world (14 time zones!) still strikes me as remarkable, even after the 28 hours of travel time to get to this north central location in China, just south of Mongolia.  There is not a chance I will begin to have the slightest understanding of the language during this 3 week trip. The cultural differences are intriguing, and I am grateful for the very tolerant hospitality and good humor of our hosts.

Some of the differences are in the realm of medical procedures and protocols: for example, here, proper operating room attire is to wear plastic flip flops with bare feet!

Yet, through this interaction of this international/intercultural group of patients, families, nurse and doctors, I quickly feel less the stranger with fewer barriers of any significance between us.

Elastin is the protein that gives skin elasticity, its tone or tautness and its resistance to stretching. Unfortunately, we lose elastin with aging, sun exposure, poor diet and exposure to toxins, like cigarette smoking. The loss of elasticity contributes to skin hanging loosely when we bend over and the bunching of skin when we drop our chin or bend at the waist.  It can also be part of the reason for there being extra skin after pregnancy or weight loss.

Although we have surgical procedures that can cut away extra skin, we have no treatments that can restore elastin: we can get rid of the extra skin, but we can’t restore the skin’s resistance to stretch, or improve laxity due to loss of tone.

This lack of laxity is why skin does relax after surgery, no matter how tight your Denver plastic surgeon may pull it. For example, when we do abdominoplasty (tummy tuck), we pull the skin so tight that people can’t stand straight for almost 2 weeks after surgery. Yet, after 6 months, people notice some folds of skin when they sit or bend over, although there is no extra skin when standing straight. Similarly, after facelift, the skin is pulled so there is no laxity at the jowls or neck, even when you drop your chin. The skin gradually relaxes to its resting tone and may not be able to maintain all of the tightness created by the surgery, so when you drop your chin, you see some folds or relaxation of the skin.

Collagen is the structural protein, the building block of the skin. Collagen gives our skin thickness. As we age, our skin gets thinner because we have less collagen. When we are young, our collagen lines up in layers of nice thick strands: our skin looks plump and smooth.  As we age, the collagen bundles are thinner and in disarray, giving us thinner, wrinkly skin.

In the face, we see a loss of volume with aging: the skin gets thinner due to the loss of collagen, some of the facial muscles get thinner, and the fat decreases, especially around the cheeks, cheekbones and lips. Coupled with the loss of elasticity, this deflation of the face causes much of what we see with the aging of the face: the flattening of the cheek mound and formation of the tear trough or hollow under the eyes make the “bags” under the eyes appear even worse. This deflated skin of the mid-face droops, adding to the deflation around the mouth, causing the nasolabial folds (the folds or creases that form a line between the nose and the corners of the mouth) and the jowls, the pouching of skin and fat along the jaw line.

The lips develop lines because the thinner less elastic skin creases from the underlying action of the lip muscles when we pucker or purse our lips. The shapes of the lips change, too: the upper lip gets thinner and longer; we lose the Cupid’s bow and the curve of the lip’s profile. We see less of our upper teeth when we smile.

The neck cords (“turkey neck”) result from the same aging changes. The fat and the skin of the neck gets thin enough to see the edges of the underlying neck muscle, the platysma, which has relaxed and has lost enough tone to hang down. (Unfortunately, attempts to exercise this muscle to prevent the cords do not seem to be adequate to preventing cords).

Another aspect of the aging changes of the skin has to do with its texture and color.  As our skin ages, the skin cells grow and replenish more slowly and the blood flow is less vigorous.  The protective dead cell layer on the surface of the skin gets too thick creating a rougher appearance and a flatter color that looks dull, gray or yellow, rather than bright, smooth and pink. This is why you have heard of the importance of exfoliation, the term we use to describe removing the excess dead cell layer.

For those in Colorado, skin care devices and products are available for purchase at our office. For gentle and effective exfoliation, cleansing the skin, and stimulating blood flow to the skin try the Clarisonic.

We are privileged to have available many Colorado skin care products that can slow and even reverse some of these aging changes.  Antioxidants like Vitamins A, C, and E repair damaged aging skin. Though not a replacement for proper sun protection, Vitamin C has been shown to repair sun damage, even as it is happening! Other products aid exfoliation and the turnover of skin cells (alpha-hydroxy’s), and stimulate the blood flow to the skin (niacin). Other products can be used to help even out pigment changes (hydroquinones).

In conclusion, the ideal facial rejuvenation process starts with prevention and continues with regular maintenance.

So, how does it work?

Let’s start with the basics of how lasers help to rejuvenate the skin: how does laser resurfacing reduce wrinkles? The answer is heat!

By heating up the collagen in the skin with the laser, a specialized Denver plastic surgeon stimulates the thickening of the collagen and an alignment of the bundles, resulting in skin that looks smoother and plumper.

There are a number of devices and techniques for laser resurfacing in Denver, which are designed to stimulate collagen to smoothen the skin: ultrasound (VASER), radio frequency (Thermage) and light energy (IPL and lasers) all “cook” collagen. (Chemical peels also perform this function.)

The key to a successful treatment is to apply enough heat to smoothen the skin (and stimulate collagen) without applying so much heat that we create excessive thermal injury (a burn).

Ablative Laser

Our older laser technologies apply the heat to the skin from the surface down, so we have to overheat the surface layers of skin cells to get enough heat to radiate down to the collagen in the deeper layers of the skin.  In a very real sense then, we’ve been using the laser to apply a controlled burn to the skin. Since the laser is destroying (ablating) the top layers of the skin, it is called the “ablative” laser technique.

While the results obtained are the most effective in smoothening wrinkles, the recovery is difficult; just the same as treating a first- or second degree burn, with stinging, redness, weepy skin and flaking for days to weeks. Depending on one’s skin type and the depth of the treatment, the redness can last for weeks to a few months. There can also be a lightening of the skin’s pigment as a result of these aggressive treatments.

The time for healing depends on the re-growth of the skin cells. Until the skin cells grow back, the skin is raw and weepy, requiring attentive dressing care to assist the growth of the new skin cells, to prevent infection and for comfort.

Not only does this mean several days of messy and tedious dressings, but also being out of the sun and possibly, away from other people, for about one or two weeks. Also, special make-up may have to be used to blend the splotchy red and pink skin for several weeks (or up to 3 months)!

Yet, there still is a place for this aggressive technique for getting the most dramatic improvements for severely damaged and wrinkled skin.

Fractional Laser

An appealing alternative in Colorado skin care, is fractional laser resurfacing that requires much less recovery time, discomfort or dressings. In fact, most patients undergoing this new technique are putting on makeup and returning to their normal activities in 3-4 days!

How is that possible?

Fractional laser technique treats a fraction of the skin.  Instead of removing (ablating) the entire surface of the skin, the fractional laser creates tiny holes in the surface to deliver the heat to the deeper collagen layer.

Think of aerating your lawn: small widely spaced plugs are removed to allow water and nutrients to penetrate to the roots of the lawn. A Denver plastic surgeon uses the fractional laser to disintegrate teeny holes in the skin of the right depth to get the laser’s heat energy down to the collagen “root layer.”

Because the holes are so small, they seal closed and heal by collapsing shut. The skin surface is sufficiently intact or repaired to apply makeup and be in public in only 3 or 4 days!

Because we use less overall heat, there is less thermal injury to the skin. This means less redness, in both the amount and the duration (usually 7-14 days of quickly fading, mild pink).

The other great effect of the fractional laser is that because we are removing a grid of so many tiny holes over the surface of the skin, the skin is tightening as the skin contracts to seal the thousands of tiny holes!

So, fractional laser tightens the skin and smoothes wrinkles by stimulating the collagen with less discomfort and recovery time.

Are we getting all the benefits with none of the disadvantages? **

Of course not. The fractional technique is doing just what the name says: it is treating a fraction of the skin, so the result is a fraction of that of the fully ablative technique.

The ablative technique does do a lot more for deep wrinkles and severely damaged skin, but most people do not need such aggressive treatment, and most of us do not have the time for a longer recovery period.

The fractional technique is more appropriate to refresh and rejuvenate mild to moderate aging changes with a much easier recovery period—essentially a long weekend!

** In skin treatments, results are proportional to the amount or intensity of treatment, but so is the recovery time and potential complications.

Mild and non-invasive therapies (use of skin care products, mild peels and IPL) produce smaller incremental improvements, but require little or no recovery time and minimal risk of complications.

More intense therapies (deep peels, laser) produce more improvements, but require more recovery time, and have more possible risks (like pigment change, infection or scar).

The degree of improvement, the amount of recovery time and the possible risks all increase in proportion to the intensity of the treatment: you cannot get the same results with non-invasive therapies, that you can achieve with more invasive techniques.  You cannot have the quick recovery of non-invasive treatments if you undergo a more invasive treatment.

For decades, antibiotic prophylaxis was standard for people with heart murmurs to prevent developing an infection of the heart valves. Recently, The American Heart Association and the American Dental Association concluded that taking an antibiotic (antibiotic prophylaxis) was unnecessary for patients with heart murmurs.

So why should women with breast implants still take antibiotic prophylaxis?

Because there is a big difference from what was studied by the American Heart Association. The likelihood that bacteria getting into the bloodstream could actually cause an infection of a heart valve was found to be insignificant. However, the stimulation of a capsule contracture is believed to be an effect of the immune system’s reaction to the presence of those bacteria.

Although we do not have absolute scientific proof that antibiotic prophylaxis will prevent capsule contracture, there have been many clinical reports of women developing contractures after a dental cleaning, even many years after having soft breast implants without capsule contractures. Because a single dose of amoxicillin (in the absence of penicillin allergy) is innocuous and very cheap, it is certainly a cost effective and prudent measure to preventing a potentially costly complication and protecting your excellent results from a Denver breast augmentation!

1. No High Impact Activities for 6 Weeks: The body takes about 6 weeks to make the capsule, after breast implant surgery. During that 6 week time period, the tissue around the implant is still a raw surface and is easily irritated by excessive implant motion, which will cause tissue irritation, inflammation and cause thickening of the capsule.  So during this time, you must avoid high impact activities like jumping or jogging, or big arm swinging activities (tennis, golf).

2. No Heavy Lifting or Repetitive Arm Motion for 6 Weeks: For the same reason noted above, the tissues need to be protected from intense or repetitive contraction of the pectoralis muscle (don’t lift more than 20 pounds), or do things like vacuuming (repetitive motion) or raking the lawn.

3. No Blood Thinners for 14 Days Before Surgery: The presence of even a small amount of blood in the implant pocket irritates the tissue. We must avoid post-operative oozing, so it is critical to avoid foods, supplements and drugs that thin the blood for a FULL 14 DAYS before your Denver breast augmentation surgery: aspirin, ibuprofen, herbal supplements, vitamins are blood thinners important to avoid. Even one baby aspirin 10 days before surgery can make a big difference!

4. Implant Manipulation Forever!: The body will naturally want to scar down the space we create at the time of surgery, so moving the implant to keep the full dimensions of the pocket is very important. I recommend a specific manipulation that takes only 10 seconds twice a day, that should be done every day starting right after surgery, and continue as long as you have implants.

5. Dental Prophylaxis: When you get your teeth cleaned by the dentist, there is a possibility that the scraping of the plaque can force some bacteria into the tiny blood vessels in the gingival (gums). The presence of bacteria in the blood stream (“bacteremia”) can stimulate the body’s defenses, the immune system to react in a way that can cause capsule contracture.  Clinical studies have shown this can happen even many years after a breast augmentation!  For this reason 40% of plastic surgeons routinely recommend antibiotic prophylaxis: a single dose of amoxicillin ½-1 hour before having your teeth cleaned or any surgical procedure.

Do these 5 really important things to help avoid capsule contracture!

What is a “capsule” and why is it so important to a successful result to breast augmentation? Is there a “good capsule”? How do you avoid a “bad capsule”? The answers are ones that every women having breast implant should know!

The Pocket: When we perform a Denver breast augmentation, we create a space (also called the “pocket”) for the implant behind the natural breast, oftentimes behind the chest (pectoral) muscle. After surgery, the body recognizes that there is a foreign object, the implant, and that it needs to move. To protect the surrounding raw tissue surfaces of the breast, muscle and ribs, the body creates a lining around the implant. Because the implant is moving in the pocket, the body creates a smooth slick lining that allows motion. This lining is very smooth and white and looks exactly like the lining of a joint called the joint capsule, which helps the motion of the joint. That’s why we also call the lining around the implant a capsule, because it looks just like the joint capsule and it helps with motion.

The Good Capsule: The ideal breast capsule is a thin delicate and supple lining with a pocket large enough to allow the motion of the implant to mimic the motion of the natural breast. The result is a natural flowing breast that moves naturally and feels naturally soft.

The Bad Capsule: If the capsule gets thick or stiff, or if it tightens down around the implant, the result is an implant that feels firm, doesn’t move with the breast, and may have an unnatural shape or position. If there has been inflammation, scarring can add to the stiffness of the capsule (“scar capsule contracture”).

How do you get a “good capsule” and avoid a “bad capsule?”  The answers are in my blog: 5 Really Important Things to Do to Prevent Capsule Contracture!