Facial Plastic Surgery

Recently, I received an inquiry from a surgical nurse who saw a feature on “The Doctors” TV show demonstrating the “latest, less invasive” neck lift technique from Beverly Hills that is supposed to be less expensive with faster recovery:

“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.

Laser resurfacing for Denver residents is in great demand because it allows a quick recovery for people wanting to improve the texture and pigment of their skin and reduce lines and wrinkles.

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 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 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.

In my practice, I have many patients who come to see me requesting revision rhinoplasty (nasal surgery) after they have had an unsatisfactory result from a procedure performed by another surgeon.. The problem is usually an unsatisfactory appearance, but may sometimes include functional (breathing) problems.

Why does this occur?

The nose is a complex structure and Denver rhinoplasty requires thorough understanding of the anatomy, facial aesthetics, nasal function, and refinement in surgical technique. Perhaps most importantly, (and no matter the specific specialty of the surgeon) consistent results in rhinoplasty depend upon the good judgment and experience of the well qualified Denver plastic surgeon. This is why some of us have developed a reputation as surgeons to see for revision rhinoplasty. The experienced rhinoplasty surgeon knows that the process begins with careful listening to the patient’s goals. Confirming that understanding is often done with computer imaging. The surgeon has to have the experience to know what can be realistically achieved and be able to communicate this to the patient.

The added complexity of secondary rhinoplasty includes working with the scarring and anatomy changes from the first procedure.

To know what to do is essential, but at least as important is to know when to do it. That insight is an important qualification of the experienced surgeon.