Are you a breast augmentation patient who either had surgery in the late 1990’s during the silicone false claim crisis or a patient who was misled into thinking that saline is an equivalent to the modern silicone gel implants? Or you were a fan of the 1990’s Bay Watch series and at the time felt that Pamela Anderson’s breast shape and size was the ideal standard. Just like houses with bathrooms and kitchens that seem dated after ten to fifteen years, requiring attention to remodeling to keep the house fresh and modern, so are breast enhancements. Stylistic changes and technology advancement of breast implant materials and fat grafting have come a long way, making your old decisions for your breast enhancement seem out of date and behind the times. Just like clothing styles and cars from the 1990’s seem dated now, so is the oversized sagging breast with saline implants, complete with rippling and pleating requiring an industrial strength bra to keep them in place. Ladies you don’t have to compromise any longer. Does your kitchen and bathroom still have brass fixtures? Then you should not have to put up with these heavy oversized misshapen breasts that are neither comfortable nor stylish. Consult a board certified plastic surgeon to review your options today.

Options not available 10-15 years ago.

First and foremost a modern plastic surgeon who has kept up with the current techniques and evidence based medicine related to breast enhancement will perform a complete tissue based diagnosis of the breast. Gone are the days hopefully of a surgeon standing in front of you without any measurements and eyeballing a one size fits all approach and telling you he or she will make you a “D” cup and you will love it. The facts are the 1990’s approach of shoving in multiple sizers or placing the largest possible smooth round saline implant under the breast without individualizing fit based on the patients breast tissue parameters lead to a revision rate of breast enhancement of 25% which manufacturers submitted to the FDA in the early two thousands. If gallbladders and knee replacements had that high of a revision rate insurance companies and Medicare would have a moratorium on the procedures. Fortunately our though leaders in plastic surgery have evaluated and re-engineered the procedures to minimize complications of capsular contracture, incorrect size placement, and avoidance of soft tissues being permanently thinned and distorted requiring complex revision procedures to correct poor outcomes. Most importantly the surgeon needs to determine the correct diameter of the devise both in width and height. The soft tissue thickness of the upper and lower pole (area above and below the nipple) is important as well as the tissue length from the fold to the nipple-areolar complex. The overall geometry of the chest and breast bone need to be noted requiring modification of procedures. It does not take an engineer to understand a women who is five feet tall and one hundred and ten pounds with a relatively short breast fold to collarbone and narrow chest with minimal breast tissue cannot have the same implant placed as a five feet, nine inch tall female with one hundred and sixty pounds with a wide frame and a large “B” cup breast. Unfortunately some surgeons did feel this way and some still do detracting from a customized approach that minimizes revision rates and unhappy patients.

Three dimensional imaging such as the Vectra has revolutionized my patient education and consultation for breast enhancements.  We can produce a very representative imaging of a women’s breast and torso and with computer simulation can demonstrate how any implant available in the United States can appear with your tissue parameters and allow the patient to see the proposed outcomes before a decision is made. This avoids wrong size surgery and allows patient expectation to be matched thus avoiding revision surgery. However the technology does not exist to provide this information if a breast already has an implant. This simulation also allows patients to see the limitations of an implant alone based on enhancement depending upon the individual’s soft tissue or bony deficiencies. This is where the discussion of fat grafting can be very beneficial to hiding the anatomic variances such as wide sternums that produce wide cleavages to provide an improved outcome and patient satisfaction. We can also demonstrate using a slightly smaller implant which has less weight and drag on poor quality soft tissue and supplementing the overall volume with large volume fat grafting to minimize implant malposition due to failure of soft tissues holding the implant in place.

Breast implants themselves have evolved over the last few decades. Today plastic surgeons can offer patients more options in size, shapes, and types of silicone than ever before also allowing for a more customized approach. I particularly have found the fifth generation silicone gel implants (Gummy Bears) to be particularly useful in petite women and very tall, thin women to exploit the positioning of the implant with differential heights and widths to maximize outcomes. I never use saline implants because they put too much strain on tissues, have excessive rippling, only can function as a round devise and can spontaneously deflate creating emergency surgical situations for patients. Based on clinical evidence, texturing of the implant can reduce capsular contracture, minimizing migration of the devise laterally over time and can maintain pocket size better than a smooth devise. Downsides include late seromas (fluid collections) and possible linkage with a very rare but easily treated form of implant related lymphomas. In my mind the benefits outweigh the small risks with texturing.

Lastly, the techniques of the actual surgery have evolved in the last ten years. These techniques include more precise, less traumatic dissections of the breast pocket, avoiding biofilm (a leading cause of capsular contracture) by minimizing the manipulation of the pockets with implants, and no touch techniques with the surgeon’s hands or patients’ skin on the devises that can minimize revision rates and improve outcomes.

In conclusion if you are a breast enhancement patient and are less than satisfied with your outcome don’t learn to live with compromise explore the modern day breast augmentation procedures available at board certified plastic surgeon’s offices around the country. Remember cell phones, cars, computers and styles have all rapidly evolved for the better compared to the 1990’s refresh yourself you will be glad you did.

When I think back to my first plastic surgery rotation as a medical student in the early 1990’s breast reconstruction was performed much differently then. During this time period the silicone implant crisis was at its peak, women were skeptical of breast implants, and the majority of reconstruction surgeries were with TRAM (Transverse Rectus Abdominus) flaps requiring large skin paddles because the breast surgeons were much more invasive in the way breasts were removed. Today silicone breast implants are safe and available in many sizes and shapes, providing patients and surgeons many more options than ever before. The technique of breast removal (mastectomies) have become much more selective, even being able to spare the nipple-areolar complex in many cases; therefore the need to transport new skin into the area is less often required in primary reconstruction. The advent of soft tissue regeneration with the addition of bio-matrices such as Acellular dermal matrices and guided tissue regeneration materials such as textile silk meshes have revolutionized the outcomes in prosthetic reconstruction. Without question one of the greatest advances in breast reconstruction is the art and science of fat grafting which can augment selected areas of volume deficiencies, improve the overall shape, and restore the health of the overlying tissues which has been previously damaged by radiation therapy.

Dr. Pat Maxwell coined the term “the bio-engineered breast” which utilizes acellular dermal matrix grafts and fat grafting to rejuvenate the soft tissues surrounding breast implants after mastectomies. I have been modifying these two techniques in my practice since 2004, which has vastly improved outcomes in both primary and revision breast reconstruction. Fat grafting has provided plastic surgeons the ability to selectively sculpt and shape breasts like never before. Implants can only occupy and provide shape and volume in specific locations on the chest and breast. Fat can influence any area desired to be modified similar to photo shopping in pictures. Fat already occupies the majority of a natural breast volume therefore restoring a reconstructed breast to normal form and function with less donor site morbidity is seen with harvesting large flaps from the abdomen and buttock region. This truly is an exciting time in plastic surgery to provide excellent results with less invasive techniques, especially compared to the past.

In addition to the soft tissue restoration procedures the new silicone gel implants have also contributed to better outcomes. The fifth generation silicone gel implants (Gummy Bear Implant) are a very cohesive polymer which maintains three dimensional shape. This for me has two advantages; the first is that we can offer implants which can more easily match a patient’s unique chest wall architecture such as creating an implant narrower in width and taller in height (for a tall thin lady) or shorter and wider for a small wide chested woman combined with a fuller projection in the lower half of the breast mirroring a normal breast shape that will have adequate volume but will not encroach on the arm pit region or have an over expanded upper pole appearance. The second advantage of these implants are the result of a stiffer polymer which resists forces of capsular contracture that have been demonstrated to be a major cause of revision breast implant surgery. With the use of bi-dimensional conceptual planning through meticulous measurements we can offer a more customized approach to reconstruction and we can educate patients on their options with a three dimensional imaging system (Vectra) to demonstrate the effect of different shapes and volumes on their potential outcomes.

Even women who have been diagnosed with breast cancer and elected to undergo “breast conservation techniques” with a lumpectomy and radiation therapy can frequently experience distortions of the breast. The affected breast can shrink in volume and change in shape compared to its baseline and with the opposite breast as a result of surgical removal of tissue coupled with imposed radiation fibrosis changes to the tissues which are permanent and progressive. In my practice I see a number of these women and have been successful in reducing deformities and restoring shape and volume with the use of internal scar release combined with fat grafting. The amount of hard woody scarring of the overlying skin can often be suppler after treatment. Contour deformities which often occur directly in the surgical field where tissue was removed can be restored in shape and volume leaving a softer breast that is more symmetric with the opposing side.

I am very proud of my field of plastic surgery which by its very nature attracts thoughtful and innovating disciples of this surgical specialty leading to a continuous evolution of scientific insights that opens the door for continuous improvements in the care we can provide patients. Breast cancer reconstruction is just one small piece that is being tackled by our field of study.

Being a mom is one of the most challenging, frustrating, yet rewarding experiences a woman can have. You put forth blood sweat and tears, not to mention an untold strain on your whole body during pregnancy. It really boils down to the genetics of your skin and fascia as to how well you can bounce back after the weight gain and abdominal stretching from your baby. Many women lament that despite dieting, exercising and lots and lots of willpower your body is never the same as it was prior to child bearing. Fortunately for the masses of dissatisfied women there are options in Plastic Surgery to boost your self- confidence and your body image. Here is a list of body corrections (Mommy Make-over) that can be performed in tandem or separately to improve the shape and how you feel about your physique.

During pregnancy the glandular component of the breast must enlarge to ready for the enhanced production of milk. Additionally weight gain with fat storage all governed by the hormonal changes can increase the breast size immensely. Unfortunately fetal regulation also makes skin “stretchy” to accommodate the increased girth of the breast and abdomen. After the resumption of normal non-pregnant hormones and the lack of need for lactation the breast volume will revert back to baseline and can even reduce in overall size compared to the original baseline. Unfortunately many times the skin does not have the ability to shrink to the original size and will stay expanded resulting in a larger skin brazier with same or even less fill than before resulting in “saggy” breast shape. With increased skin length from the breast fold to the nipple it moves the breast mound lower on the chest with less upper pole fullness. I hear many women call their breasts “sad” in appearance when they come in for consultation. Ok enough depressing thoughts… what can be done? If the skin is not excessively enlarged, the nipple-areolar complex is correct and the fold to nipple distance is not greatly elongated the solution can be to place a silicone gel implant to act as a shaper and a filler of the breast envelope restoring a pleasing breast shape. If the breast has a low positioned nipple-areolar complex, with or without increase skin length from the fold to the nipple-areolar complex, then a mastopexy (breast lift) is required. Often times tissue volume might need to be enhanced to provide better shape and upper pole fullness, thus an implant or fat grafting can be incorporated at the same time. Sometimes upper pole fullness can be accomplished by transposing extra breast tissue in the lower pole and positioning it on the chest wall deep to the rest of the breast to enhance fullness.

Abdomen:
Hormones during pregnancy direct adaptive body changes that allow healthy growth of the baby but unfortunately create lasting changes to a women’s body. The abdominal skin stretches and often can result in stretch marks (tears in the dermis with intact epidermis). Excess skin rarely retracts in these cases leading to hanging skin that drapes over the pelvis. Next the abdominal wall is distorted to accommodate the growing fetus resulting in separation of the paired rectus muscles leading to increased abdominal circumference with permanent bulges in the abdominal wall both above and below the umbilicus. This unfortunately cannot be reduced with abdominal exercise because the stretched fascia between the muscles is not contractile and will not respond to muscle strengthening. Additional weight changes with aging often can be manifested with increased abdominal girth from excess fatty tissue. So what can a Mommy Make-over achieve in the abdomen?
If skin quality is excellent and the abdominal wall is only minimally distorted often liposuction with the addition of additional energy sources such as ultrasonic energy (VASER), oscillating power hand-piece (PAL), or hydraulic power can result in removal of excess fat and create skin retraction/redistribution to improve contour. However, many women will need a full abdominoplasty with correction of excess fat with liposuction, removal of excess lower abdominal skin with tissue resection, and abdominal wall restoration by returning the rectus muscles together with a permanent suturing technique. This can result in excellent contour of the abdomen but you will trade the contour for a scar. I find most people are surprised how long the scar has to be to create the contouring necessary. Once acquainted with the results, most women will gladly trade a scar for the results of a flat smooth abdomen.

Back and Flanks:
Some women can realize their goals by correcting the anterior abdomen by itself. However many women if given the opportunity would love to three dimensionally correct their torso by sculpting their midback (bra line folds) and flanks (muffin tops) at the same time as their abdomens to circumferentially adjust their shape. This can make a tremendous change on how clothing can be worn and how the individual feels about themselves. Liposuction with either PAL or VASER makes a great deal of improvement by releasing all the ligamentous attachments between the back and flanks and the superficial skin (which results in rolls on the back) and allows even removal of fat and the skin to re-drape much smoother.

Legs:
Some women naturally store adipose tissue in their lateral or medial thighs. Depending on the skin quality and the potential for the tissue to re-drape or tighten, fatty tissue can be sculpted just as on the back. Some have significant adipose tissue below the knee down to the ankle. I generally do not add the additional power source with liposuction in this area and have achieved good results.

Buttock:
Popular trends in body shape can change just like in fashion over time. The introduction of the Latin culture into the United States in conjunction with pop culture personalities have made the appearance of a full contour buttock something to aspire to. My preference for buttock augmentation is with fat grafting and not with a prosthesis. Utilizing concepts of tissue equilibration and liposculpturing we can remove unwanted fatty tissue, harvest it as a graft, and utilize the fat as a volumizer of the buttock- while improving the contour of the rest of the body. Women who have gained and lost weight may have loose sagging skin of the buttock and restoring volume can shape and lift the buttock with little or no scarring.

Women who are unhappy with their physical appearance after giving birth to one or multiple children can restore the body to a better place with a Mommy Make-over. To me this represents more than one area of the body to be rejuvenated simultaneously to make the woman feel refreshed and erase some of the “battle scars” of pregnancy so she can feel more confident in her appearance.

Breast Implant Exchange with Fat Enhancement

Amanda’s first implants were placed by another surgeon approximately 15 years earlier

425cc anatomical saline implants were placed under the muscle

She was unhappy with the implant rippling, breast gap and muscle flexion distortion

Even under the muscle, the implants were still very visible as coverage was so thin

Being very lean also made her naturally wide breast gap seem even more prominent

Displacement and flattening of the implants occurred with every muscle contraction

Implants placed above the muscle would have resulted in more visibility due to less coverage

Implant placement under the muscle also created a wider breast gap visible in clothes

Rippling was more pronounced with saline implants especially when leaning forward

Amanda first presented to our practice 10 years earlier for her tummy tuck

Her satisfaction and trust allowed her to feel confident in having breast surgery as well

Correction involved removing the implants and restoring the muscle to its original position

Placing cohesive, gummy bear, anatomical, silicone gel implants in a new pocket above the muscle

Then filling the overlying skin envelope with fat grafts to add cover, volume and cleavage

Amanda is seen at her initial visit (left image) four years earlier with her original saline implants

The center photos show her four years after initial implant exchange to 350cc smooth, round, silicone gel implants (still under the muscle) with 50 cc of fat placed above

There was significant improvement but she still wanted to reduce the gap and muscle animation even more

As she was lean and also very athletic, she wanted complete muscle correction

Mentor MH 440 CC, anatomical, textured cohesive gel implants were placed over the repaired muscle

75 CC of fat was also placed into the overlying breast envelope for coverage, volume and contour

She is now seeing (right images) with her final results 2 months after implant relocation and fat transfer

The fat grafts have completely integrated and have the potential to last a lifetime

There are no visible or palpable irregularities and full natural breasts have been achieved

Amanda went from a C to her desired D cup and… she finally has cleavage

The animation deformity is completely corrected and a soft natural appearance is finally hers

Fighting Fifty

Today, women in their 40’s and 50’s are looking younger than ever. We no longer look frumpy or matronly like many of our grandparents did at the same age. These days we have more choices than ever before to turn back the clock. I had an opportunity to sit down with Dr. Peter Fodor, an international expert in aesthetic plastic surgery and ask his thoughts about “Fighting Fifty”. Click To Watch The Video

“The way I would think about fighting fifty, is fighting fifty and WINNING!” ~Peter B. Fodor, MD, FACS

It Begins with the Skin

“They need to exercise, they need to diet, they need to take care of themselves, and they need to use good skin care,” says Fodor. He says good skin care, is critical for this age group. As you reach your 40’s and beyond, you may be seeing dullness, uneven tone, rough texture, fine lines and some sagging in your skin.

Here’s a basic check list of what you need to know about skincare as you reach your forties.
1. Gentle cleansing. Many women will experience drier skin as they age and need to switch to a more gentle cleanser that doesn’t strip the skin. A few to try are Cetaphil and Purpose to be used morning and night.
2. For fine lines and pigment issues, start thinking about skin care with effective Look for a retinoid cream which works to resurface the skin and increase collagen in the dermis. They are best used at night and you may want to start out slow to avoid peeling and redness. Once your skin becomes more accustomed to the cream, you can increase the frequency.
3. Wear sunscreen every day. Your best choice is a broad-spectrum sunscreen which protects skin from UVA (aging rays) and UVB (rays that burn).

The Aging Eye

You may have heard, the eyes are one of the first areas of the face to show the aging process. The skin around the eye is thin and more susceptible to dryness and wrinkling. When the eye starts to sag it can create dark circles, bags and crow’s feet. Dr. Fodor says, “The upper eyelids can really make people look much older than they are at times. It can be genetic; it can come with the family. But a blepharoplasty procedure can make people look fresher and a lot less tired.”

Injectables for Immediate Results

If you really want to turn back the clock, “Botox and facial fillers such as Juvederm and Restylane work well,” states Fodor. Botox, Dysport, and Xeomin are neurotoxins for erasing lines in the upper face and around the crow’s feet.

Facial fillers can replace volume loss in your temples, cheek area and the nasolabial folds. They can also help plump up your lips.

Hormones Play a Big Part in the Aging Process

Fodor explains that as we get closer to menopause our hormones change. When this happens, “certain parts of the body that were once harmonious to the rest of our body, may start to change. It can be in the hips, the knees and the stomach. Liposuction can be a great approach for these patients,” says Fodor.

Fodor is quick to state, that the main message is for patients to take care of themselves. He says going in for an injectable or a surgical procedure that addresses the facial or the body part that you are most concerned about can bring about a rejuvenation that is as much physical as mental.
As with any procedure, make sure you go to a qualified board certified physician who is well-trained in their specialty.

Reshaping the contour of the abdomen is frequently requested in my office consultations. The most common techniques are various forms of liposuction with or without an abdominoplasty. Another tool in our repertoire which can yield effective results is the “Reverse Abdominoplasty.” The classic indications for a regular abdominoplasty is a torso which has loose excess inelastic skin of the lower abdomen, abdominal wall rectus muscle separation (diastasis), and varying degrees of excess fatty tissue. The technique eliminates the excess skin and fatty tissue in the lower abdomen, reconnects the rectus muscle together to tighten the abdominal wall, and excess abdominal fatty tissue can be reshaped with liposuction to provide a pleasing shape. A Reverse Abdominoplasty is chosen for the individual who has loose excess skin in the upper abdomen, who generally does not have a full diastasis which is affecting the lower abdominal contour, and may have excess fatty tissue in the lower abdomen without skin excess. The technique is to start with incisions that follow the lower breast fold then cross the lower sternum to connect both sides of the abdomen. These scars generally hide very well even in two piece bathing suites. The full thickness skin is elevated down the abdomen preserving the vital blood supply on either side of the belly button. If upper rectus muscles need to be tightened this can proceed. Any abdominal fatty excess can also be corrected with liposuction at this time. The elevated released excess abdominal skin can be addressed in several ways depending on the needs of the patient:

1. If a women who has the upper abdominal skin excess and also desires rejuvenation of the breast the excess elevated skin of the abdomen can be utilized as a self-augmentation under the breast to provide added fullness and shape. This is often done in conjunction with a breast lift (Mastopexy) and can avoid the need and expense of an implant. I have even performed this procedure with a woman who many years ago had bilateral mastectomies for breast cancer and we reconstructed her with implants. She had experienced some weight fluctuation and was becoming very active and requested the elimination of her breast implants but still desired a smaller breast to remain. We utilized a reverse abdominoplasty skin excess, removed the outer skin, and placed it in her implant space to fill the void and added tissue volume and shape provided with fat grafting harvested from her back, thighs, and lower abdomen giving her a smaller but still reasonable breast shape.

2. The Reverse Abdominoplasty could be incorporated as part of a treatment plan to tighten the upper abdominal contour. After the incision and elevation of the abdominal excess loose skin, the surgeon can remove the undesirable portion and fixate the remaining tissue to the rib fascia of the lower breast fold to avoid the scars from migrating inferiorly thus preventing the exposure of the scars on the upper abdomen. I have used this as a primary surgical procedure for women with loose skin of the upper abdomen that would not respond favorably to liposuction alone. I have also used this as a secondary procedure on women who have previously had an abdominoplasty with good results but over time the lower abdomen has maintained its results yet the upper abdomen has become loose and has excess as a result of weight changes, sun exposure, and of course gravity. The excess skin can be removed providing a nice tight appearance to the whole abdomen.

3. Another situation for the reverse abdominoplasty is for a women with loose upper abdominal skin combined with previous augmentation mammoplasty in which the implants have become mal-posed and have drifted inferior and lateral to the correct position. In this case the excess elevated tissue can be utilized as a autologous (meaning from your own body) soft tissue sling to help reposition and stabilize the implant similar to an Acellular Dermal Matrix (ADM) graft without the significant added cost of the product to provide long lasting results.

One of the aspects in my profession of plastic surgery I am most proud of is the innovative nature of the field. We take problem sets that patients present to our office and we create unique methods that achieve a sound result with the least amount of surgery and the lowest costs to ensure successful and happy patients. The Reverse abdominoplasty is an example of one of these off shoot procedures which fills a vital niche in my practice.

Center For Cosmetic Surgery: Todd Gerlach MD
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Torrance Plastic Surgeon Todd Gerlach MD

I love experiencing the sun and all the activities surrounding its presence such as boating, swimming, hiking, and cycling. My mood is immediately elevated witnessing its warm glow. Yes there are many benefits to the sun’s rays such as stimulating the production of Vitamin D which is essential in calcium and bone metabolism as well as supporting the immune system. It chases away the blues of seasonal affective disorder and is essential for life. However there is a risk benefit ratio to being exposed to the sun’s ultraviolet rays. Following is a list of downsides to sun exposure.

1. The ultraviolet rays of the sun damages the DNA in our skin cells which can result in malignant transformation of cells such as basal, squamous, or melanoma. The latter can be lethal. Therefore minimizing the harmful UVB rays can reduce the risk of developing skin cancer. Sun screen is not a one -time application for a whole day of exposure. It needs to be repeated at least every two hours or more often depending on water or perspiration which can reduce the effectiveness of the prevention. Sun damage is additive over a life time but taking breaks from the harmful rays can allow the tissue to heal and repair some of the mild DNA damage. Therefore year- long tanning such as tanning beds should be discouraged.
2. Exposure of both UVA and UVB rays will damage the elastin fibers in the skin permanently resulting in loose less compliant skin. This will result in the skin of the face, arms, breast, abdomen, thighs, and knees to hang and appear loose. No exercise will tone the damaged skin. Therefore protect your largest organ system, the skin, by shielding the sun with appropriate hats, clothing, and sun screen.
3. Splotchy color changes to the skin. With increased sun exposure the skin will upregulate melanin production resulting in pigmentation changes that are less than attractive and are extremely difficult to reverse.
4. Thinning of the dermis which can result in the appearance of capillaries giving a red appearance around the nose and cheeks.

Everyone wants to have that sun kissed glow to the skin. I wish I had a dollar for every time a women says tan fat looks better than pale fat. Just remember the list above and understand a large sun exposure that creates a nice tan for around a week or so causes a lifetime of damage that can result in potential skin cancer and many vexing maladies of the skin giving a marked aged appearance over time.
Fortunately if you have experienced the above sun damage we can help. A combination of good home skin care with Skin Medica products, chemical peels to remove damaged skin and remove pigmentation changes, and microneedling which can result in collagen induction and improved dermal thickness and skin tone. More educational BLOGS are available on our website.

Non-invasive aesthetic procedures have come a long way in the last ten years. The American Society of Plastic Surgery’s yearly statistics continue to demonstrate strong demand for procedures such as neuromodulators (Botox and Dysport), and hyaluronic acid filler agents (Juvederm, Voluma, Restalyn). Recently, non-invasive contouring systems that perform the techniques of cryolipolysis, such as Cool Sculpting and radiofrequency skin-tightening Ultherapy, have emerged in the marketplace. Now Allergan has added Kybella to the mix as a non-invasive injectable material to dissolve fat under the chin.

Before and After

The key to success with these treatments is consulting a comprehensive center that offers a full array of non-invasive and surgical options, and will direct you to the ideal treatment modality for your unique circumstances. Just as with any medical and surgical procedure, there are appropriate candidates and patients with contraindications.

The most important step to avoid dissatisfaction is to be evaluated by a physician who is properly trained to perform comprehensive evaluation and care for all patients with a particular aesthetic concern.

Board-certified plastic surgeons have the most comprehensive education and background experience to correctly evaluate your anatomy and determine which treatments will yield the best outcomes. The statement “if all you have is a hammer the whole world is a nail” rings true for medical spas and dermatologist offices which only have one option, such as Cool Sculpting or Kybella. Just because a treatment option is non-invasive does not mean it is inexpensive. If you factor in the cost of multiple treatments, it may be as expensive as surgery and still fall short of expectations.

When is Kybella the right choice?

With the current status of the injectable form of deoxycholic acid (Kybella) the ideal candidate must have reasonably tight skin with only mild to moderate adipose excess in the submittal and chin neck angle. The patient should not have a significant mandibular jaw discrepancy with the midface or have a particularly steep mandibular plain angle.

When is Kybella the wrong choice?

Any patient with lax skin of the neck or a significant deflation of the neck related to weight loss with demarcated platysmal bands is not a candidate. Taking away fat in this circumstance only worsens the deformity. Any patient with a deep underbite and a small chin with a very oblique chin-neck angle should also avoid Kybella. Deoxycholic acid is mostly created to dissolve fat but does produce some inflammation with the caustic material to encourage collagen production and skin retraction. Skin excess with an oblique chin neck angle and recessed chin will not yield overwhelming positive results.

Instead of Kybella, the better option is placement of a chin implant (genioplasty) with aggressive liposuction to encourage skin retraction. A middle facial third with significant skin excess and deflation combined with loose-hanging skin with platysmal bands is best treated with a corset platysmaplasty in conjunction with a neck/face lift.

Non-invasive aesthetic procedures can be a wonderful adjunct to helping people age gracefully with limited down time. Kybella in the right situation may improve necks and make people happy with the results.

Avoid being pushed into this option without a thorough three-dimensional analysis of your face to determine if it’s right for you. Nothing is more frustrating than spending a great deal of money and not realizing your desired results. Even with surgery, some deformities may not be able to be corrected. Take advice from a board-certified plastic surgeon to maximize your goals and to feel good in your own skin.

Fashion trends change, and so do accepted ideals for body appearance. The influences of Latin culture on American norms have triggered an explosion in the demand for buttock enhancement with fat grafting, which was first popularized in Brazil. Another trend patients are requesting is a more conservative and natural looking breast enhancement. A recent survey in California found that women are not looking for an oversized breast enhancement and desire a more subtle appearance. This is a healthier choice for women to choose.

Due to the prevalence of evidence-based medicine and FDA demand for data on silicone gel breast implants, findings indicate that revision breast surgeries after a primary augmentation mammoplasty are as high as 25 percent. The main reason for these revisions is capsular contracture, but size change is a factor. Thanks to the work of Dr. John Tebetts, Bill Adams and Dr. Dennis Hammond, the concept of calibrating the correct implant size for a given individual based on breast tissue characteristics allows for customization and has reduced revision rates for surgeons who incorporate these findings into their practices.

The idea of putting the largest possible implant into a women’s breast is fraught with potential complications including excess stretch on the tissues leading to thinning of the breast which may result in increased prominence of rippling of the implant, as well as mal-positioning of the device either laterally or inferiorly. This causes an unsightly aged appearance of the breast. The cost of revision can be high if treatment plans include the need for added soft tissue support utilizing acellular dermal matrices or a silk textile mesh to restore soft tissue support of the implants.

Today is a very exciting time in the field of augmentation mammoplasty, because we surgeons have a wide variety of shapes and sizes and silicone gel consistencies to choose from to provide customized results for our patients.

I strive to deliver a primary augmentation of the breast with a correct implant that is sustainable by the body to provide a long-lasting aesthetic result free of revision until the integrity of the implant has failed.

I think in terms of the height and width and projection of the breast independently and choose styles and shapes to match my patient’s desired outcome. I never want people to say that all my breast augmentations look the same. Just as all faces are unique and different, so are breasts. I want to make an individual’s breast look and feel as attractive as possible with long-lasting results. Proportionate breast enhancement is key to achieving these results.

Furthermore, now fat grafting can be performed simultaneously with implant placement, allowing surgeons to correct volume and shape asymmetries, as well as fill in spaces where an implant cannot be placed, such as the cleavage region and the chest wall/implant interface.

If you’re considering an augmentation mammoplasty, take a look at a three-dimensional analysis imaging of yourself. Then discuss your tissue type and pre-existing breast tissue with your surgeon, who will devise a plan to make a customized result that will look attractive and proportional with your frame. A skilled board-certified plastic surgeon will choose an appropriate implant with or without fat grafting to highlight your own unique figure with long-lasting results.

Rhinoplasty is cosmetic facial surgery that’s ordinarily done to further improve a person’s physical appearance or to reconstruct their nasal area for health related purposes. A rhinoplasty surgery involves adjusting the cartilages and bones of the nostril , or sometimes tissue is added in order to maximize the cosmetic appeal. The surgery is also commonly executed to fix nasal fractures as well. If rhinoplasty is performed to repair someone’s nasal fracture, the surgeon tries to recondition the nostril to its pre-injury condition. A related procedure often known as septorhinoplasty is done on patients that in addition have a nasal obstruction. Septorhinoplasty works to greatly enhance the look of the nasal area , but also stabilizes the overall structure and reduces any internal obstacles that might be blocking the patient’s nasal breathing.

Any aesthetic worries and expectations you have needs to be completely discussed before rhinoplasty surgery treatment . The recommendations of your plastic surgeon along with any special limitations concerning the structure of your nose , skin , or face in general are essential to have thoroughly stated you. Make-up free snap shots are typically taken prior to operation to assist with both the preoperative and post surgery planning stage in order to document the results .

Make inquiries and express your concerns.

Finding a professional , qualified doctor to perform your rhinoplasty surgery should be your main priority when thinking of getting any type of cosmetic operation . ASAPS ( American Society for Aesthetic Plastic Surgery ) has recommended that each patient should ideally consider the following tips for best results :

• Consult at least 3 different surgeons before choosing one

• Be sure the cosmetic surgeon you choose is board certified

• Ask where your surgeon is privileged to legally practice to ensure his credibility

• Request to see before and after photos of previous patients

• Talk in-depth about the surgery as well as the results and recovery and any potential things that may possibly go wrong or happen unexpectedly

• Ask about the surgeon’s rhinoplasty experience . How many has he done ?

• Does the surgeon have malpractice insurance ? If not , get up and leave

• Ask about the follow-up procedures

• Request to contact former patients about their own experience

• How much does the procedure cost ? What about insurance ?

The results of rhinoplasty

Rhinoplasty results could possibly be minor or major , based on the type of modification you want done, but they are however permanent. It’s very important that both you and your cosmetic surgeon are on the same page relating to the goals of your process. If you have realistic expectations and your plastic surgeon like Ernesto J Ruas MD FACS, the outcome will likely be very positive overall.

Many women are uncomfortable wearing form-fitting clothes, because the skin either above or below the bra line creates rolls detracting from the aesthetics of the female back. Unfortunately this can occur at any age. Spanx may hide the problem, but who wants to wear tight undergarments during warm weather months?

Causes: The skin of the back and shoulder must accommodate the wide range of motion of the shoulder girdle. When the arms are raised above the head, the skin in the posterior upper armpit region must stretch to avoid restricting this movement. Over time our skin begins to enlarge and increase in surface area, particularly in the posterior-axillary fold region tapering towards the tip of the shoulder blade. The skin lower in the armpit region and sides along the ribs does not require expansion, but a transitional line or fold can develop and become more pronounced with gravity causing a landslide effect of the skin above. The appearance is made worse with a restrictive band of the bra traversing this region thus forming the dreaded “bra strap fat roll.”

Anatomy varies greatly depending on skin type and quality, body mass index (BMI), and age. In some cases, skin folds are very tight without a great deal of excess fat, but the skin excess is the issue. People with greater BMI scores may have a great deal of fat deposited in this region. The other extreme is the massive weight-loss patient who has very little adiposity but has a great deal of inelastic deflated skin, which hangs over the bra. Each of these types of patients requires different treatments to achieve a pleasing result.

Treatment options: If you have slight increases in fat deposits in your back with deep tight folds, the treatment of choice is suction-assisted lipectomy with the added energy source of either VASER-assisted suction lipectomy (ultrasonic energy), power-assisted suction lipectomy (PAL), which is a mechanical rotating blade effect built into the cannula, or HydraSolve, a heat and water pulsing technique that breaks down interstitial fibers surrounding the fat. All these approaches work by breaking down the ligamentous attachments between the back and the dermis of the skin combined with the inflammatory reaction of the surgical cannulas allowing a re-draping/redistribution of skin to tighten over the back and conform to the new contour.

In my opinion, the results of these techniques are superior to liposuction alone. Non-invasive body-contouring procedures such as cryolipolysis (CoolSculpting) have no mechanism to break down the fibrous insertions to the skin from the deeper fascia, thus no elimination of the tight fold lines will occur.

If you have an elevated BMI and increased adiposity of skin folds, you will also benefit from the above-mentioned techniques of added energy sources with liposuction, but a greater degree of fat removal is necessary. Increased fat volume requires a more cell removal. However, discretion must be utilized to prevent over resection that can result in loose hanging skin on the back.

For the massive weight-loss patient or the person who has a large amount of loose-hanging skin with or without added fat volume, a skin resection technique is often incorporated with a brachioplasty to correct hanging skin of the upper arms as well. My incision choice is a vertical resection of skin along the posterior axillary line angle, which is easily concealed.

If bra line skin or fat excess is detracting from the overall aesthetics of your back, you need a board-certified plastic surgeon to thoroughly evaluate your situation to determine the right treatment option to feel more confident in your own skin. 

There are many issues in the nose that can create an asymmetrical appearance to the nose. A nose job procedure, also known as a rhinoplasty can accomplish making the nose look more symmetrical. There are a variety of techniques available to accomplish making the nose look much more symmetrical than it already is. As a surgeon, it is very important to evaluate what is causing the structural asymmetries underneath the skin soft tissue envelope. A closed or open rhinoplasty procedure can address mild, moderate, or significant asymmetries. With a closed rhinoplasty approach, all incisions are placed on the inside of the nose and dissolvable sutures fall out in about a week. If the nasal bones themselves are asymmetric and crooked, medial and lateral osteotomies of them are required with an osteotome to set them straight and parallel. If the upper lateral cartilages are convex or concave, they need to be adjusted as well. A convex upper lateral cartilage can be shaved down. A concave upper lateral cartilage will make the nose looked twisted in the mid-portion of the nose, and this is corrected with a spreader graft placement. The nasal tip cartilages are often asymmetric and they need to be adjusted as well. The mild asymmetry is adjusted with shaving down a thick lower lateral cartilage of the nasal tip, while a cartilage graft is placed on the thinner nasal tip cartilage on the opposite side. When significant asymmetry exists in the nasal tip cartilages, a full delivery with suture techniques is required to make the lower lateral cartilages of the tip look symmetrical. Asymmetrical nostrils can also be adjusted with an alar-plasty, and a columellar-plasty. A deviated caudal septum can cause the columella to be twisted as well. Dr. William A. Portuese is the medical director and founder of the Seattle Rhinoplasty Center, a Medicare certified, Washington state licensed, outpatient surgery center located in Seattle Washington.

Consider custom solutions for a sagging neckline

Necklines for both men and women can be a focal point of self-consciousness. However, the etiology of an unattractive neckline can be diverse, so treatment options must be tailored to the underlying cause. There is no one solution for everybody. Careful three-dimensional analysis of the soft tissue and underlying bony structure of the midface, lower jaw and neck are imperative to choosing the correct modality to improve your neckline.

Some common underlying causes of poor aesthetic necklines:

Small lower jaw – If you have a deep underbite despite orthodontics and a short chin, this leads to less bone support of the soft tissues of the jawline and submental region. People with this type of lower jaw may have a very obtuse chin-neck angle leading to redundant skin. An ideal treatment for this situation is bony chin advancement (genioplasty).
If your chin is horizontally too short, then an augmentation with a chin implant is an excellent choice. I prefer the Medpore implant, which is carvable, and screw fixated and becomes an extension of the bone.

Both genioplasty and chin implants can easily incorporate the technique of liposuction as a means of sculpting the soft tissues of the neckline by removing unwanted fat. Liposuction induces collagen production and facilities skin shrinkage and redistribution yielding a pleasing result. This combination therapy can produce a wonderful outcome that makes you look more facially balanced. However, if your skin is too loose and hanging, a more formal neck lift may be preferable to liposuction.

Mid face descent of soft tissues – Aging can affect facial fat compartments leading to decreased volume, which results in the midface falling over time. This sagging increases nasolabial folds and causes lower facial soft tissue to drape over the jawline. A crisper jawline can be restored by replacing missing soft tissue volume in the fat compartments of the midface with filler agents like Voluma and Sculptra or via fat grafting. Subtle volume enhancements can create a nice effect on the jawline without looking like you’ve undergone a surgical procedure.

Gravitational changes to the soft tissue of the neck – Gravity affects all of us. The skin and muscles of the anterior neck begin to pull away over time. The appearance of the platysma muscle medial bellies becomes apparent leading to unsightly banding. In the early stages of gravity-induced changes, treatments such as chemical peels, micro-needling and radio frequency can yield improvements and delay the inevitable soft-tissue sagging.
Ultimately the best treatment option is a face/neck lift. A well performed facelift by an experienced board-certified plastic surgeon will yield excellent results with longevity of up to ten years depending on how well you age forward and take care of your skin, avoiding further sun damage.

Obesity: People with elevated body mass indices will accumulate increased fat throughout the body. The neck is no exception. Very mild amounts of fat excess with firm, good quality skin may realize improved contours with Kithera (an injectable product that dissolves fat in the neck). However, in my experience, few patients I evaluate are ideal candidates for this treatment. The injection results in inflammation, which can cause collagen production and skin remodeling, but most people need bigger guns to fight the battle. The price of several rounds of injections is as much as a true liposuction with less effective results.

If you have significant fat in the submental region and reasonable skin quality, liposuction can be a great treatment option to uncover a more normal neckline without a lot of expense or downtime. However, a face/neck lift with a corset platysmaplasty is the tried and true corrective option that works very predictably.

If you’re obese and undergo bariatric surgery or make lifestyle changes to produce massive weight loss, you’ll likely develop excess deflated skin that hangs off your face and neck creating an aesthetic deformity. Modifications of standard face and neck lifts must be incorporated to achieve a pleasing result.

The takeaway is that if you’re unhappy with your jaw and neckline, you can improve your appearance and boost your self-confidence by seeking out proper consultation with an experienced plastic surgeon. During the consult, a detailed facial analysis should be performed. Treatment options can be formulated to yield the best results by addressing your unique issues as presented during the interview. No need to hide your neck behind scarves and turtlenecks any longer.

According to many websites gives an option to standard breast inserts for many women. There are two types of Natural Breast enlargement procedures; Fat transfer breast augmentation and Stem-cell breast augmentation. As the name suggests “fat transfer”, the process involves removing of fat cells from any other part of the body (thighs or buttocks) and transferring it into the breasts. On the other hand, mature stem-cells from excess fat in the client’s own body can be collected, and then injected into the breasts to be augmented, where they can generate more excess fat to enhance the breast naturally. Traditional breast augmentation isn’t completely successful, while natural augmentation has many benefits such as, less complication and threats. Also, the recovery time of naturally augmented breasts will be shorter than standard augmentation.

TRADITIONAL BREAST IMPLANTS
Saline or silicone implants are trending for decades, as they are safe. However, we cannot ignore the drawbacks of traditional breast implants; No natural look, looks lethargic for some women, and non real feel. And, if the body is not responding to the implants, then the healing process will take much longer time. Some women experience deformation due to the implants, as they can slip out of the correct place. Most of the women desire naturally augmented breast; however, due to the unavailability or costlier process, they tends to choose traditional breast implants.

NATURAL BREAST AUGMENTATION
Natural breast augmentation has the least recovery time; Only 2 days, as there are no implants involved in the process. Naturally breast augmentation surgery carries fat or stem cells from the patient’s body. Therefore, there are no risks associated with this type of surgery. This type of surgery is also helps in reducing unwanted fat from the thighs or buttocks, which is directly proportional to losing weight. This methodology doesn’t influence the women’s potential to get mammograms, not at all like traditional breast augmentation

Natural breast augmentation has many benefits but has a major drawback; Limited increase in breast size! Yes, Natural breast augmentation doesn’t support the massive increase in size, so for those women who are looking for massive increase should not go with this type of surgery. However, one cup size can be easily increased with this procedure. This is the ideal surgery for women who are looking to restore their breast dull appearance due to aging, nursing, or pregnancy. The fat transfer process or stem cell augmentation can easily make breasts considerably rounder & firmer. Some women prefer a firmer as well as the rounder breasts instead of the breast size. Cosmetic surgeons like will not reject any type of breast augmentation surgery, so it is up to you; deciding which one is the best for your appearance and desire.

It’s winter in East Tennessee, but I’m already looking forward to sunny blue skies with spring blossoms floating through warm breezes. Gone will be the heavy coats and long sleeves, replaced by sleeveless clothes and bare arms. If you’re self-conscious about your upper-arm contour, then spring might not be your favorite season. No worries. Board-certified plastic surgeons like me are at your disposal to give you the confidence to be comfortable in your own skin and bare it all. No more hiding your arms when the temperature rises.

A successful arm-contouring plan depends your specific anatomy. What’s your skin quality and quantity? Is there excess flesh with thin deflated tissue and inelastic skin? Or do you have reasonable skin quality with some increased adipose tissue and a thicker arm contour? Your personal medical history is important as well. Have you gained and lost significant weight or undergone bariatric weight-loss surgery? Do you have a history of large amounts of sun exposure with subsequent sun damage leading to a crepe paper-like skin tone?

The algorithm for management of the unacceptable upper-arm appearance starts with the question of excess skin. Particularly if there is thin deflated skin that is present the full length of the upper arm, a vertical brachioplasty is required. The advantage of this procedure is the ability to remove a great deal of excess skin along with aggressive liposuction to create a wonderful tight contour. The disadvantage is the vertical scar that runs in the posterior medial aspect of the upper arm. Generally speaking, the scar is not visible when someone is facing you or behind you with your arms in repose. The scar can be exposed when the upper arm is extended away from the center of the body.

I can say with great certainty that patients who have undergone massive weight loss, with or without bariatric surgery, would choose the scar over the skin excess any day. Of course, there can be shades of grey in terms of skin excess and laxity. Milder forms may be treated with judicious VASER-assisted lipectomy followed by a modified horizontal brachioplasty, in which the excess tissue is resected and advanced within the axilla (arm pit). Scars are only visible when the arms are elevated with a sleeveless shirt.

If there’s no skin excess and the overlying skin is of good quality and there is contour excess related to an increased volume of fat in the upper arm, the VASER-assisted suction lipectomy is an excellent choice for sculpting the arms to a new contour. The manipulation of the dermis with the cannulas used to remove the fat via small openings in the skin placed in hidden areas of the arm leads to skin re-draping and shrinking. This redistribution creates firmer skin coverage of the arm leading to a nicer sculpted appearance.

What about Cool Sculpting (Cryolipolysis)? My answer is if there is only a very limited amount of excess fat and already tight skin it may work.

However, there is no mechanism with cryolipolysis to induce inflammatory reactions leading to collagen production within the dermis, which causes skin tightening unlike liposuction or micro-needling. My advice is to save your money for the real deal. Radio frequency may have a role in skin tightening, but the results don’t warrant the investment in the expensive equipment, which certainly is passed down to the consumer.

The key to a good result or the avoidance of a disappointing outcome is good clinical experience by a knowledgeable board-certified plastic surgeon with the correct judgment to know which technique to employ to maximize results. Buyer beware when entering the multitude of medispas that exist today without competent medical supervision. Recently in the Atlanta area, an emergency room physician untrained in plastic surgery was performing liposuction in an office without hospital credentials and created injuries to the diaphragm and liver leading to the deaths of two patients. Vetting your physician before undergoing surgery can prevent tragedies like this.

Botox has certainly become part of our lexicon since the new millennium. When I was in medical school at Penn in the early 1990s, botulinum toxin was only something to be memorized in pathophysiology class as the virulence factor for the Clostridium bacterium that caused botulism. Later on, in residency at the Hospital of the University of Pennsylvania, it was used in the treatment of involuntary muscle contractions and eyelid spasms. At the beginning of my plastic surgery fellowship in 1998, Botox was just beginning to be explored as a novel approach to facial wrinkles. The literature and the applications were still in the infancy when I started practice in 2001.

Fast-forwarding to the present, what would women and yes, men, do without this little protein for facial rejuvenation and the prevention of early aging? What started out as a means to control our “elevens” or “mommy frowns” has now blossomed into a method to actually sculpt the face by applying the knowledge of muscle anatomy to deploy Botox in the right areas to balance opposing muscles of the forehead, mouth, jaw and neck, creating pleasing facial postures.

Having been part of the rise and current use of Botox, I can testify that using this neuromuscular-blocking agent can improve your current appearance with regular use and also prevent or postpone the aging process of your face. Today many clients, particularly women, look at it as yet another maintenance activity like getting your hair and nails done.

Botox can be used to selectively weaken the central brow area to reduce horizontal lines in the forehead. It can also be used on the circular superficial muscle surrounding the eyelids to minimize lateral fine lines around the eyes. Applied properly, Botox can preferentially reduce the lateral eyebrow depressor muscles to allow unopposed lift of the lateral brow by the forehead muscle, weakening the fine lines around the mouth, correcting asymmetries of the mouth, and reducing the banding appearance of a thin neck.

While the results are limited to around three months without reapplication, nothing else can achieve these desired effects as well as prevent the future etching of these lines deeper into your skin.

However, when something becomes commonplace, people begin to feel comfortable with the product to the point that they may oversimplify the treatment process. This comfort level can lead to the misconception that anyone can deliver Botox safely and reliably. For optimal safety and efficacy, Botox should only be purchased from Allergan, the owner and developer of the product. The company will only ship to licensed physician offices.

Some people try to purchase Botox online from out of the country in order to save money, which may or may not be safe or effective. The FDA recently reported that fraudulent Botox packaging was being sold on the Internet. There have been deaths or seriously neurologically impaired events when patients got a different kind of botulinum toxin which was a much stronger concentration and resulted in overdoses.

It’s my professional opinion that no one should receive Botox from an establishment that does not have a medical director who is intricately involved in the day-to-day practice of the office and has a firm command of the anatomy of the face and neck. I am baffled by the concept that dentists are now offering this service to patients as well. Having graduated magna cum laude from dental school prior to going on to medical school, I can emphatically state that dentists are not qualified to participate in these services. Botox is not inexpensive — why purchase it somewhere that might result in substandard results, not to mention nerve damage or death? The quality of the result is directly related to the skill level and knowledge of anatomy of the injector. Be good consumers and check the credentials of your provider. Caveat emptor.

“All that I am or ever hope to be, I owe to my angel mother.” – Abraham Lincoln

During this time of Mother’s Day, I try to take pause to remember how truly special my mother was to me growing up, contributing to who I am as a person and the meaning of unconditional love. She taught me to always think of others’ needs before thinking of myself. Unfortunately her pupil, her son has continued to fall short of this standard, but she sure set my internal compass to keep trying.

She had such a sunny disposition, and her greeting to everyone was “Happy Day.” Even one of my teachers growing up, who had a senior moment and could not remember my mother’s name, called her “Smiley.” In my childhood home right inside the kitchen door was a small chalkboard hung on the wall that said, “A kind word turns away wrath.” I try to remember this during times of strife with others. Even with her passing almost 14 years ago, she remains a big part of me and although my words could not express how grateful I am to her, I hope she can feel content in all she accomplished here on Earth.

For those of you who still have your mother with you, please take the opportunity while you still can and give her a big hug and tell her you love her very much.

Happy Day.

As we age, the volume in our faces diminishes over time. However, in the right hands you can age gracefully and look as good as you feel for a long time, which is the goal I have for all my patients. Volume restoration of the face, as a part of an overall comprehensive facial rejuvenation algorithm, combined with skin resurfacing and tissue repositioning, can yield beautiful results.

The aging process causes fat volume reduction in the face. The fat in our faces is organized into discrete packages and, predictably, the fat found just below our cheekbone is one package which reduces in volume first. The combination of gravity and volume loss in cheek fat results in our faces changing shape. Our cheeks appear to decrease, and our skin drops. Cheek folds become more pronounced, creating the inevitable downward-turning at the corners of the mouth and contributing to the jowling effect in the lower jaw line.

Another area that can experience volume loss is the lateral forehead in the temple region, which results in the brows re-draping downward, causing a hooding effect and obscuring the upper eyelids. Still another indication important to women is the loss of volume of the lips and the relative loss of the three-dimensional appearance of the upper lip with increased vertical lines emanating from the red border.
The tear trough region around the lower eyelid can lose volume, regardless of your age, particularly if the eyelid fat pads are prominent with a relatively soft mid face projection.

All the above areas can be treated nicely with filler agents. The advantages of out-of-the-box filler agents is they can be used quite nicely with topical anesthetic agents in the office. There’s relatively little to no bruising and no downtime. Many filler agents contain hyaluronic acid, which is a naturally occurring agent in our skin that acts like glue to hold components of our dermis together. Denser material with lots of cross-linking can have a better effect of lifting tissue. Because of its dense properties, Voluma can last up to two years and is routinely placed in the area where the cheek fat packet decreases. This filler is used to lift the cheek back to a normal position, thus improving the cheek fold and the corners of the mouth.

Lips can be enhanced to normal volumes (not the duck lips that I see coming from various spas) to create a natural red lip border with the adjacent skin helping to eliminate the vertical lines. I also enhance the vertical pillars that span between the base of the nose and the cupids bow high points, which returns a three-dimensional appearance to the upper lip. I mostly utilize Juvederm for this area.

The tear trough deformity can be handled nicely with Restalyn or Juvederm to blend the eyelid cheek junction and smooth the appearance of the lower eyelid.

Volume restoration of the temples to return the brow to a more normal position can be best handled using a step-wise approach with Sculptra, which is an injectable form of a polymer of lactic acid. When introduced to the tissue, the lactic acid induces an inflammatory response leading to the formation of new collagen. The advantage of this material is that it can restore large areas of volume loss, which would be difficult with traditional filler agents. It also slowly builds up collagen and restores volume over a six-week period making your transformation less obvious to your friends and family.

Without question, the concept of volume restoration of the face as a part of an overall comprehensive facial rejuvenation algorithm has led to superior results compared to plans that did not include volume replacement. As with Botox, the overall value of the injection material is greatly dependent on who is administering the filler agent.

Poor technique can result in poor outcomes. I liken filler agents to sculpting materials for the face. You can put clay in front of a true artist who can transform this simple material into a work of art. An untrained eye with no sense of perspective or artistic skill will create very little value out of the raw materials. The same goes for these injectable products in the Wild Wild West of aesthetic services here in American and abroad.

Board certified plastic surgeons have a very diverse training experience because we do not own a particular body part such as an Orthopedic or an ENT surgeon and we must be prepared to reconstruct or rejuvenate all parts of the body when the demand arises. Those who felt the calling to become plastic surgeons out of medical school realized their gifts and talents that could be offered to patients pertain to their unique skills of three dimensional thinking and artistic perspective to be able to see the problem and formulate a solution no matter how complicated the deformity exists.

I am troubled by the notion that patients think that facial filler agents, neurotoxins, LASERS, non-invasive contouring machines and other technologies or even surgery will work the exact same way no matter who is providing the services. I feel that Madison Avenue and corporate greed is mostly to blame because all aesthetic companies want to sell the product and place it in as many provider hands as possible to deliver their product to the masses. Many products can provide safe, and reproducible results in the right hands but in the untrained provider can result in injuries, poor outcomes and unhappy patients. None of these products are dirt cheap so why go to a clinician who is unable to critically analyze the face or body because of the lack of years of extended training. Remember if you can’t see the problem correctly then you can’t formulate a proper solution. My analogy for this situation is you can give a novice and a true artist the exact same canvas, paint and palate and ask each to create their masterpiece I hazard to guess there will be a distinct difference in outcome and quality. Why risk your face and body or your wallet to chance go to a true trained professional in aesthetic procedures. All providers are not created equal. Plastic surgeon have a unique training and perspective which I can assure you results in better outcomes.

As an example of why I feel uniquely qualified to analyze faces and what can be provided to achieve your aesthetic goals look to my experience as a craniofacial plastic surgeon who spent years mastering the art and science of the rehabilitation of the child with cleft lip and palate. It requires great understanding of the biology of the facial structures of bone, teeth, muscle, skin, fat, and cartilage and how growth and wound healing affects theses structure over time. Typically the child undergoes a lip and initial nose repair at three months of age with or without pre-surgical orthopedic repositioning of the bony segments. Followed by cleft palate repair at age six months to reposition the muscles that move the palate and close the hole between the nose and mouth. The third surgery to repair the cleft of the bone which house the teeth utilizing bone from the hip is performed somewhere around five to six years of age. After a period of six months then the cleft nasal repair is performed to balance the nasal tip with cartilage taken from the back of an ear. Additional surgeries may be required to improve speech function or revise the lip scar. We work closely with ENT’s, speech therapist, orthodontist and pediatric dentist to achieve excellent results.

These principles have been engrained in me and I can apply this knowledge to improving your aging face both non-surgically as well as surgical repositioning of aging soft tissues, changing the shape of your nose, lips and other structures. Please see below pictures of representative cases of cleft lip and palate surgery I have performed over the years. If you have any questions and if you would like a consultation we me and my staff please contact me via our website.

Age three months prior to first surgery

Age Eight after four surgeries

Age three months

Age Eight after three surgeries

Age three months

Four months after presurgical repositioning of upper jaw and bilateral lip repair

1. Will a lower body lift fix all my problems that concern me after massive weight loss?
The surgery of the lower body lift is a constellation of several procedures rolled into a single anesthesia event. It amalgamates an abdominoplasty with a lateral thigh lift, a lower flank-plasty, and buttock augmentation with the patient’s tissue derived from the flanks to give a shapelier appearance that is not flat and amorphous. Many people who have experienced the loss of over one hundred pounds have many areas troubling to the patient beyond the mid and lower torso. These individuals have redundant hanging skin of the arms and medial thighs, significant aesthetic deformities of the breast, and often premature aging of the neck and face. These above mentioned areas are addressed with additional procedures performed separately such as a breast lift with or without a brachioplasty (arm lift), medial thigh lifts, and face- neck lifts. Patients also typically inquire about the order of the procedures and I often state I prefer to perform the lower body lift first to establish the “Keystone “ area of the torso and then I can better make aesthetic judgements about the breasts and thighs with respect to the shapelier proportion of the new torso.

2. Will I spend the night in the hospital after the lower body lift?
Although the lower body lift with all its components takes about 7.5 hours of anesthesia time, The Lucas Center of Plastic Surgery’s protocol is for an outpatient surgery status. People seem amazed at this concept. My explanation is a hospital is for sick patients who require monitoring of unstable vital signs, severe pain requiring IV pain management, the inability to take oral consumption of fluids and nutrients, or the requirement of IV antibiotics. After this very significant surgery we have done very thorough evaluation of what is required to make a patient comfortable, safe and recover in an expedited manner. First of all the surgery utilizes a technique supplemented with tumescent anesthesia which provides local anesthesia with a blood vessel constrictor (epinephrine) which results in a very limited amount of blood loss eliminating any risk of unstable vital signs postoperatively. We also ensure adequate pain management with the combination of a long acting local anesthesia pump to control pain along with narcotic analgesia. There are no limitations on what you can or can’t eat afterwards. At home pain medications can be dispensed as needed, as compared to a busy hospital when your pain control may be limited by the availability of the nursing staff. Home limits the risk of hospital acquired infections which can occur on the nursing floors. Lastly one of the biggest safety measures is the prevention of deep venous thrombosis and pulmonary emboli. Early ambulation even the night of surgery is one of the most important factors along with chemo-prophylaxsiswith Lovenox which can be easily administered at home. In the hospital ambulation is once again limited by the nursing staff availability and can result in almost no mobilization the night of surgery or beyond. In conclusion home is the best place to be after this operation.

3. What are the things patients will be responsible for after surgery?
A patient will wake up in a compression garment that helps to limit swelling and support the abdomen. Four drains will be placed during surgery to reduce fluid collections on the abdomen, flanks and lateral thighs. This will require some care to encourage fluid drainage and the patient or the care giver must measure the output to determine when the drains can be removed. All incisions are closed deeply with resorb able sutures with a layer of a glue –like substance over top so no incisional care is required for two weeks. The patient may shower the first post-operative day. The most comfortable position to rest is in a reclined position to reduce the tension on the abdominal closure.

4. When can I resume normal activities and exercise?
This is a very significant operation which can result in a whole new lease on life by liberating the patient of the imprisonment of the excess hanging skin of the torso. However this comes at a cost of being quite sore and requires subsistence living for about two weeks. After this time many of the inflammatory chemical released by the body as a result of surgical trauma have cleared and most people begin to feel significantly better and are able to resume a more normal life. To feel completely normal it takes around six weeks which is also the time frame to return to regular exercise.

5. What are lifestyle loans? Can they be utilized to finance these procedures?
Lifestyle loans are now becoming more popular and several institutions such as Credit Unions and banks in Knoxville, Tennessee offer loans for cosmetic surgery procedures up to $10,000 with rates as low as 9.20% APR for up to forty eight months. This is substantially more attractive than other popular finance plans to help finance larger procedures such as body contouring after bariatric surgery. Please contact your local bank or credit union for more details.

In my practice the majority of my consultations and surgeries are on women. But over the past few years I have seen an increased demand of men requesting surgeries as well. Some of this may be related to baby boomers who have taken good care of themselves and desire to look as good as they feel. Other men don’t want their wives to look better than they do after they have been undergoing facial rejuvenation procedures so they request surgery as well.

1. Blepharoplasty: Eyelid rejuvenation
Just as women often show signs of aging around the eyes so do men. The phrase “the eyes are the window to the soul” may well be a true but I would also add the statement the “eyelids are the window treatments through which you see the soul.” Loose hanging furrowed skin, lateral brows that hang over the upper eyelids, and bulging fat pads below the eyelids with accentuated tear troughs put forth the image of fatigue and loss of vitality often resulting in friends and colleges asking if you are tired and are you getting enough sleep. Fortunately surgery to restore the upper eyelids to a crisp appearance with correction of any eyelid droop can be a game changer. The lower lids can be rejuvenated by removing excess fat with reposition this tissue over the cheek to eliminate the tear trough combined with skin and muscle tightening provide a fresh and vibrant appearance. This can be an important not only in social situations but also how a person is viewed in the workplace.

2. Neck lifts
Do you look in the mirror and say to yourself I hate this turkey neck? Is buying dress shirts getting more difficult to find that are comfortable with ties? Despite not gaining weight do you look heavier in the face? If the answer to all these questions is yes a consultation for a neck lift may well be a beneficial idea that is not just for vanity. Ideally a man should have a strong jaw line and a crisp chin neck junction. Having hanging skin with or without fat excess that obscures the jaw line certainly can put forth the image of premature aging of the individual beyond his chronologic age. A neck lift can be a valuable tool to restore your appearance and convey youth and energy without changing your overall appearance or giving an odd appearance. The surgery is very predictable in the hands of a board certified plastic surgeon and is an outpatient procedure with very little pain. Most people can be comfortable in social situation in two weeks.

3. Rhinoplasty (Nose surgery to reshape the appearance)
Proportionality is everything. If you are unhappy with the shape of the nose or how it blends with the rest of the face then request a plastic surgeon to perform a facial analysis of you. If the nose seems big maybe the lower face is out of place such as a small lower jaw or chin. Often times I will perform a chin augmentation with a rhinoplasty to provide a harmonious facial appearance. Nose surgery requires finesse and a keen understanding of the anatomy of the many subunits of the nose. The key is to provide shape without feminizing the male nose. This is also a rather easy surgery to recover from and the patient can return to work within a week usually.

4. Chin augmentation with or without an implant.
As mentioned above the facial subunits should all be proportionate to each other. If the lower jaw projection is limited by lack of growth it can portray a weaker jaw with less of a masculine appearance. By using the correct judgement a plastic surgeon can provide an enhanced projection with the combination of either an implant or repositioning of the bone in combination with liposuction of the jaw line to create a sculpted jaw which projects strength.

5. Liposuction of the abdomen and flanks
If you look in the mirror and the phrase “dad bod “screams out… liposuction maybe something to entertain. An important fact to remember is liposuction with its many variations is a contouring tool not a weight loss technique. I strongly encourage anyone who is considering body contouring should first consider diet and exercise first. If after some toning in the gym and normalized weight you are still unhappy with the shape of your body then liposuction may be a reasonable adjunct to improve the appearance. The abdominal area can be shaped as well as the flanks reduced to provide a sleeker frame. It’s a safe surgery that is easily recovered from and normally patients can return to work in a day or two. Final results take between six weeks and two months to observe the full effect of the reshaping.

6. Gynecomastia repair (Man boobs correction)
If you have excess fat and skin of the breast which can also affect the size and shape of the nipple-areolar complex this can project a very feminizing effect of the male chest. In my experience I have been very happy with the results of the combination of VASER liposuction (ultrasound assisted liposuction) with direct excision of any sub-areolar glandular elements with or without areolar reduction to achieve a masculine chest. This can be a very disturbing condition for a man of any age particularly in the teenage years. We see a bimodal distribution of people seeking treatment; those of the teenage years and men in their late forties and fifties who are seeking help to restore the loss of tone of the chest area.

Plastic surgery has continued to evolve in its perception ever since its creation after World War I. Aesthetic surgery was once viewed as taboo or something to hide because it was perceived to be too self-indulgent, now has become more common place and in the minds of many its presence is look upon as main stream. I think this evolution of societie’s views is related to the strong work of The American Society of Plastic Surgery, and the American Society of Aesthetic Plastic Surgery to ensure that board certified plastic surgeon are well trained and perform safe and predictable surgeries that patients seek and desire with excellent outcomes. Also our population is living longer with better quality of life and people are remaining active and engaged and wish to look as good as they feel and are no longer shy about requesting procedure to keep them looking their best.

“All that I am or ever hope to be, I owe to my angel mother.” – Abraham Lincoln

During this time of Mother’s Day, I try to take pause to remember how truly special my mother was to me growing up, contributing to who I am as a person and the meaning of unconditional love. She taught me to always think of others’ needs before thinking of myself. Unfortunately her pupil, her son has continued to fall short of this standard, but she sure set my internal compass to keep trying.

She had such a sunny disposition, and her greeting to everyone was “Happy Day.” Even one of my teachers growing up, who had a senior moment and could not remember my mother’s name, called her “Smiley.” In my childhood home right inside the kitchen door was a small chalkboard hung on the wall that said, “A kind word turns away wrath.” I try to remember this during times of strife with others. Even with her passing almost 14 years ago, she remains a big part of me and although my words could not express how grateful I am to her, I hope she can feel content in all she accomplished here on Earth.

For those of you who still have your mother with you, please take the opportunity while you still can and give her a big hug and tell her you love her very much.

Happy Day.

As we age, the volume in our faces diminishes over time. However, in the right hands you can age gracefully and look as good as you feel for a long time, which is the goal I have for all my patients. Volume restoration of the face, as a part of an overall comprehensive facial rejuvenation algorithm, combined with skin resurfacing and tissue repositioning, can yield beautiful results.

The aging process causes fat volume reduction in the face. The fat in our faces is organized into discrete packages and, predictably, the fat found just below our cheekbone is one package which reduces in volume first. The combination of gravity and volume loss in cheek fat results in our faces changing shape. Our cheeks appear to decrease, and our skin drops. Cheek folds become more pronounced, creating the inevitable downward-turning at the corners of the mouth and contributing to the jowling effect in the lower jaw line.

Another area that can experience volume loss is the lateral forehead in the temple region, which results in the brows re-draping downward, causing a hooding effect and obscuring the upper eyelids. Still another indication important to women is the loss of volume of the lips and the relative loss of the three-dimensional appearance of the upper lip with increased vertical lines emanating from the red border.
The tear trough region around the lower eyelid can lose volume, regardless of your age, particularly if the eyelid fat pads are prominent with a relatively soft mid face projection.

All the above areas can be treated nicely with filler agents. The advantages of out-of-the-box filler agents is they can be used quite nicely with topical anesthetic agents in the office. There’s relatively little to no bruising and no downtime. Many filler agents contain hyaluronic acid, which is a naturally occurring agent in our skin that acts like glue to hold components of our dermis together. Denser material with lots of cross-linking can have a better effect of lifting tissue. Because of its dense properties, Voluma can last up to two years and is routinely placed in the area where the cheek fat packet decreases. This filler is used to lift the cheek back to a normal position, thus improving the cheek fold and the corners of the mouth.

Lips can be enhanced to normal volumes (not the duck lips that I see coming from various spas) to create a natural red lip border with the adjacent skin helping to eliminate the vertical lines. I also enhance the vertical pillars that span between the base of the nose and the cupids bow high points, which returns a three-dimensional appearance to the upper lip. I mostly utilize Juvederm for this area.

The tear trough deformity can be handled nicely with Restalyn or Juvederm to blend the eyelid cheek junction and smooth the appearance of the lower eyelid.

Volume restoration of the temples to return the brow to a more normal position can be best handled using a step-wise approach with Sculptra, which is an injectable form of a polymer of lactic acid. When introduced to the tissue, the lactic acid induces an inflammatory response leading to the formation of new collagen. The advantage of this material is that it can restore large areas of volume loss, which would be difficult with traditional filler agents. It also slowly builds up collagen and restores volume over a six-week period making your transformation less obvious to your friends and family.

Without question, the concept of volume restoration of the face as a part of an overall comprehensive facial rejuvenation algorithm has led to superior results compared to plans that did not include volume replacement. As with Botox, the overall value of the injection material is greatly dependent on who is administering the filler agent.

Poor technique can result in poor outcomes. I liken filler agents to sculpting materials for the face. You can put clay in front of a true artist who can transform this simple material into a work of art. An untrained eye with no sense of perspective or artistic skill will create very little value out of the raw materials. The same goes for these injectable products in the Wild Wild West of aesthetic services here in American and abroad.

Board certified plastic surgeons have a very diverse training experience because we do not own a particular body part such as an Orthopedic or an ENT surgeon and we must be prepared to reconstruct or rejuvenate all parts of the body when the demand arises. Those who felt the calling to become plastic surgeons out of medical school realized their gifts and talents that could be offered to patients pertain to their unique skills of three dimensional thinking and artistic perspective to be able to see the problem and formulate a solution no matter how complicated the deformity exists.

I am troubled by the notion that patients think that facial filler agents, neurotoxins, LASERS, non-invasive contouring machines and other technologies or even surgery will work the exact same way no matter who is providing the services. I feel that Madison Avenue and corporate greed is mostly to blame because all aesthetic companies want to sell the product and place it in as many provider hands as possible to deliver their product to the masses. Many products can provide safe, and reproducible results in the right hands but in the untrained provider can result in injuries, poor outcomes and unhappy patients. None of these products are dirt cheap so why go to a clinician who is unable to critically analyze the face or body because of the lack of years of extended training. Remember if you can’t see the problem correctly then you can’t formulate a proper solution. My analogy for this situation is you can give a novice and a true artist the exact same canvas, paint and palate and ask each to create their masterpiece I hazard to guess there will be a distinct difference in outcome and quality. Why risk your face and body or your wallet to chance go to a true trained professional in aesthetic procedures. All providers are not created equal. Plastic surgeon have a unique training and perspective which I can assure you results in better outcomes.

As an example of why I feel uniquely qualified to analyze faces and what can be provided to achieve your aesthetic goals look to my experience as a craniofacial plastic surgeon who spent years mastering the art and science of the rehabilitation of the child with cleft lip and palate. It requires great understanding of the biology of the facial structures of bone, teeth, muscle, skin, fat, and cartilage and how growth and wound healing affects theses structure over time. Typically the child undergoes a lip and initial nose repair at three months of age with or without pre-surgical orthopedic repositioning of the bony segments. Followed by cleft palate repair at age six months to reposition the muscles that move the palate and close the hole between the nose and mouth. The third surgery to repair the cleft of the bone which house the teeth utilizing bone from the hip is performed somewhere around five to six years of age. After a period of six months then the cleft nasal repair is performed to balance the nasal tip with cartilage taken from the back of an ear. Additional surgeries may be required to improve speech function or revise the lip scar. We work closely with ENT’s, speech therapist, orthodontist and pediatric dentist to achieve excellent results.

These principles have been engrained in me and I can apply this knowledge to improving your aging face both non-surgically as well as surgical repositioning of aging soft tissues, changing the shape of your nose, lips and other structures. Please see below pictures of representative cases of cleft lip and palate surgery I have performed over the years. If you have any questions and if you would like a consultation we me and my staff please contact me via our website.

Age three months prior to first surgery

Age Eight after four surgeries

Age three months

Age Eight after three surgeries

Age three months

Four months after presurgical repositioning of upper jaw and bilateral lip repair

Plastic Surgery Cost Michigan

I would like to address a question that is commonly asked in our practice that relates to pricing. We often have patients who call asking for a specific price for a procedure or service that we provide – and although we would like to provide this information in most circumstances its very difficult to do. There are so many variables involved in pricing such as length of surgery, anesthesia costs, facility costs, and even variables among patients. In some cases such as breast augmentation we can provide a range for which a patient can be given information about the general costs. However, in other situations such as fat grafting to the breast or butt for example this can be more challenging. Each patient is different. So depending on the areas that we might transfer fat for example or the amount that we use or any other variables that can impact the length of surgery – these can have an impact on how long the surgery will take and reflect upon the final cost. This can be challenging of course and we want you to call the office to ask specific questions and ultimately we invite you to come in to a full consultation and evaluation whereby we can fine tune each procedure that meets your specific needs and therefore give you a more accurate pricing in the end.

For many years, facial rejuvenation was limited to skin resurfacing with lasers and peels, and various surgical soft tissue repositioning procedures. However, our options have expanded with the understanding of muscle relaxation via neurotoxins such as Botox, and the evolution of our knowledge of how fat atrophy in the face leads to stereotypical architectural changes with aging. Plastic surgeons can now add volume to refresh the face. In order to achieve a youthful but natural appearance for my patients, I use a combination of muscle balancing, skin resurfacing and tightening as well as volume restoration. Ultimately, when the battle of gravity versus skin plays out over time, surgical repositioning is required.

Let’s examine the question of how best to restore volume in the face.

One option for facial volume restoration is off-the-shelf materials such as hyaluronic acid, in various structural manifestations, as a direct filler. Another option is a polymer of lactic acid (Sculptra), which acts as an inflammatory material inducing collagen synthesis to create a guided tissue volume additive over time. Both are easily administered in the office without any donor site pain or bruising. While these procedures are easy and safe, it takes experienced hands, eyes and judgement to achieve the best outcomes. Results can be expected to last up to two years.

Fat grafting is another source of filler material to restore volume to the face. Fat is easily harvested from the abdomen or the thighs to use in the face. The technique is a gentle form of liposuctioning which then requires a minimal amount of processing followed by reinjection into the desired locations. In the office setting under local anesthesia, patients may not enjoy some of the pressure sensations required to obtain the fat. In an effort not to injure the fat and to prevent fat from being injected into vessels, blunt cannulas are utilized to place the cells into the tissues. This technique causes some degree of pressure sensation as oppposed to a sharp small needle, which can inject off-the-shelf fillers. The advantage of fat is that it is cheaper to obtain than manufactured materials. In most cases, there is a relatively unlimited supply. Furthermore, peripheral stem cells may direct cellular differentiation leading to improved tissue quality.

Fat versus fillers

Fat is certainly more technically demanding and unforgiving. For injections around the eyes to smooth the eyelid cheek junction, I prefer hyaluronic acid. When injected smoothly with appropriate application, no lumps or bumps should occur. In the lips, when I am working to recreate vertical ridges of the phyltral columns of the upper lip and “Cupid’s bow” points as well as a nice rolled margin of the lip, I prefer hyaluronic acid, because it is the consistency of caulking material and can provide shape. Fat is soft, and does not exert force on the skin in the same way as fillers. However, recent research from the University of Texas Southwestern Medical Center demonstrates excellent results of restoring large volume loss of the upper lip beyond the vermillion by placing fat cells in a broad area making the loose skin less apparent.

With regard to the common area of deflation of the sub-malar fat pad in a non-surgical case, I prefer the highly crosslinked stiff material of Voluma which does an excellent job of re-supporting the facial structures to a more youthful position. If I am already performing a surgical case of a face or neck lift, I always add volume to the face prior to elevating the tissue; this is when I choose fat, because of the ease of harvest and injection under anesthesia. Some thin women may show very demarcated loss of volume in the temple area giving the face a skeletonized appearance around the eyes and making the brows seem to sag. This is an excellent indication for Sculptra. If the volume loss exceeds several vials worth of Voluma in the sub-malar fat pad per side, I also prefer to use Sculptra.

Fat grafting is an evolving technique in plastic surgery. Every industry conference has a significant discussion about the techniques and the science behind the results with just about every region of the body applicable to its uses, including face, breast, hand, buttock and other contour deformities. For the early stages of facial rejuvenation, which can occur in the third decade of life and beyond, much of the volume restoration is performed with off-the-shelf filler agents in an office setting due to ease and convenience.

It’s a case-by-case decision.

So when do you use fat versus fillers? It depends. It’s a case-by-case decision to determine the best protocol for each patient. I take a customized approach from the consult to the procedure, based on my unique skill set and my years of experience and training. My goal is to provide the absolute optimal results for each of my patients and to cultivate a lifetime relationship.