Web Log – February 2012 – KTVB Update

Facial aging, like anything else, is a diagnosis.  Early signs of aging include skin quality changes, volume loss, and drooping tissue.  To get a coordinated treatment plan, see a plastic surgeon.

The first step is minimizing sun exposure and ceasing smoking if you are a smoker.  Next is life long skin care.  Dermatologists and Plastic surgeons can recommend medical grade products to optimally treat skin problems such as loss of elasticity and pigment changes.  I particularly like vitamin c, hydroquinone, and sun screen products.  Surface treatments like microdermabrasion are also helpful.

That is when I would discuss injectables.  Botox is good for easing wrinkle lines around the forehead, eyes, and mouth.  Injectable fillers like Juvederm and Restylane are good for filling nasolabial hollows and marionette line.  Injectables can work well for patients in their 30’s, 40’s and sometimes even 50’s, but may be overused by practitioners who cannot offer surgical options.  All these treatments do not cost as much as surgery and do not have the same risks, but do not have the long lasting and potentially dramatic results.

That is the debate that the article is addressing.  Medical lasers are well proven to help with hair reduction and skin pigment problems, but there is no magic bullet yet that reliably tightens skin and the deeper structures.  Laser and other advanced technologies have been touted to be great ways to selectively heat and shrink aged skin, but have overall disappointing results.  These treatments are expensive, may or may not have the promised effect, and that effect may not be long lasting.  I tell patients that if they are not ready for a surgery, have several thousand dollars burning a hole in their pocket, and would accept the risk of little to no improvement, the newer tightening treatments are reasonable to try.

The study authors think that patients with early indications for surgery may have higher quality tissue for repair and therefore have better and more reliable long term results than using non invasive methods early and doing surgery later.  The surgery studied, however, is not a minimal approach.  The SMAS  layer of the face was tightened and this should only be done by an well trained plastic surgeon.  Younger patient who have signs of aging should therefore feel more confident in choosing surgery as long as they can accept the risks and costs as well as possible secondary surgery when they are older.

Overall, adolescents  make up 2% of cosmetic surgery patients.  I would say that I see about that percentage here in Boise.  Approximately 1/3 of those surgeries were for prominent ears (otoplasty), 1/4 for nose surgery (rhinoplasty), 1/8 for breast reduction, and 1/8 for breast augmentation.

We have to consider both anatomic and emotional maturity when evaluating younger patients for surgery.   Anatomic maturity can vary greatly, but ears are about 80% formed by 7 or 8, noses by 13 to 16, and breasts by 16 years old.

The most important qualification is emotional maturity.  Body image is the subjective perception of the body as it is seen through the mind’s eye.  It is considered reasonably well formed in teenagers such that it can respond favorably to a surgery.    The request for surgery must originate from the patient and reflect internal motivation – “I will feel more confident” or “I will be happier with my photos” as opposed to “I will be more romantically appealing” or “people will like me more and tease me less.”

Assuming anatomic and emotional maturity, breast and nose surgery is reasonably done around 16 years old.  Breast reductions, both female and male, can really improve an adolescent’s quality of life.  Breast augmentations, however, are little different.  The American Society of Plastic Surgeons recommends that patients be at least 18 years old, unless it is to treat a birth deformity. Rhinoplasty might be timed over a long break so that the changes have healed and are less easily noticed – it’s hard to hide your face.

American women have nothing to fear in this instance.  About 20% of PIP implants were used in France and the rest were exported to Britain, Spain, and Latin America.  None were sold in the United States, thanks to more stringent testing requirements of the FDA.

There are only two companies approved for silicone implant manufacture, Allergan and Mentor.  Silicone was taken off the market in 1992 because its safety profile was never established.  After careful scientific study, silicone was proven to be unrelated to autoimmune disorders as well as a various other illnesses.  These two companies then formulated new products that caused fewer local healing problems and had easier clean up if they did rupture.

New implants have been released since 2006.  They are less liquid, or more cohesive, so they hold together better, but sill feel soft.  In fact, if you cut one in half, it does not go anywhere. The FDA use to recommend that patients have an MRI every 2 years to detect leaks, but that was rescinded, so I have been more likely to recommend silicone because it feels better and ripples less than saline.

In medicine, we like measurements and clear definitions.  Body Mass Index, or BMI, is a calculation of weight divided by height squared.  So the heavier you are, the higher your BMI.  You can find BMI calculators on the internet. BMI greater than 25 is considered overweight and greater than 30 is considered obese.  Obesity is associated with increased rates of heart disease, stroke, diabetes, certain cancers, and increased surgical complications, so it is a real public health problem.

When people reach a BMI greater than 40, they are classified as being morbidly obese.  They are at least 100 pounds over their ideal body weight and often suffer from arthritis, sleep apnea, heart burn, hypertension, and even heart and lung failure.  In these patients, traditional medical weight loss approaches are frequently unsuccessful.  Operations on the stomach and bowels created and performed by general surgeons may effectively assist with significant weight loss.  Once the weight is lost, then Plastic Surgery is done to remove excess skin if necessary.

One approach is the Roux-en-Y Gastric Bypass.  The stomach is shrunk by surgically stapling it off and drainage from the rest of the stomach is diverted downstream.  This operation offers effective and rapid weight loss, but may have complication like bowel leakage, obstruction, and malnutrition.  Another operation is Laparoscopic Adjustable Grastric Banding, or Lap-Band.  In this approach, an externally adjustable  synthetic band is placed around the entrance to the stomach to reduce its effective capacity.  No re-routing of the intestines is required, but the procedure still has problems and weight loss may not be as effective.  It is a complicated debate that should be presented by a massive weight loss general surgeon during an individual consultation.  Both St. Alphonsus and St. Luke’s have well established surgical weight loss programs with expert surgeons.  For qualified patients, insurance may cover the procedure.