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New Plastic Surgeons Technique

Oct 9, 2007
With a focus on simpler, yet more advanced procedures, plastic surgeons pioneer new techniques so that everyone can put their best face forward.

With one fleeting expression, the human face can convey contentment or drawing others closer or driving them away. It can shout of confidence or flicker with vulnerability.

Perhaps no other region of the body is so attentively cared for--and so much the focus of attention from others.

It is no wonder, then, that so many people turn to plastic surgeons to help put their best face forward.

Plastic surgeons today offer more options than ever to improve the countenance, hide imperfections and reduce signs of aging. No, they can't remake someone's identity, but they can alter features to balance out the face and bring it a more youthful look.

"Most people don't come to a plastic surgeon wanting to look like someone else," says Garry Brody M.D., USC professor of clinical surgery. "Most people still want to look like themselves, but better."

To do this, these doctors must be master sculptors, with skin and muscle as their media, lasers and scalpels as their tools. Indeed, Brady and his fellow corps of plastic surgeons inherited their name not from their use of plastic materials, but rather from the ancient Greek word plastikos: to mold or give form.

It was the horror of war, rather than cosmetic appeal, that pushed the technology of modern-day plastic surgery. World War I and its devastating weapons left desperate veterans with shattered jaws and noses, prompting doctors to innovate ways to reconstruct facial features.

Today, eight USC plastic surgeons tap on their experience with a spectrum of procedures, from carefully reconstructing a woman's breast after mastectomy for breast cancer, to repairing the mouths and noses of children born with cleft palates. Certainly, many facial procedures are elective, but plastic surgeons say they improve their patients' quality of life and outlook, too.

"Sometimes, after a procedure, patients can feel better about their total appearance and the confidence it gives them is really apparent," says John Gross, M.D., USC assistant professor of clinical surgery. "You can see a change in how they carry themselves."

And some procedures don't even require surgery.

Sun Spots

Every minute spent in the sun takes a toll on skin, explains Susan E. Downey, M.D., USC associate professor clinical surgery. The result: spots reddish discoloration, lines and roughness.

"Some people show the signs of aging worse than others," Downey says. "Genetics plays a part. Darker-skinned people don't wrinkle as much as fair- skinned people, for example."

But patients can control other factors, such as sun exposure. Sometimes, says Downey, surgeons steer patients away from surgery and instead suggest that daily skin care regimen of toners, creams and sun block can achieve a younger look. She encourages patients to wear a hat and use sunscreen every day. Secondly, don't smoke she urges. Nicotine causes capillaries all over the body to constrict, reducing blood supply and critical oxygen to the skin. That can lead to deadened-looking skin and wrinkles.

Downey recommends the Environ line of advanced skin care products, created by a plastic surgeon, either as stand-alone therapy or in preparation for surgery. "We've seen good results with them," she says noting improvements in discolorations and fine lines.

She usually starts patients on an alpha hydroxy toner, which gently peels away the skins top layer of dead cells. Toners and creams contain varying amounts of glycolic and lactic acids (alpha hydroxy acids) depending on patient need.

Then patients apply lotions containing antioxidant vitamins A and C in varying concentrations. Scientists disagree on whether the skin readily absorbs such vitamins but Downey believes at least some reaches the cells, "I've seen dramatic effects with both," she says.

Of course, skin care will not repair deep wrinkles chiseled by age. "That takes a little more work," Downey says.

Take a shot

Two popular simple procedures--Botox and collagen injections--only take five to ten minutes in a doctor's office and do not require anesthesia.

Downey calls Botox a "first line" prevention and treatment of the signs of aging. It is a toxin derived from the botulism bacteria that ordinarily cause food poisoning: but injected in diluted solution, it weakens muscle.

How does that help skin?

Over time tiny frown lines form between the eyebrows from tensing and scrunching the eyebrows. Injecting Botox into the area relaxes the muscles.

"If you weaken the muscle early you can avoid getting the lines," Gross says. Injections can also be administered for crow's feet beside the eye, weakening squinting muscles, which wields a second benefit: allowing forehead muscles to pull up the eyebrows, lifting the skin above the eyelid and contributing to a more rested, younger look.

Effects last about three to four months.

For slightly deeper wrinkles around the eyes, the surgeons inject Botox, then fill the wrinkle with injections of a form of collagen--a substance that occurs naturally in body tissues. Collagen fills out and plumps skin.

Smile lines are hardest to erase, Downey notes, though doctors can inject collagen or fat into those creases to make them subtler.

Patients usually recover quickly from the injections--some redness or bruising can occur, but ice helps. Because of the immediate results and relative case of the procedure, collagen's popularity has grown over the past decade: The American Society of Plastic Surgeons reports use of collagen injections climbed by 28 percent between 1992 and 1999.

Light Savers

Sometimes facial skin is too damaged, rough, unevenly pigmented or wrinkled to be repaired through skin care. Time for laser resurfacing or laser peels--a relatively new procedure that appears to be better tolerated and controlled than the previous standard chemical peels.

Doctors use lasers to remove damaged upper layers of the skin, leaving the fresh layer beneath. Manipulating a wand that directs a high-energy beam of light at the skin, surgeons selectively remove more or fewer skin layers, as needed.

Health educator Pattie Campbell went to Gross for a peel because brown spots and several pre-cancerous lesions had developed on her face. He agreed that laser resurfacing would help.

Campbell met first with a USC aesthetician, who instructed her on the use of products to prepare her skin for the procedure. Campbell also consulted several times with Gross to familiarize herself with the procedure.

"The procedure itself took maybe an hour," Campbell says. "It wasn't painful at all."

But, she notes, patients need to prepare themselves for recovery afterward. As with most patients, during the 48-to-72 hours after resurfacing, her face swelled and turned red. Itching and crusting followed, and she felt unsure she would ever return to normal.

"What really helped was when Dr. Gross had a previous patient call me to encourage me," Campbell says. She had been through the same thing and was so positive about it. Dr Gross knew that I needed this support from someone who had been through the same procedure. I really appreciated it." USC surgeons tell patients the deeper their procedure, the longer the recovery. For a laser peel patients can expect to stay at home for a week--or longer--as skin heals. They also must apply sunscreen and ointment religiously. Today Campbell is happy she had the peel, which gave her more confidence in public speaking. "It changed the texture and brought back a youthfulness to my skin," she says. "It's like having baby skin again."

Some patients with less damage may opt for micro-dermabrasion, a more superficial procedure where surgeons buff the skin with tiny blasts of aluminum oxide crystals. The downside: effects go away faster than those of a laser peel.

Eye Openers

Some people always seem to look tired, with drooping eyelids sagging eyebrows or bags under the eyes--even if they get enough sleep.

Two more extensive but increasingly popular procedures can help: blepharoplasty and brow lift.

"Often men come in for this procedure because they feel it will help them to compete in the workforce," Brody says. "But it is not just a pretty face that is important but the greater self confidence they gain that projects the youthful image of energy. This is a very real, emotional change, not for the sake of vanity but a distinct psychological improvement.

Blepharoplasty minimizes signs of aging above the upper eyelid and below the lower eyelid.

Candidates for upper eyelid surgery include people with excess skin that hangs over and hides the fold of the upper eyelid or those with upper lid puffiness.

Surgeons typically make an incision following the eyelid's natural line, from the lid's inside corner out to the laugh lines. They remove any fat and excess skin and close the incision, which is hidden in the eyelid's crease.

In the lower lids, surgeons make an incision just below the lower lashes, remove excess skin, muscle and fat, and tighten muscle or redistribute tissue. The transconjunctival blepharoplasty, meanwhile, offers help for patients with bags under the eyes; surgeons place the incision inside the lower eyelid and remove far from the skin below the eye.

"These can be done with local anesthetic and sedation," Brody says. "They go home right afterward, and take a week or two to heal.

As the nation ages, such surgeries have grown common--increasing by 139 percent between 1992 and 1999. Forehead or brow lifts have spiked too, increasing by 203 percent during the same time period. The lift can smooth forehead lines, raise upper eyelids and minimize frown lines.

USC plastic surgeons perform brow lifts without making the long incision along the hairline formerly required in the operation. Called an endoscopic brow lift, the procedure only requires five small incisions along the hairline. Surgeons then pull and tighten facial muscles through the incisions, which are hidden under hair.

Most patients have the procedures done as outpatients, and can return to work in about a week.

The Face in the Mirror

When a patient wants to remedy facial muscle drooping and sagging skin under the jaw, the old standby--the neck and face-lift--is in order. When a teenager feels her nose overpowers her visage, plastic surgeons offer rhinoplasty. And surgeons continue to master the use of implants to strengthen a jawline or bring the chin or cheekbones into balance with the rest of the face.

But surgeons say it is important to ask why patients want a procedure and what they expect from it, to ensure a good decision. And the decision should be respected.

"No one can understand that in-depth need for a change other than the patient and the surgeon who has heard it dozens of times," Brody says. "If people can take action, they can stop focusing on a part of the body that bothers them. They become more confident and outgoing." Gross says he strives to listen. "A lot of times, I'll have a patient hold up a mirror and look at the area they want changed," he says. "Nobody needs a procedure--it's about what they want. I try to help them achieve the appearance they want."

Surgeons consult with patients several times before surgeries to make sure they know what will happen. Often, patients will bring in old photographs of themselves so surgeons can better see the natural progression of their features, and use the information during surgery.

The doctors also ask patients to get a physical exam to ensure they are in good health before the procedure, to minimize risk. And all surgical procedures are done by faculty physicians in an operating room with lifesaving equipment, in readiness for any emergency.

While patients have asked for more advanced surgical techniques they also have requested more everyday services for the face.

USC's plastic surgery practice has grown to include aestheticians who perform facials, acne treatment and lymphatic massage. They also blend permanent makeup on eyelids and lips. "Adding aestheticians and skin care is relatively new in plastic surgery," Downey says.

In the future, Downey expects scientists will advance the field by showing how antioxidants work to battle signs of aging, adding to the dermatological toolbox.
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