• More company. Economic and demographic forecasts predict that the U.S. population will increase 12 percent between 2001 and 2010 and that the segments of the population who are most likely to seek cosmetic interventions—most notably the baby boomers—are the segments that will grow the fastest. As a result the demand for cosmetic medical care is predicted to increase 19 percent during the same time period.

• More vendors. Economists predict that soon we will see outlets along the lines of “Sam’s medi-spa-mart,” which will be the place to go for your sunglasses, toiletries, vitamins, massage, Botox, and laser hair removal. Some doctors will still focus on the patient, but the mass market will always care about the price.

• More snake oil. Tomorrow you will be exposed to ever more fantastic claims from the beauty industry. For example (as if privacy concerns weren’t an issue), you will someday soon be asked by a skin-care manufacturer to send it a sample of your DNA so that a “custom” skin formula can be developed for you based on your genetics. If it sounds fabulous, the industry will be right on the money with this concept.

What is less certain is how in the future we shall deal with the tougher issues, the concerns that are less about money and more about values.

• Media and medicine. How do we protect society’s interests from unethical advertising and unsafe practices by those who are entrusted to protect individual patients and the public welfare?

• Appearance- based social discrimination. Is this a biological imperative or can a society evolve beyond it? As historian Sander Gilman points out, beauty is culturally constituted, and what makes a person fit in to the present generation can make that person stand out in the next.2 In the same way, tolerance for difference is culturally determined. One who questions this perspective should contemplate the congenital deformity of cleft lip, for which plastic surgeons have generations of cumulative experience repairing, and yet which was recently the justification reportedly given by a couple in Europe to terminate a pregnancy.

It seems certain that cosmetic medicine will remain popu lar for quite a long time. Of course, it is always possible that society will start to honor aging faces. Nip/Tuck has already addressed that question—and tossed it aside—in an episode in which Joan Rivers asks to be surgically restored to the woman she would have been had she not undergone multiple cosmetic procedures. As soon as she saw the computer image of what she would look like, she changed her mind.

The members of society most affected by our predilection for permanent physical alterations are, of course, our children. Every generation of parents is doomed to wonder if its teenagers will come to regret those tattoos and piercings, and now we can add an array of more extensive cosmetic procedures to the list of emerging popculture fads. One can only hope that parents will always look beyond peer pressure before consenting to cosmetic interventions for their teenagers.

As for those boomers who are kicking and screaming their way through middle age into their later years, the choices are many. Still, cosmetic medicine can offer only so much, and the quality of the second half of one’s life hinges less on looks than on outlook. Regardless of your age, try the following:

• Keep busy with a variety of interests; this helps everyone adjust better to the stresses of getting older.

• Give yourself plenty of credit for where you have been and what you have accomplished.

• Adopt the attitude of “live and let live.” Rigidity of attitude about others and their behaviors will not win you any friends and will push the ones you have away.

• Don’t let your pride tie you down: Accept a little help when it is offered, and ask for it if you need it.

• Accept the things you cannot change (you know the rest of the saying).

• Be realistic about your body: Even the best cosmetic surgical result cannot turn back the clock.

The Top Ten Ways to Avoid Needing Cosmetic Medical Care

It seems strange to have to say this, but aging is a natural human pro cess. We are finite beings. What is even stranger is that despite the inevitability of growing older, our culture has managed to persuade us that it is a sign of personal weakness if we allow the signs of aging to encroach upon us without a fight. If one wishes to become the CEO of a Fortune 500 company or the spouse of a publicityprone real estate mogul, then the pressure to look “better than good” undoubtedly reflects the reality of a job requirement. For the other almost 300 million people in the United States, however, the message has become quite insistent. One is not normal if not narcissistic.

You must look great and feel great about it. If you don’t, it is your own fault if your life doesn’t work out the way you hoped. But you can’t look great without help from cosmetic medicine. In order to emphasis this imperative about actively altering your appearance, you are reminded of the “sad truth . . . that no matter how we wish it weren’t so, each day brings tiny, frustrating changes, constantly chipping away at youth and beauty.” This happy message is from a doctor in the beginning of his book about “preemptive” cosmetic procedures. So the ball is in your court. “Why sit idly by, spending the best years of one’s life waiting to look bad enough to warrant a facelift?” And if that isn’t brutal enough for you, remember that it’s your fault. You are told to “stop making things worse.” You can feel lucky that there are options because in the past all you could do was sit “helplessly watching the changes add up . . . and grind [your] teeth and wait for things to get worse.”

At any age, Americans are addicted to the quick fi x. We like ready access, rapid turnover, and immediate results. We are not very good at patience, deference, and delayed or, worse yet, uncertain satisfactions. On top of this, we can’t convince our teenagers to adopt these latter characteristics in order to ease their transition into the adult world. This chapter cannot cure you of a desire to look younger, and if you are over fifty, it will have less to offer you than if you are under thirty. Even so, we all know perfectly well that we can do more to improve our health, and by doing so we will definitely improve our looks. Nothing on the list below will be news to you, but that doesn’t make it any less true. Best of all, most of these tips cost you nothing to implement.

THE TOP TEN WAYS TO AVOID NEEDING A COSMETIC SURGEON

1. Get New Genes

Of course, you can’t do this; we know that skin type is inherited, but that does not mean that you are doomed to look like your mother or father. Upper-class women in the 1800s went to great lengths to protect their skin from the elements, but every generation since then has spent more time outdoors and has received exponentially increasing levels of ultraviolet radiation. We now have much more knowledge and better products to help us avoid skin damage. You can control the quality of your inherited skin.

2. Avoid Ultraviolet Exposure

It bears repeating. There is no single thing that you can do to keep your skin looking young that is more effective than protecting it from the sun, tanning booths, and other forms of ultraviolet exposure. There is even a scary term for this: photoaging. Worse, we physicians are now seeing patients in their twenties and thirties with basal cell carcinomas and squamous cell carcinomas—those sun-related skin cancers that we used to see only in people in their sixties and seventies—and more teenagers with potentially lethal malignant moles (melanomas).

3. Stop Smoking

Smokers always advertise their habit on their skin. Even young people who smoke have a characteristic gray skin color that is a direct result of the reduction of blood supply that ordinarily gives a young person’s skin a healthy glow. Eventually, all smokers look old before their time, and their skin, chronically starved for oxygen, develops a dull, prematurely wrinkled appearance.

4. Get More Exercise

Extreme exercise habits can actually lead to a gaunt appearance, but this applies to very few people. Most people need more physical activity, and moderate exercise has innumerable health benefi ts, including improving one’s appearance and sense of well-being.

5. Practice Good Nutritional habits

Eat a balanced diet and stay away from high-fat foods, sugar, and refined, high-carbohydrate foods that have been stripped of their natural nutrients. Consider taking a multivitamin if you do not eat a good variety of fruits and vegetables.

6. Limit Alcohol Consumption

Excess alcohol intake contributes to many problems, including weight gain. 7. Control Your Weight

We all know how much harder it is to lose weight as we get older, so it is better not to put it on. As we age our skin gradually loses its ability to “spring back” after weight loss. On the other hand, excessive thinness makes anyone look unwell or malnourished, and this effect becomes more pronounced with age.

8. Get Enough Sleep

Studies have shown that large numbers of Americans are sleep deprived. Adequate sleep is essential for good physical and psychological health.

9. Reduce Stress

Stress, whether it be job related, relationship based, or physical, can cause round-the-clock facial muscle hyperactivity that leads to increased facial wrinkling, not to mention loss of sleep, loss of appetite, high blood pressure, and other bodily effects that eventually cause premature evidence of aging and increase the risk of more serious health problems. If you feel that you are under severe stress but cannot identify and/or reduce the causes, you may need to seek outside help.

10. Stay Mentally Stimulated

This is the key to vitality. Vitality is an incredibly attractive human characteristic. People who are not physically beautiful in the classical sense can be desirable to be around simply because they project warmth, charisma, and other hard-to-define qualities that attract others to them. Stay engaged with the world of ideas. Find something that you care about, other than your appearance, on which you can focus your creative energies. Soon you will find that people care less about the way you look than they do about who you are. The purpose of this book is not to tell you whether cosmetic medicine is a good thing or a bad thing, or whether it is appropriate for you or your family or your friends. The message is that cosmetic interventions have risks and don’t make everyone who undergoes them happy that they did. If you are a princess and live in a castle with your prince who used to be frog, then by all means believe everything you see on TV. If not, research your options. See a reputable doctor. Seek a second opinion if you need to. Be a truly informed patient. If you do these things, your dreams may not all come true, but at least you will be less likely to fall down the rabbit hole.

Cosmetic Interventions for the Very Young, Teens, and the Very Old

CHILDREN

Cosmetic interventions as defined in this book—alterations of normal features—are rarely if ever appropriate for young children. However, children do undergo a variety of procedures to correct deformities related to imperfect development, injuries, or other causes. In many cases these deformities are corrected for the purpose of improving the child’s appearance and social integration rather than for any functional need. In this chapter I will not discuss surgery for cleft lip and related defects, microtia (severe underdevelopment of the ear), large moles, or treatment of large blood vessel abnormalities like hemangiomas because these deformities often have functional impact and do not properly belong in a book about purely cosmetic procedures.

Body image develops in childhood and evolves throughout adolescence. For the most part a child’s body image will adjust fairly easily to physical changes, although certain longer- lasting physical conditions may have more profound effects (for example, obese children may grow up to be adults who, despite normal body weight, see themselves as fat). For this reason surgeons try to complete reconstructions of congenital deformities during early childhood whenever possible.

Procedures for children that may have improvement of appearance as the primary goal include ear surgery (otoplasty) for prominent ears, excision or laser treatment of small blood vessel tumors (telangiectasias, spider angiomas, small hemangiomas), ear tags (branchial cleft remnants), treatment of port wine stains, and correction of problems related to ear piercing.

Fortunately, it is sometimes possible to obtain insurance coverage for these kinds of surgery in children, even when the same policy would not cover treatment of an adult with the same condition. In some cases, surgery can be performed with local anesthesia, although younger children and some older children do better with sedation or general anesthesia, especially for more extensive procedures such as bilateral otoplasties and laser treatment of large port wine stains.

Children should undergo procedures requiring anything more than local anesthesia only in a hospital or accredited ambulatory surgery facility that is properly staffed and equipped to take care of children. Fortunately, children usually do well after surgery. The two main categories of risks for children are those associated with general anesthesia, especially for the very young infant or any child with a respiratory illness, and those related to healing problems in a child too young to cooperate with postoperative wound care, thereby leading to poor scarring or the need for further surgery.

TEENS

Statistics

Of the roughly 333,000 cosmetic procedures performed on patients under the age of eighteen in 2005, the vast majority were performed on teens. Most of these were of the minimally invasive variety, often to treat acne-related conditions or for hair removal. Of the less than 80,000 reported invasive surgeries on minors, nearly two-thirds were rhinoplasties.

Psychological Considerations

Adolescents tend to fixate on visible body parts that fall anywhere outside the “average.” Typically, noses for boys and breasts and noses for girls receive the most self-scrutiny. Many teenagers, like adults, find the idea of a cosmetic intervention appealing and have a body feature that they feel could benefit from a little tweaking (even though most do not pursue surgery).

As a society we must be concerned about the effects of mediaperpetuated cultural “norms” on children. For those teens who do undergo cosmetic interventions, however, the psychological risks seem to be lower than they are for adults. Teenagers actually incorporate physical changes into their body image more readily than do adults.

One potentially psychologically risky practice that many cosmetic surgeons discourage is the “family combo.” Most commonly this scenario involves a mother and daughter undergoing the same operation (often rhinoplasty or breast augmentation) by the same surgeon on the same day. In the daughter’s case the procedure may be a birthday or graduation present. The emotional traps are numerous for the patients and the surgeon, especially if one patient gets a better result or has problems. Just as important, the mother who might otherwise be the designated caregiver becomes herself a patient, in competition with her daughter for attention during the recovery period.

Eating Disorders

Many parents are concerned about body image disturbances leading to unhealthy behaviors, including eating disorders, in their adolescent girls. Our culture is permeated with images of young girls that, for many parents, are too sexualized, too thin, or both. Cultural historian Joan Jacobs Brumberg (in Fasting Girls: A History of Anorexia Nervosa) and others have written at length about how our society has so successfully harnessed female sexuality to the interests of capitalist marketing.

An eating disorder is generally defined as a pattern of dangerous weight-control behavior usually associated with body image disturbance. The most well-known eating disorders are anorexia nervosa and bulimia nervosa. Although these potentially lethal medical problems can develop in members of almost any demographic group, they are disproportionately seen in young women and girls and may affect up to 20 percent of female college students. Eating disorders require aggressive psychiatric evaluation and treatment, and as a general rule cosmetic interventions are not appropriate for these patients. Having said that, there is some evidence that, in carefully selected patients, certain procedures such as breast reduction surgery may be helpful in the treatment of girls and women whose eating disorders stem from a specific body issue like overly large breasts.

Marketing to Teens

Since the dawn of the modern advertising age, the beauty industry has found teenagers, a population group already obsessed with appearances, to be an eager audience for its sales pitches. Teenagers report getting almost all of their information about cosmetic medical care from television and teen magazines. Undoubtedly, future surveys will add the Internet to this short list of information sources that exercise substantial influence over teens. There has been considerable controversy in recent years over the effects of advertising on teens, especially girls, and whether it predisposes them to eating and other body image disorders, self-esteem problems, and diffi culty handling pressures to be sexually active, among other concerns. The barrage of images of thin bodies, all irregularities airbrushed away, jar against the reality of increasing childhood and adolescent obesity in America. On top of the predatory media attention, teens watch as the adults around them seek cosmetic changes. A survey of readers of a magazine aimed at preadolescent girls asked for reader input on the topic of makeovers and managed to capture the confusion that many kids feel. One twelve-year-old wrote, “Aren’t adults always saying that ‘All that counts is on the inside’?”

Periodically, there is a mea culpa maneuver by the beauty industry to expand its imagery; for example, a decade or so ago magazines started to use more ethnic models. In mid-2005, magazines such as Seventeen, Teen People, CosmoGirl! and Teen Vogue claimed that they would be including more typically shaped girls in their pages.2 It remains to be seen how extensive this trend will be or how long it will last.

Specific Cosmetic Procedures for Children and Teens

Breast Surgery

For both girls and boys breast development during adolescence can be the source of considerable trauma. Girls are self-conscious about their budding breasts at any age, but a girl whose breasts do not develop in a way that she thinks is desirable may develop a variety of undesirable responses, including social withdrawal, posture problems, and even eating disorders. Certain breast confi gurations are the result of congenital deformities, such as Poland syndrome in which one breast, and sometimes the pectoral muscle and upper extremity on the same side, does not develop normally. Other potentially stressful breast configurations include lesser asymmetries, macromastia (a typical example of which is a twelve- or thirteenyear- old wearing a DD bra cup), hypomastia (minimal breast development), and in boys any degree of breast enlargement. These conditions are almost always within the range of what is considered normal, yet they can create great embarrassment for a teenager. Whereas timing is an important consideration for every teen who wants breast surgery, few cosmetic surgeons would debate the appropriateness of surgery for the problems just mentioned. In some cases the procedures may even be covered by health insurance. However, before agreeing to purely aesthetic requests—that is, for surgery on breasts that are developmentally within the normal or typical range and therefore should not be causing undo psychological distress—most surgeons feel that the patient should possess an additional level of maturity. The ASPS does not recommend purely aesthetic breast augmentation for girls under the age of eighteen. Hormone-induced pubertal gynecomastia in boys often subsides as the young men mature, but in some cases the breast tissue remains enlarged and will turn an outgoing, sports-minded boy into a hunch-shouldered adolescent who won’t take his shirt off in public. Breast surgery for gynecomastia in boys is sometimes, but not predictably, covered by insurance plans.

Several general rules apply to adolescents who wish to have breast surgery: (1) Pubertal growth should be complete and stable for at least one and preferably two years before surgery is performed. (2) Persis tent breast enlargement in boys and massive breast enlargement in girls warrant a hormone evaluation, usually by an endocrinologist, although most of the time the results of these evaluations will be normal. (3) Massive enlargement or severe psychological distress may warrant earlier surgical intervention, but patients and their families need to understand that early surgery includes the increased risk that a second operation may be required for the same problem in the future.

Ear Surgery

Surgery for prominent ears (otoplasty, ear pinning) can be performed with local or general anesthesia. After surgery the patient will have a head dressing for a few days and will likely have to wear ear protection twenty-four hours a day for several weeks and at night for months. Bruising and swelling are common, and final ear shape takes months to appear. Normally patients can resume full activities within a few weeks as long as the ears can be protected against injury. Boys are discouraged from future wrestling because even with headgear, ear injuries are very common in that sport. Scars are usually well hidden although occasionally will be problematic. Major complications are uncommon; irregularities, asymmetries, recurrent prominence, and need for additional surgery are quite common. Liposuction

Liposuction should not be offered to teens as an alternative to good eating and exercise habits, nor should it be used as a treatment for the residual and generally temporary fat distribution patterns of childhood.

Rhinoplasty

The shape of one’s nose changes dramatically during adolescence and can be the cause of considerable dismay for some. Rhinoplasty for adolescents is fairly common, and the results are usually quite successfully incorporated into both male and female teenagers’ evolving body images. This is a particularly important point for boys, who as teenagers tend to adjust much better to rhinoplasty than do their adult counterparts. All teenagers should defer nose reshaping surgery until facial bone growth is complete. This usually means delaying surgery until at least age fourteen or fifteen for girls and sixteen for boys. Decision Making for the Parents of Teens Making the decision to allow your teen to undergo a cosmetic intervention can be difficult, and in most cases it should be. Wanting to do it because “everybody else has done it” is not the decision of a mature individual and is not sufficient grounds to proceed. The ASPS has no formal policy on plastic surgery for teenagers but stresses that a patient should be physically and emotionally mature before undergoing a cosmetic procedure. The society reports that the most rewarding outcomes are likely to occur under the following circumstances:

• The teenager initiates the request.

• The teenager has realistic goals.

• The teenager has sufficient emotional maturity. In partic ular the teen must be able to handle temporary pain and disfigurement. Surgery is not recommended for teens prone to mood swings or erratic behavior, drug or alcohol use, depression, or other mental illness.

ELDERLY—OVER SEVENTY-FIVE

Elderly people—those over seventy- five years of age, say—do undergo cosmetic procedures, although as the available statistics do not stratify groups over age sixty- five, the numbers may not be large. Unfortunately, even the elderly cannot escape the buzzwords and images designed to convince them to buy cosmetic products and services. (My personal favorite absurdity: skin creams with calcium in them.) Several points regarding cosmetic procedures on elderly patients are worth mentioning:

• Elderly patients, properly selected, can undergo conservative cosmetic procedures safely, but one must always take into consideration their reduced physiologic reserve compared with younger patients.

• Older skin has less elasticity and less fat. Dramatic changes should not be expected, and overcorrection can lead to a very unappealing result.

• Bruising can be quite pronounced and prolonged.

• Long operations should be avoided to minimize risks of hypothermia, blood clots, excessive anesthesia, and joint stiffness leading to pain and immobility after surgery.

• A healthy person age seventy-five may have no higher risk than a person age sixty with multiple medical conditions.

• Cardiovascular disease is common in the older population and significantly adds to the risk of surgery for any patient.

 • Drugs, including painkillers, anesthetics, and sedatives, must be used carefully and in lower doses in older patients.

• Nutrition should be emphasized before and after surgery and supplemented if necessary.

• Procedures should be performed in a fully equipped, accredited ambulatory facility or a hospital rather than in an offi ce setting so that sufficient resources are available in case of emergency

. Any high-risk patient should have surgery only in a hospital.

• Extra attention should be paid to ensure that an elderly patient will have adequate care and means of transportation for as long as necessary after discharge from the medical facility.

Cosmetic Medicine for Non-Caucasians

The volume of cosmetic procedures performed on non-Caucasians continues to grow. In 2005, nearly a quarter of all procedures were performed on non-Caucasians, defined by the ASPS as mainly Hispanics, African Americans, and Asian Americans, whereas in 2004, these groups composed only 16 percent of the reported cosmetic surgery volume. These percentages probably do not adequately account for substantial numbers of immigrants and others who undergo cosmetic procedures in undocumented circumstances. When the numbers that are available are examined, it can be seen that each of these ethnic categories, but especially the Hispanic and African American groups, comprised a greater percentage of the cosmetic medical population in 2005 than it did a year earlier. For all ethnic and racial groups, rhinoplasty remains one of the most commonly requested operations, although for Hispanics breast augmentation and liposuction lead the list. As with the general population of cosmetic patients, Botox, injectable fi llers, and chemical peels are especially popular. There has always been a certain demand for cosmetic interventions by those who want to look less ethnic, more Caucasian, less Asian, less African, and so on. Sometimes the desire is generalized, other times it applies only to specifi c features, such as eyelids or noses. Cosmetic surgeons have been criticized for trying to “Westernize” their patients, but the demand comes from the patients themselves and often reflects social pressures to conform to the appearance of the prevailing power elite. Long before it was commonly performed in the United States, blepharoplasty (eyelid surgery) to create a more Caucasian shape was popular in Asian countries. As discussed in earlier chapters, nose surgery to remove the common Mediterranean (for example, Jewish, Italian, Arab) hump or to increase the profile of the typically fl attened Asian or African nose was very common in the early twentieth century and is still performed frequently today. For many years, rhinoplasty has been popular with Arab women who can afford it, and the operation is almost a rite of passage for Arab American female teenagers. Nonetheless, while racism has hardly been eliminated from our culture, the range of what is considered desirable has expanded. In most parts of the country it is no longer social death to carry a drop of Jewish or non-Caucasian blood. The social risk now for some patients undergoing cosmetic interventions is that they will be accused of cultural betrayal, of shunning their communities if they seek to alter a physical connection to their roots.

Beyond rhinoplasties and blepharoplasties, non-Caucasians also seek out rejuvenation procedures. However, certain considerations related to skin type apply. For any given occupation or lifestyle, non- Caucasians and certain other ethnic groups have more baseline skin pigmentation than do people of northern European extraction. As a result they sustain less skin damage from sun exposure and tend to age more gracefully. Although people of these ethnic and racial backgrounds may seek cosmetic interventions, they are less likely to seek rejuvenation procedures at as early an age. Darker skin types are also susceptible to certain undesirable effects of surgery and other injury:

• Patients with darker skin, especially African Americans, seem to be more prone to the formation of keloids (see Chapter Nine). Most patients who have a tendency to form keloids will have a history of developing a keloid after a prior injury or operation, and those patients probably are not good candidates for cosmetic interventions. Having said this, the vast majority of African American patients do not develop keloids after surgery. Also, thick scars do not develop only in dark-skinned individuals. Some of the most troublesome scars develop in fair-skinned redheads.

• Dark skin tends to depigment at the site of injury, although the loss of color is usually temporary. Wounds that result in delayed or complicated healing are more likely to have permanent pigment irregularities. Steroid injections, often used to treat thick scars, can also depigment skin.

• Any type of skin resurfacing or laser treatments (such as for hair removal) can lead to undesirable changes in skin color. All dark-skinned patients should use sunscreen beginning several weeks before treatment, and many doctors will also recommend bleaching solutions for several weeks in preparation for treatment. Very dark-skinned individuals may not be candidates for these kinds of procedures.

If an individual is considering undergoing cosmetic surgery to alter an ethnic characteristic, he or she should keep in mind that technical expertise and finesse in performing such procedures is always going to be greatest in those surgeons who specialize in or at least do large volumes of these partic ular procedures. Therefore, one should be sure to ask for referrals and inquire about the surgeon’s case volume.

The major stereotypes of the male cosmetic medical patient have been the aging, narcissistic homosexual actor and the young, narcissistic homosexual bodybuilder. Now there is a new stereotype and label for a man who cares about his appearance but does not want to be labeled gay—the metrosexual. In fact, there are plenty of males who seek cosmetic interventions who do not fit into any of these categories.

Men have the same basic concerns about appearance that women do, and there are cultures past and present where male adornment is as important if not more so than female adornment. Still, the aging process has always been more socially acceptable in men than in women. Aging tends to emphasize a man’s masculine features and tends to garner him more respect. Older men, especially successful men, have less trouble finding romantic partners than do older women. Having said that, men (and women) value fi rm, muscular, well-proportioned physiques for men. Features such as waistline fat, saggy eyelids, and too little or too much hair on certain body parts are not favored.

As we have seen, standards of personal appearance are culturally determined and perpetuated by media and marketing. In our culture, at least until recently, men have not been much targeted by the fashion, beauty, and cosmetic medical industries. In modern times, with increasingly sedentary jobs and rising obesity rates, fewer and fewer men are candidates for statuary modeling. This shifting of the typical American male body away from the Apollonian ideal has led to a series of fitness crazes and the birth of a subculture, the Bodybuilder. Beginning with Eugene Sandow, billed as “The World’s Most Perfectly Developed Man,” and followed by Tarzan, Charles Atlas, the Mr. Universe contestants, and other familiar contemporary icons turned politicians, bulked-up men have achieved a certain level of status in our society. The antithesis—the fl abby couch potato—is a person almost certain to be discriminated against socially and in the workplace. Thus liposuction has earned its place beside dusty treadmills and unused health club memberships on the to-do list of many American men. The cosmetic medical care industry has added to its mantras a new oxymoron: “Pampering Tarzan.” According to the ASPS, about 1.2 million cosmetic procedures were performed on men in 2005, less than 15 percent of the total cosmetic procedure volume. As a group, men are more inclined toward procedures with little or no downtime, no swelling or other evidence of treatment, and stripped-down skin-care instructions. Therefore, men lean toward the minimally invasive procedures and are also said to be the fastest growing segment of consumers of cosmeceuticals. Nose surgery is the cosmetic operation most frequently chosen by men. Following rhinoplasty and vying for a distant second place, the invasive cosmetic procedures men most commonly seek are hair transplantation, liposuction, and eyelid surgery. The fifth most common operation is gynecomastia surgery (male breast reduction). The volume of fringe procedures like penis lengthening, despite a certain amount of lurid press, is probably overinflated. No one knows for sure.

In the men’s noninvasive category, Botox rules, followed by microdermabrasion, laser hair removal, chemical peels, and filler injections.

MALE RHINOPLASTY

Of the nearly 300,000 cosmetic operations on men reported for 2005, about 35 percent were nose reshapings; still, far fewer men than women undergo rhinoplasty. Many cosmetic surgeons feel that rhinoplasty, despite its popularity, has signifi cant psychological risks associated with it for adult men, whereas teenage boys usually adjust well. In fact, some experienced cosmetic surgeons feel that the adult male rhinoplasty patient is the most difficult category of cosmetic patient. A reduction rhinoplasty, in which the nose is made smaller, seems particularly prone to creating dissatisfaction. As an interesting corollary, there is some evidence that homosexual men seeking rhinoplasty to feminize their features are more likely to be satisfi ed with the results.

MALE FACELIFT, EYELID LIFT, AND BROW LIFT

Men do have facelifts, but the numbers are relatively small. Often they cite professional reasons or the desire to impress a younger lover. Facelifts on a man can be more challenging surgically than is the same operation on a woman. Physiologically, male facial skin differs from female facial skin; it is thicker and has increased blood supply. The hair is of different quality, and hair distribution must be considered not only for the sake of appearance but for the mechanics of shaving. After a facelift some men can be left with an inconvenient change in their facial hair growth pattern, especially in the ear region, and some patients may even need to consider laser hair removal or electrolysis as treatment for undesirably relocated hair. The robust blood supply of a man’s facial skin leads to a higher risk of blood collection (hematoma) after surgery, which can lead to skin loss or long- term skin pigment changes. It is difficult to hide the evidence of a facelift on a man; unless he wears makeup or long hair, his barber and other close observers will likely notice the scars. Men also have eyelid and brow lifts, often to improve their fi eld of vision. Eyelid lifts are similar to those performed on women. Brow lifts on men usually present the dilemma of where to put the incisions, and the resulting scars may be visible. A man with a receding hairline may be horrified to wake up one day and discover that his scalp scar is suddenly on his forehead. Facelifts, eyelid lifts, and brow lifts are discussed in other posts.

HAIR TRANSPLANTATION

All surgical forms of hair replacement involve transplanting a patient’s own hair from one portion of the scalp to another. For men with large bald areas, operations called flap procedures may be necessary. Tissue expansion is another option, in which balloons are positioned under thick hair-bearing areas of scalp and infl ated slowly to stretch the scalp. Later, portions of the bald scalp are removed and the stretched hair-bearing sections pulled over the excised bald areas. These kinds of operations require general anesthesia. Tissue expansion creates a significant, although temporary, deformity of the head shape and as a result may not be feasible for many men. For a man whose baldness is confined to a limited spot on the crown of the head, it may be possible simply to excise the bald area during a series of operations, often under local anesthesia. This surgical technique is called scalp reduction.

Less extensive baldness is commonly treated with hair transplants and has evolved from the visible plug transplants to what is called microtransplantation, in which tiny grafts of one to three hair follicles are moved from thick growth areas on the sides or back of the head to thinned areas in front or on top of the head. Microtransplants are performed with local anesthesia, with or without sedation, in an office setting. Because the procedure is tedious, multiple sessions over many months or years may be required. Some physicians specialize in hair transplantation and have developed an extremely streamlined, labor-intensive pro cess in which up to several thousand grafts can be transplanted per “megasession.” Successful hair transplants tend to be stable and long lasting; even though microtransplanted hairs fall out shortly after surgery, most will regrow. The best candidates for hair transplantation are patients with thick, healthy hair growth along the sides and back of the scalp, the prime donor areas. Patients with extreme baldness and very little donor hair are much less likely to have a natural looking result, no matter what procedure is performed, and most prospective patients in this category should be discouraged from undergoing surgical hair transplantation.

Complications of hair transplantation procedures are low. Major flap operations have higher risks, scarring may be visible, and additional procedures are often necessary. After microtransplantation some hairs will not survive, requiring additional sessions to achieve the desired effect. The characteristics of a transplanted hair may not be the same as the original hair, and original hairs in a balding area may continue to thin out over time.

The bottom line: Hair transplant techniques have improved dramatically, but in order to get a good result, most patients still need to submit to multiple tedious procedures over a long time period at signifi cant expense.

BODY CONTOURING FOR MEN: LIPOSUCTION AND IMPLANTS

Men seek body-contouring cosmetic surgery for several reasons. Some want to reduce “middle-age spread,” some desire to rid themselves of excess skin after major weight loss, and others are involved in self-sculpture. For the first group liposuction and skin excisions are often prescribed (see Chapter Eight). For the last group, liposuction has been used to sculpt belly fat to simulate the bulging muscles of a “six-pack” abdomen, and synthetic implants may be used to enhance the contours of pectoral muscles, arms, legs, and buttocks. Synthetic implants inserted to augment muscle contours are prone to several complications, also discussed in other posts.

MALE BREAST REDUCTION

Some men have distressingly prominent tissue in the breast area. Breast enlargement in men is called gynecomastia and can be due to breast gland enlargement or obesity. Men can also develop gynecomastia as a result of using drugs such as marijuana and anabolic steroids. A man with gynecomastia that is severe or fails to resolve after adolescence should have an evaluation by an endocrinologist (a physician who expertise includes conditions caused by hormone abnormalities). In rare cases, male breast enlargement can be caused by breast cancer.

Gynecomastia can be treated surgically with excision, liposuction, or a combination of techniques. The surgery requires general anesthesia and possibly an overnight stay in the facility. Drains may be left in place for several days, and the patient must wear a tight, vestlike compression garment for weeks. Pain can be significant for the first forty-eight hours. Risks include permanent contour irregularities and noticeable scars, especially if significant amounts of skin have to be removed. Gynecomastia in teenagers is discussed in other posts.

OUTCOMES FOR MEN

Many cosmetic surgeons note that male patients do not listen or communicate as well as female patients, and as patients men can be more challenging than women. Their compliance with instructions tends to be less than ideal. As a group, men also recover from surgery differently than do women. Men have lower pain thresholds and more difficulty curbing their activity level during the recommended recovery period. Nonetheless, with the possible exception of adult male rhinoplasty patients, men overall tend to have outcomes as good as those of women. However, in order to facilitate their convalescence, prospective male cosmetic patients should make a conscious effort to be informed about what to expect postoperatively.

Much has been written about major psychological problems associated with cosmetic surgery, including body image disturbances and various forms of mental illness (cosmetic surgery addiction, eating disorders, delusional disorders, schizophrenia, and others). Studies indicate that up to 15 percent of people seeking cosmetic surgery have BDD, the most severe form of body image disturbance. In genWhat eral, prospective cosmetic medical patients with known psychological problems are at significant risk for psychiatric complications after treatment.

OUTCOMES

Goals Versus Outcomes

A patient who, going into a procedure, understands the possible outcomes is more likely to be satisfied than one who has unrealistic goals or is under the influence of false promises. Traditional operations such as facelifts and rhinoplasties have much cumulative surgeon experience and well-defined goals. Some less invasive procedures also have clear benefits for most patients. Much of the trumpeted technology of today, however, is not so clearly proven. Each patient has to decide: What are my goals? How much risk am I willing to take? How much money, time, and convenience am I willing to sacrifi ce on procedures, even those with low risks, which may yield “slight improvement” at best? Prospective cosmetic patients should remind themselves that most people would abandon a therapeutic medical treatment of a non–life-threatening condition, and maybe even dump their doctors, if they couldn’t expect better than slight improvement.

The purpose of a cosmetic intervention is to improve one’s body image by changing one’s appearance, yet good outcomes studies of the psychological benefits of cosmetic medical care have been few, especially those that look at patients long term or exclusively at patients who have undergone only minor procedures. Still, the studies that do exist suggest that after cosmetic surgery most patients are satisfied with the improvements in the appearance of the targeted body parts and would have the surgery again or recommend it to others. Interestingly, several recent studies have not been able to demonstrate improvements in patient self-esteem after cosmetic surgery, despite the long-held belief that low self-esteem is a legitimate justification for surgery.

Physical Results—Less May Be Better

Patients sometimes set goals and achieve physical results that perplex others. For example, some ignore the widely acknowledged principle that subtlety is important for an attractive result. We continue to see an array of really quite dreadful post–cosmetic treatment images coming out of Hollywood and elsewhere, and one can only assume that the patient got what she (or he) asked for. Nonetheless, most actors do not want to reveal their cosmetic interventions, and good surgeons who see large numbers of celebrity clients defi ne a good celebrity outcome as an unremarked one. In the opinion of one West Coast surgeon most actors, in contrast to East Coast consumers, actually prefer the stepwise, discreet approach to cosmetic procedures. “The funny thing is that everyone thinks Hollywood is ‘done’—Hollywood is undone. New York socialites look much more ‘done’ than Hollywood people because Hollywood people don’t want everyone talking about them.”

Major physical alterations can actually be troublesome for celebrities, models, and other prominent people, whose appearance so often defines their careers or status. Paradoxically, they may lose their appeal, especially if they have been made to look too “mainstream.” The actress Jennifer Grey famously couldn’t get work after her rhinoplasty. A celebrity may experience even stronger reactions from fans. The English actress Leslie Ash received so much hate mail after she underwent disfiguring collagen injections to her lips that she feared for her safety. Others celebrities (and this undoubtedly happens a lot) feel compelled to lie to the press about their wildly successful diet and exercise programs while concealing the fact of their liposuction. Some apparently convince themselves that they aren’t really lying, á la Bill Clinton. The Palm Springs reporters who interviewed a local socialite were told that people in that community don’t lie about having had cosmetic procedures, they just lose track: “When someone says ‘I haven’t had any work,’ maybe she means she hasn’t had any today.”

A common feature of many cosmetic procedures, even some surgeries, is that the results are temporary. Sometimes the duration of the desired effect is operator dependent; other times it is inherent in the treatment itself. Thus patients never have a final or even semipermanent outcome; they must choose whether to stay on or get off the merry-go-round of treatments and, in the case of fillers, the seesaw of overfilled, looks good, underfi lled, overfilled, looks good, underfilled (or the reverse sequence).

Even the results of major surgeries such as facelifts and eyelid lifts can be considered impermanent in that aging and exposure continue to affect skin quality. Still, the benefits of these invasive procedures persist for years, and the patient will never return exactly to his or her preoperative appearance.

Some things cannot be undone, however. Implants can be removed, but tissue that has been discarded cannot easily be replaced. For example, it is very diffi cult to rebuild a nose after reduction rhinoplasty; it is challenging to lower eyebrows that are too high, and it is generally impossible to restore hair growth to large hairless areas (for example, on a man’s face after laser hair removal). The majority of patients who undergo cosmetic procedures have satisfactory physical results and good outcomes. Unfortunately, some patients have terrible outcomes, yet no one knows the size of this group because many bad results go unreported. However, there have been increasing numbers of anecdotal reports of poor outcomes from surgeons seeing these unfortunate patients in second opinion consultations. Finally, there is always a group of patients who have acceptable outcomes in the eyes of their surgeons but who are dissatisfied with their results for a variety of reasons.

PATIENT SATISFACTION

The satisfied patient, of course, is the true holy grail of cosmetic medicine. Still, although the underlying goal of a cosmetic intervention is to bring happiness by altering the body, good doctors won’t promise happiness and patients with good results are not always satisfied. This dissatisfaction occurs despite the efforts most doctors make to “weed out” poor candidates. A study published in 2005 looked at patients from the practices of highly respected, boardcertified plastic surgeons. After one year only 64 percent were extremely satisfied with their outcomes, and at least 13 percent were not satisfi ed.5 Considering that a cosmetic intervention is entirely optional and is for the sole purpose of improving one’s appearance, a 13 percent dissatisfaction rate even in the best of hands is not to be taken lightly. One can easily imagine that dissatisfaction among patients undergoing surgery by practitioners who are less well trained and less experienced is probably much greater, and the disappointment quotient for patients undergoing all those low-risk but largely ineffec tive cosmetic medical treatments is undoubtedly quite signifi – cant. In fact, the level of satisfaction felt by the substantial numbers of patients that compose these latter groups is unmeasured, unreported, and unknown.

Discussing facelifts and eyelid surgery in The Patient and the Plastic Surgeon, Dr. Goldwyn wrote, “During the first visit I try to weed out the patients who cannot stand imperfection because, frankly, most patients . . . will have imperfections; the fl awless result is seen more often in slides at meetings and in articles in journals [not to mention in promotional materials for cosmetic surgeons and in the popular press—author] than in one’s own office.” Dr. Goldwyn’s comments could easily apply to most if not all cosmetic procedures and patients.

Although the physician and the patient may disagree about a result, the patient’s satisfaction is paramount. Most physicians subscribe to the philosophy, “If you are happy, I am happy.” Some patients are ultimately satisfied but have considerable diffi culty with the recuperation, despite the absence of complications. A patient is almost guaranteed to have a rough recovery if he or she
• Is intolerant of disorder, unpredictability, or disruptions of personal
routines;
• Has difficulty complying with rules;
• Cannot handle disapproval by family members and friends.
No one wants to go through a cosmetic procedure of any kind and
be dissatisfied with the outcome. Good advice for prospective patients
is simple:
• Have a clear idea of your goals.
• Find a reputable and qualified surgeon.
• If uncertain, choose less rather than more. It is always easier to
do more later than to re-create what has been removed.
• Understand that no physician can legitimately guarantee a result.
• Know that complications can occur.
• Do not undergo major surgery in the hope of radically altering
your life.
• Accept that after a surgical procedure you will have visible
scars.
• Understand that you may need further treatment in order to
improve your result.
• Accept that your final result will not be perfect.

The Dissatisfied Patient

Dissatisfaction after a cosmetic procedure can be related to poor physical results or to unanticipated psychological effects. Some patients hope for dramatic changes in their lives that do not materialize. Some expect to be awash in the attentions of fl attering admirers, and when this does not occur, they sink into depression. Others get attention that is unexpectedly negative. A person undergoing signifi – cant alteration of facial features, even major dental work, may look different in a way that can be disconcerting and even threatening to family and friends. Family tensions can develop when shared physical characteristics are altered by one member, and the patient may feel guilty or may even come to regret having undergone the change.

Patients themselves may be unable to adjust to major physical changes. In general, middle- aged and older adults have a harder time adapting to changes in identifying body contours—such as nose shape—and do better adapting to surgery designed to restore previous, more youthful adult contours (for example, facelifts and eyelid lifts). This is not to imply that a patient choosing to have a nose job at the age of forty-five is necessarily going to be unhappy with the result. Still, a forty-five-year-old will probably have a harder time adjusting to a new nose than would a twenty-year-old. Certainly, a forty- five-year-old who has hated her nose since she was sixteen is more likely to be satisfied than is a forty- five- year- old who developed dissatisfaction with her nose when she was forty-two. The latter patient is much more likely to be projecting her unhappiness with some other aspect of her life onto her previously innocent nose. Patient dissatisfaction after a cosmetic procedure is often not related to the occurrence of a serious complication but is the result of poor communication between an uninformed or unrealistic patient and the provider. Surgeons and psychiatrists have also identifi ed a long list of red flags signaling a high-risk potential patient, such as one who
• Tries to bypass a doctor’s appointment system in order to get an
earlier consultation appointment and is annoyed when a procedure
cannot be scheduled immediately;
• Tries to get overly chummy with the doctor’s staff and the doctor
before meeting them;
• Is unable to identify the “problem” or what he or she wants
done;
• Gives the provider carte blanche;
• Is extremely bothered by a feature that no one else can detect,
even when attention is brought to it;
• Has developed a recent dislike of a lifelong physical feature;
• Has not had prior treatment yet blames others for his or her appearance;
• Has decided before the consultation exactly what procedures
to undergo and does not want to hear about any alternatives;
What They Don’t Always Tell You 223
• Is counting on the procedure to expand his or her social circle,
lead to a relationship or job, or salvage a relationship;
• Wants to have a cosmetic procedure to please someone else;
• Wants to look like a certain celebrity, or any other individual;
• Expects not only to look younger but to feel younger;
• Has already seen multiple cosmetic providers, has had multiple
procedures, and can no longer obtain an appointment or get
calls returned from those other providers;
• Has scheduled and canceled a cosmetic procedure two or more
times for reasons other than illness or a true emergency;
• Gives a false medical history or lies about other personal information;
• Is in the midst of a life crisis;
• Has an unevaluated or untreated mental illness or substance
abuse problem and fails to reveal this information to the provider;
• Insists that the provider restrict the preoperative evaluation in
a way that impairs the formulation of a proper treatment plan;
• Is a perfectionist;
• Has seen three or more cosmetic providers for the same
problem;
• Is a cosmetic surgery addict;
• Is young and has already had multiple cosmetic operations;
• Is unhappy with the results of a previous cosmetic procedure,
especially if the new physician thinks the result is good;
• Wants a guarantee of results;
• Wants to have a procedure that another provider has deemed
unwise or unsafe;
224 t h e m a k e o v e r m y t h
• Tries to talk the provider into doing a procedure that the provider
does not enjoy doing or does not want to do on that patient;
• Dislikes, or is disliked by, the provider;
• Expects to be treated like a celebrity or “VIP”;
• Is not a celebrity but wants to have a highly covert procedure;
• Expects a great result because the provider’s fees are the highest
in town;
• Wants to undergo a cosmetic procedure despite strong disapproval
from significant others such as a spouse, immediate family,
and close friends;
• Lives out of town, wishes to undergo a major procedure, and
does not have a plan for follow- up;
• Is talked into undergoing a substantial appearance- altering
procedure that was not part of his or her original reason for
seeking consultation;
• Thinks that his or her current provider is the greatest and that
all the other providers in town are horrible.

Cosmetic Medical Care Risks, Complications, Outcomes, Satisfaction Rates, and the Dissatisfied Patient

Any patient undergoing a cosmetic procedure can develop a complication, and any person considering a cosmetic procedure must be willing to accept the possibility of a complication or a bad final result. With proper planning, however, the risks of either occurrence should be low. Most complications of properly performed cosmetic procedures are minor and can be managed without further surgery or hospitalization. This section will review the most common potential early complications, both local (that is, related to the procedure site itself) and systemic (affecting the body as a whole and which could develop after any major procedure performed with general anesthesia). I will also discuss late complications, which are significant problems that affect long-term results.

Complications are a double whammy for cosmetic medical patients because their occurrence risks deforming a normal body part, and their treatment may not be covered by regular health insurance. Prospective patients should check their insurance policies and may wish to consider purchasing separate complications insurance.

RISK FACTORS

The following are significant risk factors for the development of complications after any major surgery. All should be identified in advance, and most can be controlled or eliminated.

• Smoking. Smokers have a higher risk of complications after facelift and other surgeries where there is signifi cant disruption of tissue blood supply. Many surgeons will not perform any elective surgery on smokers. Smoking impairs healing, and these effects persist for a year after a smoker quits; therefore, a smoker contemplating elective surgery should quit smoking well in advance. Patients using nicotine patches to help them quit smoking also need to get off the patch before surgery because nicotine in any form constricts blood vessels and thereby prevents oxygen and other nutrients from getting to damaged tissues.

• Multiple procedures. Patients undergoing multiple simultaneous procedures are thought by many to be at increased risk for complications, although the studies on this issue have been inconclusive. What is certain is that adding procedures often increases anesthesia time, drug requirements (including local anesthetics), and blood loss, and may contribute to surgeon fatigue.

• Long anesthesia. Certain surgeries require a patient to be under general anesthesia for many hours. Aside from the possible risks associated with long operative sessions, a lengthy anesthesia often means that the patient will require a prolonged period in the recovery room and is unlikely to be ready for discharge until the next day. Patients contemplating such a scenario should be certain that they will be cared for in an appropriate facility until they are ready to go home. • Unrealistic expectations. Patients who have unrealistic expectations regarding the pro cess and results of a cosmetic intervention are guaranteed to experience distress and disappointment. In the short term unprepared patients can be emotionally undone by the pain, swelling, deformity, and incon venience. In the long term these same patients can be intolerant of inevitabilities such as scars, numbness, and imperfect results.

• Previous surgery. The most important reason to shop carefully for a cosmetic surgeon before having any surgical procedure is that the physician you choose has, during that fi rst operation, the best opportunity to provide you with a good result. All revision surgeries, whether or not performed by the original surgeon, are carried out on already damaged tissue, may take longer, may require more anesthesia, and may even cost more than the original operation.

• Body image problems. Body dysmorphic disorder (BDD), a body image problem that can cause severe anxiety or interfere with psychological or physical functioning, is estimated to occur in approximately 5 percent of the general population and is thought to be more prevalent in the group of people who seek cosmetic interventions. People with known BDD are clearly at high risk for dissatisfaction after cosmetic procedures, and most physicians try to identify and avoid performing cosmetic procedures on people with this condition.

COMPLICATIONS

Early Wound Complications

Infection

Wound

Any injection site or surgical incision can become infected. A wound infection is suspected in the presence of redness, swelling, increased pain, and sometimes pus draining from a portion of the incision. Wound infections are treated with antibiotics and sometimes with early suture removal. Redness and mild irritation confined to the area directly around stitches or staples usually represents a skin reaction to the suture material rather than infection. Antibiotic ointments sometimes cause redness and rash and may need to be discontinued or a substitute recommended.

Serious infections, although uncommon after cosmetic procedures, can be detrimental to the final result. Even minor infections can adversely affect the quality of the scar in the involved area.

Abscess

An abscess is a collection of infected fluid (pus) and dead tissue inside the surgery site. An abscess usually presents as an area of redness, swelling, and increased pain, and the patient often has a fever. Occasionally an abscess will drain spontaneously through an incision or elsewhere through the skin, but in most cases surgical drainage is required. Small, uncomplicated abscesses can be drained in the surgeon’s office; others entail more extensive surgery in the operating room under anesthesia. If an implant is present, it usually has to be removed. Deep abscesses are rare after cosmetic procedures but occasionally develop after breast surgery, abdominoplasties, and other body-contouring procedures. Regardless of how drainage is accomplished, in most cases the surgeon will also prescribe antibiotics to treat any remaining infection.

Generalized Skin Infection

Extensive skin redness, increasing swelling, increasing pain, and fever may indicate a serious infection of the entire surgical site and body part. This is an extremely rare but very serious problem and requires immediate evaluation by a physician.

Fat Necrosis

Fat tissue has poor blood supply compared with other body tissues, and the term “fat necrosis” describes fat that does not survive an injury. Fat necrosis is a partic ular problem after breast reduction and other body-contouring procedures, in which extensive incisions are made through fat. A patient with fat necrosis will develop symptoms resembling those of an abscess, including fever, pain, redness, and swelling at the surgical site. Antibiotics are usually prescribed in case infection is present. Drainage of an area of fat necrosis may also be necessary. Small areas of fat necrosis may never drain but instead leave firm areas that take months to soften.

Skin Separation

If skin incisions are closed under tension, the skin edges can separate (wound dehiscence) because of swelling that develops during the first few days after surgery. Draining infection, fluid and blood collections, and fat necrosis can also create openings in incisions. Small areas of wound separation can be managed with dressing changes and wound care; and the long-term effect on the scar may be minimal. Larger areas of separation are more likely to have a negative effect on the appearance of the final scar and may eventually require revisional surgery.

Skin Necrosis

Skin necrosis means failure of skin to survive because of poor blood supply or severe infection. Major skin loss is rare but not impossible after cosmetic surgery, especially after operations such as facelifts and major body-contouring procedures that require extensive elevation of large areas of skin. Factors that increase the risk of skin necrosis include a heavy smoking history or previous irradiation to the site (such as for acne or cancer), prior surgery at the same site, development of a large blood collection (hematoma) under the skin after surgery, and surgical technique.

Bleeding, Hematoma, Seroma, and Bruising

Excessive bleeding is not common after cosmetic surgery. If bleeding does occur, it may be the result of unsealed blood vessels or of a previously undiagnosed bleeding problem. Other patient risk factors include recent pregnancy, which particularly increases the blood supply of the breasts, and recent use of medications that interfere with blood clotting.

An occasional patient will develop a collection of blood under the skin called a hematoma. Untreated hematomas can lead to prolonged swelling, pain, firmness, and skin necrosis. Some patients develop seromas, which are collections of fluid (serum) that ooze from the cut surfaces inside the surgery site after the bleeding has stopped. Small hematomas and seromas are absorbed in time and do not require treatment. Larger hematomas and seromas require drainage, either in the office or in the operating room.

Bruising, although not a complication per se and to be expected after most invasive procedures, including injections, can be especially annoying for patients undergoing what they thought was a minor, “lunchtime” procedure.

Early Breast Complications

Nipple Loss

Nipple loss refers to failure of the nipple and areola to survive. Fortunately, complete nipple loss is a rare occurrence after cosmetic breast surgery.

Chest Cords

An occasional patient will develop a painful cord (superfi cial phlebitis) under the skin in her lower chest after breast surgery. This cord represents an inflamed, sometimes clotted vein. The cord may take weeks or months to resolve completely.

Milk Drainage

Women who were pregnant or have breast-fed within a year before breast surgery may have residual breast milk inside their milk ducts and may have milky drainage (galactorrhea) from the nipple or through the incisions for a short time after surgery. Rarely, a woman who has not been pregnant recently may have milk drainage and may require hormone evaluation.

Unanticipated Breast Cancer

Rarely is a breast cancer discovered during an elective breast operation. All women planning to undergo cosmetic breast surgery should have breast evaluation preoperatively. Complications of Injectables The risks and complications specific to Botox and filler injections are discussed under those subject headings later.

Systemic Complications

Anesthesia complications

When anesthetics are administered by qualified physicians or nurse anesthetists in accredited facilities, complications are uncommon and in healthy patients rare. In fact, properly performed anesthesia has become extremely safe in this country. Because of the inability to obtain accurate statistics about what happens in private offi ces, no one knows how many anesthesia-related complications have occurred that are related to the performance of cosmetic procedures. Nonetheless, there are many indications of an unacceptably high number of complications and deaths after cosmetic procedures and it appears that many of these adverse events may have been preventable. Complications can develop after the administration of topical, injected local, sedating, and general anesthetics. They range from the minor (for example, nausea or sore throat from the breathing tube) to the serious (for example, inadequate replacement of fl uid and blood loss, drug reaction, heart attack, or seizure) to the devastating (for example, stroke or death). Even topical and local anesthetics have killed people, usually as the result of unintentional overdosage.

Lungs

Atelectasis

Atelectasis refers to the collapse of small air sacs in the lungs and is fairly common in patients who undergo general anesthesia. Significant atelectasis can cause shortness of breath and fever. Atelectasis that persists can evolve into pneumonia.

Pneumonia

Untreated atelectasis or a preexisting respiratory problem can lead to a lung infection (pneumonia). Pneumonia is rare after cosmetic surgery.

Heart Problems

In healthy patients, cardiac complications during or after cosmetic procedures are rare but can occur as the result of inadequate fl uid replacement, drug reactions, or drug overdoses. Patients with known heart disease may need to be started on drugs called beta blockers before surgery and may need to undergo their procedures in a hospital.

Blood Clots

Deep Venous Thrombosis

A blood clot in a deep leg vein is a serious problem and is most likely to occur in patients who undergo long anesthetics or who have a prior history of deep venous thrombosis (DVT). Deep vein clots cause leg swelling, but more importantly, a clot can break off and lodge in the lungs (pulmonary embolism [PE]). The factors that increase a patient’s risk of DVT and pulmonary embolism are the use of contraceptives, hormone replacement, a family history of thrombosis or embolism, a genetic predisposition to blood-clotting disorders, and any preexisting swelling or other signs of poor vein function in the legs.

Pulmonary Embolism

Blood clots that pass through the heart and lodge in the blood vessels of the lungs are called pulmonary emboli. Pulmonary emboli can be fatal. Patients with a history of DVT or PE are at a higher risk for recurrence of these complications and require preventive measures when undergoing any type of major surgery. The treatment of DVT and PE usually includes blood thinners, but as a general rule patients who are on blood thinners should not undergo major elective surgery unless the blood thinners can be temporarily stopped.

Urinary Retention/Bladder Infection

Some patients have difficulty with bladder emptying or urinary tract infections after general anesthesia, especially if large volumes of intravenous fluids are given. Urinary retention may require bladder catheterization or medications. If a surgeon anticipates that surgery will take more than three hours, the patient may undergo insertion of a catheter at the beginning of the procedure. Urinary tract manipulation increases the risk of bladder infections, especially in women.

Late Complications

Problem Scars

The body heals all but the most superficial injuries by forming scar tissue. However, the scarring process is difficult to control, and scars can be of poor quality. In the absence of a complication, the quality of scarring is almost entirely a function of the patient’s genetic tendencies and the location on the body of the incisions. Existing scars are the best predictors of future scar quality.

Some patients form scars that remain red, raised, and painful for months or years. These hypertrophic scars are most common in young, often fair-skinned patients. However, they can occur in patients of all ages and skin types. Hypertrophic scars usually improve in time but may require treatment. Unfortunately, treatments are not always effective. Surgical revision alone is rarely helpful. Other treatment options include locally injected steroid medication, steroid tape or cream, silicone sheeting, pressure garments, laser treatments, and radiotherapy.

Keloids are thick, cauliflower-like scars that grow beyond the borders of the original incision. Keloids can be considered scars in which the switch that starts the pro cess of scar formation is stuck in the “on” position. Keloid scars are a concern for all patients but more so for people of color. They are more common in younger patients, and the propensity to form keloids tends to run in families. Keloids are related to but are not the same as the more common hypertrophic scars. Both types of scars may be painful or itch. Keloids are difficult to treat and may be impossible to control. True keloids cannot be treated with surgery alone because they may recur in a more severe form. Injected steroids and/or radiation therapy may be helpful alone or in combination with surgical excision. Fortunately, keloids rarely develop after cosmetic procedures, with the notable exception of ear piercing.

Skin pigment alterations

Permanent alteration of skin color can occur after many cosmetic procedures. Procedures causing inflammation, such as sclerotherapy of veins and injections of certain soft-tissue fillers, and any infection involving the skin can leave in localized darkening of the skin. Deep chemical peels and ablative laser treatments can cause permanent loss of skin color. Scars after surgery are always a different color than the surrounding skin, regardless of the patient’s skin type. Pigment loss is a partic ular concern to people of color..

Numbness

When you sense your body, you include a certain amount of space around it. Researchers call this the “buffer zone.” Numbness of a body part after surgery changes the contours of the buffer zone and can cause psychological discomfort until the numbness resolves. Permanent numbness can be especially troubling until the patient’s body image adjusts. Facelifts and brow lifts are particularly prone to causing bothersome numbness.

Contour Problems and Asymmetries

No surgeon can guarantee perfect symmetry or a partic ular contour. Most people have some degree of body asymmetry that might become more noticeable after a cosmetic procedure. Mild asymmetries caused by cosmetic surgery are common and should not be considered complications. If there are technical problems during a procedure or if a patient develops a major complication, there may be a more significant permanent discrepancy in the shape, size, or position of mirror image body structures. Further surgery will likely be required to correct this type of problem.

Need for Further Surgery

There are two time periods after a major cosmetic operation when a patient might need more surgery. First, additional surgery may be required in the early healing phase if, for example, an implant is improperly positioned or if the patient develops a major complication, such as significant bleeding, severe localized infection, major fat necrosis, or skin loss. Second, a problem may become evident after the initial recovery period that significantly compromises the aesthetic goal. For example, a patient may have significant asymmetry, a positioning deformity (for example, a nipple that is too high), a shifted or failed implant, incomplete or overcorrection of a contour, or some other failure to meet the goal. In those circumstances secondary surgeries may have to be delayed for months until initial healing is complete, scars have matured, and the final nature of the problem assessed.

Secondary procedures may be performed under local anesthesia or may require another general anesthesia. Health insurance may not cover any procedures, even if they are needed to treat complications. The success of additional treatment will be severely compromised in situations where the patient and surgeon cannot agree on an attainable goal.

In some cases, treatment of an undesirable result requires surgery that is more extensive than the original procedure. For example, an overly aggressive rhinoplasty that leads to collapse of the nose may require extensive bone and/or cartilage grafting to correct. If a patient undergoing breast reduction surgery develops signifi cant fat necrosis, she might need an implant to correct the resulting breast deformity and asymmetry. If her nipples have been positioned too high, corrective surgery may leave vertical scars on her upper breast above her areolae. Revisional surgery can also be much more diffi – cult technically than was the original procedure, and not all surgeons are experienced with the extraordinary surgery sometimes needed for a successful major revision.

The acids most commonly used for peels are (in approximate order of intensity) alpha hydroxy acids (AHA) such as glycolic acid, lactic acid, and fruit acids; beta hydroxyl acids; vitamin A (tretinoin); trichloroacetic acid (TCA); and phenol. All acids can be used diluted or full strength, depending on the patient’s skin type and the goals of treatment.

Before undergoing certain types of chemical peeling, patients may be required to pretreat their skin at home with a topical medication like Retin-A. Lighter chemical peels (AHA peels) are performed in an office setting without anesthesia. The chemical solution is painted on the skin, and the patient may experience a mild burning sensation and slight, temporary redness. Patients can resume normal activities immediately, as long as they use sun protection. TCA peels may cause a more intense reaction, especially in higher concentrations, and the patient will have some activity restrictions for a few days.

Deep (phenol) peels are generally reserved for more severely wrinkled and sun-damaged skin and are not for the fainthearted. Phenol is an especially powerful and potentially dangerous chemical and is toxic to the heart if excessively absorbed. Phenol peels should only be performed by an experienced, qualified physician in a controlled environment in which the patient has cardiac monitoring by appropriate personnel. Phenol creates a significant burn. After a phenol peel the patient may experience severe swelling and may have to avoid talking and solid foods for several days. The crust that forms after a phenol peel must be kept soft with ointments and may take several days or weeks to come off entirely. Complete healing may take as long as a month, and patients may have their activities significantly curtailed during that time. Phenol peels are rarely performed these days. Incredibly, some states allow nonphysicians to administer any type of peel, including full-strength phenol peels. Common side effects of chemical peeling are visual skin pore enlargement and blotchy pigmentation after sun exposure. Patients are strongly encouraged to use high SPF sunscreen after any type of peeling. After a phenol peel some degree of permanent skin bleaching is virtually guaranteed, and blotchy pigment irregularities may persist, especially if isolated sections of the face were treated. Infection and scarring are potential complications after chemical peels, especially medium and deep peels.

The bottom line: Chemical peels can help improve the appearance of the skin of properly selected patients. The milder peels are safer, even though multiple sessions may be necessary for a good result. Deep wrinkling requires a deeper peel, but the risks are significant. Because the results of chemical peeling are so operator dependent, the stronger chemicals are highly likely to lead to complications when improperly used. Because peels may be offered in salons and medical spas, a patient should be very careful when selecting a provider for a chemical peel.

Dermabrasion and Microdermabrasion

Dermabrasion has been used by cosmetic surgeons for decades to help smooth irregular skin surfaces, especially those affected by burns and acne. These mechanical methods of skin resurfacing can be alternatives for patients who are not candidates for chemical peels. The tool used for traditional dermabrasion resembles a small drill with a sanding bit or wire brush. Dermaplaning is a similar procedure in which the skin is shaved rather than sanded. Many physicians feel that traditional dermabrasion is overrated. It can yield some improvement of surface irregularities but almost never to the degree that the patient wants. Dermabrasion has been largely replaced by laser resurfacing, although it still has a role in treating acne scars.

Modern technology has provided a method of “dermabrasion lite” called microdermabrasion. This technology, widely available in salons, uses tiny crystals to sandblast the surface of the skin, knocking off the dead cells and leaving the skin with an appearance very much like that of a good facial. Microdermabrasion of your face is like buffing your car: You look great afterward, but the effect is short-lived.

Laser Resurfacing and Photorejuvenation

Photorejuvenation is one of the newest entries on the list of words that have been invented to describe new technological applications. It refers to light-based treatments designed to improve the appearance of the skin. There are two types of light technology, lasers and intensed pulsed light (IPL) sources. Lasers emit tremendously magnified light in a single or narrow band wavelength, and different lasers do different things to skin. Intense pulsed light (IPL) is also magnified light but uses a much broader portion of the spectrum. IPL is promoted for many of the same indications as are lasers. IPL is also used to treat sun damage and skin cancers as part of a process called photodynamic therapy. Magnified light sources are frequently used in the treatment of both cosmetic and medical skin conditions. Photorejuvenation technology has been further classified into two categories according to the goals of treatment. Some machines are designed to treat skin discoloration; others are engineered to target skin structures in an effort to improve skin texture. Very broadly, this translates to mean that various light sources are used to treat brown spots, red spots, and wrinkles. Every laser or light source has its advantages and disadvantages—things it does well and things it does poorly.

Laser and light treatments are considered ablative or nonablative, depending on how much damage the skin sustains during treatment. Ablative treatments are those causing significant burns that require long healing times; these carry more risks, yet generally yield better and longer lasting results. Most ablative lasers can be “dialed down” to nonablative settings, but results are less impressive.

Ablative laser resurfacing can be performed with numerous lasers, including a specialized carbon dioxide (CO2) laser, an erbium: YAG laser, and several new lasers such as the Fraxel. The fi rst surge of interest in laser resurfacing occurred a decade ago when the specialized CO2 lasers came on the market. However, it soon became evident that high doses of laser energy were required for good effect and that those high energy levels were yielding a significant rate of complications such as permanent skin pigment alterations and scarring. Even so, some surgeons prefer ablative lasers for treating wrinkles around the mouth and eyelids.

Fraxel is the proprietary name of a laser manufactured by Reliant Technologies that uses a mechanism of action dubbed fractional photothermolysis. The advantage of this partic ular laser technology is reported to be its ability to treat many of the manifestations of photoaging, including wrinkles, fine lines, and pigment irregularities, better than nonablative laser treatments but without the prolonged healing time of ablative treatments. To date very few studies on the effectiveness of fractional photothermolysis technology have been completed, so although the concept is promising, the value of this type of laser is too early to call. So far it appears that multiple treatments at significant cost will be required for visible effect. If this laser proves successful, we can look forward to a fl urry of “fractionating” and “fractional” technologies that may or may not have equivalent benefits.

Recovery after ablative laser resurfacing can be quite prolonged, much like that after a phenol peel. Depending on the technique used, skin healing may take weeks, during which time the patient may experience significant pain and swelling. The skin will remain red for weeks, pink for even longer. Some physicians cover the treated skin with dressings for much of the healing phase; others require the patient to apply thick layers of ointment regularly. The pendulum swings back and forth between chemical peels and laser treatments as the preferred method of skin rejuvenation. An individual provider’s recommendation will be driven by his or her experience, comfort level, and available technology.

The bottom line: The usefulness of laser rejuvenation/resurfacing depends mainly on the willingness of the patient to accept the significant downtime and risks that accompany ablative treatments. Lesser procedures have significantly lower cost/benefit ratios.

Radio Wave Treatments

Several radio frequency devices (Thermage, Thermacool, Aluma) have been approved by the FDA for treatment of facial wrinkles. In some devices, a vacuum is applied to the skin in conjunction with the radio waves. Treatments can be prolonged and painful, multiple treatments over a period of months are required, and improvement may be less impressive than is generally seen with other options. Treatment costs are very high—several thousand dollars per treatment—and numerous anecdotal reports question their cost/ benefit ratio. Physicians did not develop a standardized protocol for radio frequency treatments until the spring of 2005, which means that useful statistics regarding safety and long-term effi cacy will not be available for some time.

Nitrogen Plasma

Another evolving rejuvenation technique, nitrogen plasma treatment, consists of energy delivered to the skin by way of ionized nitrogen gas pulses. One machine, the Portrait PSR3, is on the market. Nitrogen plasma treatments can be ablative or nonablative and are moderately painful. As with other options, a series of nonablative treatments must be performed to achieve the desired effect. Longterm benefits or advantages of this technique over other treatments have not been proven. Other Skin and Hair Procedures

Hair Transplantation

Both men and women can suffer from hair loss, although women tend to have more diffuse and subtle loss than men. Hair replacement surgery is performed mainly on men and is discussed in Chapter Ten.

Laser Hair Removal

Permanent hair removal has become very popular since the development of technology that permits effective hair reduction with limited risks to skin. The technology uses laser energy, IPL, or other energy sources such as microwaves. Laser hair removal is performed in an office or spa setting, usually without anesthesia. Multiple treatments are required and are spaced several months apart. Patients may develop redness or crusting that may take several days to resolve. The degree of permanent hair reduction varies considerably from patient to patient, depending on skin and hair color and body location. Light colored hair cannot be significantly reduced with current technology.

Laser hair removal is moderately painful. Some patients elect to use prescription or over-the-counter topical creams containing lidocaine or a related anesthetic in order to reduce the discomfort of treatments. Major complications of laser hair removal include scarring, permanent skin color changes, and topical anesthetic overdose. The bottom line: Laser hair removal can lead to permanent reduction of coarse dark hair, although multiple treatments are always necessary. Laser hair removal is one of the common cosmetic procedures performed without direct physician supervision, despite risks of serious or even fatal complications.

Skin Pigment Correction

Patients with skin pigment problems may have areas of too much color (hyperpigmentation) or too little color (hypopigmentation). Birthmarks, moles, sun damage, and tattoos are a few of the most common causes of undesirable skin pigment. Pigment irregularities are a well-known potential complication after all forms of skin resurfacing and laser treatments, especially with any subsequent ultraviolet light exposure. Treatment options for hyperpigmentation include topical bleaching agents, surgical excision, laser treatments, and chemical peels, but each condition requires a correct diagnosis before an appropriate treatment plan can be developed. Lasers might seem like the perfect tool for pigment reduction, but in fact, most lasers have limited usefulness because their effects are either too specific or too broad. Unwanted pigment is often present in more than one skin layer; narrow target lasers miss some pigment and broadly destructive lasers are too likely to cause scarring. Therefore, although many pigment conditions require more than one type of laser for maximal eradication, most physicians do not have the luxury of access to a large variety of lasers.

When considering treatment of a pigmented lesion, patients should know that (1) lesions with any potential for malignancy should be removed intact and examined under a microscope; laser or other destructive treatment of many moles is not appropriate for this reason. (2) Resurfacing procedures may help reduce the extent of many types of hyperpigmentation, but the risks of creating new pigment irregularities are increased in darker skin types. (3) Complete removal of undesirable pigment in biological lesions and tattoos is often impossible, and the resulting blotchiness or blurred image may not be an aesthetic improvement over the original condition. (4) Regardless of treatment, recurrence of biological hyperpigmentation is common, especially in patients with sun damage who are not willing to be compulsive about protection from the sun.

Too little skin pigment (hypopigmentation) can be congenital (vitiligo) or related to injury, even in the absence of scarring. There is no good treatment for loss of skin pigment. Tattooing rarely leads to a natural result. Makeup is usually the best, albeit temporary, treatment.

Scar Revision

Scar revision is by definition a reconstructive procedure but is often not covered by insurance. Scars can rarely be eliminated but often can be improved. The choice of treatment depends on the nature and location of the scar; options include surgical revision, resurfacing procedures, filler injections, laser treatments to diminish redness, and steroid injections. A combination of surgical and nonsurgical treatments may work best, and treatments may have to be repeated.

Stretch Marks Treatment

Stretch marks (striae) result from the degradation of skin structures and often develop as the result of hormone influences. They are a cosmetic concern for many people, but for all practical purposes they are permanent. Numerous treatments have been reported to eliminate stretch marks, but there is very little scientific evidence as to the effectiveness of these treatments, and almost no studies comparing the relative efficacy of different treatment modalities and combinations. Reported treatments include the use of various types of lasers, topical vitamin A derivatives, microdermabrasion with and without ultrasound, and sonophoresis. Some treatments do reduce the visibility of red stretch marks, especially in light skin, but improvement is usually limited to appearances with no actual change in the skin structure. Mature (flat and faded) stretch marks are less likely to respond to any form of treatment. Treatment options are especially limited for darker skin types.

The bottom line: Under the best of circumstances multiple treatments over several months may yield slight to moderate improvement in the appearance of stretch marks in carefully selected patients, and continued maintenance treatments will likely be required.

Micropigmentation

“Micropigmentation” is the medical term for tattooing. Tattooing has an important place in reconstructive plastic surgery, most commonly as a component of nipple reconstruction after breast cancer surgery. As a cosmetic procedure, micropigmentation refers to the instillation of pigments as permanent makeup.

Micropigmentation is an offi ce procedure and may be performed by a nonphysician. Two or more procedures may be required to achieve the desired effect. Pigments must be approved by the FDA, occasionally cause allergic reactions, and can interfere with magnetic resonance imaging scans. The most common complications of medical tattooing are those related to operator error. Poor placement, excess or insufficient instillation, pigment spread, scarring, or permanent local hair loss can occur if the procedure is improperly performed. Unfortunately, many women underwent permanent eyeliner tattooing in the 1980s by physicians who did not have a clue where to apply makeup and who had received very little training in the design aspects of cosmetics application when they purchased their machines.

Like all tattooing, micropigmentation should be considered permanent. In some cases laser treatments may be the only option for tattoo removal, and the laser energy itself may damage hair follicles or may not succeed in removing all of the pigment.

Destruction of Skin Blood Vessels

Prominent skin blood vessels that are treated for cosmetic reasons fall into two main categories: small vessels (telangiectasias) and angiomas, mainly of concern on the face, and leg veins. Large leg veins are treated primarily by vascular surgeons. Smaller veins are treated by a variety of cosmetic medical providers using the methods described below. Port wine stains are red or purple birthmarks that often can be, at least partially, ablated with the same lasers that are used for small blood vessels. Treatment of port wine stains, particularly in children, may be covered by insurance.

Vascular Lasers

Lasers are now the gold standard for treatment of undesirable small skin blood vessel lesions and have replaced the old technique of cauterization. Facial spider veins (telangiectasias) are especially common in fair, sun-damaged skin and are usually treated with a laser and without anesthesia in an office or outpatient surgery facility. The pulsed dye laser is the type of laser most commonly used. Multiple sessions are almost always required, and although treatments can be performed without causing bruising, power settings that do lead to bruising usually result in faster clearing of the blood vessels. Bruising usually takes two weeks to resolve and some residual brown discoloration will take another two weeks or more to disappear. Swelling is common when large areas are treated, especially near the eyes. Scabbing can occur with high power settings and may take days or weeks to resolve. Scarring is rare but not impossible, and permanent changes in skin pigmentation may develop, especially in patients with darker skin. Laser destruction of facial blood vessels is permanent in that totally closed vessels usually do not reopen. However, the eventual development of new telangiectasias is virtually guaranteed in susceptible skin. Angiomas are the bright red, well-defined bumps often seen on the chest and abdomen. Angiomas can be effectively destroyed with lasers.

Spider veins of the legs, in contrast to those on the face, are best treated with a combination of therapies. Even small superfi cial leg vessels have a high rate of reappearance after laser treatment alone. Therefore, leg vein therapy usually must include surgical treatment of related varicose veins followed by sclerotherapy (see the following section) of all but the smallest vessels. Laser treatment is reserved as the last step of the leg vein treatment program. As with sclerotherapy, laser treatment of leg veins can lead to permanent hyperpigmentation.

Sclerotherapy

Sclerotherapy refers to the injection of an irritating substance through a small needle into a blood vessel for the purpose of causing that vessel to close and thereby become invisible. Sclerotherapy was invented decades ago in order to treat small leg veins and is sometimes used on other parts of the body, including the face and hands. Various solutions are used for injection; Sotradecol is one of the most common. Injections are performed in the office, usually without anesthesia. Multiple injections over multiple office visits is the rule, especially for leg veins. Patients undergoing leg vein injection may The Cosmetic Medical Care Product Line 195 be required to wear heavy elastic stockings for a week or more after each injection.

Sclerotherapy is generally safe, but the main undesirable side effect is permanently increased pigmentation of the skin at the vein site, especially on legs. Skin breakdown over the injected vein can also occur, which is likely to lead to scarring and pigment irregularities.

Drug Delivery Systems

Numerous pro cesses (and gimmicks) have been described that purportedly help the skin absorb skin-care products, chemicals, and drugs. You may hear about things that vibrate, stimulate, conduct, infuse, hydrate, abrade, nourish, massage, and suction in conjunction with the topical application (not injection) of substances into the skin. The implication is that by forcing the substance into the skin, a beneficial response will be seen. Although much of what is claimed about the effects on skin by chemicals delivered by these methods has no basis in science, there is some evidence that select technologies may enhance the transdermal delivery of certain kinds of molecules. For example, in sonophoresis, low-intensity ultrasound is used to facilitate the transport through skin of topically applied drugs. Recent studies have looked at the delivery of various topicals by way of sonophoresis after the skin’s barrier layer has been disrupted by microdermabrasion. The effectiveness of this technique for the purposes of skin rejuvenation is yet to be proven. A Few More Words about Lasers in Cosmetic Medicine Most people have a somewhat fantastical vision as to what lasers can do. In fact a laser is simply another tool that a surgeon may use. Certain procedures are performed far more effectively with a laser than with any alternative: Hair removal and destruction of spider veins on the face are good examples of this. Other lasers provide an alternative among several for surgeons who are trained in both laser and other techniques. Procedures will nearly always be priced higher than the alternatives if the cost of a laser must be covered.

In general the following information applies to most laser treatments:

• Despite what sales reps and some providers would like you and your surgeon to believe, a laser has not been invented that treats all conditions well. • Long-term comparative studies of the effectiveness of cosmetic lasers are virtually nonexistent. • Laser treatments can be painful. Many lasers are equipped with some type of cooling mechanism to help reduce discomfort. Some type of anesthesia, ranging from topical creams to general anesthesia, may be necessary in some circumstances. • Regardless of the condition being treated, multiple laser treatments are almost always required for substantial benefi t. • Laser treatments to the face tend to cause Herpes simplex outbreaks in susceptible patients who are not pretreated with antiviral drugs.

Dental Cosmetic

Cosmetic dental work has become very popular and can be just as expensive as major cosmetic surgery. Certainly, the smile makeover is a big component of Extreme Makeover and similar television shows. Not a few patients on those shows have undergone dental procedures that appear to have been chosen in lieu of more complex and time-consuming, although arguably more appropriate, surgical treatment. Like cosmetic medicine, cosmetic dentistry is big business. Well-known entrepreneurs like Dr. Bill Dickerson have established institutes and give motivational speeches and marketing advice for dentists looking to expand their cosmetic practices.

No one is sure how many cosmetic dental procedures are performed annually in the United States. Since 1996, the American Academy of Cosmetic Dentistry has doubled its ranks to about 4,700 members. Cosmetic dentistry is not a separate subspecialty of dentistry, and most dentists incorporate at least some cosmetic procedures into their practices. Dentists aiming for high-volume cosmetic practices may invest heavily in advertising and may use tools like computer imaging to help sell restoration work. Cosmetic dentistry is rarely covered by insurance, and the cost of some procedures can easily exceed $1,000 per tooth.

As with cosmetic medicine the current popularity of cosmetic dentistry is in part related to recent improvement in materials and technology. For example, the newer composite resins and cements allow better color matching and color stability and permit repairs that in the past would have required major crown work. Common cosmetic dental procedures include the following: • Bleaching for stained or discolored teeth • Tooth- colored composite fillings for chips, cracks, small gaps, and rough areas • Recontouring for uneven teeth • Porcelain veneers for large gaps or extensive imperfections • Tooth-colored porcelain crowns for more severe irregularities • Orthodontia (braces) for tooth straightening Just as with cosmetic medicine, there is often more than one dental option to correct a partic ular problem. Some options are quite time consuming but may be preferred because they offer a better or sturdier long-term result. Potential patients are advised to research their options. Even more important, patients should think long and hard about how much permanent change in their appearance they are willing to make. Look at the contestants on cosmetic surgery reality shows carefully; chances are you will understand why some pundits call those expensive porcelain veneers “Chiclet teeth.” Alternatives abound in the marketplace for those who have less money to invest: A row of removable prosthetic “false veneers,” custom-made to hook over your existing teeth, can be purchased for “only” $2,000 to $3,000.

Skin Care and Products

Providers often advise patients to use topical products at home as part of a rejuvenation regimen. The chemicals in these creams fall into several main categories: vitamin A derivatives (retinoic acid, tretinoin, retinol, tazarotene); diluted glycolics (acid peel chemicals); sunscreens; bleach (hydroquinones); copper peptide formulations; moisturizers; and various other “enhancements” (for example, vitamin C, vitamin E).

The popularity of noninvasive prescriptive skin treatments has provided a huge boost for over-the-counter skin-care and cosmetics manufacturers. Many of the same chemicals prescribed by cosmetic surgeons and dermatologists are available in a diluted form and incorporated into products found on the shelves of grocery stores, department stores, drugstores, and salons. Marketing rhetoric for these products typically includes references to more invasive cosmetic interventions. “If you think cosmetic procedures are too drastic, do we have an alternative for you” is the tagline for one Olay product. Another claims to provide microdermabrasion and chemical peel all in one package. Some over-the-counter lines of skin cleansers, moisturizers, and cosmetics are sold only by physicians, ostensibly so that patients will get better information about their use but also because they can be retailed at a much higher price that way.

Consumers are interested in “natural” products, and advertising usually emphasizes bio-ingredients such as collagen and plant extracts. Some of these ingredients have been used for centuries in folk remedies and in some cases do have active biological properties. However, there is little to no scientific evidence from clinical trials that these ingredients are safe or effective or that they even penetrate beyond the skin’s surface layer of dead cells.

Over-the-counter products containing both drugs and cosmetics, herbs (previously called botanicals), or “nutrients” are called “cosmeceuticals,” “herbaceuticals,” and “nutraceuticals,” although these words are not recognized by the FDA as categories. The FDA does require that substances containing both cosmetics and drugs meet the standards for both categories.

Skin care is the subject for an entire book of its own, and there may be more useful scientific knowledge about various ingredients in the future (keeping in mind that relevant controlled clinical studies are rarely performed in the cosmetics and skin-care industry). Still, a few comments are in order about nonprescription products:

• Skin cleansers and moisturizers. These products should be expected to do just what their labels say: clean the skin and add moisture/slow moisture loss. Use what you like; the ingredients are irrelevant except for sunblock. Having said that, waterbased products provide less moisturizing than do oil-based products.

• Sunscreens. Sunblock is essential, and a product containing a sunblock should be worn daily, at least on the face, and reapplied frequently. Some moisturizers contain sunblocking agents but if yours does not, you should apply a sunblock before you apply moisturizer. Look for a sunblock with SPF 30 or higher. Protection against both UVA and UVB is essential, since both wavelengths are damaging. Unfortunately, sunblocks currently available in the United States do not have good UVA protection, even though effective products for that purpose are available in other countries. The reason is that products containing sunscreens are considered drugs by the FDA and must go through the expensive premarket testing pro cess and get FDA approval before they can be sold. One well-regarded and reportedly very effective product, Mexoryl, was submitted by its manufacturer L’Oréal to the FDA for approval in 2001 but is still not available legally in the U.S.

• Tanning products: Some tanning agents are probably safe and some are known to be dangerous. In summary:

• DHA-based topicals. This is the only sunless tanning product approved by the FDA and is for external use only. The active ingredient, dihydroxyacetone, causes the outermost cells of the skin to turn brown the same way that certain sugar-containing foods turn brown in storage. This is the ingredient found in salon or home spray-on tanning products. DHA is not a sunscreen and should not be used as such.

• Bronzing gels. These are the dyes found in many cosmetic products that coat the skin with color.

• Tan accelerators and tan promoters. Some of these products contain tyrosine and theoretically can increase melanin (natural skin pigment) production, although this has not been proven. Others are based on bergapten (5-methoxypsoralen, 5-MOP), which is found in bergamot oil. Bergapten increases the skin’s sensitivity to ultraviolet light, intensifi es skin redness, and stimulates skin cells to produce melanin. It is also phototoxic and photocarcinogenic. The FDA considers all of these products to be unapproved drugs and has issued warning letters to manufacturers.

• Tanning pills. Most of these contain the color additives betacarotene and canthaxanthin. After ingestion these substances enter the blood stream and are partially deposited in skin tissue, giving the skin an orange-brown color. Neither color additive is approved by the FDA for this partic ular purpose, and products containing them are considered adulterated. Adverse reactions reported with tanning pills include stomach cramps, hepatitis, nausea, diarrhea, hives, aplastic anemia, and deposition of color in the retina of the eye.

• Antiwrinkle creams. These products come in many formulations, but the two active ingredients with which there is the most experience are the retinols and the AHAs (glycolic acids, lactic acid, and so on). The concentration of these ingredients is far less than that available in the corresponding prescriptiononly retinoids (Retin-A and Renova) and AHA peel solutions. These products will act like exfoliants and may make wrinkles appear less prominent, but there is little evidence that they have a significant long- term effect on skin. Formulations containing copper peptides may have a similar effect.

• Lip “plumpers”: Topical lip plumpers contain either an irritant that causes swelling or absorptive microspheres that fi ll in grooves. Both types of products temporarily (for hours or days) may make lips appear marginally fuller. Individuals prone to Herpes simplex outbreaks might do well to avoid substances that irritate the lips.

• Numerous other ingredients, such as growth factors, vitamin E, vitamin C, omega-3 fatty acids, other antioxidants like idebenone, and collagen, are hyped during product promotion. Some, such as argerilene and acetyl hexapeptide-3, are supposed to act like Botox without the need for injection. In their present formulations there is no evidence that these ingredients can penetrate the skin for benefi cial effects.

When evaluating any skin product, keep in mind that intact skin is supposed to act as a protective barrier, and effective transdermal (through the skin) delivery of a product or medication requires it to be in a highly concentrated form. Sometimes no tests at all have been performed on human skin using the final product, that is, after the hyped “active ingredient” has been added. Whether or not a chemical is a potent antioxidant, for example, is irrelevant if the chemical is deactivated the minute it sees light or air or if it cannot penetrate the skin’s surface.

COSMETIC MEDICAL GRAB BAG

The “We Just Don’t Know” Category Nearly everything on the cosmetics and skin-care shelf, as well as many supplements and not to mention most new technology, belongs in the “Who knows?” category. The difficulty lies in sorting out the science from the sales pitch, and most of the time there just isn’t any science to sort. Instead, we get verbiage like this: “Unique, patented formula of proven ingredients helps stimulate (skin, cells, collagen, metabolism, per for mance) and reduce the appearance of (wrinkles, fine lines, aging, sun damage).” This doesn’t actually mean anything from a scientific analysis viewpoint, but it sounds impressive, doesn’t it?

A few ingredients in this category have received quite a bit of press recently:

• Kinetin

• Peptides

• DHEA (dehydroepiandrosterone)

• Genetics- based custom topicals

The “We Don’t Know AND It Could Be Dangerous” Category

• Growth hormone. Human growth hormone sales represent a growing segment of the antiaging market, despite the fact that there is no scientific evidence that declining growth hormone levels cause aging or that taking growth hormone supplements can stop or reverse the signs of aging. In fact, animal studies suggest the opposite. More important, many patients taking growth hormone have suffered significant side effects, including behavioral changes, and users may be at increased risk for cancer and cardiovascular disease. There are only two strictly defined conditions in adults for which the FDA has approved growth hormone treatment, and all off-label uses (including athletic enhancement, antiaging, and age-related conditions) are illegal. This stands in marked contrast to many other drugs for which off-label use is permitted in appropriate circumstances.

• Breast-enhancing pills. Several dozen herbal products are advertised widely as “natural” breast-enhancing substances. However, there is no scientific data to support these claims, and risks, including adverse interactions between these herbals and other medications, are a major concern.

• Melatonin. Melatonin is a brain hormone that can be useful in the treatment of jet lag and sleep disturbances in people who The Cosmetic Medical Care Product Line 203 work night shifts. Some purveyors of antiaging treatments claim that melatonin provides, among other things, broad anti-oxidant and immune system benefits. In fact there is no science to support these claims, and no one knows if the long term use of melatonin for any purpose is effective or safe. Like many other products sold over-the-counter, melatonin is unregulated, and the concentration or even presence of melatonin in a product labeled as such should not be assumed.

The “Too Good to Be True” Category

• Facelift creams. Here is a great example of over-the-top marketing. A facelift cream is promoted as containing DMAE (2- dimethylaminoethanol). This chemical has been called a smart drug because it has led to a slightly longer life span in laboratory animals. So the ads for the facelift cream call the ingredient a “life-enhancing substance.” Impressive, but meaningless for humans.

• Facial muscle stimulators that substitute for a facelift.

• Light “wands” that presumably work like IPLs or lasers.

• At-home lasers that can eliminate skin problems.

• Body-shaper creams. I love the ad copy for these: “The at-home alternative to liposuction.” “Proven to tuck the tummy and lift the rear in four weeks.” This company offered a money- back guarantee—at two weeks.

• Creams to get rid of stretch marks or cellulite.

• Topical creams that substitute for collagen injections, Botox, and so on. These creams often contain ingredients that just happen to have trade names very similar to those of the items whose effects they purport to mimic.

Breast lift (mastopexy) is an operation in which excessive breast skin is removed and the breast reshaped to look more youthful. In many cases the nipple is repositioned higher on the breast. After mastopexy, breast volume will be slightly reduced unless an implant is inserted. An implant may be recommended to enhance not only breast size but nipple position and breast contour. Mastopexy scars are visible around the nipple-areola complex and may extend down to and within the crease under the breast. Breast lift is performed with the patient asleep or heavily sedated.

Major complications after breast lift surgery without implants are uncommon. Smokers have a higher risk of healing problems. Asymmetries of nipple position and breast shape can occur, as can nipple numbness or poor quality scars. Continued sagging due to gravity always occurs; larger-breasted women and those with inelastic skin will experience recurrent sagging more quickly. Women who become pregnant or experience significant weight change will have permanent alteration of their breast shape.

Patients can expect moderate discomfort, swelling, and bruising for a week or two after surgery and will have some activity restrictions for about four weeks. Breast shape will be irregular and scars will be tight and firm for six months or longer after breast lift surgery. The bottom line: Breast lift without implants is a relatively lowrisk operation but achieves improved breast shape at the price of visible scars. As a general rule the benefits of breast lift last longer in small-breasted women. If implants are to be added, the risks associated with breast augmentation apply, and the disruption of skin blood supply inherent in a mastopexy makes it especially important that the patient avoid requesting excessively large implants.

Breast Reduction

Breast reduction (reduction mammaplasty) is an operation in which the breast is reshaped, repositioned, and made smaller. If the procedure does not intend to achieve significant volume reduction, it is more appropriately called a mastopexy (see Breast Lift). Breast reduction surgery is one of the most commonly performed major plastic surgery operations in the “reconstructive” category, meaning that it is often performed for medical rather than cosmetic reasons. Still, some patients cannot obtain insurance approval and proceed on a self-pay basis. Breast reduction scars are located around the nipple-areola complex and in the lower part of the breast. There are many similarities between breast reduction and breast lift operations; the final location of the scars is similar and the major difference between the operations is in the amount of breast tissue and skin that is removed. Liposuction may be added to breast reduction surgery. Breast reduction surgery usually requires the patient to undergo two to four hours of general anesthesia, and the patient may stay overnight in a hospital or postoperative care facility. Breast reduction entails a significant amount of surgery on the breast. Minor complications and healing delays are common, although major complications are rare. A patient can expect activity restrictions for six weeks, and her breast shape will be irregular for at least six months. The major risks include nipple numbness, nipple loss, asymmetry, poor quality scars, and less than optimal final breast shape, especially in overweight patients. Contour irregularities may require a touch-up surgical procedure six to twelve months after the fi rst operation. The bottom line: Most breast reduction patients experience significant relief of their physical symptoms at the price of noticeable scars. In older patients the final breast shape will be mature rather than youthful. Complications, mainly healing delays, after breast reduction surgery are common, although most are minor and do not require additional surgery.

Ear Surgery

Most major external ear surgery (otoplasty) is performed on children to correct a birth deformity characterized by excessive ear prominence. Insurance companies often pay for a child to have otoplasties for prominent ears, whereas an adult is likely to be denied coverage of surgery for the same problem.

Facial Rejuvenation/Reshaping

Facial rejuvenation has expanded from facelifts and deep phenol peels to a huge menu of options for physicians and patients. Despite the availability of less invasive procedures, however, there will always be a pool of patients who have facial skin sagging and redundancy that cannot be treated any way except by surgical excision.

Eyelid Surgery

Cosmetic surgery of the eyelids (blepharoplasty) seeks to lessen the signs of aging that often make a person look tired. These signs include wrinkles, excess skin, bulges and hollows that represent shifting fat, and dark circles. Brow sagging can add to or mimic these findings, and sometimes a brow lift must be performed in place of or in addition to eyelid surgery. Aging can also cause the lower eyelid margin to stretch and bow outward. This problem must be addressed during lower blepharoplasty or will be made worse. Drooping upper eyelids may have a condition called eyelid ptosis that requires surgery on the muscle that controls the position of the upper eyelid. Ptosis surgery is generally considered reconstructive rather than cosmetic and may be covered by insurance. Likewise, if a patient has documented obstruction of vision from excess upper eyelid skin or sagging brows, health insurance may cover blepharoplasty and/or brow lift.

Blepharoplasty incisions are made in skin creases, although procedures that do not include skin removal may be performed through incisions made on the inside surface of the eyelid. The surgery is usually performed with local anesthesia and sedation. Patients need to rest and keep cold packs over their eyes for at least twenty-four hours to minimize swelling and bruising. Bruising may take several weeks to resolve entirely. Contact lenses usually cannot be worn for several weeks, although most patients resume normal activities as soon as swelling subsides. Strenuous activities should be avoided for at least ten days. Eyelids, especially lower lids, will feel stiff and numb for months after surgery.

Minimally invasive procedures such as filler injections, chemical peeling, and laser resurfacing may be recommended to enhance the surgical results of blepharoplasties. Bleaching solutions may also be recommended for patients with dark circles due to hyperpigmentation. Patients considering eyelid surgery must undergo a thorough evaluation, including a good history to rule out allergies and other treatable causes of eye symptoms. A recent complete eye examination is prudent. Eyelid surgery must be done very conservatively on patients with dry eyes to minimize the risk of complications. The major risks of eyelid surgery fall into two main categories: imperfect or asymmetrical correction of the eyelid contours, and damage to the eye or to vision from direct injury or overly aggressive surgery. Fortunately, vision loss is very rare, but contour irregularities and asymmetries are not. Most irregularities are mild and usually do not require further treatment, but very partic ular patients may be bothered by them.

The bottom line: Eyelid surgery and related procedures can help reduce the signs of aging but should be performed conservatively because overly aggressive treatment can result in serious eye problems. Postoperative asymmetries are common and, although usually minor, can be disturbing to the patient.

Facelift

A facelift (rhytidectomy) is designed to help undo some of the effects of gravity and skin laxity that are an inevitable part of the aging process. Facelifts are often advertised as restoring one’s youthful appearance, but this is an oversimplification. Not even the most talented surgeon can turn back the clock, and a facelift does not deal with every component of the aging pro cess. However, a well-designed and executed facelift can help to refresh a person’s appearance. The features that usually cause a person to consider a facelift are sagging and wrinkling cheek tissues, deep folds of the central face, prominent jowls, and excess tissue on the neck.

The term “facelift” refers to procedures intended to improve contours of the mid- and lower face and neck. A brow lift may be added, as may be any number of additional procedures to correct problems not addressed by the facelift per se. There are many different types of facelifts, and a good surgeon will choose a procedure that fi ts the patient rather than give everyone his or her signature operation. Facelifts range from procedures performed through a few small incisions in which the tissues of the face are suspended to a higher position using deep sutures (sometimes called a thread lift) or absorbable barbed implants to traditional operations in which long incisions are made, deep layers are tightened, and excess skin is removed. A multitude of lesser facelift procedures are marketed as requiring less downtime, but most of them are not suitable unless the patient is young, has good quality skin, and understands that choosing a lesser procedure may in fact make it more diffi cult and riskier to undergo a full facelift in the future.

Facelifts are performed with general anesthesia or local anesthesia and sedation. In the traditional operation, a portion of the incision is in the scalp and a portion loops around the ear and extends along the back of the hairline. There may also be an incision under the chin. Traditional facelifts take several hours, and a patient having multiple simultaneous procedures may spend most of the day in the operating room. Some patients will go home the same day, but those patients having more extensive surgery may stay overnight in a postoperative facility. After the initial bandages are removed, the patient may be required to wear a facial sling for weeks, and swelling and bruising may persist for up to six weeks. Patients undergoing lesser procedures will have a shorter downtime. Most facelift patients can return to work within two weeks but may need camouflage cosmetics to cover residual bruising. Any activity that causes increased blood flow to the face, such as drinking alcohol, sex or other strenuous activity, or saunas, will increase facial swelling and will be quite uncomfortable for several weeks. The facial and neck skin will feel temporarily numb, tight, and dry, and hair growth may be stunted near the incisions. The final results of a facelift may not be evident for six to nine months. Postoperative asymmetry is common and may be related to asymmetry that was present but unnoticed by the patient before surgery. Severe wrinkling and skin redundancy usually cannot be entirely removed with one operation. The risks of facelift surgery increase with the extent of the procedure. Injury to the facial nerve, although not common, can lead to permanent facial paralysis. Scars may be visible. Skin loss can occur in areas where the skin has been extensively lifted or if a hematoma (blood collection) develops. This can be a very deforming complication because significant scarring may be the end result. Permanent, noticeable hair loss may occur. The “operated look” is a common complication of facelift surgery and is often the result of patients and their surgeons not knowing when to quit.

Postoperatively, facelift patients can experience a variety of emotions. Some patients feel anxiety or guilt about their vanity. Many patients will experience a period of letdown—fatigue, disappointment, or even depression—in the early weeks after a facelift. These symptoms usually resolve as the swelling and bruising subside. Psychiatrists note that early depression is common in patients with controlling personalities; later depression, when the extra emotional support by family and friends wanes, is more common in patients with dependent personalities. For the majority of patients, lifestyle, physical stamina, and relationships are unlikely to change signifi – cantly after a facelift. However, patients may experience increased confidence and an improved sense of well-being without undergoing any actual personality change.

The physical effects of a facelift are permanent but not stable. In other words, the aging pro cess, gravity, and simply the pro cess of being alive continue to affect the appearance of one’s face. The bottom line: A facelift can reduce some of the signs of aging, but the end result is very dependent on the quality of tissues before surgery and the nature of the procedure that is chosen. Patients who opt for less dramatic changes often have a more attractive and natural result. Patients should not underestimate the lengthy recovery period after facelifting.

Forehead Lift

Sometimes called brow lift, a traditional forehead lift consists of an incision made in the scalp or along the hairline and removal of skin. By removing skin and pulling the forehead up, the eyebrows are permanently elevated, which tends to make the individual look more alert. The surgery has the added effect of elevating the upper eyelid and, in some cases, may eliminate the need for separate upper eyelid surgery. During a forehead lift, in order to reduce the creases in the forehead and between the eyes, the skin is separated from the underlying muscles, and the muscles at the root of the nose may be removed. If skin does not need to be removed, some surgeons prefer to use an instrument called an endoscope, which does not require a big incision and through which the surgeon can work on the facial muscles or insert suspension sutures. For some patients Botox and filler injections have eliminated the need for muscle surgery during a forehead lift. For a man with a receding hairline, a brow lift may be performed just above the eyebrows, which will leave visible scars. Forehead lifts are performed with general anesthesia or local anesthesia with sedation, and the patient goes home after surgery. Because there can be significant swelling and bruising around the eyes after surgery, rest and cold compresses are recommended for at least twenty-four hours. Patients should not drive until the swelling no longer impacts their field of vision. Strenuous activities should be avoided for several weeks.

Major complications related to forehead lift are rare. Visible scars with or without hair loss and permanent scalp numbness are possible. As with all cosmetic surgeries, brow lifts can be overdone, leaving the patient with a permanent look of surprise. Extensive muscle work will reduce the patient’s ability to raise her (or his) eyebrows or wrinkle her nose. Damage to the facial nerve can cause permanent paralysis of forehead action, including brow elevation, on the affected side.

The bottom line: A forehead lift can elevate the eyebrows and reduce muscle action that causes facial lines and wrinkles. Continued muscle action and gravity will gradually undo the effects of the surgery. Overly aggressive brow lifts give patients that unmistakable post–cosmetic surgery “deer-in-headlights” appearance exemplifi ed by more than a few middle- aged celebrities.

Injectables and Implants

Injectables

Injectables are the fastest-growing segment of the medical cosmetics industry and the most infested with knockoffs, illegal imports, dilutions, and dangerous substitutions. Injectables fall into two categories: paralytics that lessen wrinkles by stopping the muscle action that creates them and fillers that alter contours. Fillers come as semiliquid suspensions that are injected through a needle and as solid but flexible materials that are inserted through tiny holes in the skin. Some filler materials are available in both forms. The advantages of the more solid forms are that they lend themselves more readily to filling larger areas and tend to be longer lasting. Injectable substances often come in preloaded syringes; patients may be charged by syringe or by volume, and charges vary from a few hundred dollars to well over $1,000 per treatment. Because two or more repeat treatments per year may be necessary, cumulative costs can be significant.

Paralytics: Botox, Dysport, and Myobloc are brand names for purified botulinum toxin, a biological agent that has been adapted for medical use. Botulinum toxin has been used for decades for the treatment of conditions characterized by muscle hyperactivity, such as neck spasms, cranial nerve disorders, eye spasms, and excessive sweating (hyperhidrosis). Botulinum toxin injected into a hyperactive muscle will temporarily paralyze the muscle and thus temporarily diminish the wrinkling of skin attached to that muscle. Common sites of injection for cosmetic reasons are the forehead and the crow’s-feet area adjacent to the eye. Botox is manufactured by Allergan and is so far the only botulinum toxin product approved for cosmetic use, although others are under FDA review.

Botox injections are performed in an office setting, and patients resume normal activities immediately. The effects of Botox may not be fully evident for two weeks and usually last several months. Patients who want to maintain the effect must undergo repeat injections every three to four months. Some patients will experience no benefit from Botox and others may experience progressively less benefit with each injection.

Despite their expense and temporary effect, Botox injections remain very popular. They have also been widely misused and misrepresented. Even though the manufacturer of Botox keeps close tabs on the sales and delivery of the legitimate product, complications and poor results are frequently seen because of injections of diluted or fake Botox sold at a discount and marketed as the real thing. Fake Botox can be procured as readily as or more so than street drugs in many places. Despite the fact that Botox is a prescription drug, unqualified people regularly dispense Botox in salons, gyms, hotel rooms, home- based offices, and other retail venues. Complications of medical-grade botulinum toxin injections by qualified physicians are uncommon, and serious complications are rare. In unqualified hands or in compromised settings, however, injections can be extremely risky. Serious potential complications include impaired vision, difficulty swallowing owing to the migration of the toxin into undesirable areas of the face or neck, infection, or life-threatening complications due to the injection of fake Botox. The bottom line: Medical-grade botulinum toxin injections can be useful in the temporary reduction of facial wrinkling that is associated with muscle activity. In qualified hands, it is a safe treatment. A patient seeking Botox injections should be sure to get the real thing in a legitimate setting rather than risk becoming a victim of an unethical practitioner using improper technique, inappropriate doses, unsanitary conditions, or fake drugs.

Fillers: Injectable fillers are the large group of substances used to correct contour defects and are used primarily on the face to enhance lips, fill hollows, and soften the appearance of wrinkles. They can be categorized in different ways: permanent versus semipermanent versus temporary; space occupiers versus bioactivators that both fi ll space and stimulate the development of natural collagen; biological (derived from living tissue) versus nonbiological.

Whereas resurfacing procedures seek (among other goals) to even out skin topography by lowering the surface, fillers plump up low areas. Fillers may also be used in conjunction with skin excision procedures (for example, facelifts) and Botox. Fillers are intended to provide subtle corrections. Regardless of the filler chosen, repeat injection sessions are usually required, both to fine-tune the result and to re-create the effect as the filler is absorbed.

Like Botox, most injectable fillers have a temporary effect, some having no more lasting power than hair color or waxing. Longerlasting injectables have the major disadvantage of creating a displeasing result that may not be correctable. Thus there has been a trend away from permanent fillers like liquid silicone and toward temporary and semipermanent fillers. Still, neither providers nor patients has been entirely happy with the short life span of the most commonly injected fillers.

Filler injections are performed in an office setting. Some products can cause allergic reactions and require pretesting, but most products used today do not carry this risk. Local or topical anesthesia is often used. Multiple needle insertions may be required, and some discomfort should be expected. Afterward, some swelling, redness, and lumpiness are common. Final results may not be evident for months, yet correction may not last much longer. New fillers come on the market regularly as others fall out of favor. The following is a partial list of fillers used currently and in the recent past, including brand names where applicable:

• Collagen: Collagen is a vital protein that is naturally present in skin, tendons, ligaments, and other supporting body tissues. It helps these structures maintain rigidity, but its volume and quality deteriorate with age. For many years collagen was the most popular substance used for filling soft tissue defects. It generally creates minimal inflammation with minimal posttreatment morbidity. Depending on the product, one or more injections may be necessary for acceptable correction. All injected collagen is eventually absorbed, so for most products, treatments must be repeated every three to six months to maintain the desired effect.

• Bovine collagen (Zyderm, Zyplast): Cow tissue–derived collagen has been used as a filler since the 1980s. Collagen manufactured from animal tissue can cause allergic reactions in susceptible individuals, and pretesting is recommended.

• Bioengineered human collagen (Cosmoderm, Cosmoplast, Cymetra, Alloderm, Dermalogen, Autologen, Fascian): Human collagen is manufactured from donated skin, grown in laboratories, or can be made from the patient’s own tissue. Human collagen does not cause allergic reactions and does not require pretesting.

• Other human tissue

• Fat: Fat from your own body would seem like the most logical filler, and fat injections have been performed for over a century. Unfortunately, the results of fat injections are unpredictable and not always permanent, and because much of the fat that is injected breaks down, overcorrection followed by repeated procedures over a period of months is often required. Large-volume fat injections can lead to signifi cant swelling and infl ammation because of the body’s reaction to the breakdown of fat that fails to “take.” Still, some permanent enhancement may be possible with multiple procedures. Fat works best when injected into stable body areas, and because it can impair cancer surveillance by complicating the interpretation of mammograms, fat should never be injected into the breast.

• Plasmagel: Plasmagel is a protein emulsion made from a patient’s own blood and mixed with a vitamin C complex. As a soft- tissue filler its effects are short-lived.

• Hyaluronic acid: Hyaluronic acid is a natural component of connective tissues, including skin, and exists in all living organisms. Hyaluronic acid has proved to be one of the best soft- tissue fillers to date and has become immensely popular. Whereas many fillers require overcorrection in anticipation of some loss of fill in the short term, the experienced provider of hyaluronic acid injections seeks to undercorrect the deformity, because the filler immediately starts to absorb tissue water and will increase in bulk over several weeks. The effects of hyaluronic acid injections last six to twelve months. Allergic reactions are rare. Side effects (usually temporary) include pain, bruising, redness, tenderness, swelling, and skin discoloration. • Avian hyaluronic acid (Hylaform, Hylaform Plus): This form of hyaluronic acid is derived from roosters. It does not appear to have the same per sistence as does the nonanimal form.

• Nonanimal stabilized hyaluronic acid (Perlane, Restylane, Captique, Juvéderm): This form of hyaluronic acid is generated from bacteria.

• Semipermanent Fillers

• Collagen (Artecoll, Artefill): These products are microimplants, consisting of collagen and bioactivating synthetic beads currently in use in Europe, Canada, and Mexico. The newer product Artefill is awaiting FDA approval. Although the collagen is eventually absorbed, the beads are permanent.

• Calcium hydroxylapatite (Radiance, Radiesse, Bioform): Calcium hydroxylapatite is a natural mineral substance that forms the crystal lattice of bones and teeth and is manufactured as an injectable paste for use as a filler. It has been reported to last from 1 to 5 years. There is little risk of allergic reaction, but clumping, nodule formation, migration, and the formation of bone within injected tissues have occurred.

• Polylactic acid (Sculptra, New Fill): This is a synthetic contained in microsphere beads that has been approved by the FDA to treat loss of facial volume in HIV patients. Other uses are off-label. Like calcium hydroxylapatite, polylactic acid can be long-lasting but is prone to clumping.

• Permanent fillers

• Silicone: Liquid silicone has never been approved by the FDA for cosmetic use, and in fact, its use in the treatment of wrinkles and facial defects was banned in 1991. It has been approved to treat an eye problem called retinal detachment, and some physicians have purchased it and used it extensively off-label for cosmetic purposes. Liquid silicone results in tissue volume enhancement mainly by triggering the formation of scar tissue at the site of injection. Known complications of liquid silicone injection include silicone migration to other parts of the body, discoloration or loss of skin at the injection site, and the formation of hard nodules in the injected tissues. Liquid silicone can also migrate to the skin surface and extrude periodically for years after injection. Attempts to remove injected silicone may result in signifi cant deformity of the affected body area. Mainstream medical organizations do not recommend the use of liquid silicone for cosmetic injection.

Facial Implants

Facial implants are synthetic materials that are inserted into the face in order to change contours more permanently and dramatically than can be achieved with injections. Facial implants can alter a person’s appearance in a way that can be quite different from the changes created by a facelift or related procedure, largely by appearing to alter the bone structures that determine a person’s physical identity.

Implants can be small, flexible, and inserted through tiny incisions using a large-bore needle or may be larger and constructed of more rigid materials like solid silicone.

Autografts: Autografts are tissues taken from a patient’s own body and inserted elsewhere. Many tissues, including dermis, dermis-fat composites, fat, fascia, cartilage, and bone, have been used. For example, cartilage from the ear is commonly used to change the contours of the nose. Obtaining an autograft usually requires a separate incision and thus an additional scar. The limited availability of donor areas, especially for large implants, makes the use of manufactured implants more appealing for most cosmetic procedures.

Manufactured Implants: Some implants are manufactured from biological materials such as collagen (Dermaplant) and hyaluronic acid (Dermadeep, Dermalive). Most implants, however, are made from synthetic materials. Numerous substances have been used to augment facial contours for cosmetic purposes. Two of the most commonly used are described below:

• ePTFE (expanded polytetrafluorethylene, Gore- Tex, Softform, Advanta): Several manufactured synthetic polymer fi llers are available that are formed as medical-grade implants rather than injectable substances, including Gore-Tex (yes, the same stuff your boots are lined with). These implants can fill deeper lines than can collagen and are sometimes used for lip enhancement. They are truly permanent and may become too noticeable over time. They can be difficult if not impossible to remove.

• Solid silicone: Solid silicone implants come “off the rack” in many shapes and sizes. A surgeon can also fabricate a custom implant from a silicone block. The operation to insert a silicone implant is usually fairly straightforward, and the most commonly augmented sites are the chin and the cheek prominences. Either local or general anesthesia may be used, and incisions are often made inside the mouth or eyelid to avoid external scars. Some type of splinting, such as taping or an elastic garment, may be used to minimize swelling and bruising. Patients will have diffi – culty talking, eating, and brushing their teeth in the early period after surgery. Patients usually resume normal activities within a few days. The final effect of the implant will not be evident for months, until the swelling has entirely subsided.

Most complications after implant insertion are related to the presence of the foreign body or to technical factors, such as poor positioning or improper choice of implant size or shape. Implants can also shift into undesirable positions. Eyelid problems and chin numbness can result from surgery in these areas. Implants can become infected or over time cause deformity if the scar around the implant distorts adjacent normal tissues. Any of these complications can result in the need for further surgery and temporary or permanent removal of the implant. Synthetic implants are more likely to cause problems than are autografts. However, autografts can be absorbed or change shape, especially in the presence of infection.

The bottom line: Cosmetic surgeons have long used fi llers and implants to fine-tune the results of major operations, and these products can also be used alone to correct lesser contour irregularities. Temporary fillers are popular, mainly because poor results are selfcorrecting and because permanent fillers can be extremely diffi cult if not impossible to remove without creating a new deformity. However, the cumulative costs of multiple temporary treatments can be significant. Permanent implants present more surgical risks, and large implants can substantially alter a person’s appearance. Injectable fillers are increasingly used by the unqualified and unscrupulous. Unapproved and nonmedical- grade substances injected into the body can cause complications ranging from painful lumps, serious infections, or hepatitis to death from improper injection into a blood vessel.

Lip Enhancement

Lip enhancement (enlargement, augmentation) deserves mention separately from other forms of facial contouring for two reasons. First, not all materials used for facial contouring are suitable for use in the lips. Second, lip enhancement is one of the most commonly overdone cosmetic procedures and has produced some serious complications as well as some results prime for parody (look for Goldie Hawn doing a halibut imitation, or for an alternative piscan analogy, the “trout pout,” in the movie The First Wives Club). Lip enhancement is performed to reduce wrinkles, to change contours, or both. Over the years injections and implants have been used in lips. Implants have included autografts (fat, tendon, dermis), biological materials (collagen), and synthetic materials such as ePTFE.

Lip augmentation is an office procedure performed with local anesthesia with or without sedation. Depending on the material used, the procedure may take the form of an injection or a surgery performed through incisions made inside the mouth. The most recent trend has been away from permanent fillers to temporary or semipermanent materials. The current fad for “bee-stung” lips so far shows no sign of waning and nonmedical products, such as lipsticks containing topical irritants and other “plumping” substances, fl ood the market.

The bottom line: Lip enhancement can dramatically alter a person’s appearance. The options for lip enhancement are more limited than are those for other areas of the face. Complications can be difficult to manage. A shifting filler or an improperly performed procedure that results in an undesirable mouth contour will be extremely disturbing to the patient.

Jaw and Chin Surgery

The Latin word for chin is “mentum,” and an operation that enhances or reduces the chin is called a mentoplasty. Chin enlargement can be accomplished either by inserting an artificial implant or by cutting and advancing the lower jaw. If the jaw surgery includes the teeth, the procedure is considered orthognathic surgery, which is major surgery performed on one or both jaws to improve tooth alignment, correct facial deformities, or simply alter one’s appearance. Orthognathic procedures are considerably more extensive than chin surgery alone and have the potential for more serious complications. Some plastic surgeons perform orthognathic surgery, but in most communities these procedures are performed by oral surgeons. A much less complicated procedure to enhance the chin entails cutting only the lower edge of the jaw and moving it forward. The bone is wired or plated to hold it in its new position. Jaw or chin recession/ reduction is also possible either through an orthognathic operation or by a more limited procedure that removes the bony prominence of the chin.

Chin surgery can be performed alone, but surgeons also suggest this option to some patients seeking rhinoplasty in order to balance the facial profi le. In this situation, computer imaging can be useful. General anesthesia is recommended for patients contemplating all but the simplest procedures. After surgery the patient can expect swelling and bruising for several weeks. Procedures on bone usually will cause more swelling than will the insertion of an implant. The final effect on the patient’s profile may not be evident for months. Risks include damage to the nerves along the edge of the jaw, which can cause permanent lip and chin numbness; infection; and deformity related to poor positioning.

Nose Reshaping

The shape of a person’s nose is one of his or her most obviously inherited physical features. Noses are strong features: midline, protruding. Not surprisingly they can be very tied up in sexual identity for adult males. In both ancient Rome and India, nose amputation was the punishment of choice for adultery. In fact, ancient operations devised to rebuild amputated noses formed one of the foundation pillars of modern plastic and reconstructive surgery.

Nasal contours often declare one’s ethnic heritage and can be a source of pride for some people and distress for others. Cosmetic nasal surgery (rhinoplasty) evolved over centuries and has often been performed to cloak or at least downplay racial origins. By the mid-twentieth century, small noses for women were very popular, and many surgeons performed more or less the same operation on all their female patients. What came to be called the retrouseé nose became synonymous with the obviously “done” nose. That cute little nose with the turned-up tip worked for some faces and was a disaster for others. (Watch for images of actresses over the age of 50, as well as the occasional male singer, and you will fi nd many examples of retroussé noses, some of which now look quite odd.)

Rhinoplasty is performed with general anesthesia or local anesthesia and sedation. If a patient has breathing problems related to obstructing internal structures of the nose, surgery will be more extensive and recovery more prolonged than it is for patients having only some nasal tip work or perhaps reduction of a small nasal hump. Incisions often can be confined to the inside of the nose, although some patients will require an incision on the skin pillar between the nostrils (columella) and, if the nostrils are to be made less fl ared, within the creases where the nostrils join the cheeks. These external scars may be permanently visible, especially in patients with thick skin. All patients can expect considerable swelling and bruising and may have black eyes that take weeks to resolve completely. Older patients are especially prone to extensive bruising. Internal nasal surgery may include internal nasal packing or internal splints that may require the patient to breathe through his mouth for several days until the packs are removed. External splints may have to be worn for several weeks. Patients may not be able to wear glasses until nasal swelling subsides and in some cases may need to adjust or replace their frames. Nasal swelling takes months to resolve completely, and the final contours of the nasal tip may not be evident for nearly a year.

A good cosmetic surgeon will plan a rhinoplasty that will both maintain nasal stability and result in a balanced facial profi le. This sometimes requires addition of implant material, usually an autograft of bone or cartilage. The treatment plan may also include surgery on the chin.

Common minor complications after rhinoplasty include the appearance of spider vessels (telangiectasias) on the nasal skin and irregularities of nasal contour. It is estimated that at least 10 percent of rhinoplasty patients undergo revisional surgery. Secondary surgery is usually but not always minor.

Nose reshaping can have a profound permanent effect on a person’s appearance, and the incidence of dissatisfaction after rhinoplasty is significant, especially in adult men. Some authors have gone so far as to state that the average rhinoplasty patient has some type of preexisting psychiatric disturbance, although this opinion is not universally shared.

The bottom line: Rhinoplasty and mentoplasty can permanently and dramatically alter a person’s appearance in a way that can have significant familial, ethnic, and psychological implications. These potential issues should be thoroughly discussed before surgery. Postsurgical contour irregularities are common.

Skin Rejuvenation/Resurfacing

Skin rejuvenation procedures are performed to reduce surface irregularities, color changes, visible blood vessels, and fine wrinkling, and are generally not useful for deep wrinkles and excess skin.

Cosmetic medical care has borrowed a page from disease-based
medicine, called the treatment plan, that has become the defi ning
characteristic of twenty-first-century cosmetic medicine. No longer
does a patient go to a cosmetic surgeon, get an operation, and go
on about her business. Now she (or he) is recommended a lifelong
program of peels, laser treatments, injections, maybe a little surgery
here or there now and then, maybe some cellulite rolling or other
technology du jour, spa treatments, and a do-it-at-home skin-care
regimen with doctor-recommended products. Multimodality treatment
is the new industry paradigm. Patients should hold onto their
pocketbooks, because for providers there is profit every step along
the way.

Most cosmetic operations are refinements of techniques developed
decades or even centuries ago. Cosmetic surgeons have adapted
procedures and technologies from a variety of specialties in order to
achieve aesthetic goals with minimal scarring. For example, some
operations that used to leave significant scars can be performed now
through very small incisions using fiberoptics and endoscopic techniques
originally developed by gynecologists.

Now we also have a large number of minimally invasive and noninvasive
treatments that are not surgery in the traditional sense.
Most of these share the following characteristics:
• They are mostly injections or surface treatments.
• Treatments are sometimes administered by nonphysicians.
• Results are never as profound as with more extensive surgical
procedures and are frequently temporary.
• Multiple treatments are always required for best effect.
• Treatments may be performed alone or as part of a recommended
“package” that may include other invasive or minimally
invasive procedures.
• Providers are rarely if ever experienced with, use, or own all
options for minimally invasive treatments and therefore will
make recommendations accordingly.

There is an axiom in medicine that states, “The more treatment
options that are available for a problem, the less likely that any of
them work very well.” The wealth of procedures in cosmetic medicine
and the frequent lack of impressive results demonstrate the
truth of that statement. The entry of a new treatment into the market
usually follows a predictable pattern. First, there is an article in
an industry-sponsored journal (that is, a biased source) or a presen tation
at a professional meeting by Dr. Y:
Dr. Y: “We have been using X, a technique I developed a year
ago. It works great for this condition, which has no other good
treatment, and our patients love it.”
Other doctors are so impressed that they decide to give it a
try. Happily, the profit margin is good. Dr. Y is especially happy
because he was smart enough to patent the technique/product.
The Cosmetic Medical Care Product Line 155
More articles praising X are written in trade journals, inevitably
quoting Dr. Y and other physicians with a fi nancial stake
in X. Eventually, a skeptical editorial appears in a professional
journal that points out the lack of reported scientifi c evidence
to support the effectiveness of X, not to mention the unknown
risks.

Meanwhile, along comes Dr. Z, who coincidentally has developed
or has a financial interest in the similar product Q. He
makes his presentation at a meeting and is also quoted in a
trade journal: “We haven’t been too happy with X. The results
have been short-lived and the patients are disappointed. Now
we are using Q, which works great for this condition, and our
patients love it.”And so it goes.

Fads develop with operations as well, and another medical maxim
is that the wise surgeon will not be the first one to adopt a new procedure
nor the last one to abandon it. New operations are usually
presented by their developers at meetings and published in professional
journals. However, it takes time for those procedures to be
performed comfortably and successfully by others, and both the
originators and the followers accumulate experience over time that
leads to recommendations for revisions and adaptations. Two years
may pass between the time an article about a new technique is written
and the time it appears in a journal, by which time the originator
is probably already doing it differently. The best results of any procedure
are seen after years of refinements. Potential patients should
always keep this fact in mind when encouraged to agree to a relatively
new and little tested treatment.

Experienced surgeons, who have more options in their arsenal
than do nonsurgeons, often find themselves going back to the tried
and true. Yes, Botox works when used correctly on the right patient;
yes, newer alternatives are often an improvement over traditional
dermabrasion; yes, there are now better injectables than bovine collagen.
But, no, there is no substitute yet for a surgical facelift, and
no, it is not possible to get rid of sagging skin without leaving visible
scars. Nearly every busy cosmetic surgeon has in the office at least
one dusty item that was billed by the sales rep as the latest “hot”
technology and that he or she now wishes had never been purchased.
Detailed reports on the results of the latest treatment fads rarely
make it into respected academic journals because scientifi cally sound
analyses simply have not been performed. Most reports, therefore,
appear in presentations at meetings, in trade journals, in popular
press articles, or in advertising copy, where scientific standards are
looser or nonexistent. Ignoring for the moment the possibility that
some of the results are verbally exaggerated or the photos enhanced,
most documentation of results using the latest technology simply
does not provide credible support of the claims made. Either the
results are just not that impressive or the before and after photographs
are so different in their lighting, focus, positioning, makeup,
hairstyles, and facial expressions that it is literally impossible to assess
the effect of the treatment.

Spa treatments may be incorporated into a cosmetic medical treatment
plan and can seem very high tech. In fact many of them offer
little, other than the personal attention, that a customer cannot get at
home. Spa clients, like all beauty customers, decide how much they
are willing to pay for someone to pamper them. You can, for instance,
exfoliate at home using a number of inexpensive methods, or you can
splurge and pay a spa technician to run an abrasive oscillating paddle
over your body. Prices vary, but in any case you are helping to pay for
that $35,000 buffing machine. Marketing consultants continually remind
physicians and other purveyors of cosmetic treatments that it is
the personal service rather than the technology that ultimately makes
the sale. The combination of good service and slightly intimidating
machinery is a proven winning business strategy.

Any ability that the average person may have to distinguish between
science and hype will likely be further compromised by what
seems to be a new trend: prestigious medical researchers getting in
bed with purveyors of over-the-counter nonmedical products like
cosmetics and skin-care items. As noted in Chapter Three, Klinger
Advanced Aesthetics is heavily promoting its new relationship with
Johns Hopkins Medicine and the implication that Johns Hopkins is
endorsing Klinger’s Cosmedicine line of beauty products. While the
medical institution denies that it is endorsing the product but rather
is merely designing and evaluating (but not performing) the clinical
studies, the fact that the company can prominently feature the Johns
Hopkins name in its promotional material seems likely to encourage
consumers to purchase its pricey line of products.1
Prospective patients should evaluate all cosmetic medical care
claims, from invasive treatments to spa services, exactly the same
way that they evaluate all other consumer product assertions. They
should be wary if a physician claims that a procedure or piece of
technology

• Is fast, painless, and convenient;
• Has no side effects or risks;
• Contains ingredients that are secret, unique, or only available
outside the country;
• Works for a wide variety of problems;
• Is “proven” effective because of anecdotal stories or hearsay
rather than through legitimate, peer-reviewed scientifi c data
not influenced by the inventor or the manufacturer;
• Is popular and proven overseas, even though no studies have
been published in this country;
• Is underrated because government agencies or the medical establishment
have foolishly denied its value and kept it from the
public;
• Is exclusively available through only one physician in the area.
(Some manufacturers offer “territories” to purchasers of their
equipment. If, for example, the company designates 150 territories,
it is willing to sell no more than 150 machines. This is
less a promising piece of technology than a short-term, grabprofit-
while- you- can strategy.)

SPECIFIC PROCEDURES

What follows are brief descriptions of the most popular cosmetic procedures.
If you are seriously considering undergoing a cosmetic
procedure, you can find more detailed information about it from
many good sources, including those listed in Resources at the back
of this book. Be wary of books, brochures, and Web sites that emphasize
only the positives of procedures and downplay or ignore the
negatives. My focus is on the too often underemphasized aspects of
operations and procedures, whether they be the risks, outcomes, or
simply inconveniences. These are the details doctors may not emphasize
with their patients but will stress with their family members
and friends.

The list of procedures is alphabetical by category.

Body Contouring

Body contouring is a general term that refers to procedures that alter
the shape of large areas of the body, that is, mainly the trunk and
extremities. Naturally, many cosmetic procedures have this goal, but
the common use of the term “body contouring” denotes surgeries
such as liposuction, excision of excess tissue with or without muscle
tightening, and placement of implants to augment contours.
Body contouring procedures can help improve shape, but typically
they do not lead to (1) significant weight loss (with the exception
of surgeries in which large amounts of heavy skin are removed
from patients who have already undergone massive weight loss), (2) a
reduction in waist size, or (3) improvement in cellulite.

Cellulite Treatments

Cellulite is a term invented to describe the dimpling some people,
especially women, have on their thighs, hips, and buttocks. Cellulite
is the natural effect of tension on normal skin ligaments (bands that
attach the skin to deeper layers). Cellulite is not reduced with liposuction,
and in fact, there is no good treatment for it.

Endodermologie is a procedure developed in France in the 1980s
consisting of mechanical skin massage and external application of
suction that has been promoted to treat cellulite and to reduce thigh
circumference. It has been approved by the FDA for this purpose,
but its effectiveness is still being debated. Multiple treatments—perhaps
a dozen or more—are needed to yield any improvement and
the results are temporary. Fat tissue is not altered.

A new term, “laserdermology,” refers to endodermologie combined
with laser or light treatments. Again, more than a dozen treatments
at significant expense (at least $100 per treatment) are required
for improvement, and long-term effectiveness has not been proven.
The drug aminophylline has been promoted as a topical treatment
for cellulite but has been discredited.

The bottom line: Entire books have been written about treatment
of cellulite and related irregularities, usually by practitioners who
have product lines to sell, but there remains no consistently useful,
cost- effective treatment method.

Liposuction

Liposuction (suction lipectomy or lipoplasty) is a surgical procedure
in which fat tissue is extracted through a rigid tube attached to a
vacuum device. Liposuction was developed to treat localized fat deposits
that typically do not respond well to dieting or exercise. Liposuction
can permanently reduce these deposits, although fi nal
contours may not be evident for three to six months. Some surgeons
perform large-volume liposuction, which is major surgery and entails
higher risks.

Liposuction procedures may incorporate additional technology
such as ultrasound or laser, and many surgeons use the tumescent
technique, in which large volumes of fluid containing a local anesthetic
drug are injected into the fatty area in order to facilitate the
surgery. Even so, liposuction frequently requires general anesthesia,
and large-volume liposuction may take hours to perform. Swelling
and bruising can be significant, and patients often must wear compression
garments and limit activities for several weeks after surgery.
Laser-assisted liposuction, an emerging technology, may help reduce
these side effects.

Patients have died after liposuction surgery from fat and blood
clots to the lungs (fat and pulmonary emboli) and shock from fl uid
loss. Patients can also have heart complications if high doses of lidocaine,
the local anesthetic drug that is part of the injected wetting
solution, are used. All liposuction procedures can leave behind contour
irregularities that may require another surgery. Some contour
problems may be difficult to correct. Numbness and permanent discoloration of the overlying skin are other possible side effects.
The bottom line: Liposuction is most helpful for patients who are
not overweight but who have isolated bulges of fat under good quality,
elastic skin. Surgeon inexperience correlates with increased risk
of permanent contour irregularities. Patients considering largevolume
liposuction should be well informed about the risks.

Tummy Tuck

Tummy tuck is one of those unfortunate “cute” terms that achieve
popularity at the expense of misrepresenting the magnitude of operations.
The technical term, “abdominoplasty,” refers to a group of
operations that are designed to reduce belly prominence. Abdominal
bulging can result from muscle stretching during pregnancy, excess
skin after weight loss, large fat deposits in the lower abdomen or
in the “love handles,” or some combination. A traditional abdominoplasty
includes elevating the abdominal skin up to the ribs, tightening
the abdominal wall muscles, pulling down the excess skin and
repositioning the belly button into a new skin hole, removing the
excess skin and fat, and closing a long incision along the horizontal
skin crease just above the pubic bone. There are lesser procedures,
collectively called mini-abdominoplasties, performed on patients requiring
less correction and extended procedures for massive weightloss
patients. Liposuction may be combined with abdominoplasty.
Isolated surgical removal of the overhang of lower abdominal skin
and fat is called panniculectomy.

A traditional abdominoplasty requires general anesthesia and may
require several days of hospitalization. Recovery time varies with
the extent of surgery; bigger procedures may require the patient to
limit activities for several months. A patient who has had muscle
tightening as part of the surgery will not be able to stand upright for
days or weeks and will be instructed not to sit for prolonged periods.
Patients may have to wear support garments for weeks. Prolonged
bruising, swelling, and numbness are common. Scars will be prominent
for months and may be permanently visible outside the borders
of certain styles of underwear and bathing suits. Patients who have
had tummy tucks often have permanent, excessive flatness to their
abdominal contours and may have unusually shaped navels. Patients
whose initial complaints included abdominal wall pain often do not
experience complete pain resolution.

The risks of major complications after abdominoplasty, such as
infection, blood or fluid collections, blood clots, problems with skin
healing, and even death, increase as the extent of the procedure increases.
Risks are also increased in smokers and patients with medical
problems like diabetes that affect circulation. The results of
surgery may be compromised in patients who have had prior abdominal
surgery. As a general rule, women who anticipate future pregnancies
should not undergo abdominoplasty until they have fi nished
childbearing.

The bottom line: Abdominoplasties can reduce abdominal protrusion
and skin excess that frequently follow pregnancy, weight loss,
and aging. The more extensive procedures are major surgeries, carry
significant risks, require long recuperation periods, and may leave
conspicuous scars. Overall, most procedures result in improved but
sometimes not entirely natural contours.

Trunk and Extremity Lifts

Patients who are candidates for trunk and extremity lifts (arm, thigh,
buttock, trunk) usually have either poor skin elasticity, causing their
bodies to show the effects of gravity prematurely, have undergone
massive weight loss, or both. Body contouring procedures performed
after major weight loss are called postbariatric procedures. The procedures
may be performed in conjunction with liposuction, are almost
always performed under general anesthesia, and, if extensive,
may require hospitalization. Sometimes circumferential incisions are
made to remove a belt of excessive tissue in a procedure known as a
lower body lift or belt lipectomy. Body contours are improved often
at the price of considerable visible scarring.

With any lift procedure, swelling, bruising, and numbness may
last several months, and some numbness may be permanent. Scars
can be of poor quality, especially in the leg and buttock region, and
over time may descend with gravity to become visible beyond the
borders of clothing that formerly hid them. Patients who subsequently
experience significant weight change or who have poor quality
skin may develop recurrence of the undesirable contour.
The bottom line: Lifts with or without liposuction can improve
body contours for the price of potentially quite noticeable scars. Extensive
procedures entail the risks of any major operation.

Buttock, Thigh, Calf, Biceps, Triceps, and Pectoral Implants
Artificial implants are used to alter contours of various body parts.
Sometimes implants are used instead of a person’s own tissue to
reconstruct birth defects or damaged areas. For example, custom
silicone implants have been used for many years to simulate the normal
contours of missing chest muscles. Less frequently, implants are
inserted into buttocks, thighs, calves, biceps, triceps, and men’s
chests to enhance contours for cosmetic reasons. With the exception
of buttock implants, most of these procedures are requested by men
striving for bodybuilder contours.

Body-contouring implants are usually made of solid silicone or
silicone gel. They often must be placed under normal muscle, which
can lead to discomfort with muscle use. Surgery requires general
anesthesia and activity limitations for weeks. Scars may be small and
discreetly located, but bruising and swelling will be noticeable for
weeks or months. The biggest problems with implants in these locations,
just as in the breast, are imperfect positioning leading to abnormal
contours and capsular contracture (hardening of the scar
around the implant, which often leads to pain and deformity). Permanent
muscle damage can occur from the pressure of an implant.
Shifting, extrusion, or infection involving the implant usually necesThe
sitate more surgery, and the end result can be signifi cant scarring
and/or deformity.

Mesotherapy

Developed in France in the 1950s and used widely in Europe and
South America, mesotherapy is a poorly defined catchall term referring
to a treatment in which medications and other substances are
injected under the skin for a variety of purposes. Conditions for
which mesotherapy has been advocated include chronic pain, hair
loss, psoriasis, cellulite, weight loss, and spot weight loss. Thus, mesotherapy has been advocated as a nonsurgical alternative to liposuction.
The medications and plant extracts injected vary among
practitioners and according to the condition being treated and include
vasodilators, nonsteroidal anti-inflammatory medications, lecithin,
enzymes, nutrients, antibiotics, hormones, and calcitonin. Plant
extracts may be combined with drugs. One medication that has been
used in mesotherapy, isoproterenol, is a powerful medication approved
by the FDA only for the treatment of asthma, shock, pulmonary
hypertension, and slow heart rate.

For all the hype about mesotherapy, there are few standardized
protocols for what is injected or how and how often to do it, no standard
equipment to use, and no proof that it works. No pharmaceutical
drug is approved by the FDA for use in mesotherapy for body
contouring, and injectable lecithin (phosphatidylcholine), one of the
most commonly used substances, is not approved in the United
States for any use.

Complications have occurred after mesotherapy, and the injection
of mysterious substances into the body presents the very real possibility
that some day someone will experience a life-threatening adverse
reaction that the practitioner may be ill prepared to manage.
As former ASPS president Dr. Rod Rohrich put it, “It is mindboggling
to think that a physician would inject patients—or that patients
would allow physicians to inject them—with unknown,
unproved substances based on hearsay and unsubstantiated clinical
evidence.”2 Even more worrisome, some of the substances used in
mesotherapy are available online without a prescription for purchase
by untrained or self-taught individuals, who are free to inject themselves
or others at the risk of serious complications and poor results.
Fortunately, mesotherapy is falling out of favor in many areas.

Breast Surgery

Breast Augmentation

In breast augmentation (enlargement; also known as augmentation
mammaplasty) bags of saline or silicone gel are implanted under
the breast (and sometimes also under muscle) in order to make the
breasts look larger. Silicone gel implants usually provide a more
natural look and feel than does saline, but both kinds of implants
are prone to certain problems because they are foreign bodies. For
years gel implants were favored by physicians and patients; their use
was severely restricted by the FDA for the decade following the early
1990s until further research could be completed, but they are expected
back on the broader market soon. Other effective and safe
filler materials have yet to be developed.

There continued to be negative press about breast implants
throughout the final stages of the testimony that led to the FDA’s
recent decision to allow gel implants back on the market. Much of
the press was generated by consumer opposition groups; however,
when challenged, neither these groups nor the FDA was able to produce
any credible, peer-reviewed research demonstrating a correlation
between breast implants and systemic diseases such as arthritis
and other autoimmune diseases, the most serious charges previously
leveled against gel implants. In a congressional briefi ng held in May
2005, epidemiologist Dr. Joseph McLaughlin pointed out that no
device in the history of the FDA, including heart valves and vascular
stents, has ever been subject to a comparable level of review and
study.

Breast augmentation surgery is performed with the patient asleep
or heavily sedated in an office or ambulatory surgery suite. The incisions
are usually small and hidden in discreet locations but do leave
visible scars.

Any operation in which a foreign object is implanted in the body
has unique risks associated with presence of the implant. Infection
or bleeding around the implant is more likely to lead to additional
surgery than would similar complications of operations that do not
involve insertion of a foreign body. If an implant has to be removed
because of a complication, reimplantation is usually possible after an
interval appropriate to the situation. Breast implants are prone to a
condition called capsular contracture, which refers to the undesirable
hardening of the natural scar that forms around the implant
over time. Capsular contractures can be mild and asymptomatic or
they can be severe, causing pain and breast deformity. Severe capsular
contractures often require further surgery and even then can recur.
Some degree of capsular contracture is a very common event
after breast augmentation surgery, although most capsular contractures
do not require treatment.

Breast implants can also leak. Leaking saline-filled implants eventually
deflate; the saline is safely absorbed and the affected breast
looks smaller. The patient may opt to have the leaking implant removed
or replaced. For a woman with a leaking silicone gel implant,
the presence of free gel usually is not harmful per se, but the implant
should always be removed to minimize the possibility of gel migration
to other parts of the body.

Breast implant technology has improved over the years, but even
so, no one knows for sure how long a breast implant will last. Women
with breast implants should keep a copy of the technical information
about their implants for future reference.
The presence of breast implants make the performance and interpretation
of mammograms (breast x-rays) more diffi cult, and special
techniques must be used to maximize breast visualization. A woman
at high risk for breast cancer should consider carefully before choosing
to have breast augmentation.

Subsequent pregnancy may affect augmented breasts in undesirable
ways. Breast-feeding is feasible, but if a breast infection develops,
the underlying implant may be affected and have to be removed.
The forces of gravity and the effects of aging and weight changes will
alter the appearance of augmented breasts and not always for the
best. Sometimes the breasts drop, but the implants do not.
Other risks associated with breast augmentation include asymmetry
(uneven positioning), poor quality scars, nipple numbness (usually but not always temporary), and abnormal breast contour. The last can occur in thin patients in whom the upper border of the implant
is visible; in patients in whom the implants are placed under
the chest muscles, causing an unnatural deformity of the implant
with muscle activity; and, most notoriously, when excessively large
implants are inserted. Breast implants can cause pressure-related
molding of the underlying rib cage, which can be permanently noticeable
in very thin patients who have had their implants removed.
Smokers are at higher risk for complications than are nonsmokers.
Breast augmentation patients can expect moderate discomfort,
swelling, and bruising for a week or two after surgery and will have
some activity restrictions for about four weeks. Final breast size and
contour will not be evident for about six months, and because of the
unpredictability of the scar that forms around the implants, augmented
breasts have the potential to change shape indefi nitely. Dissatisfaction
with size is very common with breast augmentation
patients, and the same patient will at various points feel her breasts
are too big or too small.

The bottom line: Breast augmentation is by no means a risk- free
operation, and a woman should be fully aware of all risks, including
the significant potential for symptomatic capsular contracture. The
best results are seen in women who choose moderate rather than
dramatic enlargement.