Is This the Face For You?

Selt
Is this face Nov~
1994
'1
•
Forget that major COSMETIC SURGERY
overhaul. Forty subtle tecllniques
and advanced technology promise
fewer wrinkles and a natural appearance.
bgJuJithN@wnaan plwtographs by Peter Arnell YOU DON'T NEED TO WORRY ANYMORE mAT COSMETIC SURGERY
will leave you with a rubber face. Today, a nose job or eye tweak is designed to look natural, to create the impression of ''I've been on a lo-o-o-ng vacation" or "I'm just doing my hair differently." Not, as in past years, "I've just blown thousands of dollars on my face­ don' t you love it?" Cosmetic surgery no longer needs to be an extravaganza. Now, with about 40 subtly different procedures available for the face alone, a patient can have a nip here and a tuck there. Sophisticated changes in technique, new instruments and advanced facial implants have giv­
en surgeons a keener respect for facial idiosyncrasies. That means less of the old cookie-cutter approach to surgery. The attitudes of patients have also changed dramatically. Women are not waiting until their late fifties or their sixties for a major over­
haul. They're making minor improvements beginning in their late thirties and early forties-wrinkle blasting now, a forehead-lift with maybe some chin recontouring a bit later. "Patients achieve better, longer-lasting results when they do procedures at the beginning of the aging process, while the skin still has considerable elasticity," says Pamela Lipkin, M.D., P.e., a facial plastic surgeon from New York City. Whether from misplaced anxiety, faulty body image or just a whim, no one should have surgery too soon. But if you're certain plastic surgery is for you, you could consider having it done earlier rather than later, when a real problem grows serious. Here's what's new. aps the biggest change during the past few years has been the use of mid-face implants. Until recently, the only implants widely available were for chins (to get rid of that weak look) and cheeks. Now mid-facial implants are used most frequently for patients in their thirties and forties who look haggard but are not ready for full face-lifts. These implants can also help those who have already had a face-lift and want to get rid of the mask effect produced when a clumsy surgeon stretches the facial skin too tightly. Submalar and malar implants, as they're called, are triangular curved pieces of silicone rubber that are shaped to conform with the bones of the face. Don't confuse them with the liquid silicone used in breast implants: These implants are
made of the same nonreactive material
used to coat cardiac pacemakers.
Inserted through a tiny incision in the
mouth underneath the cheekbone, sub­
malar implants plump up the hollows
and depressions below the cheeks .
"You're elevating the soft tissues in the
middle of the face and creating the illu­
sion of increased soft tissue bulk," says
William Binder, M.D., a facial plastic
surgeon from Beverly Hills who invent­
ed the implant. Submalar implants can
be inserted alone, or they can be com­
bined with a traditional face-lift to hoist
wrinkles and folds around the mouth
that traditional face-lifts might miss.
The new anatomically designed malar
implants offer significant improvements
over the "one shape fits all" implants of
the past. Placed on the cheekbone, the
oval malar implants of the Eighties gave
women an eerie cyborg look. (Think
Brigitte Nielsen.) Today's cheek implants
are shaped more like the actual cheek­
.-rile ..urgtfH1S he/Of/Red 10 lhe American AWJCi.ulion nf Facial
Plostk and Reconstructive Surguy ar Ih~ Americ;afl Sociny oj
P4ulic und Recon:'i,rU(:l;vt: Surg~ms.
INTERACTIVE POll
Advancements in medical technology have improved the results one can expect from cosmetic surgery. Wouldyou consider it? Tell us what you think.
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bone, with tapered edges that make the
projection look far more natural. Chin
implants are also much better. These
prosthetics used to fit on the tip of the re­
ceding chin. Now surgeons are using
"wraparound" implants that can resculpt
almost the entire jawline. Used with lipo­
suction, moderate jowl fat can be sucked
away while the wraparound chin implant
is used to support skin and tissue.
For those who worry that their face
is too flat or moonlike, George Bren­
nan, M.D., director of the American
Academy of Facial Plastic and Recon­
structive Surgery, has invented a brow
implant to give the brow more defini­
tion. Dr. Brennan, who also designed
the first anatomical malar implant. now
says, "We can literally augment any
area of the facial skeleton."
.
Many of the new facial implants re­
quire no more than a local anesthetic
with heavy sedation-"twilight
sleep"-and two hours of surgery. One
to two weeks later you'll still have a bit
of swelling. Cost: about $2,000 for the
chin implants, $3,000 to $4,000 for the
cheek implants, about $2,000 for the
brow implant.
As an alternative to the more expen­
sive cheek implants, some doctors are of­
fering to remove the "buccal fat" under­
neath the cheekbone. The theory is that
once the fat is gone, the cheekbones will
look more prominent. Not everyone
agrees. "It's very aging," says Dr. Lipkin.
'That cadaverous look is ugly, and the fat
does not come back." Sniped another:
"Who's buccal fat removal indicated for?
Well, maybe a 400-pound person with al­
ligator skin and chipmunk cheeks ." In
other words, be very careful. With buccal
fat removal, your cheekbones will, quite
likely, look more prominent. But the nat­
ural process of aging removes mid-face
fat anyway. So unless you have very full
cheeks it may be better to spring for
cheek implants-and leave the fat below
your cheekbones alone.
Computer-imaged implants now of­
fer plastic surgeons a new technological
edge. At the moment, mass-produced
implants come in standard sizes. But ac­
cording to Dr. Binder, within the next
few years the customized compu-built
implants currently used for major recon­
structive surgery will be available­
though expensive-for elective surgery.
The precision results are based on three­
dimensional computer images.
oscopic··assisted cosmetic proce­ ures are the next big thing. An endo­
scope is a tiny camera on a flexible tube.
Inserted into the body, this tool allows
the surgeon to look around without mak­
ing a wide incision. Surgeons are using
endoscopy for two facial procedures: the
forehead-lift and the face-lift. The pur­
ported advantage? No brow-to-brow in­
cision. "Endoscopic forehead-lifts aren' t
for patients with serious wrinkles, be­
cause you're not removing excess skin
to smooth them," says Lawrence S.
Reed, M.D., a New York City plastic
surgeon. "Theire just for patients who
are beginning to show the signs of age. .
Or they're for patients who have already
had face-lifts but need a 'touch-up.'"
Dr. Reed (Joan Rivers once called
him her "favorite East Coast surgeon")
admits that the endoscopic procedure
produces a longer period of swelling­
about six. to eight weeks-than a normal
face-lift. But, he adds, the endoscope
offers another advantage. A normal
forehead- or face-lift inevitably requires
cutting away some hair-bearing skin.
"The hair loss may be minor," notes
Reed, "but women whose hair is already
thin are extremely troubled by it."
Endoscopic surgery remains contro­
versial. "To me, it's an operation that' s
looking for a reason to exist," says Ger­
ald Imber, M.D., a leading New York
City pl astic surgeon. "The endoscopic
forehead-lift, for example, will probably
be more expensive and will take over
three hours-all this, to replace a proce­
dure that normally takes 25 minutes. Es­
. sentially, you ' re winching up the tissue
and hoping ·it will heal in a new posi­
tion. At best, the results are just, 'Eh.'"
But Dr. Imber-and other skeptics-do
think that the endoscope could be useful
in placing and replacing implants, some
of which shift around.
TH
a e vertical marionette lines running
rom your nose to the corners of your
mouth are called nasolabial folds. As
you age, the malar fat pad, which is a lo­
calized area of increased thickness of fat
in the cheek that protects the underlying
thin-wall sinus, loses its support and at­
tachment. And skin loses elasticity, so
the fat pad slides forward as well as
down, deepening the folds and making
you look older. A conventional face-lift
does not fix them completely. Collagen
or fat injections are still used most fre­
quently to plump out the furrows . The
disadvantage? Collagen and fat tend to
dissolve in areas of the face that are
muscular and mobile, so you may need
injections two to three times a year.
To iron out the folds more securely,
John Q. Owsley, M.D., clinical professor
at the University of California, San Fran­
cisco, has perlected a new technique for
repositioning the malar fat pad, a major
surgical procedure usually done as part
of a complete face-lift. The doctor must
detach the fat pad from the underlying
muscle, and lifting up and out, resuspend
the tissue with sutures back to its original
position. This smooths out the furrows.
To cut down on swelling-it often lasts
up to six weeks-Dr. Owsley administers cortisone.
strong, not scooped out, the tip may be
refined, but it's not unnaturally angular.
Instead of removing a great deal of carti­
lage and tissue from the nose, he bends
or remolds it, holding it in place with mi­
croscopic sutures. Rhinoplasty takes two
to three hours under general anesthesia.
The nose might be mildly sensitive to the
touch for up to a year.
Traditionally, the most uncomfortable
part of the procedure had been removal of
the packing material placed in the sinuses
during surgery. But Dr. Brennan has in­
vented a suction device that's now being
adopted by other surgeons to absorb post­
op blood. The method dramatically reduces bruising around the nose and eyes.
ay, you don' t have to go for the compete nose job a la Cher. Doctors can do
small adjustments. They can narrow or
elevate the tip, trim the nasal bone to reduce the height of the upper third of the
nose or trim the cartilage to reduce the
middle third of the nose. If the bridge
happens to be too low, they can also create a more classic line with transplanted
cartilage or bone, or a Silastic implant.
Geoffrey Tobias, M.D., a New York
City plastic surgeon who teaches at
Mount Sinai School of Medicine, calls ~
the new, more natural look in rhinoplasty ~ewer than 15 separate procedures
"the un-nose job." The bridge remains are available (continued on page 178)
EYES
~
Findine the RIGHT SURGEON
. I procedure IS risk-free. But foIIowmg a few Simple rules will lessen the chances of
second-rate surgery or slipups that wID.land you back in the doctor's office with an even big­
ger problem.
Know thy dodor's credentials. The tenn "board certified" is particularly COnfusing
these days. What board? What certification? Consumer protection groups say that for a few
hundred bucks, over 100 bogus "boards" will issue a beautifully framed and meaningless
diploma. For facial wort, your doctor should be board-certified in otolaryngology and belong
to either the Americ:an Academy of Facial Plastic and Reconstructive Surgery IBOO-132.fACEI
or The American Society of Plastic and Reconstructive Surgeons 1708·228-99001.
Membership in each requires years of testing and training.
Once you've chosen a doctor, try to see as many examptes of his handiwortl as p0s­
sible. lots of people see one or two pictures of successful patients in the doctor's office and
they're satisfied. But pictures can lie. Some uRSCnIpulous doc:tor5 even try to pau off pic­
tures of other doctors' patients as examples of their own wortt. So try to see a patient in per­
son who has had successful surgery.
Some of the procedures described here have become fairly commonplace; others are only
performed by a handful of surgeons. If you can't find a surgeon in your part of the country
with the expertise you want, call the Americ:an Academy of Facial Plastic and Reconstructive
Surgery for references.
Listen carefully to what your doctor is saying A patient with unrullstic: expecta­
tions may go back for procedure after procedure, making a problem worse instead of better.
Technology is constantly changing and improving, but some changes in appear'lnce are
beyond surgical comction. So pay careful attention to what your surgeon promises ~
and what he does not.
(4) teamingup
surgery
(continued from page 163)
(conlinued from page 167)
3595 E. Fountain Blvd., Suite 1-2, Colorado
Springs, CO 80910; 719-637-8300.
for the eyes alone. There is the old
standby of removing excess fat from the
lower and upper lids (blepharoplasty).
But surgeons can now improve the eye
in tinier, subtler ways. For example, the
muscles in the upper and lower eyelids
that have relaxed too much, allowing
the lid to cover the iris, can be lifted to
produce a more open-eyed look. The
outer comer can also be elevated slight­
ly to create an almond shape.
To treat undereye bags surgeons
are adapting a new range of laser
techniques. "There's no incision,"
says R. Patrick Abergel, M.D., assis­
tant professor at the UCLA School of
Medicine and founder of the Derma­
tology and Cosmetic Laser Surgery
Center in Santa Monica. "We insert
the laser through the conjunctiva in
the comer of the eye , and the laser
zaps the fat deposits."
Since laser eyelid surgery doesn't re­
move or tighten excess skin, it works
best for younger patients with good
skin elasticity. Because the technique
requires no incision, it produces less
bruising and swelling than regular
blepharoplasties. Dr. Abergel claims
you can have the surgery on a Friday
and be back to work on Monday. (We
say: Don't bet on it Always add sever­
al days to a week to whatever overly
optimistic estimate a plastic surgeon
gives you.) Price: about $2,500.
WINDSURFING
I U.S. Windsurfing Association Sanctions
coed and women's teams and clinics
across the country. Box 978, Hood River,
OR 97031; 503-38EH3708.
Wind Women An Oregon-based group of
female windsurfers who get together for
outings and potluck meals. Box 1541, Hood
River, OR 97031; 509-538-2548.
GENERAL OUTDOOR CLUBS
Appalachian Mountain Club Sponsors rock
climbing, bicycling, cross-country skIIng,
white-water rafting and other open-air
adventures in the Northeast. 5 Joy St.,
Boston, MA 02108; 617-523-0636.
Hostelllng Internationa l-American Youth
Hostels Sponsors budget cycling, hiking,
canoeing and other outdoor trips through­
out the U.S. and Canada. 733 Fifteenth St.
NW, Suite 840, Washington , DC 20005;
202-783-6161.
Nantahala Outdoor Centar Offers coed and
women-only canoe and kayak Instruction,
rock-cllmbing outings and mountain bike
instruction In the Smoky Mountains region.
13077 HWy. 19 West, Bryson City, NC
28713-9114; 704-488-2175.
Washington Women's Sports Network An
education and advocacy group promoting
women's athletics. Box 20623, Alexandria,
VA 22320.
Wisconsin Hoofers Seven Madison,
Wisconsin-based outdoo r clubs, from
scuba diving to skIIng. 800 Langdon St.,
Madison, WI 53706; 608-262-1630.
Women Outdoors Inc. Arranges outings
that range from sea kayaking in Maine to
rock climbing In Oregon. 55 Talbot Ave.,
Medford, MA 02155.
Women's Outdoor Adventure Cooperative
Leads trips, outings and parties in and
around New Hampshire. Box 1597, Wolfe­
boro, NH 03894; 603-569-5510.
PUBLICATIONS
Fans of Women's Sports A national net·
work that lobbies for more athletic opportu­
nities for women and girls. Their newsletter
contains helpful resources for fans and sup­
porters. Box 49648, Austin , TX 78765.
New Hampshire Outdoor Compan ion A
comprehensive monthly resource for New
Englanders. Free copies at many outdoor
specialty shops; by subscription: Box 180,
Wolfeboro Falls, NH 03896; $9.95.
The Ultimate Adventure Source Book
(Turner Publishing, $29.95). Usts and lists
of nationa I networks for outdoor activities
ranging from kayaklng and rock climbing to
parachuting.
Women's Sports Connection This quarterly
newsletter links San Francisco Bay Area
women with local clubs and classes, and
reports on national events . Box
31580, San Francisco, CA 94131-0580;
$10. To subscribe or start a similar
publication In your community,call
editor-In-chief Nancy Levin at 415-241­
8879.
~
NECK
~ments ill liposucnon, the vacuum­
ing of large deposits of fat on the body,
now enable plastic surgeons to remove
minute amounts of fat from areas of the
face. "Microsuction" with a tiny two-to­
four-mm cannula removes double chins
in younger patients who have good skin
elasticity. The instrument is inserted un­
derneath the chin; the fat is drawn out.
The patient wears a compression collar
to help the skin tighten up.
Sometimes, microsuction isn't quite
enough to sculpt a sharp chin angle.
The surgeon can still make a small
one-and-a-half-inch incision under­
neath the chin and then suction (or
simply excise) the fat. The next step is
to tighten up the sagging platysmas­
those two vertical bands of superficial
muscle that give older people their
turkey wattles . The disadvantage? A
tiny horizontal scar under the chin that
fades with time. The advantage: You
avoid a full face-lift.
A chin job, done under general or
local anesthetic, is usually a once-in­
__ . . __ ... __
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t'r.r
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__ .
a-lifetime operation. It costs anywhere
from $2,000 to $4,500. You will prob­
ably be out of commission for less
than a week.
-Tex, a stringlike material origi­
nally used for repairing blood vessels
(and, yes, it's the stuff used in ski
clothes) is being strung into wrinkles to
fill them out. Most surgeons are still
wary, because it's tricky to use Gore­
Tex correctly. It must be inserted deep
into the fat layer, not just under the
skin's surface--otherwise it may cause
inflammation and irregularities.
Fat injections are becoming more
popular than collagen, which is easily
injected into the skin but is extremely
expensive and doesn't last. By contrast,
your own (relatively inexpensive) fat
produces results that can last for years.
There is one hitch: A significant per­
centage of transplanted fat cells die. So
the average patient will need several
shots for about a year to achieve the de­
sired results. Cost: $1,000.
@MEGA-WRINKLES
. rfacmg your skin
like domg the
IS
gym. It takes time. Whether it works de­
pends on everything from your genetic
predisposition to the deepness of your
pocketbook. At one end of the treatment
spectrum are the light exfoliants (usual­
ly glycolic acid) that remove dead skin
cells. They require no anesthetic (they
are virtually painless) and they can be
applied during your lunch hour. At the
other end are phenol peels that can re­
move deep wrinkles. But you will have
to spend about 10 days hiding from the
neighbors, nursing the most horrible
"sunburn" of your life.
Although skin peels haven't changed
much, doctors show greater sophistica­
tion in determining the concentration of
the acids, along with the best combina­
tion and frequency of treatments. Bev­
erly Hills plastic surgeon Robert Kotler,
M.D., author of Chemical Rejuvenation
of the Face, has pared healing from 10
days to six by coating the skin with
ointments instead of with the traditional
powders. He also believes in doing the
procedure under general anesthesia.
Fees for phenol peels range from
$2,000 to $4,500; medium-strength
trichloroacetic acid (TeA) peels and gly­
colic acid peels are considerably less.
ough surgeons have been using
asers to treat scars for a long time, they
are now combining lasers with scanner
technology to remove acne pits, wrinkles
and raised scars. When the laser beam is at­
tached to the scanner, it can be directed with
greater accuracy and the treatment is con­
siderably faster. It hurts, but it doesn't re­
quire anesthesia A scab fOnTIS on the skin.
Within a few days, the skin underneath re­
generates. For pockmarks surgeons are us-
ing micro-skin grafts to fill in the holes.
'''The trick is to make the micro-graft of nor­
mal skin and the surrounding area match
one another," says Abergel. 'Then, we use
a scanning laser to smooth the area." The
costs for these procedures vary from a
few hundred dollars to several thousand.
Eight r.eJlsons HOI to have plastic surgery 1. Your mate wants you to Just remember Billy Joel singing, "Don't go changing.._" Maybe it's your mate you need to change.
'
1. You know you don't like something about your face, but you're not quite sure what it is If you have to asII what's wrong, maybe your feeling of distress is more than skin deep. You may need a therapist, not a surgeon. 3. You're having an emotional crisis If you think higher cheekbones and tighter skin will save a relationship, we have two wonls for you: Ivana Trump. 4. Several surgeons and friends have told you the surgery you seek is unnec­
essary Our cufture's emphasis on beauty is causing some young adults to seek surgei)' at inappropriately early ages. If eveIYone is telling you tbat your problem is in your head, seeI! counseling, not surgery. 5. You scar or bruise easily Don't conceal this or other relevant medical infonnatioa from your doctor. 6. Yes, you'd look better, but you're terrified of going through with it This is not 6ke having your nails done. Surgety is invasive, more than uncomfortable, and it has its risks. Listen to your feaf$. 7. With just a little work. you could look like Michelle pfeiffer If you III1J$t have surgel)', do it with a sense of adventure and excitement-but also with realistic expectatioas. 8. You just heard about this great new procedure last week that will do wonders for you The oldest story of aU. ''The ancient Greeks used to teach tbeir physicians not to be the first to try a _ procedure, nor the Iast," warns New Yorl( City plastic surgeon George J. Berakha, M.D. And don't assume your local doctor will be proficient in every new tech­
n i q _ if he tells you he is. Cheek. Check. r
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