San Diego Facial Plastic Surgery

Update on Botox and Dysport in San Diego

2010-01-25T10:38:00.000-08:00

Botox and Dysport have now been competing head to head on the market for several months, and our San Diego patients have reported good results with the new botox competitor. In our practice, we have found that it takes approximately 3 units of Dysport to every 1 unit of Botox to achieve comparable results. Since there are 300 units in a bottle of dysport and 100 units in a bottle of botox, ounce for ounce they are pretty much the same.

For patients it is important to understand that $4/unit for Dysport is the same as $12/unit for botox- simply multiply by 3 to get the equivalent value.

Overall, having two competing products that both work means lower prices and that is what we have seen. Patients should keep their eyes peeled for specials on either product at our San Diego Face medical spa.

Several of my patients who reported that their botox has not been lasting as long as when they first starting using it have switched to dysport, to see if they can get more "bang for the buck." We will keep you posted on these results...

Maximizing Results from your Laser Treatment

2010-01-08T12:54:00.000-08:00

Active FX and Total FX are two of our most popular San Diego skin rejuvenation procedures. The reasons for this are that these procedures are quick, involve minimal downtime (generally one week at the most) and are effective. Patients achieve often dramatic improvement in wrinkles, loose skin around the cheeks, eyes, and jowls, and acne scars. Despite these great results, it is important for patients to understand that great looking skin requires maintenance. If bad habits resume after your laser skin resurfacing treatment, the brown spots, wrinkles, and crepey skin will also return.

Most of our patients pre-treat their skin with retinol and hydroquinone based products as recommended by our aestheticians. Medical grade products have a higher concentration than regularly found in the drug store, and act to inhibit hyperpigmentation (dark spots) and also allow a deeper, more effective penetration of the laser.

In addition to pre-treatment, we recommend avoiding direct sun exposure and using a high quality sunscreen with UV-a and UV-b protection.

Approximately one to two weeks following Active FX, patients are generally ready to resume their skin care, which at this time can be re-tailored to their current skin condition. The goal at this point is to maintain the result of the laser treatment, and also to build upon that with even more improvement over time. Having a great team of aestheticians and an aesthetic RN allows us partner with our patients for long term great looking skin!

Lower Eyelid Rejuvenation with Filllers

2009-12-10T13:06:00.000-08:00

While some patients truly have "bags" under their eyes which require surgical removal with a lower eyelid lift or blepharoplasty, others simply have a hollow look below their eyes that makes them look tired or older. This hollow area is called the nasojugal groove, and it forms in people with a certain bone structure predisposition as they age. The aging process results in loss of fat and elasticity, and the skin "sinks" over the bone, creating a shadow or "dark circle." Simply removing fat above the hollow area can sometimes accentuate it- making the eye seem more hollow and old. A better option is to restore volume to this area!

These days, we often use fat grafting to the area beneath the eyes, to permanently restore fullness and lessen the appearance of the nasojugal groove. For patients who don't want the expense or (relatively little) downtime of fat grafting, injectable fillers can be an easy fix.

In either case, it is best to have an experienced surgeon or injector doing these procedures, as the area around the eyes can be prone to bruising or irregularities.

My preferred injectable filler for this area is Restylane. It lasts a long time (up to a year or more)
and has relatively little swelling.

What is a Liquid Facelift?

2009-11-27T09:29:00.000-08:00

"Liquid Facelift" was probably coined in regard to Sculptra, which is a "large volume" injectable filler. Unlike a syringe of restylane or juvederm or even radiesse, sculptra comes in a bottle which generally prodcuces 5-6 syringes of product for injection. While scluptra can target specific lines like the nasolabial folds, it is better known for adding plumping volume to thin, "hollow" faces. By changing these hollow areas (below the cheek bones and in the temple, for example) to more convex or rounded, the face looks naturally more youthful. In some cases, if no volume were added and the skin was simply pulled, these thin faces could look unnatural and "operated."
Indeed, sometimes a "liquid facelift" can be better that a regular facelift for the right candidate!

The principle of liquid facelift can also be applied to fat grafting. This is another way of adding to volume to the face to make it look more youthful. It involves an addtitional procedure- liposuction- but the filler is one's own fat and the supply can be plentiful and relatively inexpensive.

So how long will it last? Sculptra has been known to last 2 years PLUS. Fat, after trasnplantation to the face, is generally permanent after six months, with most patients retaining 40-50% of the fat that is grafted.

In our San Diego practice, a "liquid facelift" is generally topped off with a "Total FX" fractionated skin resurfacing treatment. In this way, the refreshed, volume enhanced face receives a new, smooth layer of skin. The Total FX treatment removes lines, wrinkles, scars, hyperpigmentation, and tightens loose skin. The overall look is amazing, and in many cases rivals a surgical facelift.

When considering a liquid facelift, it is important to consult with a board certified facial plastic surgeon who will examine your face and tell you if you are a good candidate. If you truly need a surgical lift, this may still be the best option, and save you substantial money on fillers. Remember, a "Mini Lift" can be performed with no general anesthesia in about 1-2 hours.

Total FX Skin Resurfacing

2009-11-14T14:56:00.000-08:00

Many patients have expressed confusion about the differences between Total FX, Active FX, and Deep FX skin resurfacing, so I'd like to clarify a few things.

All these names refer to treatments performed with the same laser- the Ultrapulse CO2 Laser from Lumenis. Active FX is the term coined to refer to a frationated treatment with a 1mm spot size. Active FX allows for quick healing, minimal risk, while still achieving excellent skin contraction and tightening and removal of brown spots and sun damage. Deep FX refers to a fractionated treatment with the 120 micron (smaller) spot size, which penetrates deeper into the skin, enabling treatment of deeper scars, wrinkles and irregularities. Because of the smaller spot size, deep fx is not as effective for superficial brown spots. For that reason "Total FX" combines one pass each with each of these different spot sizes, theoretically providing the best of both worlds.

So what kind of results have we seen?

The look and feel of skin after a Total FX treatment is truly impressive, and our patients have been very satisfied. I believe that for patients with moderate skin laxity and wrinkles- Total FX is a great choice.

I advise patients not to be too concerned about the "name" of the treatment they receive. We customize all laser treatments to the patient: to their desires, their skin quality, and the downtime they want. The best choice will be made after a comprehensive consultation in our office.

Smoking and Facelifts

2009-10-07T10:13:00.000-07:00

At the recent meeting of the American Academy of Facial Plastic Surgery in San Diego, CA there was some discussion regarding facelifts and smoking.

Conventional wisdom states that nicotine and facelifting are not good partners. This is because nicotine constricts (makes smaller) the blood vessels supplying the skin. During a facelift, the skin is temporarily "lifted" away from the deeper tissues (including the blood supply) so that it can be redraped following tightening of the deeper tissue. In non-smokers and otherwise healthy patients this temporary separation of the skin causes no harm- there is still plenty of collateral blood flow. In smokers, this collateral blood flow is limited, raising the risk of inadequate blood flow to the skin edges.

Inadequate blood flow carries a certain risk for slow healing, and skin complications. A worst case scenario can be prolonged healing and poor scars that require revision.

Most plastic surgeons attempt to reduce this risk for smokers by encouraging them to quit. Generally two weeks of no smoking prior to a lift, and one week after will put patients in a "safe zone" for healing. Occasionally, patients are unable to quit completely prior to surgery and that is where the patient and surgeon need to sit down and have a frank conversation.

Patients who are "light smokers" (less than 1/2 pack per day) can often be safely treated with a "mini facelift." This involves shorter skin flaps, with less stress on the small blood vessels. However, the surgeon should be highly experienced and skilled in face lift procedures to perform this procedure safely and still achieve a good result for the patient. Most importantly, the patient needs to have realistic expectations and understand that they are still at higher risk than a non-smoker for healing complications. If I feel that my patient doesn't accept this, or doesn't understand the risks of smoking, I will not operate. Also, if I feel I cannot safely give the patient what they want- I will not operate. As with all cosmetic surgery, communication between the plastic surgeon and patient is the key to a happy outcome.

Revision Rhinoplasty for Ethnic Patients

2009-09-24T13:39:00.001-07:00

Hispanic, Asian, or African American patients who are active candidates for rhinoplasty or just thinking about having a nose job often have a similar complaint: My bridge is too low!

It is important to differentiate those ethnic rhinoplasty patients whose bridge and profile fit their other features and thus appear "natural" from those whose bridges are too low even for ethnicity. These latter patients' appearances can be greatly improved by augmenting or building up the bridge of the nose. Unfortunately, not every nasal surgeon is skilled at building the bridge up in a natural, long lasting, and attractive way. I often see ethnic rhinoplasty patients who have had surgery elsewhere and are not pleased with their bridge augmentation. Reasons range from visible or mobile implants, unnatural shaped implants, to poor bridge/tip proportion. It is very important to match the tip height (or projection) to the bridge height!

Revision rhinoplasty for ethnic patients can be complex due to the need to replace a pre existing implant, which may require dissecting through scar tissue around the implant. However, thick skin generally is a plus for allowing a smooth contour in the nose following the revision.

Silicone implants are a fairly common cause for revision bridge surgery in these patients. Silicone is difficult to sculpt, which can lead to noticable edges under the skin. In addition, it can sometimes form a capsule around itself, preventing the implant from sticking to the underlying bone and cartilage. Finally, silicone may occasionally extrude through thin skin especially if the implant is too long.

Endogenous cartilage from the nasal septum, ear, or rib can be used for bridge augmentation, however I have found gortex to be very useful in this capacity. Gortex tends to adhere nicely to the bone is very easy to sculpt and contour for a natural, long lasting appearance.

"The Only Thing that Bothers Me is my Neck.."

2009-09-08T16:29:00.000-07:00

Many patients come into our office and utter this phrase. Indeed, a "turkey waddle" (or is it "wattle"?) can be quite distressing for most folks. Even diehard naturalists who count on exercise and good nutrition thinking they can avoid the plastic surgeon will finally cave in when they see this develop under their chin. Often, they will tell me "I inherited this from my mother (or father)." While heredity can certainly contribute to the severity or rapidity of onset of an aging neck- we all get this to some degree or another.

Our necks start to "look bad" as we age for several reasons:
1) Sun Damage: UV rays directly damage the elastin fibers in our skin, causing a loss of "snap" and subsequent sagging.
2) Muscle laxity: the "bands" in our neck are the platysma muscle. This muscle extends from the collar bone to the jawline and into the cheek, and as it relaxes and loosens over time it separates from the underlying firm tissues and becomes visible under the skin- even when we don't flex it. (No, you can't fix this by flexing your neck.)
3) Fat: weight gain or cycles of weight gain and weight loss can eliminate the once youthful "90 degree angle" of the chin and neck.
4) Heredity: our underlying bones and cartilages provide the framework for our skin, fat, and muscles which can become loose. For example, a "low hyoid bone" can make it impossible for a patient to have a perfect 90 degree neck-chin angle-no matter what procedure is done.

So what can you do?

Most patients over 40 will require an actual neck lift. This involves repositioning and removing excess skin in the neck, in addition to muscle tightening and liposuction as necessary. This can be done with a short incision that is hidden behind the ear in the crease. Under age 40, most skin retains elasticity, and select patients can be treated with liposuction alone. This involves a very short incision below the chin.

The good news is a simple neck lift can be done with minimal anesthesia in approximately 45 minutes.

Liposuction is an approximately 20 minute procedure.

Recovery from these procedures is a matter of days to one week for most patients.

When patients complain about their necks, however, I always assess their jowls and cheeks as well. Occasionally, it is just not reasonable to correct the neck and ignore these other areas. Patients are then offered a mini facelift or a full facelift, depending on their needs and desires.

What's better for Lip Enhancement- fat or injectable filler?

2009-08-24T17:10:00.000-07:00

Both "artificial fillers" and fat are used in our practice for lip volume enhancement.

Juvederm has proven a popular choice with our patients for plumping and sculpting the lips. It is easy to inject, and after doing a virtually painless nerve block, patients don't feel a thing during the injection. This injectable filler can be put right into the vermillion border (the border between the red and white lip) and also can accentuate the philtrum ( the little vertical lines from the nose to the cupid's bow of the lip). When injected into the lower, deeper portion of the lips, juvederm (or Restylane) add significant volume . It can also be used to correct the corners of the mouth, where creases and lines tend to appear, and can also be injected into the vertical lines around the lips caused by smoking and sun exposure.

Fat grafting is a terrific way to add volume to the face, and is a procedure we add onto many of our facelifts to give a "3 - dimensional rejuvenation." There are two major benefits to fat:

1. It is relatively cheap (volume for volume) compared with fillers: whereas 1-2 cc of filler may cost between $400-$1200, a typical fat grafting session may involve 40- 100 cc of fat and only cost 3-4 times as much.

2. The results you have at 4-6 months are considered permanent.

In most areas of the face the fat is retained very nicely. The cheeks, lower eyes, temple, and jawline all do very well and our patients are very satisfied. The lips and smile lines are a bit less predictable, and occasionally require touchups. These areas of the face are mobile- they move when we smile and talk, and this makes it harder for the transplanted fat to attach and become permanent.

Bottom line is: if you are planning a full face fat grafting session (to correct several areas of volume loss or hollowness), it makes sense to use fat in the lips. If the lips are your only area of concern- consider using an injectable filler like juvederm or restylane. The treatment is quick, easy, and relatively cheap. The only downside- you may have to pop in once a year for a touchup.

Mini Lift versus "Full Facelift"

2009-08-12T12:19:00.000-07:00

Mini facelifts, and "branded" facelifts (facelifts given the name of their surgeon, or names like "quick lift") have received a lot of attention lately. This is because while there is a huge demand for facial rejuvenation, many potential patients fear long, costly procedures as well as being under anesthesia. One thing branded facelifts may do is help doctors to address these concerns by putting a "friendly face" on the procedure. (This is generally acceptable as long as patients are made aware of any risks- and that a mini lift or branded lift is still surgery!)

While many surgeons have branded their own facelifts, others don't believe in "branded" facelifts stating that "a facelift is a facelift."

I tend to disagree with this, as evidenced by our own "signature mini lift" that we do here at La Jolla Center for Facial Plastic Surgery in San Diego. A proper facelift will always employ some basic principles, regardless of the name or the surgeon-but it is still an expression of the surgeon's esthetic judgement, skill, and experience. Surgical technique and outcome can be quite different in different offices. For example, after performing over 1000 facelifts my own outlook and approach are much different than after my first facelift, or first 50 facelifts.

That said, an experienced surgeon who brands his own "mini" facelift should do so for reasons beyond just marketing a catchy name. The branded procedure should represent something different than a "standard facelift" in that physician's private practice-or be performed in some fundamentally unique way as opposed to other physicians who performs facelifts. A good question to ask the surgeon is: "What is different about this lift from a typical facelift that you or some other surgeon may do?"

Finally, potential patients should not forget that the most important factor in the outcome of any facelift procedure is the quality of the plastic surgeon performing the procedure-not the name of the particular lift.

Total FX for Laser Skin Resurfacing and rejuvenation

2009-08-10T16:24:00.000-07:00

Our San Diego Plastic Surgery office has performed hundreds of fractionated CO2 laser resurfacing treatments using the Lumenis Ultrapulse laser. Initially, the technology was called "Active FX" and allowed us to achieve dramatic skin tightening, wrinkle reduction and removal, and removal of sun damage- with a quick recovery of 7-10 days and minimal side effects. This has been an excellent adjunct to our practice, with about 75% of our facelift patients also undergoing an Active FX or Total FX treatment to achieve a "3-dimensional" improvement.

The company later introduced "Deep FX" which was an additional treatment head for the laser allowing a smaller spot size with deeper penetration. By combining Active and Deep FX, one achieves a "Total FX" skin resurfacing which allows resolution of deeper lines and scars as well as more superficial brown spots .

Total FX is our treatment of choice for darker skinned patients (Asian, Hispanic) with acne scars, as well as younger patients with moderate sun damage and lines.

Older skin is often best treated with an aggressive Active FX, or combination of Total and Active FX.

Age range for Rhinoplasty

2009-08-07T16:09:00.000-07:00

A lot of our rhinoplasty or nose job patients fall between the ages of 25-40, have been thinking about it for years, and have reached a point in life where they are ready to move forward. These patients are generally mature in their thinking, and know what they want. They usually have realistic expecations and goals, and when they see their imaged photos in my office they will often smile and say "Yes- that's exactly what I want." Other patients, however, require more education and guidance as to what the surgery can accomplish, and what may look best for them.

Teenagers are often terrific candidates for nasal surgery. They are young, heal quickly, and a great rhinoplasty result can be a tremendous psychological boost for them. However, these patients may be too young to appreciate the risks of surgery (however minimal they may be), and sometimes are being led into the office by a parent who wants the surgery more than they do. My favorite scenario for teenage patients is when they are accompanied to the consultation by a loving, supportive parent who lets the teen express their own desires, but asks me a lot of questions and wants to be involved. These families are a pleasure to work with, and the patients do very well. What is the minimum age for rhinoplasty? Ideally, when the patient has stopped growing. For girls, this may be as young as 15 or 16, for boys usually 17, 18 and up. A good question to ask oneself is "Has my shoe size changed in the past year?" If that answer is no, then you may be ready to proceed.

Somewhere in between the teen and "adult" years are those patients just out of college and looking to change their image before hitting the workforce. These patients generally also benefit from bringing a parent or spouse to the consultation, but can also be great candidates. I like to see that they have been thinking about surgery on their nose for at least 6 months before coming in for the consultation.

San Diego Facial Plastic Surgery - Roy Amir

2009-08-06T15:48:00.001-07:00

"Very little can compare with the sense of gratification a physician feels when he (or she) knows they have made a positive impact on a patient's life. This knowledge was what led me to medical school following my experiences as a paratrooper and medic. My fascination with the intricacy of facial anatomy and the artistic nature of plastic surgery led me to focus on Head and Neck Surgery and to subspecialize in Facial Plastic and Reconstructive Surgery. I enjoy the artistic nature of facial plastic surgery, and the challenge of continuously striving for improvement and perfection. Whether turning back the clock for a patient who shows signs of premature aging, or giving a rhinoplasty patient the look they have always dreamed of, I truly enjoy my work."