Category: Blog

In this day and age, we have a “gotta have it yesterday” mentality.  Information is sent around the world in microseconds, packages are shipped overnight, and we can even microwave dinner in three minutes.  We’re always on the go, multitasking, working even more than before. We are taking the kids from school to soccer practice, music lessons, and home for dinner, and then we have our regular tennis leagues.

I see many patients who are concerned about facial aging.  They look older than they feel and want to stay youthful and, in many instances, competitive.  They often look for quick fixes.  When I was a plastic surgery resident 25 years ago, the only treatment methods for the aging face were a facelift, forehead lift, and eyelid surgery (blepharoplasty).  Patients were either a candidate or not.  Since that time, our understanding of facial aging has increased dramatically.  We now understand that over one’s lifetime, you can lose as much as 50% of your facial fat.  In addition, the skin becomes lax and the cells are unable to retain water.  This all contributes to the face sagging, with the development of jowls, loose neck skin, prominent nasolabial folds, bags under the eyes, and drooping eyebrows.

Physicians are now not only resecting the loose skin, but also adding volume to the face, with different types of fillers including fat, hyaluronic acid, and collagen.  In addition, the face lifting procedures have expanded in techniques, to include limited dissection facelifts, thread lifts, and multi-plane facelifts.  This not only gives the patient many alternatives but also contributes to confusion as to what is the best choice.

As I have mentioned before, it’s important to seek a qualified plastic surgeon if you are a candidate for a facelift.  There are many practitioners, who are not board-certified plastic surgeons, offering “nonsurgical facelifts” as well as limited facelifts that they advertise will give you the same result as the more traditional surgical facelifts.  Ask them what their qualifications are, if you can see before and after pictures, and if you can speak with some of their former patients.  The more traditional facelifts will last 7-10 years.

The limited facelifts and “liquid facelifts” will not give as effective a result, nor will they last nearly as long.  In my practice, I utilize 3-4 different types of facelifts, depending on the patient’s needs, and I often will complement the facelift procedure with dermal fillers, Botox, and laser resurfacing. Some patients really do not want surgery, even though that may be the best treatment method.  In this situation, I explain to them alternative treatments and their limitations. There is no “one-size-fits-all formula” to treat the aging face.

There are many magazine articles as well as TV shows that discuss “nonsurgical facelifts”, “minimal incision facelifts”, “lunchtime lifts”, “lifestyle lifts”, “quick lifts” and “thread lifts”. Some of the photographs show dramatic results with minimal pain and minimal downtime. It makes it sound as easy as going for fast food during lunch.

Most board-certified plastic surgeons are trained to perform many different facial rejuvenation procedures including brow lifts, blepharoplasty (cosmetic eyelid surgery), and facelifts. The most common procedures involve elevating the skin of the cheek and neck area and tightening up the fascia layer which overlies the facial and neck muscles. The skin is then redraped over the incision and the excess is removed. I tell my patients that a properly done facelift should last 5-7 years.

Over the years there have been developments of more extensive facelift techniques which basically lift all the facial soft tissue off the bones and reposition it. These, in my opinion, result in a prolonged postoperative period, more swelling, and the possible complication of facial nerve injury. At the opposite end of the spectrum, more patients are interested in less invasive procedures with less downtime. When I was a resident 25 years ago the usual facelift patient was 55-65. We’re now seeing women and men in their 40s who are looking for facial rejuvenation before they get to the point that they need the traditional facelift. One of the more common procedures I use is the MACS lift, a procedure that was developed in Belgium. It requires less dissection and works nicely for smoothing out the neck and cheek. It’s for patients that have mild to moderate sagging.

As I have said many times in my posts, let the buyer beware. As reimbursements for health care have decreased, many healthcare providers (I won’t call all of them medical doctors) have gotten into the cosmetic surgery business. It’s a “cash up front” business and includes nonsurgical procedures such as Botox and dermal fillers, as well as surgical procedures for facial rejuvenation. Family practice physicians, gynecologists, dermatologists, dentists, and chiropractors to name a few, take a weekend course and all of a sudden become “board-certified cosmetic surgeons”. They operate out of their office because they certainly couldn’t get hospital privileges for these procedures.

I’m seeing patients in my practice, who have had some of the less invasive procedures performed and have been disappointed in the results. Many of the weekend-trained practitioners do very little “deep layer work” and their results don’t achieve near what the photos show. Lifestyle Lift, a national chain of walk-in facelift centers, was fined $300,000 by the NY Attorney General, based on a complaint of deceptive advertising. QuickLift is a procedure taught in the US by an ER physician in Pittsburgh. You can take a 2-day course that he teaches for about $2000 and become an “expert”. Buyer beware, indeed.

Spider veins are those little bothersome blue, red, or purple veins that seem to develop in patches. Most spider veins occur on the legs. Although they are not a functional problem in and of themselves, they are the physical signs of a problem with the larger veins that control blood flow from the legs back to the heart.

The larger veins in the legs contain one-way valves. Muscle action in the legs pushes the low-pressure blood flow through the venous system upwards and the valves keep the blood from pooling. Over time, these valves become incompetent and the blood backs up from the deep veins to the more superficial veins, causing spider veins to develop. The problem is more common in women particularly those who have had children, in obese patients, and patients that have jobs where they do a lot of standing such as teachers, waiters, nurses, and even surgeons.

Once spider veins develop, the evaluation and treatment must determine whether there is a significant problem with the deeper system, that needs to be treated first. This includes varicose veins and obstruction of the saphenous vein system. Noninvasive studies including Doppler studies will help diagnose these problems. If a larger problem exists, the physician must treat this first, by either ligating the veins, which means tying them off, or using a laser placed inside the vein to obliterate it.

The most common treatment for spider veins is sclerotherapy. This is a procedure where an irritant, such as high concentrations of saline solution or a detergent is injected into the vein with a very small needle to cause damage to the wall of the vein and obliterate it. If the vein is too small to insert a needle into, the laser has been shown to be effective.
With either treatment, it is often necessary to treat a second or third time in the area where the spider veins are. Wearing a support hose helps to improve the tone of the legs and decrease the development of spider veins, but it’s difficult to wear a support hose in warm climates such as Houston. Elevating the legs during the day for even 15 minutes will also help with the problem. People that sit on cramped trains or planes for hours should get up every so often and stand on their toes and move the seat back and forth to help push blood through the system.

As we age, there are a number of internal and external forces that contribute to the development of facial lines and wrinkles, sagging, and changes in pigmentation and texture.  Our skin cells no longer hold the moisture or retain the elasticity that they did when we were young. Free radicals attack the skin cells to initiate damage. Prolonged sun exposure, over the course of a lifetime, and damaging UV rays are the primary culprit.  Cigarette smoking, living in large cities, exposure to pollution, and poor dietary habits all contribute.

Fortunately, over the last 20 years, there have been significant breakthroughs in skin care and facial rejuvenation. Most skincare products now contain moisturizers, sunscreens, antioxidants, anti-inflammatory agents, and vitamin nutrients to help replenish the skin.  Patients are taking better care of their skin, no longer relying on “iodine and baby oil” as a tanning oil.  A beautiful bronze tan at age 20 doesn’t translate to a beautiful bronze tan at age 60.  There are over-the-counter skin care products that also help in exfoliating the skin including low-concentration glycolic peels.  Many patients also use vitamin C and retinoic acid products such as Renova.

Patients that I see in my office consultations vary from those with fine lines and mild skin damage to those with severe damage and deeper lines.  For the more superficial problems such as fine wrinkles and mild pigmentation changes, patients will respond to chemical peels and microdermabrasion.  The chemical peels vary in strength from the milder glycolic acid peels to the more invasive TCA (trichloroacetic acid) peels.  For patients with more severe skin problems, we offer fractional CO2 laser treatment and erbium laser treatment.  These allow penetration into the deeper layers of the skin in order to promote collagen growth as well as treat the more superficial problems.

For forehead lines and crow’s feet, Botox has become the standard to relax the muscles and diminish these lines.  For lines around the mouth and to augment soft tissue that’s diminished in the cheeks, dermal fillers such as collagen (Evolence) and hyaluronic acid (Juvederm, Restylane) are the treatment of choice.

As the holiday season approaches, there are many parties and benefits to attend. Patients want to look refreshed and rejuvenated without significant downtime. They are looking for what I call “quick fixes”.

The most common procedures that we offer are Botox injections, to relieve the wrinkling of the forehead, crow’s feet, and frown lines, and dermal filler injections to plump up the cheeks and lines around the mouth. The filters can also be used along the jawline to camouflage mild jowl formation. Most fillers will last up to a year. These include hyaluronic acid fillers such as Juvederm and Restylane, collagen fillers such as Evolence, and more permanent fillers such as Artefill. They’re great for enhancing the lips also.

On the skincare aspect, my estheticians offer Fotofacial IPL, chemical peels, and Microdermabrasion. All of these procedures are intended to remove the superficial layer of damaged skin, by various mechanisms, and encourage healthy new skin formation by stimulating collagen formation in the skin as well as promoting growth factors and improving blood supply.

At the same time, the latest technology in skincare products includes antioxidants to treat free radical damage due to external and internal factors, different soothing complexes including green tea and acai berry to reduce inflammation, and oxygen boosting agents to leave the skin fresher and healthier for the holidays.

 

What is deep vein thrombosis? 

Deep vein thrombosis (DVT), also known as venous thrombosis, occurs when a blood clot (thrombus) forms in the deep veins of the body due to vein injury or sluggish blood flow. These clots can partially or completely block blood flow through the affected vein. DVTs commonly occur in the lower leg, thigh, or pelvis, but can also develop in the arm, brain, intestines, liver, or kidney.

What is the danger of DVT? 

While DVT itself is not life-threatening, the clots can break loose and travel through the bloodstream, potentially causing a pulmonary embolism (PE) if they lodge in the lungs. PE is a serious condition that requires immediate medical attention. Additionally, about half of people with DVT in their legs may develop post-thrombotic syndrome, characterized by chronic leg pain, swelling, and other symptoms due to valve and vein damage.

Characteristics of post-thrombotic syndrome include:

• Pooling of blood
• Chronic leg swelling
• Increased pressure within the veins
• Skin discoloration
• Venous stasis ulcers (leg ulcers)

What is the difference between DVT and superficial venous thrombosis? 

Superficial venous thrombosis, also known as phlebitis or superficial thrombophlebitis, occurs when clots form in veins near the skin’s surface. These clots rarely travel to the lungs unless they move to the deep venous system. Superficial vein clots can be diagnosed through a physical exam, whereas DVT requires an ultrasound for diagnosis.

How common is deep vein thrombosis? 

In the United States, approximately 1 to 3 in every 1,000 adults develop DVT or pulmonary embolism annually, with up to 300,000 deaths resulting from these conditions each year. DVT/PE is the third most common vascular disease, following heart attacks and strokes. While acute DVT/PE can occur at any age, they are less common in children and adolescents and more frequent in those over 60. Over half of all DVT cases are linked to hospital stays due to medical illness or surgery, as extended bed rest reduces normal movement.

Symptoms and Causes

What are the symptoms of deep vein thrombosis? 

DVT usually forms in the veins of the legs or arms. While up to 30% of people with DVT may not show symptoms, some common signs include:

• Sudden swelling in the leg or arm
• Pain or tenderness in the leg or arm, especially when standing or walking
• Warmth in the affected area
• Red or discolored skin
• Enlarged veins near the skin’s surface
• Abdominal pain or flank pain (if clots affect deep abdominal veins)
• Severe headache or seizures (if clots affect brain veins)

Some people only discover they have DVT when a clot moves to the lung, causing symptoms such as chest pain, shortness of breath, coughing blood, lightheadedness, and fainting. It’s crucial to seek immediate medical attention if you experience symptoms of DVT to prevent serious complications.

What causes deep vein thrombosis? 

Risk factors for DVT include:

• Genetic predisposition to blood clots
• Cancer and certain cancer treatments
• Personal or family history of DVT
• Limited blood flow due to injury, surgery, or immobilization
• Prolonged immobility (e.g., long trips, post-surgery recovery)
• Pregnancy or recent childbirth
• Age over 40 (though DVT can affect any age)
• Overweight or obesity
• Autoimmune diseases (e.g., lupus, vasculitis, inflammatory bowel disease)
• Tobacco use
• Varicose veins
• Birth control pills or hormone therapy
• Central venous catheter or pacemaker
• COVID-19

Conclusion

Deep vein thrombosis (DVT) is a serious condition where blood clots form in the deep veins, most commonly in the legs, posing a risk of breaking free and causing potentially fatal complications like pulmonary embolism (PE). While DVT itself is not life-threatening, its complications necessitate immediate medical intervention. Symptoms can vary from none to severe, including leg or arm swelling, pain, and redness. Many risk factors contribute to DVT, such as genetic predispositions, prolonged immobility, surgery, cancer, and certain medications. Awareness and prompt treatment are crucial in preventing severe outcomes. Recognizing the signs and understanding the risk factors can help in early diagnosis and effective management, ultimately reducing the incidence of life-threatening complications.

Body contouring surgery following bariatric surgery may help patients to sustain a long-term improvement in perceived quality of life, a recent study has found.

Researchers at Utrecht University and St. Antonius Hospital in the Netherlands found that patient perception of quality of life after bariatric surgery was significantly better in six of seven domains than it was before surgery.

The investigators measured quality of life in 33 post-bariatric surgery patients at four and seven years after body contouring surgery — a mean of 11 years after bariatric surgery — and retrospectively before body contouring. It is the first study analyzing long-term perceptions of quality of life in a relatively large population of post-bariatric surgery patients, the authors wrote.

The researchers observed a small deterioration in quality of life between the four and seven-year follow-up. The decline could be due to patients acclimating to the appearance of their improved skin resection, the reality of corrective surgery being less than what they expected, and weight regains, according to the study authors.

Reconstructive surgery is a valuable component in a multidisciplinary approach to treating morbid obesity; however, surgeons should be sure to offer realistic and extensive preoperative information about both the possibilities and limits to body contouring surgery to better manage patients’ expectations, the authors concluded.

Dr. Joseph Perlman, a board-certified plastic surgeon practicing in Spring, Texas has treated many patients with skin redundancy after massive weight loss. “Although many patients have undergone surgical procedures, i.e. gastric banding, gastric sleeve, or gastric bypass, my best results are in patients who have lost weight with diet and exercise. In patients post-gastric bypass surgery, it’s very important to make sure that they are healthy from a nutritional standpoint. Some of these patients are anemic or have lost the ability to absorb certain nutrients, because of the bypass. It’s essential to have recent lab work on these patients and to speak with their treating physician.”

Dr. Perlman performs lower body lifts which is a combination of a tummy tuck with buttocks and lateral thigh lifts as well as medial thigh lifts, breast augmentation/lifts, and reduction in skin laxity in the upper arm (Brachioplasty).

The study was published in the November 2012 issue of Plastic and Reconstructive Surgery