Category: Blog

October 23rd, 2013 6-7:30 PM

Join Houston’s Top Plastic Surgeons, Joseph M. Perlman MD, FACS for an evening of education and fun.  Learn about the latest advances in body contouring and facial rejuvenation. Light refreshments will be provided.

Seminar Specials

The event is Limited to the first 30 spots. RSVP today

events@doctorperlman.com|(281)712-8105

There are many over-the-counter products that advertise dramatic results for rejuvenating the skin. Celebrity spokespersons trumpet the benefits of skincare products that turn back the clock, giving the skin a healthy youthful glow, and removing lines and wrinkles in a matter of days. Americans will spend $5 billion on skincare products and cosmetics this year alone. Some of these products are quite pricey, costing hundreds of dollars for a small jar of product that lasts a month. Because the FDA doesn’t monitor or regulate these products, it’s difficult for the consumer to know how much of the benefit they are.

There are certain ingredients that one should look for in any anti-aging product. The ingredients should address the leading causes of aging of the skin: internal sources such as diet and genetics and external sources such as UV radiation, pollution, wind, and smoking. On the cellular level, the damage from free oxygen radicals to cellular DNA, lipid, and proteins affects the integrity of our skin cells including the production of collagen. Since collagen is the main building block of our skin, decreased collagen production will cause noticeable signs of aging such as wrinkling.

Some of the more effective antioxidants occur naturally in the skin including vitamins A., C., and E. Our skin also contains coenzyme Q.-10 which neutralizes free radicals. As we age, our production of these antioxidants decreases. In addition, a diet that is lacking in sufficient amounts of these vitamins also contributes to the aging process.
Vitamin A in its biologically active form is retinoic acid or tretinoin. Vitamin A increases the growth of the epidermis as well as the metabolism of fibroblasts and collagen. They also decrease metalloproteinase which degrades collagen. Topical application of vitamin A products improves fine and coarse wrinkling and pigmentation. One of the more common vitamin A products on the market is Retin-A.

The Vitamin B group contains certain subgroups which improve wrinkles such as vitamin B 3 (niacinamide) and DMAE. Gels containing both of these drugs improve wrinkles, pigmentation, and yellowing of the skin as well as improve sagging.

Vitamin C is the most plentiful antioxidant in the skin. These biologically active forms include ascorbic acid and alpha hydroxy acid. Skincare products containing vitamin C often include tea-based products, which seemed to cause less irritation to the skin. Cellex-C is a common brand but there are many more products on the market that contain this antioxidant vitamin C products have been shown to increase blood supply to the skin, increased gene expression of type I collagen, and thus improve wrinkling, roughness, skin laxity, and sallowness.

Vitamin E is a lipophilic antioxidant. By that, I mean that it scavenges free radicals preventing their damaging lipid cell membranes. Products that contain tocopherols and tocotrienols are Vitamin E products. Studies have shown that vitamin E in combination with vitamin C decreases damage to sunburn cells and thus serves more as a protective agent.

Coenzyme Q. 10 and Squalene are also lipophilic antioxidants that decrease with age and radiation. A synthetic form of coenzyme Q. 10 is idebenone. Alpha lipoic acid is another free radical oxygen scavenger that increases collagen synthesis.

Alpha-hydroxyl acids (AHA) thin out the top layer of skin and speed up the normal process of skin cell exfoliation and regeneration. They can also increase the thickness of the skin and improve the quality of elastic fibers and collagen. Many AHAs occur naturally in foods. Roman women knew the benefits of treating their skin with wine and grapes, which contained tartaric acid, as well as citrus fruits. Ascorbic acid is found in fruits, vegetables Gary products, and tea. Glycolic acid is found in sugarcane and lactic acid is in sour milk and tomato juice. Over-the-counter concentrations of AJ’s are quite low but can be beneficial as a home therapy supplement to in-office chemical peels which are done with a higher concentration. AJ’s continued to be one of the most effective anti-aging compounds.

Botanicals are finding their way into skincare products for their antioxidant properties some of the more common ones include bioflavonoids and anthocyanins. Both of these have antioxidant and anticancer and anti-inflammatory properties. It is for the anti-inflammatory effects that they are probably most useful when combined with other antiaging ingredients.

Pentapeptides have been linked to increased collagen synthesis. One commercial product from Paris, Matrixyl, has been shown to decrease wrinkle depth and volume as well as improve the roughness of the skin even when compared to vitamin C. An eyelid-firming gel that we sell in our product line contains pentapeptides to decrease capillary fragility, reduce inflammation, and speed up the metabolism of red blood cells which cause discoloration.

In addition to using various antiaging products as part of your skincare regimen, it’s important to keep the skin moist. Petrolatum-based products are the most common to maintain the skin barrier to decrease water loss. Glycerin products are key methods, which means that they will actually hydrate the skin rather than decrease water loss. Liposomes also serve a similar function.

In choosing skincare products. Read the label to see if it contains the proper ingredients. Establish a good regimen of gently cleansing your face as well as using toners, anti-aging products, and moisturizers.

Decorative tattoos have been part of the culture for thousands of years. No longer is it limited to military personnel and athletes. We’re seeing many younger patients, especially women, getting exotic tattoos often in multiple locations. In the United States, it’s estimated that 25% of women between the ages of 19 and 35 have a tattoo.

Although many choose to have a small tattoo placed on their body in an area that’s easy to cover with clothing, we’re seeing more patients with tattoos on their lower arms and necks. These are obviously difficult places to cover with clothing. The reasons for removing the tattoo include “outgrowing the usefulness or novelty,” “my job prohibits me from having a tattoo that can’t be concealed” or “I’m no longer married to or dating the person whose name is on the tattoo.” The Harris County Medical Society, of which I’m a member, offers a “De-Tag” program for juveniles who are in custody to remove gang tattoos. Members of the Medical Society donate their time and the laser companies donate lasers and technicians to spend a few hours on a Saturday to help these young men and women try to get a new start on life.

A few tattoos can be covered with a heavy concealer, on a temporary basis, but most patients want the tattoo removed. Over the years there have been a number of techniques to expunge the dye. This includes using coarse salt and a sponge to scrub the ink out, or abrasion to sandblast the dye, freezing the tissue, and using creams to try to leech out the dye.
With the development of lasers, including Q-switched lasers in particular, physicians are able to target specific colors in the tattoo to selectively fracture the pigment granules so that they can be absorbed with less scarring.

Tattoo removal is a multi-treatment process, even with a simple black tattoo. Because of the multiple colors in many tattoos, it is necessary to use different lasers or filters. The laser light has to be specific to that color so it’s absorbed at a maximum rate. Each of the colors has a different wavelength. A green laser beam such as in the 532 nm range, will be absorbed by red pigment, and a red laser beam will be absorbed by green pigment such as in the alexandrite 755nm laser. The 1064 NdYAG laser light is absorbed by water so it is not color specific although this laser frequency works well on black or dark blue tattoos.

When I see a patient with a single color dark tattoo, I explain that it will take at least five sessions to treat the area. The goal is to burst the tattoo pigment into small enough pieces that the body will absorb it. Unfortunately, the area where there was a laser is now left lighter in color than the surrounding skin. This is fine for someone who’s fair-skinned but in a darker-skinned individual, this can leave a noticeable remainder of the tattoo that was. I also explained that the tattoo removal generates heat and treatment may end up causing hypertrophic scarring.

Some patients do not want to go through the time and expense of multiple laser treatments and would prefer to have the scar removed surgically. This can be done in a single session with small enough stars that the world could be closed without significant tension. Unfortunately, many patients have large stars that require multiple excisions of small areas of the tattoo until the tattoo is totally removed.

It is said that “the eyes are the windows to the soul”.  They are the major focus when people are looking at you, and are also one of the major areas of facial aging.  The eyelid skin is very thin, approximately 1/7 as thick as the cheek and forehead skin.

As we age, our skin cells no longer retain water, as they did when we were younger.  In addition, external forces such as cigarette smoking, pollution, and pollen aggravate the swelling of the eyelids, which further stretches the skin.  The eyebrows begin to sag, the upper eyelid skin stretches and the lower eyelids become puffy.  The puffiness of the lower lids is due to the fact that the membrane that holds the eye socket fat in place weakens and the fat protrudes forward, creating bags.

When I first started as a plastic surgeon 25 years ago, the treatment for aging eyelids was the removal of the skin and fat.  This tended to give the eyelids a hollowed look. Over the last 15 years, there have been significant surgical innovations.  Through these many facial rejuvenation procedures, we have become more conservative with the philosophy of “less is more”.  We are lifting the eyebrows through endoscopic incisions, behind the hairline, rather than making the classic “ear-to-ear cut”, or coronal brow lift.  The endoscopic lift minimizes hair loss and numbness of the scalp and improves healing time.  Upper eyelid excision of fat is more conservative and in some instances, the hollow look that one sees in the upper eyelids is actually filled in with strips of skin where the top layer is removed.

The most significant changes have occurred in lower blepharoplasty eyelid surgery.  Instead of removing all the fat that “pooches out”, we’re now reinforcing the membrane, shrinking the fat with cautery, repositioning the fat to fill the hollowed tear trough area at the base of the eyelid along the cheek, and repositioning the muscles.  This elevates the cheek to a more youthful position, minimizes the downward pull of the eyelid, and retains the almond shape of the eye.

When I was a resident in plastic surgery training over 25 years ago it seemed that everyone who had a rhinoplasty, or nose job, all seemed to have the same result. The same held true for facelifts in Spring, TX.

Things have changed dramatically in cosmetic surgery. In many procedures, the axiom has been “less is more”. By that, I mean that plastic surgeons have developed techniques to individualize the procedure to the patient’s wants and needs.

Most of the rhinoplasty patients that I see in my practice are interested in keeping the appearance of their nose, but only want it to be more refined, to look better. This holds true, especially in the Caucasian population. In my Asian, Hispanic, and African-American patient population, changes are more radical and the procedures more complicated.
During my consultation, I ask the patient what features of their nose they would like to change. I also inquire if they’re having any internal problems such as airway obstruction, whether they’ve had trauma to the nose, previous nasal surgeries, and problems with allergies. All of these factors influence the final outcome.

The most common areas of treatment are removing the hump on the nasal dorsum, narrowing the nose, refining the tip, changing the shape of the nostrils, and lessening the “gummy smile” that some patients have. It’s important to thoroughly analyze the nasal features and set up a game plan individualized for the patient. In my practice, I often use the open rhinoplasty approach to treat their problems. This technique requires making a small incision in the columella (the skin between the nostrils at the bottom of the nose) and elevating the skin and fatty tissue off the underlying cartilage, which provides the framework for the lower two-thirds of the nose. This allows access to the dorsal hump, as well as for refining the tip, by trimming some of the cartilage and using cartilage grafts to give it a better definition. I can relax the gummy smile, refine the nostril shape and correct any septal problems through this incision.

It’s important for patients to know that the final results may take up to a year to be evident and there may be noticeable swelling for the first four weeks.

The retail industry puts a heavy emphasis on teenagers looking good, wearing the right clothing, listening to the right music, and both fitting into their peer groups as well as standing out as individuals. Adolescence is a tough time in its own right. Children’s body image concerns may be further influenced by sociocultural influences such as dolls, television characters, and characters in children’s books and movies. In many parts of our country, especially in the Sun Belt area, this also means looking into cosmetic surgery.
The American Society of Plastic Surgeons (ASPS) estimates that more than 333,000 cosmetic procedures were performed on patients 18 years of age or younger in the United States in 2005, compared to approximately 14,000 in 1996 [1]. In 2005, one in four of these were surgical procedures such as nose reshaping, ear surgery, breast augmentation, liposuction in Spring, TX, chin augmentation, and abdominoplasty.

Teenagers as well as adults may be concerned about the appearance of their noses and may have functional problems. The nose grows until about age 16, so I usually reserve cosmetic and reconstructive nasal surgery on patients until that age, unless they had a nasal injury such as during sports that need to be corrected sooner.

Protruding ears are a problem that is usually treated before children start school at age 5 but my second “spike” in patients is teenage girls who are just starting to date. It’s interesting that if boys don’t have the surgery done before age 5, they don’t seem to seek treatment much at an older age.

Teenage girls who develop significant breast enlargement during puberty not only have psychological problems because everyone focuses on their breasts, possibly making fun of them, but they also experience functional problems, particularly if they are engaged in sports. Since breast development continues until age 18, and their breasts will also enlarge during pregnancy, it’s very important to assess the maturity of the patient and discuss with the patient and her family the significant outcome of a breast reduction. I have done breast reductions on girls as young as 17, only to have them come back at age 25 after having had a child and developing breast hypertrophy.

I’ve seen teenage girls who have had congenital breast deformities where one breast may be an A cup and the other breast is a C or D cup. These patients certainly should be considered for surgery. On the other hand, a teenage girl with normal breast development who wants to increase her B cup size to a D cup, because she feels this will make her more popular, needs to be looked at differently. The physician has to look at her reasons more critically.

When a teenager comes in for a cosmetic surgery consultation, the plastic surgeon needs to evaluate the patient as they would an adult seeking surgery, but with certain other considerations.

Dr. Michael Bermant recently wrote an article in which he made interesting points regarding the consultation.  Every analysis for potential surgery must weigh the following:

• The purpose for surgery: Is the proposed surgery realistic? Does the patient seem competent to make the decision to have surgery?
• Degree of deformity: Is the deformity noticeable? Are the patient’s expectations for correction appropriate?
• Level of physical maturity: Will the patient grow out of the deformity?
• Social costs: Does the patient suffer socially because of the problem?
• The patient-parent decision: Are the parents supportive of the surgery? Are the parents pushing for the surgery against the patient’s desires?
• Post-surgery patient attitude: Will the patient be able to adhere to a post-operative regimen?

Dr. Phil recently had the topic of teenage cosmetic surgery on his show. The patient who was on the show wanted a breast augmentation and it was evident from watching the show that this patient had significant psychological issues. It reinforced in my mind that dealing with cosmetic surgery issues with adolescents is as difficult a problem as dealing with many of the issues with adolescents, take it from a father of four.