Most Popular

BELLEZA

Injectables – What they can do for you

Nobody needs to know. This can be your best kept secret. The secret that keeps you young and beautiful.

One of the most commonly performed cosmetic treatments involves the use of injectable products. There are a wide variety of products that fall into this category. The two most common types of injectable products include neuromodulators and fillers.

The neuromodulators include one of the most widely known products, BOTOX ®. Other products in this same category include Dysport ® and Xeomin ®. For the most part, these treatments achieve a particular result that nothing else, including surgery, can do. And they can be an excellent complement to the results achievable with surgery. The way they work is by selectively inhibiting the activity of the muscle they are injected into. The results start to become noticeable in a few days, reach maximum effect in about 1-2 weeks, and last for 3-4 months.

As a facial plastic surgeon, I take advantage of these properties to weaken the activity of specific muscles in the face that are creating wrinkles from over activity. By inhibiting the muscles, they stop the ability of those muscles to produce a wrinkle. For my younger patients without the wrinkle present at rest, they can help to prevent that wrinkle from ever developing. Once the wrinkle is present at rest, then BOTOX ® and the other drugs in this class can help that wrinkle from getting worse and soften the appearance.

When it comes to the indications for these treatments, there are both on label uses and off label uses. What on label means is that there is a scientific study assessing the treatment for that specific area. An off label use means your treating physician knows how the product works and uses those properties to treat other areas, although no specific study has been done to verify that. Having been around for such a long period of time, many of the uses of neuromodulators are off label. The three most commonly treated areas include the area between the eyes (the glabella), the forehead, and the crow’s feet or wrinkles on the outsides of the eyes. The right dose can really help to soften the wrinkles, removing what some refer to as a less than pleasant resting face or angry appearing face.

In addition to the commonly treated areas, there are many other areas that BOTOX ® can be used to treat. For those patients who tend to wrinkle their nose when they smile, a few units can help these “Bunny lines.” Other patients tend to overuse the muscles of the chin which creates a dimply appearance. This is known as a peau d’orange or orange peel appearance. A few units into select muscles can remove these dimples. For those whose corner of the mouth turns downwards, selectively treating the muscle pulling the corner down can help to turn that frown upside down. A less common treatment for BOTOX ® is to help shape the jaw line. In some people they have over activity of one of the muscles that helps to close the jaw, called the masseter muscle. When this muscle is enlarged it creates a fullness at the bottom and back area of the jaw. Treatment with neuromodulators helps to weaken the muscle, and with enough treatment, shrink the muscle.

For those who are concerned about neuromodulators, I always remind my patients that these are used in much higher doses for non-cosmetic purposes all over the body. This includes treating migraine headaches, overactive bladders, excess sweating, eye lid twitching, and even scar improvement. And despite how they are commonly portrayed in Hollywood, the right treatment does not lead to an artificial or frozen appearance. Although they are not for everyone, for the right patients, as determined with an in person examination assessing not only your anatomy but your medical history, they can be an excellent treatment.

Now one thing that neuromodulators do not do is help with the volume loss that occurs with age or the loss of elasticity of the skin. This is important as many patients walk into my office and point to their entire face, lifting it up, indicating they just need some BOTOX ® to help lift everything. Although surgery is the gold standard for lifting and restoring volume, the other major class of injectables, known as fillers, can be very effective for those who don’t want surgery or are not appropriate surgical candidates.

The most commonly used class of fillers is the hyaluronic acid, or HA, based fillers. The nice thing about HA is that it is naturally found in the body, so the risk of any reaction is quite low. Furthermore, there is a separate product called hyaluronidase that can be injected, on the off chance you didn’t like the result, to completely remove it. It is nice to know there is this “parachute” out there for anyone who has been thinking about trying fillers but worried she wouldn’t like the result. And just as the neuromodulators had many off and on label uses, so do fillers.

One of the early signs of aging is the development of creases around the mouth. These are known as the melolabial (or nasolabial) folds which extend from the nose to the corner of the mouth, and the marionette lines going from the corner of the mouth towards the jaw. These areas develop these creases because as the volume of the cheeks begins to fall, there are attachments to the skin in those creases that don’t move. To treat these areas, you can go at the sign of aging and inject filler directly into the creases, or you can help to restore volume to the cheek and cheek bones by injecting the filler higher up to lift the cheek and soften the creases. In either scenario, fillers can do an excellent job softening these early signs of aging.

The lips are another commonly requested area to inject. Lip injection patients usually fall into one of two categories—those looking for a fuller lip and those looking for improved definition of the lip border and helping to minimize lip stick bleeding without wanting more fullness. As a facial plastic surgeon, I can take advantage of different properties of different fillers to help achieve the desired goals without creating an overdone or “duck lip.” It is quite easy to spot the overdone look, but most people would have no idea those who are treated appropriately have received any treatment, as the results are natural appearing.

One area that is quite delicate to treat is the tear trough, or the area below the eyes. This can become noticeable in those who have eye bags, hollowing around the eyes, or those who have cheeks that have fallen. Given the thinness of the skin in this area, it is always recommended that only very experienced injectors treat this area. In the right hands, for the right patient, amazing results can be achieved. For the novice injector, it is an area prone to irregularities and patient dissatisfaction.

For more superficial lines around the face, more mobile areas, weak chins, hollowing in the temple areas, etc., HA fillers can also help. All in all, there are many different HA fillers. The reason there are so many is they have different characteristics including how much water they absorb after injection, how closely the particles stay together, and how flexible the particles are. This in turn affects how long they last, how superficially they can be injected, and how much fullness they can achieve up to two weeks after injection. As a facial plastic surgeon I take advantage of these different properties to customize a treatment for the individual patient based on his or her anatomy and desired outcomes.

As you can see, there are many options available for injectable facial rejuvenation. Neuromodulators and fillers can help you maintain a more youthful appearance and even compliment surgical results. In order to learn what is best for you, I recommend you consult with a facial plastic surgeon who performs his or her own injections. This way you can learn the various surgical and non-surgical/injectable options to make sure your final aesthetic plan is what is best for you.

 

If you are ready to unleash your beauty, contact
W. Marshall Guy, MD
Facial Plastic & Reconstructive Surgeon
128 Vision Park Blvd., Suite 150
The Woodlands, TX 77384
832.956.1040 | drguyfacialplastics.com

BELLEZA NATURAL CON LA TRANSFERENCIA DE GRASA

El embellecimiento y reconstrucción del seno son algunos de los procedimientos más comunes que realiza un cirujano plástico. Si bien la mayoría de las personas está familiarizada con el uso de implantes mamarios, solución salina y silicona, los médicos también han estado utilizando el propio tejido del paciente, denominado tejido “autólogo”, para la mejora cosmética y la reconstrucción de senos, durante más de 100 años. En 1895, el Dr. Czerny realizó la primera reconstrucción de seno cuando trasplantó un crecimiento graso benigno, también denominado “lipoma”, del flanco dorsal a los senos. Desafortunadamente, el procedimiento no tuvo éxito y por ello las opciones para la reconstrucción del seno fueron abandonadas.

Ahora sabemos que las piezas grandes de tejido, como los lipomas grasos, no pueden aclimatarse en una nueva área a menos que exista un flujo sanguíneo adecuado para penetrar en los tejidos trasplantados y permitir la transferencia de nutrientes a las células grasas. La historia más moderna del uso de grasa autóloga para la mejora cosmética de los senos se ha realizado desde la década de 1950. La historia de la reconstrucción mamaria y el aumento con grasa autóloga continuó y se aceleró en la última década. Esto se debió en gran parte a los avances realizados con la transición a la mamografía digital, que luego se mejoró aún más con una tomografía tridimensional, incluso disminuyendo el costo asociado con los MRI de seno. Estas modernas modalidades de imágenes ahora permiten a los radiólogos y cirujanos diferenciar de manera más precisa los cambios postquirúrgicos normales de la transferencia de grasa.

Además, ahora tenemos una comprensión científica más fundamental de la fisiología de la grasa y sus acciones cuando se ha transferido de una parte del cuerpo a otra. Los sofisticados estudios de laboratorio molecular ahora permiten afinar las técnicas para lograr mejores resultados y la retención de la grasa transferida. Las técnicas quirúrgicas se han desplazado hacia la recolección y transferencia de lóbulos más pequeños de grasa que se recolectan en un sistema de presión bajo y constante, y se mantienen fuera del cuerpo del paciente durante un tiempo mínimo. La redistribución uniforme dentro del tejido mamario mediante técnicas de microinyección y “enhebrado” permite un flujo sanguíneo máximo para mantener la grasa trasplantada, lográndose así una mejor asimilación de parte de la mama receptora.

La comprensión de la cantidad de grasa que es segura para transferirse, a menudo está determinada por la envoltura del tejido del seno. Lo comparo con una bolsa de compras. Hay un punto final del volumen máximo de transferencia de grasa que puede acomodar individualmente cada seno. Este límite se ha apreciado como punto final de la transferencia al seno, ya que permanece por debajo del máximo admisible para que los nutrientes puedan circular aún fuera del tejido. Los pacientes de pechos densos, más jóvenes y sin estiramiento significativo de la envoltura de la piel, que serían pacientes que no tuvieron hijos, acomodarían mucha menos grasa que madres que amamantaron y tuvieron una congestión mamaria previa y estiramientos del sobre de la piel. También la edad menopáutica coincide con la disminución de los estrógenos circulantes y la convergencia de los tejidos blandos de los senos del tejido glandular al tejido adiposo, y puede acomodar de 2 a 3 veces la cantidad de transferencia de grasa en comparación con un tejido glandular mamario más joven y más denso.

Para monitorear esto durante la cirugía, usamos técnicas de medición sofisticadas para observar la presión del tejido interno durante la transferencia de grasa y mejorar la transmisión de la misma, y así proporcionar un punto final de transferencia para evitar consecuencias no deseadas como la degradación y la disolución de la grasa transferida, también llamada “necrosis grasosa”, que puede conducir a bultos y protuberancias junto con una disminución estética. Un mayor avance en nuestra capacidad para realizar procedimientos de injerto de grasa para la reconstrucción mamaria y cosmética es el uso de la expansión de “presión negativa”. Esto se logra con un dispositivo externo denominado BRAVA, que es una gran cúpula de succión con relleno de silicona que está conectada a la reconocida marca de bombas Medela, de Suiza. Muchas mujeres están familiarizadas con Medela ya que fabrican una amplia gama de extractores de leche para la obstrucción durante el período de lactancia. El uso de la bomba es una presión ligeramente diferente a la bomba de extracción de leche, pero el efecto de la presión negativa sobre el seno es que promueve una leve hinchazón y congestión del mismo, creando un espacio anatómico virtual junto con una mejora del flujo sanguíneo. En previsión de una transferencia de grasa al seno, las pacientes que son candidatas adecuadas para la expansión, utilizarán este dispositivo antes de la cirugía durante una semana y después de la cirugía durante 3 días, para permitir que se transfieran mayores cantidades de volumen de grasa, mejorando así el injerto de la grasa transferida dentro del tejido mamario.

Otra ventaja del uso de tejido autólogo para mejorar el seno es el beneficio de permitir la lipoescultura del cuerpo. Muchas veces, la silueta de una mujer aumenta no solo por el tamaño y la forma de los senos, sino también por el contorno del abdomen y los flancos en relación con el tamaño y la forma del seno. A medida que la edad avanza, la obesidad debida a los cambios hormonales es común y la lipoescultura quirúrgica durante la cosecha de la grasa mejora la silueta y la silueta general del cuerpo, ofreciendo como resultado una apariencia más femenina y atractiva.
Muchas pacientes se preguntarán por qué la transferencia de grasa al seno no es un tratamiento convencional. Hay algunas razones para esto. Actualmente, los cirujanos plásticos y reconstructivos de senos estamos sometidos a un vasto registro multinacional para la transferencia de grasa en pacientes del seno. Han habido compañías que invirtieron en tecnología para facilitar esta técnica quirúrgica al agregar grasa “mejorada” junto con la grasa de liposucción regular. Esto creó células regenerativas derivadas de tejido adiposo que estaban formadas por células muy pequeñas y que tenían propiedades similares a las “células madre”.

Las células regenerativas que están presentes en el tejido graso alrededor de los capilares se recolectan durante el proceso de liposucción y se extraen con un sistema automatizado. La FDA tenía inicialmente preocupaciones que involucraban la concentración de estas “células madre” con el potencial de expandir los diversos tipos de tejidos e introducirlos en el seno. Se consideró que la presencia de estas “células madre” dentro del seno, podrían colocarse cerca de una lesión microscópica precancerosa, y que esto pudiera acelerar su desarrollo. Esto condujo a una obstrucción de parte de la FDA en la utilización de la tecnología del uso de “células madre”. Curiosamente, se ha encontrado que no existe una diferencia apreciable al agregar el uso de “células madre” derivadas de tejido adiposo a la grasa de liposucción habitual utilizada en la transferencia de grasa.

La segunda razón por la cual esta técnica no es ampliamente usada todavía es el costo. Mientras que los pacientes vienen en todas las formas y tamaños, casi todos tienen la grasa adecuada necesaria para transferirla a sus senos, ya que la cantidad relativa de grasa necesaria para mejorar los senos es bastante pequeña en comparación con la cantidad disponible en el cuerpo promedio, incluso de una persona delgada.

Adicionalmente, no hay una ventaja significativa en la industria para el uso de tejido propio de los pacientes para la reconstrucción de senos, ya que esto anula el uso de opciones disponibles más costosas. A modo de comparación, el uso de expansores mamarios de silicona, productos de reemplazo dérmico para usar las eslingas en la parte inferior para cubrir los expansores después de la mastectomía y luego cambiarlos del expansor para implantes permanentes, puede superar los $20,000 por cirugía. En comparación, el costo total de los productos desechables para transferir la grasa, a menudo es inferior a los $1000 por paciente. Por lo tanto, no existe ningún esfuerzo publicitario por parte de la industria de la cirugía plástica para impulsar el injerto de grasa al seno. Informar y educar a los pacientes sobre esta alternativa y su idoneidad para esta opción quirúrgica, queda así en manos de los médicos.

Al consultar con mis pacientes, les hablo sobre todos los procedimientos disponibles. Cada uno tiene sus preferencias. Para algunos, se busca una mejora de aspecto más natural de los senos; en otros, un polo superior más pronunciado y completo de la porción medial superior de los senos en el escote es el resultado deseado. El trabajo de un cirujano plástico es adaptar el procedimiento al paciente y sus deseos.

Otra ventaja del injerto de grasa en el pecho es la longevidad del procedimiento; dado que no hay producto artificial dentro del paciente, generalmente se evitan las complicaciones a largo plazo, como sucede con el uso de implantes artificiales. Hay menos posibilidades de que se necesite una cirugía de revisión para abordar las temidas complicaciones de los implantes de silicón. La extracción artificial del pecho y la asimetría son menos probables con el uso de grasa autóloga. Para la reconstrucción de senos, un aspecto positivo de usar grasa autóloga es que la sensación se preserva mejor en el pezón.

Esto se debe a que los nervios de la zona mamaria pueden crecer desde la mastectomía profunda hasta la superficial, al no tener barreras mecánicas, como un implante de silicona.
El costo promedio para la reconstrucción de senos con grasa autóloga es más bajo y se usan métodos tradicionales debido a que no se requieren costosos implantes ni prolongación del tiempo quirúrgico microvascular. Típicamente, la transferencia de grasa autóloga para la reconstrucción de senos implica de 3 a 4 procedimientos, lo cual es menor que el número promedio de procedimientos necesarios para el implante y el expansor. En comparación con la transferencia microvascular libre, la reconstrucción de senos con liposucción de grasa autóloga a menudo tiene un número equivalente de cirugías, pero las cirugías son ambulatorias; los pacientes vuelven a casa el mismo día y pueden regresar al trabajo típicamente en 3 a 4 días en lugar de 5 a 6 semanas con reconstrucciones microvasculares DIEP. También el dolor después del procedimiento de transferencia de grasa es a menudo menos severo, dado que no hay intrusión en las costillas como ocurre con implantes artificiales.

Si bien una misma técnica no es necesariamente la solución para todas las condiciones de los pacientes, la transferencia de grasa autóloga continúa evolucionando como una extraordinaria herramienta y se ha vuelto cada vez más popular a medida que los avances y la tecnología están más disponibles para el cirujano. Hable con su cirujano sobre los antecedentes y el nivel de comodidad de la grasa autóloga al explorar opciones para la reconstrucción y la mejora de sus senos.

_______

Para obtener más información acerca de la transferencia de grasa a los senos, solicite una consulta experta con
Jason R. Bailey, M.D.
5600 Kirby Dr., Suite S, Houston, TX 77005
713.588.3800
www.JasonBaileyMD.com

Aging Neck – How to treat it effectively

Unfortunately, some of the earliest signs of aging can be seen in the neck. This may take the form of vertical bands running from the chin to the décolleté, skin sagging down in the jowls and neck, wrinkling of the skin, and development of a double chin. The good news is there are many different treatment options directed towards each of these problems. To appreciate why you see those signs of aging, a little anatomy lesson is in order.

Around the front of the neck is a large muscle, called the platysma. It starts around the ears and goes towards the collar bone, then comes forward and has fibers that join together the two sides of the muscle in the middle. This muscle then attaches to the overlying skin and depending on a combination of genetics, diet, and exercise, there may be a noticeable amount of fat both in front of (pre platysma) or behind (post platysma) the muscle. Below the jaw line on the sides are two glands that produce saliva, called the submandibular glands. These may or may not be visible, but they can be felt. Gravity also can pull these glands down creating fullness below the jowls. Finally, the way you bend your neck can create horizontal lines running across the neck. These lines begin to develop when you are younger and can become more pronounced with time. With this in mind, what can be done to improve the appearance of the neck?

The double chin, if present, is usually one of the first concerns that will lead people to seek treatment. There is a strong genetic component to this. The fat can develop in front of the platysma or behind it, which affects what can be done to treat it. Stress and weight gain can further exacerbate the appearance and the amount of fullness. The good news is there are several options. The most direct option is liposuction, either laser assisted or alone. Liposuction and direct removal of fat can be quite effective. It allows your surgeon to directly control how much is being removed with an immediate appreciation for the improvement. Liposuction can be effective for younger patients when performed as an isolated procedure. However, once you reach around age 35-40 the skin lacks the elasticity to tighten back up predictably, and if skin tightening is not also performed, you may change a double chin for a turkey waddle of loose skin.

Liposuction and direct removal of fat can be quite effective. It allows your surgeon to directly control how much is being removed with an immediate appreciation for the improvement. Liposuction can be effective for younger patients when performed as an isolated procedure. However, once you reach around age 35-40 the skin lacks the elasticity to tighten back up predictably, and if skin tightening is not also performed, you may change a double chin for a turkey waddle of loose skin. Non surgical treatment for the double chin can also be effective, but the results are best described as delayed gratification. One of the newer options on the market is Kybella ®. This is an FDA approved injectable product that is naturally found in the body and simply dissolves fat. Similar to liposuction, the fat that dissolves is permanently removed, and any future weight fluctuations will always leave the neck looking better than if it hadn’t been treated. Treatment with Kybella® is performed as a series of injections in the office. It takes anywhere from 2-4 treatments that are spaced about 4-6 weeks apart, and it is only approved to treat fat in front of the platysma muscle. The biggest benefit of Kybella is that there is no down time, and the treatment takes only a few minutes in the office. Another treatment option for the double chin is CoolSculpting ®. This involves the application of cold temperatures and suction on the double chin to physically kill the fat, and then the body absorbs it. Treatment takes anywhere from 35 minutes to an hour depending on the version of the device used. For heavier necks, multiple treatments may also be needed. There are other non invasive treatments out there that are approved for other parts of the body that may eventually gain approval for the double chin as well.

For those patients with loose skin being more of the problem, then liposuction, Kybella ®, and CoolSculpting ® would not offer much. For minimal skin laxity, especially in the jowl area, and for patients with good skin texture and tone, Ulthera ® can be effective. Ulthera ® works by using high intensity ultrasound to deliver heat energy to the deeper structures and effect skin tightening. It won’t address fat, but it can be combined with other treatments. Other technologies that are designed to improve the area include radiofrequency technology like Thermage ® and more invasive treatments like ThermiRF ®. To truly address the lax skin, a surgical neck lift may be the best and only option for some patient. This involves a small incision under the chin in a natural crease and a few incisions behind the ears into the hair to physically remove the excess skin and take out the slack. This can also be combined with liposuction to create very impressive results.

If vertical bands in the neck are more of the problem, then your options become a little more limited. Botox ® or another neuromodulator like Dysport ® or Xeomin ® may help to soften the bands. What these bands represent are the front edges of the platysma muscle. Neuromodulators are designed to weaken the muscle in that area so the band won’t stick out so much. The results tend to not be very dramatic, but they can be effective for mild bands. The other option is surgery which involves addressing those muscles. This is more invasive but produces a longer lasting and more dramatic result.

If the skin has appropriate tone but the texture is beginning to show mild wrinkles, then resurfacing procedures and even topical products may be all that is needed. It is important to realize that the neck skin is thinner and a different quality than the facial skin. Because of this, treatments used on the face may not be appropriate treatments for the neck. Topical products with low concentrations of vitamin A derivatives and light resurfacing treatments can work to improve these findings. For the more prominent horizontal bands there is no excellent treatment, but these options may help to soften the harshness of the line.

As it may be evident above, the gold standard for neck improvement is surgery. But surgery is not for everyone and everyone is not a surgical candidate. With that in mind, it is important to learn about all of the various ways to improve the different neck conditions. With all of the various treatment options out there, how can you decide what is best for you? The answer is you shouldn’t be deciding. It is a very complex area with many different options depending on your anatomy, your goals, your downtime available, and the time course you are hoping to get results. Because of this, it is always best to seek a consultation with a facial plastic surgeon to learn about the surgical and non surgical options for you. For some necks, surgery is the best and only option. For other patients, one or a combination of treatments will produce the best result with the least downtime. At your consultation you can learn about the expected outcomes, the treatment timeline, and what to expect during and after each treatment.

_______

For more information on this and other plastic and reconstructive surgery procedures, please contact:

W. Marshall Guy, M.D.
Facial Plastic & Reconstructive Surgeon
128 Vision Park Blvd Suite 150
The Woodlands, Texas 77384
832.956.1040 | drguyfacialplastics.com