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What’s new in facial fillers: Juve’derm Voluma XC

Posted on: July 30th, 2014
By: Jeffrey Nelson

There are many choice for facial fillers to correct fine lines, deeper wrinkles or to add real volume to the face. Juve’derm Voluma XC is the new kid on the block as a true volume filler for the midface and cheeks. The FDA approved Voluma XC for midface filling in early 2014, which makes it a fairly new product. Voluma is still a hyaluronic acid product like Juve’derm Ultra plus XC , Restylane-L, Perylane, or Belotero to name a few. Each new product even if made of Hyaluronic acid (H.A.), like many established products, still has to go through FDA guidelines to get approved so expect to see many different spin offs of hyaluronic acid over the next few years to fit specific needs for types of filling. Hyaluronic acid (H.A.) is a fancy chemical name for something your skin is naturally made of. Hyaluronic acid (H.A.) is a form of gel (think of jello) that our collagen and cells, blood vessels and nerves travel through as part of our skin. Hyaluronic acid is also known as hyaluronan. Oddly enough, back when I was a youthful general surgery resident much of my research related to collagen and hyaluronan. Little did I realize that many years later I’d be using these hyaluronan products all the time for cosmetic improvement for my patients.

So if hyaluronan is a regular part of our skin why are there so many product options. Of course one reason is pure competition by different medical product companies for parts of the market. Competition to make better products is always a good thing. More important for you the patient is to realize that each product is slightly different to fit different purposes. Voluma, to keep the concept simple, is a thicker denser form of hyaluronan than the other Juve’derm products so it can last up to 2 years, but is also designed to be placed deeper into the tissues to create a true volumizing of the face. Voluma is not meant to be used close to the surface under an individual wrinkle like Restylane or Juve’derm might. The differing densities of the hyaluronic acid products lets one be better for a real fine line and one be better for a deeper groove, and Voluma to be better for cheek augmentation as an example. There are other products like Voluma, Radiesse as an example, that can similarly be used for cheek augmentation. Both are great products, both work well, but any given patient might want one or the other for various reason, or any surgeon may prefer using one or the other. At my office I use both routinely and like both products a great deal. For the purpose of this blog we’ll focus on the H.A. product however.

Hyaluronic acid is a hydrophilic molecule. This means H.A. wants to attract water so depending on the density of the H.A. in the gel it pulls water toward it and holds on to water while the body slowly breaks down the product over a long period of time. This hydrophilic effect is what creates some of the extra volume creation by the product. It’s all pretty cool when you really think about it. We are using a natural occurring molecule that our skin looses with aging and we put it back in specific places and with specific products to get the youthful plumpness back into the skin; pretty awesome really. By changing the cross linking of the hyaluronan and the density of the product we get different degrees of water absorption (like a sponge holding water) and different rates of breakdown of the product. That’s why Juve’derm or Restylane might be great for lip lines, the Voluma would be a bit stiffer and denser and might not feel as smooth in that location. Voluma XC is an excellent midface filler and it’s great to have another option for patients. The XC designation just relates to the product having a little lidocaine anesthetic mixed in with it so the injections are less painful and the area injected gets a little numb quickly so it doesn’t feel achy after the injection. Most injectables we use in our office already has lidocaine in the product or we add it to the product prior to injection. Another nice touch is to use a topical anesthetic before injection that also makes it a more pleasant experience than a straight injection without topical anesthesia. The price of Voluma XC varies greatly from one office to another so it’s often wise to check with a given office what they are charging so you don’t pay a great deal more than you need to. Of course, balance this against the experience of the injector and office.

Take years off your appearance with Intense Pulse Light (I.P.L.) Therapy

Posted on: June 3rd, 2014
By: Jeffrey Nelson

So may Aesthetic options so little time (and of course money).  Plastic Surgery has many terrific options to keep us looking healthy vital and refreshed.  Some of these are completely noninvasive and can take years off your appearance for very little cost.  One such option is Intense Pulse Light or what we call “IPL” therapy.  While patients sometimes think of IPL as a type of laser; it’s not a laser but does use light energy to improve the appearance of your skin.  True lasers use one specific wave length of energy to do its job.  Intense Pulse Light uses a narrow range of wave lengths from the light spectrum for specific purposes.
My IPL system has multiple special energy delivery heads that serve different purposes.  Each head or hand piece has a band of wave lengths that are a part of the light spectrum.  The device has a red, green, yellow & purple hand piece to deliver different methods of laser or light source to the skin.  One head is good for brownish pigment of the skin another for reddish tones another for hair removal as examples.  If you have heard the term photofacials; IPL is that type of treatment.  What has been shown is that patients who do perhaps five photofacials each year over five or more years have skin that is much brighter, healthier and younger appearing after those five years than it was before they were ever treated.  Not only do the color tones improve but the texture, fine lines, wrinkles and general appearance of the skin is improved.
IPL treatments have a nominal cost to our patients and there is no downtime.  Photofacials or IPL  treatments are great first steps in keeping your skin looking refreshed when blended with quality skin care. Come see us for a skin care consult and start turning back the clock.

Breast Reconstruction: Nipple areola delay

Posted on: May 27th, 2014
By: Jeffrey Nelson

Many of the breast reconstruction patients I see are interested in nipple sparing mastectomies. A nipple sparing mastectomy means the cancer surgeon has decided the patient can keep all their natural breast skin including the nipple areola. Certainly keeping your own nipple areola is a nice option; the problem is once the mastectomy removes most of the blood supply coming into the breast’s skin the nipple may not have enough blood to survive. This means as days go by the nipple may darken, dry up & the skin dies a slow death from lack of blood supply. This is what we call “ischemic skin necrosis.” Ischemic is a medical term that means not enough blood supply and oxygen to keep a tissue healthy. Necrosis means it progressed to the point that the tissue didn’t survive. So when someone has a heart attack the heart is “ischemic” with less blood, and if it’s bad enough it’s called a myocardial infection for part of the heart muscle died. So when a cardiologist does a heart catherization they can put in a stent or use the medications to open the vessel blockage affecting the heart. In plastic surgery we can’t do much to help skin with poor blood supply after it happens so there is a good surgical maneuver I can use on the front end. This classic procedure is called performing a delay to the nipple areola skin. Many years ago plastic surgeons realized that if you partially remove the blood supply to an area of the skin, that over the next few weeks the small blood vessels that are still intact open up and get heartier bringing home blood to the injured skin. If my patient is a good candidate for a nipple sparing mastectomy I will often suggest that I do a “delay” procedure several weeks or more prior to the mastectomy to greatly decrease the chance the patient will have any healing problems with the skin of the nipple areola. The delay procedure means I will make a small incision that allows me to separate the nipple areola from the breast underneath for an inch or two around the whole areola. This delay procedure removes the connections to little blood vessels coming up through the breast so that the small blood vessels in the skin get bigger and stronger so when the mastectomy is performed the nipple’s blood supply is already more robust. The delay procedure is a fairly minor operation and often can be performed with local (numbing injections) anesthesia in the office.
Not everyone is a good candidate for a delay procedure. Large pendulous breasts are poor candidates compared to smaller breasted patients. Also a candidate for nipple sparing mastectomy who has a large projecting nipple needs to consider a delay procedure for their nipple is more at risk for ischemia post mastectomy than a small flatter nipple. For information on skin and nipple sparing mastectomy look at that blog.

Breast Reconstruction: Skin and Nipple Sparing Mastectomies

Posted on: May 23rd, 2014
By: Jeffrey Nelson

Patients have great interest in skin sparing and nipple sparing mastectomies these days.  Classical mastectomies used an incision across the central breast mound removing the nipple and areola as well as several inches of skin medial and lateral to the areola.  This approach gives great access to reliably remove the breast tissue, but because of the amount of skin removed I’d have to replace that lost skin with skin from elsewhere. To replace the lost skin we might use tissue from the abdomen as in a TRAM flap or DIEP flap, or from the back with a Latissimus flap (learn about these flaps in other blogs). Another option was to stretch the local skin with a tissue expander placed under skin and chest muscle. The expander is a fancy balloon that we can slowly fill with salt water over time to stretch the skin out with time. Once the skin and muscle are stretched adequately we can go back and place a breast implant or the patient’s own tissue into that expanded space to make the form of the new breast.  A skin sparing mastectomy removes as little extra skin as we can get away with, and a nipple sparing mastectomy keeps all the patient’s skin including the nipple and areola.  It’s very important for my patient’s to realize that not everyone is a candidate for a skin sparing or nipple sparing mastectomy.  Patient’s with large pendulous breasts have just too much skin to begin with to make a skin sparing type procedure logical. Mastectomies require removal of all the breast under the chest skin leaving thin long flaps of skin. If these skin flaps are fairly long there won’t be enough blood supply to keep the edges healthy. It’s easy to imagine how a very large breast would have much longer skin flaps than the smaller breasted patient so the blood supply entering the flaps don’t have as far to travel through the skin and back.

Patients also have to realize their cancer location or type may make a nipple sparing mastectomy not a good option. If a cancer is located right under the nipple areola your cancer surgeon will want to remove the nipple areola in that circumstance. As a plastic surgeon I always let the cancer surgeon first decide if the patient is even a possible candidate for skin or nipple sparing mastectomy.  If the cancer doctor says it’s ok than I can advise the patient about whether it’s a good option relative to there anatomy and reconstructive desires. While keeping your own nipple seems like a great idea on the front end, if your skin or nipple dies due to lack of blood supply it can greatly slow down your recovery, be an emotional hurdle you didn’t need, or require another procedure. No one wants more operations, or extra hiccups in their recovery if they can be avoided. An option to make the blood supply more reliable to the nipple is a procedure called a “nipple areolar delay”. This is a simple procedure to cut just enough of the blood supply to the nipple areola weeks prior to the mastectomy so that the blood supply to the skin has improved and gotten stronger so the nipple skin is healthier at the time of the mastectomy. To learn more about the delay phenomenon and it’s use in nipple sparing mastectomies read my blog on Breast Reconstruction: Nipple Areolar delay.

Skin Care for men and women

Posted on: May 15th, 2014
By: Jeffrey Nelson

If there is one thing I can say with a clear conscience is that we all can benefit from skin care.  Living here in Tucson with our endless clear sunny days and very dry climate can be tough on our skin.  You can hydrate all you want, with drinking water; a dry sunny climate is still going to steal some of the vitality from your skin.  This is as important for men as it is for women.  Granted men need a tailored approach that will work for them, but we all need to look after our skin.  In fact we have recently introduced the Turo Skin ™ care line specifically for our male patients.  With specific cleansers, skin care rejuvenators, exfoliants and shave conditioners.  This group of products is tailored for men and doesn’t overwhelm them with too many steps or products.  One advantage of male skin is it’s hearty and usually not unduly sensitive so men respond well over time with consistent use.  I’ve been consistent with my own skin care and close up photos show my skin to be much improved over 10 years ago.  I’ve seen the same effects in many male patients who are committed to mixing healthy skin with their active life styles.

Women routinely have been more accepting of skin care.  Women are more accustomed to cleaning their skin and applying products since it’s not more involved than applying makeup.  It’s just part of the process of feeling good about yourself for my female patients.  Men occasionally need a bit more of a nudge but the benefits can be huge when we look after our most important organ our skin.

“Photo Shopping” the breast with Fat Injections

Posted on: May 8th, 2014
By: Jeffrey Nelson

As Plastic Surgeons we are always looking to refine techniques and find answersto make results better.  “Photo Shopping” out minor defects or irregularities in the breast with fat injections is a good example.  I wish I could clain the term “Photo Shopping” but  I picked that up from collegues using the term over the last few years at meetings.  The concept is a simple one really.  For many years we just excepted, for example, that mastectomy patients would have to accept ripples or contour irregularities of the breast.  Now we can offer fat injections into these defects to smooth out irregularities or “Photo Shop” the breast .  You have to love the term it gives a great visual.

Typically I will liposuction some tummy or medial thigh fat from the patient to use for grafting.  The fat is cleaned of blood and free oils and injected into the breast where needed.  Insurance does not always cover this, but frequently may.  These tequniques are not only used for breast reconstruction, but can also be used in cosmetic breast surgery contour problems.

Like all forms of fat injection procedures I can’t guarantee complete fat graft take so we go for a little over correction expecting to loose a hint of the result.    As you might expect age, tissue quality and thickness all play into the results.  If someone smokes, is diabetic or has significant vascular disease their results are not as reliable as the healthy patient with no medical issues.  Still “Photo Shopping” the breast with precision fat graft placement is a nice new procedure to take our breast surgery results to the next level.

Male Cosmetic Surgery-The Male Neck

Posted on: April 17th, 2014
By: Jeffrey Nelson

As we’ve mentioned before men occasionally feel left out in the wilderness when they look for information about their cosmetic concerns. We can approach some male cosmetic issues a bit differently than women. When it comes to men’s necks the cup is often half full rather than half empty for men often only want a more subtle improvement compared to many female patients. Therefore we have more options for many of our male patients. Women will focus on changes in their necks much earlier than men and also desire a greater degree of change if neck laxity is significant. Let’s walk through some of the main things we need to pay attention to in the neck.
First is skin quality and certainly men having beards, more ruddy complexions, and often moderate sun damage to their necks. We absolutely suggest that the patients consider skin care, photo facials with our “laser” devices; but clearly men aren’t going to necessarily be as concerned about color change or skin texture as women often are. Our male patients might choose to be less aggressive about their appearance of the skin, but they do care about a chubby neck, lots of loose skin, and soft chins.

Many of our male patients may have a family trend to fat deposits in the neck. These patients may do fabulously with simple liposuction of the neck under local anesthesia. A fatty neck makes us loose the masculine definition of our chin and jawline adjust getting rid of some of these fat deposits can take years off our appearance as well as make us look more fit and energetic. On occasion it may be beneficial to do a chin implant at the same time if the chin is truly under projecting. There is always the chance that the skin might be a bit more lax after liposuction, but men have more tolerance to a little laxity compared to many female patients. So for the same degree of neck fat the female patient may want a neck lift also where the male patient may be delighted with just a slimmer neck.
A nice adjunct we have in the office to tighten neck skin is the truSculpt™ radiofrequency device. To learn more about the truSculpt™ look at our noninvasive body contouring blog. In brief the radiofrequency energy deep heats the tissue which can remove more fat as well as get the skin to tighten more. Of course if guys have a really lax neck we need to tighten that skin surgically with a neck lift. One aspect of neck lifting we can often offer men that is rarely used in female patients is direct excision of the neck skin in the mid line. The direct excision approach to skin typically can be done with local anesthesia and a technique of zigzagging the scar with what is called a Z-plasty or a W-plasty. Since men do have thicker ruddier skin and beards we can hide the direct excision scars fairly well, while women wouldn’t look quietly as elegant with the direct approach to that central skin.
Each guy I see in the office has a different threshold for how youthful they wish to look. Some men want major changes, some men want a more subtle adjustment is the jaw and neck lift. The key is we will listen and suggest options that best fit the result you are looking for.

Male Cosmetic Surgery

Posted on: April 3rd, 2014
By: Jeffrey Nelson

Sometimes guys feel a bit left out of the plastic surgery world; this couldn’t be the farthest from the truth.  In general terms men account for fifteen percent of cosmetic surgery.  In our experience this number is on the rise, especially since there are more options to help a guys self image.

When it comes to treatments above the neck guys are great candidates for neurotoxins like Botox Cosmetic, Dysport, or Xeomin.  Men have bulkier facial muscles that can make them look stern or irritated and quieting down muscles at the corners of the eyes(crow’s feet) or between the brows (glabellar area) can make a guy look friendlierand more relaxed.  Botox Cosmetic, Dysport and Xeomin as a group are called neuomodulators.  These injections into over active muscles decrease the squinting lines, the “11’s” between the brows and can soften forehead wrinkles.. Facial fillers are also great adjucts for men to consider to maintain a more virtal look.  As we age we lose volume in our faces and the folds around our mouth deepen, cheeks can deflate, and our jowls sag.  Addng volume to different zones of the face can give energetic contours back without downtime.  There are many different types of facial fillers each with it’s own advantage depending on where or how it is used to revolumize & contour the face.  Restoring your your youthful self.  The neuromodulators and the facial fillers are superb options for men looking for a more vital appearance without a surgical downtime or more signifigant facial changes.  Of course many menmay need to consider some surgical options so keep an eye out for upcoming blogs on specific surgeries for the male patient.




Revisional Cosmetic Breast Surgery: The use of Acellular Dermal Matrices (ADMs)

Posted on: February 14th, 2014
By: Jeffrey Nelson

Breast Augmentation is one of the most common aesthetic surgeries Plastic Surgeons perform. While breast augmentation is a very safe and reliable proceedure, patients can require revisional surgeries over the many years they have implants. Some revisions may be needed due to aging of the breast tissues, breast feeding, weight changes,rippling, broken implants, capsule formation around the implant, or malposition of the original implant. It has become more frequent to use acellular dermal matrices (ADMs) to correct some of these breast issues. What is an ADM exactly? The tissues that make up skin are very strong and dermis is the main strength component of skin. Some ADMs come from human sources and some are porcine (pig) skin derived. Pig skin is biochemically and structurally very similar to human skin. The cells are all removed from the collagen and other components that make up the dermis. This leaves a sheet that can be placed in the body and used to reinforce weak tissue in the breast. These sheets of dermis can help resolve ripping in the breast, reinforce areas where the weight of an implant over time has stretched out breast tissue, or improve control of implants that might be too medially placed (symmastia).
If a patient has very little native breast tissue and over the years forms a thick capsule around an implant we may need to remove all of that capsular scar tissue which may now leave weakened thin breast tissue that had been a bit stretched by the implants over the years. This patients may benefit from the addition of an ADM to give thicker coverage and better internal support to the implant. Multiple manufactures market ADMs and there is no consensus that one is superior than another. These products come in different thicknesses and sizes also so the surgeon will decide what type or thickness of product they prefer. We continue to look scientifically at these dermal products to see if some hold up better than others and try to balance the benefits against the cost or any down sides to the products.
Of course, the cost of ADMs is a significant concern to our patients so they are not necessarily indicated for all patients. Many revisional breast surgeries, if not most, do not require ADMs to fix the problem. That being said however, if a patient has had a revision failure for the same problem it is more likely that an ADM will be suggested or required to fix the issue. The added expense of the ADM product may be well worth it in those cases. As we refine the science of these products maybe someday we can have a readily available one generated by a 3-dimensional biologic printer for nominal expense to our patients. Now that would be fabulous, let’s hope the future is not to far off. For now we will use the best science we have on hand to assist patients with there breast surgery needs.

Noninvasive Body Contouring

Posted on: January 20th, 2014
By: Jeffrey Nelson

Noninvasive Body contouring: Trusculpt, Cool sculpting, Venus Freeze, Velashape, Excilis, Vanquish, Vasershape, Apollo, Zerona

There are so many nonsurgical options for body contouring it will make your head spin. In fact, for all I know by the time I finish typing this blog another company will maybe bring a new device to market. Of course market is the key word here for unfortunately so much has to do with marketing, and less at times with science or results; it’s very tough for patients to sort out the differences between these technologies. Individual offices may choose one or two options to offer patients based on their belief in what works best in there hands, or what fits best for their market. As a plastic surgeon there is the genuine advantage of offering several noninvasive options, but also knowing when surgery or liposuction truly is in the patient’s best interest.

So what are these various technologies and how do they work. First of all every device listed in the title works to some degree or another, some are more aggressive, some less so. Remember all are noninvasive treatments that don’t have the control or power of liposculpting the body, but for many of our patients that is the point. Patients frequently want a non-surgical option with no down time that can greatly improve their body shape without recovery time; just be sure you remain realistic about what these noninvasive body contouring devices can and can’t do.

Trusculpt made by Cutera is a radio frequency (RF) energy source for tissue heating. Radio frequency(RF) is a type of energy generation that passes through tissue and the natural resistance of fatty tissue makes it heat up the fat causing it to “melt away” over time. “melt away fat” is a bit of a misnomer, but gives a good image. What really is happening is the focusing of the heat energy into the fat causes a little bit of damage to the fat cells from the radio frequency energy where the trusculpt is applied. The body slowly “cleans out” and removes the injured fat cells by a mechanism called apoptosis. The best way to explain apoptosis is to realize the body naturally is cleaning up damaged cells in our bodies all the time. There is significant turn over of cells in our liver, our skin, our bowels as examples and the body naturally cleans stuff up through inflammatory mechanisms. We don’t grow new fat cells (unlike the liver or skin) after puberty so once the injured fat calls are removed by apoptosis they are gone for good. So if you trusculpt your abdomen and flanks a couple times over the next few months the tissues will thin out as the body naturally removes the injured fat cells. Another advantage of the trusculpt and radio frequency energy is that it is well documented to help tighten lax skin. Radio frequency has been used for many years as an energy source for tightening facial skin; modifying how the energy is delivered by the trusculpt lets the device decrease fat and tighten the skin at the same time. The patient get two advantages at one time. Several devices listed in the title use radio frequency energy sources to help with body contouring. Each company will tweak the way the energy is delivered such as mono-polar, bi-polar, or tripolar energy delivery. I don’t wish to get into all of the energy physics of polarity in this blog, just think of radio frequency (RF) as a way to heat the fat to injure the cells to allow for apoptosis. Some devices like Velashape will add some vacuum and infrared, Excilis with RF and ultrasound, or Venus Freeze uses multipolar RF and magnetic field energy to do the job. Vanquish is another new device coming to market that drapes over your abdomen to try to treat that abdomen and flanks at one time, but the down side is it can’t be used in other body areas and doesn’t heat enough to tighten skin like the trusculpt might with it’s greater tissue heating.

As I mentioned all devices can work to some degree so why did we choose the options we have. The trusculpt is one of our options and we chose that for several reasons over some of the other RF devices. The trusculpt can get solid results with only  two or three treatments, where many of the other devices can require 6 or more treatments to accomplish the same thing. Many patients just can’t take time out to visit the office that often to see results. Also, patients in our experience like to se results progress more quickly, and if they have to do 6 or more treatments with some of the less aggressive devices they may be taking six months to see real results. We also love the fact that we can use the trusculpt on all areas of the body and aren’t limited to only the abdomen or flanks for example.

Cool sculpting is another body contouring device that’s been on the market for a number of years now. Cool sculpting works by chilling the tissues rather than heating them. The cold injury to the fat, like heating the fat, can cause damage to the cells that leads to apoptosis just like heat damage can. The same process makes the body clear the injured fat cells and the treated area gets thinner over the next few months. Like radio frequency, the cool sculpting definitely works, it’s down side is it requires special heads that suction your tissue into the head and than it freezes the area with cold. The heads only fit certain parts of the body well so it’s limited in how many body areas can be treated. Also up to 10% of patients can have a sudden neuralgia in deep nerves making it impossible to tolerate the freezing so they fail to get a full treatment.  The pain in the nerves doesn’t appear to be long acting, it’s just an intolerance to the treatment. Another aspect of cool sculpting that I feel makes it less useful than trusculpting is that RF is documented to assist with skin contracture and cold treatments don’t have the same documentation for that.

Some technologies use ultrasound energy to lead to cell injury and apoptosis. As long as energy can be focused in a specific direction to cause some degree of cell injury apoptosis can happen and cells removed. More energy may make more heat and give faster results with less treatments, less energy devices will not feel as hot, perhaps only mildly warm, but than may have a harder time getting the same degree of cell injury to lead to “melting the fat” away via apoptosis. Zerona is another device we have in the office for noninvasive body contouring and it is as non invasive as it gets.  Zerona doesn’t heat tissue or damage cells, it uses very low level laser energy to get cells to dump fat into the area around the fat cells which the body than clears out though lymphatic flow. While we have had patients get definite results from the Zerona we do find it less reliable in all patients however so we like to use it in concert with other treatments to further augment our results. I hope this gives a little back ground on non invasive body contouring, feel free to contact us via the internet or at 520 575-8400 if you want more information or to schedule an appointment.


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