Eyelash Extensions

As a plastic surgeon, it is important to look globally at the face. For example, when examining a patient's nose, it is also important to examine his chin and neck to ascertain that the nose, the chin and the neck are in proportion. Likewise, when examining a patient's eyes, it is also important to examine the surrounding structures, especially the eyebrows and eyelashes.

Recently, eyelash extensions have become increasingly popular. Two twin brothers from Vietnam, Daniel and Jimmy (known professionally as Twin Magic), are on the cutting edge of this trend. My dear friend, Anastasia, told me about Twin Magic, so I invited them to come by the office to demonstrate the extensions. Daniel and Jimmy applied the extensions to the girls in my office, including Amanda, Carol, Cindy, Mona and Sue. Over the past several months, I have been increasingly impressed with how well the eyelash extensions complement my eyelid surgery. Eyelash extensions have become an integral part of the overall peri-orbital (peri-orbital refers to the area surrounding the eye) rejuvenation for my patients.

The initial application takes up to two hours, since each eyelash is applied individually. Touch-ups are required every few months, but the touch-up process is much quicker than the initial application. Twin Magic also gives the patient advice on conditioning the eyelashes and follows the patient carefully to determine when it is necessary to take a break from the eyelash extensions, which requires removing them temporarily every several months.

To see Twin Magic's work, simply open People Magazine or turn on Entertainment Tonight, since Naomi Campbell, Sofia Milos, Joss Stone, Lauren Sanchez and many others have been to the office to get Twin Magic's eyelash extensions.

The Tear Trough

A rarely discussed area of the face is the tear trough (or nasojugal groove). The tear trough is the groove located where the lower eyelid meets the cheek. Some people have just a hint of a groove and others have an extremely deep groove. It is often hereditary and typically gets worse with age. People often complain of "dark circles" when referring to the tear trough deformity.

There are various treatment options for the tear trough. One option is fat grafting. Fat is taken from another part of the body (abdomen, inner thigh, knee), placed in a syringe and carefully injected into the tear trough. Because the lower eyelid skin is the thinnest skin on the body, there is a risk if the fat lumping and becoming visible. Some of the fat is absorbed by the body, although a certain amount remains as living, viable fat cells.

Another option is a silicone implant. This implant, made of solid silicone rubber, is not commonly used, but it is an option for some people. Again, because of the thinness of the skin in this region, the implant can be visible.

There are a few options that I prefer, some surgical and one non-surgical:

1. Non-surgical -- I have had tremendous success with Restylane injections to the tear trough. Surprisingly, these injections are virtually painless and require just a topical anesthetic cream. The Restylane is placed deep to the skin just above the orbital bone, to minimize the risk of visibility or lumps. The best results are seen in patients with relatively thick skin, since the risk of lumps is minimized in these patients. Older patients with thinner skin are best treated with a thinner soft tissue filler, such as Cosmoderm. Bruising is fairly common with this procedure, but it can be easily covered with makeup. A recent study showed that bruising occurred in 50% of patients and minor irrecularities occured in 20% of patients. The Restylane typically lasts more than six months in the tear trough.

2. Surgical -- There are two good surgical options for the tear trough:
(a) Fat transpostion. This is probably my favorite surgical option that addresses only the tear trough. In this procedure, fat that is already present in the lower eyelids (the lower eyelid 'bags") is slid down (or "transposed") into the tear trough. Because this fat is living fat (it is left attached to its blood supply), it does not slowly go away like injected fat (see above). The incision can be either inside the lower lid or on the skin just below the lashes.
(b) Cheek lift. This is another great option to soften the tear trough. In addition to softening the tear trough, it also results in a more youthful appearance to the face in general, since it involves lifting the cheek up to cover the tear trough. The cheeks fall with age, so the cheek lift simply puts the cheeks back to where they once were. There are various ways to do this. One involves an incision in the hairline near the temple. Another involves an incision in the lower eyelid.

Face Transplant

The recent partial face transplant performed in France reminded me of the time I was the medical advisor for the movie Face/Off in 1996. The director that initially signed on to direct the then-untitled film ,Italian director Marco Brambilla, came by my office to discuss the project. I just assumed that we were talking about a relatively low-budget production. We discussed how we would portray the procedure on film and Marco toured my office and operating room taking photographs of the facilities and equipment. As Marco left, I wished him good luck in Hollywood, thinking that he was new to the United States and that he must be excited about directing what I presumed was one of his first movies.

Two days later, I am reading an article in the entertainment section of the LA Times about Sly Stallone. As I am reading the article, there is reference to the director of Stallone's big budget film Demolition Man. The director was none other that Marco Brambilla. I began to think that this small sci-fi film about two people exchanging faces may not be so small after all. Marco must have thought it was strange that I wished him good luck in Hollywood!

A few months later, I get a call from John Woo, the new director of what was now called Face/Off. Marco was off the project. John said that they had signed Nic Cage and John Travolta to star and that they were ready to start shooting. "Will you be able to come over to the set at Paramount to advise us on how to portray the procedure of Nic and John trading faces?" I agreed to come to the set the following Saturday and I arranged for a Coherent carbon dioxide laser to be delivered to the set. The CO2 laser looked high tech and would fit the role perfectly. I was trying to decide how to portray the procedure on film. Should I go with a realistic portrayal of a face transplant or with an imaginary, sci-fi type procedure?

John Woo, the cast and I discussed the options and we decided that the best way would be a stylized, sci-fi approach based loosely on real surgery. We decided to use the CO2 laser in a realistic way to make the incisions for the face transplants, but we decided not to get into more of the specific anatomic maneuvers that would be used someday in a real face transplant. I explained to the cast and crew that we would some day in the future be performing face transplants just like we perform liver transplants and kidney transplants today. In real life, we would not only transplant the face, but we would also need to transplant the arteries, veins and nerves of the face. We would also need to prescribe medications that would prevent the recipient from rejecting the new face. Although we all agreed that this was a very an exciting concept, but we felt that keeping things simple would be preferable for the movie.

It seems like only yesterday that we stood on the Face/Off set at Paramount talking about how someday in the distant future, a real face transplant would be performed. Little did we know that only eight years later, an actual face transplant would be performed on a real patient in France.

Restylane

In many practices, Restylane injections have replaced collagen injections as the soft tissue filler of choice. Restylane (hyaluronic acid) typically lasts six or more months, whereas collagen lasts three months. Restylane and collagen are typically used for the same purpose, namely soft tissue augmentation of the face. Some of the most popular areas for soft tissue augmentation with Restylane include the lips, nasolabial folds (smile lines), marionette lines and the nasojugal grooves (hollowing beneath the eyes). It can also be used for filling in irregularities the face after trauma or surgery. Restylane injections are much more painful than collagen injections, so many physicians administer nerve blocks, so that the entire peri-oral area (the area around the mouth) is numb for a few hours. This is the same thing dentists administer before they work on your teeth. Topical numbing cream is also usually used. Restylane is also more painful than collagen when the nerve block wears off. I have patients who told me their lips hurt for several days after Restylane injections. The lips are also swollen for a longer period of time with Restylane (three or four days v. one or two days with collagen). Allergic reactions are almost unheard of and the manufacturer doesn't recommend a skin test prior to treatment. A skin test is necessary prior to being treated with collagen because collagen comes from cowhide; therefore, there may be cross-reactivity because a protein from another species (cow) is being injected. Restylane is made of a substance called hyaluronic acid, a substance that is naturally found in humans.

In my practice, I use Restylane in 98% of my patients that request a soft tissue filler. A few patients still prefer collagen. If I don't use Restylane and the patient doesn't specifically request collagen, I tend to use a product called Comoplast, which genetically engineered from human skin. No skin test is necessary, since it from human skin, not cow.

Restylane is a bit too thick for fine lines, so I will often place Restylane in the deeper portion of the fold and place Cosmoderm (a thinner version of Cosmoplast) on top of the Restylane closer to the surface of the skin. This results in a better result that just Restylane or just Cosmoplast or Cosmoderm alone.

A thinner version of Restylane (Restylane Fine Line) is not yet approved in the US, nor is the thicker version called Perlane.

Mesotherapy

Mesotherapy involves injecting various medications and substances into the tissue beneath the skin. Although patients are constantly clamoring for procedures that are quick and painless with no downtime, there needs to be real, scientific data on these new procedures before most plastic surgoens will recommend them.

A comprehensive article in the April, 2005 issue of the definitive plastic surgery journal, Plastic and Reconstructive Surgery, found virtually no scientific data on mesotherapy.

Here's a little background on how some procedures become known by the public before there is solid data behind them:

Most plastic surgeons insist on seeing peer-reviewed scientific studies before recommending a treatment, but many physicians will offer a new procedure to drum up business. Many of these physicians really don't care if the procedure is effective or not. The media is always asking "what's new" when they call doctor's offices. They want the latest and greatest procedure. However, the media doesn't care if the procedure is effective or not, as long as they get a great story about this new breakthrough procedure. Frankly, if the new procedure is an absolute disaster and causes unforeseen complications, that's an even better story!

Scenario #1: A local reporter calls the doctor's ofice and asks "What's the newest, cutting edge thing you're doing?" The doctor answers "I'm doing this new procedure that was just brought to this country from Europe and I am the leading expert in this country and I am one of the only doctors currently doing it." The reporter says, "Really? I'll be right over." The television crew comes to the office, the doctor performs the procedure (on one of his nurses, perhaps) and the patient exclaims how simple and painless it was and how much she loves the results.

The segment airs on the local news, the beauty magazines all run articles on it and the doctor is on Oprah the following week. His office is swamped with calls requesting appointments with the leading expert with this new procedure and everyone is happy.

Scenario #2:

A reporter calls the doctor's office and asks "What's the newest cutting edge thing you're doing?" The doctor has been aware of Mesotherapy for some time, but because he prefers to wait for some solid scientific data about the safety and efficacy of Mesotherapy before offering it to his patients, he responds vaguely about various advances in the field of plastic surgery. The reporter becomes bored and thanks the doctor and hangs up, calling other doctor's offices looking for a better story.

There is no standard formula for mesotherapy.