“Doctor…I want to get rid of the bags under my eyes.” This is a common statement that I hear from new patients on an almost daily basis. In order to determine how to fix these “bags” we must first discover what actually causes them. Are they really bags?

The “bags” under the eyes are commonly caused by protrusion of fat from within the eyelids. This is fat that we all have for our entire lives. As we age, two major things happen to cause the lower eyelid fat to protrude: 1) The ligament that holds this fat within our eyelids actually weakens and 2) We lose volume (fat/bone/muscle) from around our eyes and cheeks.

Traditional surgery for lower eyelids often involves cutting out or removing the fat from the lower eyelid. However, I just told you that there were two main reasons for why those bags form. Neither of those reasons mention that our eyelids got fatter! The unfortunate consequence of removing fat from the lower eyelid is that in some cases, too much fat is removed, and the eyelid can actually appear to be hollow.

In most cases, instead of removing the fat, I reposition or place the fat back into the lower eyelid, where it came from. The best analogy is that of treating the fat like a hernia. It herniated out so we reduce it back into the eyelid. Only minimal fat is removed if any at all.

The next step is to fill in the volume that was lost over the years. This is done using the fat from your own body, called fat grafting. The fat is distilled/purified and then injected in very small amounts back around your eyes and cheeks. This is a long lasting/permanent fix to the lower eyelids.

Treating the “problem” will lead to the most natural looking results. I avoid the “surgical look” by following this principle. In the patient above, I treated her lower eyelids with the above mentioned procedures. She also had laser to reduce the wrinkling under her eyes and the crows feet. She is several months after surgery and notice how she looks like a markedly younger woman in the after picture.

For more information you can visit our blepharoplasty page and our fat grafting web page.

Fat grafting is a remarkable procedure performed to rejuvenate the face. As we age, we lose volume in the form of muscle, bone and fat from the face. The distribution of this fat loss will vary from person to person. The art of the facial plastic surgeon comes in when deciding where and how to place the fat.

Without question fat grafting is becoming exceedingly more popular. The effects of fat grafting are seen immediately and for years after the procedure. Since fat has a very abundant supply of stem cells within it, some people are calling the fat grafting procedure a stem cell face lift. This might make sense considering that we are injecting stem cells into the face along with the fat, however until I see definitive evidence that the stem cells play any roll in this, I will not tout it in that fashion. What I will say is that fat grafting works well, very well. As the word is getting out about this no incision procedure, more and more people are turning to it.

That being said, the most common question I get is…”How long does it last?” Fat grafting is a permanent procedure. Live fat cells are removed from the body, purified in my lab, and the transferred to the face (all at the same time). The key is making sure that the fat cells survive the sometimes traumatic process of moving it around. Harvesting, processing, and finally injecting the fat in the proper manner will ensure the longevity of this procedure. So bottom line is that the technique is crucial to the outcome and longevity of the procedure, and you must choose a surgeon very experienced in fat grafting to get the best results.

The photo above is of a patient of mine who is 1 year and 2 months after full face fat grafting. The area I want you to pay attention to is that of her cheeks. Although the entire face was injected, we will use the cheeks to demonstrate that after 14 months the cheeks are still full, and even fuller then they were at 2 months. At this point there is no question that the fat has taken and is now a part of her face.

Before undertaking any cosmetic procedure you must first understand what the goals of that procedure are. Since a picture is worth a thousand words, we put together this video of the Deep Plane Facelift complete with before and after photos. It explains the results of the surgery with commentary on the before and after photographs. To see videos about facelift surgery and the recovery involved. Please visit the facelift video page.

The answer to the above question- none of them.

What?! Are you nuts, I can’t believe you just said that! So what do I mean by this?

Simply put, a builder does not build an entire house out of concrete, just as Michaelangelo did not paint the entire Sistine Chapel in brown.

In my opinion, for an injector/physician/surgeon/artist to properly use a facial filler, he/she must have a clear artistic vision and strategy before even beginning to inject. Filling in a deep line is rarely the solution to an overall effective method of making you look younger in the most natural way. A natural looking, youthful appearance comes down to restoring the contour of a youthful face. The proper contour is well balanced and for this reason looks completely natural.

Restylane, Perlane, Juvederm, Radiesse, Evolence, etc. are all great products. I can use these products to contour the cheeks, fill in the tear troughs, enhance the lips, soften the chin and all together improve your appearance. (Notice how I specifically did not mention filling in the nasolabial folds- more on that in a different post) However, they each have VERY unique properties that make them excellent for certain goals, yet terrible for others. Without revelaing the secrets, the best, most natural results are arrived at by combining these products in order to achieve the envisioned end result.

Just as in any surgical procedure, I first envision the appearance that I would like to achieve and then I figure out what tool to use. Facial fillers are the tools that help me achieve these results. They each are unique and have their place in my tool chest.

After a very thorough review process we have introduced the latest addition to our practice, a fractional CO2 laser for skin resurfacing.  Aside from the technical and clinical reasons I chose this particular laser, I want to review why I think this technology is the biggest thing to come out in lasers since the first CO2 laser was introduced for skin resurfacing.

CO2 (Carbon Dioxide) laser skin resurfacing has been around since the 80′s.  The CO2 laser revolutionized skin resurfacing.  There is no question that CO2 laser skin resurfacing is by far and away the best laser method for facial skin rejuvenation and laser skin resurfacing.  ANY laser developed today for purposes of improving skin tone, texture, color, lines, wrinkles, sun damage and uneven skin pigmentation has to be compared to the CO2 laser because it is the GOLD standard.

So why develop new lasers if the CO2 works so well? Quite simply- the downtime and negative effects of the laser .  There is an arduous and involved 10 day healing phase after full face CO2 laser skin resurfacing. During this healing phase, new skin reforms and collagen is produced. The skin stays red for about 1 month and pink for up to 3 months after the procedure.  In addition, this laser should only be used on lighter skinned individuals as the laser itself will cause a permanent lightening of the skin called hypopigmentation.

A huge leap in laser technology came about when the idea of fractionation was introduced. Fractionation refers to the principle of dividing the laser beam into multiple tiny beams that will only treat a set percentage of the skin.  Fractionated lasers only affect a certain percentage of the skin rather then the ENTIRE surface.   1% to 100% of the skin can be treated depending on what settings are used and the laser’s capabilities.  Leaving small bridges of unaffected skin in-between the treated skin allows for a much quicker recovery. Many patients can go back to their full activities the next day and they can start wearing makeup within 4 or 5 days to resume their social activities. In addition, it virtually eliminates the risk of losing skin pigment.  In fact, fractionated technology is safe in darker skinned patients that would normally not be laser candidates.

The latest lasers combine the best of both worlds.  The power of the CO2 laser for skin rejuvenation along with the minimal downtime of the fractionated technology.  Rather then treat 100% of the skin as in with the traditional CO2 laser, a smaller percentage of the skin is treated in a grid-like pattern.

There are several of these lasers on the market including but not limited to the Lumenis Active FX and Deep FX, the MiXto laser, the Lutronic eCO2 laser, etc.  Our evaluation of the fractionated  CO2 laser is complete and we are proud introduce this technology in the platform whch we think is best based on the latest technology.  Fractional laser CO2 is safely performed in tthe comfort of our office.

One of the most important concepts in understanding facial aging is the idea of deflation. As we age, unlike in the rest of our bodies, the face loses its fullness/volume.  This exposes the underlying bone, allows the skin to sag, and contributes to an aged appearance.

Facial volume is often overlooked when thinking about rejuvenating an aged appearance. A recent research study examined the appearance of identical twins throughout life. The study revealed that the “heavier” twin appeared more youthful then their “skinnier” counterpart. To reiterate: the identical twin, who had more facial fullness, appeared younger then his or her twin, who had a less full appearing face.

The conclusion from this study is not to go out and gain weight so you can look younger. It simply illustrates the importance of volume in facial rejuvenation. This is something which I have been preaching for years now. We see the loss of facial volume begin in our 20′s and its effects are noticed by a change in our appearance as early as in our 30′s.

When I speak of facial volume in this regard, it is not about filling in lines and wrinkles, it is a matter of restoring lost facial proportions caused by volume loss- filling in the areas that have lost volume. This is an art in and of itself that restores your youthful look in a very natural appearing way.

Visit our fat grafting page for more information on this procedure or our facial filler page.

There is a new kid on the block. In the next couple of months, the FDA is likely going to approve Reloxin for a cosmetic indication to treat wrinkles. Botox received its cosmetic indication by the FDA in 2002. For the past 7 year Botox has enjoyed a competition free environment. In this same time it has rapidly grown to become the MOST commonly performed non-surgical cosmetic procedure today.

Botox is a simple and painless in-office procedure that produces remarkable results. Women and men as early as in their 20′s are reaping the benefits of Botox these days. Reloxin works in the same exact fashion.

So how do Reloxin and Botox work? The short answer is that they work by weakening the wrinkle causing muscles of the face. For those of you who love physiology, these products prevent the presynaptic transmission of acetylcholine into the synaptic cleft thus preventing muscle contraction. The results last approximately 4-6 months and the injection needs to be repeated to see continued effect and enjoy the cumulative effects of the product.

So what is the difference?
In order to better understand this we need to break down the potential benefits into several categories.

1) Effect- Which will achieve the best results- Botox or Reloxin? Theoretically they both work in exactly the same fashion, so they should be about the same. Anyway you look at it, Botox is the gold standard and Reloxin needs to prove that it is at least as good as Botox. Phase 3 clinical trials usually require that the new product be at least as good as the gold standard. So receiving FDA approval tells us at least that much about Reloxin.

Reloxin is said to spread more easily then Botox. This means that it has an effect farther away from the point of injection. This could be very beneficial in some instances and not so much in others. For example, injecting the crow’s feet or the forehead may require only one injection instead of several. I see this as a moot point since I have never had a patient complain of any pain when I inject their crow’s feet. However, less injection points will lead to less bruising, in the rare instances that bruising can occur. On the other hand, there are areas where you want to minimize the spread of product, Botox may have the upper hand in these regions.

2) Longevity- As Botox lasts 4-6 months, how long will Reloxin last? Several studies have compared the two products. One study, which was NOT biased by support from either company, revealed that Reloxin actually lasted longer then Botox. I wouldn’t close the case file on this just yet because other research studies have shown the opposite.

3) Price- Allergan, the makers of Botox Cosmetic, have enjoyed a competition free environment up until now. Perhaps consumers will reap benefits from increased competition in the marketplace.

In summary, the anticipated release of Reloxin is exciting news in the world of facial cosmetics. Perhaps there will be a role for combining both of these products in order to achieve the best possible results.

please visit the Botox information page in order to obtain more information about Botox Cosmetic

This is Part 3 of the video journey series. This video consists of the post operative interview along with an in depth, side by side review of the deep plane facelift results.

In order to give you the best possible viewing experience, this is documented in high definition. If the video is slow on your internet connection please click here.

Click to learn more about deep plane facelift surgery.

This is Part 2 of the video journey series. In this video you will experience the day of surgery with an interview immediately prior to the procedure. I review the incisions used for a deep plane facelift, and you will have the opportunity to see an interview with her the day following the surgery. Stay tuned for Part 3!!!!

In order to give you the best possible viewing experience, this is documented in high definition. If the video is slow on your internet connection please click here.

Click to learn more about facelift surgery.