Video Q & A's
with Corey S. Maas MD, FACS
- Are There Alternatives to a Facelift?Open or Close
Hi, Dr. Corey Maas I’m back again with this, trying to get a few of the questions answered through our video blog that have come in through the last week. One that I thought was really important was “What is the best alternative to getting a facelift?’
I think a lot of people, like this patient who wrote in to me, would like to find a non-surgical options rather than getting a facelift and I think the question is “What do most doctors say or is the best alternative?”
I will say in summary that a facelift does a specific thing. It helps to improve the contours of the face, the neck and the jawline specifically and also can help with the cheek area so there really is no non-surgical substitute that will do exactly what a facelift can do.
However there are number of people who come in with fine lines and wrinkles on their face and even volume loss, that really don’t need a facelift at all. So to give the simple answer to this, I would say there’s no easy substitute for facelift. There are some alternatives than can be used, including judicious use of facial fillers and volume, particularly through the cheek area, around the lips and marionette lines and the jawline, which can disguise things and make it look like a facelift.
There are also options in terms of skin tightening that can be done and for fine lines and wrinkles by far the best option is some type of resurfacing whether its fractional laser, which is preferred for recovery time, chemical peels, and dermabrasion, which is rarely done anymore. So those are all things can really improves skin surface texture, improve the contours, again they’re not substitutes for facelift.
A lot of these devices that are out now that claim to be substitutes for face-lifting surgery. There’s the Velashape machine which is a very good machine for tightening skin. The Ulthera machine, which is an ultrasonic device that heats tissue below the surface. Thermage. The eMatrix. There’s a dozen more of them that do have some improvement in skin tightening but they’re not close to a facelift.
So that’s a summary on facelift and later in the blog I’m going to show some ideas about face-lifting technique and if you watch the video I’ll have some little clips on how we do face-lifting to improve facial contour. Thank you, this is Dr. Corey Maas, checking out.
- Are There Alternatives To Eyelid Surgery or Blepharoplasty for Droppy Eyelids?Open or Close
Today I thought we’d spend a few minutes answering some questions that came up just this week with blepharoplasty, or eyelid surgery patients, and these questions were very germane, and are repeated very often, so I thought I’d share them with you.
If you have any questions that are add-ons to my comments, please feel free to write or send a video or photograph, and I’m happy to comment on those. You can do that either publicly or privately at DrMaas.com video blog.
The first question that came up was “Are there alternatives for saggy or droopy eyelids to surgery? Are there other things that are reasonable to do that can improve eyelid contour?” The answer is absolutely yes. I break this down into two categories: The first category is upper eyelid surgery, the second category would be lower eyelid surgery. With upper eyelid surgery, there is a redundancy of skin there that goes along with the brow dropping down as well as the saggy or dramatical skin; that sort of the creepy skin of the upper eyelids. There can be some improvement achieved with skin resurfacing, either with the laser or chemical peel.
Skin resurfacing, I’ve described before as a way of selectively injuring the skin surface down to the second layer of the skin, the dermis. Stimulating a wound healing process that actually improves the skin by re-creating new collagen, remodeling the existing collagen and forming new skin cells or regrowth over the skin surface. So some tightening can be achieved with skin resurfacing, but I think it’s really often over-played by resurfacing and laser experts. There’s some improvement in terms of tightening the loose skin, the fine lines and wrinkles, but it’s far from perfect if there’s a lot of redundancy to the skin. Obviously, doing a surgical procedure for the eyelids has its unique benefits, and some downsides in terms of recovery.
So resurfacing is one of those alternatives. Another alternative might be the use a botulinum toxins, and that comes in a couple of forms now. Three currently available in the United States: Botox Cosmetic, which we all know about. Dysport which is now a valiant product, and lastly Xeomin which is made by the Merz Company.
All these are type A neuromodulators botulinum toxins and they do the same thing around the eyelids if we inject the area of the lateral crows feet region, this the orbicularis oculi muscle. We can relax the muscle, but it’s primarily responsible for pulling the eyebrow down. Pulling the eyebrow down obviously create some hooding, and by relaxing the muscle that’s pulling it down we can actually get some brow elevation, and that can reduce the redundancy.
So those are some non-surgical alternatives in improving eyelid contour. Again, really saggy eyelids have to be addressed with your doctor individually, and whether you use resurfacing, botulinum toxins, or even doing an injectable filler (which is the third or last to these options or up to you and the physician you’re working with.) The last one I mentioned is a little bit controversial, or is very specific to individual physicians in their use, and that is placing a filler like Restylane, Juvederm, Radiesse or Belotero underneath the eyebrow, and just below the eyebrow in order to create some volume and a little lift to the brow itself. It’s controversial because it can also create some thickening or frontal bossing, so it has to really be done in the right patient. A little swelling is involved, but in the right patient this can be a nice way of elevating the eyebrow, which translates into a little less redundancy of the skin of the upper eyelid.
So kind of a long question, but three options we really talked about in terms of addressing non-surgically the eyelid. Option number 1: Resurfacing. Option number 2: botulinum toxins: Botox, Dysport, Xeomin. Option 3 is using a filler in the infra brow below the brow region to help to create some volume.
So thank you for asking the question and thank you for the opportunity to answer these questions, and if you have any other questions don’t hesitate to write DrMaas.com at DrMaas.com blog. Visit our website at Maasclinic.com or even our Facebook page at Facebook.com/Maasclinic. As always thank you for coming and visiting, Dr. Corey Maas on Looking Your Best.
- Blepharoplasty Eyelid Surgery Laser Versus Surgery.Open or Close
A very common question asked about Blepharoplasty is: “Should I use a laser for my Blepharoplasty?”. There’s a lot of marketing done on laser Blepharoplasty, and I’ll just say this. I have 12 to 14 lasers in my practice, and we have lasers that do just about everything. The bottom line on lasers are tools. Like any tool that we use in a surgery, it really depends on the operator of that tool. There are techniques where certainly lasers, no question, are the best option for performing the procedure, including the treatment of pigments, disorders of the vascularity, tattoo removal, and there are laser the hair removal techniques. There is no questions that lasers are the optimum source of energy for doing that.
With Blepharoplasty, I think this is a little more controversial. The benefits of doing laser Blepharoplasty, or an incision using a laser is, that there’s less bleeding. But frankly there’s very, very minuscule amounts of bleeding with Blepharoplasty using a simple scalpel, and no thermal damage. This is the key thing that we can argue about academically, but in the end having less thermal damage, in my opinion, with the incision results in better wound healing.
I use a micro cautery dissector called the Colorado needle tip when we’re doing any dissection below the skin surface. I like the incision with the scalpel better because of less thermal trauma. So there’s really not a great benefit in my opinion to doing incisions with the laser for upper Blepharoplasty, or lower Blepharoplasty, for that matter. Micro cautery needle tips work very well, and simple scalpel incisions. So I think this is more of a marketing technique than it is an actual surgical benefit. There’s nothing wrong with using a laser for Blepharoplasty, but no distinct advantages that I’m aware of that are provided by using a laser for making skin incisions.
DrMaas.com on Looking Your Best. As always, please send me your question at our blog DrMaas.com, visit our Facebook page at Facebook/Maasclinic or of course our website at Maasclinic.com. Thank you for letting me help you Look Your Best.
- Can I use topical agents before IPL?Open or Close
There was a question about the use of topical agents in skin care before getting a treatment with laser IPL, more specifically, since so many people are using Tretinoin or the Retin-A molecule, which I think is a critical part of any skin care program is, “can you use these agents before a treatment with Intense Pulsed Light IPL or photo rejuvenation?”
The simple answer to that question is “Yes”.
We typically will have people stopping the agents, just because it can be a little irritating to the skin within week or so before the treatment but it’s really not absolutely necessary. As most people know, Tretinoin and Retin-A is very sun sensitizing but in those cases its UVA or UVB ultraviolet radiation, the radiation that we see from the sun or from tanning booth, is really a sensitizing agent when you’re using this molecules on your skin.
So they’re not an integral part of IPL or photo rejuvenation treatment but they’re not contraindications either. They are things that we are cautious about when people are using them, especially if they’re using high concentrations, just because of the irritation that it can cause around the time of the treatment.
Our advice when patients are getting IPL is to stop a few days before hand. If they forget or they don’t stop it’s not a contraindication, we’re just cautious in how we deliver the energy. And, again IPL is a treatment that targets pigments. Red and brown in the skin that are unwanted and it can be treated anywhere in the body hands, arms, chest, face wherever there’s vessels, veins or brown spots that we don’t want or need on our skin.
If you have any other questions about IPL treatments, what you can or you can’t use around them or even how the systems used to treat this things, please don’t hesitate to contact us at our video blog at DrMaas.com. You can certainly call us also.
We’re always happy to answer your questions this is Dr. Corey Maas on Looking Your Best.
- Can IPL help with Rosacea or Acne?Open or Close
We’re talking today about IPL with a series of patients, and one of the questions that came up was the treatment using IPL photo rejuvenation or intense pulsed light (what IPL stands for), and the treatment of certain inflammatory skin disorders like acne or rosacea and whether they’re effective or contraindicated?
In summary, many of these inflammatory conditions can be effectively treated with IPL. In fact, rosacea has an excellent indication for the use of IPL. Rosacea, where you have small red bumps and capillaries and vessels particularly around the nose, in the middle of the face, over the cheeks. IPL can really be a very effective strategy for removing a lot of that redness, in combination with medical therapy.
IPL by itself and inflammatory conditions like acne wouldn’t be an isolated super procedure, there are some better some treatments. For example, photo-dynamic therapy, which is a treatment using an intense pulsed light machine or a blue light and pre-treating with a photo sensitizing agent known as levulan is a good way of reducing both the redness and inflammation associated with acne, as well as shrinking the glands where the acne bacteria lives, and killing the bacteria itself.
So there are a lot of conditions that are inflammatory in nature that causes pigmentary changes in the skin that IPL are very effective in treating and its really up to you and your doctor to decide whether intense pulsed light IPL (often known as photo facial) are the right conditions, and whether they offer a chance for improvement in those changes that we see that are the physical changes associated within inflammatory skin disorders.
If you have any other questions about IPL, please don’t hesitate to visit our video blog at DrMaas.com or call us with questions, I’m happy to answer all those. This is Dr. Corey Maas on Looking Your Best
- Comments on Trademarked Procedures like the Liquid Facelift.Open or Close
Dr. Corey Maas again, back for the video blog with some questions and answers on facelifting. A bunch of them came in this week, and another question that a patient asked was about the Liquid Facelift.
Just a couple of comments about liquid facelift. It’s a marketing program that some doctors have bought into and elected to participate for a small fee. The idea of participation and the liquid facelift is that there’s a group and people who signed up for it and if search it on a web, you get referred out to certain doctors.
Liquid facelift is simply a marketing strategy that employs injectable facial fillers to improve contours of the face. It’s not truly a facelift that improves the neck sagging and jowling or hanging, it’s just another way of doing facial volumization and improvement of facial contours using injectable fillers.
Nothing wrong with it, nothing wrong with marketing terms like it, but it’s certainly not a facelift. So I had to comment on it since we get a lot of question about it and I think it’s worth doing it. Thank you for viewing, DrMaas.com on :ooking your Best.
- Facelift: How to Avoid the Pulled Look.Open or Close
I’m answering questions again. I had a lot of them on facelift surgery in the last week and I wanted to try to get many of them addressed it’s a popular thing to do this time of year and a lot of people are thinking about rolling back the clock 10 or 15 years, which is really, with a lower face lifter or facelift in our standard terminology does.
The most recent question was “How can I avoid getting a pulled look from a facelift,” which all of us see when we watch TV, and we see the celebs, and we look at people in US magazine, and these bad results are so common, and I’ll tell you there’s two reasons for them, and then I’ll get back to that question.
The reasons for these unusual outcomes are either unusual or extreme expectations from the patient and usually that’s done in combination with the doctor who’s promising something that’s unusual or extreme.
There’s absolutely no reason that anyone should have a pulled or stretched look with a facelift procedure. Facelifts are designed to make people look better, to roll back the years, but they should look totally natural. Restoring the jawline, the neck angle and improving the wrinkle and creased around the mouth and cheek area.
So the patient asked me “How do I avoid it?” and I would say the simple answer is make sure you’ve got a doctor that understands what you’re concerns are, that is able to address those, and make sure that their concerns are that you get a natural look.
There are lots of docs that promote doing various kinds of facelifts, I don’t think you have to minimize the outcomes in any way to avoid the stretched look. I think you can have great contour of the jaw line, great improvement of the neck, without looking stretch or pulled, and the best way for you as a patient to get a good result is that you can control this, is to find a doctor that is seeking with you, a natural look, and restoration of the contour.
The techniques that are used are really important in this regard, they don’t want to pull the skin too tight. Many doctors do a skin only technique or a very nominal technique with the so-called SMAS or deep connective tissue layer underneath the skin.
Those typically require a lot of skin tension to get good contour. I’d just summarize by saying as long as your expectations are reasonable and you have a good idea what you want there’s absolutely no reason to get a pulled or stretched look on the face and that shouldn’t happen.
Getting referrals from friends that have had good results, looking at the doctors photographs, asking the physician surgeon about the experience they’ve had in doing facelift are all important things in terms of evaluating who does your lift, and who does your lift is really the important thing in terms of avoiding that stretch or windswept type of look.
DrMaas.com video blog, thanks for viewing. Don’t forget to send in your questions and you can send them by video if you wish, by going to DrMaas.com and dropping both a video and a message, and we can try to answer your questions. Thank you!
- Help! I Bumped my Nose after RhinoplastyOpen or Close
Another question came up on rhinoplasty, which just happened over the holidays. Somebody had their nose done. They had a little time to recover, and of course during the holiday festivities there was a lot of activity, and the nose was bumped. The question was “Will this have a long term impact on their outcome?”
The simple answer is that with light bumps it’s unlikely, but with bigger bumps the nose is. With nasal bones, the nose is relatively susceptible to injury so we’re careful in our practice to keep a nasal cast on for the first week, and we’ll return that cast to the patient if they’re doing a lot of activities. If they’re going to be outside or in a place where they might be bumped, you can place the cast which doesn’t prevent the nose bones from being dislocated, specifically, but it does defuse any pressure that’s applied directly to the nose or specifically to an area of the nose. So there are some nice preventative ways to avoid injury post-rhinoplasty.
The nasal bones are fairly fixed within the first couple of weeks with fibers adhesion, and then after a couple of months it’s very unlikely, or not any more likely than the other time, for the nose bones to be hit and disrupted or in any way deformed on the rhinoplasty.
So thank you again for tuning in. Hopefully, there’s a couple of slide presentations coming up specifically on revision rhinoplasty, which represents probably 60 or 70% of the rhinoplasty surgery I do now here in San Francisco.So thank you for your attention, again Dr. Corey Maas on looking your best at DrMaas.com.
- How Long Does a Facelift Last?Open or Close
Another question that came up recently was “How long does a facelift last?” and there’s a lot of answers to that.
There are a lot of these marketed procedures, such as mini-lifts, quick-lifts and style-lifts. These lifts are very small procedures that involve a tiny little incision in front of the ear that makes skin slightly behind the ear, and they lift a tiny amount of skin, tighten a little bit of SMAS and the deep connective tissue layer, and then take a small amount of skin out, and close up.
This does a phenomenal amount of improvement in the facial wrinkles and contour and something like that may last for a year or so in terms of slight improvement. Obviously if you’re going to invest in that, I think there are probably better ways of addressing these kinds of issues.
The question as it relates to standard face-lifting procedures is that, it depends. We (plastic surgeons) are doing different types types of facelifts, including skin only, and others that that involve the SMAS layer, the deep connective tissue, and they have varied lengths.
I don’t do this skin only types of facelifts but a number of people do and they probably last somewhere between 3 and 7 years depending on sun damage and aging. When we get in the type of procedure that I do where we’re doing extensive use of the SMAS layer, the thick connective tissue layer in elevating and re-contouring the face and using that as the primary method of re-suspending or restoring the contours to the face and general tension on the skin, we can expect 10 to 15 years of duration with a facelift. So that’s the average patient and that’s kind of a big range but that’s as close as we get.
A lot of this depends on the patients sun exposure, their physical activity and lot of other factors that we don’t have control over but the most important thing about restoring contour is that in face-lifting in particular is a long lasting quality result turning the clock back but not stopping it from ticking. Thanks for visiting the DrMaas.com blog, please send in your questions.
- How Long Does it Take To Recover from a Facelift?Open or Close
I got a question today about facelift recovery, and I think we have a lot of the information published on our website at Maasclinic.com. I encourage you to go look at the site if you want some written information. DrMaas.com is the video blog and Maasclinic.com is where there’s a repository of information.
This patient was concerned about how much time she’s have to take off work, and when she could go back into the public eye and not look scary, or as she described, “like a freak.”
Facelift recovery is at the most about a 10-day to 2 week process for most patients. The first week, people are pretty swollen, and sort of, in many cases, pumpkin head swollen, so you got to be prepared and not be doing any social activities for the first week.
The rate limiting thing in terms of returning back to your normal social activities is bruising, and for most people bruising is pretty much limited to just focal areas within about 10 days, which can easily be disguised with make-up since the incisions are hidden in the hairline and other areas. That’s not really a worry because there’s light red, but bruising really is where the rubber meets the road in terms of getting back into the normal social activities.
10 days, 2weeks in that range with a little make up. Most people can be back and doing normal things without anybody having you know “we had something done.”
That’s a general idea obviously, we’re assuming everything goes smoothly, and I think for most people with us, that’s the general range for people in recovery from a standard lower facelift.
Dr. Corey Maas, DrMaas.com video blog, or visit us on our site at MaasClinic.com, and don’t forget to send in your questions.
- Introduction to the Facelift ProcedureOpen or Close
This is Dr. Corey Maas on looking your best. I want to take a few minutes just to give a very short synopsis on face-lifting and the current state of face-lifting in our world. And there’s a lot of confusion about it but it really is become very important, as the techniques and the technology have made it quite simple. And with today’s world with people living much longer, living healthier lives, many working and being very active well into their 80’s and even 90’s, the face of aging is something that, really a lot of people are concerned about. We can change our bodies, we can stay healthy but those aging changes that occur and are often seen when we looked in the mirror are something that really are best addressed with a surgical intervention and we do have very good answers for that.
The surgical techniques involved are relatively well established and with advanced surgical techniques, like those that offered at the Maas Clinic, we’re actually using the thick connective tissue layers underneath the skin to restore contour to the lower face. As you can see here, this is often referred to as the so called “SMAS layer” and the SMAS layer, when it’s elevated, allows us to achieve really effective restoration of contour without giving that poled or windswept look that is so commonly seen in televisions in Southern California, and that’s just something that most of our patients are not interested in having.
The results of these surgeries are most commonly very natural looks when we see aging and jawling in this area, and we see the neck restored to a nice and natural contour with very good improvements. We’re very happy and the patients are genuinely happy. They go from a kind of a “grandmotherly-look” where this jawling effect that tracks along the jawline, and the hanging extra tissue around the mid-cheek area is restored.
In this case, the patient has also had laser skin resurfacing, and we really see that the patient transformed from someone that looks tired or weary into someone that looks much brighter and much fresher.
These can be done in any age range of patients but typically, we see patients that are in their early to late 50’s and moving on into their 60’s. We see these in both men and women as an example here, a gentleman who just said his neck bothered him, he looked like a grandfather, didn’t feel like one and wanted to see the improvement.
You can also see that after the surgery, even in a man, the scars that are hidden along the hairline and in behind the ear area are almost impossible to see within a few months after the surgery. So surgical scars are not an issue and the other issue that most people ask about is comfort. The techniques we use with anesthesia, monitored deep sleep anesthesia, as we refer to it now, are quite simple.
There are newer technologies you don’t have to be under general, where you’re paralyzed and have a tube down in the trachea, and on a respirator. We can keep you at a nice gentle level of sleeping and I use local anesthesia to numb the surgical areas up effectively so that there’s no pain that your brain even perceives during the procedure.
So we can see these reliable and consistent results with patients, and really have no scars or visible scars and really change somebody’s life by restoring that natural contour and improved appearance of the face.
This really has a big impact on the people that are looking at the professional workforce and getting back into it, or reentering it. The youthful workforce that is out there now associates aging changes with loss of energy which is completely untrue and we can restore a very natural and very long lasting youthful and vibrant look, with the procedure that can be done with a recovery period of not much more than about 10 days.
So the summary about facelifts now I think are putting to rest a lot of the older concerns, I’ll also mention that many of those that you see advertised on TV, that can be done in an hour, are much less than what we’ve describe here. Pulling a little skin up is certainly not going to give you an effect like you see demonstrated here, that last the patient for 10 to 15 years at a minimum and so we really want to make sure that if our patients are making an investment, they get a long term and effective return with the procedure, and a great result that they’ll be very satisfied with for the long term.
If you have any questions about facelift or any other aging face or balanced symmetry procedures, don’t hesitate to call the clinic at 415-567-7000.
Reach out to us at Massclinic.com there’s a contact form there.
You can visit my video blog at DrMaas.com, or of course we’re welcome to have you come and join us as a fan at Facenook.com/Maasclinic.
As always, I appreciate your attention. This is Dr. Maas on “Looking your Best”
- Is Fractional Laser Resurfacing Comparable To A Facelift?Open or Close
I had some questions on facelift, and another I want to address today is the overplaying of the value of lasers.
Lasers are wonderful tools, I have 15 of them that are used for various different indications. These machines are invaluable parts of what we do in managing the aging face and the aging skin that we take care of everyday.
With that said, it doesn’t mean that the lasers are a magic wand that can cure every malady that we have. One patient wrote to me that she had a doctor that lives nearby her, I won’t mention the area, and that the doctor was recommending a certain type of fractional laser that was an alternative that would lift her skin like a mini facelift would do, and that’s just simply not true.
There is a skin tightening effect with any type or resurfacing whether it’s fractional, laser, chemical peel or dermabrasion, which is not commonly used anymore. The skin tightening effect is not a substitute for lifting, which improves the contours of the face.
So if you think of it simply, contours of the face are improved using resurfacing devices, very common areas, the fine lines around the mouth, cheeks and even in the full face, where there are fine wrinkles, brown spots which we call discromias, those are very good indications for laser resurfacing.
If someone has hanging jowls, has a really significant contour change, we really need surgical or filler options to improve those. Obviously the surgical options include mini facelift, neck lift, lower facelift or full facelift, which would include brow. All those options are available and are certainly great in the right patient.
I think there’s a tendency in our field to, it’s like the old adage, if you have a hammer everything looks like a nail. Just because you have a laser doesn’t mean resurfacing does a facelift. It does a great job on its specific indication in any good derma surgeon, aesthetic plastic surgeon, facial plastic surgeon, anyone that is involved in this field should be able to honestly tell you what the limitations of lasers are, and what the benefits are.
So thanks again for that question, and don’t forget to send your question, videos and photographs on DrMaas.com
- Is IPL suitable for use on Asian skin?Open or Close
We have a question that I wanted to bring up that related to the treatment using IPL for different skin types. More specifically, the question was asking whether “Asian skin” or other types of olive complexion skin are suitable for use with IPL, and the answer to that question is, of course, yes, and it comes down to treating the skin type with the different variables that are offered by an expert on the equipment. So the equipment itself, depending on the quality of the device that’s being used can really be adjusted to any skin type.
Asian skin type, or any olive skin type can be tuned or adjusted for, on the machine settings. With the right technician, at least in California, it’s a physician or a nurse doing the treatment, they can tune it in to target unwanted brown spots that overlay olive skin, or even unwanted vessels in a very safe and effective way.
In summary we know that IPL is a non-invasive treatment that has virtually no downtime maybe a little pink or sun burn look afterward that goes away within an hour or two, and it’s a very effective way of quickly eliminating unwanted pigments. (It is available for) any skin type really, except for the very, very darkest of skin. IPL is a good treatment option to get unwanted pigments, which include vascular or red lesions and brown spots.
If you have any other questions about IPL or treatment of pigments don’t hesitate to contact us DrMaas.com. As always this is Dr. Corey Maas on looking your best.
- Is the Ribbon Lift a Facelift?Open or Close
A bunch of questions came in this week about face lifting and various forms of face-lifting, and I wanted to address these questions. There is so much confusion out there that I think it’s worth addressing some of them.
There’s been a lot of media attention recently with Madonna and others to have been reported to have the so-called ribbon lift, the GN Papa suture that was strung from ear to ear underneath the skin.
There’s a new mattressing type of suture called the eye guide that goes underneath the neck, crisscrossing a lot like a mattress. There’s an endotine which looks like a ribbon and I suspect that the ribbon lift is probably a good marketing way of describing the endotine device, which is a device that’s made of polylactic acid, it’s basically a small flat device with several holes in it, polylactic acid is what vicryl suture is made and over time dissolves so that’s a benefit but it shaped and formed like a ribbon and at the end of it there’s a small spike catch device that is engaged into the soft tissues.
This technique is used to a very commonly for elevating the mid-face region. A small incision is made in a temporal hairline and under the lip. The device is inserted underneath the skin, engages the fatty tissues of the cheek and is elevated and sutured into place. That device dissolves over time.
There’s a much better way, in my opinion of doing mid-face lifting with the technique that we’ve developed called the endoscopic midface lift, or the percutaneous mid facelift, more specifically.
If you want more information on the percutaneous mid facelift, please don’t hesitate to visit our website Maasclinic.com. I will be doing a video blog demonstrating the actual percutaneous mid facelift very soon, so that should be available on DrMaas.com, as well as MaasClinic.com our website which is a library of information.
Thank you for asking the question, don’t forget to send your videos and questions to DrMaas.com. Dr. Maas on Looking Your Best.
- Learn about Botox Xeomin Dysport.Open or Close
I have an opportunity today to talk a little bit about some minimally invasive options for improving or enhancing our facial appearance, and actually other areas. One of them is the injectable neuromodulators; the big fancy term for a group of medicines that affect our facial expression. These are really adverse facial expressions like the frown lines between theeyebrows, the crows feet area as well as forehead lines and some other areas in the face. The main products we use for that are Botox, which everybody has heard is a household name now. Dysport, which was approved a few years ago and is a very good competitor to Botox.
Now there’s a newer one, Xeomin, and soon to be a fourth one within a year or so. So let me just say a few words about the products themselves, and how they work. Then we’ll get in to a little bit about what they do for you, or what indications we would be looking at for each individual. There are three major products that we use as neuromodulators: Botox, Dysport and Xeomin that are currently available in the United States, and my preferences right now are still limited to Botox and Dysport for some specific reason; Xeomin being the newer one.
All of these are actually naturally occurring proteins. People think of them originally discovered as poisons that were in canned foods. But like any medicine in the right dose, they can be great for people, and then the wrong dose or in higher doses they can be poisonous. So the thought of these as being poisonous or dangerous to people has largely been overcome.
Now I think everybody understands that Botox and Dysport in the right doses are very beneficial. Again they’re naturally occurring proteins, they’re used in a tiny little needle injection specifically in the muscles that we’re targeting, and it relaxes that muscle for period of three or four months on average. Although, we do have some patients that will go as long as about 6 months. So on average, our patients are here two or three times a year getting Dysport or Botox, and that’s a great supplement to whatever program we’re doing to manage the aging process: The angry scowl, the tired look. There’s a lot of benefits in terms of using these.
So welcome to the clinic and hopefully we can go ahead and get a little Botox and Dysport for you today.
- Non-Surgical Facelift. Does it Actually Exist?Open or Close
I wanted to respond to some questions that, in fact a number of questions that have been coming up about newer therapies that relate to facelift and again facelifting, we’ve spoken a lot about it, is a term that’s overly used now with people using that term to describe anything from something in a jar to a minimally invasive laser procedure, all the way to a surgical procedure which we typically think of as being a facelift and so I think it’s really important at least for our patients and followers to understand what the terms means so that they can have realistic expectation for outcome.
First of all, everybody should be aware that there’s no magic cream that does a facelift because facelifts by definition, by our surgical and medical definitions, are actually improving the contour of the lower face and or the neck and that’s really, by definition, what facelifts do.
I’ve commented before in definitions of facelift and I’ve described it to our viewers and readers as a mini-lift when it lifts this portion of the face, a mini neck lift when it lifts this portion of the head neck or face and if it lifts both the lower face and the neck that is by definition a facelift or as I like the more accurately describe it a lower facelift.
A lot of my patients will come in and say “Oh I’ve had a full facelift you know 5 years ago, 7 years ago and its sagging again.” Unfortunately too many people are saying that and what they’re really referring to is having had a brow lift, eyelid surgery, upper and lower blepharoplasty, chemical or laser resurfacing around the eyes, in the mouth or full face and the lower facelift. That, in their mind is a full facelift and again that’s a little confusion in terms.
So let’s keep in mind, the creams are nice for your skin surface depending on which ones you’ve chosen. I’ve said it many times before you need a retinoid, you need a vitamin c, you need sun protection and then you need gentle exfoliation. If you’re doing those four things you’re doing 90% of what we know works. So those are important but none of them do a facelift.
Facelifts, by definition, should be improving contouring. Well, then we get into some of these procedures or technologies where people are claiming facelifts and I’m not sure that that’s really what you’re getting.
The first of them were really lasers. When lasers skin resurfacing first came out, a lot of people were claiming that it lifted the face. Well, in fact, what resurfacing does is tighten the skin a little bit. It makes the surface texture smoother, it makes wrinkles much less perceptible, in fact, in many cases it can make them go away, but it is not physically or substantially changing the contour to the skin.
Then there have been a number of non-ablative devices that come out and I will say this is a gray area because some of these devices show some promise. We’re not sure quite how much lifting they’re doing, but there is a promise that there is some general tightening to this that goes beyond the skin, which in fact could translate into some contour improvement, and again contour means sharpening of the jaw line, loss of laxity of the neck or repositioning of the cheek tissues.
So if we talk about those things, the cheek and lower facial tissues, cheek and lower facial tissue repositioning, jawline definition and a better cervicomental angle, the definition of the neck itself.
We’ll talk about some of the non-ablative technologies. Those that came out early include Thermage, there are treatments like Velashape, eMatrix, there’s a whole series of them that came out and they were skin tightening devices by FDA clearance, not lifting devices.
Then, more recently, the first device that’s ever been approved for a non-surgical intervention that actually does lifting. It actually got the term lifting in its FDA clearance, it’s the Food and Drug Administration’s seal of approval, is a treatment called Ulthera. I’ll talk a little bit in my next segment about Ulthera how it works and I do take it adds a new dimension to what we’re offering our patients.
But lastly then comes the term facelift and I wanted to make sure everybody was clear on it because there are so many now, trade names out there. There’s the S-lift, the Q-lift, the P-lift. You put a name to it, the Click Lift, the Wonder Lift, the Vundabar Lift, the Bloomer Lift, the Liquid Lift, etc.
There is all of these different terms out there, and even now people are now saying stem cell facelift. I would encourage you to go to our Facebook page its facebook.com/maasclinic, and I’ve done an interview with a health and beauty reporter very extensively on this whole topic of the term facelift and I encourage you to take a look at that. It’s linked at our Facebook page and I’ll repost it or I’ll tag it to top. So I think that will help a lot in definitions.
But just again to clarify the most important thing about facelift is that we’re changing the contour to the lower face and neck and a traditional approach involve an incision that starts somewhere in or around the hairline, above the ear, it goes somewhere around the ear, and again in my practice, for men and women, I’m hiding it behind this piece of cartilage called the tragus, so there’s no scar in front and then high on the back of the ear, and again into the hairline, some people will be in or in front of the postierior hairline, the back behind the ear hairline. I’m not favorable to the hairline type incisions in most patients, although I’m not ruling it out, because of the visible scar.
The key to good lifting is getting good contour and having minimal scaring and naturally where it’s all about. When we’re done with a true facelift, better described again as a lower facelift, we’ve got the neck nice and tight with a good angle, we’ve got the jawline nice and tight, and then we’ve got a nice contour to the lower portions of the face.
So relative to this, I’ll put some posts up what I think are good before and after result with facelifts. In our next segment I’m going to talk a little bit about Ulthera and the technology, and we’ll do a little bit of series on Ulthera because I do think it’s the best and most promising technology that’s coming out for actual lifting, that’s non-surgical.
Dr. Corey Maas, as always we welcome your questions, videos, and photos on our website at DrMaas.com. Please don’t hesitate to write and call, get a live person on the phone. As always, Dr. Maas here to make sure that you’re Looking Your Best.
- Ultherapy: Is It a Facelift?Open or Close
I want to spend a few minutes today to talk about a new technology, Ulthera. Ulthera is an ultra-sound device that has been cleared by the FDA for actually doing lifting, using a non-invasive technology. It’s the first and only device in the United States that’s got a clearance from the FDA for lifting, and you will see actually some photographs that we’ll post here on blog and also some demonstrations if you view my website at Maasclinic.com, some very good examples of actual lifting improvement that is achieved by using ultrasound.
Now I want to talk a little bit about how the technology works and then contrast it against some of the other technologies that have made some claims about lifting but are really devices cleared for med skin tightening.
So these technologies, I wanted to describe graphically how they work and I’ll focus in on Ulthera in just a second, but if you can imagine this has being the skin surface and subcutaneous tissues, here’s the surface here, the epidermal layer, the sub-dermal ,or the dermal layer here and the sub-dermal layer immediately below that you can see the little fat globules here and the fibers tissue bands that are part of the fascia that belong down below here which is the brow line and the fascial layers they’re the most areas of the face.
So again it goes skin surface, epidermis, that dermal layer which is very important, that’s where collagen, elastin and hyrolic acid reside, sort of the ground substance of the skin. The sub-dermal layer which includes fat, fascial bands and then a very thick connective tissue layer the fascial area like the SMAS in the face, the so-called subcutaneous musculo aponeurotic system.
When we do laser skin re-surfacing as can be described here in the fractional layer, what we’re doing is creating little thermal injuries that go through the epidermal layer and into the second layer of the dermis and depending on heating, that can go all the way through, that is why we’re very careful. It’s a selective injury and lasers work on the skin surface only. They do smoothing, a great job at fine lines and wrinkles, contour and texture, so that’s where that category of energy delivery device for the skin, is.
The next category of skin injury device, and actually you could include in this area chemical peels, or even full laser resurfacing or dermabrasion, in which case you wouldn’t see little lines of thermal injury like you see represented by this little triangles, you’d actually see the full layer here of skin being gone, and how that rehabilitates itself or recovers, is by migration of new skin cells from the adnexal tissues below the skin, with are the oil and sweat glands and hair follicles etc and re-epithelialization of new skin over the surface. Fractional lasers are different in that it heals much faster, and we’ve talked about that in other of our sessions.
The next type of technology which is most interesting and, I really believe in and has a good application in many of the things we do is radio frequency or electrical energy, basically that’s being delivered to the skin and tissues below the skin surface.
There are many devices, one which we have the Velashape 3, which is the newest of them from Syneron. There’s a handful of devices, one of which is Thermage. When Thermage first came out, of course it’s improved a lot now, it’s grounded distally with a little grounding pad and there’s a surface treatment handle that’s placed on the skin surface, and with that electricity is passed through the skin, and the skin acts as a resistor with the fat and skin cells creating impedance and whenever there’s a resistor impedance to electrical energy flow there’s heat built up, and you can see its built up near the skin surface the yellow where it’s hottest, the green less heat, and then down lower, the least amount of heat.
So what we’re seeing with velashape and thermage and the radio frequency devices is gentile heating, and this is all control based on the energy level set in the operator using it, down to and including maybe the top, maybe through the dermis and in some cases we think we can get sub-dermal.
There’s a lot of energy delivery that is done this way. I think we can see general skin tightening and some contour improvement is seen also, particularly with these new devices but there is really need for further research in terms of how much contour we can actually get. Sort of excited about what we’ll be able to see with the new velashape 3 device getting the tissues up to 42, 43c with thermage, they’re actually getting up into the 50 some degree range here and causing skin tissue tightening. Now, “How much contouring it gets?” That’s another question and I’ll leave that for further discussion at another point.
The last of this technology, Ulthera, uses ultrasound energy and those are literally sound waves, high frequency sound waves that are delivered through the skin surface and based on the tip that’s being used or the transducer on the end you can lay the ultrasound energy really at the fascial layer 4 to 5 millimeters below the skin surface at the junction between the subcutaneous tissue and the dermis at about 3 or 4 millimeters and then much nearer the skin surface if we want to do fine lines at about 1 1/2 millimeters.
There’s a small hand piece that’s applied to the skin surface. Typically patients get very small amounts of anesthesia with this and those energy delivery depending on the hand piece would lay little rows or dots and contour along the lower face, neck and even brow area. This showing what it would be if it was a 4.5 millimeter transducer, this little dots were representing it 3 millimeter transducer if you were targeting those areas. But, for general contour and we’re primarily using this 4.5 millimeter transducer to get improvement in contour.
So Ultherapy, I think represents a significant technological advance in the area of facial contouring. This is a procedure that’s often offered in the office with no downtime. There’s no injury whatsoever to the skin surface when it’s properly performed.
It has minimal discomfort, and we have a whole protocol for people who are a little sensitive, with doing very light skin blocks so they feel absolutely nothing. The company actually just recommends Ibuprofen, but we want to make sure it’s a totally comfortable procedure. If you’re reading about it and you’ve seen some uncomfortable reviews with patients, they have likely not been offered a blocking alternative, I think doing a small local anesthesia block is so simple and easy that for anybody that is little sensitive, that is easy to do.
We’re seeing really good results, it’s certainly not a facelift and I don’t ever think it should ever marketed as a replacement for facelift, but for people who are younger in their 40’s, they’re late 30’s, or even with sun damage, or people who have already had a lift and just need a little tightening, Ulthera may very well be the best option for them.
If you have any questions about Ulthera again, we encourage you to visit our website at maasclinic.com. There are before and after pictures there, as well as a detailed explanation of how the technology works. Or, visit our blog at DrMaas.com, I’m open to any question you have. You can visit the blog site, send me photos, videos or written questions and we’re happy to talk about it. I’m Dr. Corey Mass on Looking Your Best.
- What is a Non-Surgical Nose Job?Open or Close
Good morning. DrMaas.com video blog and answering some questions that I just encountered this week with some rhinoplasty patients.
We did three this week, there were some very good questions brought up. One of them was, “What is a non-surgical nose job?”
Really, there’s been a lot of media attention with it, a lot of internet traffic about non-surgical nose jobs, and actually I have some examples of non-surgical rhinoplasty or nose jobs on my website at maasclinic.com. So if you want to visit and see that that would be a good way of, we getting a sense of it.
But basically, it’s a very limited number of patients who are candidates for non-surgical nose jobs and they’re typically patients who either have a saddle depression of the bridge of their nose where (it) goes down slightly, or they have a very weak bridge of the nose and we can use and injectable filler product to improve the height of the bridge of the nose and to some extent the tip of the nose.
So, we can get a little bit of tip definition, and we can also raise, or contour the dorsal height of the nose. In some cases of post rhinoplasty patients, patients that have had previous nose job surgeries where there is small irregularities, I can go in with an injectable filler, and there’s a number of different choices for this, and create some improvement in the contours that are clearly evident.
So I think it’s been a little over played because not everyone is a candidate for a “non-surgical rhinoplasty” and you know I use that in quotes.
There are number of patients, particularly Asian patients in our practice here in San Francisco, who have a weak bridge or dorsum to the nose, and we can improve the contour and definition there and really see a nice result that is satisfactory. These are typically not permanent results but they are quite long lasting.
So if you have any questions about non-surgical rhinoplasty I encourage you again to visit maasclinic.com, call the office or write us. At the DrMaas.com video blog, you can send questions. This is Dr. Maas on “Looking your Best”
- What is the best energy technology to treat skin?Open or Close
I had a number of questions this week that came out about the treatment of pigments on the skin, and more specifically treatments using laser versus intense pulsed light, which we described previously, and I wanted to get to a couple of them.
The first one which is a very common question is “What is the best laser or energy technology to treat pigment,” and there’s not really a right answer to that question.
I will say that, intense pulsed light, IPL, often known as photorejuvenation, is a treatment that will get most all of the pigments in the skin that are unwanted be they red or brown. When we treat with IPL, we’re treating an entire facial zone or neck zone, so it’s almost like treating the entire area and letting the instrument itself , or the energy, pick up the unwanted treatments rather than targeting a specific lesion or brown spot or some sort of unwanted pigment. Really, the nice thing about IPL is that it’s a broad way of getting all the skin clear, or using the like-crystal that is applied to the skin surface and treating a zone, like the entire face, and all those unwanted pigments.
In summary, IPL represents a great way of doing large area treatments and debulking the unwanted pigments or chromofores that we see in our skin whereas lasers are more of a targeted treatment for specific indicated vessels or lesions that we see in the skin.
As always, I’m happy to take questions you can go to our blog, DrMaas.com, and you can call us at our office 415-567-7000. This is Dr. Corey Maas on Looking Your Best.
- What is Voluma?Open or Close
Today I wanted to answer a few of the questions that we’ve had about the new injectable HA filler, Allergen’s Juvederm Voluma. Voluma is another in the family of HA or hyronic acid fillers, which are in a sense long chain sugars, commonly found in our body, that are used as injectable products for volume enhancement and line treatment.
Many people are familiar with Juvederm, Restylane, Restylane Lyft and Boletero, and now Juvederm Voluma, a product that is specifically indicated for volume enhancement. It’s designed as such that it will last a very long time and that’s what the studies show, which we’ll get into in a minute, and it was specifically indicated for the mid-face volume loss that’s common in facial aging. This doesn’t mean it’s limited to use there but that’s the on-label indication for Voluma.
What we’ve seen is that this product may replace a lot of the other volumizing fillers which use inflammatory processes to essentially create the volume, and don’t have as long of duration of effect.
So let me talk a little bit about these studies that lead to Voluma’s approval and then I’ll talk a little bit about how we use it in our practice, and in general how it is being used across the country, from the prospective of the key opinion leaders that we’re invited to the launch in Southern California a few months ago.
The Voluma Clinical trials that we’re done by the FDA looked at a series of 282 patients over 15 sites, and the specific indication was in mid-face volume loss. Now these areas were divided, as you can see, into regions or zones of the face that included the mid-face zone, or the anteromedial cheek, the zygomatic or cheekbone, and then the submalar zone. Each of these zone were addressed independently as being fully corrected or not, and there was a series of pictures taken for each of the patients throughout the study to look at volume.
What we can see, is the effectiveness of the drug over time, or the device, more specifically, over time and when we’re looking at the response rate of patients, we can see that 86% of the patients in the treatment group were considered responders of the primary endpoint, and that duration in months, as you can see, went out to really, almost 24 months for over half of the subjects that were treated. So, even those patients that were not fully corrected still had some correction at the end of two years of the study.
Now the product itself is used by injecting into zones of the mid-face, and we can see an example of the typical patient here for the study, where mid-face zone was treated, or is being treated for, volume loss.
In this patient, a 61 year male, who had 6cc’s originally and a 1cc touch up, that’s 1 milliliter or syringe, and better shown on this 3 quarter view, where the volume enhancement is really significant. You can see the edge of his cheekbone here and then the after treatment the cheekbone looks fuller.
Another patient that had a 6ml treatment with a touch up and the improvement in the mid-face volume, softening of the lines and even just some of these contour changes that were visible are clearly apparent.
The treatment itself is done with a small needle. Topical application of numbing medicine can be used or just a little bit of ice, but the product voluma does have local anesthesia in it, and targets include the mid-face, as were done in the study, but you can also do areas like the temple or jawline.
You can see in this example, the patient look before, immediately after the treatment, and then two years later, still a very good correction from her baseline to after the treatment itself. So I’m quite excited and I think most of the investigators and key opinion leaders in the field are excited about this drug.
A 56 year old woman, very flat through the cheeks here, restoration of the cheek bone in a very natural way and we’re using this in other areas too, we can see this mid-face zone but the temporal area, the jawline areas might also be good targets for use of the product.
These are immediately after the treatment in an older gentlemen and a series of these patients can be shown and I’ll kind of go through them quickly but it’s fairly dramatic the improvement that is seen. It can be done with any filler but the difference is that you don’t get a lot of swelling after this treatment, you don’t have to wait for a period of time for the volume to fill up, it’s an immediate and enduring effect and its one that lasts for up to 2 years and beyond in many patients.
The product can be used in younger patients, when we see this distribution of volume being reduced, and this is a side view showing the examples of those patients.
Younger and older patients can see improvement and overall volume, a very sharply defined cheekbone in this lady who’d like a little bit less angular, a little more roundness of the face. What we’ve found from the study was that it was a very safe medication to use for mid-face volumization, again jawline, temporal regions can also be used, and really it’s a product that I think is going to change the way we think about volumizing in our patients for the future.
So in summary I’d say that Juvederm Voluma, is a new product that’s an HA filler used for mid-face, temporal volume loss, as well as contouring along the jawline, areas where we’d like long duration of true volume correction.
I don’t know if it will replace autologous fat injection or transfer as a means of creating mid-face and other facial volume losses, but it’s certainly one that can be done in the office within
an enduring 2 year-effect, and so that’s a significant advance in strategies that we have for using soft tissue fillers for the aging process.
If you have any questions about voluma please don’t hesitate to call our office at 415-567-7000.
Visit the website at Maasclinic.com or of course you can visit our video blog DrMaas.com, and we’re open to any questions, photographs if you want, and video questions that we can answer and share with others.
Dr. Corey Maas on Looking Your Best.