Dr. Niamtu’s Weblog

One of the true joys of being alive in this day and age is the Internet.  For those of us that are older than 20 years of age it is hard to imagine life without it.  The Internet has empowered us and made encyclopedias and dictionaries obsolete.  It seems that you can find out anything with just a few clicks.  To Google has become a common verb!

Information is definitely power, but if that is true, misinformation is then weakness.  The decision to have cosmetic facial surgery and the ramifications that go along with it can be tasks of awesome proportion.  There are many surgeons to choose from, many procedures to have done, there are also considerations of patient health, recovery and budget.  When you think of all of this at one time (as most patients do when walking blindly into a consult) it is a miracle that a decision can be made.  So much information, so little time!

Bulletin Boards have become common and popular forums for humans to share information….or misinformation.  I have picked up some great tips on various bulletin boards like how to repair my 1965 Jaguar, how to tune my boat engine, what fishing lures to use on the James River, the best abdominal exercises, etc, etc.  Sometimes I have to wade through some incorrect or opinionated data and it can vary from confusing to dangerous.  With the Internet you have to take the good with the bad.  Cosmetic surgery bulletin boards are numerous, frequently factual, sometimes entertaining and frequently misleading.  On a positive note, these bulletin boards allow patients to discuss and compare data and experiences on various procedures, products and surgeons.  I have seen a lot of very good comments, ideas and advice on these bulletin boards, but I have also seen downright false, mean spirited, confusing and doubtful information as well.  Cosmetic facial surgery is not only my job, but it is my passion, so I am basically consumed with it during my waking hours.  It is my profession and my hobby.  At work, I see patients and operate, at home I work on my website and blog and for leisure I read cosmetic journals and text books.  For fun, I write journal articles and textbook chapters.  My wife thinks I am crazy, but she understands a man driven.

It was my honor to find out that I came highly recommended on several of these bulletin boards.  It is downright flattering to have your passion reflected by nice comments and appreciation of your work.  Sooner or later, however, I (like many compassionate surgeons) may be maligned by an unhappy patient with an ax to grind.  No one likes to hear negative comments about themselves, if they are serious about what they do for a living.  I have one friend who is truly a world class surgeon and is very good at what he does.  He had an unhappy patient (as all doctors will from time to time) that made it their hobby to assassinate this surgeon on virtually every forum that would accept a post.  Due to this, this surgeon has been very discredited for what was not really his fault.  To his defense, he did not deserve it.  There may be others that do.  Some doctors are complacent and are not patient oriented.  They may have consistent poor outcomes and unhappy patients.  A person like this may warrant the bad publicity, but we should all stop and take a deep breath before we discredit someone.  We have all gone to a great restaurant and had a bad meal, or gone to a famous vacation destination and had poor service, etc.  The same can happen with cosmetic surgery.  Because one patient had a bad experience or outcome may not mean that all patients would have the same.  A complication may be the surgeon’s fault (we are human too) or it may have been the patient’s fault.  Some patients refuse to follow pre or post op instructions, others use medications they are warned not to.  Some patients smoke and lie about it and some patients just had bad luck. 

I have been very fortunate that I have been able to have positive dialogue with 99.9% of my patients from the time I meet them.  I always try to personally answer emails on a timely basis, I give all my patients my cell phone number and I am surrounded by a great compassionate and caring staff.  It is not that we never have problems because if you have a very successful and busy practice, you will have problems from time to time.  The most critical thing is how they are handled.  Sometimes it is merely the fact that the patient does not understand, or they are anxious and communication, hand holding and compassion go a long way.  Sometimes, they feel that the surgeon is not responsive or has done something wrong.  Sometime it as simple as the surgeon saying “I am sorry”.  Sometimes the patient is totally unreasonable and sometimes the doctor may be unreasonable.  Fortunately, most successful surgeons have good people skills and are able to smooth out the things that happen.  Sometimes a good surgeon gets a bad patient and vice versa.  Successful surgeons become good at “picking” the right patients.  Over the years, the surgeon and staff develop a sixth sense about patients that may be problematic.  These include patients that are know it alls, patients that don’t listen, patients that talk bad about previous surgeons and patients that are not dependable.  Many patients also have a sixth sense about surgeons, offices and staffs and can tell a genuine proficient and caring surgeon from someone who is faking it.  Having said all of this, usually the patients choose the correct surgeons and the surgeons choose the correct patients.  Everything works out well.  When it does not, it takes responsible communication from both sides to try to make things better.  The problem with some bulletin board postings is that they only tell one side of the story.  If I said that one specific hospital had a high mortality rate, it may cause many people to speak badly about it.  If I said in the next sentence that it was a hospital that only treats terminal cancer patients, you hear the other side of the story.  Some patients will never be happy no matter whom they see because they are not happy with themselves.  Cosmetic surgery requires a stable, rational and psychologically secure patient for the best outcomes.  Some patients have psychological and or image problems and have no business having cosmetic surgery.  The surgeon that operated on them has made a mistake before the first scalpel cut.  Don’t get me wrong, there are surgeons with these issues as well, most of them aren’t busy or popular.  The more good work you do, the more good press you get.  Unfortunately, it only takes one bad apple to spoil the whole bunch and we all should keep that in mind when things get sticky.  Doctors should not talk bad about other doctors or patients, that is a matter of ethics (by the way, doctors that talk bad about other doctors probably talk bad about their patients and that should be a warning sign).  Patients should not go out of their way to demonize a well meaning surgeon who may have been a victim of circumstance.  There are no official ethics here, just the Golden Rule…”Do unto others”.  Just great words for which to live ones life.

I see many patients each day and those whom have visited my website (or other sites and bulletin boards) usually have an advantage of education about what we do and how we do it.  Occasionally, I see a patient that has been brainwashed with misinformation to the point that they feel they know more about the technique than I do.  Obviously that would be a poor choice to operate on that patient.  A know it all or a patient that tells a surgeon how to do a procedure is a gamble and a set up for problems.  It is fine to ask about a given technique or discuss options, but it should be the surgeon that directs the care.  I may present the patient with 4-5 options (filler vs laser vs facelift, etc) and by providing them information such as before and after pictures, patient references, brochures, etc. they can make and informed decision.  I have heard many patients discuss things that they saw on a bulletin board and were not true, or at least not true the way I practice.  Discussion should be two way. The patient and surgeon should both talk and listen.  A bullheaded patient (or doctor) is hard to deal with. The beauty of it all is that no one “has to have” cosmetic surgery, it is totally elective.  If they don’t have a good feeling about a surgeon, they should find another one.  Same for the doctor.  If a certain patient has personality traits that do not blend in with the way you practice, then they should not operate on that patient.  One thing every patient and surgeon should evaluate between each other is “how will he or she act if there is a problem”.  That goes for surgeons and patients.

Education and bulletin boards are great things when they are factual.  You can’t believe everything you read or hear.  Remember, there are Liberian Bank schemes, people trying to steal your identity and a host of other examples of misinformation on the Web.  Be rational, fair, consider the source, hear both sides and most importantly, as you parents told you…………….if you can’t say someting nice………

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

Cosmetic facial surgeons frequently see patients with keloid scars.  There are many types of scars.  Hypertrophic scars are those which enlarge within the boundaries of the original scar and keloid scars are those that enlarge outside the boundary of the original scar.  Due to this, keloids can become quite large and disfiguring.  Although any race can develop keloids, they are most common in darker skin types.  The actual cause of keloids remains unknown but they frequently develop as a response to irritation, such as ear piercings, traumatic lacerations or surgical incisions.  Some areas of the body are notorious for forming keloids such as the earlobes or the sternum (breast bone) in open heart surgery incisions.

Over the years there have been many different treatments for keloid scars.  Although it is tempting to merely excise them, they will most often return with a vengeance, growing larger than the original keloid.

One of the most simple and frequently effective treatments for keloids is injection with an anti inflammatory steroid such as Kenalog (triamcinalone).  This causes the keloid to shrink and repeated injections can be quite effective in softening and reducing the size of the keloid.  A chemotherapy drug called 5 flourouracil can also be mixed with the Kenalog for even more scar dissolving power.  Sometimes injectable steroids are quite effective and can dissolve the entire keloid.

The patient above was treated with Kenalog injection only.

Another method of treating keloids is to surgically excise the keloid and begin immediate injection of Kenalog.  I have used this technique on smaller keloids with good success.

The most effective method for treating larger keloids is to surgically excise the keloid, then proceed immediately to the hospital for a single radiation to the area.  This has been my most successful treatment for very large keloids.  Although it is impossible to guarantee the the keloid will not reoccur, the combination of surgical excision and single dose radiation has been a very positive treatment in my practice.

The above keloids was treated with surgical incision and immediate single dose radiation.  This treatment is frequently covered by insurance.

For more information on the cosmetic treatment of head and neck scars and other cosmetic facial surgery procedures, see

www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, VIrginia

Facial scars are very common from injuries or surgical procedures.  If you call your average cosmetic surgeon and tell them that you have a recent scar, the chances are they will tell you that there is nothing that can be done for a year after the injury.  Unfortunately, this is frequently misinformation.

There is evidence that by treating a scar early, the outcome of the result can be improved.  Some studies have shown that when a scar is treated within 8 weeks of the injury or surgery that it can heal much better than waiting an extended time.  I have adopted this method of treating traumatic and surgical scars of the head and neck and it has worked well.  When a patient presents with a scar of the head or neck that is less than 8 weeks old, I will begin treatment with various modalities including steroid injection, silicone sheeting and pressure.  When the scar reaches its point of primary healing then I will most commonly treat it with the CO2 laser.  The laser performs several functions to improve the scar.  Number one, it allows uneven tissue margins to be blended or smoothed down.  Number two, it causes new collagen to be produced to fill in the irregularities and number three it helps blend the coloration with surrounding tissues.  Lasering the scar is usually done under local anesthesia and takes only a few minutes.  The area will be raw for the first 5-6 days and then be a smooth pink.  This pinkness will fade over the ensuing weeks but may last several months in some cases.

The above scar was treated with CO2 laser resurfacing about 6 weeks after the injury.  This was an exceptional result and not all scars of this type respond to such an extent from a single treatment, but this case shows the power of the CO2 laser for scar treatment. 

The above patient sustained this scar from a surgical procedure at another office.  Dr. Niamtu treated the scar with two sessions of CO2 laser resurfacing.

Sometimes the scar is lasered multiple times as it improves with each treatment.  While simple lasering may work great for simple scars, more complex scars may need surgical intervention first.  Many surgical procedures exist to make scars less noticeable by changing the direction of the scar, making it it more random (straight line scars stand out more) or making the margins even.  Sometimes Dr.  Niamtu will perform a surgical scar revision and then follow up with laser resurfacing to better blend the scar.

Some depressed scars (those that are like craters) respond will to filler injection.  By injecting silicone or other fillers, many depressed scars can be simply “popped out” by filling the base of the depression with filler.  This is useful in acne or pock scars.  Subcision is another useful technique.  Subcision is a process in which a special needle is used to break up scar tissue at the base of a depressed scar.  A depressed scar has spider web like bands called adhesions that, in part, are what keep the depressed scar tethered down.  By inserting this cutting needle under the scar and swiping it back and forth, these adhesions can be separated and allow the base of the depressed scar to rise up and fill in.  Subcision can be performed multiple times to improve a depressed scar.

This patient sustained a severe facial scar from a motorcycle accident.  This scar required surgical treatment followed by laser resurfacing and silicone injection.

There are many myths surrounding the treatment of surgical and traumatic scars.  Applying Vitamin E, commercial products like Mederma or Scar Guard or covering the scar with silicone sheeting are probably all useful, even if not scientifically proven.  Keeping a new scar protected from the sun is also important.

For more information on the cosmetic treatment of facial scars or other cosmetic facial surgery see

www.lovethatface.com

 Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

Having a blog requires keeping it up to date and therefore bloggers are continually looking for new, interesting and relevant content.  I have recently read a fantastic journal article in Dermatologic Surgery about Tanning and the associated dangers. 

Ibrahim SF, Brown MD.

Tanning and cutaneous malignancy.

Dermatol Surg. 2008 Apr;34(4):460-74.

This article by Drs. Ibrahim and Brown is entitled “Tanning and Cutaneous Malignancy” is one of the best and most authoritative articles I have ever seen on the subject.  I have summarized the article by a series of self explanatory and sometimes startling facts and also added a few of my own.  After reading these bullet points, one should have a good understanding of the dangers of outdoor and indoor tanning.  All tanning is dangerous.  A tan (and worse, a  burn) represents DNA damage to the skin cells and increased the chances of melanoma and nonmelanoma skin cancers.  There is no such thing as a safe tan.  Although it would be ideal to never get any sun exposure, it is ludicrous to think that younger people will refrain, so I recommend moderation and common sense.  The basis of these facts will be self evident and gives us all something to think about.  Tan now, pay later!

Facts about Sun Exposure and the Associated Dangers

1.       Every civilization has had an unwavering reverence for the sun

2.       Before the industrial revolution a tan was a sign of lower class field workers and “porcelain paleness was the epitome of high society” and after that workers went into factories and those with leisure became tanned.

3.       Fashion icon Coco Chanel  sparked the tanning craze in the western world  proclaiming “a 1929 girl must be tanned….A golden tan is the index of chic”

4.       Bikini’s were introduced in 1946 and the “California Beach Culture” of the 1960’s further exposed the skin and increased sun exposure.

5.       A 1907 study in France noted the grape pickers developed increased numbers of cancers on sun exposed areas.

6.       Over the past 40 years, the association between sun exposure, prematurely aged skin, and cutaneous malignancy has become indisputable.

7.       However the desire to tan is higher than ever before. 

8.       In a survey of 8,000 Americans 94%  were concerned that exposure to UV light could lead to skin cancer, yet 68% felt they looked better with a tan.

9.       The first ad for a sun lamp appeared in Vogue in 1923 and there are up to 50,000 indoor tanning facilities in the USA.

10.   There is little sound evidence for any medical benefit from recreational tanning.

11.   We are currently experiencing a skin cancer epidemic and exposure to UVR (ultraviolet radiation) remains the single most modifiable risk factor for the prevention of skin cancers.

12.   Sunlight is 95% UVA and 5% UVB.  UVB is a complete carcinogen and are largerly responsible for sunburn, tanning and carcinogenesis.

13.   Tanning is a response to DNA damage.

14.   Cancer Stats

a.       The WHO estimated in the year 2000 up to 70,000 deaths worldwide were attributable to excessive UV (ultraviolet) exposure.

b.      In the USA skin cancer represents for more that 50% of all malignancies

c.       Mortality from melanoma in the USA occurs at the rate of approximately one life per hour or more that 8,000 deaths annually.

d.      Although melanoma only represents 3% of total skin cancers, they are responsible for over of 80% of skin cancer deaths.

e.      Skin cancer incidence is rising faster than any other cancer and the lifetime risk of an American to develop melanoma has increased 2,000% in the last 75 years.

f.        Melanoma is currently the second most common cancer (after thyroid) form women in their 20’s.

g.       Residents of New Zealand and Australia have the highest melanoma rates in the world due to largely fair skin and live close to the equator.

h.      Caucasians have 23 times higher incidence of melanoma than blacks.

15.   Red heads, fair skinned people and light eye color are at more risk, as is excessive sun exposure before the age of 18, and sunburn at any age have been repeatedly shown to increase one’s lifetime risk for development of melanoma.

16.   “A single severe in childhood may double the risk of melanoma” (ref 77 in article).

17.   The tanning industry generates $5 billion annually, up from 1 billion in 1992.  1 million people tan daily and 70% are Caucasian females form 16-49.  30% of teens between 13 and 19 are tanning with girls 2-3X over boys.

18.   Indoor Tanners are

a.       More likely to tan outdoors

b.      Less likely to use sun protection

c.       Less knowledgeable about skin cancer risks

d.      More influenced by social factors

e.      More concerned about weight

f.        More likely to smoke

g.       More likely to binge drink

h.      More likely to use recreational drugs

i.         More likely to have parents who tan

19.   20 minutes in a tanning bed is equal to 2-3 hours in the noon day sun.

20.   Evidence shows several positive associations between indoor tanning and melanoma, particular with exposure before age 35.

21.   Patients that use indoor tanning think they are protected and hence spend more time in outdoor sun, which is bad.

22.   Studies show that up to 88% of tanning salons allowed minors to tan without parental permission and 75% provided reassurance of the safety of tanning.

23.   Sun is not necessary for Vit. D which is in many foods, 5 minutes at noon in the June Boston sun is adequate for maximal cutaneous production.  2 glasses of milk or orange juice cover it, as does incidental exposure of face and back of hands.

24.   Tanning can produce endorphins and contribute to “tanner’s high”

25.   The link between natural and artificial sun and skin cancer is becoming much like cigarettes and lung disease or alcohol abuse and liver damage.

To find out more about skin aging and facial rejuvenation see

www.lovethatface.com

Joe Niamtu, III DMD

Richmond, Virginia

There is no more unreliable media than the cosmetic surgery media.  It is fueled by promises of miracle treatments that provide something for nothing.  As good as it sounds, it is a rare innovation that allows dramatic results with little or minimal treatment.  The only thing that I can even think of that comes close to that in the last 30 years is Botox.  It satisfies the definition of innovation.  Never before were patients able to get of wrinkles (albeit temporary) in a non surgical manner.

It is impossible to pick up a paper or magazine of to turn on the news and not hear about some new “miraculous” cosmetic treatment.  Unfortunately, most provide empty promises.  I ( as well as many other surgeons) have seen many come and go.  Thermage, which was all the rage several years ago has proved disappointing to the point where many docs are trying to unload their machines.  The Contour Thread Lift was another dud and the company is no longer in business.  Although there are many new minimally invasive lasers and light devices, I predict most of them will also fall by the wayside because they just don’t deliver dramatic enough results to warrant the cost of treatment.  I will admit that all of these technologies do provide some result, but not enough to satisfy the demanding patients in most surgical practices.  If a non surgical specialist can tighten the neck skin 5%, for $6,000 and some of their patients see tiny a result, they may be happy, but 100% of patients in my practice would want a refund for these minimal results.  My patients, like many other surgeons want to see a dramatic difference.  They realize they won’t get that without surgery and recovery; they are realists!

Back to the cosmetic media.  There has been a lot of news buzz lately about patients having cosmetic surgery to fare better in the work place.  A reporter called me the other day and was surprised to hear me say that I think that is a silly pretense.  Don’t get me wrong, I am obviously an advocate of cosmetic surgery and I will agree that all patients want to look younger.  I will also agree that younger, thinner, less bald and taller patients get more promotions.  That is just a fact of life.  There is nothing wrong with wanting to look younger.  If you have a big “turkey wattle” neck and you work with a bunch of 35 year olds, it makes sense to want to look younger.  However, to think that tightening ones neck or lopping off some eyelid skin will enable promotion or retention is rather ludicrous in my opinion.  Although cosmetic surgery can make a patient look younger, the best surgeon in the world cannot make a 68 year old patient look like a 45 year old.  Cosmetic surgery can make you look younger, but will it really make you look that much younger?

First of all, patients need to have the right motivation to have happiness after cosmetic surgery.  If they go through the recovery and expense of cosmetic surgery and do not move forward in their job, it will only serve to compound their unhappiness.  Sometimes we need to look at our inner beauty!  We are all going to get old, count on that.  Progress in the workplace is much more about attitude, team work, accountability and reliability.  If you really want to do advance in the workplace, a conscious effort to work harder that any other employee will go a lot further than geting your eyelids tucked.

I love performing cosmetic facial surgery, it is my passion and there is not better feeling for me than making patients look and feel better.  Sometimes my work may lead to a new relationship or a job promotion, but usually it simply leads to a patient with better confidence and self esteem.  I relate it to the way one feels when their car is dirty and how good you feel when you drive out of the car wash.  Cosmetic surgery patients feel like that for years.  Cosmetic surgery makes you look better, but can also make you feel better.

It is imperative to consider many aspects of ones life prior to making the decision to have cosmetic surgery.  Health, recovery and budget are important points, but the true underlying motivation is the most important factor and has much to do with the patent’s perception of success of the procedure.  Do it because you want to look better, be more confident and elevate your self esteem.  The relationships, jobs and modeling contracts may or may not follow.

To find out more about cosmetic facial surgery or Dr. Niamtu in Richmond, Virginia, see

www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

If the eyes are the seat of the soul, they are the foundation of beauty.  The eyes are a beautiful, intricate and unique structures and are the first thing that humans notice about the face of other humans.  The youthful eyelid is tight, well defined, sculpted and is one of the basic clues about ones age.  As we get older, the upper face ages more rapidly than the lower face and it is not uncommon for me to perform eyelid surgery on patients in their late third decade and through their eight decade.  A healthy person is never too old to look younger!

Most us that are over 35 can testify to the subtle changes that begin in the mid 30’s.  Usually we fires notice the “crow’s feet” wrinkles that develop on the side of the eyes and are accentuated when we squint and smile.  The next change that becomes apparent is the excess skin that forms on the upper and lower eyelids.  The upper lids get droopy and the excess skin can lie on the eyelashes or lower.  This can actually obstruct a patient’s vision and if this is the case is often covered by health insurance.  For a cosmetic procedure to be covered, the patient must first visit their eye doctor and undergo a test to see if the skin excess qualifies for insurance.

Women will notice that they can no longer wear eye shadow because the eyelid shelf (the area above the lashes) is covered with skin.  Men will usually notice that their eyes look smaller.

The other big change is the development of fat bags around the upper and lower lids.  The eye is surrounded by a protective cushion of fat and as we age, the tissues that keep the fat in place weaken and the fat pockets protrude under the skin.  This (along with skin changes) gives patients a puffy and tired appearance.  It is not usual for patients to present to the office and say “Dr. Joe, I work out, watch my diet and take care of my self but I always look tired. My friends ask me if I am stressed or not sleeping!”  What these patients are actually saying is that they have aging changes in the eyelids.

The above picture illustrates aging changes in the eyelids.

Many patients that think they need eyelid surgery actually need brow and forehead lift surgery.  See this topic on my previous blog topics.  Brow and forehead lift is sometimes performed alone or with the combination of brow and eyelid surgery.  The photo below shows a patient with a tired appearance that was refreshed with brow lift and eyelid surgery.

The above patient complained of looking tired and was treated with brow and forehead lift and blepharoplasty (cosmetic eyelid surgery).

Upper eyelid cosmetic surgery is a relatively standard procedure in that an incision is made on the upper lid and excess skin, muscle and fat are removed or recoutoured.  The procedure takes about 20 minutes per upper lid and stitches are placed the dissolve or are removed at about 5 days.  The recover for upper eyelid blepharoplasty is usually about a week although most patients could don sunglasses and go about their business (excluding heavy lifting) in several days.  Many surgeons use scalpel or scissors for eyelid surgery.  Dr. Niamtu performs all his cosmetic eyelid surgery with high technology modalities such as lasers and radiowave surgery.  By using these advance devices, there is virtually no bleeding.  This means less pain, swelling and bruising and a faster recovery.

Lower eyelid surgery is more diverse in the number of surgical approaches the doctor uses.  Basically there are external approaches which leave a scar on the lower lid and internal approaches which are performed from the inside of the lower eyelid (transconjunctival approach) that leave no scar.  Dr. Niamtu generally uses the internal approach due to the fact that there will be no scar and also there are less complications with lower eyelid position with this approach.  Using the external approach can cause a pulled down lower eyelid which is not a problem with the internal approach.  When using either approach, the excess fat is reduced or repositioned to improve the bags under the lower eyelids.  This represents the first part of the operation and the second part is tightening the excess lower eyelid skin.  This thin, crinkly skin is addressed by numerous methods including cutting, lasering and chemical peeling.  Dr. Niamtu prefers treating the skin with the laser as there are no incisions.  The upside of the laser is that it makes new skin.  The aged skin is removed as well as pigment that contributes to dark circles under the eyes.  The downside is that the recovery is longer as the patient cannot wear makeup for about 10 days and will have some residual pinkness that can be covered with make up which can last up to several months.  The best results are available with the laser if the patient can tolerate the recovery.  Dr. Niamtu prefers chemical peel as the second option for lower eyelid skin tightening.  Although not quite as effective as the laser, the chemical peel also tightens the skin and removes unwanted skin damage and has a much shorter recovery which is usually a week and the patient is back in makeup.  A third method of tightening lower eyelid skin is to remove a small amount of skin.  Dr. Niamtu usually reserves skin removal for selected patients that are not candidates for laser or chemical peel.

The patient plays an important part in the success of any operation and especially eyelid surgery.  Serious complications are rare with eyelid surgery.  Bleeding behind the eye can be catastrophic and although very rare can be caused by bending, lifting, over activity, high blood pressure and medications as simple as aspirin that can affect the clotting system.  It is vitally important to adhere to the pre and post operative instructions provided by our office.

The following pictures show before and after cases of cosmetic eyelid surgery. 

Dr. Niamtu and his staff invite you to visit our office for a free consult for eyelid rejuvenation as well as visit our website www.lovethatface.com for more information about Dr. Niamtu and cosmetic eyelid surgery in Richmond, Virginia.

Although it seems like a minor problem, thousands of people with pierced ears have torn earlobes and with the popularity of body piercing the number will surely grow dramatically.  The torn earlobes can result from the continual wearing of heavy earrings, trauma, getting earrings snagged on phone cords, pull over sweaters, bath towls, hairbrushes or children pulling them.  The actual tear may be a partial tear or a full thickness tear that completely splits the earlobe.  Torn earlobes bother patients from a cosmetic standpoint as they are unattractive and also because the patient either cannot wear earrings or the earrings tip or move out of place due to the large hole.

The above image shows a partial earlobe tear.

The repair of torn earlobes is a very simple process that takes about 15 minutes.  Local anesthetic is injected in the earlobe to make it numb and depending upon the severity of the tear, there are several means of fixing it.  Partial tears are treated by cutting out the pulled apart area and resuturing the hole.  Total tears require a bit more surgery and are treated by excising the borders of the completely torn earlobe and placing dissolvable sutures on the front and back of the ear.

Dr. Niamtu has publilshed several articles on this procedure in the maxillofacial and dermatologic literature and was the first to publish a method on simultaneous piercing.  SInce most patients don’t want to go without wearing earrings, Dr. Niamtu can repair the tear and at the same time place a special sterile earring stud through the stitches so the patient can heal with the new earring in place.

Although the technique is simple it requires finess to properly line up the earlobe to have a natural curve and shape.  Dr. Niamtu also performs laser or radiowave surgery on earlobes that heal wiht a notch which sometimes happens in the best of hands.

The recovery is also simple.  Generally dissolvable stitches are used and the patient can resume normal activities that do not place tension on the ear.  The stitches dissolve in about a week and a fine linear scar is visible for several weeks and generally fades to an acceptable result.  For the suture scar that does not heal gracefully, Dr. Niamtu will resurface it with the CO2 laser which dramatically improves it.  If the ear is not pierced at the time of the surgery, the patient generally waits about a month to repierce the ear.

Dr. Niamtu also performs earlobe reconstruction on “piercings gone bad” where people intentionally stretch the earlobes or susain disfiguring tears of the ears or lobes from body piercng.  He also treats keloids of the earlobes.  Finally, many patients are born with very large earlobes and Dr. Niamtu frequently performs earlobe reduction in these patients to reduce the size of their earlobes.

The above pictures show several cases of earlobe repairby Dr. Joe Niamtu in Richmond, Virginia. 

For more information about earlobe repair, earlobe reduction or earlobe keloids  or other cosmetic facial surgery procedures see www.lovethatface.com.

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

www.lovethatface.com

Liposuction is one of the most common cosmetic surgery procedures and has become much easier over the past 20 years.  Unlike body liposuction where large volumes of fat may be removed , the procedure is much more conservative in the head and neck.  Most patients do not have large areas of fat in the head and neck and therefore much less fat is removed.  Where quarts of fat may be removed from the body, the amount of fat removed in the head and neck is measured in “tablespoons”.  The main areas in the head and neck for fat deposition are the jowls, the area under the chin, and the neck.

Figure 1. shows common areas of fat deposition in the facial region.

The most common misconception about neck liposuction is that it will tighten lose neck skin.  Many patients present for the consult and have a large “turkey gobbler” area of excess skin.  Even if there is fat under the lose skin, removing the fat will only serve to accentuate the lose skin and make it look worse.  The bottom line is that if a patient has excess skin under the chin and neck, they will need a facelift to correct this. 

Having said this, liposuction of the neck and chin (submental region) can be very effective in the proper patient.  This is usually a younger patient with fat deposits under the chin and without significant excess skin.  In these patients, removing some of the excess fat by conservative liposuction can make a huge difference in the patient’s profile.  The younger the patient is, the more the skin will tighten up after removing fat, as there actually is some degree of skin tightening in most patients.  The jowls, cheeks (to a lesser extent) and neck can also respond to liposuction.  It is important to remember that liposuction is not treatment for obesity but rather for genetic fat deposits that are resistant to generalized weight loss.

The Procedure

Head and neck liposuction can be performed with local anesthesia or with IV sedation.  The area is sanitized  and a dilute solution (tumescent anesthesia) of local anesthesia and epinephrine is used to inflate the tissues to be liposuctioned.  This tumescent solution not only numbs the area but also decreases bleeding and facilitates the actual liposuction procedure.  A tiny puncture is made in a skin crease to hide any scar, and the liposuction cannula (a thin metal, straw-like instrument) is inserted under the skin .  The cannula is briskly moved back and forth through the excess fat and the fat is emulsified into a liquid that is suctioned out.  It is important not to over treat an area because removing too much fat (especially in the neck and under the chin) can cause very visible irregularities under the skin.  The treated area will usually stay numb for several hours after the procedure, so pain is not a common problem.

After the procedure the patient is given a compression dressing (Jaw Bra) to wear for several days.  Depending upon the amount of fat removed and the amount of excess skin the dressing may be worn for 5 days continuously and at night for the next week.  For most patients, this type of liposuction is a weekend recovery unless they bruise, which extends the recovery from a cosmetic standpoint.

Figure 2 shows a patient treated with liposuction only of the chin and neck regions.

Buccal Fat Pad Removal

All humans have walnut sized collections of facial fat called the Buccal Fat Pads that lie in the cheek.  In patients that desire to have their face “slimmed” the buccal fat pads can be reduced at the same time (or in place of) the liposuction.  This is done by making a small incision inside the mouth, next to the wisdom teeth and the fat pad is teased out of its position and conservatively reduced.

Icing on the Cake (Chin Implant Surgery)

Another means of dramatically complimenting the liposuction procedure is to place a chin implant in the appropriate patient.  Many patients with submental fat also have a retrusive profile from a weak chin.  By removing some of the chin and neck fat with liposuction and simultaneously placing a chin implant, the result is made better than doing either procedure by itself.

The chin implant can be placed from the inside of the lower lip so no surgical scar is visible.  The recovery for chin implant surgery is about one week.

Figure 3 shows a patient treated with liposuction and a simultaneous chin implant.

For more information about head and neck liposuction by Dr. Joe Niamtu in Richmond Virginia see:

http://www.lovethatface.com/cosmetic_facial_surgery_richmond_va/face_neck_liposuction.html

For more information about chin implant surgery by Dr. Joe Niamtu in Richmond, Virginia see”:

http://www.lovethatface.com/cosmetic_facial_surgery_richmond_va/chin_surgery.html

For more information about other Cosmetic Facial Surgery from Dr. Joe Niamtu in Richmond, Virginia see:

www.lovethatface.com

Joe Niamtu, III DMD

Richmond, Virginia

www.lovethatface.com

Although most patients are interested in augmenting their lips, some patients are interested in making their lips smaller.  This is more common in certain ethnic or racial groups and is popular with men and women.  Some patients also have lip enlargement due to trauma and this can be treated similarly.

At the consultation, the Dr. Niamtu explains the procedure to the patient and discusses how much smaller the lips would be.  Since you can always take more away, it is always better to error on the conservative side.  This means that some patients may require a touch up procedure to further reduce the lip size, but this has been rare.

The Procedure

The procedure can be performed with local anesthesia or IV sedation and takes about 25 minutes per lip.  The goal of the procedure is to remove a wedge of skin from the inside of the lip.  By placing the incision in this area, the scar will be hidden.  After the wedge is removed, the area is sutured together which allows the lip to roll back reduce its profile.

Figure 1 shows the intended area of skin excision to reduce the bulk and volume of the lip.

The recovery is variable but generally takes about a week.  Swelling and discomfort are usually moderate although some patients may experience significant swelling which resolves with anti swelling medication.  In the early post operative period, patients should refrain from excessive oral function.  Some swelling may persist for several weeks.

Click to enlarge

Figure 2 shows a before and after picture of lip reduction.

Although different from lip reduction, another procedure is used to shorten the upper lip known as a “subnasal lift” or a “bullhorn procedure” (due to the outline of the incision resembling horns).  This procedure is used for patients who have an elongated lip and do not show any of their edge of their front teeth when they talk.  Most female patients show several millimeters of tooth structure when talking.  Failure to show any tooth edge gives the appearance of a “denture smile” or an older appearance.  As we age, the lip becomes longer and loses its form.

With the subnasal lift, a curved area of skin is outlined and removed where the lip skin meets the nose.  After the excess skin is removed, the incision is closed which not only elevates the lip but also causes the lip to “roll out” giving it a more pouty appearance.

Click to enlarge

Figure 3 shows the area of skin excision used in the subnasal lift.

Click to enlarge

Figure 4 shows a before and after image after a subnasal lift.  Note that the elongated lip is shortened and now has more pout.

For more information about lip reduction in Richmond, Virginia and to see before and after pictures go to:

http://www.lovethatface.com/cosmetic_facial_surgery_richmond_va/lip_reduction.html

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

www.lovethatface.com

Chemical peeling is one of the most time tested procedures in cosmetic facial surgery.  It was practiced by the Egyptians using fermented fruit acids and has been safely and effectively utilized since then.  The basis of chemical peeling is to intentionally damage the outer layers of the skin.  This is done by coating the skin with an acid solution.  Many types of acid solutions are available and which one is used is determined by the preference and skill level of the cosmetic surgeon.

Not all Chemical peels are the same!  As most people are aware, some chemical peels are very light and are popular at the beauty shop, spa or even at home.  These peels are very light and also do very little by themselves.  To see serious results, one must undergo a more comprehensive type of chemical peel.  Since a stronger acid solution must be used, the procedure is too painful to be done without anesthesia and comprehensive chemical peels are generally done with some type of IV sedation.  One of “Dr. Niamtu’s Rules of Cosmetic Surgery” is that “if a skin resurfacing procedure (laser or peel) can be performed on an awake patient, the results will be minimal.”  With few exceptions, this means that in order to see significant results, the skin needs to be damaged to a specific level.  It is very painful to achieve this level of skin damage and most patients won’t tolerate that level of discomfort.  For this reason these types of peels and laser treatments must be done under sedation otherwise the needed level of cellular damage cannot be achieved in most patients.  In other words, to see great results, you need a deeper peel.  A deeper peel is painful and anesthesia is required.  Don’t get me wrong, some patients can sit there and “white knuckle the chair” with tears in their eyes and tolerate the procedure, but there is no need to go through that punishment with safe, modern sedation techniques.

Preparing for your Peel

When considering a chemical peel, it requires a serious look at the patient’s skin care program (or lack thereof).  A surgeon should never “just peel a patient”.  All patients that are going to have a chemical peel must first pre condition their skin by using prescription skin care products.  Retin A and a bleaching agent like hydroquinone are the bare minimum treatment that must be done several weeks before a chemical peel.  By using these creams, the skin is conditioned to allow the acid to better penetrate and the healing is also easier.  In addition, the post peel complications are also reduced by pre conditioning the skin a month before the peel.  Getting your face peeled is like getting your car painted and just as you must take care of the new car finish, the patient must also care for their new skin.  In reality, all patients should be on a “lifetime skin care” program and beginning this before the peel is a great place to start.  Then, after the peel, these creams are continued as every day skin care, hopefully forever.  There is scientific basis that these products, in prescription strength, can reverse many aging changes as well as reduce future problems.  This type of skin care is really simple and cost effective and takes about as long as brushing ones teeth, so there is really no excuse not to embrace this concept.

The darker the skin type, the more potential problems there are with skin resurfacing.  Pigmented skin can be unpredictable in terms of peeling and healing.  Skin of color can be much more reactive to post peel pigmentation changes and by using the prescription creams, many of these problems can be reduced or eliminated.  If a patient does not have enough discipline to use prescription skin care products before and after their peel then they should not have a peel as they are missing the ability to make a true difference in their final result.

Types of Peels

There are many types and levels of chemical peels varying from ultra light to deep peels.  The lighter the peel, the less the recovery and result.  Again, the result from a chemical peel is directly related to the depth of the skin damage.  Lighter peels are tolerable without anesthesia because the acid is weaker and the damage is less.  This means that the patient will not see very much change in pigment and wrinkles.  If a patient has many light peels over a period of time, they may see a change but a patient who expects much from a light peel will be disappointed.

The medium depth peels are the most popular because the deliver a bigger “bang for the buck”.  These peels generally require anesthesia (at least in my practice as I disdain suffering) and the recovery is about one week.  Patients undergoing a medium depth peel can expect really noticeable and lasting improvement in their pigment related problems.  Most age spots, liver spots and sun spots (all slang for the medical term “lentigos”) and freckles are generally improved or eliminated with medium depth peeling.  In addition, fine lines and wrinkles (like the type on the lower eyelids) are generally improved.  The medium depth peel will also improve skin tightness and smoothness and in some cases reduce pore size.  This type of peel is like stripping coats of wallpaper or paint or power washing your deck.  It literally gets rid of the aging changes of the outer skin layers.  Finally, the entire chemical peel process causes the deeper skin layers to produce new collagen which is the building block of youthful skin firmness and tightness.

Even with medium depth peels, the skin damage may not be totally corrected and the patient may require additional peels.  I have some patients that do a medium depth peel every 3-4 years and I have some patients that do them twice a year.  It all depends upon the amount of skin damage and the patient’s desired result.

There are also very aggressive chemical peels know as “deep chemical peel”.  This type of peeling is more dangerous and has many more complications and has largely fallen out of use by most practitioners, largely due to the availability of laser technology.

Before your Peel

The remainder of this blog will deal with medium depth chemical peeling.  Since the skin is damaged to a deeper level with the medium depth peel, several medications are used before and during the recovery.  An antiviral drug is used to prevent herpes outbreak and an antibiotic is used to prevent a bacterial infection of the healing skin.  These are frequently started 1-2 days before the peel and taken for about a week.

During the Peel

In my office, the patient arrives the morning of the peel with nothing to eat or drink eight hours before surgery.  They are photographed with digital photography and ultraviolet photography (which shows the pigment better) and an IV is started with sedation administered.  The face is then cleansed with acetone to remove the skin oils and the peeling acid solution is applied.  The patient does not feel the discomfort due to the sedation but if they were awake, it would be intolerable.  Several coats of the acid are applied depending upon the patient’s skin type, color and degree of damage.  As the peeling acid is applied the skin takes on a white appearance (referred to as a frost) which indicates the degree of damage to the outer skin layers.  The procedure is stopped when the appropriate level of penetration is achieved.  At this point, the face is coated with Vaseline and the anesthesia discontinued.  When the patient awakes, they will feel the sensation of asunburn, but it is not an intolerable feeling.

After the Peel

For most patients, the first few days after the peel are very uneventful.  Their skin will become somewhat darker looking and there is tightness but not usually any significant discomfort.  Once in a while, some patients will experience significant swelling, especially around the eyes and cheeks, but this is an exception instead of a rule.

Post peel care involves  washing the face with a gentle cleanser such as Cetaphil and patting the face dry with a towel.  Vaseline is applied continually, around the clock, until the peeling is finished.  At this point a gentle moisturizer is then applied.

About the third to the fifth day after the procedure the dead skin will begin to split and peel.  This will occur first in the areas of increased movement such as around the mouth or the Crow’s Feet regions.  The rest of the face (and or neck) will also begin to peel and it is important for the patient not to pick at the peeling skin (although it is tempting) as it can leave scars on the face.  Generally, all the peeling is complete by one week and the patient is back in makeup if desired.  This relatively short recovery makes peeling an attractive option.  If it weren’t for the fact that the patient has skin peeling from their face, they could go to work as there is usually no pain or problems, they just look scary!  Patients that work from home or don’t care that their co-workers know they had a peel may not miss any work.  I personally had a medium depth peel and went to work every day of the process.  It was actually helpful to show patients what they would also look like with the same procedure

Actual Pictures of Dr. Niamtu’s Medium Depth Chemical Peel

It is important to protect the new skin with sun block and to continue gentle washing and application of a neutral moisturizer.  Several weeks after the peel it is important to get back on the prescription creams to maintain the new result and reduce future damage.  Most patients are more serious about skin care after the peel as they desire to “protect their investment”.

Before and after chemical peel to eliminate freckles

For more information about chemical face and neck peels see

http://www.lovethatface.com/cosmetic_facial_surgery_richmond_va/facial_peels.html

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia