Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Injectable Fillers in a Busy Cosmetic Facial Surgery Office

collage3 January is always an interesting time of the year as we review and reflect on our procedure numbers from the previous 12 months.  I was both amazed and intrigued to have injected 1,761 syringes of filler in the past 12 months.  I knew I was in the top 10% of injectors nationally, but did not ever really count the volume in the past as we mostly tracked surgical procedures.  What is also notable is that I personally do all filler and neurotoxin injections in my office.  Some practices have multiple physician injectors or non-surgical staff such as nurses and nurse practitioners that may inject.  In our office it is just me, so 1,761 syringes of filler means I was really busy.

In further reflecting about the popularity of injectable fillers, so much has changed in 15 years.  For those of us that were using fillers in the 1990’s, the choices were pretty slim.  Basically we had Zyderm and Zyplast which was collagen from cow tissue.  One big draw back was that some patients could have severe allergic problems and when mad cow disease surfaced, it upped the scare factor for animal collagen.  Allergy was rare, but allergy testing was a hassle because the patient had to come in a month before injection to have a test dose to determine allergic response.   Hard to imagine now in this day of “walk in/get injected” treatment.  The other and biggest problem of collagen filler was that it simply did not last.  It did OK for fine lines and wrinkles but sometimes only lasted a matter of weeks.  It was also pretty “creamy” in texture and did not do much for lifting or plumping.

Fast forward 10 years and NASHA fillers were introduced.  This stands for Non Animal Stabilized Hyaluronic Acid.  Hyaluronic acid is a naturally occurring carbohydrate that is found in many body tissues.  It has the consistency of hair gel and can be produced in thin and thick formulations.  The thinner (more watery) formulation (Restylane, Juvederm Ultra, Belotero) are used more for fine lines and wrinkles or outlining lips.  The thicker formulations (Perlane, Juvederm Ultra Plus, Voluma) are well suited for more robust applications like lifting or volume restorations, such as filling cheeks and smile lines.  If you desire more trivia, this viscosity or adhesivity is referred to as “G Prime”.

These hyaluronic acid fillers have been game changers because there are no allergy problems, and the results last for up to a year.  Another huge advantage of the hyaluronic acid fillers is the fact that they can be reversed overnight.  Although most patients want their filler to hang around, there are times where they may not like the result.  Injecting hyaluronidase (an enzyme that dissolves the filler) can reverse the result in a matter of hours.  That can be a great insurance policy.  Although we have semi-permanent and permanent fillers, they cannot be reversed and permanent filler can turn into a permanent complication.  I personally inject Radiesse and fat which are semi-permanent filler and silicone oil which is permanent filler.  Where and how we use these types of fillers is different from every day filler applications.  95% of patients are best suited for hyaluronic acid fillers.

Finally, the other reflection about fillers is how our usage has changed over the past 15 years.  I can promise you that no one ever walked into my office in the mid 1990’s and asked for cheek, teartrough, or brow filler.  In one respect, we did not think about it and in the other respect, it would not have worked well with the available products at that time.  Today, we use fillers in the upper face for forehead lines, eyebrow lift, and crow’s feet wrinkles.  We use them in the midface for teartrough, cheek, smile line and nose treatment, we use them in the lower face for lip, chin, jowl, mandibular angle and jawline augmentation.  The versatility of modern fillers has been both exponential and amazing and is truly an enjoyable part of my practice.  I routinely publish on filler use and technique and teach courses major filler companies to train other doctors.  I love performing surgery, but I also enjoy the artistry and sculpting that involves injectable fillers.  This is one of the reasons my job is so much fun.

January 27, 2013 Posted by | Lip and Wrinkle Fillers, Lip Augmentation, Minimally Invasive Cosmetic Facial Surgery, Removing Excess Lip & Wrinkle Filler | , , , , , | 3 Comments

Tell Me About Belotero, the Newest Injectable Filler

Belotero is the newest FDA injectable filler available in the USA.  It has been used for years in Europe with excellent patient satisfaction and safety margin.  This filler is unique in several ways.  Most notably, it is made with a dual cross linking process that gives it some of its unique properties.  The biggest advantage with Belotero is that it can be injected very superficially for fine lines and wrinkles.  This is important as many other fillers are too thick (honey like) to be injected in the very superficial dermis and when this is done, it can leave a thickened line.  Belotero, on the other hand is engineered specifically for superficial injection.  I must say that when I began using it for fine lines and wrinkles it was hard to believe how superficial it could be injected.  Having said that, it can also be used like conventional fillers for deep wrinkles and lips.  I think the biggest innovation is that the company states that due to the Belotero’s particle properties, it does not cause a Tyndall effect when injecting in the tear trough region.  The Tyndall effect (in this case) is when a clear product is injected under the skin and produces a bluish hue due to the way the light is reflected.  Although harmless, it produces dusky skin that can make a patient look older, as in dark circles.  To avoid this, most fillers are injected deep on the bone in the tear trough region.  Belotero, however, due to its unique composition, can be injected much more superficially which gives the doctor more control of improving wrinkles and rejuvenating this region.  I have been using Belotero and so far have found it to live up to the claims of the company.  I will keep my blog updated on this topic.

Click here to see a video of Dr. Niamtu injecting Belotero.

To find out more about cosmetic facial surgery by Dr. Joe Niamtu, III in Richmond, Virginia visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


March 7, 2012 Posted by | Belotero, Lip and Wrinkle Fillers, Minimally Invasive Cosmetic Facial Surgery, New Cosmetic Surgery Technology | , , , , | 1 Comment

Dr. Niamtu appointed to Xeomin Teaching Faculty


The introduction of Botox by Allergan in the 1990’s proved to be a paradigm shift in cosmetic surgery as it was a safe and easy treatment that worked and had no previous type of treatment.  Obviously Botox was the first and still the
most popular neurotoxin (now called neuromodulator) with millions of treatments all over the world.  Like any industry,
progress introduces competition and several years ago Medicis introduced their product Dysport which although not exactly the same drug as Botox, has the same results.  Dysport has caught on and is a popular option for some patients that prefer it to Botox for various reasons, one of them being it is a little less expensive.  Dr. Niamtu is recognized as a Key Opinion Leader (KOL) in cosmetic facial surgery and serves on the teaching faculty   Botox and Dysport.  In addition, he is the only Diamond Level Botox provider in Richmond and the largest solo injector in Virginia (he personally performs all injections).

Dr. Niamtu is proud to be a member of the Xeomin (Merz Aesthetics) teaching faculty.  He has recently returned from Berlin, Germany completing instructor training for Xeomin and also had the rare opportunity to tour the actual plant where Xeomin
is produced.  He, along with other Key Opinion Leaders in plastic surgery and dermatology, will be teaching Xeomin
injection techniques to physicians in the USA.

Xeomin is the third neuromodulator to be FDA approved in this country and will represent yet another option for patients seeking
improvement of facial wrinkles.  Xeomin has been used around the world for safe and effective treatment of facial wrinkles since 1995. Although all these products are technically known as botulinum toxin A, they all have slightly different chemical structures.  Xeomin is the first neuromodulator that is processed in a manner to eliminate a part of the molecule known as the accessory protein coat.  It is this protein that contributes to allergic reactions.  Users of Xeomin can expect the same results as Botox or Dysport although the initial price will probably be less.  Otherwise the products are administered the same and have the same results that last the same amount of time.  The number of units injected with Xeomin is compatible with Botox injections.

Dr. Niamtu is pleased and honored to be included in the international teaching faculty for Xeomin and is excited to be the first doctor in Richmond to offer this treatment in his practice. Consumers should be prepared for the release of more new neuromodulators that are in the FDA pipeline and just like the different fillers, the multiple neuromodulators will offer more options for patients.  For more information about Xeomin or cosmetic
facial surgery visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


November 10, 2011 Posted by | Botox, Minimally Invasive Cosmetic Facial Surgery, New Cosmetic Surgery Technology, Uncategorized, Xeomin | , , , | Leave a comment

Buyer Beware: Cosmetic Facial Surgery

In this day and age of media hype, it is not uncommon to see, hear or read about “miracle” skin and surgery procedures that “can be done awake without anesthesia”, have “little or no down time” and promise to “take years of aging” off of the skin.  BE CAREFUL!  Some general rules to consider are:

• If it sounds too good to be true, it is.
We see so many patients that fell for these “miracle” procedures, spent a lot of money and saw no results.  Do your homework.  Research the procedure you are considering.  You may be surprised how many unhappy patients and doctors there are out there with that specific procedure.  Many of the procedures and devices you see on TV and Doctor shows turn out to be duds.  When you see infomercials on “miracle or revolutionary” facelifts or procedures, stop and think.  If something was truly revolutionary, would everyone be doing it?  Wouldn’t you be more likely to read about this tremendous advance in the mainstream media?  Believe me, if someone invents a facelift that is truly revolutionary and can be done awake with no downtime, they will receive a Nobel price, be on cover of Newsweek, etc.   And no one would do “old style” lifts.  This is called a paradigm shift.  You don’t see horses on the expressway because the combustion engine was such an advancement that everyone drives cars.  If and when we see paradigm shifts in cosmetic surgery you won’t learn about it from infomercials!  Some examples of true cosmetic paradigm shifts include Botox, lasers and liposuction.

• Any skin resurfacing or tightening procedure that can be done without anesthesia is probably not going to do much, especially in a single treatment.
To truly address skin aging, deeper dermal treatment is important and this is simply too painful to be done without sedation.  I see many patients that were treated awake and it was a terribly painful experience.  Remember, in this day and age of safe and easy sedation, there is no reason to suffer for a procedure.  I feel the same way about facelift surgery.  Small facelifts can be done with local anesthesia, but larger lifts, in my opinion, can be done faster and better with sedation.  I recently heard a surgeon discuss how he does facelifts with local anesthesia and his patients take bathroom breaks and have snacks.  Not the way I want to do it, I can do a comprehensive facelift with platysmaplasty and SMASectomy in under 3 hours, but it requires sedation.  Please don’t misinterpret me, some surgeons are very versed at local procedures, and do safe and effective surgery but the average facial surgeon uses sedation.  Patients should have a good idea about the “standard” means of performing surgery and anesthesia and look closely at those surgeons that deviate from this definition.  Does not mean they are bad, maybe just different.  It is the safety and outcome that matters, so do your due diligence, look around.

• How many procedures are required to see a difference?
This is important as I see patients that were treated elsewhere and thought that their “light laser” was a single treatment.  When they saw little or no difference, their doctor told them they need 3-5 more treatments to be effective.  Personally, I think it would be advantageous to have a single Classic laser treatment and take 10 days off of work than to have 3-5 “fractional laser” treatments that take 3-5 days to heal.  Remember, there are no miracle treatments and your result is equal to your recovery.  Procedures with short recoveries have small results.  Procedures with longer recoveries have much more impressive results.

• Don’t be afraid to ask!
Too many times, patients are hesitant to ask their surgeon to see actual before and after pictures of a procedure.  It is important to make sure that the before and after pictures are from your doctor and not from a laser company.  If you are considering a procedure from a doctor and they cannot show you ten before and after pictures, there may well be a reason!  Ask the surgeon how many of these procedures he or she has done and ask for some patient references.

• Every Picture Tells a Story
As digital photography has progressed there should be no reason for any doctor to use poor quality or unstandardized before and after pictures.  Although it is rare that surgeons “photoshop” their pictures to improve the outcome (yes, it happens) it is very common for some doctors to have very poor pictures.  In my experience, surgeons that take pride in their images and pay attention to detail, do the same with their surgery.  Beware for before pictures take without a flash (shadowy) and after pictures taken with a flash.  This always makes the outcome look better because the shadows are gone in the after picture.  Also look for before and after pictures that are not the same size, not the same background, not in focus.  This is just astute observation I have made over the years.  Doctors that have sloppy or misleading before and after pictures may not pay attention to detail.  I always tell young doctors that “your images represent you and your ability”.

What kind of Surgeon Should I have do my Surgery?
This is important and the true answer is that in reality there are many specialties that are qualified to perform cosmetic surgery.  Some specialties are deeply involved in turf battles and would like the consumer to think that only their specialty is qualified to perform cosmetic surgery.  Nothing could be farther from the truth and these arguments are self serving to attempt to capture patients and dollars.  If you are considering facial surgery, you could choose a cosmetic trained dermatologist, oculoplastic surgeon, oral and maxillofacial surgeon, ENT surgeon,  or plastic surgeon.  No one specialty is better than the other and it all boils down to the competency of the individual surgeon.  Their training, ability, patient safety, and clinical outcomes are the most important thing.  Numerous specialties are qualified.  When seeking a surgeon, look for:
• A doctor that you feel good about and that has time for you.
• A doctor that has training in the area that you are considering.
• A doctor that has experience and can show you many examples of his or her work including patient testimonials.
• A doctor that has an accredited facility.
• A doctor that you can easily get in touch with if you need them.
• A doctor with a caring staff.
• A doctor that will back up their work and be able to handle complications.

For more information on cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia visit www.lovethatface.com


Niamtu, III DMD
Richmond, Virginia

September 7, 2011 Posted by | Choosing A Cosmetic Surgeon, Cosmetic Facial Surgery Consultation, Cosmetic Surgery for the Wrong Reasons, Minimally Invasive Cosmetic Facial Surgery, New Cosmetic Surgery Technology | , | Leave a comment

Minimally Invasive Facelift: Counterpoint

I was recently asked by a major cosmetic publication to discuss my feelings on minimally invasive facelifts.  Although I think they are a possible option for younger patients, I believe they are over used on patients that actually require a more comprehensive facelift and therefore lead to many unhappy patients that are left with a lesser result, all in an effort to attempt to shave a few days off of recovery.  The following represents my thoughts on this issue.

Facelift surgery has been around it its current form for about 100 years.  During that time, virtually every permutation of the procedure has been attempted; some with success, some without.

In today’s fast moving cosmetic market, companies, media, surgeons and patients eagerly await “new advances” for devices and procedures.  We all want a simpler means of obtaining similar results but sometimes the cart gets in front of the horse.

Let me preface this discussion by saying that the best facelift technique is the one that works well in the hands of the specific surgeon, provides good results with low complications and most importantly, happy patients.  This means that there are many ways to approach lower face and neck aging.  I have a large facial surgical practice and my patients expect dramatic results.  Many of them have already had negative experiences with minimally invasive facelifts and are very frustrated.  This patient will only be happy with a comprehensive facelift.  Having said that, my good friend down the street is a dermatologist and performs only minimally invasive facelifts with local anesthesia.  His patients are also happy and that procedure works fine in his office with his patients.  So, we are both doing the right thing.

Also, I must point out that there are many renowned cosmetic surgeons that are staunch advocates of minimally invasive facelifts, so they obviously work well for these people. I consider a minimally invasive facelift (also called short scar facelift) to be a lift with an only a preauricular incision that terminates at the mastoid region with no posterior auricular and scalp incision.  These lifts are also usually performed without midline platysmaplasty and frequently utilize variations of purse string sutures.

 Expressing my feelings on minimally invasive facelifts may be discounted by short scar advocates, but I can back up what I say in my series of almost 700 facelift procedures over the past 12 years.  Is 700 facelifts a big number?  For some surgeons it is not as they have partners, fellows, interns, etc. that may do a big part of each procedure.  In my office, it is me alone, every cut and every stitch, so my 700 may be more experience than someone else who has done 1,500.

The remainder of this article will deal with why I personally, don’t favor minimally invasive facelifts. It is not that I never do a short scar facelift, but my parameters are only for young individuals with minimal aging.  This means patients with early jowling and almost minimal neck laxity.   I perform an average of two facelifts each week.  Last year I performed almost 80 facelifts and of these, only two were short scar lifts, so it represents 2.5% of my yearly lifts. 

There are many reasons that I don’t favor these lifts but the primary reason is that I am thoroughly convinced that even younger patients need a larger lift.  I have a policy when I perform a short scar lift that during the procedure if I ascertain that the patient will be better served with a traditional lift, I have their permission to convert to a conventional pre and post auricular procedure.  I have changed to the larger lift in mid surgery numerous times and have been glad I did as even patients that did not exhibit significant neck laxity actually had impressive skin excess as evidenced when the posterior auricular incision was completed .

I think there are many reasons that short scar facelifts have become fashionable.  Number one, there are a lot of different specialties that now perform cosmetic facial surgery including facelift surgery.  Some of these practitioners did not have training in larger lifts and therefore feel comfortable with the smaller variety of lift.  Similar to this, some surgeons do not have the ability or the facility to utilize IV anesthesia or general anesthesia and the minimally invasive lift can be performed with local anesthesia.  This is all fine and well, again safe surgery with good outcomes and happy patients is the bottom line.

Another reason for the increased popularity of these lifts is the significant media hype that is so pervasive in our society today.  Many consumers equate “new” with better.  This is an area where I begin to have problems with the promotion of these small lifts.  I can’t turn on my TV without seeing ads for what I call “franchise facelifts”.  These are corporate entities include franchised physicians and the targeted marketing drives patients to these surgeons. My problem is not with the surgeons but rather with the franchise. This type of lift is promoted as “new” and “revolutionary” and catch phrases such as “takes about an hour”, “no bandages”, “drive home from office after  your lift” and “go back to work in several days”.  I take great umbrage to these statements and the way they are presented.  First of all, short scar facelifts with purse string sutures are not new and have been done for almost a century as evidenced by the diagram from a 1927 French textbook (figure 1). 

       This figure from a 1927 textbook shows the same procedure being performed by some doctors and advertised on TV as “new” and “revolutionary”. 


Secondly, the before and after images shown in these commercials and accompanying literature are not standardized and the results appear more dramatic than they really are.  The old trick of taking the pre facelift picture with the chin tucked in and no flash, then taking the post facelift picture with the chin extended and using a flash is a well known means of manipulating an actual result. Also, if you look at the fine print, some of the patients also had platysmaplasty and simultaneous laser skin resurfacing, hence the minimally invasive theory goes out the window.  I think this form of marketing is unethical and I (as well as many colleagues) have retreated unhappy patients that underwent “franchise” facelifts.  These patients feel betrayed as they were promised a maximum result with minimum surgery and they still have laxity.  They paid more than I charge for a traditional facelift and now have to have a second surgery to get the result they could have gotten in the first place if they had an age appropriate facelift.  Buyer beware!

The other reason that I think these lifts have become popular is that some surgeons get lazy.  I realize that I am going to take some torpedoes with this statement, but I think it is true.  A traditional facelift (pre and post auricular incisions, platysmaplasty and SMAS treatment) is a lot of work.  If you are the sole surgeon and do it correctly, it is an intense procedure.  I have seen numerous colleagues slowly back off from the traditional procedure.  First they omit platysmaplasty and maybe do less with the SMAS, next they eliminate the posterior incision and pretty soon they are only doing short scar lifts without platysmaplasty.  Most say they get the same results, but I personally question this.  I too have gone through phases in my career where I attempted to eliminate platysmaplasty and posterior incisions, but I have consistently gone back to basics because I felt I had better, longer lasting results.  Some readers may say “well, maybe he is not proficient with the short scar techniques”.  Fair question, but I think my experience trumps that.

 As many surgeons have become much more conservative in their approach to facelift surgery, I have become more aggressive and can clinically justify my decisions.

My biggest problem with short scar facelifts is the lack of a post auricular incision that extends into the scalp.  To me, this is the most important vector to truly manage significant cervical and submental skin laxity.  Any sacrifice in this vector will affect the surgeons ability to tighten the neck.  I realize that with some short scar procedures proponents advocate a more vertical flap tension to compensate, but again, no one can convince me that this is as effective as the traditional  posteriolateral vector used with post auricular incisions.  In reality, all facelift incisions should be engineered to be perpendicular to the vector of pull for skin excess and thus the traditional 10 o’clock and 2 o’clock vectors are in my mind, superior. 

My second big problem with short scar lifts is that many surgeons omit platysmaplasty.  I abandoned this myself for several years and saw less dramatic necks that developed banding within several years.  This led me to resume with even more aggressive submentoplasty and all of my rhytidectomy patients receive simultaneous platysmaplasty.  I do not perform submental liposuction as the first step, but rather perform a subcutaneous scissor dissection with care to leave adequate submental and cervical fat attached to the dermis.  I then, prefer to perform “open” liposuction where I can actually see what I am removing or sculpting.  I am fairly aggressive with this liposuction as I like to see the actual platysma muscle.  I then perform a midline plication with 2-0 braided nylon sutures from the mandibular border at least to the thyroid cartilage if not below.  I place 5-7 sutures and this not only tightens the neck, but also elevates the submental tissues and allows for the best cervicomental angle possible.  I generally do not remove subplatysmal fat unless grossly excessive as this contributes to a central depression.  If the patient has microgenia, a silicone chin implant is frequently inserted.  I am always amazed by the amount of excess skin present after aggressive platysmaplasty and submentoplasty.  I am thoroughly convinced that this skin excess would not be as impressive without platysmaplasty and would be more prone to early relapse.

As I stated earlier I am not a fan of purse string sutures.  I think that suspending the SMAS with one or two sutures leaves too much room for laxity. My average preauricular flap dissection is 6-8 cm and I perform a SMASectomy that is closed with five to eight 2-0 braided nylon sutures. These sutures secure the distal SMASectomy incision to the fixed SMAS over the parotid and begin at the malar region and extend into the superior cervical area below the mandibular border.  I am convinced that this repair is solid, addresses multiple SMAS vectors and will not relapse when patients turn their head or sneeze in the early post op period. Although some surgeon do not advocate significant skin removal, I typically remove 3-6 cm of skin on older patients.

The problem with trying to redistribute posterior skin in short scar procedures without a post auricular incision is the significant mastoid skin bunching that occurs and takes months to resolve.  Where does it go?  It is not magic, it flattens out with time (sometimes a long time) but there is still excess skin present, it is just redistributed.  My answer is to remove it in the first place.

In conclusion, there exists a trend to perform less invasive facelift surgery, primarily to decrease recovery time and make the surgeons life more simple.  I do believe that these short scar lifts are appropriate on some patients but at the same time feel that the do not comprehensively address the average facelift patient (fifth decade and beyond).  I feel that these smaller lifts are over rated and too often performed on patients that should have had a larger lift.  I can back this up by the revision facelifts that I do on patients that should have had a larger lift in the first place.  In terms of recovery, my average patient is suitable for work in two weeks.  That may be a long time for some surgeons and patients, but I tell my patients that to take two weeks off to reverse a half century of aging is really not a bad deal.

I fully realize that many surgeons will disagree with me and as previously stated, if their smaller procedure works better in their hands and they have lasting results with happy patients, then we are all winners.  I do things the way I do because my experience has shown that in my hands a more aggressive lift produces more natural and longer lasting results.  To each his own.  I believe there is a time for minimally invasive facelift, but it is not “most of the time”.  I feel that using these smaller procedures on the average facelift patient is a short cut facelift and the patient will have short cut results.  When patients ask me about “lunchtime facelifts” I tell them they will last till “dinner time”.  Patients get what they pay for.  Not in terms of money, but in terms of recovery.  Facelifts that heal in a week or less are simply not comprehensive enough to compete with traditional facelift procedures.


Tight, natural and long-lasting results are very predictable with traditional facelift surgery.  Unfortunately, there are surgeons that would attempt to perform  a minimally invasive lift on the above patient.  It is simply not possible to obtain the results and longevity with minimally invasive procedures.


To learn more about facelift surgery and other cosmetic facial surgery procedures by Dr. Joe Niamtu in Richmond, Virginia visit www.lovethatface.com 

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

March 10, 2011 Posted by | Facelift Surgery, Minimally Invasive Cosmetic Facial Surgery, minimally invasive facelift, New Cosmetic Surgery Technology | , , | Leave a comment

Dear Dr. Joe, what do you think about the MACS facelift?

Sometimes routine questions that I receive on my web page make interesting reading and I occasionally post these in my blog.  This following is an actual question and answer concerning the MACS facelift technique.

Question:   Dear Dr. Joe, I am 46 years old and getting my mother’s neck.  What do you think about the MACS lift?  Where can I see before and after pictures of your facelift results?


Answer:   Thank you Annie,

If you go to lovethatface.com on each procedure page, there is a Mona Lisa Icon and if you click that you will see hundreds of pictures of procedures.  I believe I have about 16,000 pictures on the site.

The inventor of the MACS lift (Dr. Alexis Verpaele) is a friend of mine and we have lectured together in the US.  Personally I do not agree with that procedure for the vast majority of my patients.  I think it is a shortcut procedure that does not address all the aging changes comprehensively and is a bit of a fad.  It is not a bad procedure for minor aging, but, in my opinion not comprehensive enough for more advanced aging.  When a surgeon tries to do facelift surgery without an incision behind the ear, there is a compromise.  It limits the amount the neck can be tightened and also presents fewer options for the direction of the skin pull, which can give an unnatural appearance.  Also this procedure does not comprehensively address the anterior neck and platysma.  I believe using a posterior ear incision (with the front incision of course) and performing platysmaplasty is the gold standard for the most natural, long-lasting and tightest lifts.  Many surgeons are searching for and easier facelift, i.e., Lifestyle Lift, Quick Lift, Liquid Facelift, etc.  Again, I personally believe they are all compromises of what we know has worked well for years.  Much of it, in many cases is just marketing hype.
There are many prominent surgeons that like these lifts and may get good results on younger patients.  I too, will perform and abbreviated lift on patients with minimal aging, but out of about 80 facelifts that I perform each year, only several are the “short cut” variety.  Basically, facelifts come in small, medium and large.  For patients requiring a small lift any of these “new” lifts will suffice and I also do them, but in my experience, most people need more.
Consults are free, come and see us.

Dr. Joe

To find out more about facelift surgery by Dr. Joe Niamtu, III DMD in Richmond, Virginia visit www.lovethatface.com

November 9, 2010 Posted by | Facelift Surgery, Minimally Invasive Cosmetic Facial Surgery, minimally invasive facelift | , , | Leave a comment

Botox Customization and the Droopy Brow

The discovery of neuromodulators to treat hyperfunctional lines was the cosmetic shot heard around the world and ushered in the most popular cosmetic procedure in the world.  When I began injecting Botox in 1996, it was a pretty much unheard of cosmetic therapy and the “pretty poison” was only used by those early adapters.  Back in the day, patients wanted paralysis, plain and simple.  If I injected a patient and they had even minimal muscle movement, they considered it a failure and wanted a refund.  It was not hard (still isn’t) to pick out those patients with mask-like expressions from total upper facial paralysis.

Things have changed greatly in the past decade.  Botox (and now Dysport, and soon to be others) has become an everyday procedure and the fear from “the toxin” has diminished.  What has also diminished is the desire for patients to look “done”.  Contemporary cosmetic surgery patients desire the ability to retain positive animation while stopping negative animation such as scowling.  After being injected for years, most patients now have an appreciation for exactly what they want their Botox to do.  Whereas in the past, they came in for injection and said “do what you think I need”, now they come in with their own tailor made request of units and injection patterns.  Although this bothers some surgeons, I welcome this “Botox customization”; after all, we are here to please the patient.

It is now common for patients to stretch or disperse their Botox units to achieve what they want.  I also feel that the sour economy we have seen over the last several have added to this where patients are trying to get more for their buck.

The most common customizations I see are in the glabella and frontalis.  Whereas the traditional 5 point glabellar injection is still the most common treatment, numerous patients present and request a more central glabellar treatment because fear of “lowering their eyelids”.  The same thing has occurred in my practice with the frontalis.  First of all the frontalis was the second most requested treatment in my office for over a decade, but has fallen to number three with the lateral canthal regions (crow’s feet) now being second.  The main reason for backing off of the frontalis is the fact that when coupled with glabellar treatment, a significant loss of animation can occur.  Again “my eyelids get droopy” (the real truth about this later) is a complaint from aggressively treating both glabella and frontalis.  This trend has led to my frequently injecting the glabella and using “half the units” on the frontalis.

Cosmetic surgery patients are finicky, but when patients feel that they have “droopy lids” from Botox, they can become livid and rebellious.  Proportionately, it seems patients can get madder about this condition than most other “real” cosmetic surgery complications.

Patients must understand the pathology of the “droopy Botox brow”.  Botox cannot make extra skin, but it can prevent patients from elevating their brow.  Many females, especially those with excess lid skin, perpetually elevate their brows.  It is subconscious and they cannot help or control it, they simply spend their waking hours with their brows elevated.  Ask any surgeon who performs brow lifts and they will confirm that it is impossible to take a before picture on many women with their brows relaxed.  Herein lies the problem.  When patients with excess upper eyelid skin raise their brow (via the frontalis muscle) they have the appearance of having less excess upper eyelid skin because the skin is stretched.  In some cases, they can also see better as the obstructing skin is elevated, hence improving vision.  If these patients are aggressively treated with a neuromodulator and cannot elevate their brow, they notice the extra eyelid skin (usually about 3 days after injection while applying eye makeup) and can become quite upset.  They think that the Botox gave them extra skin (impossible) or that they have true upper eyelid muscular ptosis (extremely rare).  What they frequently fail to understand is that they are chronic brow elevators and now they cannot elevate to their preinjection level.  The picture below is of your truly.  Admittedly, I need blepharoplasty or a brow lift.  I am bald, so the brow lift is out the window and I am simply too busy fixing everyone else to have my own blepharoplasty.  In the top picture, I am raising my brow and I look better that the bottom picture with my brow relaxed.  This picture tells the story!

It is imperative (especially for novice injectors) to recognize patients (usually older females with excess upper lid skin) who may be at risk for the “low brow”.  In these patients, especially those who are getting Botox for the first time, it is best not to inject the glabella and frontalis at the same time.  If the patient has a low hairline, the glabellar injection can deactivate a good portion of the frontalis.  If the frontalis and the glabella are to be simultaneously injected, it is better to use only 10 units of Botox (or 30 units of Dysport) over the entire frontalis to lessen the effect.  Also a good idea on any person is to taper off the Botox units and injections over the lateral brow.  Having a good central effect with a lateral tapering effect will still allow brow elevation.

Unfortunately, we cannot reverse neuromodulators so an unhappy patient may be unhappy for several months.  Fortunately, the lateral brow elevations seems to return before all the toxin is worn off.   The inventor of a botulinum toxin reversal agent will be a wealthy man or woman!

My advice to novice injectors is to include discussion of the above in the consent and to treat lightly with the frontalis.  My advice to patients is to be conservative as more Botox can always be added and to realize they may be in need of a browlift or blepharoplasty.

To find out more about cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia, visit


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

April 25, 2010 Posted by | Botox, Brow Lift Surgery, Minimally Invasive Cosmetic Facial Surgery, Risks of Cosmetic Surgery, Uncategorized | , , | Leave a comment

Dysport Units and Dilution Versus Botox Units and Dilution: 3 to 1 will get it done.



As neurotoxin science continues to advance and more drugs become available, patients will be offered more choices of treatments.  Currently Botox (Allergan) and Dysport (Medicis) are the only FDA approved neurotoxins (also called neuromodulators) to treat facial lines and wrinkles.  Numerous other similar drugs are currently in the pipeline for FDA approval, including products from China and Germany.  Patients outside the USA have more options and US patients will soon have some of these options.  More options are not necessarily better options as Botox and Dysport have long track records of safety and efficacy, but these new products will more than likely also offer safety and effectiveness and may also be more cost effective for patients.

All neurotoxins will be compared to Botox in terms of safety, efficacy, time of onset and duration of the effects.  As with any new product competitor on the market, positive and negative rumors will abound that can assist or detract from the new product.  Finally, all new products will settle in to their niche based solely on their effect and not conjecture.

Dysport has big shoes to fill in taking on Allergan’s previous monopoly of Botox.  Dysport has an excellent track record in Europe where it has been an option for a decade.  Like any new drug, doctors must figure out “the right way to use it”.  More than ever before, drug companies are strapped in getting the word out by Big Pharma regulations.  Although regulation is necessary, drug companies are literally hamstrung and sometimes voiceless.  Dysport would love to tell doctors the “best way” to use the new drug, but simply are not allowed, so it rests in rumor and conjecture as the means of determining “best practices”.

The biggest question of doctors new to Dysport is “how does the Dysport dosage relate to Botox dosage.  Being a consultant for both companies, I am asked this question frequently in my teaching travels around the US.  Initially, doctors were saying that “one Botox unit should equal 2.5 Dysport units”.  Although not an official comparison, this suggested that in order to have an equal effect, a patient that would normally have 20 units of Botox to treat their frown lines would require 50 units of Dysport to appreciate the same effect.  Comparison of units are not “apples to apples” official pharmicopia, but rather convenient conversions to anecdotally arrive at a standard between the two drugs.  Unfortunately, I believe that this first round of “units to units” comparison gave Dysport the short end of the stick.  Here is the reason.  When a new drug is introduced that competes with a standing giant, patients will try it (or not try it) based on numerous factors.  These selection factors include the advice of the treating doctor, cost factors, rumored advantages, the “newness” factor and the possibility that the new drug will simply work different or better.  Herein lies the catch.  If a patient has been getting successful Botox treatments with 20 units to their frown lines and wants to try the new Dysport and their doctor gives the rumored 2.5:1 ratio (50 units of Dysport), the patient is going to be a hard line test of which one works best.  In my experience, the 2.5 conversion is not enough Dysport to produce the effect of 20 Botox units.  If so, the patient will have a less profound or shorter acting effect and Dysport will be “dissed”.  My experience (and that of other surgeons) of using 3 Dysport units for 1 Botox unit seems to be a more accurate dosage in the quest for equipotent treatment between the two drugs.  If doctors are truly interested comparing these two drugs, they must use an equipotent dosage, which I believe to be 3 Dysport units for each Botox units or 60 units of Dysport for an area usually treated with 20 units of Botox.  Failure to use this ratio may give patients a false comparison of the effects and longevity of Dysport. 

Why is all of this important?  Personally, I feel that Allergan and Medicis are both great companies and I use fillers and neurotoxins from both of them.  From a doctor standpoint, you have to offer all contemporary options to your patients and from a consumer standpoint, every Coke needs a Pepsi.  What is important is that when comparing on new product to another, it is done in a fair way for the surgeon and patient to accurately evaluate.  Having said this, I believe the fair and balanced (hey, does that sound familiar?) way to this is to inject 3 Dysport units for where you would use 1 Botox unit.  Then the surgeon and patient can fairly evaluate the drugs.  It is unfair for the company and patients to compare with a lesser amount.  You will never find an official chart that says use 3:1 and Medicis is not allowed to even think that out loud, so it is up to the experience of scientifically minded clinicians to fairly sort this out for everyone else.  I am trying to do my part and I think it is 3:1 ad nauseum. To prepare Dysport for this dilution, 3 cc of preserved saline is added to the 300 unit Dysport vial.  Five  syringes are drawn up and each will contain 0.6 cc or 60 units.

To find out more about Botox, Dysport and cosmetic facial surgery in Richmond, Virginia visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


November 22, 2009 Posted by | Botox, Dysport, Minimally Invasive Cosmetic Facial Surgery, New Cosmetic Surgery Technology | , , , | Leave a comment

The Liquid Facelift: there’s a sucker born every minute!


P.T. Barnum, the great circus promoter is frequently quoted as saying “there is a sucker born every minute”.  I am sure he would be quite amused by the new amazing miraculous “Liquid Facelift”!

In this day and age, the best way to promote one’s agenda is to “invent” a really sexy sounding facelift.  First you need an unusual name so the media can key in on it and it will make patients think it is new.  Next, you need to make it sound like it is some new “miracle” that has displaced previous technology.  Finally, you need to make it sound really desirable.  The best way to do this is to tell people that it is non surgical and has little or no recovery.  If someone can put these three things together and find someone in the media to promote it, they will frequently get their 15 minutes of fame.  In the best case scenario the entire hype concept will really take off and the “miracle procedure” will fill the appointment book of the promoting doctor and he or she will frequently franchise their technique to teach other doctors this gift to humanity.  It all goes great guns……………..until…………..well until the other doctors, the public and the media find out four things.

  1.  It is really not a new technique, only a hyped repackaged version of procedures that have been around for decades.
  2. It is very expensive; it has more recovery that promoted.
  3. It is really not a facelift and the results in the average patient are disappointing
  4. It doesn’t work.

When all of these factors fall into place, and they always do, many patients are left disappointed and with skinny wallets in the wake of disappointment. 

We have seen this many, many times!  Do names like the Contour Thread Lift, Thermage, The Life Style Lift sound familiar?  I am not sure which is sadder, the fact that so many doctors try to make something out of nothing for personal gain or publicity or the fact that the poor public is so gullible and easily parted from their hard earned cash.  To me, this is much like the weight loss or diet industry.  It is a well established fact based on science and physiology that if you restrict caloric input and exercise you will lose weight.  That simple, no magic!  Yet as I was typing this blog, a commercial came across about the Cookie Diet.   All you have to do is eat these yummy cookies and the weight will fall off!  Please! This should be illegal, but I am sure thousands of gullible people will try the cookie diet and that it will soon fade into obscurity that the thousand diets before.  Will the public ever learn?  If it sounds too good to be true, is it true?

Back to the liquid facelift.  What this procedure really is, is filler injection.  Yep, filler injection, Restylane, Juvederm, the same stuff that thousands of docs do every day.  The liquid facelift is nothing more than a mega filler injection session.  Instead of just filler in the lips or smile lines, it goes in the midface, the jowls, and other place.  Nothing new as most of us that inject filler inject it in these areas when requested.  So, please consider several things.

  1. The liquid facelift is not a facelift.
  2. The liquid facelift is filler injection.
  3. Fillers laser up to a year in the best scenario.
  4. Fillers are extremely expensive and a liquid facelift can use up $5-8,000 of filler in 20 minutes.
  5. Most people that need a facelift have excess skin and loose muscle.  The liquid facelift does not tighten the skin or muscle; it just fills up hollow spaces.  This is fine, but is it worth it for a year of looking better.
  6. A facelift can last 10-20 years, and yes, it required surgery and 2 weeks of recovery.  So what, if you want a real facelift with real facelift results, have a real facelift.
  7. All the filler in the world won’t tighten up turkey gobbler skin on the under the chin and under the neck.


Is there anything good about the liquid facelift?  Sure, fillers are great and even though I do almost 100 facelifts a year, I am one of the busiest filler injectors in my state.  Fillers are great, but they are not a facelift and should never be used in conjunction with the word “facelift”.

If P.T. Barnum were still alive and if he was a doctor, I bet he would be a big proponent of the liquid facelift.

To find out more about Dr. Niamtu or cosmetic facial surgery in Richmond, Virginia, visit http://www.lovethatface.com.


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


June 16, 2009 Posted by | Facelift Surgery, Minimally Invasive Cosmetic Facial Surgery, minimally invasive facelift, New Cosmetic Surgery Technology | , , , | Leave a comment

Dysport: the new “Botox”


If Allergan’s Botox is Goliath, then Medicis and their new neurotoxin is David.  No one can argue that Botox has enjoyed a monopoly in the United States for past 15 years.  After all, Botox was a true paradigm shift in cosmetic surgery.  Never before, without surgery, could a patient have wrinkles disappear.  The introduction of Botox was something so different and so easy that it truly heralded in a new era known as minimally invasive surgery.  What began as a “pretty poison” has grown into “cosmetic maintenance” and now women and men get regular Botox injections with the same regularity that they get their hair colored or teeth cleaned.  Botox has not only continued to be safe and effective, but has gone on to treat many conditions from headaches to hemorrhoids.

Botox has gone largely unchallenged and Allergan has become a corporate giant due to its sales.  Second to Viagra it is the largest selling drug.  A brief challenge came in the “at the turn of the last century” with Myoblock, a similar product but chemically different.  Unfortunately for Myoblock, it did not live up to the effectiveness of Botox, and its popularity was short lived.  It is still used for the few patients that have a resistance to Botox, but is a small player.

Dysport is chemically very similar to Botox and has been used in the United Kingdom for 15 years.  It varies from Botox in its biochemistry and protein structure but basically does the exact same thing.  This drug has recently received FDA acceptance and will be sold in the United States under the same name.  Dysport will make a big bang with the media upon it final FDA acceptance and rumors will fly.  The Dysport FDA trials showed that Dysport took effect somewhat faster than Botox and basically lasted the same amount of time, about three months.  Why challenge the king of neurotoxins (more politically correctly called neuromodulators) with a drug that basically does the same thing.  I call it Coke versus Pepsi marketing.  Consumers and surgeons desire choices in everything from clothes, to cars to, carpet and want choices.  There is also some bragging rights from being the “new kid on the block” (just ask Red Bull).  Cosmetic consumers and media are fascinated by “new” technology and if it is new then it must be better.  Frequently this does not pan out, but a well marketed and effective competitor can certainly gain market share.  When all the US automakers were getting bailed out by the Federal government, Toyota (who was a newcomer to this country) remained strong.

To cut to the chase, Dysport is exciting because it is new and is also taking on heavyweight Botox.  It is likely to become a popular competitor.  What remains to be seen, and could make the difference in the wrinkle wars, is how Dysport is priced in comparison with Botox.  If Medicis significantly undercuts Allergan, Dysport could potentially displace the king.  I doubt that this will happen as corporate America is not fond of less profit.  A similar scenario occurred with Restylane, the revolutionary lip and wrinkle filler from Medicis.  This was the first new filler that was FDA approved and made a meteoric rise to the top of facial injectables.  There was no significant competition for about 4 -5 years until Allergan obtained FDA approval for Juvederm.  In the pre release period, much speculation occurred as to whether Allergan would significantly undercut the pricing of Restylane.  Guess what?  They did not.  Their pricing was almost identical and Juvederm no doubt took a chunk out of the filler sales dominated by Allergan.  Competition is generally a good thing as it offers the public more choices and can sometimes drive down prices, but don’t look for this with aesthetic companies.  They figure if patients will spend $500 for X, then they will spend it for Y.  Time will tell.

To find out more about Botox, Dysport and other cosmetic facial surgery procedures, visit www.lovethatface.com.


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


January 14, 2009 Posted by | Botox, Dysport, Minimally Invasive Cosmetic Facial Surgery, New Cosmetic Surgery Technology | , , , | Leave a comment