Dr. Niamtu’s Weblog

….on cosmetic facial surgery

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

Dr. Charles Hard Townes: I Met The Man That Invented LASERS

Dr. Niamtu and Dr. Townes in 2010 

I have had my picture taken with a lot of people, I guess you could say it is sort of a hobby, like some people collect coins, etc.  I have John Glenn, Neil Armstrong, Steven Spielberg, a President and a VP as well as many celebrities and sports figures.
One of my proudest handshakes was with Dr. Charles Townes.  This guy pretty much invented the LASER.  That includes the one on your key chain, the ones I treat patients with and the ones on our military aircraft.  Talk about a cosmetic surgery super hero!  When we chatted, he talked about Einstein’s  opinion of his project!  He worked with Einstein, I had goose bumps, I felt like I was standing next to Sir Issac Newton! The following is a shortened biography courtesy  of Wikipedia.  Thanks for all you have done Dr. Townes!  The hundreds of people that I have helped with scars and wrinkles with my lasers have you to thank.
Townes was born in Greenville, South Carolina on July 28, 1915 and in 1964 received the Nobel Prize in Physics with N. G. Basov and Aleksandr Prokhorov for contributions to fundamental work in quantum electronics leading to the development of the maser and laser.
Townes completed work for the Master of Arts degree in Physics at Duke University in 1936, and then entered graduate school at the California Institute of Technology, where he received the Ph.D. degree in 1939 with a thesis on isotope separation and nuclear spins.
A member of the technical staff of Bell Telephone Laboratories from 1933 to 1947, Townes worked extensively during World War II in designing radar bombing systems and has a number of patents in related technology. From this he turned his attention to applying the microwave technique of wartime radar research to spectroscopy, which he foresaw as providing a powerful new tool for the study of the structure of atoms and molecules and as a potential new basis for controlling electromagnetic waves.
At Columbia University, where he was appointed to the faculty in 1948, he continued research in microwave physics, particularly studying the interactions between microwaves and molecules, and using microwave spectra for the study of the structure of molecules, atoms, and nuclei. In 1951, Townes conceived the idea of the MASER, and a few months later he and his associates began working on a device using ammonia gas as the active medium. In early 1954, the first amplification and generation of electromagnetic waves by stimulated emission were obtained. Townes and his students coined the word “MASER” for this device, which is an acronym for microwave amplification by stimulated emission of radiation. In 1958, Townes and his brother-in-law, Dr. Arthur Leonard Schawlow, for some time a professor at Stanford University but now deceased, showed theoretically that MASERS could be made to operate in the optical and infrared region and proposed how this could be accomplished in particular systems. This work resulted in their joint paper on optical and infrared MASER, or LASERS (light amplification by stimulated emission of radiation). Other research has been in the fields of nonlinear optics, radio astronomy, and infrared astronomy. He and his assistants detected the first complex molecules in the interstellar medium and first measured the mass of the black hole in the center of our galaxy.
In 1961, Townes was appointed Provost and Professor of Physics at the Massachusetts Institute of Technology (M.I.T). As Provost he shared with the President responsibility for general supervision of the educational and research programs of the Institute. In 1966, he became Institute Professor at M.I.T., and later in the same year resigned from the position of Provost in order to return to more intensive research, particularly in the fields of quantum electronics and astronomy. He was appointed University Professor at the University of California in 1967. In this position Townes is participating in teaching, research, and other activities on several campuses of the University, although he is located at the Berkeley campus.
In addition to the Nobel Prize, Townes has received the Templeton Prize, for contributions to the understanding of religion, and a number of other prizes as well as 27 honorary degrees from various universities.
To find out more about Dr. Joe Niamtu, III Cosmetic Facial Surgery in Richmond Virginia, visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

October 10, 2011 Posted by | Academic Cosmetic Surgery, Laser Resurfacing, New Cosmetic Surgery Technology, Personal, Technology | , , , , , | 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

The Aesthetic Show Las Vegas 2011

Dr. Niamtu and “The Doctors” host Dr. Andy Ordon were among faculty speaking at The Aesthetic Show in Las Vegas

I lecture at an average of 20 meetings a year, all over the world, and enjoy them all.  I am writing this blog post from a truly phenomenal meeting; The Aesthetic Show which is at the Aria Hotel in Las Vegas.  What makes this meeting so special?  Many reasons.  Number one, the meeting’s leader and originator, Michael Morretti knows how to throw a great party.  Not just the fun party, but an educational party as well.  Michael has been able to combine the thought leaders of cosmetic surgery and aesthetic medicine all in one place, and a fun place at that.
The landscape of cosmetic surgery and medicine has changed many ways over the past 20 years.  The boom in the popularity of cosmetic surgery and medicine is largely a result of the numerous specialties that have become involved in this arena.  Whereas 30 years ago, cosmetic surgery and medicine was controlled by a small number of specialties, contemporary cosmetic surgery and medicine is inclusive almost all specialties.  All of these specialties (dermatology, plastic surgery, ENT, oral & maxillofacial surgery, ophthalmology, Ob/Gyn, and many others) have brought advances from their own specialties to the collective table of cosmetic surgery and medicine.  It creates synergy where the total is greater than the sum of the parts.  All of this input, research, and publication has advanced the field.
I was truly honored to share the podium with cosmetic superstars from numerous specialties.  Dr. Andy Ordon who co-hosts the TV series “The Doctors” was the keynote speaker and is really a great guy!  He is as down to earth as they come.
My lecture topics were “Marketing the Cosmetic Surgery Practice” and “Contemporary Laser Skin Resurfacing”.  I also enjoyed Dr. Angelo Cuzalina’s lectures on cosmetic body surgery, Dr. Steve Mulholland’s lecture on fractional laser, Dr. Dore Gilbert’s (on his 60th birthday, he enlisted and will be manning a US Army hospital in Kabul!) talk on laser hair removal.  Dr. Michael Gold chaired this session and presented in the way only he can. Dermatologist par excellence Dr. Phil Wershler  served as program chair and assembled a truly ecumenical  all star cast.  The well known players were too numerous to name but they added so much to the event.
There were so many other great lectures and the exhibit hall was abuzz with new and cool products for cosmetic surgery and medicine.  Walking around this meeting and meeting so many docs and staff, all coming together to share information on cosmetic surgery and medicine, is truly exhilarating.  One of  the best meetings I have attended in a long time.  Way to go Michael Morretti, his wife Leah, Jennifer Pantele and staff.  I hope I am invited back in the future to speak at such a well orchestrated event.
To find out more about cosmetic facial surgery by Dr. Joe Niamtu, III in Richmond, Virginia, visit www.lovethatface.com

Joe Niamtu, III DMD.

June 4, 2011 Posted by | Academic Cosmetic Surgery, Cosmetic Surgery Education, New Cosmetic Surgery Technology, Uncategorized | | Leave a comment

Please Don’t Call Me a Plastic Surgeon

The field of cosmetic surgery has increased at an exponential rate over the past several decades.  Many paradigm shifts have occurred and this has changed the entire landscape of aesthetic surgery.  If a practitioner that performed aesthetic surgery procedures 40 years ago were to spend a day in my office they would be amazed by the new changes and technology.  Botox, lasers, endoscopic surgery, injectable fillers are just a few of the changes that have improved the profession.

Also among the changes is the fact that numerous specialties include aesthetic surgery in their core curriculum.  These procedures are taught in most residency programs to ophthalmologists, dermatologists, ENT docs, plastic surgeons, oral and maxillofacial surgeons and gynecologists to name a few.  In most of these specialties, cosmetic surgery procedures are part of the resident’s training, they are part of the board exams for those specialties and they are covered under the malpractice policies for those specialties.  Contemporary educators will freely admit that aesthetic surgery is well within the accepted scope of numerous specialties.  No single specialty owns the body or the face and each of these specialties have brought advancements to the collective table of aesthetic surgery.  For instance, dermatologists pioneered laser surgery and invented tumescent liposuction.  The current American Society of Plastic and Reconstructive Surgeons were originally founded by oral surgeons and physicians and was called the American Society of Oral Surgeons until 1931. Oral and maxillofacial surgeons also made significant advanced in aesthetic skeletal surgery and facial implants.  Ophthalmologists have contributed many techniques for cosmetic eyelid surgery and gynecologists have introduced or improved cosmetic vaginal surgery.  ENT physicians have advanced the field of cosmetic nose surgery on a continual basis. The list goes on and anyone that disagrees with the fact that contemporary aesthetic surgery is a multispecialty realm simply has their head in the sand or has intentions of secondary gain, such as limiting the competition, turf battles, and the desire to control patients and dollars.

So…what is “plastic surgery” and how does it differ from “aesthetic surgery” or “cosmetic surgery”?   A Plastic Surgeon is a noun (or could be an adjective) that describes a surgical specialty of medicine.  When used as to describe a type of surgery it has a much broader definition.  Any surgery that is intended to improve form, replace or restore missing or damaged tissue can also be called “plastic surgery”.  So, having said that, if one calls them self a plastic surgeon, it should indicate that they performed a general surgery residency and then a plastic surgery residency and they would be considered a plastic surgeon.  There are, however, exceptions.  Otolaryngologists (ENT’s) changed the name of their specialty to “facial plastic surgery” and ophthalmologists developed a specialty designation of “oculoplastic surgery”.  These practitioners often refer to themselves as “plastic surgeons”.  Other specialties will surely follow this lead in the future to represent their contemporary scope.

In my situation, I am a board certified oral and maxillofacial surgeon.  I am very proud of my unique qualifications to provide aesthetic facial surgery.  My early dental training (I never practiced general dentistry, but had to have a dental degree to enter a maxillofacial surgery residency) gave me excellent dexterity and artistic perspective as well as four years of studying facial anatomy.  My oral and maxillofacial surgery residency provided me not only with medical and surgical training, but also with an unparalleled level of head and neck anatomy and expertise in that region.  I feel that my specialty has an intense level of head and neck training (if not more) than any specialty.  As with any specialty, a surgeon can decide to focus on specific areas that he or she likes to do or excels in.  My true love is cosmetic facial surgery and over the years it became a bigger and bigger part of my practice and in 2004, I limited my practice to only cosmetic facial surgery.  If a doctor does nothing but cosmetic facial surgery then I believe it is practical to refer to them as a cosmetic facial surgeon. 

One huge misconception is that “plastic surgery” is synonymous with cosmetic surgery.  This could not be further from the truth.  Some plastic surgeons have excellent cosmetic surgery training and do a lot of cosmetic surgery.  Others have very little cosmetic surgery training and do very little cosmetic surgery.  Remember, plastic surgery is not necessarily cosmetic surgery.   I have some plastic surgery friends that are excellent at cosmetic procedures and do a bunch and others that are not so proficient and do more reconstructive and wound surgery instead of cosmetic procedures

 In reality, it is not about the specialty, it is about one’s training and expertise in what they do.  A poor cosmetic surgeon does not stay in business long regardless of the specialty.

Why don’t I want to be referred to as a plastic surgeon?  The reason is simple.  Number one, that is not my specialty and I have no need to feign credentials.  Number two and most important, I limit my practice to cosmetic facial surgery and “plastic surgery” is not necessarily cosmetic surgery, so if I did attempt to call myself a plastic surgeon, it would be detrimental to my practice as it would indicate that I do not spend 100% of my time doing cosmetic facial surgery.  The third reason that I do not want to be called a plastic surgeon is that I have many plastic surgery friends on a local, national and international level and it would be an affront to them and their training.  Most plastic surgeons are pretty sharp people and do some amazing reconstructive procedures all over the body, but having that specialty designation does not automatically imply proficiency in aesthetic surgery.

The real bottom line is that numerous specialties perform competent and safe cosmetic surgery.  That can’t be disputed.  Some competitive practitioners who are still fighting the worn out turf battles will attempt to say that other specialties have more complications, but again, the people that usually are saying this are the ones with the most complications.

So, I am not a plastic surgeon, but no one can dispute that my practice is limited exclusively to cosmetic plastic surgery procedures of the head and neck.

I am quite happy and secure being a board certified oral and maxillofacial surgeon and a DMD that only does cosmetic facial surgery.  It is very difficult for any practitioner of any specialty to limit their practice solely to cosmetic surgery and very few ever get to that point.  It is even more difficult to limit a practice to cosmetic procedures of the face and neck because not doing body surgery significantly reduces available surgical options.  I am proud to be one of the few surgeons of any specialty in my state to have a practice limited to cosmetic facial surgery, as well as one of the busiest.  I am also proud to be a fellow of the American Academy of Cosmetic Surgery and the American Society of Laser Medicine and Surgery.  I am proud to have published and lectured on cosmetic surgery more in the last decade than most of my naysayers will in their lifetime.  I am proud of my most recent textbook, which has set sales records and has sold well to all the recognized cosmetic specialties.  Cosmetic facial surgery is my passion, my life’s work, my job and my hobby.    I teach cosmetic facial surgery (to all specialties including plastic surgeons) at over 20 venues a year.  This sounds like bragging, but it isn’t; instead it is passion. I love cosmetic surgery, I love going to work, I love the patients and I love operating. Finally, this is how I feed my family and take care of the numerous expenses required by being the father of two severely handicapped children.  This I take the most seriously.

I do what I do well.  It is not a problem to call me a cosmetic facial surgeon because all I do, all day; every day is cosmetic facial surgery.  But please don’t call me a plastic surgeon.  It does not accurately describe a practice that exclusively performs cosmetic surgery.

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


Joe Niamtu, III DMD

March 18, 2011 Posted by | Academic Cosmetic Surgery, Choosing A Cosmetic Surgeon, Cosmetic Surgery Around the World, Cosmetic Surgery Education, Doctors Badmouthing Other Doctors, New Cosmetic Surgery Technology, Only Use A Board Certified Plastic Surgeon? | , , , , , , | 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

Dr. Niamtu Announces 2011 Ultimate Cosmetic Facial Surgery Course

Seminar Brochure 2011 (download pdf)

I am proud to announce our schedule for our seventh annual cosmetic facial surgery course.  We have trained hundreds of surgeons from every surgical specialty including plastic surgery, facial plastic surgery, ENT, ophthalmology, oculoplatic surgery, oral and maxillofacial surgery, dermatology, cardiac surgery, general surgery, Ob/Gyn and others.  We are also proud to have trained surgeons from many countries all over the world.

The gang from the November 2010 Ultimate Cosmetic Facial Surgery Course

We were proud to have surgeons from 6 countries at our November 2010 Ultimate Cosmetic Facial Surgery Course


To learn more about Cosmetic Facial Surgery in Richmond, Virginia by Dr. Joe Niamtu, visit


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

November 25, 2010 Posted by | Cosmetic Surgery Education, New Cosmetic Surgery Technology | , , , , | Leave a comment

Online Cosmetic Surgery Consultation: what’s up with that?

I saw a very interesting article in the New York Times (1-21-2010, page E3) recently about how many cosmetic surgeons are offering virtual online consults for patients.  This article discussed how many cosmetic docs are currently offering online video consultation for patients where the surgeon and patient are connected via web cam and a telemedicine consultation is performed, frequently for a fee.  A group called Surgeonhousecall.com has recruited 55 plastic surgeons to provide online consultation for cosmetic surgery. This got my mind churning about the pros and cons of this technology.

If someone told me 30 years ago that I could take all of my record albums and cassettes and put all that music on my pocket sized telephone I would have thought that was a radical statement.  Admittedly, when I purchased my “100 CD capacity CD player” I never saw the digital music revolution coming.  We can all relate similar stories about the fax machine, email and Internet surfing.  So when someone suggests that cosmetic surgeons may be someday (or currently) performing consultations via a computer screen, I must consider this plausible and possibly a paradigm shift for medicine and surgery, although it somewhat rubs me the wrong way. 

Medicine and surgery are historically based on “the laying of the hands” and for the last thousand years, has been practiced in that manner.  Not being able to actually see and touch a patient probably makes any surgeon feel at a disadvantage.  We use all of our senses to consciously and subliminally formulate thousands of impression about a patient and their diagnosis and treatment.  When you think about it, a flurry of information streams through our brain via sight, touch, smell, hearing, and analysis.  We lose much of this sensory input, staring at a two dimensional picture on a monitor.  Regardless of your surgical discipline, there are many cases where an accurate diagnosis and treatment plan could be formulated via a video conference.  Personally, I could probably perform a relatively accurate consult for blepharoplasty, facelift, skin resurfacing or Botox and fillers by looking at a patient on a monitor and talking to them over the Web, but would I feel comfortable enough with this information to meet them in the operating room the next day?  Probably not!  There is simply not enough sensory input to cover all the minute specifics that are imperative during consultation.  Do they have lower eyelid laxity, how much of the submental excess is fat versus skin, is the skin pigment epidermal or dermal, how many syringes of filler will they need would be information that I would be lacking.

I don’t think that the surgeons who advocate or are currently performing online consultation intend for the consult to be “final or comprehensive” in nature, but rather to serve as a general informational or screening tool in advance of actual personal consultation.  So from that aspect, this process has merit.  Whether we realize it or not, many of us are already performing some form of digital consultation anyhow.  I routinely look at patient’s pictures that are emailed to me for informal discussion.  It is important that I do not render an official medical opinion and I have the following disclaimer on my emails.

Any correspondence should not be construed as medical advice, evaluation, or consultation and should never be considered a replacement for a formal evaluation by the physician in his office and related consultation. Therefore, the information and correspondence that is involved with this email or future emails do not constitute a formal doctor-patient relationship. If you desire to schedule a consultation, please feel free to call the office to arrange for this type of appointment. Please be advised that your own physician should approve any change that should be undertaken regarding to your therapy. Explanation of off-label services and/or products that are mentioned herein does not reflect an endorsement nor promotion and should not be construed as such.

Doctors must be very careful not to construe casual opinion as formal medical consultation for numerous reasons.  First of all, if you do not have a license in the state or country of the recipient you may be in violation of the law.  Secondly, if you offer an opinion that somehow turns out to be incorrect or damaging, you may find yourself named in a law suit.  As farfetched as this sounds, I have a friend in that exact position, so it can and does happen. Also, patient confidentially and HIPPA concerns come into effect as you never know who may somehow obtain this sometimes confidential information or pictures by hacking into your computer.  Given all of these potential problems, we have to wait for medical societies, state boards, and possibly the federal government to set standards of how this activity should or can occur.  Right now, the cart is in front of the horse.

I was a bit surprised to see that there are some pretty well known practitioners that currently have free or paid video consultations available on their websites.  This bothers me because I consider myself and my website to be pretty technologically advanced.  “How did I miss that boat” was my first thought.  My second thought was ” I am not sure I want to be part of that boat at this time”.  It makes me wonder if doctors that offer these online video consultations are hurting for business and need this marketing tool to stay alive.  It also begs the question “if I did this in my practice, when would I find the time to do this”?  I already spend too much free time in the evenings updating my website, blog, etc, so I don’t want to be “seeing patients at home”.  At work, I am too busy with face to face patients to incorporate this technology into an already overly hectic surgery and consult schedule.  Then there is the frank reality that if this kind of thing really becomes popular, I will have to do it to maintain a competitive edge.  This bothers me more than anything as none of us enjoy doing something because everyone else is doing it and now we have to!  Finally, there are so many “tire kickers” out there in cyberspace that are not serious about having a procedure but would relish the opportunity to obtain a free video consult, “just in case” or “just for the fun of it.  I already have too many of those in my real time practice.

So I ask myself if this is a flash in the pan marketing ploy for those that are not already busy enough or is it the crest of a paradigm shift in digital medicine and in the future I will be intentionally leaving open spaces in my schedule for my “virtual patients”.  I have never charged a patient to look at email images and I don’t charge for in office consultations, but if this technology becomes mainstream, I will have to be compensated for my time is some way.

I am one that feels that still feels that accurate diagnosis still requires a hands on approach and that the doctor/patient relationship should remain personal.  I feel that unregulated virtual consultation somehow cheapens the entire relationship.  Having said this, I have always been an early adapter of technology and have in the past eaten words concerning “I will never do that” dogma.  I think telemedicine is a great situation for emergency scenarios and underserved areas or populations that may otherwise not have access to care.  I frequently have out of town patients or even local patients send digital or cell phone pictures to address concerns and have more than once seen an impending problem and was happy to have this early intervention opportunity.  Having said this, I guess I am talking out of both sides of my mouth.  In many ways being able to see a patient before an actual consult may save time for both the patient and surgeons as the proposed surgery may be out of the question and save wasting further time.  Seeing post operative patients that either cannot come in for consult due to geographic, transportation or after hours may in fact head off a potential serious problem such as hematoma, infection, etc.  So there is certainly merit to this technology.

In conclusion, there is no doubt that telemedicine will become a part of contemporary surgical practice.  I am not sure that want to begin seeing online consults just because other surgeons are doing it.  I, again, feel that this entire process needs standardization, regulation and security before it becomes mainstream. Does a patient who gets a plastic surgeon’s recommendation before a face-to-face visit really “win?” Can poor quality video or pictures provide inaccurate diagnosis or misinformation?    Will the “best” surgeons be available or just those who aren’t busy?  . I also fear that virtual consultations may become bidding wars for patients to simply look for the cheapest price.

Supporters cite that shy patients or others may desire a semi anonymous consultation and they want to know cost, and what they get for that cost before they make a commitment, or walk through the office door.” No doubt, some early adaptors will encounter some problematic aspects including lawsuits while this all gets sorted out.  I love technology and gadgets and I am sure that online video conferencing will impact my practice in my working lifetime.  It is an exciting thought but still a bit disconcerting as to when and how I will find time to do this and protect myself and the patient in cyberspace

Time will tell.

To learn more about Dr. Niamtu and Cosmetic Facial Plastic Surgery in Richmond, Virginia visit www.lovethatface.com.

Joe Niamtu, III DMD

January 30, 2010 Posted by | Cosmetic Facial Surgery Consultation, New Cosmetic Surgery Technology, Technology | , | 2 Comments

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