Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Joan Rivers and Cosmetic Facial Surgery


Lover her or hate her, Joan Rivers is funny.  She has become the self proclaimed poster child for cosmetic surgery and is the brunt of many jokes, but old Joanie actually looks pretty good these days.  Anyhow…..every day I do numerous consults and people have to decide how to budget get their cosmetic surgery around other expenses. I came across a Joan Rivers quote which is of her typical humor.

“Better to get out of an old car with a new face, than to get out of a new car with an old face!”

Wish it was that simple, but Joan has a way of putting things.

To find out more about cosmetic facial surgery visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


February 16, 2012 Posted by | cosmetic surgery addiction, Uncategorized | , , , , | 1 Comment

Merz European Expert Injector Summit: Berlin, Germany

Some of the “crew” at Checkpoint Charlie in Berlin

I am writing this blog flying back across the Atlantic Ocean after attending the Merz European Injector Expert Summit in Berlin, Germany.  This was a great meeting and also the first time in years that I traveled internationally and did not have to work on a lecture.  It was a strange feeling not to be ramming through PowerPoint for numerous talks.  So, I actually got a lot of catch up work done including working on some articles and before and after pictures that were stacking up

I was honored to be part of the American contingency of well-known aesthetic experts from dermatology, plastic surgery, facial plastic surgery, and other specialties.  You can’t hang around with the likes of dermatologists Mario Bussa, Oscar Hevia, Derek Jones, Heidi Waldorf, Phil Werschler, Tina Funt, Rhoda Narins, facial plastic surgeons  Amir Moradi, Steven H. Dayan, Timothy C. Flynn, and plastic surgeons  Paul Lorenc, Brian Kinney, David Funt and Michael Kane and not learn something.  Keeping this group together and on track from Merz Aesthetics were Dennis Condon, Brian Pilcher, Jennifer Redmond and Wendy Johnson.  These people are the ultimate professionals and their knowledge of fillers and neurotoxins is amazing.  Besides this, they all have shining personalities.

The fellowship was awesome and again, you can’t hang out with a group of master injectors like this and not come back without pearls.  One great highlight was having the unique opportunity to tour the Merz plant where the neurotoxin Xeomin is produced.  The efficiency, sterility and automation of this facility was unbelievable and everyone that completed this tour now understands neurotoxins a little better.  In addition, we had the opportunity to learn more about the Merz company and their century of innovation.

A pleasant surprise that occurred on the trip was the announcement by the FDA that Belotero has received approval.  This now gives doctors and patients a new option for treating superficial wrinkles and the tear trough region.  Due to the unique arrangement of the filler particles in Belotero, it is well suited for superficial injection in the tear trough region without worrying about creating the bluish coloration under the skin knows as the Tyndall Effect.

The academic presentations were all high tech and it was very interesting seeing experts from all over the world discuss their means of treating aging with Xeomin, Radiesse and Belotero.  Although there was good spirited discussion and disagreement (what do you expect from a group of world experts), I was impressed that injection is pretty much approached the same all around the world.   The live injection sessions were particularly interesting as any injector will always admit that he or she leans something (good or bad) by watching other experts inject.

Berlin is a beautiful city and we all (as a group) had the ability to visit several world class museums and drink some world class beer!  I can’t think of the last time I packed so much learning and fun in over a 4 day period.  Sitting in yet another airport, can’t wait to go to work tomorrow and operate and inject.

Like all meetings, the meeting was as good as the people you met and to that end, this meeting was priceless.

To learn more about Xeomin and cosmetic facial surgery by Dr. Joe Niamtu, III DMD in Richmond, Virginia, visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


November 21, 2011 Posted by | Bolotero, Uncategorized, Xeomin | , , | Leave a 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

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

On Being a Vegan: the first 100 days

Exercise and proper nutrition have been an important regimen in my life for the last 40 years.  Over the years, I have trained as hard as competitive athletes and I have the knee and shoulder operations to prove it!   Over this time, I pretty much subscribed to the old school theory of high protein and low carbohydrate, low fat diet.  Unfortunately, for much of my younger years, I paid little attention to fat intake as like most athletes, as long as I was getting plenty of protein, I thought I was doing the right thing.  As I went through professional school and hospital residency, I began testing my lipids and always had a high normal level of cholesterol, generally hovering around 200.  My HDL’s were always high so I was pretty content.  When one of my buddies had a heart attack in his early 40’s, I pretty much eliminated red meat in my diet, spare an occasional steak or burger several times a year.  As I got into my fifth decade, my LDL (bad cholesterol) began to climb.  My red meat intake was minimal but I was eating a lot of white meat chicken, turkey (tons of turkey) fish and my usual protein supplements.  I pretty eliminated processed carbs over all this time as well.  When my LDL climbed to 114 my physician suggested I begin taking a statin and I began taking Zocor 40 mg each evening.  This allowed me to maintain my same diet but lowered my total cholesterol and LDL to normal limits.

I have to admit that in the past I pretty much harassed and verbally tortured my vegetarian friends.  I thought they were crazy, after all, our teeth, digestive system and evolution were adapted for carnivorous habits.  They put forth pretty good arguments for eliminating animal products, but my teasing remained incessant; after all, that is how I was brought up.  Lift weights, do cardio and eat protein.

Fast forward to 2009.  I have many friends who are cardiologists and cardiothoracic surgeons.  Most of them are pretty health conscious as they see the ravages of the toxic food environment we live in first hand.  Everyone of these docs mentioned a book called “The China Study” that is an evidence based text that not only extols the virtues of a vegan diet, but presents scientific proof that this diet can prevent and even reverse numerous diseases.  I really did not want to read it because I did not have any desire to change my diet and exercise regimen.  When I received an iPad as a gift, I needed a book to read on it, so I ordered “The China Study” and read it.  In some ways it is not an easy read as there is so much medical and scientific documentation, it is somewhat like reading a medical journal.  Having said that, it is fascinating!  This text discusses the disgusting state of nutritional affairs in our society.  It underlines that we are getting lazy, fat and sick from the fat and sugar that we eat and the alarming ignorance of nutrition that exists in our country and world.  Reading this book really makes you feel like a slug.  You can almost feel the fat in your arteries as you turn the pages.  We are an obese society and we are producing more obese offspring, all destined to become victims of diseases of affluence.  Diseases of affluence relate to cultural progress.  Underdeveloped societies  subsist largely on non animal foods, thus eat a lot of vegetables and grains.  The title “China Study” follows the life work of internationally known nutritionist Dr. Colin Campbell.  He has followed rural societies in China that subsist primarily on a vegetarian diet and compares them to urban Chinese populations that eat primarily animal based protein.  He shows, over numerous generations and subpopulations, that the rural Chinese that eat mostly vegetables have much lower incidences of heart disease, prostate, colon and breast cancer, diabetes, autoimmune disorders and other common “Western” diseases.  He backs each statement with scientific documentation.  This is important to me as I am as skeptical as they come when it comes to “miracle diets” and claims.  His point is that as societies progress and obtain wealth, they then begin to raise and eat animals and dairy products and this is when the diseases of affluence begin.  He even has corrected the studies for smoking and other societal variables.  People in poorer countries (assuming proper hygiene standards) are generally much healthier than the average American.  The reason is that they don’t eat significant animal protein.  Cardiac bypass surgery, type II diabetes and the increased incidence of many cancers and even Alzheimer’s disease can be directly correlated with societies that eat meat and dairy.

He makes the point that although heredity may play a part in disease, people adapt the diseases of the place they live.  A case in point is that Japanese men have a low incidence of heart disease in their homeland, but Japanese men that moved to Hawaii become clogged and sick.

What is really awakening in the book is the chapters on Dr. Caldwell B. Esselstyn a cardiothoracic surgeon at The Cleveland Clinic.  His life work consists of studying the effects of a vegetarian diet on hardening of the arteries.  He has shown in vegetarian and control groups of heart attack patients that he could in fact reverse atherosclerosis of the coronary arteries by eliminating animal protein (meat and dairy).  He shows the scans of reversal of plaques in the vegetarian group and the improvement in their lifestyle while numerous patients in the non vegetarian group got worse and some died of their disease.  You cannot read these chapters and not question your current diet.

The China Study also discusses the “toxic food environment” of our society in depth and reading this makes you feel fat and clogged, even if you eat well.  Our children are growing up sloths and processed foods such as fast foods , snacks, pastries and supersized portions are making them sicker than ever and at an earlier age.  We are on a downward spiral in terms of fitness.  Computer games have replaced exercise and even the NFL is employing programs to try to get children to be more active and eat better.

One of the biggest problems is the ignorance of the average person about diet, fat and nutrients.  Many doctors are also contemporarily uniformed as well.  Paying close attention to what we eat can have huge payoffs in terms of health, disease and longevity.  We have been brainwashed by a corporate mentality that milk, orange juice, beef and eggs will make us healthy.  In reality, avocados have much more vitamin C than do oranges, red meat with hormones and artery clogging fat is bad, chicken has more cholesterol than red meat,  and many of the allergies plaguing our children can be traced to dairy products.  I know that many of you are shaking you heads as this sounds like a cult or plot, but money talks and the food industry is interested in profit and not health.  Eliminating sodas and snacks from school vending machines and offering more healthy alternatives is finally beginning to outpace the food industry who again is interested in profit and not health.

It is human nature to say “my uncle smoked and drank and ate red meat all his live and lived to be 90”.  This may be true but is a huge exception and not a rule.  Yes, heredity does play a role, but banking your health on an exception is not a good investment strategy.  Yes, lots of people have had poor diets and habits and lived long, but the final decade of life is important and to spending it in a nursing home is not optimal.  The vast majority of adult health problems are from diseases of affluence.  High blood pressure, obesity, diabetes, heart disease and many cancers can be traced to gluttony and poor nutrition.  Add alcohol abuse and tobacco and you have an even deadlier prognosis to enjoy your last decade of life.  Go to any hospital and most of the total joint patients are overweight and have destroyed their knees and hips.  Obesity also produces or contributes to high blood pressure, diabetes and heart disease.  COPD and liver disease in many cases is a direct result of lifestyle choices.  So many of these conditions are preventable, but it takes self control, discipline and nutritional education.

One of my past arguments was against vegetarian diets was that humans evolved teeth that were designed for eating meat.  What I did not take the time to think out was the fact that humans were never designed to live into old age.  Teleologically, our main goals are self maintenance and reproduction.  The fact that humans can reproduce as early as 12 years of age never included old age in the evolutional master plan.  We did not need to live long, biologically we only needed to live long enough to reproduce.  So in effect, diet did not matter as long as you could find enough calories to survive and reproduce.  In nature, many species of animals die immediately after mating.  Due to the fact that compared to a infant calf that can leave the cow at birth and be on all fours in minutes, humans need protection as they mature more slowly, so we did need to hang around long enough to insure nurturing, maturation and safety of our offspring, but evolution sees no need to live 90 years.

I know all of this sounds like fanaticism, but in a way, that is what discipline requires.  Most people simply can’t do it.  Playing a musical instrument or being good at a sport is difficult and that is why the average person doesn’t do it.  Eating healthy is similar.  It requires knowledge, practice and discipline.  I really think that if we all had to go to work naked one day a year we would pay more attention to how we look.  Unfortunately, it is also more expensive to eat healthy, but not prohibitive.  Low income individuals can easier get a Wendy’s triple burger than to go to a grocery store and purchase nutrient filled foods.  Posting caloric content is so very important as many people eat fast food meals that have more fat in a single sandwich than they should get in an entire day.  Obviously, the food industry is resistant to post calories as it may influence profit.

If you observe nature, deer, birds and virtually all other animals spend their entire life foraging.  In the wild, it is not easy to find calories and at one time humans did the same.  You may walk miles to find a fruit, vegetable or insect to eat.  In primal times, corn did not grow in vast fields and herds of cattle in pens did not exist.  It was all we could do to find enough calories to survive and many times we did not and were returned to the earth.  Survival is tough!  Today, we have easy and cheap access to calories and we have way more than we need.  We are hard wired to consume calories but not in the excess that we can and this is why we are fat.  Calories used to be hard to find, now they are easy.  Also, fat is a tremendous energy source with 9 calories per gram.  That is more than double carbohydrates and protein, so teleologically, we are programmed to like fat.  It meant survival at one time, and although necessary for health, if often means death now.

I read the book and it was alarming and eye opening.  Dr. Esselstyn’s son Rip is a retired world class triathlete and now a Texas firefighter.  His book “The Engine 2 Diet” is a much easier read and is more designed for vegan athletes and those who exercise.  You can read this book in a day and it is chocked full of tasty vegan recipes  and exercise routines. This is a better book for the “hip vegan”, but the China Study really gets to the heart of the matter.

So……………..after reading both these books and seeing my cardiology and cardiothoracic buddies trying the vegan diet, I decided to give it a shot for 90 days.  My goal was number one to see if I could lower my cholesterol and LDL to the point where I did not have to take the Zocor.  Number two to see if I had the discipline to eliminate my much beloved animal protein and number three to see if I could maintain my energy level and muscle mass.

I have to tell you, I hate telling people that I am a “vegan” as to many it conotates as a weed and seed eating hippy with a tie dyed shirt and dreadlocks (not that there is anything wrong with that!).  I have no problem using animal products or leather, just on a true vegetarian diet sans the politics of veganism.

 First I eliminated all the animal based products from my house.  Gave my protein powder away, no more skim milk or egg whites, forget the poultry I subsisted on previously, it actually has more cholesterol than red meat.  If you are a vegan, you don’t eat anything with a mother or a face.  That was a bit tough for a sushi addict like myself.  No cheese either and you have to be careful about little things like crackers that may contain animal fat or products.

I am here to tell you that you can’t do a vegan diet based on what you have in your fridge or pantry, forget it or you will be living on carrots and celery.  The biggest surprise was that I was actually eating a much more broad range of foods than I had for years because in the past, I really limited the carbs.  The saving grace of the contemporary vegan diet is the fact that many companies make a wide variety of non animal vegan products.  Many of these are soy based, and there is vegan pizza, vegan spaghetti, vegan chili, vegan pudding and yogurt, vegan ice cream, vegan turkey (Tofurky) and even vegan buffalo “chicken” wings.  All these things taste really great to me, although my wife is more discriminating.  I am lactose intolerant (along with about 70% of the planet) so I have always had a love/hate relationship with dairy.  I am now in love with soy milk and almond milk.  Still get the calcium and vitamins, but without the cholesterol and lactose problems.  By the way, it really helps to have you spouse on the same diet, makes life much easier.  You have to do a little bit more shopping and all cities have whole food stores, but I have been pleasantly surprised by how many mainstream supermarkets carry vegetarian and vegan food choices.  This is partly due to the popularity of a growing movement of vegans including Mike Tyson and Steve Winn of Las Vegas fame.

Dining out can be challenging, but usually it is easy to get salads, baked potatoes, grains, tofu, hummus and vegetables.  I mentioned that I have, since high school, been a protein powder freak.  Gotta have those shakes.  I now do the same, but use soy protein powder.  I think that athletes still need more protein that average couch potatoes but not nearly as much as we have been led to believe. 

Do I crave meat and milk?  That has been the strange thing.  For 59 years I have been eating animal products and at no time over the first 90 days did I crave anything.  That was the biggest surprise for me.  At first it was sort of weird not eating meat, dairy or fish, but my vegan buddies told me that my palate would change and they were correct.  Not only do I not crave meat and dairy, but I actually look forward to multicolored veggies, salads and fruits. Other than a couple of M&M’s I have not eaten any animal products for 100 days.

What about my Cholesterol?  Well, it worked, I dropped my total cholesterol from 173 to 133!  That is pretty impressive.  I am not sure if my cardiologist will stop my Zocor or cut the dose so I still reap the anti inflammatory properties.

So, at 100 days, my goal was to go back to eating at least fish and skim milk, but now that the deadline has passed I really don’t have any pressing intention to deviate from the vegan gig.  Not saying I never will or not saying that I may broaden my diet from time to time in moderation, but I can say that in no circumstance will I go back to living on poultry, skim milk, fish and scant carbohydrates.

How do I feel?  Let me preface by saying that I hate people that try a diet, vitamin or supplement and all of a sudden their whole life has changed.  There is a lot to be said about the placebo effect!  Really, I don’t feel any different.  Since I was always health conscious (thanks dad) I never felt “bad”.  I don’t notice more energy or anything similar, but I don’t notice anything negative.  I feel “cleaner” or “less greasy”, but admittedly a lot of that is mindset.  I don’t ever get that “ate too much feeling” and I have not changed social drinking of occasional wine or beer.  My lactose intolerance is obviously cured.  Without getting too personal, let’s say that vegans probably spend more time in the bathroom than do meat eaters.  Fiber has many advantages including colon health.  My cardio and weight training has not changed and I don’t think I have lost any muscle mass.  One thing……………I have gained 8 lbs., while my wife lost 8 lbs.  I truly think my body holds on to carbohydrate calories with extreme efficiency and my carb intake is certainly up and nuts are little fat bombs and need to me eaten in moderation.  Also during the 90 days of archery season here in Virginia, I cut my workouts in half, partially for time and partially for healing (as I train hard the other 9 months), so I anticipate losing the winter weight soon after the first of the year.  Most vegans lose significant fat in the first 30 days.  This underlines that even good calories in excess will cause weight gain.    My biggest accolade was the dramatic reduction in cholesterol and LDL levels and I am most proud of that.

Many people say life is too short to limit ones diet to such levels but I say it is too short not to.  None of us have a guarantee of longevity, but it makes sense that by limiting heart disease and numerous cancers and other diseases like diabetes we will have a better chance.  The studies supporting vegan diets reducing plaques that contribute to Alzheimer’s disease are also very attractive.  Some people simply love food as a passion, hobby and past time.  While that is great, many of them are way out of shape.  In reality, keeping fit and trim is very simple; eat less and move more.  Seems so simple, but look around, the average person simply lacks the discipline.

In conclusion, now at 100 vegan days, I have enjoyed the change, don’t crave what I used to eat and I have less joint pain than in the past but not sure if that is directly related.  I love the lower cholesterol and LDL and for now will stay on track.  Again, I may broaden my choices to fish and egg whites in the future, that is what former president Clinton does, an extended vegan diet.  They say that if you get your cholesterol under 150 and your LDL under 70 you will be “heart attack proof”.  Time will tell.

Suggested Readings:

The China Study

T. Colin Campbell



The Engine 2 Diet

Rip Esselstyn


To find out about more about feeling better, looking better and cosmetic facial surgery visit http://www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

December 28, 2010 Posted by | Uncategorized | , , , , | 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

Writing a Textbook: the hardest thing I have ever done.


Over the years I have written several hundred cosmetic surgery journal articles, text book chapters and general publication articles.  Over this time I have edited three textbooks and contributed 18 chapters to other author’s textbooks.
Last September, I was asked to write a textbook on cosmetic facial surgery by Elsevier which is one of the largest publishers of medical textbooks in the world.  This was quite an honor and I explained that I know some of the best surgeons in the world to contribute chapters.  To my amazement and honor, Elsevier informed me that they wanted a single author textbook.  Ouch!  Again, a great honor, but I knew that this would be a task of awesome proportion.  And it was!
Last October I started writing a comprehensive textbook that would encompass the most contemporary cosmetic facial procedures.  My goal was to write an “atlas” type text that would describe each procedure in step by step detail accompanied by actual intraoperative photographs.  I wanted this text to be not only an instructional book, but also be able to guide surgeons through the step by step of each procedure.  My average chapter is ten thousand words and one hundred pictures, but some of the larger chapters like facelift and laser grew to 55,000 words and 250 images.  I was given a July deadline and finished at 11:48 on June 30th!  This was the hardest thing I ever did for numerous reasons.  First of all, I wrote every word off the top of my head.  When you write an instructional text, there is no room for error or missteps, so everything has to be accurate.  I wrote several hours every day.  On several days I wrote over 11 hours and one Sunday I typed for 13 hours with several breaks.  I wrote on airplanes, on trips where I was a passenger in the car, on my father’s couch at Christmas, and even typed two chapters on my iPhone while at a beach vacation.  I simply wrote and wrote and wrote every day.  My wife has been a “text widow” for the last 9 months, but has been unbelievably supportive.  Having completed 16 chapters and thousands of photographs, I am now editing video for the DVD that accompanies the textbook.  This has been another load of work.
I truly want this book to be my “Opus” and want to leave behind something that not only documented my cumulative cosmetic surgery experience, but something that could serve to teach other surgeons how to perform these wonderful cosmetic operations.  I wanted to be able to save novice surgeons some of the hard learned lessons of cosmetic surgery and to distill the knowledge to a very understandable level.  To that end, I believe I have accomplished my goal.
There is still a lot of work to be done finishing the videos and then there will be the proofing all the chapters which is very difficult.  It is very hard to have to go back and reread all the material that you write!  My fingers are sore from typing, and I have to really be conscious about my posture as hunching over a computer all this time can make someone a hunchback.  I feel that I have accomplished something that only a handful of surgeons ever get to do.  The book started out as 600 pages then went to 800 pages and I am hoping the publisher will allow a lot more than that because I have sent them much more.  I am not sure if it will all fit in a single volume.  May take two.
Writing this textbook is the hardest thing I have ever done!

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

July 5, 2009 Posted by | Uncategorized | , , | Leave a comment

The Art of the Peel


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

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


Preparing for your Peel


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

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


Types of Peels


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

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

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

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


Before your Peel


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


During the Peel


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


After the Peel


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

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

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

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

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


Before and after chemical peel to eliminate freckles

For more information about chemical face and neck peels see




Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

May 18, 2008 Posted by | Chemical Face Peel, Chemical Peel, Uncategorized | , , , , , | Leave a comment