Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Cosmetic Injectable Fillers Can Kill You: The wrong filler in the wrong hands.

You have to wonder what people are thinking when they agree to be injected by lay personnel.  Lately, the news has featured several high profile cases where patients sustained serious health problems and even death after injection of industrial substances instead of approved soft tissue fillers.  You may think it is because of the lower fee, but the case detailed below cost the patient $4,000 and maybe her life.  Medical or surgical treatments should only be performed in a clinic environment by experienced personnel; never in a hotel room, “filler party” or someone’s home.  The cases detailed below involve silicone purchased from a home improvement store and flat fixer from an auto parts store.  Cement was also used in the second case, but we are not told what type of cement.  Injecting anything into your body is serious stuff people and it can kill you.

Medical grade silicone is FDA approved and used off label to plump lips and wrinkles and is one of my favorite fillers.  I have been safely injecting silicone in patients for a decade and follow very strict principles of treatment and remain very conservative.  Silicone is a very good and safe filler when used by experienced injectors. It is permanent filler which is a good thing, as long as it is done correctly.  Otherwise it is a permanent complication!  No patient should ever allow any non-healthcare personnel to inject any filler anywhere in their body and when using doctors or nurses, do your homework.  Make sure that the person injecting you is experienced.  He or she should be able to show you many before and after pictures of their work.  Doctors that lecture or publish on fillers are generally the most experienced.  Don’t risk your life for an alleged “bargin”.

 

Baltimore — The Food and Drug Administration and other health agencies are investigating incidents across the country in which unlicensed, untrained practitioners are performing cosmetic procedures with supplies that may have been purchased in home improvement stores.

A Baltimore exotic dancer injected with silicone to enhance her buttocks has become another victim in a growing trend that has led to illnesses, injury and even deaths, the Baltimore Sun reports.

An FDA affidavit contained in court documents identified the woman who injected the unnamed dancer as Kimberly D. Smedley, 45, of Atlanta. Ms. Smedley was arrested in Washington in October with three 18-gauge medical needles found among her belongings. The case remains sealed, and the specific charges are unknown, the Sun reports.

The dancer was hospitalized twice less than four days after the last of her injections in March, according to court documents. On her second visit she was given blood thinners to alleviate clots, and she remained hospitalized for 10 days. A CT scan showed silicone in her lungs, where it remains.

Court records state that the silicone Ms. Smedley allegedly injected into the dancer came from an unlabeled jug that may have been purchased at a home improvement store, where it is sold as caulk and other adhesives, according to the Sun.

The dancer paid $1,000 for each of four sets of injections after meeting Ms. Smedley in the club where the dancer worked. She told authorities that Ms. Smedley also injected silicone into other dancers in a downtown Baltimore hotel, the Sun reports.

In similar incidents, a woman was arrested in Miami recently after allegedly injecting a woman with tire-repair liquid to enhance her buttocks, and earlier this year a British woman died after an improper procedure in a Philadelphia hotel room, according to the Sun. A New York City woman also was arrested on charges that she performed illegal breast- and buttocks-enhancement procedures in her home, according to news reports.

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

December 15, 2011 Posted by | Can Cosmetic Facial Surgery Change Your Life?, Choosing A Cosmetic Surgeon, Cosmetic Surgery by Unqualified Personnel, Cosmetic Surgery for the Wrong Reasons, Lip and Wrinkle Fillers, Lip Augmentation | , , , | Leave a comment

Facial Thirds: a good way to look at the face

I see a lot of patients this time of year who have made a resolution to look better and feel better about themselves.  This is a great time to have cosmetic surgery because you can cocoon in the winter and then the butterfly comes out in the spring!

The best way to decide what procedure is right for you is to divide your face into four parts: the upper face is the forehead and upper eyelids; mid-face is the lower lids, cheeks and upper lip; lower face is the jowls and neck; and the fourth area is the skin.

When patients come in for a complimentary consultation, I look at each of these areas separately and evaluate what kind of aging is there. Together, the patient and I decide whether it requires a surgical or non-surgical solution. All surgeries are performed in my fully accredited, in-office surgery suite.

For the upper face, surgical options consist of either a brow or upper lid lift. These are very effective procedures because the eyes are the first place to show age. Non-surgical upper face options include Botox, Dysport, and Xeomin and facial line fillers for mild to moderate wrinkles.

For the mid-face, lower lid surgery and cheek implants will lift the cheeks and eliminate bags, and can be performed in about an hour.  Injectible cheek, lip and smile line fillers are moderate  non-surgical procedures with no downtime.

For the lower face, surgical procedures include facelifts, liposuction and chin implants. There are varying degrees of facelifts, depending on the patient’s needs, budget and available recovery time. Botox Dysport, and Xeomin and fillers can also be effective non-surgical options.

Chemical peels and laser resurfacing are very effective for skin rejuvenation. Moderate aging and brown spots can be treated with fractional or light laser resurfacing for shorter recovery.  Non-surgical procedures include radio frequency mole removal, spider vein removal, and medically based (prescription strength) lifetime skincare.

If there’s something you’d like to change, 2012 is a good time to do it. I invite you to come in for a free consult and skin scan. You do so much for others. Let this be the year you do something for yourself!

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

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

December 14, 2011 Posted by | cosmetic facial surgery, Cosmetic Facial Surgery Consultation | , | Leave a comment

Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.

This image shows an actual surgery patient of Dr. Niamtu.  The aging midface (left) is rejuvenated by lower eyelid surgery and cheek implants (right).

 

Facial aging is an interesting multi factorial phenomenon.  Many things contribute to an aged midface including sun damage to skin, atrophic and gravitational changes to fat, muscle and bone.  Two of the biggest things that make us look old and tired occur in the lower eyelids and cheeks.

The lower eyelids can undergo aging changes as early as the third decade.  The skin becomes crinkly and sags, fat can protrude from around the eyeball and produce sausage shaped fat bags on the lower eyelids.  This protruding fat also causes a shadow from overhead light which contributes to the dreaded “dark circles” under the lower lids.  In addition, due to the aforementioned changes, the “tear trough” (technically the nasojugal groove) becomes accentuated.  This produces a deep grove under the eye from the side of the nose across the cheek.

Extremely related to midface aging is volume loss in the midface.  Young patients have full, plump and rounded cheeks.  This good fat in good places produces a smooth, continuous contour under the eyes and around the cheeks.  Gravitational and atrophic aging changes causes volume loss in the cheeks and gives us a drawn, gaunt and hollow appearance.  This is also very related to the lower eyelid aging as the lower lids are the upper cheeks.  The combination of aging produce an old and tired look and the only means to address this aging comprehensively is to address both the lower eyelids and cheeks at the same time.  I find it rare that patients with lower eyelid aging don’t need attention to the cheeks (midface).  I would say that 95% of my lower lid patients that are over 40 would benefit from simultaneous midface augmentation.  Fortunately, many of these patients understand this and combing procedures.

My approach to the healthy lower lid is pretty simple.  I remove conservative fat with a laser incision from the inside of the lid (transconjunctival blepharoplasty).  This means no external scar and no bleeding due to the laser.  No bleeding means faster surgery and recovery with less bruising and pain.  I am always very careful to only recontour the excess fat as not to produce further volume loss.  The second step of lower eyelid rejuvenation is addressing the aging skin of the lower lids.  Although some surgeons still cut off lower eyelid skin, I think that is a bad idea.  It only stretches the skin; it does nothing for rejuvenating the skin.  The skin will return to its normal wrinkling in a short time.  More of a problem is the fact removing skin from the lower eyelid can also contribute to lower eyelid malposition.  Due to the scarring that can occur inside the lower lid, the eyelid can be pulled down which looks unnatural and can cause problems.

To truly rejuvenate the lower eyelid skin, it needs to be resurfaced.  I prefer CO2 laser resurfacing or chemical peeling.  These modalities actually remove wrinkles and brown spots and makes new, younger skin. That is truly rejuvenation!

Since the aging does not stop at the lower lid, this is an excellent time to also address the midface.  The patient is already sedated and will be taking a week off of work, so why not be comprehensive with the rejuvenation?   My most common method of augmenting the aging midface is the use of silicone cheek implants. (Click here to view a video about cheek implants and facial aging)There are many reasons that I like cheek implants.  Among them is the fact that they are inserted from the inside of the mouth so there is not visible scar.  They are held to the cheekbone with a micro screw, so they are permanent, but they can be changed or removed in 30 minutes if the patient desires.  Not many things in cosmetic surgery are permanent but reversible!

By placing cheek implants, the youthful contour of the midface is reestablished and many times the tear troughs and even the nasolabial folds are also improved.  Alternatively, the cheeks and tear troughs can be volumized with injectable fillers.  This is non-surgical and is also reversible.  The downside of midface filler augmentation is that it is a temporary fix.

Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.  If a patient seeks lower eyelid rejuvenation and the surgeon does not discuss the midface aging, a second opinion may be in order.

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

 

Joe Niamtu, III DMD

December 6, 2011 Posted by | cheek implants, Cosmetic Eyelid Surgery, Eyelid Surgery, minimally invasive facelift | , , , , , , , | 4 Comments

On NOT Being a Vegan

Although 99% of my blog entries involve cosmetic surgery, I occasionally write about more personal issues.  About a year ago, I wrote a blog about being a vegan.  I had just read “The China Study” by Colin Campbell at the recommendation of about every cardiologist and cardiothoracic surgeon I know.

I was impressed by the medical evidence in favor of a plant based diet so my wife and I decided to take the vegan plunge for 365 days to fully evaluate the benefits.  The good news is that my cholesterol dropped a whopping 50 points, which is pretty amazing.  My doc still recommended my staying on a statin for beneficial anti-inflammatory effects.

I have never been a junk food person and have always eaten pretty healthy, low carb and low fat, but did eat lean meats and fish.  Going vegan meant no animal products, no meat, no dairy or cheese, no fish.  Pretty much sounds like a prison sentence for the average American.

The switch over was pretty seamless as we shopped at health food stores and substituted much of our previous diet with soy alternatives.  Actually it was sometimes hard to tell a difference.  The main problem with the vegan diet is the difficulty of keeping carbs low and protein high; the opposite of my diet for the last 3 decades.  I, unlike many people, actually gained a little weight which I attribute to the increased carbohydrates.  Did I feel any better?  The answer is somewhat disappointing no.  I never felt bad before the diet and did not feel better on the diet.  Having said that, you cannot feel “prevention” so it was not like I expected some huge boost.

There is no doubt that the biggest problems with a vegan diet were boredom and inconvenience.  If you grew up with a typically omnivorous diet, it is tough to totally eliminate animal products for the rest of your life.  If you were raised on a plant based diet it would be much easier.  Also, variety is important in any diet and the options are much decreased with the vegan diet.  I missed sushi, fish and turkey, but never craved it and never cheated for a full year.  The inconvenience is probably the biggest issue.  First of all, shopping is difficult because not all stores carry vegan items.  They are also much more expensive and much to my surprise very heavy laden with sodium.  Perhaps the worst inconvenience is eating out.  This is twofold.  One problem is finding vegan items on typical restaurant menus.  Many have them, most will do something special and some ask what is a “vegan”?  Akin to this is the fact that the “veganites” become the center of attention which inevitably slows down the ordering and service and creates a hassle factor, as the server has to leave the table and speak to the chef, etc.  Secondarily is the kidding and harassment from your friends.  People are always willing to bash those whom are different and this is a great opportunity!  My carnivorous pals would whip me unmercifully about being “veggie boy” and the usual diatribe inspired by meat eating hedonism.  Gotta’ have thick skin to be an out of the closet vegan.

In any event, I gave it an entire year, 365 days.  I eased back into (as Jimmy Buffett would say) my carnivorous habits.  I did maintain some vegan vestiges such as soy or almond milk and vegan chili but added back fish and white meat poultry.  I missed it, but did not crave it.

So………….bottom line, being a vegan is rigid and difficult and I applaud those who are able to do it permanently.  I gave it a good go and really did not notice any outward differences, but appreciated the cholesterol improvement. We all realize the benefits of a plant based diet and I feel that it is important to lean that way but I also believe that lean meat and fish also have benefits and using moderation is perhaps more important that severely limiting diets.

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

 

Joe Niamtu, III DMD

December 2, 2011 Posted by | Personal | , , | Leave a 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

www.lovethatface.com

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

Dr. Niamtu appointed to Xeomin Teaching Faculty

xeomin

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

Gauged Ear Lobe Repair

Although people have been adorning or stretching their ear lobes for thousands of years, it has become socially fashionable with younger people along with tattooing and body piercing.  I have seen many patients that are now entering the workplace and consider the stretched ear lobes a liability for being hired.  To my surprise, many of these patients did not realize that this is usually a pretty simple process.

The above image shows a patient with gauged earlobe plugs and rings in place.

When patients present for consultation, the first thing we do is to get the plugs out and allow the lobe to shrink down for 12 weeks or so.  This allows a more conservative surgical procedure as there is less “hole” to deal with.  The pictures below show patients that presented after having the plugs out for 12 weeks.

The above image shows gauged ear lobes ( 3 months after leaving the plugs out and before repair) and the after images taken 6 weeks after the repair.  The lobe is still pink from the CO2 laser treatment to improve the scar and will return to normal color.

Some patients cannot or do not want to wait for the holes to shrink or their lobes are so stretched, that they will not shrink.  In those cases, we will do surgery at their convenience without waiting for shrinkage.
The surgical procedure is simple and is performed with local anesthesia.  The lobe is numbed and cleaned with surgical scrub to sterilize the tissue.  The excess tissue is then removed and the lobe is sutured into a more natural configuration.  In smaller repairs, a single surgery may take care of the problem but larger stretchings may require several surgeries to restore the lobe to normal.
Some surgeons do not realize that “finishing” procedures can make a big difference in the final result.  Some patients are left with a pointed lobe after repair. Using radiowave surgery to blunt any “pointing”  on the lobe takes only seconds and will restore a normal border contour.  In addition, CO2 laser resurfacing of the final incision can homogenize the scar, making is almost invisible.  Silicone injections can also be used to plump the lobe as repair will sometimes hollow the lobe.  These small perfections can make all the difference in the final result.

The above image shows a patient before and after picture of gauged earlobe repair.  The lobe is still pink several weeks after the laser resurfacing procedure to blend the scar.


For more information of earlobe reconstruction or cosmetic facial surgery visit www.lovethatface.com

Joe Niamtu, III DMD
Cosmetic Facial Surgery
Richmond, Virginia

October 28, 2011 Posted by | Earlobe Repair, Gauged Ear Lobe Repair | , , , | 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

Boomer Magazine Interview with Joe & April Niamtu 10-2011

Click here to view PDF of interview

October 6, 2011 Posted by | People with disabilities, Personal | , , , | Leave a comment

FAQ from Dr. Joe

Click here to view full size PDF

October 5, 2011 Posted by | Cosmetic Facial Surgery Consultation | , , | Leave a comment