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

My New Textbook: the first 90 days

I have written several blog posts about the task of writing a comprehensive cosmetic facial surgery textbook.  The first post was written as I was mid way into the project


and the second entry was written after it was finished and I realized what I did.


Again, writing a sole author text of 17 chapters for the best known medical publishing house (Elsevier)  is a task of awesome proportions.  I did get help with a single chapter where my friend Angelo Cuzalina, M.D. wrote the rhinoplasty chapter, but I wrote the other 17 chapters.

So after all this hard work of writing, taking and editing 3,300 images, proofing your won work, fighting the editor and publisher about content and then after 2 years finally signing off on the book……what happens?  Well, for a long time nothing happens as a 1,000 page text with 3,300 images is sent out to another country to print.  So, the data has to get there, get printed and get shipped back to the U.S.  All of this took many months and finally in September of this year, I got my hands on an advanced copy.  It was a very strange but rewarding sensation to finally see a physical copy of something that has been only seen on a computer screen for the last several years.  It was decided by the publisher that the book would retail for $269 but Amazon introduced a pre release special that was discounted.

The book has done unbelievably well as it has sold over 1,000 copies in the first 90 days.  I am told by the publisher that this is exceptional for a large book with a large price tag.  The book has sold well in numerous specialties including plastic surgery, facial plastic surgery, ENT, oral and maxillofacial surgery, ophthalmology, oculoplastic surgery, dermatology and even at some dental meetings.  Obviously this makes me proud as this book is a representation of my 30 years of doing and teaching facial surgery.  I feel that it is a true accomplishment and although it took several years to produce, I am so glad I did it as many surgeons vow to publish a comprehensive text but few pull it off.

I am told that the book will be reprinted and that this is an honor as the company obviously feels it will continue to sell.  Many books only make it through a single printing because they simply don’t sell.  Again, I am very humbled by the entire experience.  I have done book signings at several medical meetings and it is a true honor, although I sometimes feel embarrassed, but truly humbled when a doc purchases the book and requests a signature.

We will most likely write a second edition in the future and I have begun documenting new procedures or material that was not in the first printing as I know that  this daunting task will rear its head in several years.  It is amazing how fast technology changes where you write the latest material and by the time the book gets to the market, some things have changed.  I would hate to write computer books!  Interestingly we have only found 3 mistakes so far and I am sure more will surface.  These too will be corrected in the second edition.

Finally I was pleased to find out from the publisher that the book is selling well on the international market as well.  In this sour economy it has done well here and abroad.  Although I have written several smaller texts and over 20 textbooks chapters in other author’s books, this one was special and I won’t be able to top this academically in my lifetime, but again, that was my goal.

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

Joe Niamtu, III

December 12, 2010 Posted by | Academic Cosmetic Surgery, Technology | , , , , | Leave a comment

Dr. Niamtu Recent Featured Cosmetic Facial Surgery Patient

Name: Brenda Michaels

Age: 61

See a video of Brenda Discussing her Surgery

Procedures Performed:

  • Facelift
  • Upper and lower eyelid surgery


I am a recent widow.  I have two sons and two beautiful daughter-in-laws, and three adorable grandchildren, ages three, five, and seven.


Self employed- buying and selling plastic raw materials.


I enjoy hiking, gardening, reading and playing my piano.

Why you wanted to have cosmetic surgery:

I had wanted a facelift for a number of years as time continued to take a toll on my neck and face.  For me, my neck was the deciding factor in my decision to have a facelift.

Why did you choose Dr. Niamtu:

When I found Dr. Niamtu’s website, I was most impressed with the amount of information that was given about cosmetic facial procedures and I just knew that he was the doctor that I wanted to perform my facelift.

What were you hoping to achieve with the surgery:

I wanted to achieve a more youthful looking face and neck and Dr. Niamtu gave me that.

How did you like the results:

I am most pleased with my facelift.

What advice would you give other women considering cosmetic facial surgery:

Several of my friends have told me that they wouldn’t want to spend the money for cosmetic surgery or put themselves through the surgery and recovery.  Certainly having cosmetic surgery is a very personal decision, but for me the results were worth it all.  I “love my face” and for any woman considering cosmetic facial surgery I would say “Go for It!”

Any special thoughts on your experience:

I feel that I was blessed to have found Dr. Niamtu and to have him perform my surgery.

Comments from Dr. Niamtu:

I think I have the greatest patients in the world and feel very lucky to do what I do for a living.  It just keeps getting better!









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

November 25, 2010 Posted by | Cosmetic Eyelid Surgery, Cosmetic Facial Surgery Consultation, Eyelid Surgery, Facelift Surgery | , , , | Leave a comment

Fat Transfer: taking it from where you don’t want it and putting it where you do.

Fat is a natural and predictable filler that has been used for a century to increase volume, fill voids, and plump wrinkles.  Some of the main advantages of using fat include the fact that it is a natural filler, since it is harvested from the patient, there is no allergic issue, it is easy to harvest and the average patient has plentiful reserves.

Fat transfer is also referred to as “Fat Injection” or “lipo transfer” and is a popular cosmetic surgery procedure.  The basic premise of fat transfer is to harvest fat cells from the patient (from an area where they don’t need it) and inject it into an area on the patient’s body where they do need it.

Harvesting Fat

Common areas of fat harvest include the area around the belly button, the flank region “love handles”, the outer thigh and the buttocks.  Fat harvest is a simple procedure that is usually performed with local and tumescent anesthesia.  A dilute solution of lidocaine (anesthetic) and epinephrine (decreases bleeding) is injected into the site of the anticipated fat harvest.  After waiting about 15 minutes for the tumescent anesthesia to take effect, the fat is harvested with a device called a cannula,  which is a narrow hollow rod with a suction source.  Depending upon the amount of fat needed, 10 to 100 cc’s are removed.

Processing the Fat

After the fat is harvested it is processed.  This may include separating the fat from the other tissue by products by using a device called a centrifuge which spins the “good” (live) fat from the other cells.  Some surgeons feel that rejuvenating cells known as “stem cells” are included with the live fat cells.

Many surgeons do not centrifuge the fat, but process it by draining, washing and rinsing.  Regardless of the processing, the live harvested fat cells are placed in smaller syringes for the transfer process.

Fat Transfer Procedure

The harvested fat in the small syringes is injected with tiny blunt needles called micro cannulas.  A small puncture is made in the skin with a needle and the small, blunt cannula is placed under the skin and the small amounts fat in the syringe are injected.  The technique of the fat injection is paramount to the success of the procedure.  If large amounts of fat are injected in a single area, the body will attempt to dissolve it.  If very small “grains” of fat are injected into multiple tissue planes (over bone, in muscle, in other fat and under the skin) the body does not dissolve the fat as rapidly.  Performing multi level, small volume fat injection allows the many of the transplanted fat cells to survive and the augmentation to become permanent.

Where is Fat Transfer used?

Fat can be used as a filler in just about any part of the body.  Fat is most commonly injected in the face to increase youthful volume.  This includes the temples, regions around the eyes, the cheeks, the jawline, smile lines ,frown lines and lips.  Fat can also be used to inject under the skin of the back of the hands for rejuvenation of the skeletonized appearance of aging.  Some surgeons use fat to augment the breasts, buttocks and calf’s or to fill in defects from trauma or surgery.

What Type of Maintenance is Required with Fat Transfer?

Some  transplanted fat cells will live forever and produce a permanent augmentation.  This is not true for all the transplanted cells and many of them will be dissolved by the body.  For this reason “touch up” fat transfer treatments may be necessary.  Some surgeons will recommend 2-3 touch up procedures to obtain a “permanent” result and this may also require some touch up transfer injections every several  years.

For touch up injections, some surgeons will reharvest more fresh fat for each procedure, while other surgeons will freeze extra fat at the first harvest appointment and thaw out this fat at each touch up appointment.

Complications and Draw Backs

Like any filler procedure, complications can include bleeding and infection, both which are rare.  A relative drawback of tat transfer is that two sites are required, one to harvest and one to inject.  Over correction and under correction can be experienced with any filler.  Over correction is a minor problem with injectable fillers such has hyaluronic acid as the filler is digested over time by the body.  Fat, on the other hand can be a permanent filler and if over correction occurs, the excess must be surgically removed.  While most experienced surgeons obtain lasting results, each patient has specific differences and fat transfer may or may not be the optimal treatment.  Like all procedures, the specifics of the procedure and alternative treatments should be discussed with an experienced surgeon.  To find out more about cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia visit http://www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

August 9, 2010 Posted by | Fat/Lipo Transfer | , , , , | Leave a comment

Evolence: A New Breed of Fillers


Recently, new wrinkle filler called Evolence has been getting a lot of attention, especially after Demi Moore and other Hollywood types have admitted using it.

This is an exciting time in cosmetic surgery as many new and effective products have become available.  As the minimally invasive revolution continues, patients find it difficult to take precious time away from work or play and want significant lasting results with minor recovery.  Enter Evolence!

Evolence is new to the United States after recent FDA approval, but is the number one filler in Israel and has been used outside of the US for ten years.

What sets Evolence apart from other wrinkle fillers is its unique collagen composition.  While most of the other popular fillers are made of synthetic substances, Evolence is the first all natural filler.  It is made from porcine tendon which has the closest structure to human collagen and has been used for decades in heart valves, skin grafts and other medical and surgical products.  Although collagen fillers are not new, they fell out of favor due to two things.  One was that patients were allergic to the older bovine collagen fillers.  Evolence has a unique proprietary process of removing the allergic components of collagen and no allergy testing is required!  This is a huge and new step for injectable collagen fillers.  The other drawback of previous collagen fillers was that although they did a good job, they simply did not last.  Evolence has a patented Glymatrix technology which is a sophisticated cross linking process that extends the length of the filler for up to or over a year.  I can speak personally to this filler.  I was chosen to be one of the teaching staff for Evolence and attended an injection training session in January of 2008 in the Cayman Islands.  The meeting was off shore as new fillers that are not FDA approved cannot be injected on US soil.  The instructors were offered free filler, so I had my smile lines injected.  As I type this blog entry it is exactly one year later and my filler is still present.

The main difference between Evolence (the new collagen) and other fillers is that Evolence actually becomes part of your tissue.  It is collagen and is designed to replace the collagen we lose due to aging.  When injected, instead of being recognized as a foreign body (like most fillers) it is recognized as collagen and the body integrates it into the natural surrounding tissue and even grows blood vessels into it.  It also causes the body to produce some new collagen which can add to the result.  Pretty cool.

Perhaps the biggest advantages of Evolence is the fact that since collagen has many special properties, there is less swelling, pain and bruising with Evolence.  It is great for the patient who wants treated but has a big party in several days.

Right now Evolence is only FDA approved for the nasolabial folds (smile lines) but an new product called Evolence Breeze will be available for lip injections and is used very successfully in other countries.

Since new fillers seem to come and go every month (Artefil went out of business last in December 2008 ) it is critical for surgeons and patients to critically evaluate all new products before recommending them to patients.  Having had Evolence treatment on my own smile lines as well as using it on my patients, I can say that this product is a welcome addition to the armamentarium of cosmetic surgery providers that utilize injectable wrinkle fillers on their patients.  To find out more about Evolence visit www.evolence.com and for more information about cosmetic facial surgery by Dr. Niamtu in Richmond, Virginia visit www.lovethatface.com


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


January 21, 2009 Posted by | Lip and Wrinkle Fillers, minimally invasive facelift | , , , | Leave a comment

“On Being on a Magazine Cover”


I recently had the honor of being featured on the cover of Plastic Surgery Practice magazine.  Usually people get on magazine covers if they do something really good or something really bad.  In this case it was the former.  This magazine profiles leaders in plastic and cosmetic surgery and has featured some of the best known surgeons in the country.  Obviously, it was a huge honor for me.

When I reflect on what it took to get there the thought takes me back over a decade ago when I first became interested in cosmetic facial surgery.  At the end of 1996 I noticed a trend that cosmetic surgery was really starting to blossom and permeate numerous specialties besides Plastic Surgery.  Many programs including ENT, Oral and Maxillofacial Surgery, Ophthalmology and Dermatology were teaching cosmetic surgery procedures to their residents.   In my specialty, Oral and Maxillofacial Surgery, cosmetic facial surgery became part of our board exam and was covered by our malpractice insurance.  Having seen all of these changes and always enjoying the cosmetic aspects of Oral and Maxillofacial Surgery, I began to seek more knowledge about cosmetic procedures.  I soon became aware of a group called the American Academy of Cosmetic Surgery.  This was a somewhat unusual group as it was made up of members from virtually every specialty that wanted to share their knowledge about cosmetic surgery.  This does not sound that unusual now, but in 1996, many surgeons and specialties operated in stealth, not willing to share knowledge with colleagues.  All of my life I have become obsessed with my passions and it quickly became obvious that I was about to become obsessed with cosmetic facial surgery.  Prior to this time, I had a very successful and enjoyable time practicing routine maxillofacial surgery.  I began a solo practice and with the help of awesome partners, grew it to an 8 man, 6 office machine with 75 employees. As much as I enjoyed what I did for a living, there was something missing.  I felt withdrawn from academics, as many practitioners do after a decade or so of practice.  I was looking for some mental and surgical stimulation and cosmetic facial surgery filled that need.

It did not start out as an easy ride.  As my cosmetic surgery acumen grew, I began marketing my cosmetic services and that ruffled the feathers of some local competing specialists.  A number of detractors attempted to keep me and others from performing cosmetic facial surgery, mostly by deception with other doctors, patients and politicians.  A driven person will not accept defeat at any cost and I was determined to pursue my practice in a cosmetic direction.  As my experience grew so did my patient volume and producing good results with happy patients will trump adversaries over the long run. 

Around 2003, I decided that I enjoyed cosmetic facial surgery so much that I would limit practice to that discipline.  It was a big decision as it is difficult to maintain a practice on cosmetic surgery only, especially a head and neck cosmetic practice.  Surgeons performing full body surgery have more to choose from.  Cosmetic facial surgeons are limited to that area and there is only one other surgeon in my city besides me who limits his practice to cosmetic facial surgery.  Many Plastic Surgeons dabble in cosmetic surgery and fall back on reconstructive surgery to fill the voids but having a dedicated cosmetic practice is much more difficult.

From the onset of my cosmetic surgery experience I meticulously documented my learning and surgical techniques.  I began using this information to publish and teach.  I have always enjoyed writing and used my free time to publish articles on cosmetic facial surgery.  To date, I have published over 200.  I have also always enjoyed teaching and seriously considered a career in academics when I finished my residency.  In 1997 I gave my first cosmetic surgery lecture at a surgical meeting.  As I progressed, I submitted abstracts to more and more meetings from various specialties and organizations.  This is a very time consuming process as it requires unbelievable time and effort to lecture.  I think I spend more time using PowerPoint than anyone on the planet!  Also, a teacher must remain at the cutting edge of what is happening, so it is a significant commitment.  Over the past decade, my ability to teach and lecture became appreciated by various societies and specialties and in 2008 I lectured nationally and internationally 27 out of 52 weekends.  There have been many drawbacks from this; time away from home, work and family, missing hobbies such as bow hunting and fishing and spending countless hours in airports.  There have also been many rewards.  I have met thousands of cosmetic surgeons from all specialties, all over the world.  Some of my best friends have been made on the road and I cherish this family of cosmetic surgeons.  With this experience came committees and board appointments with the American Academy of Cosmetic Surgery.  I have served on numerous committees, was on the board of directors of the Cosmetic Surgery Foundation and have served as a co-chair for two annual meetings.  Also with experience comes other honors and I have been appointed to editorial boards of such publications as Cosmetic Dermatology, Aesthetic Surgery and Medicine and Cosmetic Surgery Times.  Finally, I have been asked by Elsevier, one of the leading companies in medical publishing, to write a textbook on cosmetic facial surgery.  This is a supreme honor and my chance to leave something behind.

I feel very lucky to love my job and I am excited to move into our new cosmetic facial surgery office and surgery center which is a state of the art facility here in Richmond, Virginia.  This magazine cover comes on the same week that we move into our new facility and serves to make me feel good about all the countless hours I have invested in cosmetic facial surgery.  As many of my friends that I trained with ponder retirement, it is my hope that I can work another 20 years, because I love what I do.  I also feel great about the fact that I have given back to the community by treating many patients that were unable to pay.  There is no better feeling that helping someone who has no other place to turn, especially children.

So, I spend my days performing cosmetic facial surgery and my evenings making before and after pictures, updating my web site, working on my text book and writing on my blog.  I sometimes feel overwhelmed and wonder what keeps me going.  It is simply that I have a passion for what I do. 

So what does it take to get on a magazine cover?  It takes passion!

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


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

November 23, 2008 Posted by | cosmetic facial surgery | , | Leave a comment

Facial and Neck Liposuction


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


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

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

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


The Procedure


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

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


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


Buccal Fat Pad Removal

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


Icing on the Cake (Chin Implant Surgery)


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

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


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

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


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


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



Joe Niamtu, III DMD

Richmond, Virginia



May 27, 2008 Posted by | Chin Implants, Face and Neck liposuction, Minimally Invasive Cosmetic Facial Surgery | , , , , | 1 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

Otoplasty: Pinning Back Protruding Ears

blogmickeyI am a lucky person because I love my job!  Cosmetic facial surgery is not only my profession, it is my passion!  One of my favorite procedures is otoplasty (surgically repositioning the ears).  For one reason, this is the only purely cosmetic surgery that is performed on children.  Second of all, it is a unique procedure that is not easily learned and is very rewarding because it makes a difference in the life of a child.  Having two special needs children myself, I can certainly appreciate the pain that children receive from peer ridicule and teasing.  Actually, it has been shown that teasing by peers can affect a child’s self esteem for the rest of their life.  We all know how grade school kids are, they will tease each other about any minor difference.  Children with protruding ears are easy targets from intentional teasing by classmates and unintentional attention from adults.  No child likes to be teased or ridiculed about any physical deformity and protruding ears simply brings out the jokes.

Frequently children will come to their parents with the request to have corrective ear surgery and sometimes they are naive to the situation and the parents must be proactive.  Let me clairify that there are probably thousands of children who grow up happy and healthy and into adulthood without ever having their protruding ears corrected.  This (like all cosmetic surgery decisions) is a personal family decision.  I have seen kids that wanted the surgery and the parents did not and the opposite.  Again, it is a personal decision.  Most kids don’t want braces either, but their parents make them aware of future appreciation and it’s a significant motivator.

The reason we prefer to correct these deformities early is to avoid peer teasing.  The ear is more than 80% developed by 5 years of age and usually fully grown by 7 years of age, so we prefer to perform this surgery before the child starts school.  This is not to say that we never treat this later as I have done many teens and adults.  Sometimes the time is not right until the time is right.  I have performed this surgery pro bono for hardship cases and continue to do so as I am always willing to assist a child in need.

The Diagnosis

Not all protruding ears are the same.  Most cases (with the exception of severe deformities) can be divided into three classifications.

     A. Problems with excess ear cartilage

protruding ear correction Dr. Niamtu Cosmetic Facial Surgery Richmond Virginia www.lovethatface.comThe above image shows a protruding ear from excess cartilage behind the ear.

     B. Problems with the anatomy of the ear anatomy


The above picture shows a protruding resulting from incorrect anatomy on the face side of the ear.  Normally there is a natural fold of the cartilage (antihelical fold).  In the the above deformity, there is a lack of the antihelical fold which causes the ear to protrude.  The left picture shows the protruding ear without a fold and the right sided picture shows the new fold recreated and the ear in normal position.

     C. A combination of the above

Problems with excess cartilage are common and usually heriditary.  In this situation the patient has excess cartilage behind the ear and this caused the ear to sit out in a more prominet position from the average.  This is treated in numerous ways, but I prefer an operation called a Davis Procedure.  While some surgeons merely stitch the protruing cartilage back to bend it, my experience (and that of many other surgeons) is that when cartilage and sutures fight, the cartilage will win!  In other words, the elastic cartilage can frequently pull throught the sutures causing the corrected ear to relapse back into a protruding position.  This cannot happen with the Davis procedure as it addresses the real problem by removing a small wedge of excess cartilage from a hidden incision behind the ear. 


The above image shows how a small wedge of cartilage is removed from behind the ear to allow the ear to set back in a more normal position.

Problems with an abnormal cartilage fold allow the ear to stick out similar to the inside of a sattelite dish.  Because there is no fold, the ear protrudes.  By placing special sutures and slicing the cartilage of the fold, the fold can be reshapped into a normal position.  This is called a Mustarde procedure, named after a french surgeon.

As stated earlier, some patients need excess cartilage removed while others need the normal fold recreated.  Many times, protruding ears are a result of both problems, in which case I perform both a Davis and Mustarde procedure simultaneously.

Either (or both) of these procedures can be performed with local anesthesia, but it is much more comfortable to use a light sedation, especially for young ones.  The Davis procedure is made by making a hidden incision behind the ear and a kidney shaped piece of cartilage is removed and the ear is allowed to relax into a normal position.  With the Mustarde procedure, the same hidden incision is used and the area where the new fold will be created is weakened by slicing small groves into the cartilage.  Then, specialized, permanent sutures are used to form the new fold and it grows back into a permanent position.  It is important for the surgeon to make the correct diagnosis as well as to perform the proper operation (or combination of procedures) to get a natural and lasting result.

After surgery, the patient wears a head bandage overnight.  Young children do extremely well with this type of surgery and have very little down time.  In fact, they have so little recovery it is hard to keep them from overactivity.  Most kids (or adults) are back to their normal routines in a few days although the healing takes several weeks to mend.  It is important to refrain from swimming or activities that may pull on the ear for the first week.  Activities that require rough contact should be put off for at least a month.  We prefer the patient to wear a headband or stocking cap for the first 5 days and then at night for another 5 days.  This keeps the ears pressed back and also serves as a reminder for the patient to take it easy on the ears.  Generally te scars are not noticable after several months.

Complications are rare and include bleeding, infection and relapse (the ears sticking out again).  All of these are rare. In addition over correcting the ear is noticable, so the surgeon must be very precise and accurate.


 protruding ear surgery dr. niamtu cosmetic facial surgery richmond virginia www.lovethatface.com 


otoplasty dr. niamtu cosmeticfacial surgery richmond virginia www.lovethatface.com

The above images show several patients that have undergone corrective ear surgery by Dr. Niamtu, cosmetic facial surgery in Richmond, Virginia.

For more information about corrective ear surgery or to see more before and after picutres, click on


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

May 13, 2008 Posted by | Otoplasty for Protruding Ears | , , , , | 1 Comment

Facts on Facial Fillers


 Introduction to Injectable Fillers


The use of Injectable facial fillers is one of the fastest growing areas in the field of cosmetic surgery.  Many advances in have been made in the last 5 years that have led to safer, more predictable and longer lasting fillers.


Historically, surgeons have injected substances into the face and lips for over a century.  For the past 25 years, the choice of FDA approved fillers was very limited and basically was the use of bovine collagen (obtained from cows) products such as Zyplast and Zyderm.  While these fillers were effective, they required allergy testing and a one month wait for injection after a negative allergy test.  In addition, the did not produce lasting augmentation and the results were often gone at 3 months or less.


In December of 2003, the FDA approved Restylane for treating facial folds and wrinkles.  Restylane represented a new type of filler and is made from hyaluronic acid which is a naturally occurring carbohydrate that is found in the skin and other tissues of all mammals.  This substance is a clear gel with similar consistency as hair gel.  Since it is not made from animal products, there is no need for allergy testing which is a huge advantage as the patient can come to an office and have same day filler injection.  In addition, the hyaluronic acid fillers have a chemical process known as “cross linking” which prolongs their effect in the body, giving augmentation that can last 8-12 months.  Medicis, the company that makes Restylane also has a more robust filler known as Perlane which was FDA approved in 5-07.  This is a thicker filler that is used for smile lines (nasolabial folds) and other areas and provides a firmer support and lasts longer than Restylane.


Since the FDA approval of Restylane, Allergan Inc. (the makers of Botox) have had 2 injectable fillers approved by the FDA in 2006.  Juvederm Ultra is a hyaluronic acid filler similar to Restylane and Juvederm Ultra Plus is a larger particle, more robust filler, similar to Perlane.  The hyaluronic acid based fillers (Juvederm and Restylane) currently remain the most popular filler choices.


Hylaform, Hylform Plus are animal based hyaluronic acid fillers FDA approved in 2004,  formerly marketed by Inamed (now Allergan) that have declined in popularity with the newer non-animal derived hyaluronic acid fillers. Captique (also marketed by Allergan) is an additional non-animal hyaluronic acid filler that was FDA approved in 2004.


There is a continued effort to develop longer lasting fillers.  Although a permanent filler may sound like a perfect thing, if a patient has complications such as over fill or asymmetry, then permanent may not be a good thing!  In experienced hands, the longer lasting fillers work well and their lasting effect is appreciated by both surgeons and patients.


There are numerous fillers that claim to last longer than the hyaluronic acid fillers.  One of these FDA approved fillers is Radiesse.  This filler is made from a substance that has similar properties to the organic matrix in bone or sea coral.  These fillers have a consistency similar to tooth paste and due to their composition, can last up to 18 months.  Radiesse is most often used in the nasolabial folds and for cheek augmentation, but may be used in the lips by some injectors.  Since this is a thicker filler, it is generally used in deeper areas of the skin so there are not irregularities in the superficial skin.


Another new, longer lasting filler is Artefil.  This filler consists of microscopic plastic beads that look like pearls under a microscope.  The beads are mixed in a collagen carrier for injection.  Since the beads are plastic, they will remain in place permanently and thus provide a lasting augmentation.  One drawback to this filler is that since it contains collagen, it requires allergy testing one month before injection. 


With the previously described fillers, they work by filling the lip or wrinkle with volume and are gradually digested by the body.  Basically, when these fillers are injected, “what you see is what you get”.  There exists another class of injectable fillers that work in a different manner than simple augmentation.  Silicone and Sculptra work by an alternate method.  These fillers are injected into the deeper skin and they cause the body to make new collagen.  When these fillers are injected, they cause the collagen reaction that actually causes the area to grow over a 3-4 week period.  This means that when Silicone of Sculptra are injected, there may be little noticeable result at first, but over the next month, the body will produce collagen in the injected areas and the augmentation will actually grow.  With Silicone, very small micro droplets are injected into the lips or wrinkles and over the next month these tiny droplets of silicone will become surrounded with collagen and enhance the augmentation.  Since the Silicone will “grow” it is injected in very small volumes on a monthly basis until the desired result is achieved.  Silicone is considered a permanent filler as it stays in place and the body does not digest it.


Sculptra is substance known as L-Poly Lactic Acid which is similar to the material used to make a type of suture that is used to close lacerations.  This material, similar to Silicone, will cause the body to make new collagen in the area where the filler is injected.  Due to this, the reaction (like Silicone) is not immediate but increases over the next 3-4 weeks after injection.  Sculptra is popular for injection into the nasolabial folds and for cheek augmentation.  Some surgeons may also inject Sculptra in the lips and other regions of the face.  Sculptra, like Silicone does not require allergy testing.

Since the science of fillers is so prolific, we will see new fillers introduced on a regular basis.  In Europe, cosmetic surgeons have over 70 choices of various injectable filler products.  Several very recent FDA approved fillers include Evidence, Elevess, and Prevelle.


Elvess is a hyaluronic acid filler that contains local anesthetic (0.3% lidocaine) and was FDA approved in 12-07.  By combining a local anesthetic with the filler, the injection process is more comfortable for the patient, although most surgeons use local anesthetic injection routinely before filler administration.  Prevelle Silk is another hyaluronic acid filler with local anesthesia marketed by Mentor and is representative of the process of adding lidocaine to the actual filler product.


Evolence is a filler that is made from porcine collagen (derived from pig tissue) and claims to last up to a year when injected into the nasolabial folds.  Evolence has the consistency of a paste, does not require allergy testing and is yet another exciting example of the new generation of fillers.




Who is a Candidate for Injectable Fillers?



Facial fillers are administered over a wide age range.  Younger patients may seek filler injection for lip plumping and fillers are used in the lips and other areas on aging patients.  Men are also candidates for injectable fillers and are one of the fastest growing filler patient populations. Since filler injection is basically a simple and safe procedure most patients are candidates for injectable fillers if they want to plump their lips or wrinkles.  Fillers should only be injected by appropriately trained personnel that can manage any potential complications. 



Who is not a Candidate for Injectable Fillers?


Patients with significant allergies should check with their doctor before having any filler injected.  Also patients taking aspirin or any medication that could affect blood clotting should notify their surgeon prior to injection to avoid hematoma, bleeding or severe bruising.



What is the Intended Result of Filler Injection?



Fillers are intended to plump lips and soften wrinkles.  Different patients have different areas in need of improvement for their lips.  Younger patients may only need some slight plumping to augment their already youthful lips while older patients may need plumping, outlining (restoration of the youthful border of the lips) and injection of lipstick lines.


For wrinkles and folds, fillers are intended to “soften” the wrinkle or fold, not to eliminate them.  It is important that the patient has reasonable expectations prior to the treatment as not to be disappointed.  If you consider the wrinkle a depression in the skin, the filler will plump up the depression to make it less severe, but will not make it completely disappear.  Having realistic expectations is very important.



How Long Can I expect the Filler to Last?


Filler longevity is extremely variable and depends upon the type of filler used, the area it was placed and the metabolism of the individual patient.  Fillers generally do not last as long in areas of extreme movement such as the lips as compared to less mobile areas like the cheekbones.



How is the filler administered?


Every surgeon has a different way of injection filler.  Most surgeons will use a topical anesthetic cream and also administer local anesthetic injections (dental injections) prior to injecting fillers.  Ice is also applied before and after injection.  Injection generally only takes several minutes and some fillers cause immediate swelling so the patient may appear “over treated” at first.  This swelling generally resolves in several hours.  A follow up appointment several weeks after filler injection is a good idea so the surgeon can evaluate the result and touch up any areas in need.



What is the Recovery for Filler Injection?


For most patients, fillers can be injected in the lips or wrinkles and they can return to work the next day.  Occasionally some patients will swell dramatically, especially in the lips, so for a first time patient; they may want to schedule the initial injection on a Friday.  Occasionally patients will bruise from lip or wrinkle filling and this can usually be covered with makeup, but it is a good idea not to schedule filler injection right before an important social function in the event the patient experiences unusual bruising.



What are the Possible Complications of Injectable Filler Injection?


Like any procedure, filler injection can cause complications, but fortunately they are generally rare and minor.  The most common post injection complications are swelling and bruising, both of which generally are short lived and self limiting.  Over correction or under correction are also possible.  For under correction, more filler can be added.  In cases of over correction, sometimes the excess filler can be expressed out of the lip or wrinkle through a small needle puncture.  Hyaluronidase is a medication that will dissolve the hyaluronic acid fillers and can be used to reduce areas of over treatment.  Asymmetry is another possible complication where one side may be different from the other and again, requires filling of the deficient side.


In rare case allergic or foreign body reactions have been known to occur with fillers, but this is extremely rare.  All of the above potential complications should be thoroughly discussed with your doctor before injecting fillers.





Injectable facial fillers have broadened the scope of minimally invasive cosmetic facial surgery and provided increased rejuvenative options for both doctors and patients.  The represent an exciting and rapidly expanding part of anti-aging treatment and hold much promise for new fillers on the horizon.  What used to require surgery can now, oftentimes be accomplished in several minutes with minimally invasive injectable facial fillers.


For more information on injectable facial fillers and other cosmetic facial surgery click on




Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

May 9, 2008 Posted by | Lip and Wrinkle Fillers | , , , , , | 1 Comment