Exilis

Some exciting news! Exilis won for “ Best Skin Tightening Device” at The Awards Ceremony @ The Aesthetic Show in Las Vegas. No other device was mentioned, and this was voted on by the attendees at the meeting.

                    Photo from the Awards Ceremony at The Aesthetic Show in Las Vegas last Sat night.

Body Contouring After Massive Weightloss

Body Contouring After Massive Weightloss

Congratulations on having lost the weight. It is truly the greatest thing you could have done for yourself and your loved ones. You are now “thin”. The diabetes and hypertension are gone and you feel great. But maybe you weren’t prepared for what is next. The scale tells one story but your skin tells another. This realization is often accompanied by depression and despair. Don’t despair, you made the right choice. The end results of your efforts are in sight. The road is just a bit longer than you anticipated.

Introduction to Procedures

By 12-18 months after your gastric bypass or lap band surgery your weight plateaus and you are ready to begin the journey. Ideally your weight should be stable for 3 months before the first contouring procedure. Body contouring after massive weight loss has emerged as a surgical subspecialty in plastic surgery. Traditional contouring techniques were not designed for the excess skin we currently see when greater than 100 lbs is lost. But Plastic Surgery has risen to the challenge. Techniques developed over the last 5-10 years, now yield outstanding results. Areas generally affected are the arms, breasts, abdomen, buttocks and legs. The face may also appear older once the volume has diminished but this is also related to your age at the time of weight loss surgery.

The distribution of body fat is very variable. Some individuals selectively deposit fat in their trunk sparing the legs. Others deposit the fat in their legs sparing their trunk. The correct surgical procedure is dictated by the individual presentation. Truncal contouring procedures range from abdominoplasty to belt lipectomy to the lower body lift. The abdominoplasty will address the excess skin of the abdomen but not the lower extremities or the back. A belt lipectomy is a circumferential procedure which will address the excess skin of the abdomen and fullness about the waist. A lower body lift is a circumferential procedure which addresses not only the excess skin of the abdomen and flanks but lifts the thighs and buttocks as well. None of these operations directly address the medial thigh which often requires a medial thigh lift as a second stage operation.

Depending on how the weight is lost breast lift or reduction may be required. In fact, with dramatic loss of weight in the breast, consideration of breast augmentation with an implant may be necessary to achieve the desired aesthetic in conjunction with a lifting procedure.

The arms and back can also be areas of significant concern. Traditional brachioplasty can be extended to address the excess skin. Back rolls can also be addressed by direct excision. In extreme cases an upper body lift can be done to remove excess skin of the upper torso not corrected by the lower body lift.

 

 

Lower Body Lift

This operation was first described about 12 years ago by a surgeon who was dissatisfied by the limitations of the abdominoplasty. Whereas the abdominoplasty improved the appearance of the front of the abdomen, the lower body lift improved the entire truncal area from the rib cage to the knees with a single operation. Although originally described for the moderate weight loss patient the technique has broad applicability and has been modified to address the current population of individuals who have lost in excess of 100 lbs.

The operation is a circumferential procedure which is essentially three procedures in one. The first component is the high lateral tension abdominoplasty, which addresses the excess skin of the abdomen and the abdominal muscle tightening (see tummy tuck for further description). The continuation of the incision, within a garment line, allows for the lifting of the outer thigh and the buttock. This may be done in conjunction with liposuction of the lateral thigh and flanks to achieve the desired contour.

The procedure is about 6-8 hours and so I do not combine this operation with other contouring procedures. Although the incision is circumferential, the area of most discomfort is where the muscles have been brought together. I use local anesthesia in the muscle during surgery to minimize this discomfort on awakening. The recovery is a bit tougher than the abdominoplasty due to the discomfort of a circumferential incision and also to the length of surgery.

I require my patients to spend the night in the surgical facility with observation by a registered nurse. I strongly recommend another day of nursing care before returning home on the second day after surgery. Most individuals are off their pain medications by a week and are moving about fairly well. Drains placed at the time of surgery are generally removed between day 7 and 10.Although you are feeling well by the end of the first week, I recommend a 2 week recovery before returning to work.

 

 

Brachioplasty

 This is a surgical procedure to address the excess skin and fat of the arms. The inner arm skin is thin and as we age the elasticity gives way creating the hanging skin which doesn’t tighten now matter how much we exercise or lose weight. There are variations in surgical techniques which must be applied to your unique contour. They range from liposuction alone to excisions which can be limited to the arm or extend onto the chest wall.

Liposuction alone has limited applicability as few people have excellent skin quality and localized fat. If that is you though you are in luck Liposuction can be done through small incisions placed in cosmetically silent areas. The procedure is done as an outpatient and the recovery is quick. The discomfort is described as “soreness”, like after a vigorous work out.

Most people however, will require an excision of the excess skin which is present along with removal of the excess fat. There are 2 excisional procedures which I use to achieve your desired contour and that is dictated by your presentation.

The first technique involves incisions in the axilla, arm pit, and one extending onto the arm in the area just below your bicep muscle. This is an excellent operation for mild to moderate excess skin as the length of the incision on the arm is as long as it needs to be to remove the excess skin. I like the incision below the bicep as this is an area which falls into shadow when the arm is extended. In our daily activities the exposure of the inner arm happens infrequently as this area generally is facing the chest wall. Some surgeons place the incisions on the back of the arm or close to it. I do not care for this placement for two reasons. The first is that you may not see the incision but everyone behind you can. The second reason is that the damaged skin responsible for the laxity is the thin inner arm skin, more of it is removed with an incision just below the bicep than on the back of the arm.

The second technique is required when there is more significant skin excess of the arm and fullness is present under the arm overhanging the bra. Instead of ending in the axilla, arm pit, this incision crosses over onto the chest wall and removes excess skin and fat there as well. Not only improving the contour of the arm but also the chest and back.

The operations are done as outpatient surgery. You will have drains for the first few days. You are in a support garment immediately after surgery for at least 4 weeks. The first week movement of your arms should not be above your head. The second week you begin range of motion and resume light activity. The operation can be combined with other procedures but we will need to talk about this. We rely on arms a great deal when recovering from other procedures, so operating on the arms at the same time makes for a tougher recovery.

When approaching body contouring a definite plan has to be created with your surgeon. The sequencing of your surgeries should be dictated by your priorities along with appropriate safety concerns. If your arms and breasts concern you more than your abdomen, do them first. Safety should always be your surgeon’s primary concern. I believe limiting body contouring surgery to 6-8 hours at a time is the best way to safely achieve the desired result. More than one area may be addressed during this time interval depending on the procedures planned. As mentioned the lower body lift will address the abdomen, lateral thigh and buttock in one operation.

Although the staged approach takes time, each stage is a marked improvement. This leads to enthusiasm for the next stage as you see your new form emerge. The transformation is dramatic and powerful. Restoring harmony between the scale and your appearance will help you to realize your tremendous accomplishment. It is your reward for a job well done.

Hand Rejuvenation

 Before

After

 

Hand Rejuvenation

 

The hands and the face are the only 2 areas of the body which are continuously exposed to the environment and the public. We are all aware of the aging face but little attention has been paid to the aging hand. In fact, the hand is one of the first areas to show signs of aging. As the hand ages volume is lost, the veins and tendons become more prominent and the spaces between the fingers on the back of the hand deepen. The skin appears thinner and the joints appear larger. In addition to this we develop hyperpigmentation or "age spots".
This imbalance is further exaggerated after a facial rejuvenation procedure. This lack of harmony is particularly obvious with daily maneuvers such as raising a glass to take a drink. The contrast of a 45 year old face and a 60 or 70 year old hand can be dramatic. I have had women tell me they intentionally keep their hands out of view because they are unhappy with their appearance. After the surgery, they are thrilled because they can begin wearing their jewelry again without concern about the appearance of their hands.

The aging process affects the skin as well as the deeper tissues and all elements must be evaluated and addressed for a complete rejuvenation. Surgical and nonsurgical techniques can be combined to accomplish this goal.

The surgical procedure involves the transfer of fat cells from one area of the body to the dorsum (back) of the hand. The fat is harvested by liposuction and can be done under sedation or under general anesthesia in conjunction with other surgery. The surgery can be done in 2 hours or less. It is an outpatient procedure and normal activity can be resumed by 7 days with some restrictions. The procedure is very safe with minimal complications and little post operative discomfort. I have performed this procedure on 45 year old and 75 year old women with equal efficacy. They are all pleased with their results.

Once the volume is adequately restored attention can be turned to the discoloration of the skin. Topical treatments of retinoic acid and hydroquinone can be very effective for mild to moderate hyperpigmentation. More severe hyperpigmentation generally requires either chemical peel or Intense Pulsed Light. Balancing the skin tone and thickening the dermis compliments the volume restoration yielding the ultimate aesthetic result.

Few people are aware of the surgical and nonsurgical interventions available to improve the appearance of the hand. In fact, the procedure was only described within the last 10 years and only a few plastic surgeons have a significant experience with it. The surgical procedure will restore fullness to the hand giving it a more youthful appearance. Topical lightening agents, chemical peel or IPL may be required to reverse the pigmentary changes of the skin. This procedure restores harmony between the face and hands. You can wear your jewelry again.

Depending on your unique findings one or a combination of all of the techniques described may be necessary. This will be determined by your board certified plastic surgeon.

Telltale Signs of a Facelift



Before

After

 Telltale Signs of a Facelift

The science and art of Plastic Surgery have made tremendous advances over the last 10 years. New insights into the aging process have improved our approach to the aging face. How skin is handled during the procedure and how the deep tissue can be manipulated to minimize scarring have all been worked out. Natural youthful results without the stigma of surgery are easily obtained when in the hands of a well trained aesthetic plastic surgeon.

Although this is true we still see people on a daily basis with these obvious signs of surgery. It is important to understand that each of these "Telltale Signs of a Facelift" is avoidable. The following observations and explanations are offered for your education. Recognizing these problems will help you evaluate your surgeon and improve your overall satisfaction with your result.

They are:

Temporal Hair Loss

The hairline in front of and above the ear is pulled back increasing the distance from the beginning of the hairline to the corner of the eye. Not only is this unnatural in appearance it has the effect of aging the face. This occurs when an incision is placed in the hairline without accounting for the elevation of the facial skin. The second reason is when a surgeon cannot create fine scars they choose to place an incision in the hairline to hide them. Hair is then mistakenly removed permanently altering the hair style choices of the individual.

Occipital Hair Loss

As with the temporal hair loss, a misplaced incision within the hair bearing skin behind the ear will mistakenly remove the hair. This creates an unusual step off in the hair preventing the person from wearing the hair up ever again. Both of these conditions can only be corrected with hair transplantation. This usually requires multiple treatments at significant additional cost.

Poorly Placed Scars

An artistic eye is required to identify the appropriate placement of the facelift incision. Scars are less obvious when placed in areas of color change or shadow. These areas exist about the anterior ear which is the most common area for misplaced incisions. Cheek skin is a different color and has a different texture than the skin of the ear. The most common error is to place the incision in front of the ear or at the border of the sideburn. White scars can form here and are obvious from across the room. This is particularly true in male patients who are condemned to maintaining long sideburns regardless of hair style trends. Incisions must be placed in the natural curves of the ear and in areas of color change to achieve a near imperceptible scar.

Wide Scars

Scars become wide when the skin is closed under tension or if there is suboptimal wound healing. The skin is not a supporting structure, it is a veneer. The tension created when the face is lifted must be born by the deeper tissues. If a traditional skin lift is done the incidence of wide scarring both in front of and behind the ear is unacceptably high. A small percentage of the population will develop hypertrophic or keloid scars. These are biologic conditions which are more prevalent in populations with darker skin tones. However, surgical technique also contributes to this problem. Delayed wound healing after surgery will also lead to wide scarring. This occurs most commonly, immediately in front and behind the ear just below the hair. This is related to tension on closure which compromises blood supply. The blood supply can also be compromised by bulky compressive dressings and poor head positioning after surgery.

Lateral Sweep

You have all seen this one. The skin is pulled so tight the person looks like they have been in a wind tunnel. A few months later as the skin relaxes semicircular lines form across the cheeks. There are no natural lines which run in this orientation. This is again created by techniques which pull skin back toward the ear without deep tissue elevation or support for the skin. Aging is a vertical and radial process which can not be addressed solely by tightening the skin. The deeper tissues need to lifted vertically while the skin is redraped in a more natural orientation.

"Pixie Ear"

This is defined as an ear lobe which has been pulled forward on the cheek and placed under tension. Rather than having a sharp or distinct transition from the cheek to the lobule, the ear lobe has been blended with the cheek. The lobule position is advanced in front of the ear and is lower on the cheek than it should be. It derives its name from early drawings of the mythical pixies. The lobule of the ear should maintain a distinct transition from the cheek but should also sit about 15 degrees behind the long axis of the ear.

Shotgun Deformity

Over the last 10 years greater attention has been paid to the neck contour during facelifting procedures. In fact, a great majority of patients present to my office more concerned about their neck than their face. Current techniques allow greater manipulation of the deeper structures of the neck. If done well the results are excellent, if done poorly or in the wrong patient type, a depression immediately below the chin can be created. Instead of a soft curve in the submental area there is a central depression with fullness on either side. There is nothing natural about this appearance.

Vertical Skin folds behind the Ear

The Short Scar facelift was developed to help surgeons who consistently developed wide scars behind the ears. The scar is short because the skin is gathered behind the ear rather than extending the incision to allow the skin to lie smoothly. Over time many of the folds become smooth. However, many of the folds do not, creating unnatural vertical skin folds behind the ear. This problem is now seen with increasing frequency because of the increasing popularity of this technique. As previously discussed, wide scarring can be avoided by placing tension on the deep tissue and avoiding tension on the skin.

Loss of Tragal Definition

The firm prominence in front of the ear which prevents visualization of the auditory canal is the tragus. It is well defined and has distinct borders. There is a depression in front of the tragus which is an aesthetic separation from the cheek. It is oriented to partially cover the auditory canal. The tragal definition can be lost by failing to recreate the anterior depression, leaving the skin over the tragus too thick, in males failing to remove the hair follicles which subsequently grow on the ear and finally placing incisions which fail to respect the boundaries of the tragus. The thick skin over the tragus blurs the normal transition of these separate structures, the cheek and the ear. Tension placed in this area will also pull the cartilage forward changing the orientation of the tragus and allowing visualization into the auditory canal.

Use this information to improve your decision making process. Ask to see your surgeons’ before and after photos and scrutinize them looking for the points mentioned above. The more you know about your procedure the happier you will be with your results. I hope this will help you achieve the results I know are possible.

 ~ Dr. Robert W. Kessler