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Cosmetic surgery is getting a makeover

NY TIMES NEWS SERVICE, VANCOUVER, BRITISH COLUMBIA
Wednesday, Apr 28, 2004, Page 16

Corina van Leeuwen opted for surgery on holiday. PHOTO: AGENCIES

People want to look younger, rather than different -- to have the face in their mind's eye, not the one in the mirror. They want quicker, less expensive and less invasive procedures and new medical technologies are feeding and increasing the demand.

Along with the incremental improvements comes another change. Surgeons are seeing younger as well as older patients as cosmetic improvement becomes a lifelong pursuit.

"I think there is a paradigm shift in thinking, right at this moment," said Dr. Leroy Young of St. Louis, chairman of the emerging trends task force for the American Society for Aesthetic Plastic Surgery. The group had its annual meeting here this month.

Surgeons, Young said, are backing off from more aggressive surgeries and moving toward nips, tucks and injections. Operate early and often might be the new motto.

The change, said Dr. Brian Kinney of Los Angeles, a member of the trends panel, "comes for three or four reasons."

"One is younger people who aren't going to wait," Kinney said. "They want to start surgery now. Smaller budgets. They don't want to spend as much money. Also, they don't have time. We're an instant-gratification society."

This patient before, and three years and seven months after lipostructure to her forehead, between her eyebrows, cheeks, lips, brow, around the mouth, jawline, chin, and suctioning from the submentum.

Drastic changes in appearance are the rare exception, despite the potential influence of television shows that feature extensive surgery like Extreme Makeover and The Swan. More typical is the surgeon who asks patients to bring in their high school yearbooks, to see how he should go back to the future.

Combination pictures show Corina van Leeuwen before and after having breast enlargement surgery in Penang, Malaysia.

Another force that continues to change cosmetic surgery is the emergence of new technologies. In the past, liposuction and Botox injections were revolutionary. New parts of the body are always attracting attention. Calf implants never really took off, although they are available. But gluteal implants, for what one surgeon called "the J-Lo look," might take off, although numbers remain very small.

Much more important are a raft of new fillers coming on the market for injection under the skin to fill out the face rather than lift it. The whole idea of the lift, some experts say, is old-fashioned and inappropriate. Gravity is not the enemy of youth, they say, but loss of volume.

Risa Arato is shown in this combo photo, before, left, and after her cosmetic surgery for rounder eyes, and a bigger nose.

Lifting faces

Face-lifts live, but they have become very specific. It's not the face, but the brow or midface that is done. And there are new minimalist techniques, some involving new sutures, used to produce the weekend face-lift, so-called because the recovery time is so short.

But most surgeons are holding on to their knives, and few predict that the traditional face-lift will be replaced entirely. Dr. Sydney Coleman of New York is a partisan, the acknowledged guru of fat injections. He developed techniques and instruments to take fat from one part of the body and inject it in tiny quantities into the face and other areas. Fat is living tissue, and, under the right conditions, will survive in its new location.

Coleman also works with other fillers, and he said these methods, all to restore the volume of the aging face, are replacing old-fashioned cutting. "Syd really doesn't do face-lifts," Young said. "And of course, when you've got a hammer, the world is a nail."

But, Young said, fillers and more limited surgery might well be the future in the intense worldwide pursuit of rejuvenation.

Statistics show that the traditional procedures, if Botox and liposuction are included, continue to dominate the field. But the new developments occupied much of the meeting, as surgeons disagreed about the promise and safety of various procedures.

What was clear was the intense interest in new substances as fillers, and in the approach to aging that suggests filling out is more important than lifting up. Coleman and partisans of volume say the damage from gravity has been exaggerated. The real culprit, he says, is the loss of tissue under the skin.

A brow lift, he said, tackles the wrong problem. The brow, "descends only because you're missing huge volume, so yanking it up doesn't really make sense," Coleman added.

He takes a person's own fat and pushes it under the skin in tiny amounts, using a blunt-tipped instrument called a cannula. He does the same for a sagging lower eyelid, arguing that it makes no sense to cut muscle and fat, the usual surgery. That procedure leaves a hollow-eyed look, he says.

For lips, however, he uses a new material, hyaluronic acid, a substance found in the body that also fills out tissue, but is not permanent. Although there are 24 or so fillers on the international market, few are approved in the UD. But that is changing, Young said, noting, "The fillers are evolving so rapidly that there's a new one every month almost."

One approved for use is calcium hydroxylapatite, also a natural substance. Coleman was critical of its widespread use, although many doctors find it useful. "No one has ever used it for more than two years in subcutaneous tissue," he said. "There is no experience."

Although hyaluronic acid is temporary, calcium hydroxylapatite is semipermanent. It is not known how long it lasts, Young said. "In dogs," he said, "it lasts up to five years. There is no data in humans out that far."

There are many concerns about fillers: how they will change over time and whether hazards or problems may emerge years later. One hundred years ago, doctors injected paraffin under facial skin, but found eventually that it broke up into small particles, giving a bumpy, uneven look to the skin.

Filling holes

With any filler, technique is important. With a sharp needle, an artery can be pierced and the fat injected into it can block capillaries, shutting blood flow to a part of the body. Liposuction patients have died of pulmonary embolisms in this fashion.

Injections in the face have caused at least two instances of blindness, when the retinal artery was accidentally blocked, Coleman said. In another case, the soft tissue on and around the nose died and simply sloughed off the face.

A more mechanical innovation involves barbed sutures. The synthetic thread, used for stitching, has barbs all along its length, to help it anchor in tissue. In a traditional face-lift, surgeons make a large cut in the face, lift a section of skin and the tissue beneath it and tie in sutures like bridge cables to pull up the face. The recovery from such an operation takes weeks.

With the new barbed sutures, surgeons say, they can make a small incision, then use a long needle to thread the suture under the skin to the place where it needs to be anchored and tie it at the top.

Dr. Woffles Wu of Singapore described how he performed what he called the Woffles face-lift with barbed sutures. He presented the cases of a woman who needed a quick improvement for her daughter's wedding, three weeks away, and another woman who wanted to look fresh for her husband, who was coming home after a long time away. This is the face-lift as hairdo.

The safety of the sutures themselves was not questioned. But many surgeons had doubts about their endurance and how the results would appear. Dr. Fritz Barton of Dallas said at a panel: "Plastic surgery is not different from the rest of life. There is no little procedure with a big benefit."

Surgery is becoming less invasive, in other ways said Dr. Robert W. Bernard, departing president of the society. Endoscopes see work under the skin, eliminating the need to lift large flaps of skin. Until seven or eight years ago, Bernard said, for a brow or forehead lift, "you needed to have an incision that stretched from ear to ear" over the top of the head. That worked quite well, he said, but when it was explained to patients, "they were out the door and gone."

Neither noses nor breasts, the bread and butter of cosmetic surgery, are what they used to be. At the annual meeting of the American Society for Aesthetic Plastic Surgery here last week, the president of the society, Dr. Robert Bernard, said in an interview that when he started out "the look among youngsters was a little, tiny turned-up nose." Now he said, it is more natural.

Dr. Adrien Aiache, of Beverly Hills, California, who has done a lot of work with calf and buttocks, or gluteal, implants, said that because of a different standard of beauty, gluteal implants were far more popular in Brazil and that breast augmentations were less popular.

One of the most common procedures in cosmetic surgery is breast augmentation. But, Bernard said, there are clear regional variations. "In the Sun Belt area," he said, "larger means larger than it does in the Northeast."

From a to be

He said that in a conservative area like Westchester County, where he practices, when women have breast augmentations they want subtle changes. "If they're an A, they want to be a B," he said. "They don't want to be a D. There is a constant refrain: `Don't make me too big, don't make me too big.' Literally, as they're being wheeled in to the operating room, they'll say that to the nurses.

"And yet, when I talk to some of my friends from other parts of the country, they laugh at me when I tell them the size implant that I use. It's nothing."
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