You may have deep smile lines around the eyes or around the mouth, and the treatment for each is quite different.

Smile lines around the eyes which are also called crow’s feet are very effectively treated with Botox injections.  The Botox relaxes the orbicularis muscle which causes the skin to crease into the smile lines.  When the muscle is relaxed, the surface of the skin becomes smoother.  The results of Botox treatment of the crow’s feet typically last for four months.

Laugh lines or smile lines around the mouth are most effectively treated with injectable fillers.  For superficial lines, we use Restylane, and for deep lines we use Juvederm Ultra Plus.  Both of these products are hyaluronic acid gels but they have different properties.  Restylane is more appropriate for superficial lines, and typically lasts 5 or 6 months.  Juvederm is more extensively cross-linked and is more effective for deep lines and folds, and Juvederm has been shown to last for one year. 

By far, the best way to tighten sagging facial skin without surgery or downtime is Thermage.  Thermage uses radiowaves to tighten the collagen in the deep layers of the skin, and is very useful to clean up jowls and a loose jaw line. 

Thermage has been getting mixed reviews, and in fact on the REALSELF.COM website, only 35% of patients felt that Thermage was “worth it”.  However, do not let this discourage you from exploring this very useful technique.

Dissatisfied Thermage patients are not the result of the technique itself but, of improper applications as follows:

A). Patient selection is critical.  If Thermage is tried on a patient who has a great deal of jowling and skin laxity in the neck, it is quite predictable that the improvement is going to be insufficient, and that a patient like this will really only be helped by surgery.  There is no age cut off, but younger patients do better with Thermage. 

B). Thermage has to be done just right.  It requires a great deal of experience and a good eye.  As with anything else in Cosmetic Medicine, the machine is only as good as the person using it.  If you are going to have Thermage, make sure that you go to an office where they do a lot of it, and ask to speak to a patient who has had it. 

C). Very often, not enough energy is used in Thermage to save money.  An individual head has to be bought for each patient, and heads come in different sizes, ranging from 200 pulses to 900 pulses.  The greater the number of pulses, the more the energy delivered to your skin, and in general the better the result you will get.  The problem is that the larger heads with more pulses cost more money, and there are practices that cut corners and use small heads which provide inadequate energy.  Predictably in this situation, the result will be disappointing. 

We only use 750 pulse and 900 pulse heads, depending on the individual patient and the individual area. 

D). The final point to make about Thermage is that patient education is important, and you have to have realistic expectations.  You can expect very significant improvement but, the results will not be as dramatic as with a well performed scarless mid-facelift or with a short scar facelift.

In women who have a lower face that is too square, the cause is usually bulging of the masseter muscles. These muscles are too thick and cause the jawline to be too wide and even masculine.

The masseter muscle bulging can be softened and reduced with Botox injections, so you get a softer, more oval jawline. This is a new application for Botox.

The results are pleasing and they last 9 to 12 months. As a side benefit, Botox helps some patients who have a problem grinding their teeth.

• Press on.
• Nothing in the world can take the place of persistence.
• Talent will not; nothing is more common than unsuccessful men with talent.
• Genius will not; un-rewarded genius is almost a proverb.
• Education alone will not; the world is full of educated derelicts.
• Persistence and determination alone are omnipotent.

Every year, whether you are fat or thin, whether you lose weight or gain, 10 percent of your fat cells die.  And every year, those cells that die are replaced with new fat cells, researchers in Sweden reported Sunday.

The result is that the total number of fat cells in the body remains the same, year after year throughout adulthood.  Losing or gaining weight affects only the amount of fat stored in the cells, not the number of cells.

These findings were published in the New York Times on May 5th.  They explain why the improved contour and reduced size caused by lipsuction appears to be so permanent.  The fat cells removed with liposuction do not grow back.

Bromelain is a pineapple extract that we use in our cosmetic surgery practice in New York City.

Bromelain is taken by mouth and we give it to patients recovering from cosmetic surgery together with arnica.

Bromelain has a number of great properties that make it so useful in the healing period.

1) It reduces pain.

2) It reduces swelling.

3) It reduces inflammation.

4) It reduces bruising.

5) It promotes healing.

There are several liposuction devices marketed to plastic surgeons - and sometimes directly to patients and patients ask for the latest technique they have read about.  But, the latest is not always the best and there is often a lot more salesmanship than science.  Doctors have to resist these pressures.

One device for which in my opinion there is little scientific evidence is VASER.  The word VASER stands for: Vibration Amplification of Sound Energy at Resonance.  It adds a new source of energy to liposuction without obvious benefit.  And any source of energy can have a potential downside.

The secrets to great body sculpture with liposuction are not that new. 

They are:

1) Injecting fluid into the tissues before liposuction (tumescent technique).

2) Using tiny cannulas.

3) Doing liposuction at both the deep and superficial levels.

4) Using micro tunnelling to tighten the skin.

5) Taking as much time as necessary.  This is sculpture and cannot be rushed.  I proceed slowly and constantly check for contour, smoothness and symmetry.

Some patients have complained to us that they were disappointed with the results of thermage that they had done elsewhere. It would be too bad if thermage does not maintain its high reputation becasue in fact we have seen impressive results and we have a lot of happy thermage patients.

There are two likely reasons for poor results with thermage. The first is poor technique. You have to do it right. Our nurse Maria La Cava is excellent with Thermage and she has done hundreds of procedures.

The second likely reason for poor results is that some offices do not buy large enough one time use treatment heads for the Thermage machine (because the large heads are more expensive) and therefore not enough energy is delivered to the tissues. We use the laregest treatment head made so that more than enough energy is available.

We have had the most success with Thermage in the lower face, in the arms, in the abdomen, and in the front and inside of the thighs.

Everyone knows about Botox injections to correct frown lines, forehead wrinkles, and smile lines around the eyes. Botox also raises the eyebrows and creates a “chemical brow lift”.

The topic of this note is different. It is about Botox in the lower face and neck where its benefits are less well known, and where it can be quite helpful in creating a youthful appearance

I. Artistically and anatomically placed Botox injections in the lower face are effective in two areas:

1) The corners of the mouth can be tilted up with Botox. This is done with a small amount of Botox between the corner of the mouth and the jaw line. The injection in this site relaxes the muscles that pull the mouth down, and therefore the corner of the mouth naturally rises.

2) The vertical lines in the upper lip, and also in some patients the lower lip, that cause running lipstick can be improved by small amounts of Botox which relax the muscle that causes pursing of the lips.

II. Botox can make the neck look younger. One of the most common causes of a loose neck and double chin are muscle bands, caused by the platysma muscle in the neck pulling the skin downward. The platysma muscle is large and must be adequately treated. But when this is done well, the platysma muscle relaxes and the neck bands can improve substantially. This produces a cleaner, more youthful neck and jawline. Botox injections in the neck are particularly useful for women who are not ready to undergo a neck lift.

The typical cost of Botox treatment around the mouth is $400, and the typical cost of Botox treatment in the neck is $700.

If you have any questions, please call are nurse Maria La Cava.

I published a brief communication concerning extended abdominoplasty or tummy tuck for the patient who has lost a lot of weight in the February 2008 issue of Plastic And Reconstructive Surgery. This is the most respected plastic surgery journal. The aim of my published remarks is to make the extended abdominoplasty safer and more widely available to patients.

I thought this would be a good occasion to review the various options that people have to improve the appearance of their stomachs. There are basically 8 different options and I will touch on each of them briefly:

• Thermage
• Liposuction
• Liposuction followed by Thermage
• Mini-abdominoplasty
• Modified abdominoplasty
• Full abdominoplasty
• Extended abdominoplasty
• Circumferential body lift

1. Thermage: This is a noninvasive office procedure that requires no anesthesia and no down time. We have seen some quite impressive results with Thermage in patients who have some looseness of the skin of the abdomen, especially around the belly button. The procedure does not usually need to be repeated and is quite useful for patients who are not ready for surgery.

2. Liposuction: The three things which can make the stomach look bad are excess skin, excess fat and loose muscles. When the problem is excess fat in the upper and lower abdomen and when the skin is relatively tight, then major improvement can be achieved just with liposuction of the stomach which is scar free and has a very short recovery period.

3. Liposuction with Thermage: For patient who have excess abdominal fat and a mild degree of skin looseness, we avoid the scar and the longer recovery associated with the tummy tuck by first flattening the stomach with liposuction and several months later tightening the skin of the stomach with the non-invasive Thermage procedure mentioned above.

4. Mini-Abdominoplasty: This is an ideal procedure for women who already have a C-section scar and have some fullness and droopiness of the stomach that is limited to the area below the belly button. The surgery is limited to the lower abdomen and involves a short scar and a quick recovery period.

5. Modified Abdominoplasty: This is an excellent operation for patients who have only moderate skin looseness but who have weakness of the rectus muscles (also called a diastasis). The muscles can be sutured together and tightened above and below the belly button through a relatively short incision above the pubic hair and some of the excess skin is removed by slightly sliding the belly button down.

6. Full Abdominoplasty: This is the classic procedure for patients who have significant amounts of loose skin, significant amounts of fat and significant weakness of the muscles. This operation gives full correction but has a longer scar running at the level of the pubic hair, and it has a longer recovery period.

7. Extended Abdominoplasty: This was the actual subject of my recent publication, and it applies to patients who were severely overweight and then lost a massive amount of weight, either by diet and exercise or, more commonly, by gastric banding or gastric bypass surgery. This is a separate and distinct group of patients who have truly enormous amounts of loose excess skin that has to be tailored. The skin excess is both present in the vertical and in the horizontal directions and therefore there is both a vertical and a horizontal scar. These patients are so happy to be rid of the folds and layers of excess skin that they readily accept the scars and the quality of their life is dramatically improved.

8. Body Lift: This is also a fairly extensive operation which is usually reserved for the massive weight loss patient. In the front, it is equivalent to the full abdominoplasty and it corrects the weak muscles as well as removing excess skin and fat. This operation goes entirely around the hips to remove redundant skin and fat from the sides and the back as well. Obviously, this operation is associated with a long scar and significant recovery time.