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Q & A

To a certain extent – and within reason – that’s true. As you can well imagine, it’s certainly more likely that we’ll get a more youthful look with a more youthful patient. Regarding the longevity of the result, the more healthy the tissue on which we’re working, the more likely it is to retain the results of the surgery, and younger tissue often translates to more healthy tissue. Also, it has been shown that younger people generally tend to be happier with smaller levels of rejuvenation than older people are with even more dramatic levels of rejuvenation.

That being said, volume loss and sun-damaged skin are better treated with volume augmentation and lasers respectively than with a facelift. Both of these conditions tend to show up earlier than the conditions that are best treated with a facelift, those being the effects of gravity, accumulation of fat at the jowl areas, and stretching and shifting of connective tissues beneath the skin.

Remember too, that any invasive procedure will alter the anatomy somewhat. Structures are moved and stitched into a different position, and the nature of some of the operated tissue changes just by virtue of the natural healing process. So the fewer times someone has a lift over the course of their life, the lower the risk of complications.

Chronological age has less to do with age than individual genetics and lifestyle choices. I remember one day when I was operating, I had a 48 year old and a 64 year old back-to-back. The scrub nurse commented that even before the surgery, the 64 year old looked closer to 48 and the 48 year old looked closer to 64. The bottom line is that “how old” we look is becoming less and less a matter of numbers.

Lastly, make sure your doctor is someone whom you can trust to have your best interests in mind. A couple years ago I had a patient from out of town who had been told that she needed several things done including a facelift, and the fees came to well over $17,000. She was a beautiful, fit 36 year old with a slight genetic obliquity under her chin rather than the well-defined angle we associate with a young neck. She also had some early hooding at the upper lids and the beginning of some volume loss between her cheekbones and her nose. She had absolutely no indications for a facelift, much in keeping with most women that young. I gave her the contour she wanted at her neck, restored her upper lids and gave her some volume where she had lost it for way less than what she had been quoted and with much less invasiveness.

Generally, 3 to 4 days should be enough. If you’re using a stronger concentration of a retinol or you normally experience a little dryness or flaking with your retinol, you may want to try a quarter size area at your temple and at your jawline for a night to see if your skin is ready.  If you experience irritation or the skin feels too dry, wait a couple more days and try again.

The Starflower Essentials skin care products are made right here in Sarasota, Florida, although the ingredients are sourced from all over the world. Cherylyn Van Kirk, the alchemist of Starflower, dedicates herself to finding the highest quality ingredients for her products and combining them for super-efficiency without the irritation that can occur with some organic products. Her ingredients are all food-grade, truly organic and cruelty-free. The products have an amazing ability to calm, hydrate and clear without any heaviness or greasiness at all. They are pristinely packaged in glass and have a shelf life of about 18 months in most cases, without any synthetic preservatives at all.

This is a great question and the short answer is, it depends on where it’s going and who’s giving it. Most physicians who are experienced with replacing lost volume in the face are going to have their favorites of course, but different fillers have different attributes, and at least a small armamentarium is necessary to address the needs of different patients and different parts of the face in an individual.

Any injectable must be FDA-approved and must have been ordered directly from the manufacturer to avoid the disasters of “bootleg” products. Beyond that, the particular filler (or fillers) chosen is tailored to the individual’s needs. Then if the physician is skilled, ethical and has an intuitive understanding of facial harmony and proportion, the outcome should look entirely natural.

There can be unfortunate results with any filler, but some of the same qualities that can make Radiesse more desirable for certain applications are the same ones that also can be problematic.

First, just to clarify things for those of you who may want a little background, the most commonly used fillers are hyaluronic acid-based. Hyaluronic acid (HA, sometimes referred to as hyaluronate) is a sugar that is found naturally in the body. There are various incarnations of this, most commonly Restylane, Perlane, Juvederm and the fairly new Belotero. Radiesse is made of calcium hydroxylapatite (CaHA), another compound found in the body in bone. Contrary to some Internet silliness that was floating around in the past, Radiesse will not “turn into bone”. It eventually breaks down into calcium and phosphate, substances that you take into your body every day.

Radiesse is an excellent filler in several ways. It’s relatively thick, so for any given amount of volume that’s administered, we just seem to get more fullness than with the hyaluronic acid fillers. Secondly, it’s a “biostimulator” in that it stimulates collagen quite actively. The hyaluronic acid fillers do that a bit, but not as much as Radiesse, which does that by design. Also, in most people it seems to last longer than the hyaluronic acid fillers.

As with any substance taken into the body, there are rare instances of a sensitivity to the product, but in all the injections I’ve done over the years (usually several each day), I’ve seen only one patient in which I suspected an allergy to Radiesse. Also, with anything injectable, strict attention must be paid to cleanliness to avoid the possibility of an infection and your doctor must be eminently well-versed in the minutiae of facial anatomy – and delicate in technique – to avoid injecting the product into a blood vessel or placing it so that it presses enough on one to cut off the blood supply.

But as for Radiesse in particular, it should never be injected into the lips as the movement of the muscle tends to form nodules. It also is, in my opinion, too thick to be injected into superficial wrinkles and is best used for contouring. The main problem I tend to see is overinjection or poor placement. The longevity that makes Radiesse such a great choice as a volumizer can make it especially frustrating when someone comes in with too much of it and/or poor technique as it can seem like an eternity waiting for it to break down and go away. With the hyaluronic acid fillers, a benign enzyme (hyaluronidase) can be injected with a satisfyinly rapid dissolution of the product.

My first encounter with a lovely patient of mine, her equally lovely friend and her father was where they had all been terribly overinjected by a well-trained individual who had gotten these patients to the point where I drove home in tears that evening, wondering how this could have been allowed to happen. The friend had been given Radiesse to the mid-cheeks to the point where it looked totally out of proportion and Perlane had been given to a depressed scar near the nose, creating an elevation where there had been a depression. I injected a little hyaluronidase to the elevation and it deflated rapidly, allowing me to fix the scar in a timely manner. But it was a waiting game with the Radiesse over a period of months with her and with the two other patients. So the bottom line here is that the advantage of Radiesse is that it tends to go further and last longer than most of the hyaluronic acid products, but it is less forgiving and requires, I believe, perhaps a more accurate “eye” along with considerable skill and experience for an optimal result.

Lastly, and I haven’t seen a whole lot written about this, but if you’re on Actonel (risedronate) for bone density, it may eat up your Radiesse. Medications such as Evista (raloxifene) have a different mechanism of action and won’t affect the Radiesse. Fosamax (alendronate) has the same mechanism of action as Actonel, but it just doesn’t seem to affect the Radiesse in my experience. I had a number of disappointed patients early on, who came back after about a month and said, “I thought you told me this would last longer…” and I gave away an awful lot of hyaluronic acid filler feeling like a horrible person, until the common denominator became clear.

A: Interestingly, most people who come to my office check “Yes” in the “Bruises Easily” box on their intake form. A majority of these people also take nutritional supplements and eat healthy foods. This is good, but there are a few caveats when you’re going to have injections or surgery. Let me just mention that if you have any medical condition, check with your doctor before adding or subtracting anything from your diet or supplements. Always let your doctor know all medications and supplements that you take and never discontinue a prescribed medication, including aspirin, without checking with your doctor first. Bruising always goes away and nothing as elective as a cosmetic procedure is worth gambling with your health.

Now, why do we bruise? Bruising is basically a little blood leaking out of a blood vessel from a bump, scrape or nick. Our body has its own seal-it-off and clean-it-up team that clears bruises for us, usually over a matter of days to a week, but very occasionally bruises can last two weeks or longer. In the interim we can watch a bruise go through some charming color changes that generally can be concealed, especially once the bruise is looking more reddish than blue.

We’re built with an excellent blood supply to the head. Our brains and eyes (the eyes actually being extensions of our brains) require a tremendous amount of oxygen relative to the rest of the body to function properly. The good news is that all those blood vessels with their oxygen make it much more difficult to get an infection at the face than say, at the legs or feet. The other side of the coin is that we can be a bit juicy at the face even with a superficial scrape.

On top of that, every little millimeter on a face shows because the facial features are small compared to the rest of the body, so even a little bruise is a larger part of the whole picture. Plus, you can’t really throw a coat over it.

While I’m a big proponent of a vegan or vegetarian diet – better for you, better for the planet, certainly better for the animals – there is a whole list of mostly fruits and several veggies that can thin your blood and make you bruise more easily. I advise going easy on these foods for a prescribed amount of time before an injection or surgical procedure. Berries, grapes, citrus fruits, tomatoes or Omega-3 nutrition (like fish, fish oil or flaxseed) can thin the blood. Peas, corn, cauliflower, carrots and broccoli will not thin the blood. Bananas won’t either. Some of the more common supplements such as garlic, ginkgo biloba, St. John’s wort, grapeseed extract and cayenne can promote bruising. Your doctor can give you advice regarding your diet prior to a procedure. We have a comprehensive list we give to our patients.

Foods aside, the three major players regarding bruising are alcohol, aspirin and non-steroidal anti-inflammatory agents (e.g., ibuprofen as in Advil or Motrin, or naproxen as in Aleve or Midol). While no one will object if you skip martinis or wine for a while, let me stress again that you should never discontinue a medication your doctor has advised or prescribed without checking with her first. If a person is on blood-thinning medications such as Coumadin, Plavix or aspirin and we’re considering a surgical procedure, I will speak with the prescribing doctor and we’ll agree on the best advice for that individual.

If you’re having injections, cool compresses just before and after the procedure will help constrict the blood vessels so they aren’t as likely to bruise. The compresses also have a little numbing effect. After surgery on the face or neck, you will have a prescribed regimen that usually will involve using cool compresses and keeping your head elevated about 30 degrees from the horizontal.

A. They are wonderful, aren't they? Regarding photofacials (for the uninitiated, photofacials are performed in a doctor’s office with “intense pulsed light,” often called “IPL”), generally it will take from 2 to 4 sessions to erase brown spots and blood vessels. These sessions can be 3 or more weeks apart. As you’ve no doubt noticed, there is a lovely little side effect from the heat of the light that makes the texture of the skin finer and silkier looking, due in part to the stimulation of collagen formation in the skin. Maintenance photofacials can be performed as often as monthly, depending upon your skin type, however I would recommend 3 or 4 of them a year once the skin has been cleared of brown and red spots. Despite the moniker, photofacials can be performed anywhere on the body, and the results can be gorgeous and a huge relief for those of us who are regretting our sunbunny days.

You can maintain the skin nicely with a retinoid (the original was Retin-A and there are numerous variations available now). A good prescription-strength retinoid, light but consistent exfoliation, and the diligent use of sunscreen will be an ideal way to keep your skin healthy between sessions. The retinoid will also gently stimulate collagen production in the skin and will slow down the aging process of the skin over the years. Your aesthetician can recommend the proper retinoid for you.

Now regarding peels, there are a lot more variables in the mix. If you’re using a retinoid and are exfoliating regularly, you may not need a peel as often as you would otherwise. The time between peels also depends on the type of peel, as they can be superficial enough to give you an extra glow for that evening to deep enough to have you housebound for the better part of a week – or more. A basic rule of thumb is as long as your skin is reacting well and not getting overly sensitive or irritated, your timing and your choice of peel are good. Over-the-counter peels will recommend the frequency of application, usually once or twice a month. The stronger peels will be performed by a professional who can follow up with you and make recommendations tailored to your skin. Remember too, that the needs of your skin will vary with dietary changes, weather, hormonal changes, etc., so you may need to be flexible with your regimen.

A final word -- if you are using a retinoid, discontinue it for 2 to 4 days prior to a peel or photofacial to avoid irritating the skin.

A. Why we lose hair where we want it and sprout it where we don’t want it has always seemed to be a basic engineering problem to me, but there you are. Here are a few ideas to help:

1. Lash enhancers such as Latisse or RevitaLash really work and their effects will show up usually within a few weeks. Occasionally, someone may be a little sensitive to them, but they work beautifully for most people. Remember to apply them to the base of the lashes – that’s where they do their work – rather than applying them (like eyeliner) more on the lid skin. It also takes a wee bit more attention to apply them at the exact outer corner of the eye, but it’s just another few seconds out of your evening, so make every bit count. A number of my patients report that their eyebrows have responded well to these lash enhancers as well.

2. You can also create the effect of lashes at the outer corners of the eyes by placing liner or shadow there.

If you use a pencil liner, make sure the texture is soft enough to make a smudgy little V-on-its-side shape at the outer corner without your having to pull your eyelid at the corner (more on that next month). Use light, short strokes and keep the V slightly tilted upwards as you place one leg of it at the upper lash line and the other at the lower lash line. Continue the line toward the nose at the upper and lower lash lines to taste but keep the V a bit thicker and more dense at the outer corner of the eye. Make sure the whole thing is softened a bit at the edges, unless you’re purposefully aiming for a hard line. Most of us can’t get away with that after the mid-twenties -- Mother Nature is quite adept at making us look harder as we get older anyway, without our help, thank you.

For more control in application, you can use eye shadow to achieve the same effect. Use a deep color, even a black, and apply it with a small brush and a light hand. If you use powder shadow, tap off the excess before applying it so you don’t end up with a sooty cheek. Keep it darkest at the corner and right at the lashline, and blend it slightly out and up at the outer edges. If you’re really artistic, you can take a pencil and draw little lines radiating out at the corners to simulate lashes (remember Twiggy?). If you do this, soften the effect with a bit of shadow or a few extra pats with an eyeliner brush.

3. Finally, remember that your eyelashes are subject to breakage, just like the hair on your head. Since most waterproof mascaras almost require a jackhammer to remove, try to wear regular mascara whenever you can. If you have a problem with regular mascara smudging onto your lower lid, wear regular mascara at the upper lashes and apply waterproof mascara very lightly at the lower lashes. At night, remove the eye make-up as gently as possible.

These techniques may require a little learning curve, but they’ll become quick and easy in no time. If you want some help, schedule an appointment with Jill, our talented aesthetician, and she can show you exactly what to do.

Peels are great for renewing the skin, but there are several reasons why your skin may be breaking out afterwards. All or one of the following may be contributing to the problem:

1. The strength of the peel, most often determined by the percentage of peeling agent (for instance, glycolic or salicylic acid) in the mix may be too stimulating for your skin. In this case, a lighter peel may be more suited to your skin.
2. Manipulation of the skin can stimulate the sebaceous (oil-producing) glands and promote breakouts. If extractions are being done or if the skin is massaged at the time of the peel, this may actually be causing the breakouts. Over-stimulation of the glands may also result from rubbing the skin as you remove flaking from the peel.
3. If you are susceptible to breakouts anyway, you might be experiencing a normal purging reaction as a result of the peel. However, you may want to try a lighter peel in this instance too, and work up to a stronger peel over time.
4. Just after a peel, the skin is more vulnerable to environmental pollutants, so remember to protect the skin with a light, oil-free moisturizer and keep the pH normalized by using a gentle toner after cleansing. Drink plenty of water and keep your diet healthy with lots of fruits and veggies.
5. Because of the flaking of the skin after a peel, some people will over-moisturize the skin, and this can cause break-outs. Avoid anything heavy and go with moisturizers that are light and more hydrating.
6. Remember that while microdermabrasion can be great for the skin, it may not be a good choice for acne-prone skin. You’ll do better with topically applied peels.

Hope this helps!

Dr. Barbour's Answer: That depends on two issues: The first is about addressing what is causing the bags and the second has to do with your own idea of what is acceptable as a result. Sometimes a nice little improvement is improvement enough or can allow you to delay surgery.

The bags under the eyes are usually genetically determined, but other factors such as allergies, sun damage, repeated rubbing of the eyes or pulling at the lids to insert contact lenses can create or exacerbate the situation. Additionally, sometimes what people call “bags” are just some fine wrinkles under the eyes and not really bags at all. Let’s go over what contributes to the appearance of bags.

Loss of skin elasticity.
A protrusion of fat at the lower lids above the bone (the orbital rim)
Bulking up of the muscle at the lower lids (which sometimes can look like fat on casual observation).
“Festoons” which are right at or under the cheekbone.
A false protrusion of the lower lid that is actually a result of lack of volume under the lower lid.
Any combination of the above.
So you can see that your first step is to have the situation evaluated by a physician who is well trained and experienced in the anatomy around the eye. Then the two of you can decide how to proceed. If there is truly excess fat at the lower lids, the only precise way to address it is surgically, however even in these cases sometimes a non-surgical approach can help cosmetically.

Wrinkles at the lower lids can be tightened up with lasers or, to a lesser extent, radiofrequency (RF) devices. Both will also stimulate collagen formation at this very thin skin and make it more durable. Peels can help somewhat, but don’t expect them to perform miracles.

Sometimes it’s not so much that the bags are out as much as what’s around them is in, and this is where some carefully placed fillers can make an absolutely amazing difference. Again, if this route is the way to go make sure your doctor is an expert around the eyes. This is a challenging area for the most skilled physicians and should not be approached cavalierly or without a great deal of experience with the eyelid anatomy and with several types of fillers.

Occasionally, the appearance of a bag can actually be caused by the overuse of a muscle that encircles the lids. This can be helped surgically, however with some time and patience it often will improve with tiny amounts of a neuromodulator (BoTox, Dysport or Xeomin) over time. This is not for everyone with this condition and the lids must be thoroughly evaluated prior to its use there.

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dr barbour

Oculofacial Plastic Surgeon,
Sarasota, Florida

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